Orthopaedics & Traumatology: Surgery & Research 101 (2015) 597–600
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Original article
Feasibility of a reduction protocol in the emergency department for diaphyseal forearm fractures in children S. Pesenti a,b,∗ , E. Litzelmann a , M. Kahil c , C. Mallet a , P. Jehanno a , J.-C. Mercier c , B. Ilharreborde a , K. Mazda a a
Service d’orthopédie pédiatrique, hôpital Robert-Debré, université Paris 7, Paris, France Service d’orthopédie pédiatrique, hôpital d’enfants de la Timone, Aix-Marseille université, Marseille, France c Service d’accueil des urgences pédiatriques, hôpital Robert-Debré, université Paris 7, Paris, France b
a r t i c l e
i n f o
Article history: Received 19 January 2015 Accepted 1st June 2015 Keywords: Diaphyseal forearm fractures Fracture reduction in the emergency department Fracture reduction protocol Pediatric fracture
a b s t r a c t Introduction: Diaphyseal forearm fractures are very common pediatric traumas. At present, distal radius metaphyseal fractures are often successfully treated with closed reduction by emergency physicians. However, the management of diaphyseal fractures remains controversial. The purpose of this study was to analyze the results of diaphyseal forearm fractures in the emergency department (ED) in children. Materials and methods: In a prospective 2-year-study, all closed diaphyseal forearm fractures in patients under 15, with an angle of > 15◦ and treated by closed reduction in the ED were included. Fractures with overlapping fragments were excluded. Reduction was performed by an emergency physician, with a standardized analgesic protocol (painkillers and nitrous oxide). Clinical tolerance was checked within the first 24 hours, and the radiographic stability of reduction was assessed at days 8 and 15. Initial and final follow-up radiographs were analyzed. Elbow and wrist range of motion was assessed at the final follow-up. Results: Sixty patients (41 boys and 19 girls) were included. Mean age was 5.2 years old (±3). At initial evaluation, the maximum angle was 30◦ (±11.3). After reduction, the maximum angle was significantly reduced (30◦ vs. 5◦ , P < 0.001). Mean immobilization in a cast was 11.7 weeks (±2). There were no cast related complications in any of these children. There was no surgery for secondary displacement. Full range of motion was obtained in all patients at the final follow-up. Discussion: The outcome of conservative treatment of closed diaphyseal forearm fractures, without overlapping fragments was excellent. However, reduction is usually performed in the operating room by orthopedic surgeons under general anesthesia and requires hospitalization, which is very expensive. The results of this study show that high quality care may be obtained in the ED by a trained and experienced team. These results are similar to those for distal metaphyseal fractures, which could extend the indications for reduction in the ED. Level of evidence: Level IV. Retrospective study. © 2015 Elsevier Masson SAS. All rights reserved.
1. Introduction Pediatric bone trauma is frequent in the emergency department (ED). Indeed, more than 30% of children present with at least one fracture before the age of 17 [1]. Forearm fractures are frequent in children (nearly 30%) [1–3]. Distal fractures of the metaphyseal
∗ Corresponding author. Service d’orthopédie pédiatrique, hôpital Robert-Debré, université Paris 7, 48, boulevard Serrurier, 75019 Paris, France. E-mail address:
[email protected] (S. Pesenti). http://dx.doi.org/10.1016/j.otsr.2015.06.003 1877-0568/© 2015 Elsevier Masson SAS. All rights reserved.
radius are the most frequent, and several authors have shown that management in the ED is usually considered to be effective [4,5], with successful reduction and a decrease in the number of hospitalizations and general anesthesia. On the other hand, the therapeutic approach to diaphyseal fractures is less clear. The hypothesis of this study was that diaphyseal fractures of both forearm bones could be effectively managed in the ED. The goal of this study was to prospectively evaluate the short and intermediate term clinical and radiographic results of orthopedic management of diaphyseal fractures of both forearm bones in the ED by emergency room specialists.
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Fig. 1. Pre- and post-reduction in a 7-year-old child presenting with a diaphyseal fracture of both forearm bones.
2. Materials and methods 2.1. Population All patients aged 15 years or younger, managed in a pediatric unit of the ED for a diaphyseal fracture of both forearm bones with an angle greater than 15◦ , were consecutively and prospectively included between January 1, 2010 and December 31, 2011. Exclusion criteria were the presence of a metabolic or bone disease, fractures with neurovascular or cutaneous complications, fracture overlap, multiple trauma patients, recurrent fractures and fractures with an angle of less than 15◦ . Monteggia and Galeazzi lesions were also excluded. 2.2. Management protocol Patients presenting to the ED with a suspected forearm fracture were examined by a senior emergency physician then immobilized with a posterior brachial-antebrachial-palmar plaster splint for pain relief. The patients were then sent to the emergency radiology department and standard X-rays were obtained in 2 orthogonal views. Patients with diaphyseal fractures of the forearm that corresponded to the inclusion criteria were included in the study. A protocol for pain relief was begun at admission to the ED. This included 0.3 mg/kg of oral morphine sulfate (ORAMORPH® , Norgine Pharma, France). Before reduction and 30 to 45 minutes after administration of analgesics, sedation was obtained with nitrogen protoxide inhaled for 3 minutes. Reduction was performed by one of three emergency physicians, and controlled by a senior orthopedic specialist. When good clinical results were obtained, the upper limb was immobilized in three layers of 3 padding without cotton wadding. The arm was immobilized in neutral prono-supination with the elbow flexed at 90◦ . AP and lateral X-rays were performed to confirm successful reduction immediately following the procedure. In case of satisfactory reduction [residual angle < 10◦ on AP and lateral views (Fig. 1)], the child was allowed to return home after 1 h of supervision. The child was scheduled for an ED consultation 24 h after the procedure for clinical follow-up to confirm tolerance to the cast,
an absence of the compartment syndrome, then a follow-up consultation on D8 and D15 with control X-rays to confirm that there was no secondary displacement. The patient was immobilized for 2 to 3 months depending on fracture union and the age of the child. Wrist and elbow joint range of motion were evaluated at the final follow-up, as well as the residual angle on the follow-up X-ray. 2.3. Evaluation criteria Evaluation criteria were the age of patient, the time until management in the ED, and evaluation of radiographic data and joint range of motion at the final follow-up. Radiographic evaluation criteria were the following: AP and lateral diaphyseal radial and ulnar angles. These criteria were evaluated on D0 before and after reduction, on D8 and D15 and at the final follow-up. The maximum angle of deformity on AP or lateral views and on one of the two forearm bones were the main evaluation criteria. For reduction to be considered effective on D0, the residual angle of the radius and ulna had to be < 10◦ on both AP and lateral views. The rate of reduction was defined as follows: Rate of reduction =
Initial maximum angle − maximum post-reduction angle × 100 Initial maximum angle
2.4. Statistical analysis Data were presented as means, ranges and ±. A student t-test was used to compare means when the distribution of data was normal, otherwise a non-parametric Wilcoxon test was used. A P value of ≤ 0.05 was considered to be significant. 3. Results During the inclusion period, 112 patients were admitted to the ED for fractures of both forearm bones. Fifty-two of these patients were not evaluated because they presented with at least one
S. Pesenti et al. / Orthopaedics & Traumatology: Surgery & Research 101 (2015) 597–600 Table 1 X-ray results before and after reduction in the emergency department. The results are presented as means and ranges (in parentheses).
Radius AP Lateral Ulna AP Lateral Maximum
Initial deformity (◦ )
Deformity following reduction (◦ )
12 (0–40) 27 (0–60)
3 (0–10) 5 (0–10)
11 (0–40) 22 (0–40) 30 (15–50)
3 (0–10) 2 (0–10) 5 (0–10)
P
< 0.001
exclusion criteria. At the final follow-up, 60 patients were included in the study (41 boys and 19 girls). The mean age at inclusion was 5.2 years old (1.1–14.2, ±3 years). The median age was 4.3 years old. The mean delay between admission to the ED and reduction was 108 minutes (45–210 minutes, ±44.4). Radiographic results are summarized in Table 1. The mean rate of reduction was 81.1% (33.3–100%, ±17.7%). During follow-up, one case of secondary displacement was noted on D8 (2.3%) and 5 on D15 (11.4%). Because of the small residual angle of the fracture (< 10◦ ), none of the patients required a revision procedure. The mean follow-up was 14.5 months (6–72 months). Patients were immobilized for a mean 12 weeks (±2 weeks). At the final follow-up all patients had complete, symmetric wrist (palmar and dorsal flexion, prono-supination and radial and ulnar inclination) and elbow (flexion-extension) range of motion. The mean maximum angle was 4.4◦ (0–10◦ , ±4.5◦ ). The difference between the angle at the final follow-up and after reduction was not statistically significant (5.6◦ vs. 4.4◦ , P = 0.15). A recurrent fracture was reported in 4 patients (6.7%). The mean delay between initial and recurrent fractures was 6 months. Two of these fractures required internal fixation with elastic stable intramedullary nailing (3.3%). The two others were again managed conservatively with satisfactory results at the final follow-up.
4. Discussion Treatment of diaphyseal fractures of the forearm in children under the age of 15 can be surgical or conservative [6–8]. Nevertheless, first line treatment of this type of fracture should be conservative, especially because of the greater potential for growth in these patients and thus remodelling. Surgical treatment is indicated in case of irreducible fractures, secondary displacement in the splinted arm or recurrent fracture [9,10]. Since the 1990s, several studies have shown that elastic stable intramedullary nailing is better than traditional intramedullary techniques: preservation of the fracture hematoma, absence of postoperative immobilization. . . [7,11,12]. Although the efficacy of surgical treatment has been shown [7,13,14], this type of treatment has been associated with a complication rate of nearly 15% with delayed union in certain cases [6,15,16]. Conservative management therefore seems to be an interesting option in this type of fracture [9,17], although longer immobilization is necessary. Because of the importance of restoring the anatomical axis of the diaphysis of both forearm bones, in particular for pronosupination, conservative treatment is only indicated if the angle of the radius and ulna is less than 10◦ on 2 orthogonal views [17]. Thus despite the potential for remodelling, reduction is essential to recover pronation-supination in a diaphyseal fracture with an angle of greater than 20◦ . This rule is even more important if the child is older and the potential for remodelling is low [18].
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It has been shown that reduction can be performed in fractures of the distal radius by well trained emergency physicians with results that are as good as those of orthopedic surgeons [4,5]. On the other hand, to our knowledge, there have been no studies showing the feasibility of this procedure for diaphyseal fractures of the forearm. The results of this study show that management of diaphyseal fractures can be performed in the ED, with successful reduction in more than 80% and residual deformity at the final follow-up of less than 5◦ . This procedure could be improved by ultrasound or fluoroscopic control during reduction [19,20]. In this case, the use of ultrasound seems especially interesting because the effective radiation dose can be reduced [21]. Analgesics used during fracture reduction should be effective and compatible with outpatient management. Although the use of powerful drugs such as propofol have been described in the literature [22,23], this is not compatible with outpatient management. The protocol used in this study included a level/stage 3 pain killer then light sedation with inhaled nitrous oxide during the procedure. Wattenmaker et al. [24] showed that this type of sedation was sufficient for closed reduction maneuvers, with the additional advantage of having a very short half-life. This type of sedation is therefore compatible with outpatient patient management and a relatively short hospital stay in the ED [25]. In this study three emergency department specialists were trained by orthopedic surgeons to reduce fractures. Further study to identify the influence of experience on the quality of reduction are needed, like those in the distal radius [4].
5. Conclusion This is the first study in the literature to evaluate the outcome of management of diaphyseal fractures of both forearm bones in the ED. These results show that high quality reduction can be obtained with complete functional recovery. This type of fracture can therefore be managed in the ED, to reduce the number of hospitalizations while obtaining good radiographic and clinical results. Contraindications to management in the ED are fracture overlap, cutaneous and neurovascular complications and recurrent fractures. For optimal management, ED specialists must be properly trained. Moreover, development of an effective analgesic protocol that is compatible with a short hospital stay in the ED is necessary.
Disclosure of interest The authors declare that they have no conflicts of interest concerning this article.
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