Distal Radius Buckle Fractures Research Articles

Volar Distal Radius Buckle Fractures: Is Bracing and Home Management Safe?

A removable brace with home management is widely accepted treatment for distal radius buckle fractures, which most commonly involve the dorsal cortex. The purpose of this study is to determine if a removable brace and home management treatment is safe for volar distal radius buckle fractures. Isolated distal radius buckle fractures in children (3-16 years) diagnosed at an acute care visit (April 1, 2019 to May 31, 2022) were identified. Final diagnosis was confirmed using strict criteria including cortical buckling without cortical breach or physeal involvement. Cortical buckling was categorized as either dorsal or volar. Demographic data, mechanism of injury, treatment, and any complications were recorded and analyzed. Three hundred thirty-three fractures were either dorsal (254, 76%) or volar (79, 24%) buckle fractures. Mean age (SD) for volar fractures (9.3 [2.2 years]; range, 4-14 years) was significantly higher than for dorsal fractures (8.5 (3.0 years); range, 3-15 years; P = 0.012). More girls had volar fractures (48 [60%], P = 0.006). Most fractures occurred after a standing-height fall. Two hundred forty-four (96%) dorsal and 76 (96%) volar fractures were initially treated with a removable brace. Two hundred fourteen (84%) dorsal and 66 (84%) volar fractures had orthopedic follow-up. Brace treatment continued for 167 (167/204, 82%) dorsal and 56 (56/63, 89%) volar fractures. Treatment changed from initial brace to cast for 37 (37/204, 18%) dorsal fractures and 7 (7/63, 11%) volar fractures, influenced by caregiver preference and/or sport participation requirements. Only 1 (1/79, 1%) patient with a volar fracture returned for an additional visit for persistent pain. When diagnosis of volar buckle fracture is made using the same strict criteria used for dorsal buckle fractures, removable brace and home management treatment is safe. Shared decision making with caregivers may alter buckle fracture treatment.

Enhancing Patient Management and Financial Efficiency: Adherence to National Institute for Health and Care Excellence (NICE) Guidelines for Pediatric Distal Radius Buckle Fractures.

Pediatric distal radius buckle fractures are commonly encountered in the emergency department (ED) and are considered non-complex and stable injuries. The National Institute for Health and Care Excellence (NICE) guidelines recommend managing these fractures with a soft cast and discharging patients directly from the ED. However, prevailing practices often involve rigid casts and follow-up clinic visits, leading to unnecessary congestion, prolonged waiting times, excessive radiographic examinations, and frequent cast changes, resulting in additional financial burdens on hospitals. We conducted an initial audit over a 6-month period at Hull University and Teaching Hospitals, reviewing 184 pediatric distal radius fractures, of which 84 were buckle fractures in children under 12 years old. Data on demographics, subsequent clinic visits, treating doctor's grade, additional radiographs, initial and final treatment approaches, and cast change frequency were collected. After the initial audit, NICE guideline compliance was promoted through the education of parents and healthcare providers. A second audit was performed on patients within the following 6-month period. This study assessed the management of pediatric distal radius buckle fractures in a cohort of 84 patients. 39/84 (46.4%) of patients sought medical attention within one week of sustaining the injury, with 33/84individuals being discharged during their first visit, either by consultants or registrars. Most patients (69/84) required only a single X-ray examination in the ED, while some needed two or three X-rays during their evaluation. However, after implementing NICE guidelines, in the second audit cycle,62 out of 64 were discharged directly from the ED, with 42 receiving focal rigidity casts (FRCs) removed at home and 10 discharged with simple crepe bandages. Conclusions: This closed-loop audit effectively showcased that adherence to NICE guidelines yielded better patient management by avoiding unnecessary visits, radiographs, and platers. The adoption of the guidelines leads to the conservation of time and resources.

Return to sport after forearm fractures in children: A scoping review and survey.

A common question faced by clinicians is when a child may return to sport after treatment for a pediatric forearm fracture. There are few published recommendations and fewer supported by evidence. The aims of this study were to summarize existing published recommendation for return to sport after pediatric forearm fractures and to conduct a survey to determine usual clinical recommendations. A scoping review was performed on Ovid MEDLINE, Cochrane Central Register of Controlled Trials, Embase, Scopus, and Google Scholar in accordance with the Joanna Briggs Institute guidelines. In addition, 64 orthopedic surgeons were anonymously surveyed asking for recommendations regarding return to sport after pediatric forearm fractures. Participants were to assume children were 9 years old and played a sport with an average risk of forearm injury. Twenty-two publications for return to sport were retrieved. Children with distal radius buckle fractures safely commonly returned to sport by 4 weeks after initial injury, while survey respondents recommended over 6 weeks. Survey respondents valued fracture stability the highest when making return to sport recommendations. Children with simple, metaphyseal, single-bone fractures were usually allowed to return to sport at 8-10 weeks post-injury. Diaphyseal and complete fractures were prescribed longer return to sport intervals. Australian respondents also prescribed longer return to sport intervals. Children with distal radius buckle fractures may return to sport by 4 weeks after initial injury, sooner than recommended. Published recommendations remain limited for other fractures. However, our survey suggests children with simple, metaphyseal, single-bone fractures may return to sport at 8-10 weeks. Children with diaphyseal and complete fractures should abstain from sport for longer than metaphyseal and greenstick fractures, respectively. level V.

Children’s orthopaedics

The February 2023 Children’s orthopaedics Roundup360 looks at: Trends in management of paediatric distal radius buckle fractures; Pelvic osteotomy in patients with previous sacral-alar-iliac fixation; Sacral-alar-iliac fixation in patients with previous pelvic osteotomy; Idiopathic toe walking: an update on natural history, diagnosis, and treatment; A prediction model for treatment decisions in distal radial physeal injuries: a multicentre retrospective study; Angular deformities after percutaneous epiphysiodesis for leg length discrepancy; MRI assessment of anterior coverage is predictive of future radiological coverage; Predictive scoring for recurrent patellar instability after a first-time patellar dislocation.

Trends in Management of Pediatric Distal Radius Buckle Fractures.

Distal radius buckle fractures (DRBFx) represent nearly half of the pediatric wrist injuries. DRBFx are stable injury patterns that can typically be successfully managed with brief immobilization. The purpose of this study was to evaluate opinions and preferences of pediatric orthopaedic specialists regarding the management of DRBFx. The POSNA Trauma Quality, Safety, and Value Initiative (QSVI) Committee developed a 20-question survey regarding the treatment of DRBFx in children. The survey was sent twice to all active and candidate POSNA members in June 2020 (n=1487). Questions focused on various aspects of treatment, including type and length of immobilization, follow-up, and radiographs and on potential concerns regarding patient/family satisfaction and pain control, medicolegal concerns, misdiagnosis, and mismanagement. A total of 317 participants completed the survey (response rate=21.3%). In all, 69% of all respondents prefer to use a removable wrist splint, with 76% of those in practice <20 years preferring removable wrist splints compared with 51% of those in practice >20 years (χ 2 =21.7; P <0.01). Overall, 85% of participants utilize shared decision-making in discussing management options with patients and their families. The majority of participants felt that the risk of complications associated with DRBFx was very low, but concern for misdiagnosis and mismanagement have required some respondents to perform closed or open reductions. In 2020, the majority of respondents treat DRBFx with removable splints (69%) for 3 or fewer weeks (55%), minimal follow-up (85%), and no reimaging (64%). This marks a dramatic shift from the 2012 POSNA survey when only 29% of respondents used removable splinting for DRBFx. Level II.

A Review of Pediatric Distal Radius Buckle Fractures and the Current Understanding of Angled Buckle Fractures.

Distal radius buckle fractures (DRBFs) are the most common pediatric fractures and resemble the rounded portion of a Greek pillar or torus. They result from compressive forces applied to a child’s highly plastic radius. DRBFs lack cortical and physeal disruption, which makes them relatively stable. In this review, we discuss angled DRBFs, a hypothesized subset of buckle fractures that results from an off-center compressive force. Some authors refute the existence of angled DRBFs, instead proposing new criteria for DRBF classification: measuring more than 1 cm away from the physis with two to three inflection points. Without universal diagnostic criteria, misdiagnosis is common, and the utilization of flexible treatment modalities is infrequent. Rigid immobilization with short-arm casting continues to be the mainstay of treatment in clinical practice. Yet, new protocols implementing removable elastic bandages have had comparable results to casting, including reduced healthcare expenditure, less stiffness, and improved convenience and patient tolerability. Despite the discrepancies in categorizing DRBFs, complication rates remain low, and diagnostic confusion insignificantly affects clinical outcomes. Angled DRBFs have been theorized to have intraphyseal extension, making them unstable Salter-Harris fractures. Radiographic evidence supporting or denying this claim is limited. Further research is essential to determine the stability of the angled DRBF subtype and whether they should continue to be defined and managed as buckle fractures.

Pediatric Orthopedic Trauma Care During the COVID-19 Pandemic: A Survey of the Pediatric Orthopedic Society of North America.

Background: The COVID-19 pandemic has dramatically altered the practice of pediatric orthopedic trauma surgery in both outpatient and inpatient settings. While significant declines in patient volume have been noted, the impact on surgeon decision-making is unclear. Purpose: We sought to investigate changes in pediatric orthopedic trauma care delivery as a result of COVID-19 and determine their implications for future orthopedic practice. Methods: An electronic survey was distributed to all members (N = 1515) of the Pediatric Orthopedic Society of North America (POSNA) in March to April 2021; only members who provided care for pediatric orthopedic trauma patients were asked to complete it. The survey included questions on hospital trauma call, inpatient care, outpatient clinic practice, and 3 unique fracture case scenarios. Results: A total of 147 pediatric orthopedic surgeons completed the survey, for a 9.7% response rate, with 134 (91%) taking trauma call at a hospital as part of their practice. Respondents reported significant differences across institutions regarding COVID-19 testing, hospital rounding, and employee COVID-19 screening. Changes in outpatient fracture management were observed, including a decreased number of follow-up visits for nondisplaced clavicle fractures, distal radius buckle fractures, and toddler's fractures. Of respondents who changed their fracture follow-up schedules due to COVID-19, over 75% indicated that they would continue these outpatient treatment schedules after the pandemic. Conclusions: This survey found changes in pediatric orthopedic trauma care as a result of the COVID-19 pandemic. The use of telemedicine and abbreviated follow-up practices for common fracture types are likely to persist following the resolution of the COVID-19 pandemic.

Impact of Cost Information on Parental Decision Making: A Randomized Clinical Trial Evaluating Cast Versus Splint Selection for Pediatric Distal Radius Buckle Fractures.

Price transparency purports to help patients make high-value health care decisions, however, there is little data to support this. The pediatric distal radius buckle fracture (DRBF) has 2 equally efficacious but not equally priced treatment options (cast and splint), serving as an excellent potential model for studying price transparency. This study uses the DRBF model to assess the impact of up-front cost information on a family's treatment decisions when presented with clinically equivalent treatment options for a low-risk injury. Participants age 4 to 14 presenting with an acute DRBF to a hospital-based pediatric orthopaedic clinic were recruited for this randomized controlled trial. Participants were randomized into cost-informed or cost-blind cohorts. All families received standardized information about the injury and treatment options. Cost-informed families received additional cost information. Both groups were allowed to freely choose a treatment. Families were surveyed regarding their decision factors. Cost-blinded families were subsequently presented with the cost information and could change their decision. Independent samples t tests and χ2 tests were utilized to evaluate differences. A total of 127 patients were enrolled (53% cost-informed, 47% cost-blind). The 2 groups did not significantly differ in demographics. Immobilization selection did not differ between groups, with 48% of the cost-informed families selecting the more expensive option (casting), compared with 47% of the cost-blind families. Cost was the least influential factor in the decision-making process according to participant survey, influencing only 9% of families. Only one family changed their decision after receiving cost information, from a splint to a cast. Families appear to be cost-insensitive when making medical treatment decisions for low-risk injuries for their child. Price transparency alone may not help families arrive at a decision to pursue high-value treatment in low-risk orthopaedic injuries. Level I.

Follow-Up Care of Distal Radius Buckle Fractures

Source: Colaco K, Willan A, Stimec J, et al. Home management versus primary care physician follow-up of patients with distal radius buckle fractures: a randomized controlled trial. Ann Emerg Med. 2021;77(2):163-173; doi:10.1016/j.annemergmed.2020.07.039Investigators from the University of Toronto conducted a randomized controlled trial to assess outcomes associated with home management versus physician follow-up in children with distal buckle fractures. Children were eligible if they were 5-17 years old and were diagnosed in the study ED within the previous 3 days with a distal radius buckle fracture during the 2018-2019 study period. The standard management for all patients diagnosed with a distal buckle fracture at the study ED is a removable splint. All participants completed a demographic survey at enrollment as well as a baseline modified Activities Scale for Kids-38 (ASKp38) scale that assessed wrist function the week before injury (with the average score for patients with no disabilities being 95%).Participants were randomized to either removal of the splint at home with physician follow-up as needed or to see their primary care physician 1-2 weeks after the ED visit. All participants were advised to wear the splint continuously (except for bathing) for the first week and then as needed to manage pain or swelling symptoms. All participants were advised to restrict activities that could lead to reinjury for 6 weeks.The primary outcome was ASKp38 scores at 3 weeks post-ED visit, assessed via telephone. A secondary outcome was health care resource use and parental expenses related to the child’s injury, assessed by parent report at 3 and 6 weeks post-ED visit and medical records. Total patient health care costs were estimated by multiplying health care resources data by corresponding unit prices. The investigators assessed outcomes by allocation arm using an intention-to-treat analysis.There were 149 participants enrolled, 73 in the home management group and 76 in the primary care physician follow-up group. Follow-up was completed for 90.4% of participants in the home management group and 88.2% of the physician follow-up group at 3 weeks, and 89% and 86.8%, respectively, at 6 weeks. There were no significant differences in baseline demographics or baseline ASKp38 scores. Mean ASKp38 scores at 3 weeks were similar between both groups (95.4% and 95.9% in the home management and physician follow-up groups, respectively). Total mean healthcare and parent costs in the physician follow-up group were greater than in the home management group ($149.10 vs $26.80, respectively).The investigators conclude that home removal of splints for distal buckle fractures is noninferior to physician follow-up and less costly.Dr Bechtel has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.Buckle (torus) fractures of the distal radius are the most common fractures in children.1 There are many ways these fractures can be managed, as they are very stable and have an excellent prognosis. Primary care physicians are becoming the standard of care for follow-up of buckle fractures instead of orthopedic or fracture clinic follow-up. Primary care physician follow-up for distal forearm buckle fractures has demonstrated excellent recovery and management mainly based on patient symptoms rather than frequent radiographic follow-up common to orthopedists or fracture clinics.2 The current investigators sought to determine whether symptomatic home management versus primary care provider follow-up of torus fractures had equivalent functional outcomes in children managed with a removable splint.Indeed, the authors did find that home management was just as efficacious as primary care provider follow-up in terms of functional use scores at 3 weeks. Notably, children who were managed at home had even lower costs and fewer follow-up radiographs obtained than children who had follow-up with their primary care provider. There are, however, 2 significant limitations of the current study that should be noted. The first is that most of the population had post-secondary school education and telephone and electronic access and had a primary care provider. Thus, extrapolating the results to a different population (eg, lower parental education, lack of telephone access or a primary care provider) is not possible at this time. The second limitation is that the population was also primarily English-speaking, so it is likely not practical to expect similar results in a non-English speaking population of caregivers based on the current study.In English-speaking families with telephone and electronic access and a primary care physician, at-home management of children with torus fractures with a removable splint is less costly and just as efficacious as follow-up with a primary care physician.The benefits that accrue with home splint removal are potentially more than financial. Parental time away from employment or other priorities, as well as school absence by affected children, are obviated by home management of distal radius fractures.

Home Management Versus Primary Care Physician Follow-up of Patients With Distal Radius Buckle Fractures: A Randomized Controlled Trial

In patients with a distal radius buckle fracture, we determine whether home removal of a splint and physician follow-up as needed (home management) is noninferior to primary care physician follow-up in 1 to 2 weeks with respect to functional recovery. We also compare groups with respect to health care and patient-level costs. This was a noninferiority randomized controlled trial conducted at a tertiary care children's hospital. Eligible patients were randomized to home management versus primary care physician follow-up and received telephone contact at 3 and 6 weeks after the index ED visit. Functional recovery was measured with the Activities Scale for Kids-performance, and participants reported wrist-injury-related health care interventions and expenses. The primary outcome was a comparison of the performance score between groups at 3 weeks. We enrolled 149 patients with mean age 9.5 years (SD 2.7 years), and 81 (54.4%) were male patients. Of the 133 patients (89.3%) with completed 3-week follow-up, the mean Activities Scale for Kids-performance score was 95.4% in the home management group (n=66) and 95.9% in the primary care physician follow-up group (n=67) (mean difference -0.4%; lower bound of the 95% confidence interval -2.4%). There was a mean costs savings of -$100.10 (95% confidence interval -$130.0 to -$70.20) in health care and -$28.2 (95% confidence interval -$49.6 to -$7.0) in patient costs in the home management versus primary care physician follow-up group. In patients with distal radius buckle fractures, home management is at least as good as primary care physician follow-up with respect to functional recovery. Implementation of the home management strategy also demonstrated significant cost savings.

The single visit treatment of pediatric distal radius buckle fractures–A center's experience with the treatment algorithm

IntroductionThis descriptive study aims to review and evaluate the implementation of a single visit treatment protocol for pediatric distal radius buckle fractures at our center - its success, learning points and limitations. It hopes to raise awareness of the efficacy of the protocol and its benefits to promote its utilization. MethodsFollowing a pilot study, the protocol was implemented from 1 March 2017. A retrospective review of clinical records over 2 years since implementation for patients with a new-visit diagnosis of "distal radius buckle fracture" was conducted. Data collected included age at time of injury, gender, side of injury, whether the patient was enrolled into the protocol, number of clinic visits, and number of radiographic examination(s) performed. Each record was reviewed up to 3 months post-injury to check for any complications or return visits. Costs of specific treatment interventions were also obtained from the hospital's finance department. Results286 patients with buckle fractures of the distal radius eligible for enrolment into the single visit treatment protocol were identified. Of these, 202 patients (70.6%) were enrolled and managed with the protocol, while 84 patients (29.4%) were treated with conventional management. Of the 202 protocol-managed patients, all fractures healed without complications. Only 4 patients returned for additional clinic visits. Another 4 patients had additional X-rays taken on top of their initial injury film. A breakdown of expenses for treatment also showed cost savings of USD 110.67 and USD 320.80 for residents and non-residents respectively for single visit treatment. ConclusionSingle visit treatment of pediatric distal radius buckle fractures is recommended and supported by evidence, with advantages of convenience, cost reduction, and being less labor intensive.

The Diagnostic Accuracy of Ultrasound in Detecting Distal Radius Fractures in a Pediatric Population

Objective: Sports ultrasound (US) is becoming popular in diagnosing musculoskeletal injuries. This study, also called the Pediatric Distal Radius Ultrasound Study (PeDRUS), compared the diagnostic accuracy of sports US with plain radiographs in possible distal radius buckle fractures in pediatric population. Methods: In this prospective observational study, patients (2-15 years) presenting to an outpatient orthopedic injury clinic with distal forearm injuries without deformity were recruited. Bedside ultrasonography was performed and interpreted by the investigators as positive or negative for fracture. Plain radiographs were then performed and interpreted by the same investigator. The radiographs were considered the definitive imaging study for this investigation. Results: Fifty-one patients were included with a mean age of 9.9 years. Fractures were diagnosed on both US and plain radiographs in 34 patients. Fractures were ruled out on both US and plain radiographs in 16 patients. There was only one case in which the US was interpreted differently than radiograph. For fractures of the distal radius in this population, the sensitivity was 97.1% [95% confidence interval (CI) = 89.2-97.1] and the specificity was 100% (95% CI = 82.5-100). The positive predictive value was 100% (95% CI = 91.8-100), whereas the negative predictive value was 94.1% (95% CI = 77.7-94.1). The positive likelihood ratio was infinite, suggesting utility in confirming a fracture. The negative likelihood ratio was 0.03 (95% CI = 0.03-0.13), suggesting that US has value in ruling out a fracture. Conclusions: Our study suggests that diagnostic sports US is sensitive and specific for detecting distal radius fractures in pediatric patients with nondeformed forearm injuries, demonstrating that US is an acceptable alternative to plain radiographs for evaluating fractures in a pediatric population.

Increasing Brace Treatment for Pediatric Distal Radius Buckle Fractures: Using Quality Improvement Methodology to Implement Evidence-based Medicine.

Multiple randomized trials have showed equivalent outcomes and improved patient/family satisfaction using a removable brace to treat pediatric distal radius buckle fractures (DRBF). We tested the hypothesis that we could use quality improvement (QI) methodology to increase the proportion of patients with DRBF treated with removable braces at 2 tertiary care orthopaedic clinics from a baseline of 34.8% to 80%. Clinic billing records were reviewed monthly to determine treatment (brace vs. cast) of DRBF and tracked using control charts (p-chart). Balance measures including correct application of the diagnostic criteria and algorithm were monitored. Process measures including the number of follow-up visits, radiographs obtained, and total cost of treatment were collected. Baseline data were obtained over a 3-month period, followed by a 12-month period of interventions using Plan-Do-Study-Act cycles targeting both individuals and groups of providers. The proportion of DRBF treated in a brace increased from a combined baseline of 34.8% to a combined 84% at the end of the study period. Following intervention, 83% (15/18) of providers began using braces for a majority of patients (defined as >67%), with only 1 provider continuing to use casts 100% of the time. Patient preference was cited as the most common reason for use of cast treatment. There was a significant decrease in the number of radiographs obtained at 1 of 2 institutions. The charges for brace treatment averaged $630 less per patient than for cast treatment, leading to an estimated medical-cost savings of $205,000 following intervention. Implementation of brace treatment for pediatric DRBF using QI methodology resulted in a shift toward brace treatment in the majority of patients, leading to substantial medical and nonmedical cost savings. Although patient preference was cited as the most common reason for persistent cast treatment, the data show the use of cast treatment to be more dependent upon individual provider preference. Level II-therapeutic.

One Brace: One Visit: Treatment of Pediatric Distal Radius Buckle Fractures With a Removable Wrist Brace and No Follow-up Visit.

Previous studies have showed the efficacy of removable brace treatment for distal radius buckle fractures in children, whereas others have independently suggested that these injuries do not require additional radiographic imaging. However, no study has sought to collectively determine whether treating pediatric distal radius buckle fractures with a removable brace and no follow-up visit or imaging after the initial visit is a safe and satisfactory protocol. In total, 42 consecutive patients with a distal forearm buckle fracture seen by a single fellowship trained pediatric orthopaedic surgeon were eligible to participate. Two patients refused participation, yielding 40 patients treated with a standard protocol of immobilization with a removable wrist brace for a prescribed period of time with no additional imaging or clinical follow-up. Two staggered telephone surveys were then conducted. The first survey was conducted within 1 week of the designated brace-removal date to determine the exact date the brace was discontinued. The second survey was conducted 5 to10 months postinjury to determine patient outcomes and parent satisfaction. In total, 100% of patients were reached for the initial survey and 90% (36/40) of patients were reached for the secondary survey. There were no complications, including refracture or residual pain, following treatment. In total, 100% of parents felt their child had returned to full and normal function and all said they would choose to have the same treatment again. In total, 67% of parents would have had to take time off from work and 77% of children would have missed school if they had hypothetically been required to attend a follow-up appointment. Treatment of pediatric distal forearm buckle fractures with a removable wrist brace and no follow-up visit or radiographs results in both excellent patient outcomes and parental satisfaction. Level IV-case series.

Inappropriately Timed Pediatric Orthopaedic Referrals From the Emergency Department Result in Unnecessary Appointments and Financial Burden for Patients.

Musculoskeletal injuries are among the most common reasons for emergency department (ED) visits in the pediatric population. Many such injuries can be managed with a single follow-up outpatient visit. However, untimely (ie, premature) referrals by emergency physicians to orthopaedic surgeons are common and may inadvertently create need for a second visit, generating unnecessary expenditures. We sought to elucidate the cost of premature musculoskeletal follow-up visits to the patients, families, and the health care system. We performed a retrospective review of pediatric patients with acute musculoskeletal injuries referred from our ED (without a formal orthopaedic consult) to our outpatient clinic. Patients were retrospectively reviewed in a consecutive fashion. The appropriateness of the recommended follow-up time interval was determined for each patient, and the direct and indirect cost of the inappropriate services were calculated utilizing a combination of traditional cost accounting techniques and time-driven activity-based costing. The characteristics of patients with appropriate and untimely follow-up referrals were compared. Two hundred consecutive referrals from the ED were reviewed. Overall, 96.5% of the follow-up visits recommended by the ED were premature, which led 106 (53%) patients to require a second visit to complete their clinical care. Patients who required a second visit were significantly younger (P=0.005), more likely to be male (P=0.042), more likely to have a fracture (P<0.001), and less likely to have a sprain (P<0.001) or dislocation/subluxation (P<0.001). Over 40% of second visits were accounted for by 3 diagnoses (distal radius buckle fractures, nondisplaced Salter-Harris 1 fractures of the ankle, and buckle fractures of the finger). Across the whole cohort, the total financial impact of untimely visits was $36,265.78, representing an average cost of $342.93 per patient. Untimely referrals for follow-up of acute pediatric musculoskeletal conditions are very common and represent a significant financial burden to patients, families, and the health care system. Over 40% of unnecessary visits resulted from just 3 diagnoses. Improved orthopaedic follow-up guidelines, particularly for these readily recognizable conditions, and feedback to referring providers may reduce poorly timed clinic visits and decrease costs in the treatment of common orthopaedic injuries in pediatric patients. Level III.

Are Unnecessary Serial Radiographs Being Ordered in Children with Distal Radius Buckle Fractures?

Background. Torus or buckle distal radius fractures are common injuries in the pediatric population. By definition, they are stable and can be treated conservatively with a wrist splint or soft crepe bandage. Objective. The objective of this study was to evaluate the utility of serial radiographs in the clinical outcome of children with stable distal radius buckle fractures. Materials and Methods. A one-month retrospective analysis was undertaken at two major hospitals in Queensland—Logan and Redlands Hospital. Statistical analysis was performed to identify any relationships between serial radiographs and certain demographic parameters including fracture characteristics, age, sex, and limb side. Results. Of the 136 patients, 50% had more than one radiograph series taken. A total of 576 single radiographs and 251 radiograph series were taken. All fractures healed without complications and did not require active intervention. There was a statistically significant relationship (p = 0.0015) between fracture angulation and multiple radiographs series. A cost analysis revealed $55,890 per year could be saved by not performing serial radiographs. Conclusion. Serial radiographs did not appear to change the excellent clinical outcome for children with distal radius buckle fractures. There is a potential to reduce costs and prevent unnecessary ionizing radiation exposure to children.

One Visit-one Brace: Patient and Parent Satisfaction After Treatment for Pediatric Distal Radius Buckle Fractures*

One Visit-one Brace: Patient and Parent Satisfaction After Treatment for Pediatric Distal Radius Buckle Fractures*

Improving Management of Paediatric Buckle Fracture in Orthopaedic Outpatients: A Completed Audit Loop.

IntroductionPaediatric patient bone fractures are the source of a large number of orthopaedic outpatient visits, especially for fracture clinics. The National Institute for Health and Care Excellence (NICE) guideline NG38 provides guidance on assessing and managing non-complex fractures, such as buckle (i.e., torus) fractures in paediatric patients.ObjectiveWe retrospectively audited outpatient records of children younger than 12 years presenting with distal radius buckle fractures for May and June 2017. We compared our practice against the NICE guideline standards. We made certain changes in our practice and then repeated the exercise prospectively for two months from July 15 to September 15, 2017.Material and MethodsWe identified 31 patients who fit our inclusion criteria. After instituting changes based on the NICE guidelines, the number of children included in the prospective data collection was 33 patients.ResultsFor the 31 children treated according to our older protocol, we had 59 outpatient visits, with an average of 1.90 visits for every child. After the NICE-driven changes were made to our management, 33 patients were treated in 39 visits with an average of 1.2 visits per child.ConclusionIntroducing NICE guidelines allowed for considerable improvement in the management and treatment of paediatric patient bone fractures. It is important to fully implement the NICE guidelines not only in fracture clinics but also in other departments, such as accident and emergency departments.

Increasing Brace Treatment for Distal Radius Buckle Fractures: Using Quality Improvement Methodology to Implement Evidence-Based Medicine

There is no financial information to disclose. Multiple randomized trials have demonstrated equivalent outcomes and improved patient/family satisfaction in the treatment of distal radius buckle fractures (DRBF) with a removable splint or brace when compared to traditional cast immobilization,1-3 although casting still remains the default treatment.4 We tested the hypothesis that we could use quality improvement (QI) methodology to increase the proportion of patients with DRBF treated with removable braces at two tertiary care orthopaedic clinics from a baseline of 33% to 80%. Clinic billing records were reviewed monthly to determine treatment of DRBF (brace versus cast), which was tracked using control charts (p-chart). The number of follow up visits, radiographs obtained, and total cost of treatment was collected. Baseline data were obtained over a three month period, followed by a 12-month intervention period (1/1/16 – 12/31/16) using Plan-Do-Study-Act (PDSA) cycles targeting both individuals and groups of providers. Patients/families were given a cost survey to determine non-medical costs associated with follow-up clinic visits. The proportion of DRBF treated in a brace increased at both centers from a combined baseline of 33% to a combined 94% at the end of the study period, and 83% over the last quarter. Following intervention, 83% (15/18) of providers began using braces for a majority of patients (defined as > 67%), although 1 provider continued to use casts 100% of the time. Patient preference was cited as the most common reason for use of cast treatment. There was a significant decrease in the number of radiographs obtained at one of two institutions. The charges for brace treatment averaged $630 less per patient than for cast treatment, leading to an estimated medical-cost savings of $205,000 overall following intervention. Furthermore, 98% of patients treated in a brace did not return for follow-up, saving each patient an average of $70 per visit in lost wages, travel, and childcare expenses. (Fig. 38-1) •Implementation of brace treatment for DRBF using QI methodology at two tertiary care centers resulted in a significant increase in brace treatment, leading to substantial medical and non-medical cost savings.•Although patient preference was cited as the most common reason for persistent cast treatment, the data demonstrate the use of cast treatment to be more dependent upon individual provider preference.•Quality improvement methodology can be utilized to enact and track implementation of Level-I medical evidence into practice, although barriers still exist that may be provider-dependent.

Point-of-Care US and Nonangulated Forearm Fractures

Research Article| August 01 2017 Point-of-Care US and Nonangulated Forearm Fractures AAP Grand Rounds (2017) 38 (2): 17. https://doi.org/10.1542/gr.38-2-17 Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Facebook Twitter LinkedIn MailTo Tools Icon Tools Get Permissions Cite Icon Cite Search Site Citation Point-of-Care US and Nonangulated Forearm Fractures. AAP Grand Rounds August 2017; 38 (2): 17. https://doi.org/10.1542/gr.38-2-17 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search toolbar search search input Search input auto suggest filter your search All PublicationsAll JournalsAAP Grand RoundsPediatricsHospital PediatricsPediatrics In ReviewNeoReviewsAAP NewsAll AAP Sites Search Advanced Search Topics: diagnostic radiologic examination, forearm fractures, point-of-care ultrasonography, pain Source: Poonai N, Myslik F, Joubert G, et al. Point-of-care ultrasound for nonangulated distal forearm fractures in children: test performance characteristics and patient-centered outcomes. Acad Emerg Med. 2017; 24(5): 607– 616; doi: https://doi.org/10.1111/acem.13146Google Scholar Researchers from multiple Canadian institutions conducted a cross-sectional study to determine the utility of point-of-care ultrasonography (POCUS) in children with suspected nonangulated distal forearm fractures. Children were eligible if they were 4–17 years old and presented to the study emergency department (ED) with a suspected nonangulated distal forearm fracture, defined as maximal pain and tenderness at the distal third of the forearm after an acute fall on an outstretched hand. Each participant underwent radiography and POCUS of the distal ulna and radius. POCUS was performed and interpreted by 4 POCUS-certified pediatric ED physicians with at least 2 years of POCUS experience who were not involved in the patient’s care. POCUS evaluators were blinded to the radiographs, and radiography technicians and radiologists were blinded to POCUS interpretations. Each study child was classified as having a fracture or not on the basis of a radiologist’s interpretation of the patient’s radiographs. The primary outcome was the sensitivity and specificity of the POCUS evaluation by the ED physician (fracture or no fracture) when compared to radiograph interpretation. Secondary outcomes included (a) patient self-reported pain immediately after radiography and POCUS by using Faces Pain Scale–Revised scores, (b) caregiver satisfaction with each imaging procedure by using a single-item question and a 5-point Likert scale, and (c) duration of POCUS and radiography procedures. Of 169 children enrolled, 76 had a fracture on radiographs. The most common type was a buckle fracture (80%). The sensitivity and specificity of POCUS were 94.7% (95% confidence interval [CI], 89.7%–99.8%) and 93.5% (95% CI, 88.6%–98.5%), respectively. There were 4 fractures missed with POCUS (1 distal radius buckle fracture and 3 ulnar styloid factures). There were 6 nonfractures that were interpreted as fractures at POCUS. POCUS was associated with a significantly lower median pain score when compared with radiography. There was no significant difference in median caregiver satisfaction scores with POCUS and radiographic procedures. POCUS was associated with a significantly lower median procedure duration than radiography (1.5 vs 27 minutes, respectively; P < .001). The researchers conclude that using POCUS to assess distal forearm injuries in children is accurate, timely, and associated with low levels of pain. Dr Stevenson has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device. POCUS is a useful tool in the pediatric ED setting. The current study is 1 of several published in recent years to evaluate its use in forearm fractures in children. A recent meta-analysis of these studies supports the high sensitivity and specificity reported in the present study,1 which excluded children with obvious forearm deformities and thereby reduced the potential for inflated test performance. Few prior studies have been conducted to evaluate pain... You do not currently have access to this content.