The development of ACPs in specialty care makes children’s fracture care more efficient in centers with the volume to support such a system. In our center, the orthopedic staff train not only orthopedic residents and fellows but also ACPs in fracture management, including closed reductions in the ED. This has helped us deal with resident work requirements and with increased patient volume. Proper training and supervision allows ACPs to manage children’s fractures safely and efficiently.

Today most children’s fractures can be safely reduced in the ED ranging from forearm fractures to femur fractures (in very young children). Initially the treating orthopedic surgeon had the sole responsibility for analgesia, reduction, and casting. With newer methods, most EDs can provide an environment that allows a systematic “team approach” for fracture reduction. The ED staff physician can oversee the administration of conscious sedation, a nurse can monitor the patient, and a portable image intensifier allows one to monitor fracture reduction (Fig. 4-2).

Trends in mechanism of injury for childhood fractures are both consistent and evolving. Although monkey bars and trampolines continue to be a common cause of many pediatric fractures, we have also seen a rise in fractures sustained from hoverboards and “small wheeled” scooters. Seasonal trends are also noted; football-related injuries and fractures occur mostly in the fall season and snow-related (ski, snowboard, sledding) fractures occur mostly in the winter.

Fractures occurring during a patient’s vacation are common because our institution is located in a city considered to be a tourist destination. We provide our services, as appropriate, and direct the patient and family to obtain their imaging studies and records via our Medical Records office for return to their often distant home city. We also assist the family in finding a pediatric orthopedist who can continue their care in a timely manner based on their home city (we use the POSNA site http://orthokids.org to find a pediatric orthopedist).

In centers with resident training programs, the improvements noted above have allowed residents to provide efficient fracture care, decreasing the need for staff orthopedic surgeons to be present for every reduction. Traditionally, most North American centers required a staff orthopedic surgeon to be present for all reductions performed in the OR. The presence of supervising, attending emergency room physicians (who provide overall supervision for the case) now allows
resident fracture reduction in the ED with the on-call staff orthopedic surgeon in attendance only for problem cases. The staff physician reviews the case by telephone/digital x-ray images prior to treatment in all but the simplest of cases. The same applies to ACPs who reduce fractures.

The continuing development of the electronic medical record (EMR) and picture archiving and communication systems (PACS) help with efficient off-site staff supervision of residents. Also, the resident and ACPs now have the ability to take a photo of a wound with their cell phone that is immediately deposited in the child’s EMR, which is accessible by an off-site staff physician to help guide treatment when needed.

There are many advantages in using this technology; however, there are also pitfalls that can negatively affect patient care. Obtaining a clear and thorough history of present illness and the patient’s physical exam is of utmost importance prior to obtaining and sending digital images. This is especially important in situations when outside facilities are transferring this information to a resident or ACP.

Each fracture reduced during nighttime hours is reviewed with the on-call staff in the morning. Also, all reductions are reviewed in a weekly conference that all orthopedic residents, an ACP representative, and staff in attend. The goals of the conference include ensuring that patients have received appropriate care and timely follow-up, as well as providing constructive feedback to residents regarding closed reduction and cast application quality.

Patients arrive to our ED either through self-referral or referral from an outside facility or from their primary doctor. When a child is sent from an outside facility, a call has usually already been made notifying either the orthopedic team or the ED staff. In some cases, the team may decide (after talking with the referring person/institution) that an expensive emergency visit is not required and the patient can be managed in our early evening “Fracture Clinics” that run daily from 4 to 6 p.m. (Table 4-1).

Simple fractures (or suspected fractures) should be managed with a splint and sent to our outpatient clinic within a few days. Of course, this is often hard to ascertain by telephone, and we note errors weekly. A small puncture wound may not be recognized as an open fracture, and a 1 a.m. transfer for a “severe supracondylar fracture” is sometimes just a buckle fracture.

Once a patient has been accepted for treatment, both the orthopedic team and the ED staff should be notified so that triage can be started immediately upon arrival. This assures prompt treatment and limits unnecessary waiting time in an already busy ED.