Isolated Distal Radius Fracture Reductions in Adult Emergency Department Patients in a Large Healthcare System.

introductionDistal radius fractures account for up to 18% of fractures in older adults and up to 20% of all fractures treated in the emergency department (ED). These fractures often require reduction and immobilization, with different modalities to provide analgesia. Our objective in this study was to summarize the management for distal radius fracture reductions in the real world of community and academic EDs.

methodsWe identified adult visits for isolated distal radius fractures over a four-year period across three academic and 18 community hospital EDs from more than 490,000 per annum total visits. Visits were grouped by whether they were reduced, or not, in the ED. Reductions were further categorized by use of ultrasound-guided nerve block (UGNB), procedural sedation, or hematoma block. We recorded patient demographics, age, sex, race and ethnicity, and Emergency Severity Index scores. Our primary outcome was patient-reported pain scores (0-10 scale) at presentation and prior to disposition. Secondary outcomes were total milligrams of morphine equivalents administered, ED length of stay and 30-day ED return rates.

resultsThere were 3,642 total patients with distal radius fractures, and 2,608 (71.6%) met inclusion criteria. Of these, 695 (26.6%) had fracture reduction. Of the reductions, 522 (75.1%) were hematoma blocks, 151 (21.7%) procedural sedation, and 22 (3.2%) UGNB. The majority of UGNB (72.7%, n = 16), procedural sedation (64.2%, n = 97), and hematoma block reductions (51.3%, n = 268) were performed in community hospital EDs. Patient age was greatest for the hematoma block (median 67 [57, 76]), followed by no ED reduction (65 [51, 77]), UGNB (65 [51, 68]), and procedural sedation (62 [43, 72]) (P < .01 for the four-group comparison). Most patients (93.7%) were White and not Hispanic or Latino (94.5%). There was no difference in treatment type by race or ethnicity. Pain score reduction between arrival and last score reported in the ED was statistically greatest for the procedural sedation group (8 to 4, difference of -4 [-6, -2]), followed by UGNB (8 to 5, difference of -3 [-5, 0]), hematoma block (8 to 5, difference of -3 [-5, 0]) and no reduction (7 to 5, difference of -2 [-4, 0]), (P < .001). Median total milligrams of morphine equivalents was higher for UGNB (7.5 [6.8, 13.9]) and procedural sedation (7.5 [2.0, 14.0]), as compared to hematoma block (6.7 [0, 13.0]) and no ED reduction (4.0 [0.0, 7.5]) (P < .001). Length of stay was longest for the UGNB group (314 minutes [226, 432]) compared to hematoma block (275 minutes [204, 370]), procedural sedation (258 minutes [192, 350]) (P = .08), and no reduction (190 [127, 290]) (P < .001 for the four-group comparison). Thirty-day return rates were 16.6% for procedural sedation, 15.1% for hematoma block, 12.3% for no reduction, and 9.1% for UGNB (P = .18).

conclusionMost distal radius fracture reductions were done with a hematoma block. Ultrasound-guided nerve block was a less common than procedural sedation, and done predominantly in the community EDs. Procedural sedation and UGNB were most effective to reduce pain. Triage severity scores, milligrams of morphine equivalents, and length of stay were similar between UGNB and procedural sedation.