Pediatric fracture reduction in the emergency department

Risk Factors for Failure of Closed Forearm Fracture Reduction in the Pediatric Emergency Department

OBJECTIVES

This study aimed to explore risk factors for failure of forearm fracture closed reduction in the pediatric emergency department (ED) and to suggest indications for initial surgery.

METHODS

This retrospective cohort study included all patients aged 0 to 18 years who presented to our pediatric ED with an extraarticular forearm fracture treated with closed reduction between May 2017 and April 2021. We explored risk factors for procedural failure, defined as a need for surgical intervention within 6 weeks of the closed reduction attempt.

RESULTS

Of 375 patients (median age 8.1 years, 294 [78.2%] boys), 44 (11.7%) patients sustained a reduction failure, of whom 42 (95.5%) had both radius and ulna fractures. Of the 259 patients with fractures of both bones, the following parameters were independent predictors for reduction failure: refracture (adjusted odds ratio [aOR] 17.6, P < 0.001), open fracture (aOR 10.1, P = 0.007), midshaft fracture (aOR 2.6, P = 0.004), radial translation rate 37% and higher in either plane (aOR 5.1, P = 0.004), and age of 10 years and older (aOR 2.9, P = 0.01).

CONCLUSIONS

Most pediatric forearm fractures can be successfully managed by closed reduction in the ED. Two-bone fractures had the strongest association with reduction failure. Refracture, open fracture, midshaft location, initial radius bone translation of 37% and higher (and not initial angulation), and patient age of 10 years and older are independent risk factors for reduction failure in two-bone fractures. We propose a risk score for reduction failure that can serve as a decision-making tool.

Possibility of Avoiding Anesthesia in the Reduction of Greenstick and Angulated Forearm and Distal-End Radius Fractures in Children: A Comparative Study

Introduction Greenstick and angulated forearm bone fractures are the most common fractures in children and invariably require closed reduction under anesthesia. However, pediatric anesthesia is somewhat risky and not always available in developing countries like India. Therefore, this study aimed to evaluate the standard (quality) of closed reduction without anesthesia in children and to determine satisfaction among parents. Materials and methods The present study included 163 children with closed angulated fractures of the distal radius and fracture shafts of both forearm bones, who were treated by closed reduction. One hundred and thirteen were treated without any anesthesia (study group) on an outpatient department (OPD) basis, whereas 50 children of similar age and fracture type underwent reduction with anesthesia (control group). After reduction by both methods check X-ray was done to evaluate the quality of the reduction. Results The average age of the 113 children in the present study was 9.5 years (range: 3.5-16.2 years), of which 82 children had radius or ulna fractures, and 31 had isolated distal radius fractures. In 96.8% of children, ≤10° of residual angulation was achieved. Furthermore, 11 children (12.4%) used paracetamol or ibuprofen for pain control in the study group. Moreover, 97.3% of parents stated that they would like their children to be treated without anesthesia if any fracture occurred again. Conclusions Closed reduction of greenstick angulated forearm and distal-end radius fracture in children in the OPD without anesthesia achieved satisfactory reduction and high parent satisfaction while reducing the risks of pediatric anesthesia and its associated complications.

Correlation of temperament characteristics and early functional exercise compliance in school-age children with limb fractures: Implication for clinical nursing care

Early functional exercise plays a very important role in the rehabilitation and nursing care of children with fractures. We aimed to evaluate the role of temperament characteristics in the early functional exercise compliance in school-age children with limb fractures, to provide evidence to clinical nursing care. School-age children with limb fractures admitted to our hospital from January 1, 2021 to June 30, 2022 were selected. We collected the general information, evaluated the temperament characteristics and their functional exercise compliance in school-age children. Correlation and regression analyses were conducted to assess the correlation of temperament characteristics and early functional exercise compliance. A total of 126 school-age children with limb fractures were finally included. There were 68, 36, and 22 children that were rated as easy-going, troublesome and initiate slow temperament, respectively. The children with easy-going temperament had the best early functional exercise compliance, followed by children with initiate slow temperament, and compliance of children with troublesome temperament was the worst. The reaction intensity factor in the temperament characteristics of school-age children with fracture was negatively correlated with early functional exercise compliance (P = .007). Reaction intensity was a risk factor for early functional exercise compliance in school-age children with fractures (P = .004). Health care providers must consider the influence of temperament characteristics on compliance in school-age children with fractures, and take targeted nursing measures according to different temperament characteristics of children to improve early functional exercise compliance in school-age children with fractures, so as to improve the functional recovery and prognosis of children.

Elbow dislocation with and without an associated fracture in children: A prospective study of functional outcomes following 3 weeks of immobilization

INTRODUCTION

The initial management of elbow dislocations in children, emergency reduction and brachial-antebrachial-palmar (BABP) immobilization, remains the most widely used method. Osteosynthesis could be associated in case of fractures. On the other hand, there is no consensus on the duration of immobilization in the recent literature. The objective of this study was to describe the medium-term functional results of a prospective cohort of children presenting with an elbow dislocation immobilized for 3 weeks, with or without an associated fracture. The hypothesis of this study was that 3 weeks of immobilization was sufficient and made it possible to obtain a satisfactory, rapid functional recovery without residual instability.

MATERIAL AND METHOD

All children with an elbow dislocation with or without an associated fracture were included. The dislocation was urgently reduced and subsequent surgery could be indicated in the event of associated injuries. All the children had 3 weeks of immobilization with a BABP cast. Radiological and clinical follow-up was carried out for 2 years. The parameters evaluated were: 3 functional scores and the range of motion (ROM) of the elbow. Clinical or radiological complications were sought.

RESULTS

A total of 50 children were included, the mean age was 10.6 years (± 2.6). Functional score results were "good' or "excellent' at 3 months of follow-up, "excellent' at 6 months and thereafter. The mean limitation in ROM at the last follow-up was 4.7° (± 7.2°) with all ranges combined. Eighty-two percent of children had a mean limitation in ROM of less than 10°. None of the children presented with a recurrence of elbow dislocation and instability.

CONCLUSION

Immobilization of elbow dislocations for 3 weeks in children confers good medium-term functional results without exposing them to the risk of instability, whether or not the dislocation is associated with a fracture.

LEVEL OF EVIDENCE

II; Prospective cohort study.