Redefining Orthopaedic Expectations of Pediatric Fracture Reductions Performed in Hybrid Emergency Departments

BACKGROUND: Many pediatric emergency department (ED) visits do not occur at a standalone pediatric hospital. Although anticipated outcomes after pediatric fracture reductions are published by tertiary children's centers, limited data originate from the more common hybrid (pediatric and adult) ED setting, where general emergency medicine (EM) clinicians perform reductions. This study aims to clarify success rates after pediatric fracture reductions were performed within a regional health network's emergency medicine system, whereafter subsequent in-network pediatric orthopaedic surgeon follow-up was routine. METHODS: Patients 16 years old or younger who underwent ED manipulation of an isolated, acute fracture within a 16-hospital health network during a 5.5-year period were retrospectively reviewed. Radiographic minimal threshold criteria were analyzed to define postreduction fracture alignment as improved versus unchanged. Each patient's reduction was then categorized as successful, suboptimal, or failed. Outcome categories acknowledged clinically relevant differences between orthopaedic versus EM goals (ie, nonoperative management after improved alignment versus a temporizing reduction that allowed safe outpatient follow-up). Univariate logistic regression identified risk factors associated with each clinical course. RESULTS: Among 437 fractures (mostly forearm) in patients averaging 10.1±3.6 years old, 96% received at least one reduction attempt by an EM clinician. Alignment was successfully improved in 267 (61%) patients and suboptimally improved in an additional 89 (20%). EM clinicians did not change alignment after reduction in 77 (19%) patients. Age 10 years or younger yielded higher odds of success (OR: 1.8, 95% CI: 1.2-2.6). Reduction in the coronal/sagittal plane carried higher odds of improving alignment (OR: 13.1, 95% CI: 7.5-22.4) than translation or correction of prereduction bayonet apposition. Multiple reduction attempts, age older than 10 years, and pharmacological analgesia without conscious sedation were associated with failure. CONCLUSION: General EM physicians often achieve some form of success during pediatric fracture reductions. Pediatric orthopaedic leaders should encourage EM physicians to prioritize coronal/sagittal alignment, be aware that patients 10 years old or younger can remodel certain fractures better than older patients, optimize anesthetic strategies during reduction, and seek orthopaedic input before multiple manipulation attempts in a child. LEVEL OF EVIDENCE: Level IV.