a b s t r a c t

Introduction: Forearm fractures are common pediatric injuries. Most displaced or angulated fractures can be man- aged via closed reduction in the operating room or in the Emergency Department (ED). Previous research has shown that emergency physicians can successfully perform closed reduction within ED; however, the fracture morphology amendable to ED physician reduction is unclear. The aim of this study is to detail the fracture char- acteristics associated with successful reduction by ED physicians.

Methods: We conducted a retrospective study of children (aged <18 years) presenting to the ED of a Tertiary care children’s hospital (annual census 90,000) between January 2018 and December 2018 with closed distal and midshaft forearm fractures requiring reduction. Data collected included patient demographics, fracture morphol- ogy, management, and complications. Successful ED physician reduction was based on predefined criteria. Ortho- pedic referrals included those patients sent directly to the operating room, closed reductions performed by orthopedic trainees within the ED, and patients requiring orthopedic consultation after failed ED reduction.

Results: A total of 340 patients with forearm fractures were included in the study. ED clinicians attempted to re- duce 274 (80.6%) of these fractures and were successful in 256/274 (93.4%) cases. Of the 84 Orthopedic referrals, 18 were after failed ED clinician attempt, and 66 were ab initio managed by orthopedics (37 in the operating room and 29 in ED). Compared to the fractures with successful ED reduction (n = 256), factors associated with orthopedic referral (n = 84) included: increasing age, midshaft location, higher degree of angulation, and completely displaced fractures. Angulated distal greenstick fractures were most likely to be successfully reduced by ED clinicians. There were no difference in complication rates between the two groups.

Conclusion: In this series, fractures most amenable to reduction by ED clinicians include distal greenstick frac- tures, whereas midshaft and completely displaced fractures are more likely to need treatment by orthopedics.

(C) 2021 Published by Elsevier Inc.

1. Introduction

Forearm fractures are common childhood injuries. In 2010 the United States’ National Electronic Injury surveillance System (NEISS) recorded over 140,000 forearm fractures in the pediatric age group, representing around 2.6% of ED presentations. [1] Most angulated and/ or displaced forearm fractures are managed by closed reduction. [2] His- torically, this was performed in the operating room under general anesthesia, [3,4] although procedural sedation in the ED is now commonplace. [2]

* Corresponding author at: Emergency Department, Royal Children’s Hospital, 52 Flemington Rd, Parkville, VIC 3052, Australia.

E-mail address: [email protected] (S.M. Hopper).

Within the ED, fracture reductions in children are commonly per- formed by Orthopedic surgeons with emergency physicians providing procedural sedation. Emerging literature describes successful fracture reduction by emergency clinicians (including nurse practitioners), [3] which reduces time and cost, especially outside of traditional business hours, and simplifies care. In pediatric comparison studies, outcomes are similar, and large case series of ED physicians reducing fractures show a high proportion of successful reduction and maintenance of ac- ceptable position. [5-8] Whilst each study describes in part the fracture type, classification is not consistent or sufficiently informative. More- over, the case series and studies generally specify which fractures are attempted by ED clinicians without describing those referred to ortho- pedics for reduction (either in the ED or in the operating room using closed reduction or surgical fixation). Hence, in terms of an ED clinician

https://doi.org/10.1016/j.ajem.2021.06.073 0735-6757/(C) 2021 Published by Elsevier Inc.

contemplating the management of a specific fracture, this literature is limited and there remains uncertainty as to the exact fracture morphol- ogy amenable to closed reduction within the ED setting thus avoiding the need for orthopedic referral. Information relating fracture morphol- ogy to the likelihood of success for a given operator and venue would be beneficial to guide decision-making and optimize resource utilization.

The aim of this study was to compare the detailed clinical character-

istics of closed midshaft and distal forearm fractures associated with successful reduction by ED clinicians to those that were managed by or- thopedic services. Secondarily, we aim to describe rates of success and complications including late re-manipulation and cast problems. This will ultimately assist clinicians in making management decisions within the ED and potentially reduce secondary manipulation after initial failure.

1. Methods
   1. Study design, setting, and participants

We conducted a retrospective study of children aged 0-18 years who attended the Royal Children’s Hospital (RCH), Melbourne, Australia between January 2018 and December 2018 and underwent a reduction of a fracture of the distal or midshaft radius and/or ulna. RCH is a large pediatric tertiary care hospital and level-1 trauma center with an annual ED census of 90,000 patients. We extracted data from patients’ electronic medical records.

Inclusion criteria were patients between 0 and 18 years with a radio- graphic diagnosis of a fracture of the physeal, metaphyseal, or mid- diaphyseal region who underwent reduction in the ED or operating room. Patients excluded were those with Open fractures, proximal frac- tures, fractures with dislocation (i.e. Galeazzi and Monteggia), and path- ological fractures. We also excluded patients with missing information in the medical records including when the initial radiograph was unavailable.

• 1. Study setting

Fracture reductions in this ED are commonly performed by emer- gency physicians (i.e. trainees and attendings) and nurse practitioners under direct supervision. Referral to orthopedics is at the discretion of the ED team, who may request assistance for a reduction in the ED or refer for management in the operating room. This mainly relates to ED clinician confidence in managing a particular fracture. The method of sedation for an ED reduction is chosen by the clinician and can include procedural sedation or Regional blocks. The ED does not have access to an image intensifier (e.g. fluoroscopy, C-arm, mini C-arm), physician as- sistants, or cast technicians. Unsplit circumferential plaster of Paris casts are applied immediately after reduction. All patients undergoing reduc- tions are followed up by orthopedics in fracture clinic. Generally, pa- tients will have appointments at 1, 2 and 6 weeks post-reduction at a minimum.

Whilst the Australian health care system is a Hybrid model of univer- sal mandatory Public insurance combined with optional private health insurance, the vast majority of emergency care and pediatric care is un- dertaken by the public system. Employees at RCH are generally salaried rather than paid fee-for-service.

• 1. Outcomes

The primary outcome was successful reduction by ED clinicians compared to those that received an orthopedic referral, either primarily or after a failed ED Reduction attempt. Secondary outcomes included late loss of position and/or re-manipulation, unscheduled ED re- presentations following reduction, and cast complications.

• 1. Definitions

Fractures were classified as being successfully reduced by ED clini- cians (emergency physicians or nurse practitioners) if the post- reduction position was acceptable according to established local guide- lines [9,10] (as set out in Box 1) and based on prior literature [11,12] after the first or second attempt within the ED.

Following reduction, position was classified as anatomical (complete anatomical reduction without any translation or angulation), good (<10 degrees angulation or < 50% translation), fair (acceptable angle but >10 degrees angulation or > 50% translation) or failed (if either bone was angulated beyond the parameters listed in Box 1). This classi- fication method was initially used by Alemdaroglu et al [13] and several studies since. [14-16] Following failed reduction, management deci- sions were made at the clinician’s discretion. Orthopedic referral was defined as: initial referral for reduction in the operating room without an ED reduction, the provision of orthopedic assistance with reduction in the ED at any time, or referral to the operating room after failed ED reduction.

Patients who did not attend fracture clinic were classified as lost to follow-up. At follow-up, loss of position was determined radiographi- cally with a change of >10 degrees of angulation in any plane from postreduction radiograph (whether or not the angle was acceptable ac- cording to our definitions) or > 50% translation. Re-manipulation was defined as loss of position requiring intervention, including repeat re- duction under procedural sedation, closed reduction under general an- esthesia, closed reduction and internal fixation (CRIF), and open reduction with internal fixation (ORIF).

• 1. Data collection and analysis

Data were extracted from electronic medical records and included sex, age, date of visit, triage category, side of injury, mechanism of in- jury, examination findings, radiographic findings, initial fracture man- agement, and success rate of reduction (ED manipulation vs Orthopedic manipulation in the ED vs operating room reduction), type of analgesia provided in the ED, cast type, unscheduled ED representa- tions and follow-up at fracture clinic including outcomes (e.g. loss of po- sition and intervention, cast complications, date of cast removal, malunion, neurovascular and skin complications). Radiographs taken at initial presentation were stored using SYNAPSE PACs (Picture Archiv- ing and Communication System, Fuji film medical system, NSW, Australia). We assessed all fractures for location (i.e. midshaft, distal metaphyseal, growth plate), bone fractured, type of fracture (e.g. com- plete, greenstick, buckle, plastic deformation, Salter-Harris I-IV), anteroposterior angle (identified on lateral film), radial-ulnar angle (identified on posteroanterior film), translation (defined as displace- ment of distal fragment relative to the proximal fragment), direction of angulation (ulnar/radial, palmar/dorsal), and complete displacement (i.e. 100% translation with shortening). Complete fracture was defined as fracture with disruption to both cortices on both the lateral and posteroanterior films. When both radius and ulna were involved, we gave statistical primacy to the more deformed bone as we believe this would dominate the treatment decision and outcome of the attempt to reduce.

Box 1

Definition of successful reduction.

Fracture type Age (years) Acceptable angle (anteroposterior or radial-ulnar) (degrees)

Metaphyseal and Diaphyseal 0-5 <20

5-10 <15

10-15 <10

Growth plate Pre-pubertal <20

Data collection was performed by a single investigator (KR), follow- ing best practice guidelines. [17,18] Data collection was pilot tested by two non-blinded abstractors (KR & SH), collated, compared, and modi- fied for discrepancies prior to data extraction to ensure abstractor interrater reliability. Two additional study personnel (SH & EF-L) re- peated 20% of randomly selected cases, which were collated and com- pared for discrepancies to ensure inter-observer reliability. An agreement between reviewers was found in 960/1000 discrete datapoints. A data dictionary informed a standardized electronic data collection form to ensure continuity across cases and reduce abstractor bias. Where conflicting or ambiguous data were found, coding was achieved by consensus between the two abstractors. In cases where consensus could not be achieved, the opinion of a third reviewer (CK, a senior Pediatric Orthopedic Surgeon) resolved the deadlock.

Data were collected and managed using REDCap [19] electronic data capture tools. Statistical analysis was performed using Stata 15 (Statacorp, College Station, Texas, USA). Simple descriptive and fre- quency analysis was performed on multiple variables. Data are

presented as median and interquartile range when not normally distrib- uted. Risk factors associated with orthopedic referral were analyzed using univariate and multivariate logistic regression. Significant factors identified in the univariate analysis were included in a multivariate analysis using logistic regression model. A p-value of <0.05 was consid- ered as statistically significant.

• 1. Ethics

This study was reviewed and approved by the Royal Children’s Hos- pital Melbourne Human Research Ethics Committee (HREC), reference number 38337.

1. Results

Of the 458 cases initially identified, 340 patients met inclusion criteria for the study (Fig. 1). Patient demographics and fracture charac- teristics are outlined in Table 1.

Screened

n=458

Exclude: n=118

X-ray not available 47 Open fractures 2

With dislocation 9

Proximal fracture 50

Pathological fracture 3

Missing information 7

Fracture reduction attempt by ED clinicians

n=274, 80.6%

Included cases

n=340

Orthopedic referral: manipulation in ED n=29, 8.5%

Orthopedic referral: Surgical management n=37, 10.9%

Closed reduction n=8 ORIF n=10 CRIF n=19

Successful

n=253

Unsuccessful n=21

Successful re- manipulation by ED

n=3

Orthopedic referral:

n=18, 5.3%

Re-manipulation in ED n=6 CRIF n=6

ORIF = 2

Closed reduction in operating room=4

Total ED success

n=256

93.4% of attempted reductions 75.3% of all fractures

Fig. 1. Flowchart outlining management of all forearm fractures requiring reduction (n = 340). CRIF- closed reduction, internal fixation.

Total Orthopedic referral

n=84, 24.7%

ORIF- open reduction, internal fixation.

Table 1

Patient demographics and fracture morphology of fractures reduced by ED clinicians and those requiring orthopedic referral (n = 340).

Characteristic	Total	Successful reduction by ED staff	Referral for reduction by orthopedics after failed reduction by ED staff	Referral for reduction by orthopedics without attempt by ED
Total number of patients	340	256	18	66
Demographics
Sex, Male n (%)	232 (68.2%)	174 (68.0%)	15 (83.3%)	43 (65.2%)
Age (mean, SD)	8.88 +- 3.53	8.48 +- 3.44	10.83 +- 4.06	9.89 +- 3.40
Mechanism – height n (%)
Fall from standing height	147 (43.2%)	110 (43.0%)	6 (33.3%)	31 (47.0%)
Fall > standing height	193 (56.8%)	146 (57.0%)	12 (66.7%)	35 (53.0%)
Mechanism – activity n (%)
Playground	116 (34.1%)	88 (34.4%)	8 (44.4%)	20 (30.3%)
Sports	67 (19.7%)	49 (19.1%)	4 (22.2%)	14 (21.2%)
Running	61 (17.9%)	47 (18.4%)	1 (5.6%)	13 (19.7%)
Non-motorized vehicle	52 (15.3%)	39 (15.2%)	3 (16.7%)	10 (15.2%)
Other	44 (12.9%)	33 (12.9%)	2 (11.1%)	9 (13.6%)
Deformity, yes (n)	301 (88.5%)	218 (85.2%)	18 (100%)	65 (98.5%)
Neurovascular compromise (n)	17 (5.0%)	11 (4.3%)	0	6 (9.1%)
Fracture characteristics Single bone fracture n (%)	126 (37.1%)	108 (42.2%)	5 (27.8%)	13 (19.7%)
Midshaft n (%)	8 (2.4%)	7 (2.7%)	0	1, (1.5%)
Complete (n)	4	3	–	1
Greenstick (n)	4	4	–	0
Completely displaced (n)	0	0	–	0
AP angulation (median)	17	17.5	–	8
UR angulation (median)	0	0	–	0
Distal shaft/metaphysis n (%)	71 (20.9%)	63 (24.6%)	3 (16.7%)	5 (7.6%)
Complete (n)	23	16	3	4
Greenstick (n)	44	44	0	–
Completely displaced (n)	4	3	0	1
AP angulation (median)	20	20	30	18
UR angulation (median)	0	0	6	14
Growth Platea n (%)	47 (13.8%)	38 (14.8%)	2 (11.1%)	7 (10.6%)
AP angulation (median)	24	22.4	29.5	30
UR angulation (median)	0	0	0	0
Both bone fracture n (%)	214 (62.9%)	148 (57.8%)	13 (72.2%)	53 (80.3%)
Mid-shaft fracture n (%)	82 (24.1%)	51 (19.9%)	7 (38.9%)	24 (36.4%)
Complete (n)	38	24	5	9
Greenstick (n)	29	25	0	4
Completely displaced (n)	15	2	2	11
AP angulation (median)	25	26	22	21
UR angulation (median)	11	10	13	16.5
Distal fracture n (%)	124 (36.5%)	92 (35.9%)	5 (27.8%)	27 (40.9%)
Complete (n)	31	27	0	4
Greenstick (n)	47	46	1	–
Completely displaced (n)	46	19	4	23
AP angulation (median)	22	22	18	30
UR angulation (median)	12	10	6	15
Growth platea n (%)	8 (2.4%)	5 (2.0%)	1 (5.6%)	2 (3.0%)
AP angulation (median)	17.5	15	17	25
UR angulation (median)	6.5	13	11	12.5

Values and percentages are shown as total number of cases

Angles are reported in median values. AP = anteroposterior, UR = ulnoradial, SD = standard deviation.

^a Growth plate fractures include fractures with distal physeal involvement, Salter Harris I-IV.

The mechanism of injury was most commonly a fall from above standing height (56.4%) in playground or sporting incidents. On clinical examination, visible deformity was present in the majority of patients (86.7%), and neurovascular compromise was uncommon (5.0%). Of the 340 cases, there were 214 (62.9%) involving both radius and ulna, 124 (36.5%) isolated radius fractures, and 2 (0.6%) isolated ulnar fractures.

• 1. Fracture reductions performed by emergency and orthopedic teams

Fig. 1 outlines the management and outcomes according to the oper- ator (i.e. emergency or orthopedic). Over three-quarters of all fractures were successfully reduced by emergency clinicians who succeeded in 93.4% of fractures they attempted (92.3% on first attempt and 1.1% on second attempt). Of the 84 fractures where orthopedic referrals were made, 29 underwent successful reduction in the ED by orthopedic

trainees without attempt by ED clinicians, 6 were reduced in the ED after a failed attempt by ED providers, and 49 were managed in the op- erating room (37 without an attempt in the ED and 12 after a failed ED attempt). The majority of patients managed in the operating room underwent surgical fixation (37/49).

Across all venues and operators, closed reduction achieved accept-

able position in 303/340 (89.1%) of all fractures. Following successful closed reduction, anatomical reduction was achieved in 18.6%, good in 58.8%, and fair in 22.6%. ED clinicians managed 256/303 (84.5%) of these closed reductions independently.

• 1. Factors associated with orthopedic referral and failed ED reduction

We compared the fractures successfully reduced by ED clinicians (n = 256) to those undergoing Orthopedic reduction (with or without attempt by ED, n = 84) and performed univariate (supplementary

Table 2

Comparison of potential risk factors for orthopedic referral (multivariate analysis) be- tween groups (Success ED reduction n = 256 vs orthopedic referral n = 84)

Odds Ratio (95% CI) P value

Increasing age 1.24 [1.11-1.38] p < 0.0001

Both bone fracture 1.68 [0.67-4.21] p = 0.271

Midshaft fracture 5.04 [1.59-15.97] p = 0.006

Distal fracture 1.50 [0.56-4.04] p = 0.418

Completely displaced fracture 5.01 [2.35-10.68] p < 0.0001

Greenstick fracture 0.15 [0.05-0.42] p < 0.0001

Increased Angulation 1.02 [1.00-1.05] p = 0.063 Odds ratio and p-value obtained by multivariable logistic regression.

table 1/supplementary material??) and multivariate analysis (Table 2) to determine characteristics associated with orthopedic referral. Factors associated with orthopedic involvement included: increasing age, greater degree of angulation, combined radius and ulna fractures, midshaft fractures, complete fractures, and completely displaced frac- tures. All significant factors indicated by univariate analysis were in- cluded in the multivariate analysis and remained significant except fractures involving both radius and ulna (Table 2). The most predictive variables associated with orthopedic referral were midshaft and completely displaced fractures.

Factors less likely to result in orthopedic referral included greenstick fractures and distal fractures. However, only greenstick morphology remained significant after the multivariate analysis.

• 1. Success of ED clinician reduction based on fracture characteristics

Fig. 2 outlines success rates of ED clinician reduction based on frac- ture characteristics. Regarding fracture morphology, greenstick frac- tures were more likely to be successfully reduced by ED clinicians compared to complete fractures. Overall, single bone fractures were more likely to be successfully reduced by ED clinicians compared to combined radius and ulna fractures. The fracture types least successfully reduced by ED clinicians included combined radius and ulna, complete, midshaft and growth plate fractures, with over a third resulting in or- thopedic referral. Overall, ED clinicians attempted to reduce 89.7% of single bone fractures and 75.2% of both bone fractures.

• 1. Loss of position and re-manipulation

A total of 331 (97.4%) of patients attended follow-up. Seventy-one (21.5%) patients met criteria for loss of position, on average 16.6 (2.0-45.0) days after initial presentation. Of these 71 patients, 24 (or 7.1% of all fractures) required re-manipulation including closed reduc- tion under sedation (n = 4, 1.2%), closed reduction under anesthesia (n = 10, 2.9%), closed reduction internal fixation (n = 6, 1.8%), and open reduction internal fixation (n = 4, 1.2%). There were 3 cases of late loss of position deemed too late for re-manipulation. The further 44 patients were managed conservatively with some undergoing a cast change with moulding at clinic. All 44 patients had a satisfactory resolution in deformity within one year of follow up.

Number of patients

Fig. 2. Fracture morphology – numbers, success, and referral rate.

Type of Fracture

Completely displaced

Distal greenstick Midshaft Growth plate Distal complete Midshaft greenstick complete

0

80

70

60

50

40

30

20

10

ED Success

ED Fail

ED not attempt

100

90

ED not attempt = no attempt by ED staff; orthopedic service reduction (in ED or OR).

ED fail = ED staff attempt, but reduction failed; referred to the orthopedic service for reduction. ED success = ED staff reduction with no assistance from the orthopedic service.

• 1. Unscheduled ED visits and cast complications

A total of 37 (10.9%) patients had unscheduled re-presentations to the ED. Twenty-nine (8.5%) patients returned with cast complications and 5 (1.5%) for pain. The most common complication in both groups was a tight cast (ED success group 17/256, 6.6% vs Orthopedic referral 4/84, 4.8%, OR = 0.77 [0.23-2.19], p = 0.56). Following presentation with a tight cast, the majority of casts were bi-valved; however, 2 were changed and 4 required only elevation and education. There were no re-presentations with compartment syndrome.

1. Discussion

Our study shows that many pediatric forearm fractures are amena- ble to reduction in the ED by ED clinicians. Fractures at high risk of re- quiring orthopedic referral for reduction (either in the ED or the operating room) include midshaft and completely displaced fractures. Fractures most likely to be successfully reduced by ED clinicians include greenstick fractures. To the best of our knowledge, no study has outlined fracture characteristics at increased risk of requiring orthopedic in- volvement or which fractures are more amenable to reduction in the ED setting. Hurt et al. [8] created a composite score of 3 dichotomized variables to characterize fracture complexity: angulation, displacement (presumably translation), and shortening (presumably completely displaced). Our study goes on to quantify the strength of association and interaction of these factors, as well as fracture location, in describing fracture complexity.

It is axiomatic that the success of a procedure relies on selecting the optimal techniques for the given clinical problem related to the opera- tor’s skill and confidence. In a milieu where closed reduction in the ED by ED clinicians is the dominant method, and ED reductions are the de- fault, the majority of fractures are amenable to reduction by ED clini- cians. In particular, we have demonstrated that distal, greenstick fractures are extremely likely to be successfully reduced without ortho- pedic involvement. As complexity increases, we see midshaft and completely displaced fractures yield lower success rates and higher re- ferral rates, implying a greater degree of difficulty. In our study, ED cli- nicians successfully reduced 75.3% of all fractures and 93.4% of fractures they attempted, therefore indicating a general success of closed reduction of most midshaft and distal fractures of the forearm in keeping with previous reports. [3,5,7,20] A comparison to these pub- lished reports is not possible as the characteristics of fractures sent di- rectly to the operating room or not managed by emergency clinicians were incompletely detailed or not described. However, it seems that with appropriate selection criteria ED reduction is a viable and effective option.

In our study, we captured the spectrum of midshaft and distal closed forearm fractures and described their management in order to inform the decisions faced by ED clinicians when contemplating the manage- ment of a fracture. At this time, there is limited scientific guidance informing the viability or difficulty of reducing any given fracture. These findings might inform an entry point into ED reduction of forearm fractures for departments not currently performing this procedure. This may eventually reduce the reliance on orthopedic consultations and limit Transfer of patients when orthopedic services are not readily available.

With regards to methodology, in order to describe the limits of ED capability, we grouped seemingly heterogeneous care (e.g. fractures sent directly to the operating room, closed reductions performed by or- thopedic trainees within ED either primarily, or after failed ED reduc- tion) as fractures likely to fail ED reduction. Whilst the decision to send a patient directly to the operating room is usually based on fracture morphology, other reasons may include complex medical conditions, operator confidence, and availability of the orthopedic team. We were unable to define the level of training of the operator in the ED as

reductions were performed by consultant-led teams of mixed skill levels at our institution.

At follow-up our re-manipulation rate was 7.1%, much lower than the rate of loss of position (21.5%), which is consistent with other liter- ature. [3,14,16] Rates of re-manipulation between groups (i.e. reduc- tions originally performed by ED clinicians or orthopedics) could not be compared as the groups had markedly different baseline morphology and surgical fixation was common in the orthopedic referral group.

This research offers a comprehensive description of fracture mor-

phology and relates morphology to treatment. A clinical decision tool via a classification system could assist clinicians in making management decisions to optimize outcomes, minimize costs, and lead to manage- ment guidelines informing which fractures are amenable to reduction by ED clinicians and which should be referred to orthopedic surgeons.

• 1. Study limitations

A retrospective chart review has limitations. Medical charts are not designed for research, and therefore abstraction of data relies to some extent on interpretation. Despite rigorous quality control measures some information was unavailable and some data points were open to interpretation. We attempted to mitigate this using methods outlined by Gilbert et al [17] and Kaji et al [18].

RCH has a long history of procedural sedation [21] and fracture man- agement in the ED. The ED is large and staffed with extended senior ED physician coverage. Orthopedic trainee backup is relatively freely avail- able. The ED does not use an image intensifier (i.e. fluoroscopy or mini C-arm) nor a cast technician. Therefore, the application of these findings to a different environment should proceed with caution. Results are in- termediate term and related to radiographic appearance rather than long term functional outcome. Lastly, the decision to re-manipulate was at the clinician’s discretion, which will differ between institutions and individuals.

1. Conclusion

Many forearm fractures are amenable to reduction by emergency clinicians. The fractures most likely to be reduced successfully are distal greenstick fractures and represent an obvious entry point for emer- gency clinicians to commence this practice. The characteristics associ- ated with orthopedic referral include completely displaced fractures and midshaft fractures. We advise a cooperative approach to reduction of fractures with these characteristics to reduce the need for secondary intervention.

Authorship statement

All authors contributed to conceptualization and methodology, KR SH abstracted the data; all authors wrote, reviewed, and edited the manuscript.

Funding

The study was supported in part by the Victorian Government’s In- frastructure Support Program, Melbourne, Victoria, Australia.

Declaration of Competing Interest

None (all authors).

Appendix A. Supplementary data

Supplementary data to this article can be found online at https://doi. org/10.1016/j.ajem.2021.06.073.

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