It is five o’clock on a scorching summer Saturday evening. At pitches, playgrounds, and paddling pools, children frolic and play. At a local Paediatric Emergency Department, patients line up to check in; pale, pained children hold their deformed forearms pronated and tightly pressed to their epigastria.
Which of these children will have prompt, definitive management of their forearm injuries in the ED? Which will require the Orthopaedic team’s involvement? What is the optimal way to manage these patients?
For me, few things are as gratifying as a perfect fracture reduction. The thrilling ‘click’ of the bone fragment into its rightful place, the careful crafting of a presentable plaster of Paris, and the self-satisfied glow when reviewing a flawless check x-ray. Of course, not all go so smoothly.
An accepted practice in many Emergency Departments worldwide, the reduction of forearm fractures under procedural sedation in children is part of our job. However, the literature in this area has hitherto neglected to explore which fractures are amenable to EM doctor reduction and which are likely to have better outcomes under Orthopaedics. This paper from Rimbaldo et al., entitled ‘Deformed pediatric forearm fractures: Predictors of successful reduction by emergency providers’, aims to address this, attempting to relate fracture morphology to the likelihood of success for a given operator and venue. They also aim to describe success rates and complications, including late re-manipulation and cast problems.
Rimbaldo KM, Fauteux-Lamarre E, Babl FE, Kollias C, Hopper SM. Deformed pediatric forearm fractures: Predictors of successful reduction by emergency providers. The American Journal of Emergency Medicine. 2021 Jul 2. doi.org/10.1016/j.ajem.2021.06.073
Rimbaldo et al. conducted a retrospective study of children who presented to the ED of a large tertiary care children’s hospital over one year with closed distal and midshaft forearm fractures requiring reduction. Patient data, treatments, and the success rates of EM manipulation and complications were collated.
Who did they include?
Children aged 0 – 18 years who attended the Royal Children’s Hospital, Melbourne in 2018 and underwent a reduction of a fracture of the distal or midshaft radius and/or ulna were included. Open fractures, proximal fractures, fractures with dislocation (e.g. Galeazzi and Monteggia) and pathological fractures were excluded.
458 patients were screened. 340 patients met the inclusion criteria. Most of those excluded had proximal fractures, or X-rays were not available for review. The most common mechanism was a fall while playing sports or in a playground. Most were visibly deformed but neurovascularly intact. The radius and ulna were involved in 62.9%, the radius only in 36.5%, and only the ulna was fractured in 0.6%.
What happened to them?
There were 274 fracture reductions (80.6%) attempted by EM doctors, and these were successful most of the time (256, 93.4%).
There were 18 referrals to Orthopaedics after a failed reduction in ED and 66 initial referrals to orthopaedics – together, they make up one-quarter of all children in the study. Of these 84 fractures referred, 29 – a third – underwent a successful reduction in the ED by orthopaedic trainees without an attempt by EM doctors, 6 were reduced in the ED after a failed attempt by EM, and 49 – over half – were managed in the operating theatre (37 without an attempt by EM and 12 after a failed EM attempt). Most patients managed in the operating room had surgical fixation.
Most patients attended follow-up. Of all fractures included, 24 (7.1%) required re-manipulation. Rates of manipulation between EM and orthopaedics were not compared, as there were major differences in fracture types between the groups, and many orthopaedic cases had internal fixation.
Unscheduled re-presentations to the ED occurred in 37 cases (10.9%). Cast complications accounted for 29 re-presentations (mostly due to a tight cast) and pain for 5 cases.
Were these outcomes predictable?
Univariate and multivariate analyses were performed to elicit factors associated with orthopaedic referral. The most convincing were midshaft fractures and completely displaced fractures (odds ratios 5.04 and 5.01). Increasing age and a higher degree of angulation were also more likely to be referred to orthopaedics (odds ratios 1.24 and 1.02). Angulated distal greenstick fractures were most likely to be successfully reduced by ED clinicians.
What does this mean?
This paper provides further evidence that EM reduction of forearm fractures is viable and effective, in keeping with previous studies. This could help encourage the adoption of EM reduction of forearm fractures for departments not currently performing this procedure, so adding high-quality evidence to this pool is valuable.
Rimbaldo’s team found that midshaft and completely displaced fractures were more likely to require orthopaedic involvement and that distal greenstick fractures were most likely to do well under EM management.
Limitations
This was a retrospective chart review study; this will always be inferior to prospective data collection due to the limitations of interpreting after-the-fact note-making, and some information will inevitably be lost.
It was also a single-centre study at the RCH, Melbourne. The RCH has a long history of fracture management and procedural sedation and has a skill mix that is more senior than many Paediatric EDs worldwide. These findings may not be generalisable to other Paediatric EDs.
A nice touch for this study would have been including the EM operator’s training level for fracture manipulation. The skill level of the operator may have a significant bearing on outcomes.
Keep manipulating paediatric forearm fractures in the ED, particularly if a distal greenstick
Consider involving Orthopaedics for the initial reductions of midshaft or completely displaced forearm fractures.
My perspective
Prof Dan Perry, Paediatric Orthopaedic Surgeon, Alder Hey Hospital, UK
This undoubtedly highlights the high quality of care that is going on in emergency departments worldwide – with prompt investigations and treatments that are preventing the need for admission and investigation.
However, perhaps a bigger question is which of these actually needs manipulation in the first place. The off-ended distal radius fractures were the most likely to be referred to orthopaedics for surgical treatment – though it is also these very fractures for which there is a growing body of evidence (amongst the under 11-year-olds) to demonstrate that complete remodelling is expected in a relatively short space of time (i.e. usually a few months).
“It’s only a quick push”, “It’s only a wire”, and “It’s a straightforward plating” is what we typically hear as justification for the procedures – but if it doesn’t make any difference, is it really necessary? If the bone slips back after manipulation and you accept the slipped position – shouldn’t you just have accepted it in the first place? If the wire gets infected and the child gets osteomyelitis (I’ve had two in 6 years as a consultant), can I really be happy with my treatment? Was the lifelong scar and second operation to remove that plate really needed?
The notion that parents won’t be prepared to accept deformity is actually often not true – by talking to parents, we often understand that their greater fears are around sedation/ anaesthesia rather than coping with temporary deformity.
So, what does this mean?
One joke about orthopaedic surgery (there are many!), if I have a hammer, then everything is a nail….don’t fall into this trap! Paediatric orthopaedic surgery is far cleverer, and growth is our friend! As paediatric emergency clinicians, learn to embrace and be excited about growth (just as much as you may be about giving sedation). Ultimately….consider whether the next manipulation in ED is for your benefit or the patients!
(Disclosure – check www.CRAFFTstudy.org for a really cool study about remodelling in kids)
Selected references
Betham C, Harvey M, Cave G. Manipulation of simple paediatric forearm fractures: a timebased comparison of emergency department sedation with theatre-based anaesthesia. The New Zealand medical journal. 2011;124(1344):46-53. Babl FE, Belousoff J, Deasy C, Hopper S, Theophilos T. Paediatric procedural sedation based on nitrous oxide and ketamine: sedation registry data from Australia. Emergency medicine journal : EMJ. 2010;27(8):607-12. doi:10.1136/emj.2009.084384
Khan S, Sawyer J, Pershad J. Closed reduction of distal forearm fractures by pediatric emergency physicians. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine. 2010;17(11):1169-74. doi:10.1111/j.1553-2712.2010.00917.x.
Milner D, Krause E, Hamre K, Flood A. Outcome of Pediatric Forearm Fracture Reductions Performed by Pediatric Emergency Medicine Providers Compared With Reductions Performed by Orthopedic Surgeons: A Retrospective Cohort Study. Pediatric Emergency Care. 2018;34(7):451-6. doi:10.1097/pec.0000000000001152.
Pace JL. Pediatric and Adolescent Forearm Fractures: Current Controversies and Treatment Recommendations. The Journal of the American Academy of Orthopaedic Surgeons. 2016;24(11):780-8. doi:10.5435/jaaos-d-15-00151.
Putnam K, Kaye B, Timmons Z, Wade Shrader M, Bulloch B. Success Rates for Reduction of Pediatric Distal Radius and Ulna Fractures by Emergency Physicians. Pediatr Emerg Care. 2019;36(2):e56-e60. doi:10.1097/pec.0000000000001691.
