title: Reducing Cost and Radiation Exposure During the Treatment of Pediatric Greenstick Fractures of the Forearm.
abstract: 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. Ninety-four 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.
  
  
  METHODS
  Level IV-economic and decision analyses.
authors.affiliation: *Harvard Combined Orthopaedic Residency Program, Massachusetts General Hospital †Clinical Research Center ‡Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, MA.
authors.forename: Beverlie L
authors.initials: BL
authors.lastname: Ting
authors.forename: Leslie A
authors.initials: LA
authors.lastname: Kalish
authors.forename: Peter M
authors.initials: PM
authors.lastname: Waters
authors.forename: Donald S
authors.initials: DS
authors.lastname: Bae
mesh_terms: D000293:Adolescent; D002370:Casts, Surgical; D002648:Child; D002675:Child, Preschool; D003362:Cost-Benefit Analysis; D004636:Emergency Service, Hospital; D005260:Female; D005543:Forearm Injuries / Q000175:diagnosis / Q000191:economics / Q000628:therapy*; D006801:Humans; D008297:Male; D000069079:Radiation Exposure / Q000517:prevention & control*; D011859:Radiography; D011885:Radius Fractures / Q000175:diagnosis / Q000191:economics / Q000628:therapy*; D012189:Retrospective Studies; D016896:Treatment Outcome; D014458:Ulna Fractures / Q000175:diagnosis / Q000191:economics / Q000628:therapy*