title: Reduction of radial-head subluxation in children by triage nurses in the emergency department: a cluster-randomized controlled trial.
abstract: BACKGROUND
  Radial-head subluxation is an easily identified and treated injury. We investigated whether triage nurses in the emergency department can safely reduce radial-head subluxation at rates that are not substantially lower than those of emergency department physicians.
  
  
  METHODS
  We performed an open, noninferiority, cluster-randomized control trial. Children aged 6 years and younger who presented to the emergency department with a presentation consistent with radial-head subluxation and who had sustained a known injury in the previous 12 hours were assigned to either nurse-initiated or physician-initiated treatment, depending on the day. The primary outcome was the proportion of children who had a successful reduction (return to normal arm usage). We used a noninferiority margin of 10%.
  
  
  RESULTS
  In total, 268 children were eligible for inclusion and 245 were included in the final analysis. Of the children assigned to receive physician-initiated care, 96.7% (117/121) had a successful reduction performed by a physician. Of the children assigned to receive nurse-treatment care, 84.7% (105/124) had a successful reduction performed by a nurse. The difference in the proportion of successful radial head subluxations between the groups was 12.0% (95% confidence interval [CI] 4.8% to 19.7%). Noninferiority of nurse-initiated radial head subluxation was not shown.
  
  
  CONCLUSIONS
  In this trial, the rate of successful radial-head subluxation performed by nurses was inferior to the physician success rate. Although the success rate in the nurse-initiated care group did not meet the non-inferiority margin, nurses were able to reduce radial head subluxation for almost 85% of children who presented with probable radial-head subluxation.
  
  
  BACKGROUND
  Clinical Trials.gov, no. NCT00993954.
authors.affiliation: Department of Pediatrics (Dixon), University of Alberta; Stollery Children's Hospital (Dixon), Edmonton, Alta.; Clinical Research Unit (Barrowman), Children's Hospital of Eastern Ontario Research Institute; Children's Hospital of Eastern Ontario Research Institute (Clarkin, Correll, Osmond, Plint), Ottawa, Ont.; Department of Pediatrics and Emergency Medicine (Osmond, Plint), University of Ottawa, Ottawa, Ont. Andrew.Dixon@AlbertaHealthServices.ca.
authors.forename: Andrew
authors.initials: A
authors.lastname: Dixon
authors.affiliation: Department of Pediatrics (Dixon), University of Alberta; Stollery Children's Hospital (Dixon), Edmonton, Alta.; Clinical Research Unit (Barrowman), Children's Hospital of Eastern Ontario Research Institute; Children's Hospital of Eastern Ontario Research Institute (Clarkin, Correll, Osmond, Plint), Ottawa, Ont.; Department of Pediatrics and Emergency Medicine (Osmond, Plint), University of Ottawa, Ottawa, Ont.
authors.forename: Chantalle
authors.initials: C
authors.lastname: Clarkin
authors.affiliation: Department of Pediatrics (Dixon), University of Alberta; Stollery Children's Hospital (Dixon), Edmonton, Alta.; Clinical Research Unit (Barrowman), Children's Hospital of Eastern Ontario Research Institute; Children's Hospital of Eastern Ontario Research Institute (Clarkin, Correll, Osmond, Plint), Ottawa, Ont.; Department of Pediatrics and Emergency Medicine (Osmond, Plint), University of Ottawa, Ottawa, Ont.
authors.forename: Nick
authors.initials: N
authors.lastname: Barrowman
authors.affiliation: Department of Pediatrics (Dixon), University of Alberta; Stollery Children's Hospital (Dixon), Edmonton, Alta.; Clinical Research Unit (Barrowman), Children's Hospital of Eastern Ontario Research Institute; Children's Hospital of Eastern Ontario Research Institute (Clarkin, Correll, Osmond, Plint), Ottawa, Ont.; Department of Pediatrics and Emergency Medicine (Osmond, Plint), University of Ottawa, Ottawa, Ont.
authors.forename: Rhonda
authors.initials: R
authors.lastname: Correll
authors.affiliation: Department of Pediatrics (Dixon), University of Alberta; Stollery Children's Hospital (Dixon), Edmonton, Alta.; Clinical Research Unit (Barrowman), Children's Hospital of Eastern Ontario Research Institute; Children's Hospital of Eastern Ontario Research Institute (Clarkin, Correll, Osmond, Plint), Ottawa, Ont.; Department of Pediatrics and Emergency Medicine (Osmond, Plint), University of Ottawa, Ottawa, Ont.
authors.forename: Martin H
authors.initials: MH
authors.lastname: Osmond
authors.affiliation: Department of Pediatrics (Dixon), University of Alberta; Stollery Children's Hospital (Dixon), Edmonton, Alta.; Clinical Research Unit (Barrowman), Children's Hospital of Eastern Ontario Research Institute; Children's Hospital of Eastern Ontario Research Institute (Clarkin, Correll, Osmond, Plint), Ottawa, Ont.; Department of Pediatrics and Emergency Medicine (Osmond, Plint), University of Ottawa, Ottawa, Ont.
authors.forename: Amy C
authors.initials: AC
authors.lastname: Plint
mesh_terms: D002648:Child; D002675:Child, Preschool; D016000:Cluster Analysis; D004636:Emergency Service, Hospital; D005260:Female; D006801:Humans; D007223:Infant; D004204:Joint Dislocations / Q000451:nursing*; D008297:Male; D009726:Nurses / Q000592:standards*; D019637:Orthopedic Procedures / Q000379:methods*; D011884:Radius / Q000293:injuries*; D016896:Treatment Outcome; D014218:Triage / Q000379:methods*; D000092464:Elbow Injuries