American Association for Hand Surgery
Theme: Beyond Innovation

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Fluoroscopy as Definitive Post-Reduction Imaging of Pediatric Wrist and Forearm Fractures Is Safe and Saves Time
Avi Goodman, MD; Devin F Walsh, MD; Mark R Zonfrillo, MD, MSCE; Craig P Eberson, MD; Aristides I Cruz, Jr., MD
Alpert Medical School of Brown University, Providence, RI


Introduction
Recent studies indicate that formal post-reduction radiographs may be unnecessary for closed, isolated pediatric wrist and forearm fractures when mini C-arm fluoroscopy is used for reduction. Our institution changed the Emergency Department (ED) management protocol in 2017 to reflect this. We hypothesized that using fluoroscopy as definitive post-reduction imaging would decrease total encounter time and cost, without an increase in the rate of re-reduction or surgery.

Materials & Methods
A retrospective chart review was performed for all patients with isolated, closed wrist or forearm fractures that required sedation and reduction (under mini C-arm fluoroscopy) who presented to our Level 1 pediatric ED both before and after this policy change. Before, all patients had formal post-reduction radiographs ("before"); after, the decision was left to the provider ("after"). Fractures were classified as distal radius and/or distal ulna (DR/DU), or both bone forearm (BBFA). Timestamp data was collected, as was the need for re-reduction or surgery. In addition to descriptive statistics, between-group differences were analyzed with t-tests, chi-square tests, and multivariable regression (to determine odds ratios [OR]).

Results
243 patients were included (119 before and 124 after). 165 patients sustained DR/DU fractures, and 78 sustained BBFA fractures. Demographic data were broadly similar between the before and after groups.
After protocol implementation, sedation times were longer, while the total ED time and the time from sedation beginning to discharge were similar (Table 1). The proportion of patients requiring re-reduction or surgery were similar before and after implementation.
However, on multivariable regression, "fluoroscopy as definitive imaging" was the only independent determinant of the various time intervals, compared to using conventional radiography. The length of sedation was 13.8 minutes longer (p<0.001), while the interval from sedation beginning to discharge was 15.8 minutes shorter (p=0.007), and total ED time was 33.0 minutes shorter (p=0.018). Fluoroscopy as definitive imaging was not a predictor of surgery (OR 0.63, p=0.520), although having a BBFA increased the likelihood (OR 4.5, p=0.008).

Conclusion
Implementing a protocol in which the provider could use mini c-arm fluoroscopy for definitive post-reduction imaging after manipulation of a closed, isolated wrist or forearm fracture, was found to be safe, with no increase in the need for re-reduction or surgery. Regression analysis further demonstrated time savings associated with foregoing conventional radiographs.


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