Abstract
Background
Forearm fractures are among the most frequently encountered orthopedic injuries in
children. The maintenance of satisfactory alignment can be problematic and postreduction
displacement with resultant malunion can occur.
Objectives
The objective of the study was to evaluate pediatric emergency medicine (PEM) physicians’
performance on forearm fracture reduction to determine the impact of a Process Improvement
Intervention Program (PIIP) on postreduction displacement rates after initial reduction.
The PIIP was designed to improve our PEM physicians’ skills and knowledge in how to
properly apply and mold casts to better maintain the alignment of reduced forearm
fractures.
Methods
A PIIP was implemented during 2015–2016 when orthopedic surgeons mentored postfellowship-trained
PEM physicians. Patient cohorts from pre- and post-PIIP implementation were investigated
and compared to evaluate the impact of the PIIP on PEM physicians’ initial fracture
reduction success rates and postreduction displacement rates. Descriptive and analytical
statistics including univariate and multivariate models were tested to understand
changes in physicians’ performance.
Results
Pre- and postcohorts had similar demographic and clinical characteristics and similarly
high initial reduction success rates. When distal and midshaft fracture types were
combined, there was no significant difference in postreduction displacement rates
between the 2 cohorts, but when stratified based on fracture type, the distal radius
postcohort showed a statistically significant improvement in postreduction maintenance.
Conclusions
A PIIP by pediatric orthopedic surgeons did not change the PEM physicians’ initial
fracture reduction success rate, but it did result in a statistically significant
improvement in maintenance of reduction rates.
Keywords
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References
- The most frequent traumatic orthopaedic injuries from a national pediatric inpatient population.J Pediatr Orthop. 2005; 25: 39-44
- Incidence of childhood distal forearm fractures over 30 years: a population-based study.JAMA. 2003; 290: 1479-1485
- Epidemiology of fractures in children and adolescents.Acta Orthop. 2010; 81: 148-153
- Redisplacement after manipulation of distal radial fractures in children.J Bone Joint Surg Br. 1993; 75: 453-454
- Displaced fracture of the distal radius in children. Factors responsible for redisplacement after closed reduction.J Bone Joint Surg Br. 2005; 87: 841-843
- Remodeling of forearm fractures in children.J Pediatr Orthop B. 1999; 8: 84-87
- Reduction versus remodeling in pediatric distal forearm fractures: a preliminary cost analysis.J Pediatr Orthop B. 2003; 12: 109-115
- Distal radial fractures in children: risk factors for redisplacement following closed reduction.J Pediatr Orthop. 2015; 35: 224-228
- Is there still a place for cast wedging in pediatric forearm fractures?.J Pediatr Orthop. 2014; 34: 246-252
- ACGME program requirements for graduate medical education in pediatric emergency medicine. ACGME approved focused revision: effective: July 1, 2013.(Available at:)https://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/324_pediatric_emergency_medicine_2017-07-01.pdfDate accessed: December 8, 2018
- Pediatric fractures: temporal trends and cost implications of treatment under general anesthesia.Eur J Trauma Emerg Surg. 2012; 38: 59-64
- Manipulation of simple paediatric forearm fractures: a time-based comparison of emergency department sedation with theatre-based anaesthesia.N Z Med J. 2011; 124: 46-53
- Report Brief. The future of emergency care in the United States health system.National Academy of Sciences, Washington, DC2006
- Redisplacement after closed reduction of forearm fractures in children.J Pediatr Orthop. 1990; 10: 79-84
- Cast immobilization versus percutaneous pin fixation of displaced distal radius fractures in children: a prospective, randomized study.J Pediatr Orthop. 2005; 25: 490-494
- Pediatric distal radial fractures treated by emergency physicians.J Emerg Med. 2009; 37: 341-344
- Closed reduction of distal forearm fractures by pediatric emergency physicians.Acad Emerg Med. 2010; 17: 1169-1174
- Outcome of pediatric forearm fracture reductions performed by pediatric emergency medicine providers compared with reductions performed by orthopedic surgeons: a retrospective cohort study.Pediatr Emerg Care. 2018; 34: 451-456
- Risk of redisplacement after first successful reduction in paediatric distal radius fractures: sensitivity assessment of casting indices.J Pediatr Orthop B. 2011; 20: 376-381
- Both-bone midshaft forearm fractures in children.J Pediatr Orthop. 1986; 6: 306-310
- Displaced paediatric fractures of the distal radius.Arch Orthop Trauma Surg. 2008; 128: 55-60
- Risk factors in redisplacement of distal radial fractures in children.J Bone Joint Surg Am. 2008; 90: 1224-1230
- Risk factors for redisplacement of pediatric distal forearm and distal radius fractures.J Pediatr Orthop. 2012; 32: 687-692
- Short arm plaster cast for distal pediatric forearm fractures.J Pediatr Orthop. 1994; 14: 211-213
- Management of completely displaced metaphyseal fractures of the distal radius in children. A prospective, randomized controlled trial.J Bone Joint Surg Br. 2002; 84: 413-417
Article info
Publication history
Published online: June 20, 2019
Accepted:
April 20,
2019
Received in revised form:
April 17,
2019
Received:
February 12,
2019
Footnotes
Reprints are not available from the authors.
Identification
Copyright
© 2019 Elsevier Inc. All rights reserved.
