| Acute (n=155) | Subacute (n=186) | P value | |
|---|---|---|---|
| Age, y ± SD (range) | 7.9 ± 4.0 (0.9-17.8) | 7.9 ± 3.8 (1.0-16.4) | .901 |
| Male, n (%) | 79 (51.0) | 86 (46.2) | .384 |
| Site of fracture, n (%) | .022 | ||
| Forearm | 142 (91.6) | 151 (81.2) | |
| Hand or foot | 12 (7.7) | 33 (17.7) | |
| Leg | 1 (0.6) | 2 (1.1) | |
| Mechanism of injury, n (%) | .045 | ||
| Fall | 141 (90.9) | 152 (81.7) | |
| Direct blow | 5 (3.2) | 15 (8.1) | |
| Other/unknown | 9 (5.8) | 19 (10.2) | |
| SD, standard deviation. | |||
Acute vs subacute management outcomes
Of the 341 patients included in the study, 155 patients were treated acutely and 186 patients were treated subacutely. For the subacute management group, mean time between injury and treatment was 2.5±2.6 days ( TABLE 2 ). We observed no poor clinical outcomes in either acute or subacute management groups. All patients, regardless of time elapsed from injury to initial splinting, recovered without complication. The difference in number of clinical visits between the acute and subacute management groups was not significant (acute 3.2±0.5; subacute 3.1±0.5). The mean length of clinical follow-up from initial splinting to discharge from orthopedic care was higher in the acute management group (acute 32.9±17.1 days; subacute 28.9±13.4 days).
Most patients presented with non-angulated fractures, regardless of time from injury to initial presentation ( TABLE 2 ). The degree of angulation worsened in a small proportion of fractures during convalescence. The difference in initial angulation, final angulation, or change in angulation between acute and subacute management groups was not significant.
A higher proportion of patients in the acute treatment group presented directly to the ED for care, whereas a higher proportion of patients in the subacute treatment group presented to their PCP during routine working hours and were referred to the orthopedic clinic ( TABLE 2 ). For both acute and subacute management groups, we compared outcomes for patients seen initially in the ED or orthopedic clinic. No adverse outcomes occurred among any of the studied patients.
TABLE 2
Clinical outcomes did not differ between acute and subacute management groups
| Acute (n=155) | Subacute (n=186) | P value | |
|---|---|---|---|
| Time from injury to initial care, d ± SD (range) | 0 | 2.5 ± 2.6 (1-14) | <.001 |
| Good outcome, n (%) | 155 (100) | 186 (100) | 1.0 |
| Time from initial treatment to final follow-up, d ± SD (range) | 32.9 ± 17.1 (8-169) | 28.9 ± 13.4 (9-164) | .016 |
| Number of clinical encounters (primary care physician, ED, or orthopedic clinic), n ± SD (range) | 3.2 ± 0.5 (2-5) | 3.1 ± 0.5 (2-5) | .051 |
| Initial angulation, n (%) | .541 | ||
| None | 145 (93.5) | 170 (91.4) | |
| Mild (<10°) | 10 (6.5) | 16 (8.6) | |
| Final angulation, n (%) | 1.0 | ||
| None | 136 (87.7) | 163 (87.6) | |
| Mild (<10°) | 19 (12.2) | 23 (12.4) | |
| Change in angulation, n (%) | .907 | ||
| No change | 144 (92.9) | 175 (94.1) | |
| Worse | 10 (6.4) | 10 (5.4) | |
| Improved | 1 (0.6) | 1 (0.5) | |
| Point of entry to health care system, n (%) | <.001 | ||
| Primary care physician | 44 (28.4) | 115 (61.8) | |
| ED | 108 (69.7) | 54 (29.0) | |
| Orthopedic clinic | 3 (1.9) | 17 (9.1) | |
| Location of initial management, n (%) | <.001 | ||
| ED | 132 (85.2) | 81 (43.5) | |
| Orthopedic clinic | 23 (14.8) | 105 (56.4) | |
| ED, emergency department; SD, standard deviation. | |||
Charge analysis
We compared total charges (professional and technical) for managing buckle fractures initially in the ED with those initially seen in the orthopedic clinic. Total charge per patient in the ED, including subsequent follow-up in the orthopedic clinic, was $4397 ($2516, professional; $1881, technical). Total charge per patient for treatment only in the orthopedic clinic was $1426 ($918, professional; $508, technical). Total charge per patient was $2971 more for patients treated initially in the ED.
Between July 1, 2004, and August 31, 2007, 159 patients (46.6%) with buckle fractures entered the health care system through their primary care physician. Of these, 44 patients were seen acutely by the physician; 115 patients were seen on a subacute basis. Of the 44 patients seen acutely, 24 (54%) were referred directly to the ED; 20 (45%) were referred to the orthopedic clinic. Of the 115 patients seen subacutely, 27 (23%) were referred directly to the ED, and the remaining 88 (76%) were referred to the orthopedic clinic. In sum, 51 patients (32%) were seen initially by a PCP, who referred them to the ED. The cost savings with each patient seen subacutely in the orthopedic clinic was $2971, and avoiding ED treatment for all patients could have yielded a total gross savings of approximately $150,000.
Discussion
Buckle fractures are inherently stable and almost universally heal without complication.4,5 Perhaps because of the high likelihood of good outcome, there is a relative paucity of articles in the recent literature addressing the management of this common pediatric fracture. Older studies have addressed casting vs splinting and the need for follow-up, but no study has yet examined whether immediate treatment is necessary.6,7 Although some studies have noted incidentally that many children have delayed presentation for care,5 none has specifically examined the clinical or economic impact of a delay in care or the effect of subacute treatment on outcomes.