From Theatre to Front Door: Changing the way we deliver fracture manipulation Mr Nick Beattie ST7 Trauma and Orthopaedic Surgery Royal Hospital Sick Children Edinburgh Clinical Change

Co Authors Mr J Tsang ST6 Trauma and Orthopaedic Surgery Miss Kate Bugler ST7 Trauma and Orthopaedic Surgery Mr Simon Roberts ST6 Trauma and Orthopaedic Surgery Mr Alastair Murray Consultant Paediatric Orthopaedic Surgeon Miss Emily Baird Consultant Paediatric Orthopaedic Surgeon

Declarations No financial conflict of interest declared BOA 2016

Fractures in Children 30% of Children suffer a fracture before the age of 17 Cooper et al 2004 Forearm fractures account for 30% to 50% of all pediatric fractures BOA 2016

Operative Journey Initial Radiograph Provisional Cast 19:33 20:00 Provisional Cast 10:54 Theatre Film 15.5 hours Time to Definitive Management BOA 2016

Problem Time Consuming, Expensive, not needed BOA 2016

The Aim of this Study Is MUA in A+E a safe procedure and does performing the procedure in theatre have any actual benefits Potential to initiate change in practice BOA 2016

The A+E Protocol BOA 2016

Operative Journey (ED Method) 17:10 Initial Radiograph 18:46 A&E Fix 1:5 hours Time to Definitive Management BOA 2016

Study Methods All fractures deemed appropriate for MUA without instrumentation referred to Orthopaedics at RHSC From August 1st 2015 for 6 consecutive months BOA 2016

Results BOA 2016

Results Mean time to treatment in theatre group was 18 hours Vs 3 hours in the ED group Re fracture in the ED group and 1 re fracture in the theatre group All fractures united within acceptable limits No re operations in either group No complications from the procedural sedation or anaesthesia BOA 2016

Saving: £1800 per patient Theatre cost: £2000 per patient Cost Implications Theatre cost: £2000 per patient A+E cost: £112 per patient Saving: £1800 per patient BOA 2016

Saving: £64,192 Theatre cost: £112,000 A+E cost: £6272 Cost Implications Theatre cost: £112,000 A+E cost: £6272 Saving: £64,192 BOA 2016

But…… Further reduction in costs still possible BOA 2016

Conclusion No adverse affects on union, malunion, reoperation or anaesthetic complications Quicker and significantly lower in cost when compared with admission and treatment in theatre BOA 2016

Recommendations Treatment in Emergency Department for all fractures of the forearm and distal radius that can be managed by closed reduction and casting in children who are safe to undergo procedural sedation BOA 2016

Questions BOA 2016