Many Kids With Distal Radius Fractures Undergo Unneeded Reductions

By Reuters Staff

February 21, 2020

NEW YORK (Reuters Health) - New research suggests children with distal radius fracture often undergo unnecessary closed reductions in the emergency department.

"Our data suggest that a significant number of children presenting to our ED with distal radius fractures could have had the fractures immobilized and treated as an outpatient with clinical cast application instead of having undergone procedural sedation and manipulation, based on evidence-driven radiographic and demographic criteria," Dr. Keith J. Orland of Emory University School of Medicine and colleagues write in JAMA Network Open.

"The findings suggest that improved awareness of these acceptable deformities in young children may be associated with limiting the number of children requiring reduction with sedation, improving emergency department efficiency, and significantly reducing health care costs," they add.

Studies show children under 10 with distal radius fractures with bayonet apposition and angulation of 20% or less can have "excellent functional and radiographic outcomes" without reduction, Dr. Orland and his team write. "Despite these findings, the decision to tolerate a grossly visible deformity in a young child can be met with hesitation from patients, families, and ED clinicians," they add.

The authors hypothesized that some children with distal radial fractures and deformity within acceptable parameters were having closed reduction with procedural sedation, and that this would occur more frequently in patients transferred from other hospitals.

They looked at 258 consecutive children under 10 with distal radius fracture, with or without ulna involvement, treated at their pediatric ED in 2016-2017, including 142 (55%) who had closed reduction with procedural sedation. Sixty percent were male; the mean age was 6.7 years.

Thirty-eight procedures (27%) were rated as possibly unnecessary, based on the published criteria of less than 1 cm of shortening of the radius bone and angulation of less than 20%.

Children who underwent closed reduction spent a mean of 4.3 hours in the ED, versus 2.2 hours for those who did not.

Fifty-seven of the 61 patients (93%) transferred from other facilities underwent reduction and sedation, compared to 43% of non-transfers (odds ratio 2.3). The rate of potentially unnecessary reductions was 37% for transferred patients compared to 20% for non-transfers.

Mean sedation time was 13.9 minutes; 21 patients (14.8%) developed complications, with 10 having severe apnea or hypoxia events that necessitated oxygen or bag mask ventilation while they were sedated.

Closed reduction and manipulation with procedural sedation in the ED cost $8,078, based on Common Procedural Terminology (CPT) charges, compared to $1,027 for outpatient casting.

Unindicated reductions occurred in 15% of patients in the study, the authors note. Given that there are about 280,000 distal radius fractures treated at U.S. EDs every year, this suggests eliminating unnecessary reductions could save almost $270 million annually.

"Although this figure is just an estimate, it is indicative of the profound cost associated with these highly incident fractures. With improved treatment algorithms, there is opportunity for cost reduction without sacrificing clinical outcomes," they write.

SOURCE: JAMA Network Open, online February 14, 2020.