101 Adherence to evidence-based care of distal forearm buckle fractures in a tertiary care pediatric emergency department

Abstract

Pediatric buckle fractures of the distal forearm are a common reason for emergency department (ED) visits. Evidence has clearly demonstrated that a removable splint is as good as a circumferential cast for treatment of these injuries, and may be superior with respect to patient preference and return to activity. Children should be instructed to wear the splint for comfort only, without a specific duration of wear. These injuries are safely managed without primary care physician (PCP) or orthopedic follow-up. Our objective was to assess the adherence to evidence-based recommendations for isolated distal forearm buckle fractures in a tertiary care pediatric ED. Our primary outcome was the proportion of patients treated with a splint. Secondary outcome measures were the proportion of patients a) instructed to wear the splint for comfort only without a specific duration of wear, and b) receiving instructions for no required follow up. A retrospective chart review of all children < 18 years presenting to a pediatric ED between May 1 to July 31, 2017 was conducted. We identified children with fractures of the forearm using ICD-10 codes (S52.500, S52.580, S52.590, S52.600 and S52.800). The electronic medical record was reviewed to identify patients with isolated buckle fractures of the radius and/or ulna as diagnosed by the ED physician and confirmed by radiology report. Of the 274 patients identified by ICD-10 code, 83 had an isolated distal forearm buckle fracture. 93% were treated with a removable splint, and 7% received a cast. For splint wear instructions, 29% were told to wear as needed for comfort, 47% were told to wear continuously and 24% had no documentation of splint instructions. Of children who were told to wear the splint continuously, 6% were instructed to wear it for 7 days, 6% for 10 days, 39% for 14 days, and 49% for ≥ 21 days. 48% of patients were asked to follow up with their PCP, 10% were referred to orthopedics and 31% were told no follow-up was required. Only 17% of patients were managed with all 3 recommendations for evidence-based care. Although good evidence for management of isolated buckle fractures has existed for over a decade, adherence to evidence-based care in our centre varied by measure, ranging from 29% to 93%. Only 17% of patients were managed with full adherence to recommendations. This data lays a foundation for targeted quality improvement initiatives in this area.