Paediatric forearm fractures manipulated in the emergency department: incidence and risk factors for re-manipulation under general anaesthesia.

Abstract

Re-manipulation of paediatric forearm fractures under general anaesthetic may be required following inadequate closed reduction under conscious sedation. Manipulation under general anaesthetic carries significant inherent risks and is preferably avoided. We assessed one institution's experience with paediatric forearm fracture reduction and investigate the incidence of re-manipulation under general anaesthetic of fractures initially managed under conscious sedation without fluoroscopy. All paediatric forearm fractures presenting to the children's emergency department of our national children's hospital between 1 January 2019 and 30 June 2019 were studied. Radius and ulna fractures were categorised according to fracture location (distal third, middle third, proximal third), any associated injury, and any plan to proceed to the operating room that was documented prior to manipulation in the emergency department. Univariate and multivariate statistical analysis was carried out to test for differences between discrete and continuous data and odds ratios were calculated. Three-hundred and nine patients presented during the study period with 267 being eligible for analysis. Fifteen point seven percent (42/267) required fracture manipulation in the operating theatre following initial reduction in the children's emergency department. Independent risk factors associated with significantly higher rates of failed reduction under conscious sedation (p<0.001-0004) were patients who had a delay in presentation to hospital, were older, or had a non-distal fracture site. There are higher rates of re-manipulation under general anaesthetic in children presenting to the emergency department of our national children's hospital with forearm fractures than seen in comparative international studies. Risk factors which predict an inadequate initial reduction and interventions to improve this are discussed.