title: Feasibility of a reduction protocol in the emergency department for diaphyseal forearm fractures in children.
abstract: BACKGROUND
  Diaphyseal forearm fractures are very common pediatric traumas. At present, distal radius metaphyseal fractures are often successfully treated with closed reduction by emergency physicians. However, the management of diaphyseal fractures remains controversial. The purpose of this study was to analyze the results of diaphyseal forearm fractures in the emergency department (ED) in children.
  
  
  METHODS
  In a prospective 2-year-study, all closed diaphyseal forearm fractures in patients under 15, with an angle of >15° and treated by closed reduction in the ED were included. Fractures with overlapping fragments were excluded. Reduction was performed by an emergency physician, with a standardized analgesic protocol (painkillers and nitrous oxide). Clinical tolerance was checked within the first 24hours, and the radiographic stability of reduction was assessed at days 8 and 15. Initial and final follow-up radiographs were analyzed. Elbow and wrist range of motion was assessed at the final follow-up.
  
  
  RESULTS
  Sixty patients (41 boys and 19 girls) were included. Mean age was 5.2 years old (±3). At initial evaluation, the maximum angle was 30° (±11.3). After reduction, the maximum angle was significantly reduced (30° vs. 5°, P<0.001). Mean immobilization in a cast was 11.7 weeks (±2). There were no cast related complications in any of these children. There was no surgery for secondary displacement. Full range of motion was obtained in all patients at the final follow-up.
  
  
  CONCLUSIONS
  The outcome of conservative treatment of closed diaphyseal forearm fractures, without overlapping fragments was excellent. However, reduction is usually performed in the operating room by orthopedic surgeons under general anesthesia and requires hospitalization, which is very expensive. The results of this study show that high quality care may be obtained in the ED by a trained and experienced team. These results are similar to those for distal metaphyseal fractures, which could extend the indications for reduction in the ED.
  
  
  METHODS
  Level IV. Retrospective study.
authors.affiliation: Service d'orthopédie pédiatrique, hôpital Robert-Debré, université Paris 7, Paris, France; Service d'orthopédie pédiatrique, hôpital d'enfants de la Timone, Aix-Marseille université, Marseille, France. Electronic address: seb.pesenti@gmail.com.
authors.forename: S
authors.initials: S
authors.lastname: Pesenti
authors.affiliation: Service d'orthopédie pédiatrique, hôpital Robert-Debré, université Paris 7, Paris, France.
authors.forename: E
authors.initials: E
authors.lastname: Litzelmann
authors.affiliation: Service d'accueil des urgences pédiatriques, hôpital Robert-Debré, université Paris 7, Paris, France.
authors.forename: M
authors.initials: M
authors.lastname: Kahil
authors.affiliation: Service d'orthopédie pédiatrique, hôpital Robert-Debré, université Paris 7, Paris, France.
authors.forename: C
authors.initials: C
authors.lastname: Mallet
authors.affiliation: Service d'orthopédie pédiatrique, hôpital Robert-Debré, université Paris 7, Paris, France.
authors.forename: P
authors.initials: P
authors.lastname: Jehanno
authors.affiliation: Service d'accueil des urgences pédiatriques, hôpital Robert-Debré, université Paris 7, Paris, France.
authors.forename: J-C
authors.initials: JC
authors.lastname: Mercier
authors.affiliation: Service d'orthopédie pédiatrique, hôpital Robert-Debré, université Paris 7, Paris, France.
authors.forename: B
authors.initials: B
authors.lastname: Ilharreborde
authors.affiliation: Service d'orthopédie pédiatrique, hôpital Robert-Debré, université Paris 7, Paris, France.
authors.forename: K
authors.initials: K
authors.lastname: Mazda
mesh_terms: D000293:Adolescent; D002370:Casts, Surgical; D002648:Child; D002675:Child, Preschool; D018483:Diaphyses / Q000293:injuries; D004636:Emergency Service, Hospital; D005240:Feasibility Studies; D005260:Female; D005596:Fractures, Closed / Q000628:therapy*; D006801:Humans; D007223:Infant; D008297:Male; D008349:Manipulation, Orthopedic; D011446:Prospective Studies; D011885:Radius Fractures / Q000628:therapy*; D014458:Ulna Fractures / Q000628:therapy*
keywords: Diaphyseal forearm fractures; Fracture reduction in the emergency department; Fracture reduction protocol; Pediatric fracture