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Scientific Articles   |    
Mini-C-Arm Fluoroscopy for Emergency-Department Reduction of Pediatric Forearm Fractures
Mark C. Lee, MD1; Norman E. Stone, III, MD2; Andrew W. Ritting, MD3; Eric A. Silverstein, MD1; Kristan A. Pierz, MD1; David A. Johnson, MD4; Ryan Naujoks, MD5; Brian G. Smith, MD6; Jeffrey D. Thomson, MD1
1 Connecticut Children's Medical Center, 282 Washington Street, Hartford, CT 06106. E-mail address for M.C. Lee: mlee01@ccmckids.org
2 Maimonides Medical Center, 4802 Tenth Avenue, Brooklyn, NY 11219
3 University of Connecticut Health Center, 263 Farmington Avenue, Farmington, CT 06030
4 Southern Maine Medical Center, 1 Medical Center Drive, Biddeford, ME 04005
5 Orthopaedic Associates of Middletown, 512 Saybrook Road, Middletown, CT 06547
6 Yale-New Haven Hospital, Yale Physician's Building, 800 Howard Avenue, 133, New Haven, CT 06519
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Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

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Investigation performed at Connecticut Children's Medical Center, Hartford, Connecticut

Copyright © 2011 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2011 Aug 03;93(15):1442-1447. doi: 10.2106/JBJS.J.01052
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Abstract

Background: 

Reduction of pediatric forearm fractures with the patient under sedation in the emergency department is a common practice throughout the United States. We hypothesized that the use of a mini-c-arm fluoroscopy device as an alternative to routine radiographs for evaluation of fracture reduction would (1) allow a more anatomic fracture reduction, (2) decrease the number of repeat reductions or subsequent procedures, (3) reduce overall radiation exposure to the patient, and (4) decrease the orthopaedic consultation time in the emergency department.

Methods: 

A retrospective cohort analysis of 279 displaced forearm and wrist fractures treated with closed reduction and casting with the patient under sedation in the emergency department of a level-I pediatric trauma center was performed, and the data were compared with historical controls. One hundred and thirteen fracture reductions were assessed with a mini-c-arm device, and 166 fracture reductions were evaluated with radiographs. All patients had radiographs of the injury. Blinded, independent reviewers graded the quality of reduction for residual angulation and translation of the reduced fracture. Radiation exposure was determined by the average number of radiographs made through either modality. Emergency department and outpatient charts were reviewed to determine the total orthopaedic consultation time and the need for repeat reductions or operative intervention.

Results: 

Pediatric forearm fractures undergoing closed reduction with assistance of the mini c-arm had a significant improvement in reduction quality (average angulation [and standard deviation], 6° ± 4° vs. 8 ± 6°; p = 0.02), a decrease in repeat fracture reduction and need for subsequent operative treatment (two [2%] of 113 fractures vs. fourteen [8.4%] of 166 fractures; p ≤ 0.0001), and a decrease in radiation exposure to the patient (mean, 14.0 ± 10.3 mrem vs. 50.0 ± 12.7 mrem). The average orthopaedic consultation time was decreased with use of a mini c-arm (28 ± 12 min vs. 47 ± 19 min, p < 0.001).

Conclusions: 

Use of the mini c-arm to assist in the closed reduction of pediatric forearm and wrist fractures in the emergency department can improve the quality of the reduction, decrease the radiation exposure to the patient, and decrease the need for repeat fracture reduction or additional procedures. Mini-c-arm imaging can also decrease the average orthopaedic consultation time for fracture reduction.

Level of Evidence: 

Therapeutic Level III. See Instructions to Authors for a complete description of levels of evidence.

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    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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