ED management of distal radial fractures in children
Distal radial fractures are among the most common fractures in childhood, and are a frequent presenting complaint in the emergency department. Traditionally, ED management of displaced distal radial fractures in children has included closed reduction and splinting of displaced fractures, usually under sedation. While generally safe when proper monitoring is used, procedural sedation nonetheless carries risks of respiratory depression, hypoxia, hypotension, vomiting, and emergence reactions.1 In addition, procedural sedation is time- and labor-intensive, resulting in longer lengths of stay for patients and sequestering physicians and nursing staff away from seeing other patients, which can backlog even the most efficiently run ED. Therefore if a fracture can be managed effectively without procedural sedation, it would be welcome news both for patients and busy emergency departments everywhere.
Fig. 1: Radiographs of a nine-year-old patient with overriding distal radial fracture and ulnar metaphyseal fracture.
Data suggests that many displaced and angulated distal radial fractures in children do not require anatomic reduction to achieve good outcomes. Children have tremendous remodeling potential in their bones, with younger age and proximity to growth plates corresponding to greater degree of remodeling. Because growth plates begin to close at puberty, young children with more years of bone growth ahead of them exhibit greater remodeling potential than do older children. In addition, the distal forearm is a particularly “forgiving” area for fractures, and greater degrees of displacement and angulation can be tolerated. This is due to its proximity to the highly biologically active growth plates of the distal radius and ulna, which are responsible for 75% and 81% of the longitudinal growth of each bone, respectively.2
Fig. 2 [L]: Radiographs after splinting.
Note that overriding fragment has not been reduced, but dorsal angulation is improved.
A recent study published in Journal of Bone and Joint Surgery suggests that the usual ED management of children with displaced distal radial fractures – procedural sedation and closed reduction – may not be necessary. Crawford et al prospectively followed 51 consecutive patients aged 3 to 10 years with closed overriding distal radial shaft fractures.3 Children were excluded if they had open fractures, fractures through the growth plate, neurovascular injury, metabolic bone disease, or multiple injuries. Fractures were treated with simple casting and only gentle pressure to correct angulation. No sedation, analgesia, or fracture reduction was performed. The results? At one-year follow-up, all patients had full range of wrist motion and all parents reported they were satisfied with treatment. A secondary cost analysis demonstrated that closed reduction with either procedural sedation or general anesthesia in the OR was five to six times more expensive than the treatment used in this study.
Fig. 3 [R]: Radiographs after 6 weeks of cast immobilization.
Note callous formation and early remodeling.
The findings of another study mirror these results. Do et al performed a retrospective review of 34 skeletally immature children who had redisplacement of their distal radial fractures following closed reduction.4 They were allowed to heal with up to 1 cm of radial shortening and up to 15 degrees of angulation. All patients had complete recoveries with return to normal level of activities without restriction, pain, or stiffness. A secondary cost analysis projected a 50% cost savings which would result from avoided closed reduction.
Fig. 4: Follow-up radiographs 2 years after injury. (Reprinted with permission)
So which fractures can be managed without procedural sedation and closed reduction? Clearly, open fractures, fracture-dislocations, neurovascular injury, and high-grade growth plate injuries need emergent orthopedic evaluation. Uncomplicated distal radial fractures, even if completely displaced, can be managed with simple splinting and orthopedic follow-up provided they do not have excessive angulation or rotational deformity. UpToDate offers age-related guidelines for allowable degrees of angulation in distal radial fractures: For children less than age 5, up to 35 degrees of angulation is allowable, for age 5-10, up to 25 degrees, and for age greater than 10, up to 20 degrees of angulation.5 Tintinalli offers slightly more conservative values, stating that children age 8 or younger with up to 15-20 degrees of angulation, and children older than 8 with up to 10 degrees of angulation, can be managed without closed reduction.6 Unlike angulation, rotational deformity does not heal as well, and thus fractures with rotational deformity may require reduction.7
In summary, in the management of distal radial fractures, patients with open fractures, neurovascular compromise, fracture-dislocations, or Salter-Harris type III, IV or V injuries require emergent orthopedic evaluation in the ED. Those with displaced fractures but an allowable age-related degree of angulation can be managed by splinting and outpatient follow-up, with a courtesy call to the orthopedist on call to confirm this plan. Patients with excessive angulation or rotational deformity should undergo closed reduction under sedation in the ED, performed either by an experienced emergency physician or an orthopedic surgeon.
References
1. Cote CJ, Karl HW, Notterman DA, Weiberg JA, McCloskey C. Adverse sedation events in pediatrics: analysis of medications used for sedation. Pediatrics. 2000;106:633-44.
2. Noonan, KJ, Price CT. Forearm and distal radius fractures in children. J Am Acad Orthop Surg. 1998;6:146-56.
3. Crawford SN, Lee LSK, Izuka, BH. Closed treatment of overriding distal radial fractures without reduction in children. J Bone Joint Surg Am 2012;94:246-52.
4. Do TT. Strub WM, Foad SL, Mehlman CT, Crawford AH. Reduction versus remodeling in pediatric distal forearm fractures: a preliminary cost analysis. J Pediatr Orthop B 2003;12(2):109-15.
5. Schweich P, Wang J. Initial management of distal forearm fractures in children. UpToDate. Available at http://www.uptodate.com/contents/initial-management-of-distal-forearm-fractures-in-children?source=search_result&search=distal+radial+fractures&selectedTitle=2%7E24. Accessed March 26, 2012.
6. Hopkins-Mann C, Ogunnaike-Joseph, D, Moro-Sutherland D. Musculoskeletal Disorders in Children. In Tintinalli’s Emergency medicine: A Comprehensive Study Guide. 7th Ed. Tintinal
li JE, Ed. New York, McGraw Hill, 2001:899-900.
7. Rodriguez-Merchan, EC. Pediatric fractures of the forearm. Clin Orthop Relat Res 2005;432:65-72.
2 Comments
What about the concept of splinting a fracture and having the patient follow up with an orthopedist within 48 hours to consider reduction and casting? One should be able to reduce a fracture even up to a week after the injury, and circumferential plaster might be safer to place after acute inflammatory edema and hematoma have some time to partially resolve. This also allows the orthopedist a chance to sleep at night, and decrease resource utilization in the ED associated with attempted (and occasionally unsuccessful anyway) reduction under sedation.
I began my training as a surgical intern so covering the Ortho Cast room was part of my scut work at night which I enthusiastically relished. Few procedures are as satisfying as crunching action of reducing an ankle fracture or various hand deformities. We had an ortho tech but nobody to perform procedural sedation. So hematoma blocks became the hammer for each of these nails. Later during EM training I learned how to perform Bier blocks and you name it in terms of cocktails for procedural sedation. Many years later as a community doc during a busy fast track shift my go to reduction is a hematoma block. Quick, effective, tolerable by even a three year old, you get an immediate reduction; and the parent, patient, and importantly the consulting Orthopod are all thankful. The RVUs are sufficient to pay for college so why pass up the opportunity to take two broken ends and put them together. Yes eventually they heal well either way but patient/parent satisfaction in the ED is important and I don’t have time to read letters ( and then respond) complaining that the doctor did nothing except put a bandaid over the broken bones. Even in the cited article one of the 54 eligible patients left seeking treatment elsewhere. Just think of the number of letters and complaints that adds up to each year (good luck keeping your contract). What this article serves is as a reminder that you don’t need a perfect reduction every time and failed reductions could be splinted and sent to the office. Most importantly there is an immediate reduction in pain with this block and while temporary it is always welcomed.