P2.D078: Clinical Outcomes and Patient Experience with a Shared Decision-Making Pathway for Low-Risk Distal Forearm Fractures: A Quality Improvement Initiative

Purpose/Objectives: Fractures of the distal radius are among the most common childhood fractures. Evidence demonstrates that buckle fractures and minimally angulated transverse and greenstick distal radius fractures can be safely treated with splints, avoiding the discomfort and costs associated with casts. In our ED, use of splints for treatment of forearm buckle fractures was standard practice, but transverse and greenstick fractures were treated with casts. We aimed to increase the use of splints in children with minimally angulated transverse and greenstick distal radius fractures to 50% within one year, using a shared decision-making process.

Design/Methods: A clinical treatment pathway based on published literature and local consensus was created for children aged 5-12 years, and education was provided to physicians and orthopedic technicians. A shared decision-making tool supported families in choosing splint or cast treatment. Parents were asked for consent to be contacted for telephone and email follow-up. The primary aim was proportion treated with splint. Additional outcomes included proportion of parents reporting shared decision-making, patient and family experience at 1 and 8 weeks, patient satisfaction, proportion experiencing change of treatment devise, change in fracture angulation, and proportion experiencing complications (balancing measure). Primary outcome analysis was by statistical process control.

Results: During the 13 months following release of the clinical pathway, 80 children met inclusion criteria (mean age 9.5 years). 54 children (68%) were treated with a splint and 26 (32%) were treated with a cast. The P chart (Figure 1) demonstrated a stable process with a center line of 68%. 65 parents (81%) completed a phone interview at 1-2 weeks and 35 (44%) completed email follow-up at 8 weeks. Among participants interviewed, 37% reported participating in shared decision-making. Of these, 92% chose splinting over casting (p < 0.01). At the first orthopedic follow-up, 13% of splints were changed to casts and 35% of casts were changed to splints. Of patients initially treated with a cast, the average change in fracture angulation at last follow-up in the same device was -0.1 degrees. Of patients initially treated with a splint, the average change in fracture angulation was +0.8 degrees (p=0.81). One patient treated with a splint had unacceptably increased angulation at the follow-up visit and returned to the ED for a reduction. 82% of parents whose child was treated with a splint would choose a splint again, whereas 69% of those treated with a cast would choose a cast again (p=0.39).

Conclusion/Discussion: In our ED, creating a clinical pathway for minimally angulated distal radius transverse and greenstick fractures led to most patients being treated with splints. Splints were preferred by most families and resulted in similar clinical outcomes as treatment with a cast. Shared decision-making was an acceptable approach for treatment of children with this fracture type.