Success Rates for Reduction of Pediatric Distal Radius and Ulna Fractures by Emergency Physicians

Abstract

Background Emergency physicians are trained in urgent fracture reduction. Many hospitals lack readily available in-house orthopedic coverage. Objectives The aim of this study was to determine success rates for reduction of pediatric distal radius or ulna fractures by emergency department (ED) physicians. Methods We conducted a retrospective study of children younger than 18 years presenting to a large, urban, freestanding children's hospital from January 1, 2009, to December 31, 2010, with forearm fracture. Exclusions included open fracture, those requiring immediate surgical intervention, or additional fractures. The primary end point was the proportion of successful closed forearm fracture reductions in the ED, as defined by orthopedic follow-up. Results All reductions were performed by a board-certified/eligible pediatric emergency medicine (PEM) physician or PEM fellow. Two hundred ninety-five fractures were reduced in the ED during the study period. Mean age was 8.27 years (median, 8 years; range, 1–16 years), and males comprised 69.2% (n = 204). A total of 222 fractures (76%) were of the distal forearm, and 70 involved the midshaft (24%). Orthopedic follow-up was completed in 77.3%. A total of 33 patients (11%) required remanipulation; 24 in the distal forearm fracture group (22 closed reductions, 2 open reductions with internal fixation) versus 9 in the midshaft group (7 closed reductions, 2 open reductions with internal fixation) (P = 0.948). Conclusions The literature reveals 7% to 39% of children with fracture reductions performed in the ED by orthopedic surgeons/residents require remanipulation. Our rate of 11% is consistent within that range. With training, PEM physicians have similar success rates as orthopedists in forearm fracture reductions.

Comparative efficacy of anaesthetic methods for closed reduction of paediatric forearm fractures: a systematic review

“…Effective anaesthesia is necessary to provide adequate pain relief and muscle relaxation during the process. These two affect the success of reduction2 and subsequent fracture healing 3. Moreover, effective anaesthesia improves parent, physician and patient satisfaction, reduces resource utilisation and the need for general anaesthesia 4…”

Displaced Distal Radius Fractures in Children: To Reduce or Not to Reduce? To Pin or Not to Pin?

“…Even after successful reduction, the risk of re-displacement is reportedly high (29-91%). 9,10 Children have undergone a second reduction or surgery in 9-14% of cases following emergency provider reduction, 11,12 and 7-39% of cases reduced by an orthopedic team. 13,14 The cost of reduction is also far greater, ranging from 50% to 700% more than non-reduction treatment.…”

Outcome of reduction of paediatric forearm fracture by emergency department clinicians

“…1 The re-manipulation rate for emergency physicians has been reported as 11%. 2 This variability may be because of a range of both patient and procedural factors. 3 Additionally, more complex fractures may be referred directly to orthopaedic surgeons.…”

“…Previous studies have found that rates of operative re‐manipulation of paediatric forearm fractures (after initial reduction by orthopaedic clinicians) vary from 7% to 39% 1 . The re‐manipulation rate for emergency physicians has been reported as 11% 2 . This variability may be because of a range of both patient and procedural factors 3 .…”