Closed Reduction of Distal Forearm Fractures by Pediatric Emergency Medicine Physicians: A Prospective Study
Condition: Pediatric Distal Forearm Fractures
MeSH terms: Emergencies; Fractures, Bone
Study type: Interventional

Summary: 
      Distal forearm fractures are amongst the most frequently encountered orthopedic injuries in
      the pediatric emergency department (ED). Immediate closed manipulation and cast
      immobilization, is still the mainstay of management. The initial management of non-displaced
      or minimally displaced extremity fractures and relocation of uncomplicated joint dislocations
      is part of the usual practice of emergency medicine. Although focused training in
      fracture-dislocation reduction techniques is a part of the core curriculum of emergency
      medicine training programs, there is limited data discussing outcomes following restorative
      fracture care by pediatric emergency medicine (PEM)physicians.

      The primary objective of this study is to compare length-of-stay and clinical outcomes after
      closed manipulation of uncomplicated, isolated, distal forearm fractures, by PEMs to those
      after manipulation by pediatric orthopedic surgeons. Our hypothesis is that there is no
      difference in emergency department length-of-stay when fracture reduction is performed by a
      PEM versus a post graduate year 3 or 4 orthopedic resident. Secondary outcomes that will be
      assessed include: loss of reduction needing re-manipulation at follow up, cast related
      complications, radiographic and functional healing at 6-8 weeks post injury.
    

Detailed description: 
      Pediatric forearm fractures are common injuries and a frequent cause for an emergency room
      admission. Ward et al have outlined the demands that emergency department coverage places on
      practicing orthopedic surgeons. Assuming no statistically significant differences in
      outcomes, there are potential advantages of having PEMs provide restorative fracture care at
      the initial visit. This practice would permit judicious orthopedic consultation at a time
      when several emergency department's are facing an "on call" specialist coverage crisis and
      there exists a nationwide shortage of fellowship trained pediatric orthopedic specialists, in
      addition to ACGME mandated duty hour restrictions for orthopedic residents.

      Pershad et al conducted a retrospective study with historical controls, of 60 patients with
      distal radius fracture that were reduced by an orthopedic resident or PEM physician. In this
      review, there were no differences in rates of re-intervention to restore fracture alignment
      or ED length-of-stay between the two groups.Mean facility charges were lower in the group
      treated by PEMs.

      It is our hypothesis that with goal directed training, PEM physicians can perform closed
      reduction of uncomplicated distal forearm fractures with outcomes that are similar to when
      fracture reduction is performed by senior orthopedic resident physicians.
    

Intervention name(s): Distal Forearm Fracture Reduction
Intervention type(s): Procedure
Intervention description(s): Fracture reduction
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Single (Investigator)
Primary purpose: Health Services Research
Keywords: Pediatrics; Distal Forearm fractures; Pediatric Emergency Medicine; Pediatric Orthopedics