Closed Reductions of Pediatric Wrist, Forearm, and Elbow Fractures in a Free-Standing Ambulatory Surgery Center is a Safe and Cost-effective Alternative to the Emergency Department

Carson D. Strickland, MD1 Robert Neel, BS2 Evan Porter, MD1 Benjamin W. Sheff er, MD1 Derek M. Kelly, MD1

1 University of Tennessee-Campbell Clinic Department of Orthopaedic Surgery & Biomedical Engineering Memphis, Tennessee 2 University of Tennessee

Health Science Center

College of Medicine

Memphis, Tennessee

Corresponding Author

Derek M. Kelly, MD

1458 W. Poplar Avenue, Suite 100 Collierville, TN 38017 P: 901-759-5552 F; 901-435-5654 dkelly@campbellclinic.com

Closed Reductions of Pediatric Wrist, Forearm, and Elbow Fractures in a Free-Standing Ambulatory Surgery Center is a Safe and Cost-eff ective Alternative to the Emergency Department

Background

Pediatric extremity fractures and dislocations have historically been treated on the day of presentation to the pediatric emergency department (PED). As the use of ambulatory surgery centers (ASCs) has increased, so has delayed treatment of these injuries in an outpatient setting.

Objectives

The goal of this study was to examine clinical and radiographic outcomes, as well as length of stay, in the treatment of pediatric upper extremity fractures below the elbow in the pediatric ED, hospital ASC (hASC), and a free-standing ASC (fASC).

Methods

A retrospective chart review identifi ed pediatric patients who had closed manipulation and immobilization of upper extremity injuries distal to the elbow from October 2013, to December 2018. We specifi cally looked at 3 venues of care: a level 1 PED, a hASC, and a fASC. There were 95 and 99 patients in the hASC and fASC cohorts, respectively. To match these numbers, the fi rst 99 patients in the PED group were considered. The primary outcomes were length of visit, length of sedation, time from admission to procedure, time from initial presentation to reduction in the outpatient groups, post-procedure radiographic parameters of angulation and change in angulation, procedural complications, need for remanipulation, and need for conversion to open treatment.

Results

There was a signifi cant di erence in the length of visit between all groups, with the fASC being about 80 and 73 minutes shorter compared to the PED and hASC groups, respectively (p<0.05). There was no signifi cant di erence amongst the groups for length of sedation. On average, patients waited approximately 193 minutes prior to reduction in the PED compared to 83 minutes at the fASC and 143 minutes at the hASC, which was signifi cant (p<0.05). Pre- and post- radiographic fracture angulation and displacement were similar for the groups. There were no procedural complications for any of the groups, and there was no signifi cant di erence in the rates of remanipulation and conversion to open treatment.

CARSON D. STRICKLAND, MD

Hometown: Columbus, Georgia Undergraduate Institution: University of Georgia Medical School: Mercer University School of Medicine Dr. Strickland is the older of two children, and his sibling Chandler is a NICU nurse in Athens, Georgia. Dr. Strickland is the fi rst MD in his family. Dr. Strickland and his wife Klaire became best friends after college and were married in 2013. Klaire is an insurance claims analyst who works remotely from home while also taking care of their two children - fi ve-year-old Mary Jennings, and twoand-a-half-year-old Collins. When asked why he chose medicine as a career: Growing up, I was interested in science and athletics. Though I enjoyed playing sports, I realized pretty early on that professional athletics weren't in the cards for me. The opportunity to take care of athletes and sports injuries seemed like a nice consolation to playing in the big leagues, and this is what initially attracted me to medicine, and especially, orthopaedics. And why he chose orthopaedics as a specialty: Ultimately, I was blessed to have many mentors who helped me learn that there was much more to orthopaedics than being on the sidelines on Friday night. We are able to provide pain relief, deformity correction, and improvement in functioning in a generally quick manner. There is nothing more rewarding than seeing someone you’ve treated return to an active lifestyle or be able to walk with a plantigrade foot. Plans After Campbell: Dr. Strickland will complete a Foot and Ankle Fellowship at OrthoCarolina in Charlotte, North Carolina, and will then join the sta at Mid-Tennessee Bone and Joint Clinic in Columbia, Tennessee. Dr. Strickland adds: To the Campbell Clinic staff : I sincerely thank you for your patience, wisdom, and teaching that you have imparted on me. I have learned so much about orthopaedics and how to run a private practice from each of you, but also about life and the art of medicine. It has been an honor to train here under your guidance, and I am forever grateful for my time here. I would like to thank the trauma staff for teaching me how to operate and take care of the vast majority of traumatic orthopaedic injuries I will encounter in practice. Lastly, I would like to give a special thanks to the foot and ankle staff for your mentorship and helping me become a foot and ankle surgeon. I have learned so many diff erent techniques and philosophies from each of you, and my practice will bear aspects from each of yours. I am excited for next year, but I feel like I have already had the best foot and ankle training in the country. To the residents: It has been a pleasure working with of all you, and I cherish the friendships and memories we have made over the past fi ve years. Best of luck to everyone still going through the process. It gets better. To my parents: Thank you for your unwavering support and always putting your children before yourselves. I would not be here today without all the sacrifi ces you have made for me. To my wife, Klaire: You are the glue that holds our family together, and you have been the real MVP during this long and arduous process. You deserve just as much credit as I do for completing residency. Thank you for your love and support in helping me realize my goals. I love you.