Written by Clay Smith
Over one quarter of children under 10 with distal radius fractures may be undergoing sedation and fracture reduction unnecessarily.
Why does this matter?
If the degree of coronal or sagittal angulation is <20 degrees and shortening <1cm, it is debatable whether or not younger children benefit from fracture reduction. Younger children can remodel after injury, and perfect initial anatomic alignment is not needed to heal and preserve function. Are kids with milder angulation or shortening undergoing needless sedation and reduction?
Man, that arm is jacked up
This was a retrospective review of patients under age 10, with distal radius fractures, to determine the rate of potentially inappropriate sedation and closed reduction. Of 258 children, 142 underwent reduction (55%). Of these 142, 38 (27%) were potentially unnecessary based on review of the radiographs. Patients who were transferred to the facility had twice the odds of reduction. Keep in mind, this was single center and retrospective. But it was written by experts – orthopedic surgeons. Finally, consider the example given of a potentially avoidable reduction. Would you be comfortable not reducing this?
Although there is a defined standard of acceptable angulation and shortening, it is very difficult to accept a visible deformity and simply splint it in situ. However, clearly there is room for improvement, and fewer children may need reduction than at present. There is risk with sedation and closed reduction: 7% adverse sedation events in this study – all mild hypoxia or apnea. In addition, reduction increased cost ($7,000 more) and ED length of stay (2 hours more). If outcomes are the same, then in select cases a simple splint or cast, without sedation and fracture reduction, would be better.
Resource Utilization for Patients With Distal Radius Fractures in a Pediatric Emergency Department JAMA Netw Open. 2020 Feb 5;3(2):e1921202. doi: 10.1001/jamanetworkopen.2019.21202. DOI: 10.1001/jamanetworkopen.2019.21202
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