O3262: Outcomes of Toddler’s Fractures after Implementation of Comprehensive Care Management Protocol with Controlled Ankle (CAM) Boots

Background: Skin breakdown is a known complication associated with casting/splinting of toddler’s fractures (TF) and has been a continued issue at our institution. Based on literature review and clinical evidence, we implemented a new treatment algorithm for TF. Our purpose was to evaluate the outcomes of the new protocol with a particular focus on skin breakdown and cost efficacy.

Methods: Our protocol included controlled ankle motion (CAM) boots for immobilization, coaching emergency department and urgent care teams on proper CAM boot placement, parent handouts with an emphasis on frequent boot removal and skin checks, and standardized scheduling protocols. A retrospective chart review of 445 patients with TF between 2019-2023 was performed. This included 370 patients prior to implementation of the new protocol (pre-protocol) and 71 patients after protocol implementation (post-protocol). Patient demographics, immobilization method, radiographic parameters, skin breakdown complications, and cost data were recorded and analyzed.

Results: Patient age and sex were similar between the groups. Significantly more patients were treated in CAM boots in the post-protocol group as compared to the pre-protocol group, 66/71 (93%) vs. 116/370 (32.4%), p=0.0001. In the pre-protocol group, 61/370 (16.5%) had skin breakdown, the majority of whom had been treated in a long leg cast (85.2%). In the post-protocol group, 7/71 (9.9%) had skin breakdown. This was not statistically different as compared to the pre-protocol group (p=0.208). However, all post-protocol patients with skin breakdown originated from outside facilities with wounds present at initial visit to our institution. When comparing wounds that developed during our treatment, the post-protocol group had significantly less skin breakdown as compared to the pre-protocol group, 0/7 (0%) vs. 27/61 (44.3%), p=0.037. No cases of nonunion, malunion, refracture, or persistent deformity occurred. The new protocol resulted in a $196 average direct hospital cost decrease, $85 average hospital revenue increase, and $187 average patient bill decrease per encounter. A further theoretical savings for patients of $489 (tibia/fibula radiograph charge) per encounter is expected by eliminating the routine follow up and radiograph at 1 month.

Conclusion: A care management protocol using CAM boots and a single outpatient follow-up visit without repeat radiographs for TF was successfully implemented at our institution and has decreased skin breakdown complications for our internally managed patients as well as costs to both the hospital and the family. Additionally, we have now eliminated routine 1 month follow-up and radiographs based on these results and literature review. This results in decreased radiation for patients and theoretical savings of $489 for patients by cutting out an additional tibia/fibula radiograph. We continue to see skin breakdown in patients whose care originated at outside facilities unfamiliar with the protocol. This is an ongoing project and future efforts will focus expanding the protocol to referring institutions.