Introduction
Forearm fractures are among the most common injuries in pediatric emergency departments (EDs) (1), with a high incidence in children aged 6-13 years and a predominance in boys (2-4). Distal forearm fractures account for most of these cases (5). While orthopedic surgeons have traditionally performed closed reductions (CRs) for displaced fractures, pediatric emergency medicine physicians (PEMPs) are increasingly managing such injuries independently due to specialized training and availability.
Previous studies have reported success rates for reductions by PEMPs between 70.8% and 93.4%. For example, Putnam et al. (6) reported a 76% reduction rate by PEMPs, with 11% requiring re-manipulation. Similarly, Rimbaldo et al. (7) showed a 93.4% success rate in 274 attempted reductions in an ED, with predictors of orthopedic referral including higher angulation and midshaft fractures. Importantly, no difference in complication rates was observed. Alrashedan et al. (8) reported a 70.8% success rate (34/48) for CR in a study of diaphyseal fractures, with significant redisplacement in some cases, highlighting the variability depending on fracture type.
Despite these findings, limited data exist comparing outcomes of pediatric fracture care provided by PEMPs and orthopedic residents. This study was performed to address this knowledge gap by evaluating the clinical outcomes of forearm fractures managed in the ED by the 2 clinician groups. We aimed to assess the quality of care and outcomes for forearm fractures treated by PEMPs versus orthopedic residents.
Methods
1. Study design and setting
We conducted a retrospective study of patients under 18 years old who presented to the pediatric ED of Samson Assuta Ashdod University Hospital with forearm fractures from January 2017 through December 2021. The institution is a newly established public hospital in Israel, serving a population of approximately 500,000. The pediatric ED is staffed 16 hours per day by 5 PEMPs, and supported by 2 pediatric orthopedic specialists who are available for referral on-site or by phone, as well as an experienced cast technician.
During the study period, fractures were treated according to the PEMPs’ discretion, based on the fracture type, their clinical experience, or the availability of an orthopedic resident. This decision-making process considered fracture complexity and the likelihood of successful ED management. Fractures at high risk of requiring orthopedic referral, either in the ED or operating room, included midshaft or completely displaced fractures, while greenstick fractures were more likely to be managed successfully by PEMPs. When a PEMP determined that a fracture was appropriate for ED management, CR was performed independently. In cases where the fracture characteristics raised concerns, the PEMP referred it to an orthopedic specialist, either on-site or by phone, and the decision to proceed was made jointly. If deemed complex, the orthopedic resident typically performed the CR. Plain radiography was used to confirm realignment after the CR. The study protocol was approved by the institutional review board of our hospital with a waiver for informed consent (IRB no. 0045-21-AAA).
2. Inclusion and exclusion criteria
We included all patients diagnosed with forearm fractures who underwent CRs, while excluding those who had incomplete data or required immediate surgical interventions. Data were extracted from electronic medical records and included: age, sex, timing of visit (day [07:00-15:00], evening [15:00-23:00], and night [23:00-07:00 on the following day]), visits during weekends, Triage Emergency Assessment (9), Visual Analogue Scale (10), location of fracture (midshaft radius/ulna, distal radius, other ulnas, midshaft radius, or radial head), and provider of the initial CR (PEMP or orthopedic resident).
3. Outcomes
The primary outcomes were: 1) the proportion of successful CRs performed in the ED, defined as correction of the fracture deformity on post-reduction examinations or follow-up radiographs, based on age-specific angulation criteria, as well as 2) ED length of stay (EDLOS), measured in minutes from triage to discharge from the ED. Acceptable post-reduction angulation was defined as follows: for children under 5 years, 10°-35° (lateral radiographs) and < 10° (anteroposterior); for children aged 5-10 years, 10°-25° (lateral) and < 10° (anteroposterior); and for those over 10 years, 5°-20° (lateral) and 0° (anteroposterior) (11).
The secondary outcomes were hospitalization and positive prognosis at follow-ups, defined as adequate fracture healing without the need for additional interventions (e.g., reapplication of casting or splitting). These positive prognosis were analyzed not only from the study population but also from the patients with non- or minimally-displaced fractures. Although the latter group of patients did not belong to the study population, we analyzed the variables from the extra population in order to show their expected favorable outcomes even without the orthopedic referral
Results
Of 920 patients diagnosed with forearm fractures during the study period, we excluded patients who had incomplete data (n = 222) and who required immediate surgical interventions (n = 19), leaving 679. Among the 679 patients, 120 met the inclusion criteria, while the other 559 were identified as having non- or minimally-displaced fractures through radiographs and treated solely with casting or splinting. Among the 120 included patients, 77 (64.2%) were treated by the orthopedic residents and 43 (35.8%) by the PEMPs. Between the 2 groups, no difference was found in their baseline characteristics, such as the location of fracture (Table 1).
Successful CR was achieved in 112 of the 120 patients (93.3%), with no difference between the 2 groups (orthopedic residents, 92.2% vs. PEMPs, 95.3%; P = 0.508). A mean EDLOS was shorter in the PEMP group (orthopedic residents, 297.5 ± 58.2 minutes vs. PEMPs, 228.9 ± 102.4 minutes; P < 0.001) (Table 2 and Figure). The hospitalization and positive prognosis showed no differences between the groups. No surgical interventions, unplanned return visits to the ED, or complications were observed in either groups.
Of the 559 patients with non- or minimally-displaced fractures, 281 (50.3%) were managed by orthopedic residents (Appendix, https://doi.org/10.22470/pemj.2025.01256). Of the 559 patients, the positive prognosis showed no difference between the groups (orthopedic residents, 27.8% vs. PEMPs, 32.4%; P = 0.128).
Discussion
Our study found no significant difference in the rate of successful CR for forearm fractures performed by the orthopedic residents and PEMPs. Most reductions were successful with a 6.7% failure rate, which is consistent with previous comparisons between PEMPs and orthopedists (12-14). The study findings support the growing role of PEMPs in fracture care, including both procedural competence and follow-up outcomes.
Importantly, this study may complement previous findings regarding the involvement of PEMPs in the care of fractures. Our study showed the rate of successful CR (93.3%), which is higher than the previously reported 76% success rate for fracture reduction (6), suggesting an improved case selection or procedural techniques. The previously reported 93.4% success rate for reductions by emergency physicians (7) is comparable to the 95.3% success rate in our patients treated by the PEMPs. Rimbaldo et al. (7) also noted that midshaft or completely displaced fractures were more likely to require orthopedic referrals, supporting our own case selection strategy where PEMPs handled simpler greenstick or metaphyseal fractures. Alrashedan et al. (8) showed that 82.4% of diaphyseal fractures responded to CRs, but 29% eventually required surgical intervention, and 32% of both-bone (radius and ulna) fractures showed redisplacement. In our population, no surgical interventions or redisplacements were observed, likely due to appropriate case selection or post-reduction care.
The secondary analysis on the patients with non- or minimally-displaced fractures showed similar proportions of the positive prognosis between the 2 groups (Appendix), reinforcing the safety and efficacy of PEMP-led care in selected low-risk cases. Children’s fractures often remodel well, leading to favorable outcomes even if initial CRs are challenging. For simple fractures like torus fracture, the most common type of distal forearm fractures, it is usually effective to treat conservatively, such as splinting (15). Our findings indicate a 92.8% success rate with this approach, often without requiring orthopedic consultation. This supports a broader role for PEMPs in managing simple pediatric fractures in EDs.
Another important consideration is EDLOS. Delays in fracture care may occur if orthopedic surgeons are engaged in other cases or on their way to EDs. In contrast, PEMPs can initiate such care on the spot. As detailed in the section of “Study design and setting,” the management process in the ED allows for timely care while preserving orthopedic resources This availability contributes to a significantly shorter EDLOS, by approximately 70 minutes, thereby improving patient flow, enhancing satisfaction, and potentially reducing healthcare costs (16).
This study has several limitations, other than those due to the single-center, retrospective design. First, all 5 PEMPs who performed CRs were experts in the field whereas all orthopedic surgeons who did CRs were residents. This discrepancy in training levels might limit the generalizability of the findings. Second, although fracture management was documented in detail, follow-up data were not available for all patients, limiting the ability to fully assess long-term outcomes. Lastly, the absence of randomization might introduce selection bias based on provider availability and clinical judgment.
In conclusion, PEMPs achieved a rate of successful CRs of forearm fractures, which was comparable to that done by orthopedic residents, with a shorter EDLOS. In the selected cases of non-displaced fractures, PEMPs effectively managed them without orthopedic referrals. These findings support the safe expansion of fracture care responsibilities within pediatric emergency medicine.
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