Conscious sedation and reduction of fractures in the paediatric population: an orthopaedic perspective

Clinical Audit of Manipulation of Paediatric Forearm Fractures in the Emergency Department at a District General Hospital: A Quality Improvement Project

Background Early reduction of paediatric forearm fractures under procedural analgesia has the benefit of avoiding admission and general anaesthesia. In addition to lowering the risks of treatment and reducing the number of treatment episodes, this approach also reduces the psychological stresses on the child and the parents. British Orthopaedic Association Standards for Trauma and Orthopaedics (BOAST) and Getting It Right First Time (GIRFT) guidelines recommend that all units managing paediatric fractures should have protocols to facilitate procedural analgesia for manipulation of forearm fractures. A recent standard operating procedure has been created for this purpose and has outlined local standards to adhere to. Regular audits of paediatric manipulations in the emergency department must be undertaken in line with GIRFT recommendations. The aim is to identify potential barriers to implementation, which can be improved, and to ensure that a high standard of care is delivered.  Aim The aim of this study was to assess the effects of the introduction of local guidelines on the manipulation of paediatric fractures in the emergency department, to assess the adherence of the emergency/orthopaedic departments with these guidelines, and to assess the outcome of all childhood forearm manipulations at University Hospitals Dorset (UHD), to help guide further practice. Material and methods This was a retrospective and prospective study in which the patients admitted to Poole Hospital, Poole, United Kingdom were identified according to the criteria and were analyzed in three separate groups in terms of pre-implementation and post-implementation. Patients were gathered from the orthopaedic on-call trauma lists. All paediatric patients who had a forearm fracture were included (including those who were not manipulated). The first group was the surveillance group in which a clinical audit was completed to review if any of the paediatric patients with forearm fractures were being manipulated in accident and emergency (A&E). The second group included the patients for whom the first standard operating procedure documentation was initiated with the intention of improving the service provided and reduce the number of paediatric forearm fractures going to theatre for simple manipulation and prevent a general anaesthetic. The third group was to review the established pathway and to see which areas of the pathway needed focus to make it better and more in line with the flow of patients through the emergency department. These plan, do, study, act (PDSA) cycles took place from March 2022 to March 2023. Paediatric patients with open or neurovascular damage were excluded from the cohort. The findings and the data were analysed in Microsoft Excel (Microsoft Corporation, Redmond, Washington, United States) and presented through regional meetings to discuss the progress and potential changes in making the pathway by involving all the stakeholders, i.e., the emergency department, orthopaedic department, and theatre managers. Results  An overall reduction was seen in paediatric forearm fractures going to theatre. Almost 30% of the forearm fractures were attended to in the emergency department, identification of factors that affect the numbers was quantified, and improvement in documentation throughout the PDSA cycles was observed.

Closed reduction and cast immobilization of overriding distal forearm fractures under nitrous oxide as conscious sedation without the use of imaging control

PURPOSE

The management of overriding distal forearm fractures is still controversial. This study aimed to evaluate the efficacy of immediate closed reduction and cast immobilization (CRCI) at the emergency department (ED) using equimolar nitrous oxide (eN2O2) as conscious sedation, and without the use fluoroscopic assistance.

METHODS

Sixty patients with overriding distal forearm fracture were included in the study. All procedures were performed in the ED without fluoroscopic assistance. Antero-posterior and lateral wrist radiographs were taken after CRCI. Follow-up radiographs were taken 7 and 15 days post-reduction, and at cast removal to evaluate callus formation. Depending on the radiological outcome, two groups of patients could be identified: Group 1 (satisfactory reduction and maintenance of alignment) and Group 2 (poor reduction or secondary displacement requiring further manipulation and surgical fixation). Group 2 was additionally divided into Group 2A (poor reduction) and Group 2B (secondary displacement). Pain was assessed using Numeric Pain Intensity (NPI) score, while functional outcome was measured according to Quick DASH questionnaire.

RESULTS

Mean age at the time of injury was 9.2 ± 2.4 years (range, 5-14). Twenty-three (38%) patients were aged between 4 and 9 years old, 20 (33%) patients between 9 and 11, 11 (18%) patients between 11 and 13, and 6 (10%) patients between 13 and 14. The mean follow-up time was 45.6 ± 12 months (range, 24-63). Satisfactory reduction with maintenance of alignment was achieved in 30 (50%) patients (Group 1). Re-reduction was performed in the remaining 30 (50%) patients (Group 2) due to poor reduction (Group 2A) or secondary displacement (Group 2B). No complications related to the administration of eN2O were recorded. No statistically significant difference could be identified between the three groups for any clinical variable (Quick DASH and NPI).

CONCLUSION

Overriding distal forearm fractures may be safely treated with CRCI at ED using eN2O2 as conscious sedation. However, fluoroscopic assistance during CRCI might significantly improve the quality of reduction thus avoiding further treatment as the lack of relaxed muscle can restrain reduction.

Pediatric Fracture Epidemiology and US Emergency Department Resource Utilization

OBJECTIVE

Fractures are common childhood injuries that result in emergency department (ED) visits. National trends in pediatric fracture epidemiology and resource utilization are not well described. Our objective is to analyze national trends in pediatric fracture epidemiology, ED disposition, and ED resource utilization from 2010 to 2015.

METHODS

This is an epidemiological study of fracture care in US EDs from 2010 to 2015 for children 0 to 18 years old using the Nationwide Emergency Department Sample. We calculated frequencies and national rates using weighted analyses and census data. We used the test for linear trend to analyze incidence, hospital admission, transfer, and procedural sedation over time. Multivariate logistic regression analyses identified encounter- and hospital-level predictors of transfer, admission, operative care, and use of procedural sedation.

RESULTS

During the study period, from 2010 to 2015, a total of 5,398,827 children received ED care for fractures. The pediatric fracture rate was 11.5 ED visits/1000 persons (95% confidence interval [CI], 10.6-12.5) and decreased over time. The admission rate for pediatric fracture patients was 5% and stable over time. The transfer rate increased from 3.3 to 4.1/100 fracture visits (linear trend: odds ratio, 1.06; 95% CI, 1.03-1.09). Utilization of procedural sedation increased from 1.5% to 2.9% of fracture visits (linear trend: odds ratio, 1.17; 95% CI, 1.09-1.25). Predictors associated with disposition and resource utilization include patient age, fracture location, insurance type, hospital type, and region.

CONCLUSIONS

The national incidence rate of pediatric fractures decreased slightly. Emergency department resource utilization increased over time. With high national volume, understanding pediatric fracture epidemiology and resource utilization is important to the health care system.

Pediatric fracture reduction in the emergency department

Limb fractures are a large part of pediatric trauma activity. Conservative treatment is possible because of children's bone remodeling potential. In case of displaced fractures, when a closed reduction can be done in the emergency room (ER), this avoids general anesthesia, hospitalization and the associated costs. In well-defined situations, there is a consensus about the indication for fracture reduction in the ER. Some complex fracture cases require immediate treatment in the operating room: intra-articular fractures, pathological fractures, fractures with associated skin, nerve or vascular injuries and/or early signs of compartment syndrome. And last, there is another set of fractures where the indication is not so clear. To specify the indications and technical implementation of these treatments in ER, we did a non-systematic narrative review of literature in the MEDLINE® database using the PubMed search engine to query "emergency room AND children AND fracture AND reduction". We retained the most recent articles addressing the questions related to indications and their care, sedation protocol and complications. The sedation protocol for the ER is established collaboratively by surgical, ER and anesthesia teams. The residual angulation that can be tolerated after reduction depends on the patient's age, remaining growth potential and location of the fracture line. When reduction is done in the ER, the complication and secondary displacement rates are not higher, although surgeon experience and specific procedural training appear to be crucial.

Functional and radiographic outcomes of Gartland type II supracondylar humerus fractures managed by closed reduction under nitrous oxide as conscious sedation

The management of Gartland type II supracondylar fractures remains controversial. This study aimed to evaluate the clinical, functional, and radiographic outcomes of Gartland type II supracondylar fractures treated by immediate closed reduction and casting in the emergency department using equimolar nitrous oxide as conscious sedation. All patients were treated non-operatively using equimolar nitrous oxide as conscious sedation during closed reduction and cast immobilization. Three out of 34 patients (three elbows; 8.8%) were lost during follow-up. The mean follow-up time was 26.4 months (range: 6-48). The mean Quick DASH score at cast removal was 22.4 (range: 19-40) and 2.3 (range: 0-9) at the last follow-up visit in patients without secondary displacement (n = 26; 76.5%). The mean Quick-DASH score of patients (n = 5; 16.1%) requiring closed reduction and percutaneous pinning under general anesthesia because of secondary displacement was 21.4 (range: 19-25) at cast removal and 0.9 (range: 0-2.3) at the last follow-up visit. No significant differences between the two groups were found at any time (P = 0.38 and P = 0.48, respectively). The two groups also showed a comparable radiographic outcome and similar Flynn's criteria. The mean Numeric Pain Intensity was three (range: 0-6). No complications related to the administration of equimolar nitrous oxide were recorded. The use of equimolar nitrous oxide as conscious sedation for closed reduction and casting appears to be a safe, inexpensive, and appropriate conservative method of treatment for displaced Gartland type II supracondylar fractures in children. A regular follow-up is mandatory to detect early secondary displacement, as 16.1% of fractures required additional closed reduction and percutaneous pinning under general anesthesia. Level IV, retrospective study.