Mini-C-Arm Fluoroscopy for Emergency-Department Reduction of Pediatric Forearm Fractures

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 degrees +/- 4 degrees vs. 8 +/- 6 degrees; 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.