ORIGINAL ARTICLE
Reducing Cost and Radiation Exposure During the Treatment of Pediatric Greenstick Fractures of the Forearm Beverlie L. Ting, MD,* Leslie A. Kalish, ScD,w Peter M. Waters, MD,z and Donald S. Bae, MDz
Background: We hypothesize that after successful closed reduction of pediatric greenstick fractures of the forearm, there is a low rate of lost reduction requiring intervention. By reducing the frequency of clinical and radiographic follow-up, we can reduce costs and radiation exposure. Methods: A retrospective analysis was performed on patients aged 2 to 16 years treated with closed reduction and cast immobilization for greenstick fractures of the forearm at our institution between 2003 and 2013. The primary endpoint was a healed fracture with acceptable alignment at the final radiographic evaluation. Time-derived activity-based costing was used for cost analysis. We estimated radiation exposure in consultation with our hospital’s radiation safety office. Results: One hundred and nine patients with an average age of 6.9 years (range, 2 to 15 y) met the inclusion criteria. The initial maximal fracture angulation of the affected radius and/or ulna averaged 19.3 (SD = ± 8.7) degrees (range, 2 to 55 degrees). Patients were followed for an average of 60 days (range, 19 to 635 d). On average, patients received 3.6 follow-up clinical visits and 3.5 sets of radiographs following immediate emergency department care. Ninetyfour percent of patients met criteria for acceptable radiographic alignment. Only 1 patient (0.9%; 95% confidence interval, 0.2%5.0%) underwent rereduction, as determined by the treating physician. If clinical follow-up were limited to 2 visits and 3 sets of radiographs total, there would be a 14.3% reduction in total cost of fracture care and a 41% reduction in radiation exposure. Conclusions: This retrospective study suggests that pediatric greenstick fractures of the forearm rarely require intervention after initial closed reduction. We propose that 2 clinical follow-up visits and 3 sets of radiographs would reduce overall care costs and radiation exposure without compromising clinical results. Level of Evidence: Level IV—economic and decision analyses. Key Words: forearm fractures, greenstick fractures, radiation, reducing costs, reducing radiation, closed treatment greenstick fractures of the forearm (J Pediatr Orthop 2015;00:000–000)
From the *Harvard Combined Orthopaedic Residency Program, Massachusetts General Hospital; wClinical Research Center; and zDepartment of Orthopaedic Surgery, Boston Children’s Hospital, Boston, MA. The authors declare no conflicts of interest. Reprints: Donald S. Bae, MD, Department of Orthopaedic Surgery, Boston Children’s Hospital, 300 Longwood Avenue, Hunnewell 2, Boston, MA 02115. E-mail: [email protected]. Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
J Pediatr Orthop
F
orearm fractures occur in approximately 1 in 100 children each year, with the highest frequency reported in the 5 to 14 years’ age group.1 Diaphyseal forearm fractures are often described by their anatomic location (proximal, middle, or distal thirds), degree of fracture displacement and angulation, and fracture pattern: plastic deformation, incomplete fracture or greenstick fracture, and complete fracture.2 Greenstick fractures are “incomplete” fractures, defined by disruption of 1 to 3 cortices on orthogonal radiographic views.2 These injuries are typically torsional injuries that can be successfully managed with closed reduction and cast immobilization. After initial reduction and wellmolded cast application, serial clinical and radiographic follow-up is recommended; however, the optimal frequency of follow-up is unknown. This is in part due to the paucity of published literature on loss of reduction (LOR) rates of greenstick fractures. Moreover, the criteria for acceptable alignment and LOR vary across studies.3–7 Although greenstick fractures have been shown to maintain reduction better than complete forearm fractures, the reported LOR rate ranges from 0% to 23%.3–7 Recommendations have included weekly clinical and radiographic follow-up for up to 4 weeks after initial reduction, in addition to a final clinical visit at 4 to 6 weeks for cast removal.8–10 In response to more recent concern over the potential harms of cumulative doses of radiation in children, 1 prospective study suggested that 2-week postreduction radiographs alone would detect nearly all cases of early fracture redisplacement in forearm fractures requiring reduction.7,11 The purpose of this investigation was to evaluate the LOR rate requiring intervention—including either repeat closed reduction or surgical reduction and fixation—following closed reduction and cast immobilization of pediatric greenstick forearm fractures. A secondary goal was to evaluate the optimal frequency of clinical and radiographic follow-up during the treatment of these injuries. We hypothesized that if adequate alignment is obtained after initial closed reduction and application of a well-molded cast, there is low risk of subsequent LOR requiring intervention. Therefore, serial outpatient clinic visits and radiographs impart unnecessary cost and radiation exposure without adding meaningful clinical benefit.
METHODS A retrospective analysis was performed of patients who presented between January 2003 and June 2013 to a
Volume 00, Number 00, ’’ 2015
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
www.pedorthopaedics.com |
1
Ting et al
level 1 pediatric trauma center with greenstick fractures of the forearm. Institutional Review Board approval was obtained. Inclusion criteria consisted of skeletally immature children between the ages of 2 and 16 years with adequate prereduction and postreduction anteroposterior (AP) and lateral (LAT) forearm radiographs obtained within a week of initial reduction. Patients with torus fractures or complete fractures, Monteggia fractures, Galeazzi fractures, pathologic fractures, open fractures, forearm refractures (within 6 mo of original injury), fractures >1 week old, or fractures that underwent initial manipulation at an outside hospital were excluded from the analysis. All patients were treated with closed reduction and above-elbow cast immobilization in the emergency department. The decision to bivalve the cast or leave it circumferentially intact was made by the treating attending orthopaedic surgeon. The attending surgeon also determined the frequency of subsequent clinical and radiographic follow-up. Demographic variables considered included age at time of injury, sex, laterality of the injury, and hand dominance. Radiographs were reviewed for initial degree of fracture angulation, whether the radius and/or ulna was involved, fracture location (proximal third, middle third, or distal third radius or ulna), the number of cortices involved on orthogonal radiographs (1, 2, or 3 cortices), the quality of reduction, the quality of casting as measured by both the cast index and the 3point index, and acceptable final radiographic alignment.12 Fracture angulation was measured separately in each bone and defined by the maximal angle from LAT and AP views. In patients who fractured both the radius and ulna, the overall fracture angulation was defined as the maximum across both bones. Apex radial and apex volar angulations were assigned positive values. Acceptable radiographic alignment of forearm fractures was defined as angulation of r10 degrees for all proximal third forearm fractures regardless of age. For middle and distal third forearm factures, alignment was considered acceptable in patients less than or equal to 8 years of age with r20 degrees of angulation and in patients greater than 8 years of age with r10 degrees of angulation.13 The primary endpoint was a healed fracture with acceptable alignment at the final radiograph based upon the criteria detailed above. We also examined how often LOR (> 5 degrees and >10 degrees compared with the first postreduction x-ray) was observed at different intervals over time, and how early this LOR was first detected. Time-derived activity-based costing (TDABC) was used for cost analysis.14 Detailed process maps were created for an established level 2 outpatient visit, AP and LAT forearm radiographs, and cast application expenses.14 Casting expense during follow-up was based on the application of a short arm cast in 84 patients (77%) and a reapplication of a long arm cast in 13 patients (12%); the remaining 12 patients did not require reapplication of a cast during an outpatient visit. For each process map, time estimates were created for each step, including time with the attending surgeon, midlevel pro-
2 | www.pedorthopaedics.com
J Pediatr Orthop
Volume 00, Number 00, ’’ 2015
vider, cast technician, x-ray technician, and receptionist. Hourly capacity cost rates were calculated for each provider based on annual salary and time available for clinical duty.14 Total cost was the product of capacity cost rate and time spent with the patient. We estimated radiation exposure in consultation with our hospital’s radiation safety office. The average radiation exposure dose for 6- to 10-year old patients undergoing forearm radiographs, calculated using methodology described by Huda and Gkanatsios,15 was used to estimate radiation exposure during the course of treatment. Unless otherwise stated, continuous measurements were summarized with the mean and SD ( ± SD) and categorical measurements with a percentage. When categorizing week of follow-up, we defined week 0 to be days 0 to 3 after reduction and used ± 3-day intervals for subsequent weeks (eg, week 1 was defined as days 4 to 10). Cast index and time in cast were compared between groups with a 2-sample t test. P-values are 2-sided and considered significant when 5 degrees
> 10 degrees
39 37 88 99 26 13
3 6 10 8 3 0
(7.7) (16.2) (11.4) (8.1) (11.5) (0.0)
1 2 0 2 2 0
(2.6) (5.4) (0.0) (2.0) (7.7) (0.0)
29 32 66 81 21 11
2 1 6 3 0 0
(6.9) (3.1) (9.1) (3.7) (0.0) (0.0)
0 0 0 0 0 0
(0.0) (0.0) (0.0) (0.0) (0.0) (0.0)
40 39 94 106 27 13
4 7 14 11 3 0
(10.0) (17.9) (14.9) (10.4) (11.1) (0.0)
1 2 0 2 2 0
(2.6) (5.4) (0.0) (2.0) (7.7) (0.0)
following intervals: week 0, week 1, week 2, week 3 to 4, week 5 to 7, week 8 to 10, week 11+ (Table 2). The most frequent intervals for follow-up x-rays were week 1 (90% of all patients), weeks 3 to 4 (86%), and weeks 5 to 7 (98%). We observed that the highest prevalence of LOR, defined as change in radiographic angulation of >5 degrees compared with the first postreduction radiograph, occurred at a week 2 visit (17.9%) (Table 3). Twenty patients (18.3%) exhibited LOR at some time during follow-up. Of these, 16 (80%) were first detected within 4 weeks and 19 (95%) within 6 weeks. However, based on final radiographs, 103 (94.5%) of 109 patients met criteria for acceptable alignment. Of the 6 patients who did not meet criteria for acceptable radiographic alignment at the final visit, 3 patients were 5 years of age or younger with many years of growth remaining and remodeling potential: 1 patient had a distal third radial shaft fracture with 28-degree angulation, another with a proximal third radius fracture with 11-degree angulation, and the final patient had a proximal third radius fracture with 12 degrees of angulation. The remaining patients included a 14 year old with a mid-diaphyseal radius fracture with 16-degree angulation, an 11 year old with a 12degree distal third radius fracture, and a 10 year old with a 12-degree distal third radius fracture; all of whom were judged by the attending surgeon to have the ability to remodel their fracture malalignment with growth remaining. Unacceptable radiographic alignment was first appreciated by the 2-week postinjury visit in 5 of 6 of these patients. Only 1 patient (0.9%; 95% confidence interval, 0.2%-5.0%) underwent repeat closed reduction, as determined by the treating physician based on clinical and radiographic follow-up 10 days after injury. This patient
2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
www.pedorthopaedics.com |
3
J Pediatr Orthop
Ting et al
was a 5-year-old male with a both bone mid-diaphyseal fracture with initial fracture angulations of 12 and 19 degrees of his radius and ulna, respectively. On his first follow-up visit, he was noted to have 14 and 15 degrees of angulation of his radius and ulna, respectively. After rereduction in the operating room, his angulation improved to 9 and 9 degrees with full range of motion noted in the operating room. No patient required operative fixation.
Cost Analysis On the basis of our findings that the highest prevalence of LOR occurred at the 2-week mark and that nearly all patients who did not achieve acceptable final radiographic alignment could be detected at the 2-week visit, the 2-week postinjury visit is imperative. Furthermore, nearly all patients who exhibited LOR, did so by the 6-week postinjury mark; thus we propose a final 6-week postinjury visit. The potential cost-saving of scheduling only 2 clinical visits with radiographic evaluation was estimated using TDABC, which accounts for the cost of each resource used and the quantity of time the patient spends with each resource during a cycle of care.14 The total cost of care, including emergency department care, was estimated to be $1046.13 for an average of 1.41 emergency department x-rays, 3.6 outpatient orthopaedic follow-up clinical visits, 3.5 outpatient radiographs, and 1 outpatient short arm cast application. This could be reduced to $896.14, a 14.3% reduction in the cost of total care, by following a protocol of 1 set of emergency room x-rays, 2 clinical follow-ups, and 2 sets of radiographs, including elimination of transition to a short arm cast.
Radiation Exposure The estimated entrance skin exposure for 3 views of the forearm in a child aged 6 to 10 years of age is 20 mrem without a cast on, and 28 mrem with a cast on. The calculated equivalent whole body dose is 1.5 and 2 mrem, respectively. By obtaining only 2 follow-up forearm radiographs with a cast on, we would reduce overall radiation exposure by 41% during the total course of care.
DISCUSSION In cases of pediatric forearm fractures requiring manipulation, several authors have advocated for frequent clinical and radiographic follow-up to detect early LOR.8,9 At our institution, the most frequent follow-up intervals for greenstick fractures of the forearm were week 1, week 3 to 4, and weeks 5 to 7. Following care in the emergency department care, patients on average had 3.6 follow-up clinical visits and 3.5 radiographs. On the basis of this investigation of solely pediatric greenstick fractures of the forearm, we propose that scheduling clinical and radiographic evaluations at week 2 and 6 after injury will reduce both cost and radiation exposure, while still providing opportunity to detect LOR during the highest risk period. Although there were changes in radiographic alignment that occurred after 2 weeks from time of reduction, there were only 4 of 109 patients with >10-degree change in angulation from
4 | www.pedorthopaedics.com
Volume 00, Number 00, ’’ 2015
postreduction radiographs. Of these 4 patients, LOR > 10 degrees was detected by 2-week postreduction in 2 patients. These 4 patients included a 6-year old with a distal third fracture, initial maximal fracture angulation of 18 degrees, and postreduction maximal angulation of 7 degrees, who lost reduction 15 days after reduction and ultimately healed with 18 degrees of maximal angulation. There was a 2-year old with a proximal third fracture, initial maximal fracture angulation of 40 degrees, and postreduction angulation of 0 degree, who was found to have 20-degree angulation 6 days after reduction. This patient ultimately healed with 3 degrees of maximal angulation. There was also a 5-year old with a middle third fracture, initial maximal radial angulation of 17 degrees on a LAT radiograph, and 3 degrees of maximal radial angulation on postreduction films, who was found to have 15-degree angulation 28 days after reduction. Finally, there was a 3-year old with a distal third fracture, initial maximal fracture angulation of 25 degrees, and postreduction angulation of 4 degrees who lost reduction 32 days after reduction with 18 degrees of maximal angulation. All of these patients met criteria for acceptable radiographic alignment at the final follow-up. Ultimately, only 6 patients (5.5%) did not meet criteria for acceptable alignment based on final radiographs. Furthermore, only 1 patient underwent remanipulation, and no patients required operative fixation. The highest prevalence of LOR of >5 degrees occurred at the 2-week visit. Thus, a 2-week clinical visit would allow for detection of early LOR in a timely manner, allowing for intervention if warranted. In 95% of patients with LOR > 5 degrees, the LOR was first detected within 6 weeks. A final visit at the 6week postinjury mark with radiographic evaluation and cast removal will allow for evaluation and documentation of interval healing. Considerable cost savings would be realized by eliminating the postreduction radiograph and scheduling only 2 additional clinic follow-up visits and radiographs, without compromising the ability to identify LOR or ultimate clinical results. Furthermore, while TDABC is a powerful accounting methodology for characterizing cost of care, it is possible that additional, unmeasured cost savings from a societal perspective (eg, fewer clinic visits would result in less parental time off from work and perhaps greater satisfaction) would be realized with the changes in follow-up proposed here. Limitations of this study include its retrospective design, with the attendant selection and treatment biases. Specifically, decisions regarding continued observation or intervention were determined by the treating attending pediatric orthopaedist. There was variation in follow-up intervals, as treating providers determined follow-up schedules independently. More uniform follow-up intervals would ensure that analysis at each interval applied to all patients; however, using our categories, we had at least 83% to 89% follow-up at week 1, week 3 to 4, and week 5 to 7. Second, rotational alignment was not analyzed. Rotational malalignment is difficult to accurately assess radiographically. Proposed techniques to measure rotational alignment include obtaining contralateral forearm Copyright
r
2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
J Pediatr Orthop
Volume 00, Number 00, ’’ 2015
radiographs, assessing the shape and diameter of fracture fragments, and examining the radius crossover sign.16 Furthermore, we do not have long-term clinical follow-up for our patients and thus cannot draw conclusions regarding the effects on long-term range of motion. However, the high rate of fractures that met acceptable alignment criteria based on final radiographs is reassuring. There were no return visits regarding long-term loss of forearm rotation following the acute treatment of any forearm greenstick fracture in our electronic medical records database. In addition, satisfaction with care was not characterized; future investigation should include the effect—positive or negative—of decreasing frequency of follow-up evaluations on patient and parent satisfaction. Finally, we did not account for radiation exposure from the fluoroscopic imaging intensifier during fracture reduction in the emergency department. Recent studies support that there is a linear relationship between increasing radiation exposure and cancer risk and that there is no threshold radiation dose. Thus, even a small increase in radiation exposure can result in an increased cancer risk, especially in children.11,17 Every effort should be made to eliminate radiographs that do not affect clinical care. By reducing the number of radiographs and associated follow-up visits, health care expenditures can also be reduced in a country where health care costs continue to soar at an unsustainable rate.18 This retrospective study suggests that pediatric greenstick fractures of the forearm rarely require intervention after initial closed reduction. We propose that 2 clinical follow-up visits and 3 sets of radiographs (injury films, 2-wk follow-up films, 6-wk follow-up films) would reduce overall radiation exposure and care costs without compromising care. REFERENCES 1. Chung KC, Spilson SV. The frequency and epidemiology of hand and forearm fractures in the United States. J Hand Surg. 2001; 26:908–915.
Copyright
r
Reducing Cost and Radiation Exposure
2. Bae DS. Pediatric distal radius and forearm fractures. J Hand Surg. 2008;33:1911–1923. 3. Evans EM. Fractures of the radius and ulna. J Bone Joint Surg Br. 1951;33-B:548–561. 4. Davis DR, Green DP. Forearm fractures in children: pitfalls and complications. Clin Orthop. 1976;120:172–183. 5. Green JS, Williams SC, Finlay D, et al. Distal forearm fractures in children: the role of radiographs during follow up. Injury. 1998;29: 309–312. 6. Boyer BA, Overton B, Schrader W, et al. Position of immobilization for pediatric forearm fractures. J Pediatr Orthop. 2002;22:185–187. 7. Bochang C, Katz K, Weigl D, et al. Are frequent radiographs necessary in the management of closed forearm fractures in children? J Child Orthop. 2008;2:217–220. 8. Bohm ER, Bubbar V, Yong Hing K, et al. Above and below-theelbow plaster casts for distal forearm fractures in children. A randomized controlled trial. J Bone Joint Surg Am. 2006;88: 1–8. 9. Bowman EN, Mehlman CT, Lindsell CJ, et al. Non-operative treatment of both-bone forearm shaft fractures in children: Predictors of early radiographic failure. J Pediatr Orthop. 2011;31: 23–32. 10. Beaty JH, Kasser JR. Rockwood and Wilkins’ Fractures in Children. Philadelphia, PA: Lippincott Williams & Wilkins; 2010. 11. Kleinerman RA. Cancer risks following diagnostic and therapeutic radiation exposure in children. Pediatr Radiol. 2006;36(suppl 2):121–125. 12. Alemdarog˘lu KB, Iltar S, Cimen O, et al. Risk factors in redisplacement of distal radial fractures in children. J Bone Joint Surg Am. 2008;90:1224–1230. 13. Price CT. Acceptable alignment of forearm fractures in children: open reduction indications. [Miscellaneous article]. J Pediatr Orthop March 2010. 2010;30(Suppl 2):S82–S84. 14. Kaplan RS, Porter ME. How to solve the cost crisis in health care. Harv Bus Rev. 2011;89:46–52. 54, 56-61 passim. 15. Huda W, Gkanatsios NA. Radiation dosimetry for extremity radiographs. Health Phys. 1998;75:492–499. 16. Wright PB, Crepeau AE, Herrera-Soto JA, et al. Radius crossover sign: an indication of malreduced radius shaft greenstick fractures. [Miscellaneous article]. J Pediatr Orthop. 2012;32:e15–e19. 17. Health Risks from Exposure to Low Levels of Ionizing Radiation: BEIR VII Phase 2. Available at: http://www.nap.edu/openbook.php?record_id = 11340&page = 6. Accessed May 27, 2014. 18. Berwick DM, Hackbarth AD. Eliminating waste in us health care. JAMA. 2012;307:1513–1516.
2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
www.pedorthopaedics.com |
5
Reducing Cost and Radiation Exposure During the Treatment of Pediatric Greenstick Fractures of the Forearm Beverlie L. Ting, MD,* Leslie A. Kalish, ScD,w Peter M. Waters, MD,z and Donald S. Bae, MDz
Background: We hypothesize that after successful closed reduction of pediatric greenstick fractures of the forearm, there is a low rate of lost reduction requiring intervention. By reducing the frequency of clinical and radiographic follow-up, we can reduce costs and radiation exposure. Methods: A retrospective analysis was performed on patients aged 2 to 16 years treated with closed reduction and cast immobilization for greenstick fractures of the forearm at our institution between 2003 and 2013. The primary endpoint was a healed fracture with acceptable alignment at the final radiographic evaluation. Time-derived activity-based costing was used for cost analysis. We estimated radiation exposure in consultation with our hospital’s radiation safety office. Results: One hundred and nine patients with an average age of 6.9 years (range, 2 to 15 y) met the inclusion criteria. The initial maximal fracture angulation of the affected radius and/or ulna averaged 19.3 (SD = ± 8.7) degrees (range, 2 to 55 degrees). Patients were followed for an average of 60 days (range, 19 to 635 d). On average, patients received 3.6 follow-up clinical visits and 3.5 sets of radiographs following immediate emergency department care. Ninetyfour percent of patients met criteria for acceptable radiographic alignment. Only 1 patient (0.9%; 95% confidence interval, 0.2%5.0%) underwent rereduction, as determined by the treating physician. If clinical follow-up were limited to 2 visits and 3 sets of radiographs total, there would be a 14.3% reduction in total cost of fracture care and a 41% reduction in radiation exposure. Conclusions: This retrospective study suggests that pediatric greenstick fractures of the forearm rarely require intervention after initial closed reduction. We propose that 2 clinical follow-up visits and 3 sets of radiographs would reduce overall care costs and radiation exposure without compromising clinical results. Level of Evidence: Level IV—economic and decision analyses. Key Words: forearm fractures, greenstick fractures, radiation, reducing costs, reducing radiation, closed treatment greenstick fractures of the forearm (J Pediatr Orthop 2015;00:000–000)
From the *Harvard Combined Orthopaedic Residency Program, Massachusetts General Hospital; wClinical Research Center; and zDepartment of Orthopaedic Surgery, Boston Children’s Hospital, Boston, MA. The authors declare no conflicts of interest. Reprints: Donald S. Bae, MD, Department of Orthopaedic Surgery, Boston Children’s Hospital, 300 Longwood Avenue, Hunnewell 2, Boston, MA 02115. E-mail: [email protected]. Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
J Pediatr Orthop
F
orearm fractures occur in approximately 1 in 100 children each year, with the highest frequency reported in the 5 to 14 years’ age group.1 Diaphyseal forearm fractures are often described by their anatomic location (proximal, middle, or distal thirds), degree of fracture displacement and angulation, and fracture pattern: plastic deformation, incomplete fracture or greenstick fracture, and complete fracture.2 Greenstick fractures are “incomplete” fractures, defined by disruption of 1 to 3 cortices on orthogonal radiographic views.2 These injuries are typically torsional injuries that can be successfully managed with closed reduction and cast immobilization. After initial reduction and wellmolded cast application, serial clinical and radiographic follow-up is recommended; however, the optimal frequency of follow-up is unknown. This is in part due to the paucity of published literature on loss of reduction (LOR) rates of greenstick fractures. Moreover, the criteria for acceptable alignment and LOR vary across studies.3–7 Although greenstick fractures have been shown to maintain reduction better than complete forearm fractures, the reported LOR rate ranges from 0% to 23%.3–7 Recommendations have included weekly clinical and radiographic follow-up for up to 4 weeks after initial reduction, in addition to a final clinical visit at 4 to 6 weeks for cast removal.8–10 In response to more recent concern over the potential harms of cumulative doses of radiation in children, 1 prospective study suggested that 2-week postreduction radiographs alone would detect nearly all cases of early fracture redisplacement in forearm fractures requiring reduction.7,11 The purpose of this investigation was to evaluate the LOR rate requiring intervention—including either repeat closed reduction or surgical reduction and fixation—following closed reduction and cast immobilization of pediatric greenstick forearm fractures. A secondary goal was to evaluate the optimal frequency of clinical and radiographic follow-up during the treatment of these injuries. We hypothesized that if adequate alignment is obtained after initial closed reduction and application of a well-molded cast, there is low risk of subsequent LOR requiring intervention. Therefore, serial outpatient clinic visits and radiographs impart unnecessary cost and radiation exposure without adding meaningful clinical benefit.
METHODS A retrospective analysis was performed of patients who presented between January 2003 and June 2013 to a
Volume 00, Number 00, ’’ 2015
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
www.pedorthopaedics.com |
1
Ting et al
level 1 pediatric trauma center with greenstick fractures of the forearm. Institutional Review Board approval was obtained. Inclusion criteria consisted of skeletally immature children between the ages of 2 and 16 years with adequate prereduction and postreduction anteroposterior (AP) and lateral (LAT) forearm radiographs obtained within a week of initial reduction. Patients with torus fractures or complete fractures, Monteggia fractures, Galeazzi fractures, pathologic fractures, open fractures, forearm refractures (within 6 mo of original injury), fractures >1 week old, or fractures that underwent initial manipulation at an outside hospital were excluded from the analysis. All patients were treated with closed reduction and above-elbow cast immobilization in the emergency department. The decision to bivalve the cast or leave it circumferentially intact was made by the treating attending orthopaedic surgeon. The attending surgeon also determined the frequency of subsequent clinical and radiographic follow-up. Demographic variables considered included age at time of injury, sex, laterality of the injury, and hand dominance. Radiographs were reviewed for initial degree of fracture angulation, whether the radius and/or ulna was involved, fracture location (proximal third, middle third, or distal third radius or ulna), the number of cortices involved on orthogonal radiographs (1, 2, or 3 cortices), the quality of reduction, the quality of casting as measured by both the cast index and the 3point index, and acceptable final radiographic alignment.12 Fracture angulation was measured separately in each bone and defined by the maximal angle from LAT and AP views. In patients who fractured both the radius and ulna, the overall fracture angulation was defined as the maximum across both bones. Apex radial and apex volar angulations were assigned positive values. Acceptable radiographic alignment of forearm fractures was defined as angulation of r10 degrees for all proximal third forearm fractures regardless of age. For middle and distal third forearm factures, alignment was considered acceptable in patients less than or equal to 8 years of age with r20 degrees of angulation and in patients greater than 8 years of age with r10 degrees of angulation.13 The primary endpoint was a healed fracture with acceptable alignment at the final radiograph based upon the criteria detailed above. We also examined how often LOR (> 5 degrees and >10 degrees compared with the first postreduction x-ray) was observed at different intervals over time, and how early this LOR was first detected. Time-derived activity-based costing (TDABC) was used for cost analysis.14 Detailed process maps were created for an established level 2 outpatient visit, AP and LAT forearm radiographs, and cast application expenses.14 Casting expense during follow-up was based on the application of a short arm cast in 84 patients (77%) and a reapplication of a long arm cast in 13 patients (12%); the remaining 12 patients did not require reapplication of a cast during an outpatient visit. For each process map, time estimates were created for each step, including time with the attending surgeon, midlevel pro-
2 | www.pedorthopaedics.com
J Pediatr Orthop
Volume 00, Number 00, ’’ 2015
vider, cast technician, x-ray technician, and receptionist. Hourly capacity cost rates were calculated for each provider based on annual salary and time available for clinical duty.14 Total cost was the product of capacity cost rate and time spent with the patient. We estimated radiation exposure in consultation with our hospital’s radiation safety office. The average radiation exposure dose for 6- to 10-year old patients undergoing forearm radiographs, calculated using methodology described by Huda and Gkanatsios,15 was used to estimate radiation exposure during the course of treatment. Unless otherwise stated, continuous measurements were summarized with the mean and SD ( ± SD) and categorical measurements with a percentage. When categorizing week of follow-up, we defined week 0 to be days 0 to 3 after reduction and used ± 3-day intervals for subsequent weeks (eg, week 1 was defined as days 4 to 10). Cast index and time in cast were compared between groups with a 2-sample t test. P-values are 2-sided and considered significant when 5 degrees
> 10 degrees
39 37 88 99 26 13
3 6 10 8 3 0
(7.7) (16.2) (11.4) (8.1) (11.5) (0.0)
1 2 0 2 2 0
(2.6) (5.4) (0.0) (2.0) (7.7) (0.0)
29 32 66 81 21 11
2 1 6 3 0 0
(6.9) (3.1) (9.1) (3.7) (0.0) (0.0)
0 0 0 0 0 0
(0.0) (0.0) (0.0) (0.0) (0.0) (0.0)
40 39 94 106 27 13
4 7 14 11 3 0
(10.0) (17.9) (14.9) (10.4) (11.1) (0.0)
1 2 0 2 2 0
(2.6) (5.4) (0.0) (2.0) (7.7) (0.0)
following intervals: week 0, week 1, week 2, week 3 to 4, week 5 to 7, week 8 to 10, week 11+ (Table 2). The most frequent intervals for follow-up x-rays were week 1 (90% of all patients), weeks 3 to 4 (86%), and weeks 5 to 7 (98%). We observed that the highest prevalence of LOR, defined as change in radiographic angulation of >5 degrees compared with the first postreduction radiograph, occurred at a week 2 visit (17.9%) (Table 3). Twenty patients (18.3%) exhibited LOR at some time during follow-up. Of these, 16 (80%) were first detected within 4 weeks and 19 (95%) within 6 weeks. However, based on final radiographs, 103 (94.5%) of 109 patients met criteria for acceptable alignment. Of the 6 patients who did not meet criteria for acceptable radiographic alignment at the final visit, 3 patients were 5 years of age or younger with many years of growth remaining and remodeling potential: 1 patient had a distal third radial shaft fracture with 28-degree angulation, another with a proximal third radius fracture with 11-degree angulation, and the final patient had a proximal third radius fracture with 12 degrees of angulation. The remaining patients included a 14 year old with a mid-diaphyseal radius fracture with 16-degree angulation, an 11 year old with a 12degree distal third radius fracture, and a 10 year old with a 12-degree distal third radius fracture; all of whom were judged by the attending surgeon to have the ability to remodel their fracture malalignment with growth remaining. Unacceptable radiographic alignment was first appreciated by the 2-week postinjury visit in 5 of 6 of these patients. Only 1 patient (0.9%; 95% confidence interval, 0.2%-5.0%) underwent repeat closed reduction, as determined by the treating physician based on clinical and radiographic follow-up 10 days after injury. This patient
2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
www.pedorthopaedics.com |
3
J Pediatr Orthop
Ting et al
was a 5-year-old male with a both bone mid-diaphyseal fracture with initial fracture angulations of 12 and 19 degrees of his radius and ulna, respectively. On his first follow-up visit, he was noted to have 14 and 15 degrees of angulation of his radius and ulna, respectively. After rereduction in the operating room, his angulation improved to 9 and 9 degrees with full range of motion noted in the operating room. No patient required operative fixation.
Cost Analysis On the basis of our findings that the highest prevalence of LOR occurred at the 2-week mark and that nearly all patients who did not achieve acceptable final radiographic alignment could be detected at the 2-week visit, the 2-week postinjury visit is imperative. Furthermore, nearly all patients who exhibited LOR, did so by the 6-week postinjury mark; thus we propose a final 6-week postinjury visit. The potential cost-saving of scheduling only 2 clinical visits with radiographic evaluation was estimated using TDABC, which accounts for the cost of each resource used and the quantity of time the patient spends with each resource during a cycle of care.14 The total cost of care, including emergency department care, was estimated to be $1046.13 for an average of 1.41 emergency department x-rays, 3.6 outpatient orthopaedic follow-up clinical visits, 3.5 outpatient radiographs, and 1 outpatient short arm cast application. This could be reduced to $896.14, a 14.3% reduction in the cost of total care, by following a protocol of 1 set of emergency room x-rays, 2 clinical follow-ups, and 2 sets of radiographs, including elimination of transition to a short arm cast.
Radiation Exposure The estimated entrance skin exposure for 3 views of the forearm in a child aged 6 to 10 years of age is 20 mrem without a cast on, and 28 mrem with a cast on. The calculated equivalent whole body dose is 1.5 and 2 mrem, respectively. By obtaining only 2 follow-up forearm radiographs with a cast on, we would reduce overall radiation exposure by 41% during the total course of care.
DISCUSSION In cases of pediatric forearm fractures requiring manipulation, several authors have advocated for frequent clinical and radiographic follow-up to detect early LOR.8,9 At our institution, the most frequent follow-up intervals for greenstick fractures of the forearm were week 1, week 3 to 4, and weeks 5 to 7. Following care in the emergency department care, patients on average had 3.6 follow-up clinical visits and 3.5 radiographs. On the basis of this investigation of solely pediatric greenstick fractures of the forearm, we propose that scheduling clinical and radiographic evaluations at week 2 and 6 after injury will reduce both cost and radiation exposure, while still providing opportunity to detect LOR during the highest risk period. Although there were changes in radiographic alignment that occurred after 2 weeks from time of reduction, there were only 4 of 109 patients with >10-degree change in angulation from
4 | www.pedorthopaedics.com
Volume 00, Number 00, ’’ 2015
postreduction radiographs. Of these 4 patients, LOR > 10 degrees was detected by 2-week postreduction in 2 patients. These 4 patients included a 6-year old with a distal third fracture, initial maximal fracture angulation of 18 degrees, and postreduction maximal angulation of 7 degrees, who lost reduction 15 days after reduction and ultimately healed with 18 degrees of maximal angulation. There was a 2-year old with a proximal third fracture, initial maximal fracture angulation of 40 degrees, and postreduction angulation of 0 degree, who was found to have 20-degree angulation 6 days after reduction. This patient ultimately healed with 3 degrees of maximal angulation. There was also a 5-year old with a middle third fracture, initial maximal radial angulation of 17 degrees on a LAT radiograph, and 3 degrees of maximal radial angulation on postreduction films, who was found to have 15-degree angulation 28 days after reduction. Finally, there was a 3-year old with a distal third fracture, initial maximal fracture angulation of 25 degrees, and postreduction angulation of 4 degrees who lost reduction 32 days after reduction with 18 degrees of maximal angulation. All of these patients met criteria for acceptable radiographic alignment at the final follow-up. Ultimately, only 6 patients (5.5%) did not meet criteria for acceptable alignment based on final radiographs. Furthermore, only 1 patient underwent remanipulation, and no patients required operative fixation. The highest prevalence of LOR of >5 degrees occurred at the 2-week visit. Thus, a 2-week clinical visit would allow for detection of early LOR in a timely manner, allowing for intervention if warranted. In 95% of patients with LOR > 5 degrees, the LOR was first detected within 6 weeks. A final visit at the 6week postinjury mark with radiographic evaluation and cast removal will allow for evaluation and documentation of interval healing. Considerable cost savings would be realized by eliminating the postreduction radiograph and scheduling only 2 additional clinic follow-up visits and radiographs, without compromising the ability to identify LOR or ultimate clinical results. Furthermore, while TDABC is a powerful accounting methodology for characterizing cost of care, it is possible that additional, unmeasured cost savings from a societal perspective (eg, fewer clinic visits would result in less parental time off from work and perhaps greater satisfaction) would be realized with the changes in follow-up proposed here. Limitations of this study include its retrospective design, with the attendant selection and treatment biases. Specifically, decisions regarding continued observation or intervention were determined by the treating attending pediatric orthopaedist. There was variation in follow-up intervals, as treating providers determined follow-up schedules independently. More uniform follow-up intervals would ensure that analysis at each interval applied to all patients; however, using our categories, we had at least 83% to 89% follow-up at week 1, week 3 to 4, and week 5 to 7. Second, rotational alignment was not analyzed. Rotational malalignment is difficult to accurately assess radiographically. Proposed techniques to measure rotational alignment include obtaining contralateral forearm Copyright
r
2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
J Pediatr Orthop
Volume 00, Number 00, ’’ 2015
radiographs, assessing the shape and diameter of fracture fragments, and examining the radius crossover sign.16 Furthermore, we do not have long-term clinical follow-up for our patients and thus cannot draw conclusions regarding the effects on long-term range of motion. However, the high rate of fractures that met acceptable alignment criteria based on final radiographs is reassuring. There were no return visits regarding long-term loss of forearm rotation following the acute treatment of any forearm greenstick fracture in our electronic medical records database. In addition, satisfaction with care was not characterized; future investigation should include the effect—positive or negative—of decreasing frequency of follow-up evaluations on patient and parent satisfaction. Finally, we did not account for radiation exposure from the fluoroscopic imaging intensifier during fracture reduction in the emergency department. Recent studies support that there is a linear relationship between increasing radiation exposure and cancer risk and that there is no threshold radiation dose. Thus, even a small increase in radiation exposure can result in an increased cancer risk, especially in children.11,17 Every effort should be made to eliminate radiographs that do not affect clinical care. By reducing the number of radiographs and associated follow-up visits, health care expenditures can also be reduced in a country where health care costs continue to soar at an unsustainable rate.18 This retrospective study suggests that pediatric greenstick fractures of the forearm rarely require intervention after initial closed reduction. We propose that 2 clinical follow-up visits and 3 sets of radiographs (injury films, 2-wk follow-up films, 6-wk follow-up films) would reduce overall radiation exposure and care costs without compromising care. REFERENCES 1. Chung KC, Spilson SV. The frequency and epidemiology of hand and forearm fractures in the United States. J Hand Surg. 2001; 26:908–915.
Copyright
r
Reducing Cost and Radiation Exposure
2. Bae DS. Pediatric distal radius and forearm fractures. J Hand Surg. 2008;33:1911–1923. 3. Evans EM. Fractures of the radius and ulna. J Bone Joint Surg Br. 1951;33-B:548–561. 4. Davis DR, Green DP. Forearm fractures in children: pitfalls and complications. Clin Orthop. 1976;120:172–183. 5. Green JS, Williams SC, Finlay D, et al. Distal forearm fractures in children: the role of radiographs during follow up. Injury. 1998;29: 309–312. 6. Boyer BA, Overton B, Schrader W, et al. Position of immobilization for pediatric forearm fractures. J Pediatr Orthop. 2002;22:185–187. 7. Bochang C, Katz K, Weigl D, et al. Are frequent radiographs necessary in the management of closed forearm fractures in children? J Child Orthop. 2008;2:217–220. 8. Bohm ER, Bubbar V, Yong Hing K, et al. Above and below-theelbow plaster casts for distal forearm fractures in children. A randomized controlled trial. J Bone Joint Surg Am. 2006;88: 1–8. 9. Bowman EN, Mehlman CT, Lindsell CJ, et al. Non-operative treatment of both-bone forearm shaft fractures in children: Predictors of early radiographic failure. J Pediatr Orthop. 2011;31: 23–32. 10. Beaty JH, Kasser JR. Rockwood and Wilkins’ Fractures in Children. Philadelphia, PA: Lippincott Williams & Wilkins; 2010. 11. Kleinerman RA. Cancer risks following diagnostic and therapeutic radiation exposure in children. Pediatr Radiol. 2006;36(suppl 2):121–125. 12. Alemdarog˘lu KB, Iltar S, Cimen O, et al. Risk factors in redisplacement of distal radial fractures in children. J Bone Joint Surg Am. 2008;90:1224–1230. 13. Price CT. Acceptable alignment of forearm fractures in children: open reduction indications. [Miscellaneous article]. J Pediatr Orthop March 2010. 2010;30(Suppl 2):S82–S84. 14. Kaplan RS, Porter ME. How to solve the cost crisis in health care. Harv Bus Rev. 2011;89:46–52. 54, 56-61 passim. 15. Huda W, Gkanatsios NA. Radiation dosimetry for extremity radiographs. Health Phys. 1998;75:492–499. 16. Wright PB, Crepeau AE, Herrera-Soto JA, et al. Radius crossover sign: an indication of malreduced radius shaft greenstick fractures. [Miscellaneous article]. J Pediatr Orthop. 2012;32:e15–e19. 17. Health Risks from Exposure to Low Levels of Ionizing Radiation: BEIR VII Phase 2. Available at: http://www.nap.edu/openbook.php?record_id = 11340&page = 6. Accessed May 27, 2014. 18. Berwick DM, Hackbarth AD. Eliminating waste in us health care. JAMA. 2012;307:1513–1516.
2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
www.pedorthopaedics.com |
5
