Resource Utilization for Patients With Distal Radius Fractures in a Pediatric Emergency Department

Question How often do children younger than 10 years with distal radius fracture undergo a potentially unnecessary closed reduction with manipulation and procedural sedation? Findings In this cross-sectional study of 258 children younger than 10 years with a distal radial metaphyseal fracture who were seen in a pediatric emergency department, 55% underwent closed reduction with procedural sedation; 27% of these were considered to be potentially unnecessary. Meaning The findings suggest that improved awareness of remodeling potential and acceptable deformity for distal radial metaphyseal fractures in young children may be associated with improved emergency department efficiency, reduced health care cost, and reduced number of children undergoing closed reductions with sedation. This cross-sectional study examines the frequency of potentially unnecessary closed reduction procedures using manipulation and procedural sedation in children with a distal radial metaphyseal fracture. Importance Improvement of clinician understanding of acceptable deformity in pediatric distal radius fractures is needed. Objective To assess how often children younger than 10 years undergo a potentially unnecessary closed reduction using procedural sedation in the emergency department for distal radial metaphyseal fracture and the associated cost implications for these reduction procedures. Design, Setting, and Participants This retrospective cross-sectional study included 258 consecutive children younger than 10 years who presented to a single, level I, pediatric emergency department and who had a distal radius fracture with or without ulna involvement between January 1, 2016, and December 31, 2017. Reductions were deemed to be potentially unnecessary if the coronal and sagittal plane angulation of the radius bone measured less than 20 degrees and shortening measured less than 1 cm on initial injury radiographs. Use of procedural sedation or transfer status to another facility was noted if present. Statistical analysis was performed from April 2019 to June 2019. Main Outcomes and Measures Potentially unnecessary reduction was the primary outcome. Radiographic findings were measured to determine reduction necessity. Additional variables measured were age, sex, time in the emergency department, transfer status, required reduction procedure, use of sedation, and cost associated with care. Results Of the 258 participants studied, 156 (60%) were male, with a mean (SD) age of 6.7 (2.3) years. Among 142 patients (55%) who underwent closed reduction with procedural sedation in the emergency department, 38 (27%) procedures were determined to be potentially unnecessary. Review of Common Procedural Terminology charges revealed an approximately $7000 difference between the stated cost of a reduction procedure in the emergency department vs a cast application in an outpatient orthopedic clinic for distal radial metaphyseal fractures. The mean (SD) maximal angulation in either plane for fractures that underwent appropriate reduction was 30.6 degrees (10.3 degrees) compared with 13.9 degrees (4.5 degrees) for those unnecessarily reduced (P < .001). Patients who were transfers from other facilities were more than twice as likely to undergo a potentially unnecessary reduction (odds ratio, 2.3; 95% CI, 1.1-5.0; P = .03). Conclusions and Relevance 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 substantially reducing health care costs.