Improving Fracture Reduction Process Delivers Results

Tom Hurt, MD – Mary Bridge Children’s Emergency Department
Rebecca Whitesell, MD – Mary Bridge Children’s Orthopedic Services

Summer is right around the corner, and that means kids are chomping at the bit to get outdoors.  Although kids tend to be healthier in the summer, the number of broken bones goes up.  When it comes to treating pediatric forearm fractures, the orthopedic surgeons and emergency department (ED) physicians at Mary Bridge Children’s Hospital are carrying out a joint quality improvement project that’s showing promising results.

Even though the 2016 ACGME Revised Program Requirements for Pediatric Emergency Medicine state that “fellows should be provided didactic training and clinical exposure to attain competency in techniques of closed fracture reduction/splinting,” the reality is that few graduates of fellowships nationwide are actually trained to reduce difficult fractures and apply definitive casts.  Even in the expert hands of pediatric orthopedists, some studies have reported re-displacement rates after closed reduction and casting as high as 21-47%.

For the past two decades, a longstanding mentoring program between the veteran Mary Bridge ED (MBED) physicians and the newly hired members of the ED physician staff has resulted in all the MBED physicians attaining a satisfactory degree of competency in fracture reduction and casting.  A 2015 retrospective look at forearm fracture reduction outcomes in the MBED showed a re-displacement rate of 14.3%.  While this rate compared favorably with many programs nationwide, we felt there still was room for improvement.  We designed a process improvement project that involved mentoring of every MBED physician by one of the Mary Bridge pediatric orthopedic surgeons.  After every ED physician was mentored, a prospective outcome data collection phase was begun.  At the half-way mark of the post-intervention phase, the re-displacement rate has improved to only 6.4%.  Analysis of cost impact shows that fracture reduction and casting performed in the ED is associated with an average savings of $11,600 per patient when compared to patients taken to the operating room.  Fracture reduction carried out by ED physicians results in significant savings to the families, more timely care with shorter lengths of stay, and greater convenience to the on-call orthopedic surgeons.

Three related articles:

McLauchlan GJ, Cowan B, Annan IH, & Robb JE. Management of completely displaced metaphyseal fractures of the distal radius in children. J Bone Joint Surg (Br) 2002;84-B:413-17

Goldstein RY, Otsuka NY, Egol KA. Re-displacement of extraphyseal distal radius fractures following initial reduction in skeletally immature patients. Can it be prevented? Bull Hosp Jt Dis 2013;71(2):132-7.

Gulati A, Dixit A, Taylor GJ. Pediatric fractures: temporal trends and cost implications of treatment under general anesthesia. Eur J Trauma Emerg Surg 2012;38:59-64.