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young girl sitting on a bed with a cast

Creating better casts

young girl sitting on a bed with a cast

Each year, millions of children in the U.S. come to hospital emergency departments with fractures. While broken bones are commonplace, the expertise to stabilize these injuries and cast them is not, says Children’s National Health System orthopedic surgeon Shannon Kelly, M.D.

Most fractures are casted by an on-call resident without the assistance of an orthopedist, she explains. Whether that resident applies a cast successfully depends largely on how well he or she learned this skill as an intern. While most current training models have interns take calls with residents, picking up casting skills through hands-on experience from their more senior peers, they can also pick up mistakes – which get repeated once they’re caring for patients independently as residents themselves, Kelly says.

Casting mistakes aren’t trivial, she adds. They can have serious consequences for patients. For example, a cast that’s not tight enough in the right places can leave bones vulnerable to shifting, a scenario that doctors call a loss in reduction, Kelly explains. If bones aren’t in the right position to heal, doctors must reposition them either in the operating room, often exposing patients to general anesthesia, or through painful, in-office procedures.

Conversely, casts that are too tight – particularly on a fresh fracture that’s prone to swelling – can damage tissues from loss of circulation. To avoid this latter problem, doctors often create a “bivalve” cast in which the two halves are split like a clamshell, leaving room for tissues to expand. But they must use extreme care when they cut open the cast with a saw to avoid cutting patients with the rotating blade or burning them with heat generated from its friction.

“Each year, thousands of children are harmed from improper casting and must go through additional procedures to fix the damage done,” Kelly says.

That’s why she and her colleagues are developing a better way to train interns before they start their orthopedics rotation. Starting this spring, the team will be directing a series of casting workshops to train interns on the proper casting technique.

The workshops will take advantage of models that allow interns to practice without harming patients. Some of these models have simulated bones that show up on an X-ray, allowing participants to evaluate whether they achieved a good reduction once they’re finished. Other models are made of wax that melts if the heat of a cast saw becomes too intense and show nicks if the blade makes contact. Learning proper technique using this tool can help spare human patients painful burns and cuts, Kelly says.

To broaden this effort beyond Children’s National, Kelly and her colleagues received a $1,000 microgrant from the Pediatric Orthopaedic Society of North America to create videos based on material from these workshops. These videos will help trainees at medical institutions across the country learn the same pivotal casting skills.

“A broken bone is difficult enough,” Kelly says. “We’re hoping to decrease the number of times that a child has to have an unnecessary procedure on top of that from a casting mistake that could have been avoided.”

Femoral fracture

Broken system? Pain relief for fractures differs by race/ethnicity

Femoral fracture

Data collected by a multi-institutional research team show that kids’ pain from long bone fractures may be managed differently in the emergency department depending on the child’s race and ethnicity.

Children who experience broken bones universally feel pain. However, a new multi-institutional study presented at the American Academy of Pediatrics (AAP) 2018 National Conference & Exhibition suggests that emergency treatment for this pain among U.S. children is far from equal. Data collected by the research team show that kids’ pain may be managed differently in the emergency department depending on the child’s race and ethnicity. In particular, while non-Latino black children and Latino children are more likely to receive any analgesia, non-white children with fractured bones are less likely to receive opioid pain medications, even when they arrive at the emergency department with similar pain levels.

“We know from previously published research that pain may be treated differentially based on a patient’s race or ethnicity in the emergency department setting. Our prior work has demonstrated that racial and ethnic minorities are less likely to receive opioid analgesia to treat abdominal pain, even when these patients are diagnosed with appendicitis,” says study leader Monika K. Goyal, M.D., MSCE, assistant division chief and director of Academic Affairs and Research in the Division of Emergency Medicine at Children’s National Health System. “Emergency departments delivering evidence-based care should treat all pediatric patients consistently. These findings extend our work by demonstrating that children presenting with long bone fractures also experience differential treatment of pain based on their race or ethnicity.”

The AAP calls appropriately controlling children’s pain and stress “a vital component of emergency medical care” that can affect the child’s overall emergency medical experience. Because fractures of long bones – clavicle, humerus, ulna, radius, femur, tibia, fibula – are commonly managed in the emergency department, the research team tested a hypothesis about disparities in bone fracture pain management.

They conducted a retrospective cohort study of children and adolescents 21 and younger who were diagnosed with a long bone fracture from July 1, 2014, through June 30, 2017. They analyzed deidentified electronic health records stored within the Pediatric Emergency Care Applied Research Network Registry, which collects data from all patient encounters at seven pediatric emergency departments.

During that time, 21,642 patients with long bone fractures met the study inclusion criteria and experienced moderate to severe pain, rating four or higher on a 10-point pain scale. Some 85.1 percent received analgesia of any type; 41.5 percent received opioid analgesia. Of note:

  • When compared with non-Hispanic white children, minority children were more likely to receive pain medication of any kind (i.e. non-Latino black patients were 58 percent more likely to receive any pain medication, and Latino patients were 23 percent more likely to receive any pain medication).
  • When compared with non-Latino white children, minority children were less likely to receive opioid analgesia (i.e., non-Latino black patients were 30 percent less likely to receive opioid analgesia, and Latino patients were 28 percent less likely to receive opioid analgesia).

“Even though minority children with bone fractures were more likely to receive any type of pain medication, it is striking that minority children were less likely to receive opioid analgesia, compared with white non-Latino children,” Dr. Goyal says. “While it’s reassuring that we found no racial or ethnic differences in reduction of patients’ pain scores, it is troubling to see marked differences in how that pain was managed.”

Dr. Goyal and colleagues are planning future research that will examine the factors that inform how and why emergency room physicians prescribe opioid analgesics.

American Academy of Pediatrics National Conference & Exhibition presentation

  • “Racial and ethnic differences in the management of pain among children diagnosed with long bone fractures in pediatric emergency departments.”

Monika K. Goyal, M.D., MSCE, and James M. Chamberlain, M.D., Children’s National; Tiffani J. Johnson, M.D., MSc, Scott Lorch, M.D., MSCE, and Robert Grundmeier, M.D., Children’s Hospital of Philadelphia; Lawrence Cook, Ph.D., Michael Webb, MS, and Cody Olsen, MS, University of Utah School of Medicine; Amy Drendel, DO, MS, Medical College of Wisconsin; Evaline Alessandrini, M.D., MSCE, Cincinnati Children’s Hospital; Lalit Bajaj, M.D., MPH, Denver Children’s Hospital; and Senior Author, Elizabeth Alpern, M.D., MSCE, Lurie Children’s Hospital.