Abstract
PURPOSE To determine whether the clinical outcome of buckle fractures in children differs between those treated acutely on the same day of trauma and those treated subacutely, and whether a change in practice patterns based on these data would result in cost savings.
METHODS In this retrospective cohort study—approved by the institutional review board—we reviewed the cases of 341 consecutive patients <18 years of age seen by the pediatric orthopedic clinic for treatment of isolated extremity buckle fractures between July 1, 2004 and August 31, 2007. Time from injury to treatment was used to divide patients into 2 groups: acute (≤1 day; n=155) and subacute treatment (>1 day; n=186). Clinical outcome at final orthopedic follow-up was recorded for each patient. We defined adverse outcome as fractures requiring manipulation, clinically apparent deformity, or functional impairment. Charge analysis compared differences in management costs for patients with buckle fractures presenting initially to the emergency department (ED) and those seen solely in the orthopedic clinic.
RESULTS No adverse outcomes were identified in either acute or subacute treatment groups. Total clinical visits did not vary (acute, 3.2 vs subacute, 3.1; P=.051). Presence of mild angulation of fractures on radiographs did not differ significantly between acute and subacute management groups at initial presentation (6.5% vs 8.6%; P=.541) or at final follow-up (12.2% vs 12.4%; P=1.0). A cost savings of approximately $3000 could have been realized for each patient referred to the ED who might otherwise have been seen subacutely in the orthopedic clinic.
CONCLUSIONS No adverse clinical outcomes resulted from subacute treatment of stable buckle fractures. Cost and time savings may be realized with subacute management of buckle fractures without affecting clinical outcome.
Next time a child in your care has a suspected fracture as a result of a fall and x-ray films reveal a buckle fracture, consider telling parents there’s no need for an urgent visit to the ED. As long as the pain is manageable, treating the injury within a day or so will likely be more convenient for the family, will cost less, and will not result in any complications for the child.
Buckle (or torus) fractures—the most common type of fracture occurring in the pediatric population and accounting for a large number of visits to primary care physicians (PCPs), EDs, and orthopedic clinics each year1 —involve impaction of bone along only 1 cortex and are therefore inherently stable.2 Even with only minimal immobilization, the overwhelming majority of buckle fractures heal without complication.3 Although many patients present directly to the ED for management of these fractures, many others present initially to their PCP, given the relatively minor nature of their symptoms and mechanism of injury.
At our institution, the radiology department and referring physician jointly triage out-patients when radiographs requested by the referring physician show evidence of a fracture. Stable and unstable fractures are referred for immediate care—in the pediatric orthopedic clinic if the clinic is open and appointments are available; otherwise in the ED for initial splinting, with follow-up in the orthopedic clinic as soon as possible.
Referral of patients with buckle fractures for same-day care in the ED may bring about unnecessary costs and inconvenience for patients and families. However, policy at our institution dictates that all fractures, including stable buckle fractures, be referred for treatment immediately, once identified.
To determine whether patients with buckle fractures can be safely counseled on the possibility of nonurgent management, we compared the clinical outcomes of pediatric buckle fractures treated acutely or subacutely. The results of our study have practical implications for the timing of treatment or referrals, and for the management of buckle fractures by appropriately trained PCPs, especially in settings where orthopedic consultation may not be readily available.
Methods
Patient selection
The Vanderbilt Children’s Hospital institutional review board approved this retrospective cohort study, with waiver of patient consent. We reviewed 1923 consecutive charts of patients who were seen in the hospital’s pediatric orthopedic clinic for stable fractures between July, 1, 2004 and August 31, 2007. We identified patients for our study population by current procedural terminology (CPT) codes for fracture care that were compatible with buckle fracture or other stable fracture management without manipulation. Applicable CPT codes included the following fracture sites: radial head/neck (24650), ulnar shaft (25530), distal radius with or without ulnar styloid (25600), metacarpal (26600), phalanx of hand or foot (26720, 28510), distal fibula (27786), and metatarsal (28470).
Inclusion and exclusion criteria. Inclusion criteria among this screened population were an isolated buckle fracture mentioned in the official radiology report or pediatric orthopedic clinical note, and age <18 years at the time of injury. We excluded patients for the following reasons: uncertain date of injury (n=67), lack of final clinical follow-up (n=59), acute manipulation of the fracture (n=10), multiple concurrent injuries (n=11), or known metabolic bone disease (n=3) or coagulopathy (n=1).