125 Reducing Displaced Forearm Fractures in Children: Are we following the guidelines?

Primary Subject area Emergency Medicine - Paediatric Background Forearm fractures account for 45% of pediatric fractures, mainly involving the distal third of the forearm. Some will be displaced, requiring a closed reduction and plaster cast immobilization. Re-displacement during follow-up is reported in 7 to 35% of the cases. Objectives To identity discrepancies between hospital guidelines and patient management for forearm fracture reduction in children aged 1 to 17. Design/Methods This retrospective case series was conducted by a medical audit committee of CHU Sainte-Justine for the purpose of improving quality of care. This project aimed to evaluate the clinical course following closed reduction of forearm fractures in patients presenting to the emergency department (ED) or to the orthopedic clinic in a pediatric tertiary care centre. Children aged 1 to 17 years old presenting between January 1 and December 31 2019 were considered for this study. We selected a convenience sample of 50 consecutive cases and reviewed their medical and radiological data from first consultation through follow-ups. The management of these cases was evaluated against established hospital guidelines for primary or secondary fracture reduction (primary outcome). The angulation and displacement of fractures were measured using original imaging taken prior to reduction, and at follow-up. At their last appointment, all patients’ range of motion and angulation were assessed. Complications of sedation and immobilization were also reviewed. Descriptive statistics were performed for all variables. Results From the 106 radiologic files retrieved of closed forearm fracture reduction using fluoroscopy, a convenient sample of 50 cases was reviewed. The mean age was 7 years and 60% of them were boys. Forty-eight (96%) had an initial fracture reduction consistent with the local practice guideline for need of reduction. Sedation adverse events were noted in 10 patients (20%), most often nausea, but no severe adverse event was identified. According to the local practice guideline, 13 (26%) patients suffered re-displacement at follow-up. Of these, 3 underwent a second closed reduction, 4 had a gypsotomy, and 6 had no attempt at a second reduction. Five patients (10%) had a second reduction during follow-up, despite the displacement not meeting the local guideline criteria for reduction. Cast-related issues were reported in 14 patients (28%), with the molding technique accounting for most of the problems observed. At their final follow-up, 40 patients (80%) had an excellent or good functional outcome. In the remaining 10 (20%), the range of motion was more limited, but measurements were done for many of them following immediate cast removal. Forty patients (80%) had either a normal or near normal alignment at their final follow-up. In the remaining 10 (20%), none of these patients had an angulation greater than 20 degrees. Conclusion From this audit of patients presenting with displaced forearm fractures in a pediatric tertiary care centre, the initial management of patients was in accordance with the established guidelines of practice in 96% of cases. Re-displacements at follow-up were identified in a quarter of patients. Nonetheless, angulation and the final range of motion of the wrist were favorable shortly after cast removal. Further improvement in the management could be achieved by improving the technique of cast immobilization.