Comparison of reamer irrigator aspirator (RIA) suspension versus bone marrow aspirate concentrate (BMC) for percutaneous treatment of long bone nonunions-A preclinical canine model.

OBJECTIVE: To compare the bone healing effects of percutaneously delivered bone marrow aspirate concentrate (BMC) versus reamer irrigator aspirator (RIA) suspension in a validated preclinical canine ulnar nonunion model. We hypothesized that BMC would be superior to RIA in inducing bone formation across a nonunion site after percutaneous application. The null hypothesis was that BMC and RIA would be equivalent. METHODS: A bilateral ulnar nonunion model (n= 6; 3 matched pairs) was created. Eight weeks after segmental ulnar ostectomy, RIA from the ipsilateral femur and BMC from the proximal humerus were harvested and percutaneously administered into either the left or right ulnar defect. The same volume (3 ml) of RIA suspension and BMC were applied on each side. Eight weeks after treatment, the dogs were euthanized, and the nonunions were evaluated using radiographic, biomechanical, and histologic assessments. RESULTS: All dogs survived for the intended study duration, formed radiographic nonunions 8 weeks after segmental ulnar ostectomy, and underwent the assigned percutaneous treatment. Radiographic and macroscopic assessments of bone healing at the defect sites revealed superior bridging-callous formation in BMC-treated nonunions. Histologic analyses revealed greater amount of bony bridging and callous formation in the BMC group. Biomechanical testing of the treated nonunions did not reveal any significant differences. CONCLUSION: Bone marrow aspirate concentrate (BMC) had important advantages over Reamer Irrigator Aspirator (RIA) suspension for percutaneous augmentation of bone healing in a validated preclinical canine ulnar nonunion model based on clinically relevant radiographic and histologic measures of bone formation.

The construct validity and internal consistency of QuickDASH in pediatric patients with upper extremity fractures.

BACKGROUND AND PURPOSE: Investigation of treatment options in the pediatric population necessitates the use of valid patient-reported outcome measures (PROMs). We aimed to assess the construct validity and internal consistency of the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) in the pediatric population with upper extremity fractures treated both operatively and conservatively. PATIENTS AND METHODS: QuickDASH, along with several reference PROMs and objective outcome measures, was obtained from 148 5- to 18-year-old patients with a humeral medial epicondyle fracture or a fracture of the distal forearm in a cross-sectional setting with a single follow-up visit. Spearman's rank correlation and linear regression models were used to assess convergent validity, exploratory factor analysis (EFA) to assess structural validity, and Cronbach's alpha to investigate internal consistency. RESULTS: The direction and magnitude of correlation showed by QuickDASH with reference outcome measures was consistent and demonstrated good convergent validity. EFA indicated a 3-factor model with poor fit indices and structural validity remained questionable. Construct validity was considered acceptable overall. QuickDASH demonstrated good internal consistency with an acceptable Cronbach's alpha (α = 0.75). CONCLUSION: QuickDASH demonstrated acceptable construct validity and good internal consistency and is thus a valid instrument, with some limitations, to assess disability and quality of life in pediatric patients with upper extremity fractures.

Physeal Fractures of the Distal Ulna: Incidence and Risk Factors for Premature Growth Arrest.

BACKGROUND: The aim of this study is to assess the rate of distal ulnar growth arrest following physeal fracture and to identify specific risk factors for premature physeal closure. METHODS: A retrospective review of patients with a distal ulnar physeal fracture was performed at a single United States children's hospital. Patients without 6-month follow-up were excluded. Patient demographics, injury characteristics, treatment, and outcomes were abstracted. Fractures were classified by the Salter-Harris (SH) system. All follow-up radiographs were reviewed for changes in ulnar variance or signs of premature physeal arrest. RESULTS: Fifty-six children with distal ulnar physeal fracture at a mean age of 10.7±3.3 years were included with a mean follow-up of 1.9 years. The most common fracture pattern was a SH II (52.7%), versus SH I (29.1%), SH III (9.1%), and SH IV (9.1%). Of displaced fractures (41.1%), the mean translation was 40.2±38.3% the and mean angulation was 24.8±20.9 degrees. Eleven fractures (19.6%) demonstrated radiographic signs of growth disturbance, including 3 patients (5.4%) with growth disturbance but continued longitudinal growth and 8 patients (14.3%) with complete growth arrest. The average ulnar variance was -3.4 mm. Three patients underwent subsequent surgical reconstruction including ulnar lengthening with an external fixator, distal ulna completion epiphysiodesis with distal radius epiphysiodesis, and ulnar corrective osteotomy. Patients with displaced fractures and SH III/IV fractures were more likely to develop a growth disturbance (34.8% vs. 3.2%, P =0.003; 50.0% vs. 11.1%, P =0.012, respectively). Children with less than 2 years of skeletal growth remaining at the time of injury had a higher risk of growth disturbance (46.2% vs. 9.5%, P =0.007). CONCLUSIONS: SH III and IV fractures are more common injury patterns in the distal ulna compared with the distal radius. Growth disturbance or growth arrest occurs in ~20% of distal ulnar physeal fractures. Displaced fractures, intra-articular fractures, fractures requiring open reduction, and older children are at increased risk of distal ulnar growth arrest and should be followed more closely. LEVEL OF EVIDENCE: Level IV--case series.

Do We Need a Strictly Lateral Radiograph for Fracture Management of Forearm Buckle Fractures in Children?

OBJECTIVES: Buckle fractures of the distal forearm are a common fracture entity in children treated conservatively. Diagnostics primarily include radiographs in 2 planes. Inadequate images may occur in the mostly very young patients. Therefore, additional lateral radiographs are often obtained to assess a possible angular tilt. The aim of this study is to investigate whether a strictly lateral x-ray image has an influence on fracture management. METHODS: Seventy-three children with buckle fractures of the distal forearm were included in this retrospective analysis. All cases were analyzed by quality of radiographs, necessity to obtain an additional lateral radiograph, and what influence on fracture management resulted. Follow-up was performed 2 to 4 weeks after immobilization. RESULTS: Thirty-five girls and 38 boys with a mean age of 7.16 years were included; 40 had fractured right and 33 had fractured left arms, respectively. Isolated distal radius fractures occurred in 48 cases, isolated distal ulna fractures in 6 cases, and both bones in 19 cases. Initial radiographic images were evaluated as inadequate in 25 cases. In each of those cases, an additional lateral image was obtained by fluoroscopy without resulting in an alternated fracture management protocol, which was chosen conservatively in each case and resulted in excellent clinical outcome at follow-up examination. CONCLUSIONS: Based on our results, the acquisition of additional lateral radiographs seems to be unnecessary in the diagnostic procedure of buckle fractures of the distal forearm, in case a possible palmar or dorsal angulation cannot be entirely assessed on the initial set of radiographs. An additional lateral image had no influence on fracture management, which was chosen conservatively in every case and led to excellent clinical results.Level of evidence: level III.

Improved forearm rotation even after early conversion to below-elbow cast for non-reduced diaphyseal both-bones forearm fractures in children: a secondary 7.5-year follow up of a randomized trial.

BACKGROUND AND PURPOSE: previous RCT compared short-term results of above-elbow cast (AEC) with early conversion to below-elbow cast (BEC) in children with non-reduced diaphyseal both-bone forearm fractures. After 7 months both groups had comparable function. Our primary aim was to investigate whether forearm rotation improves or worsens over time. Secondary aims were loss of flexion and extension of the elbow and wrist, patient-reported outcomes measures, grip strength ratio, and radiographic assessment. PATIENTS AND METHODS: We performed long-term follow-up (FU) of a previous RCT. All patients were invited again for the long-term FU measurements. Primary outcome was limitation of forearm rotation. Secondary outcomes were loss of flexion and extension of the elbow and wrist compared with the contralateral forearm, the ABILHAND-Kids questionnaire and the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, grip strength ratio, and radiographic assessment. RESULTS: The mean FU was 7.5 (4.4-9.6) years. Of the initial 47 children, 38 (81%) participated. Rotation improved in both groups over time, with no significant difference in the final forearm rotation: 8° (SD 22) for the AEC group and 8° (SD 15) for the BEC group with a mean difference of 0° (95% confidence interval -13 to 12). Secondary outcomes showed no statistically significant differences. Finally, children < 9 years almost all have full recovery of function. CONCLUSION: Long-term follow-up showed that loss of forearm rotation after a non-reduced diaphyseal both-bone forearm fracture improved significantly compared with that at 7 months, independent of the initial treatment and children aged < 9 will have almost full recovery of function. This substantiates that the remaining growth behaves like a "friend" at long-term follow-up.

Epidemiology, classification and treatment of olecranon fractures in adults: an observational study on 2462 fractures from the Swedish Fracture Register.

PURPOSE: This nationwide study aims to describe the epidemiology, fracture classification and current treatment regimens of olecranon fractures in adults. METHODS: We performed a descriptive study based on registered data from the Swedish Fracture Register (SFR). All non-pathological olecranon fractures reported between 1 January 2014 and 31 December 2018 in patients aged ≥ 18 years were included. Data on age, sex, injury mechanism, fracture classification (according to the modified Mayo classification system), primary treatment and seasonal variation were analyzed. We compared patients < 65 with those > 65 years regarding injury mechanism, distribution of fracture types and subsequent treatment. RESULTS: In total, 2462 olecranon fractures were identified in the SFR. Median age was 66 years and 65% were women. Of all fractures, 303 (12%) were proximal avulsion, 1044 (42%) simple central, 717 (29%) comminuted central and 398 (16%) distal olecranon fractures. Nonoperative treatment was performed in 21% of the patients < 65 and 35% of the patients > 65 years. Tension band wiring was used for most simple central fractures. Plate fixation was used in almost half of the operatively treated fractures classified as unstable comminuted central and distal olecranon fractures. Men show a higher proportion of high-energy trauma than women in both age groups. CONCLUSION: Isolated fractures of the olecranon occur after a low-energy trauma, especially in older women (> 65 years). Non-operative treatment is common in uncomplicated fractures and operative treatment in more complex fractures nationwide. A shift to plate fixation in the more unstable fracture patterns is observed. These results may help health care providers and clinicians gain a better understanding of isolated olecranon fractures.

Management of Geriatric Elbow Injury.

Approximately 4.1% of all fractures in the elderly involve the elbow. Most elbow injuries in geriatric patients occur as the result of low-energy mechanisms such as falls from standing height. Elbow injuries in elderly patients present complex challenges because of insufficient bone quality, comminution, articular fragmentation, and preexisting conditions, such as arthritis. Medical comorbidities and baseline level of function must be heavily considered in surgical decision making.

Deformed pediatric forearm fractures: Predictors of successful reduction by emergency providers.

INTRODUCTION: Forearm fractures are common pediatric injuries. Most displaced or angulated fractures can be managed via closed reduction in the operating room or in the Emergency Department (ED). Previous research has shown that emergency physicians can successfully perform closed reduction within ED; however, the fracture morphology amendable to ED physician reduction is unclear. The aim of this study is to detail the fracture characteristics associated with successful reduction by ED physicians. METHODS: We conducted a retrospective study of children (aged <18 years) presenting to the ED of a tertiary care children's hospital (annual census 90,000) between January 2018 and December 2018 with closed distal and midshaft forearm fractures requiring reduction. Data collected included patient demographics, fracture morphology, management, and complications. Successful ED physician reduction was based on predefined criteria. Orthopedic referrals included those patients sent directly to the operating room, closed reductions performed by orthopedic trainees within the ED, and patients requiring orthopedic consultation after failed ED reduction. RESULTS: A total of 340 patients with forearm fractures were included in the study. ED clinicians attempted to reduce 274 (80.6%) of these fractures and were successful in 256/274 (93.4%) cases. Of the 84 orthopedic referrals, 18 were after failed ED clinician attempt, and 66 were ab initio managed by orthopedics (37 in the operating room and 29 in ED). Compared to the fractures with successful ED reduction (n = 256), factors associated with orthopedic referral (n = 84) included: increasing age, midshaft location, higher degree of angulation, and completely displaced fractures. Angulated distal greenstick fractures were most likely to be successfully reduced by ED clinicians. There were no difference in complication rates between the two groups. CONCLUSION: In this series, fractures most amenable to reduction by ED clinicians include distal greenstick fractures, whereas midshaft and completely displaced fractures are more likely to need treatment by orthopedics.

Accuracy of point-of-care ultrasound for determining the adequacy of pediatric forearm fracture reductions.

BACKGROUND: The objective of the present study was to the determine the accuracy of point-of-care ultrasound (POCUS) in assessing closed reduction (CR) of pediatric forearm fractures in a pediatric emergency setting. METHODS: After determination of the need for CR using X-ray images by an orthopedic consultant, POCUS examinations were performed just before and after the reduction attempt. The transducer was positioned longitudinally over the dorsal, volar, and lateral surfaces of the radius and ulna to view the fracture site. The presence of angulation, displacement, or bayonetting of the fracture fragments was recorded. The adequacy of realignment according to the POCUS and the orthopedic consultant's final determination were recorded. RESULTS: Sixty-two patients were enrolled in the study and 96 bones were evaluated. The sensitivity and specificity of POCUS for adequacy of CR were 95.8% [95% confidence interval (CI): 88.3-99.1)] and 95.8% (95% CI: 78.8-99.8), the positive predictive value was 98.5% (95% CI: 91.0-99.7), and the negative predictive value was 88.4% (95% CI: 71.6-95.8). The corresponding positive and negative likelihood ratios were 23 (3.37-156.77) and 0.04 (0.01-0.12). There was high agreement between POCUS and X-ray images for predicting adequacy of CR [κ: 0.892 (±0.053)]. There was also a significant correlation between POCUS and X-ray measurements of angulation and displacement performed before and after CR, respectively (p < 0.001). CONCLUSION: Our study has reported the successful use of POCUS for the management of pediatric forearm fractures in a pediatric emergency department. Point-of-care ultrasound can minimize radiation exposure and appears to be an alternative and accurate tool for reduction attempts.

Common Fractures of the Radius and Ulna.

Fractures of the radius and ulna are the most common fractures of the upper extremity, with distal fractures occurring more often than proximal fractures. A fall onto an outstretched hand is the most common mechanism of injury for fractures of the radius and ulna. Evaluation with radiography or ultrasonography usually can confirm the diagnosis. If initial imaging findings are negative and suspicion of fracture remains, splinting and repeat radiography in seven to 14 days should be performed. Incomplete compression fractures without cortical disruption, called buckle (torus) fractures, are common in children. Greenstick fractures, which have cortical disruption, are also common in children. Depending on the degree of angulation, buckle and greenstick fractures can be managed with immobilization. In adults, distal radius fractures are the most common forearm fractures and are typically caused by a fall onto an outstretched hand. A nondisplaced, or minimally displaced, distal radius fracture is initially treated with a sugar-tong splint, followed by a short-arm cast for a minimum of three weeks. It should be noted that these fractures may be complicated by a median nerve injury. Isolated midshaft ulna (nightstick) fractures are often caused by a direct blow to the forearm. These fractures are treated with immobilization or surgery, depending on the degree of displacement and angulation. Combined fractures involving both the ulna and radius generally require surgical correction. Radial head fractures may be difficult to visualize on initial imaging but should be suspected when there are limitations of elbow extension and supination following trauma. Treatment of radial head fractures depends on the specific characteristics of the fracture using the Mason classification.

Refracture Rate of Both Bone Forearm Fractures: A Retrospective Comparison of Casting Alone Versus Casting and Extended Functional Bracing.

BACKGROUND: One of the most common pediatric fractures is a midshaft both bone forearm fracture. The preferred nonoperative treatment is cast immobilization for 6 to 8 weeks; however, 4% to 8% refracture within 6 months. There are no comparative studies evaluating the efficacy of bracing after cast immobilization. We hypothesized that children treated with prolonged functional bracing would have a lower rate of refracture than casting alone or short-term bracing. METHODS: This is a retrospective review of children younger than 15 years of age treated nonoperatively following radius and ulnar shaft fractures treated at 3 tertiary pediatric hospitals. We excluded distal radius/ulna fractures, isolated fractures of the radius/ulna, and fractures near the elbow. Logistic regression analysis on casting plus functional bracing was run to determine if age, translation, or the number of days in brace were associated with refracture. The incidence of refracture was compared between groups. RESULTS: A total of 1549 patients were screened and 426 were included in the study [111 casting only (CO), 259 casting plus functional brace <8 wk (CFB <8 wk), 56 casting plus functional brace ≥8 wk (CFB ≥8 wk)]. In comparing the groups, CO was the youngest (4.4 y vs. 6.3 and 8.4 y). The initial translation and angulation of the radius and ulna were significantly greater in the CFB ≥8 weeks group. Regression analyses shows no association between refracture and initial fracture characteristics including age, translation, or the number of days in brace. The CO group had 3 refractures (2.7%), the CFB <8 weeks group had 13 (5%) and the CFB ≥8 weeks group had 1 (1.8%); demonstrating no statistical significance. CONCLUSION: Extended fracture bracing, following a period of cast immobilization, did not lead to a statistically significant difference in refracture rate. Contrary to previous cases series, the benefit of bracing seems nominal. Larger, prospective studies are needed to better understand targets for treatment. LEVEL OF EVIDENCE: This is the first level III retrospective comparison study of its kind.

Diaphyseal Both-Bone Forearm Fracture Due to a Grip Lock Injury in a Female Pediatric Gymnast: A Case Report.

CASE: A 13-year-old female gymnast sustained a diaphyseal both-bone forearm fracture due to a grip lock injury. CONCLUSION: This is a report of a diaphyseal both-bone forearm fracture due to a grip lock injury in a female pediatric gymnast, successfully treated with closed reduction and cast immobilization. The rare mechanism of injury, education, and treatment have been discussed.

Comparison of ultrasound-guided versus fluoroscopy-guided reduction of forearm fractures in children.

PURPOSE: Point-of-care ultrasound (POCUS) can be used to guide and assess reduction of pediatric forearm fractures. In this study, we sought to compare the success rate of ultrasound-guided fracture reduction with fluoroscopy-guided fracture reduction. We also sought to determine whether there are cost or time benefits to using ultrasound instead of fluoroscopy. METHODS: The electronic medical records of patients less than 18 years of age presenting to a pediatric emergency department with a forearm fracture between April 2016 and March 2019 were screened for inclusion in this study. A total of 27 ultrasound-guided reductions were identified during this time period and 81 fluoroscopy-guided reductions were randomly selected for comparison. Cost data was provided by the financial department. Reduction success, total length of stay, and costs were compared between the two groups, and multiple linear regression was used to determine the influence of any confounding predictor variables. RESULTS: There were no failed reductions in either group. Length of stay was shorter in the POCUS group (221 min) compared with the fluoroscopy group (254 min, p = 0.014), but this significance was lost in the regression model when adjusted for ketamine use. Provider costs ($430 v $442, p = 0.822) and total costs ($1219 v $1204, p = 0.851) were the same between the POCUS group and the fluoroscopy group, respectively. CONCLUSION: POCUS appears to be an equally effective imaging modality to guide reduction of forearm fractures as compared to fluoroscopy.

Human placenta-derived matrix with cancellous autograft and demineralized bone matrix for large segmental long-bone defects in two dogs with septic nonunion.

OBJECTIVE: To report the successful treatment of septic nonunion in two dogs with large segmental defects secondary to long-bone fractures by using a novel human placenta-derived matrix (hPM) as adjunct to fixation. ANIMALS: One 3-kg 9-year-old neutered male Yorkshire terrier with a distal antebrachial fracture and one 6-kg 4-year-old spayed female miniature pinscher with a distal humeral fracture. STUDY DESIGN: Short case series. METHODS: Both dogs presented for septic nonunion after internal fixation of Gustilo type II open diaphyseal fractures from dog bite injuries. During revision, debridement of nonviable bone resulted in segmental defects of 32% and 20% of the bone length for the antebrachial and humeral fractures, respectively. The antebrachial fracture was stabilized with a circular external fixator, and the humeral fracture was stabilized with biaxial bone plating. The fracture sites were not collapsed, and full length was maintained with the fixation. Autogenous cancellous bone graft and canine demineralized bone allograft were packed into the defects, and hPM was injected into the graft sites after closure. RESULTS: Radiographic union was documented at 8 weeks and 6 weeks for the antebrachial and humeral fractures, respectively. Both dogs became fully weight bearing on the affected limbs and returned to full activity. CONCLUSION: Augmenting fixation with grafts and hPM led to a relatively rapid union in both dogs reported here.

Elbow Fracture-Dislocations: Determining Treatment Strategies.

Elbow dislocations represent common injuries. A quarter of these injuries involve at least 1 fracture. The sequel of elbow fracture-dislocations can be fraught with complications, including recurrent instability, posttraumatic arthritis, elbow contracture, and poor functional results. The 3 main patterns of injury are valgus posterolateral rotatory instability, varus posteromedial rotatory instability, and transolecranon fracture-dislocation. This article discusses each pattern individually, including the anatomy, the typical injury pattern, and treatment strategies. It also discusses common complications that can occur.

Aluminium Splint Incorporated Fibreglass Cast Preserves Limb Function in Bovines with Olecranon Fracture.

OBJECTIVE: Olecranon process fractures are rare in bovines. The aim of the study was to put on record satisfactory limb usage in cattle and buffaloes suffering from olecranon fractures and treated conservatively, primarily for carpal contracture or to prevent it, using aluminum splints incorporated within a fiberglass cast along with stall confinement. STUDY DESIGN: This one year study included 19 olecranon fractures in bovines (15 buffaloes and 4 cattle). Out of 19, 12 bovines (9 buffaloes and 3 cattle) were treated primarily to manage the associated carpal contracture, using external coaptation of aluminium splints incorporated within a fiberglass cast for 6 to 8 weeks. The owners of the remaining 7 bovines (6 buffaloes and 1 bullock) were only advised to keep their animal in stall-confinement, due to various reasons. RESULTS: Slipping and falling on hard surfaces was the primary aetiology of olecranon fractures (17/19). Most of the fractures (14/19) were presented more than 10 days after a traumatic event, with a mean duration of 24.0 ± 26.6 days. On follow up, all the treated bovines showed satisfactory limb usage whereas all stall-confined buffaloes showed no improvement. CONCLUSION: Slipping and falling on hard surfaces is a common cause of olecranon fracture in bovines. Olecranon fractures associated carpal contracture can be successfully treated/prevented by applying full limb cast (if possible including elbow) along with aluminum splints leading to satisfactory limb usage in bovines. Further it is concluded that stall confinement alone is insufficient to prevent limb contracture (which usually develops with olecranon fracture in bovines) leading to permanent non-weight bearing disability.

Olecranon Stress Fracture.

Olecranon stress fractures are a rare upper extremity fracture that primarily affects throwing athletes. The incidence of olecranon stress fractures are increasing owing to the number of patients playing and the volume of engagement in competitive sports, especially in the pediatric population. However, olecranon stress fractures can present a challenge from a management and a rehabilitation perspective owing to their vague presentation, thereby affecting how these patients are diagnosed and managed. Therefore, it is imperative to further evaluate the disease process, diagnosis, and treatment of this condition to best manage our patients.

Improving Quality in the Treatment of Pediatric Forearm Fractures: Minimizing the Need for Repeat Intervention With Long-arm Extension Casting.

PURPOSE: Repeat intervention for pediatric forearm fractures after closed manipulation is as high as 46% with flexed elbow (FE) long-arm casts. Casting with the elbow extended (EE) has been advocated as an alternative technique. We documented outcomes of patients treated with closed manipulation and casting with EE long-arm casts for displaced, diaphyseal both-bone forearm fractures. METHODS: We retrospectively reviewed charts for patients who had sedated manipulations and casting for closed, diaphyseal forearm fractures. Open fractures, immediate surgical intervention, metabolic bone disease, recurrent fractures, and Monteggia injuries were excluded. Closed manipulations were performed by orthopaedic residents assisted by cast technicians, with sedation provided by emergency department physicians. Radiographic angulation and displacement of the radius and ulna on immediate postreduction radiographs and all follow-up radiographs were recorded. Patients requiring repeat intervention were compared with those who did not by using the Mann-Whitney U and Fisher exact tests. RESULTS: Of 86 patients (7.2±2.8 y) available for analysis, 82 (95.3%) completed treatment after a single-sedated manipulation and placement of an EE long-arm cast. There were no malunions or nonunions. The average follow-up was 50 days. Four (4.7%) patients required repeat interventions (2 had surgery, 1 had a repeat sedated manipulation, and 1 had a nonsedated manipulation). There were no statistically significant differences in age, sex, laterality, fracture position in the diaphysis, or immediate postreduction angulation of the radius or ulna. A literature review showed average repeat intervention rates of 14.9% (range, 0% to 45.9%) for FE casts and 3.3% (range, 0% to 15%) for EE casts. CONCLUSIONS: There was a low rate of repeat interventions (4.7%) in patients with EE casts compared with historical rates for FE casts. Improving the quality of health care involves identifying and implementing practices that provide the best outcomes at the lowest costs. The use of EE long-arm casts following closed manipulation of pediatric forearm fractures may decrease the rate of repeat manipulation or surgery compared with conventional FE casts. LEVEL OF EVIDENCE: Level IV-case series.

Utility of Postreduction Radiographs After Fluoroscopy-Guided Reduction and Casting of Uncomplicated Pediatric Forearm Fractures.

OBJECTIVE: The aim of the study was to determine efficacy of performing postreduction radiographs in managing uncomplicated pediatric forearm fractures after reduction and casting under fluoroscopic guidance. DESIGN: This is retrospective analysis of consecutive cases. SETTING: The study was conducted in a large urban hospital pediatric emergency department (ED). PARTICIPANTS: Pediatric patients presenting to the ED with a forearm fracture between the ages of 0 to 18 years. All received orthopedic manual reduction with fluoroscopic guidance and casting, then followed by performance of a dedicated 2-view radiographic series of postreduction forearm to document proper alignment and cast placement. MAIN OUTCOME(S) AND MEASURE(S): Of 236 consecutive cases studied, there were only 5 cases (2%) in which the managing orthopedist determined that a further reduction attempt was warranted based on the postreduction radiograph results. All were mid-shaft fractures of both radius and ulna, which were angulated and/or displaced. The remaining 231 patients with an uncomplicated forearm fracture received no further ED clinical orthopedic intervention after performing postreduction radiographs. The mean ED time to ultimate discharge was prolonged an average of 89 minutes per patient after reduction and casting while awaiting performance/orthopedic review of postreduction radiographs. A calculation of postreduction radiograph cost amounted to a total of nearly US $50,000. CONCLUSIONS: Performance of postreduction radiographs in children with uncomplicated pediatric forearm fractures that are reduced and casted under fluoroscopy has little clinical utility and contributes to increased radiation exposure, patient health care cost, and time spent in the ED. Patients with mid-shaft forearm fractures involving both radius and ulna (especially if angulated or displaced) are at risk for unacceptable reduction after casting and may be the target group in which performing post reduction radiographs has potential benefit.