After initial patient selection, a CAQ-certified pediatric radiologist (with additional fellowship training in pediatric musculoskeletal radiology) and a board-certified orthopedic surgeon (with pediatric orthopedic fellowship training) examined available radiographic images to confirm the diagnosis of a buckle fracture. We further excluded patients whose radiographic findings did not meet criteria for isolated buckle fractures.
Study populations
The final study population consisted of 341 children with confirmed isolated buckle fractures. We assigned patients to acute or subacute treatment groups based on the length of time between injury and presentation for care. Patients were assigned to acute treatment (n=155) if they presented for care on the same day as the injury. All others first seen >1 day after documented time of injury were assigned to subacute treatment (n=186).
We determined length of time between injury and presentation based on data available in the electronic medical record. If the injury was first documented in the orthopedic clinic, we reviewed notes to determine when the patient had initially sought care, and whether from our institution, a PCP, or an outside ED. If documentation showed that initial contact with any health care professional occurred within 1 day of the injury, we assigned the patient to acute management.
Data analysis
Data collection from computerized medical records included date of injury, date of initial care, anatomic location of fracture, mechanism of injury, referring physician, whether the patient was seen initially in the ED, date of last orthopedic follow-up, number of clinical visits, and clinical outcome. Clinical outcome was judged as “good” or “poor” at the last orthopedic follow-up visit, approximately 3 to 4 weeks after injury. A poor clinical outcome could indicate a clinically apparent deformity or functional impairment, need for subacute manipulation, or refracture. We deemed 1 patient’s outcome uncertain due to an ambiguous final clinical note, and we had this case reviewed by a pediatric orthopedist. Any visit to a PCP, ED, or orthopedic clinic was included in the total number of a patient’s clinical visits.
Consulting radiologists also noted the presence and degree of fracture angulation for each patient on initial and follow-up films. Degree of angulation was rated as mild (<10°), moderate (11°-20°), or severe (>20°). Follow-up films were not available for 14 patients (5.2% of acutely treated patients; 3.2% of subacutely treated patients), as final clinical follow-up occasionally occurred outside our institution. In these cases, we relied on the clinical note to determine degree of angulation, if present.
We obtained total charges (technical and professional) for buckle fracture treatment for patients treated initially in the ED and for patients seen initially in the orthopedic clinic.
Statistical analysis
We used an independent samples t-test to compare mean patient ages, times from initial treatment to final treatment, and the numbers of clinical encounters for patients in the acute and subacute treatment groups. For the acute treatment group, time from injury to initial care, by definition, was considered “0.” For the subacute treatment group, we constructed 99.9% confidence intervals around the mean time from injury to initial care to determine whether or not they included “0.”
We used Fisher’s exact test to gauge differences in the proportions of absent or mild initial angulation, absent or mild final angulation, and the point of initial care between the acute and subacute treatment groups. We used Pearson’s chi-squared test to assess between-group differences in the distribution of fracture sites (forearm, hand/foot, or leg), mechanism of injury (fall, direct blow, other), change in angulation (none, improved, worsened), and point of entry into the health care system (PCP, ED, orthopedic clinic). We performed statistical analyses with the statistical package SPSS v15 (SPSS, Inc., Chicago, Ill).
Results
Patient characteristics
Of the 1923 pediatric patients with stable fractures seen in the orthopedic clinic at our institution during the study period, 588 had isolated buckle fractures. Of these, we excluded 151 based on predefined criteria (see Methods). After consensus review of radiographs by a pediatric orthopedist and pediatric radiologist, we excluded an additional 96 patients with inconclusive radiographs. The final study group numbered 341 pediatric patients with confirmed isolated buckle fractures.
The forearm was most commonly affected, with isolated distal radius fractures accounting for 67.7% (231/341) of all fractures, and combined radius/ulna fractures accounting for 14.7% (50/341). The most common mechanism of injury was a fall (85.9%; 293/341), usually a direct fall, with a higher percentage of patients with direct falls in the acute management group ( TABLE 1 ). Mean age and sex were not significantly different for the 2 treatment groups.
TABLE 1
Baseline characteristics of study populations