Orthopedics

Feature Article 

Procedural Sedation With Ketamine Versus Propofol for Closed Reduction of Pediatric Both Bone Forearm Fractures

Todd Morrison, MD; Chris Carender, BS; Brendan Kilbane, MD; Raymond W. Liu, MD

Abstract

Effective treatment of pediatric both bone forearm fractures consists of timely restoration of anatomic alignment with manipulation and immobilization, often accomplished with the aid of procedural sedation in the emergency department setting. The current lack of consensus regarding a safe and optimal regimen may result in inadequate sedation, compromised quality of reduction, or patient harm. The current study was conducted to answer the following questions for pediatric both bone forearm fractures treated with closed reduction with either ketamine or propofol procedural sedation: (1) Is there a difference in the rate of unacceptable alignment 4 weeks after reduction? (2) Is there a difference in the rates of major sedation-related complications? Medical records, data on procedural sedation, and radiographs of 74 skeletally immature patients with diaphyseal or distal metaphyseal both bone forearm fractures treated with manipulation were reviewed (ketamine sedation, 26; propofol sedation, 48). Rates of unacceptable alignment for the 2 cohorts were similar both immediately after reduction and at 4 weeks. Rates of complications of procedural sedation did not differ between cohorts. The duration of procedural sedation was longer and the padding index was greater with ketamine. Malalignment after reduction was more likely in older patients and those with a higher padding index. Although no difference was found in the rates of malalignment or sedation-related complications between fractures reduced with ketamine or propofol sedation, the sedation regimens differ in both procedural duration and padding index. Careful consideration of the risks and benefits of procedural sedation for closed reduction of pediatric forearm fractures is warranted. [Orthopedics. 2017; 40(5):288–294.]

Abstract

Effective treatment of pediatric both bone forearm fractures consists of timely restoration of anatomic alignment with manipulation and immobilization, often accomplished with the aid of procedural sedation in the emergency department setting. The current lack of consensus regarding a safe and optimal regimen may result in inadequate sedation, compromised quality of reduction, or patient harm. The current study was conducted to answer the following questions for pediatric both bone forearm fractures treated with closed reduction with either ketamine or propofol procedural sedation: (1) Is there a difference in the rate of unacceptable alignment 4 weeks after reduction? (2) Is there a difference in the rates of major sedation-related complications? Medical records, data on procedural sedation, and radiographs of 74 skeletally immature patients with diaphyseal or distal metaphyseal both bone forearm fractures treated with manipulation were reviewed (ketamine sedation, 26; propofol sedation, 48). Rates of unacceptable alignment for the 2 cohorts were similar both immediately after reduction and at 4 weeks. Rates of complications of procedural sedation did not differ between cohorts. The duration of procedural sedation was longer and the padding index was greater with ketamine. Malalignment after reduction was more likely in older patients and those with a higher padding index. Although no difference was found in the rates of malalignment or sedation-related complications between fractures reduced with ketamine or propofol sedation, the sedation regimens differ in both procedural duration and padding index. Careful consideration of the risks and benefits of procedural sedation for closed reduction of pediatric forearm fractures is warranted. [Orthopedics. 2017; 40(5):288–294.]

Effective nonoperative treatment of pediatric both bone forearm fractures consists of timely restoration of length and anatomic alignment and immobilization. This treatment is often aided by procedural sedation to reduce patient awareness.1 Achieving adequate procedural sedation to perform closed reduction can be accomplished with intravenous sedatives such as ketamine hydrochloride2 or propofol.3–5 Ketamine is a phenylcyclidine derivative with rapid onset and short duration of action that functions to temporarily dissociate the limbic and cortical systems, imparting both amnestic and analgesic effects. Propofol is a lipid emulsion anesthetic that is often used for its amnestic deep sedative effects. Propofol has an additional benefit of reducing skeletal muscle tone,6 which may aid in achieving fracture reduction. Few studies have examined the effect of the sedation regimen on the outcome of both bone forearm fracture reduction. Lack of consensus regarding an optimal regimen for procedural sedation may result in complications caused by excessive sedation or potentially compromised quality of fracture reduction as a result of inadequate sedation.3,7,8

The current study was conducted to answer the following questions for pediatric both bone forearm fractures treated with closed reduction with either ketamine or propofol procedural sedation: (1) Is there a difference in the rate of unacceptable alignment 4 weeks after reduction? (2) Is there a difference in the rates of major sedation-related complications?

Materials and Methods

This single-center retrospective cohort study of pediatric both bone forearm fractures treated at a level I pediatric trauma center between 2012 and 2015 received approval from the institutional review board. Eligibility criteria included skeletally immature patients who received procedural sedation with intravenous ketamine or propofol in the emergency department setting for manipulation of diaphyseal or distal metaphyseal both bone forearm fractures. Patients with open fractures, fractures involving the physes, multiple traumatic injuries, or neurovascular deficits on presentation as well as those who underwent operative fixation at the time of initial presentation were excluded. Patients who did not have a complete procedural sedation record or did not have a minimum of 4 weeks of radiographic follow-up also were excluded.

All reductions were performed acutely in the emergency department by an orthopedic surgery resident in the first, second, or third postgraduate year of training. All residents had completed at least 11 months of an orthopedic internship and had attended a course on immobilization and splinting with a professional cast technician. Procedural sedation was administered by pediatric emergency department attending physicians or fellows, and both the choice of sedation agent and the dosing schedule were at their discretion. Additional doses were provided based on decreased sedation score or increased pain score, as documented every 5 minutes by a bedside nurse. Additional analgesia in the form of hematoma block or supplemental intravenous morphine was administered at the discretion of the orthopedic resident physician and the pediatric emergency department attending physician or fellow, respectively. Reductions were assessed with fluoroscopic images before placement of a well-padded sugar-tong splint. Radiographs were obtained immediately after reduction. At the initial outpatient follow-up, the splint was overwrapped with fiberglass and radiographs were obtained. If necessary, the cast was wedged or revision reduction was planned.

Medical and procedural sedation records were reviewed. Duration of procedural sedation was defined as the time between initial administration of sedation medication and completion of postsedation monitoring, when the bedside nurse documented a sedation score of 0, which equates to being awake and responding in an age-appropriate manner. Respiratory depression during procedural sedation was defined as oxygen saturation of less than 90% as measured by continuous pulse oximetry, end-tidal CO2 of greater than 50 mm Hg or absent end-tidal CO2 waveform as measured by continuous nasal capnography, or the need for a respiratory intervention, including additional supplemental oxygen with a non-rebreather mask at any time during the procedure.3

Orthogonal radiographic images of the forearm or wrist obtained initially, immediately postreduction, and at follow-up were evaluated for fracture characteristics. Fracture angulation was measured with Centricity PACS (GE Healthcare, Chicago, Illinois) digital imaging software. Diaphyseal fractures were defined as occurring between the proximal and distal metaphyses, which were defined by drawing a square area the width of the respective physis on the anteroposterior radiograph (Figure 1). Because of the retrospective nature of this study, standardization of radiographs was not feasible. Therefore, both forearm and wrist radiographs were used to assess the angulation of metaphyseal fractures, and forearm radiographs alone were used to measure diaphyseal both bone forearm fractures.

For forearm anteroposterior and lateral radiographs, the distal radius metaphysis was divided into thirds, and angular measurements were created for each segment with the midpoint of the segment used as an imaginary fracture line. These segments included the proximal metaphyseal angle (PMA), middle metaphyseal angle (MMA), and distal metaphyseal angle (DMA) (A). For wrist anteroposterior and lateral radiographs, the metaphysis was similarly divided into thirds, and the angular measurement of each segment was obtained in a similar fashion. The distal metaphysis was defined by a square the width of the distal physis (B).

Figure 1:

For forearm anteroposterior and lateral radiographs, the distal radius metaphysis was divided into thirds, and angular measurements were created for each segment with the midpoint of the segment used as an imaginary fracture line. These segments included the proximal metaphyseal angle (PMA), middle metaphyseal angle (MMA), and distal metaphyseal angle (DMA) (A). For wrist anteroposterior and lateral radiographs, the metaphysis was similarly divided into thirds, and the angular measurement of each segment was obtained in a similar fashion. The distal metaphysis was defined by a square the width of the distal physis (B).

Angulation of the radius and ulna in both bone forearm fractures was determined as previously described by Bowman et al9 (Figure 2). The primary outcome was the degree of residual angulation after reduction as well as achievement of acceptable alignment. Previous clinical and cadaveric studies defined acceptable diaphyseal alignment of radius fractures for girls 8 years or younger and boys 10 years or younger as 20° for the distal third, 15° for the middle third, and 10° for the proximal third.10–16 Acceptable radial diaphyseal alignment for girls older than 8 years and boys older than 10 years was defined as less than 10° at all levels.10,11,16–18 Acceptable distal radial metaphyseal angulation is controversial19; therefore, for the current study, acceptable angulation was defined as 20° for girls 8 years or younger and boys 10 years or younger and 10° for girls older than 8 years and boys older than 10 years.14 Fracture union was defined as the finding of bridging callus on 3 cortices. The padding index was calculated on immediate postreduction radiographs as described previously.20,21

Angulation of the radius and ulna was determined by measuring the angle subtended by a line drawn from the center of the diaphysis at the distal extent of the radial bicipital tuberosity to the center of the proximal segment fracture site and a line drawn from the center of the distal segment fracture site to the center of the physis for diaphyseal (A) and metaphyseal (B) fractures on forearm anteroposterior and lateral radiographs. Angulation was measured similarly for wrist anteroposterior and lateral radiographs of distal metaphyseal fractures, with the center of the most proximal visible diaphysis used in lieu of the bicipital tuberosity (C).

Figure 2:

Angulation of the radius and ulna was determined by measuring the angle subtended by a line drawn from the center of the diaphysis at the distal extent of the radial bicipital tuberosity to the center of the proximal segment fracture site and a line drawn from the center of the distal segment fracture site to the center of the physis for diaphyseal (A) and metaphyseal (B) fractures on forearm anteroposterior and lateral radiographs. Angulation was measured similarly for wrist anteroposterior and lateral radiographs of distal metaphyseal fractures, with the center of the most proximal visible diaphysis used in lieu of the bicipital tuberosity (C).

The natural angulation of the radius was accounted for in all diaphyseal fracture angulation measurements with previously established population-based correction factors.9 To the authors' knowledge, the natural angulation of the distal radius metaphysis has not been evaluated previously. To account for the natural angulation of the metaphysis, a random sample of 32 uninjured wrist radiographs and 32 uninjured forearm radiographs that were considered to represent the patient cohort based on age and sex were assessed. The natural angulations of the distal radius metaphysis as measured on the uninjured forearm and wrist radiographs differed (Figure 1). Angulation measurements of distal metaphyseal both bone forearm fractures were adjusted with the correction factor for the corresponding segment, derived from either the forearm radiograph or the wrist radiograph, as described in Table 1.

Correction of Diaphyseala and Metaphysealb Both Bone Forearm Fracture

Table 1:

Correction of Diaphyseal and Metaphyseal Both Bone Forearm Fracture

Assuming a 51.1% incidence of unacceptable postreduction angulation with closed reduction techniques at 4 weeks9 and α=0.05 and ß=0.20, a priori power analysis indicated that 24 subjects were needed in each group to detect a 70% relative and 40% absolute increase in the incidence of unacceptable reductions.

Comparison of independent categorical variables between cohorts was achieved with chi-square or Fisher's exact test where applicable. Comparison of continuous variables between cohorts was achieved with Mann–Whitney U analysis. Correlation between continuous variables was accomplished with the Pearson correlation coefficient. Multinomial logistic regression was performed to determine the effect of confounding variables on the primary outcome. All statistical analysis was performed with SPSS software, version 23.0 (IBM, Armonk, New York).

Results

During the study period, 117 pediatric both bone forearm fracture manipulations were performed with procedural sedation. Of this group, 44 patients did not meet the eligibility criteria. Of these, 3 required operative management at initial presentation for open injury, 3 had concurrent administration of intravenous ketamine and propofol, and 38 had incomplete procedural sedation records or inadequate follow-up. Of the 74 patients included in the study, 26 patients were included in the cohort that received ketamine sedation and 48 patients were included in the cohort that received propofol sedation. Characteristics of the cohorts were similar regarding patient sex, age, and initial fracture characteristics (Table 2).

Baseline Characteristics of Patients With Diaphyseal and Metaphyseal Both Bone Forearm Fractures

Table 2:

Baseline Characteristics of Patients With Diaphyseal and Metaphyseal Both Bone Forearm Fractures

The rates of unacceptable alignment immediately after reduction for the ketamine and propofol cohorts were similar at 15.4% and 14.6%, respectively (Table 3). At a minimum of 4-week follow-up, the rates of unacceptable alignment increased for both the ketamine and propofol cohorts to 34.6% and 47.9%, respectively. This increase was statistically significant only for the propofol cohort (chi-square, 0.003). Total angulation of the radius immediately after closed reduction was significantly greater in the ketamine cohort (10° vs 7°, U=416, P<.05). The difference in radial angulation did not persist at a minimum of 4-week follow-up. Paired Student's t test showed an overall increase in total angulation of the radius from reduction to follow-up of combined cohorts (9° vs 14°, respectively; P<.05). The ketamine cohort had a greater padding index after reduction (0.39 vs 0.24, U=379.5, P<.05). When accounting for the effect of fracture angulation and fracture location, the padding index was greater for fractures reduced with ketamine procedural sedation. Except for 3 patients in each cohort, residual angulation was believed to be amenable to remodeling. Of these patients, 5 required open reduction and 1 patient required corrective osteotomy for malunion.

Fracture Angulation Outcomes After Closed Reduction and After at Least 4 Weeks of Follow-up

Table 3:

Fracture Angulation Outcomes After Closed Reduction and After at Least 4 Weeks of Follow-up

Several fracture characteristics differed between patients who had acceptable and unacceptable alignment at both study time points (Table 4). Children with unacceptable vs acceptable alignment both immediately after reduction and at a minimum of 4-week follow-up were older. The padding index was significantly greater in fractures with unacceptable vs acceptable alignment after reduction (0.34 vs 0.27, U=209.5, P<.05). The level of training of the resident performing the procedure had no effect on alignment after reduction or at 4-week follow-up. Similarly, initial fracture angulation, displacement, or shortening had no effect on alignment at either time point. When accounting for the effect of age, multivariate regression analysis showed no difference in the rate of unacceptable alignment between the ketamine and propofol cohorts at a minimum of 4-week follow-up.

Characteristics of Fractures With Acceptable or Unacceptable Alignment at 4 Weeks or More of Follow-up

Table 4:

Characteristics of Fractures With Acceptable or Unacceptable Alignment at 4 Weeks or More of Follow-up

No major complications occurred in either group. In the propofol cohort, 6 patients had respiratory depression. Of these, 2 had oxygen saturation of less than 90%, 1 had end-tidal CO2 of greater than 50 mm Hg, and all 6 required the use of a non-rebreather mask. A single patient in the ketamine cohort had respiratory depression, with oxygen saturation of less than 90%, and required the use of a non-rebreather mask. Lower oxygen saturation values were observed in the propofol cohort (97% vs 95%, U=303.5, P<.01); however, there was no significant difference in respiratory interventions or rates of respiratory depression between the 2 groups. The propofol group was more likely to require intravenous morphine analgesia (P<.05). The number of doses of intravenous sedation administered during the procedure was greater for the propofol group (4 vs 5, U=341.5, P<.05). Pain scores and depth of sedation were similar for the 2 cohorts, but the duration of procedural sedation with propofol was shorter (24.7±6.4 vs 19.9±6.8 minutes, P<.05).

Discussion

The decision to treat closed both bone forearm fractures nonoperatively is dependent on the quality and maintenance of reduction. Attempts at reduction and immobilization may be compromised by inadequate analgesia or the depth of sedation. Although propofol can induce deeper sedation than ketamine, it does not have the analgesic effect of ketamine.3 The current study attempted to identify the effect of the choice of intravenous sedative for procedural sedation on the outcomes of nonoperatively treated both bone forearm fractures.

This study found similar rates of unacceptable alignment after closed reduction with procedural sedation with either ketamine or propofol. The observed rates of unacceptable alignment are comparable with those of previous studies.9,18,22 Fractures reduced with both sedation regimens showed further malalignment at follow-up. A possible explanation for this finding is poor immobilization with the use of a sugar-tong splint and fiberglass overwrap before conversion to a short arm cast. Levy et al23 performed a prospective randomized trial comparing maintenance of reduction for distal radius and distal both bone forearm fractures with either a long arm cast or a sugar-tong splint converted to a short arm cast after 1 week. They found better postreduction alignment, less loss of reduction, and less need for remanipulation with sugar-tong splints. However, there was no difference between groups at cast removal.23 In the current study, only 19% of fractures with unacceptable alignment at follow-up underwent operative intervention, and the average age of those patients was 15.7 years compared with 8.7 years for patients with unacceptable alignment who did not receive interventions. It has been suggested that reluctance to perform remanipulation for younger patients with malaligned both bone forearm fractures was influenced by remaining growth potential to correct residual deformities.24 The current results also suggest that remaining growth potential strongly influences the decision as to whether to intervene with fractures that have unacceptable alignment. Although the current study did not show a higher rate of malalignment in fractures reduced with ketamine procedural sedation, this cohort had a higher padding index. The clinical explanation for this finding is unclear; despite the longer procedural time with ketamine sedation, no correlation was found between sedation time and padding index. It is possible that a higher padding index and a longer procedure duration were proxies for more difficult reduction procedures that did not result in malalignment.

The current study did not find a difference in major or minor complications related to procedural sedation for reduction of both bone forearm fractures with either regimen. However, patients undergoing fracture manipulation with propofol sedation had lower oxygen saturation, although the clinical significance of this finding is likely minimal because the average lowest oxygen saturation level for either cohort was greater than 92%. Further, end-tidal CO2 obtained with nasal capnography, which has been shown to accurately detect alveolar hypoventilation and reduce hypoxemia during procedural sedation in children,25 was similar between cohorts. In addition, the duration of procedural sedation with ketamine was longer than with propofol. Uri et al26 performed a retrospective study of 60 adults undergoing painful orthopedic procedures, including fracture manipulation, and found an average procedural sedation duration of 16 minutes and 42 minutes for propofol and ketamine, respectively. In conjunction with the current study, these findings suggest that propofol procedural sedation may have a role in expedited fracture manipulation in the emergency department, but attention must be paid to potential respiratory complications.

Limitations

This retrospective cohort study had several limitations. Initially, fractures were immobilized with splints, necessitating the use of the padding index rather than the cast index to measure the quality of immobilization. Although the cast index has been shown to effectively predict maintenance of reduction of diaphyseal27 and distal28 forearm fractures, a padding index of greater than 0.3 has been identified as a predictor of redisplacement of pediatric forearm fractures.20,21 Lack of long-term follow-up is another potential criticism. However, with an average follow-up of 6.4 weeks, radiographic union was observed in all patients who did not require subsequent interventions. Further, Luther et al29 recently showed that there is minimal change in pediatric forearm fracture alignment after 2 weeks, and most interventions are based on radiographic assessment during that period. Because the current study was retrospective, not all of the patients had forearm radiographs available for evaluation. The authors corrected for this as much as possible, although the method they used was sensitive to the amount of diaphysis included in the image. Therefore, some inconsistency in the measurements likely persisted.

Conclusion

Rates of malreduction of both bone forearm fractures achieved with propofol or ketamine sedation regimens were similar, with minimal complications related to procedural sedation. However, the propensity for these fractures to progress toward malalignment regardless of sedation regimen underscores the importance of achieving optimal reduction and immobilization in addition to close radiographic follow-up. Differences between the sedation regimens included shorter procedure duration, greater use of supplemental intravenous analgesia, and lower oxygen saturation levels with propofol as well as an increased padding index with ketamine. Careful consideration of the risks and benefits of procedural sedation for closed reduction of pediatric forearm fractures as they relate to individual patients is warranted.

References

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Correction of Diaphyseala and Metaphysealb Both Bone Forearm Fracture

Fracture Location/Radiographic ViewProximal ThirdMiddle ThirdDistal Third
Diaphyseal
  Forearm radiograph
    Anteroposterior1.5° apex radial6.0° apex radial1.8° apex radial
    Lateral0.0°0.0°0.0°
Metaphyseal
  Forearm radiograph
    Anteroposterior9.5° apex radial10.9° apex radial12.3° apex radial
    Lateral0.0°0.0°4.3° apex dorsal
  Wrist radiograph
    Anteroposterior1.8° apex radial2.1° apex radial2.5° apex radial
    Lateral0.0°0.0°3.1° apex dorsal

Baseline Characteristics of Patients With Diaphyseal and Metaphyseal Both Bone Forearm Fractures

CharacteristicaKetamine (n=26)Propofol (n=48)
Sex, No.
  Male21 (80.7%)30 (62.5%)
  Female5 (19.3%)18 (37.5%)
Age at fracture, median (range), y8.8 (5.3–12.2)7.8 (3.0–16.6)
Laterality, No.
  Left11 (42.3%)18 (37.5%)
  Right15 (57.7%)30 (62.5%)
Diaphyseal fractures, No.16 (61.5%)32 (66.7%)
  Proximal1 (3.8%)1 (2.0%)
  Middle6 (23.0%)15 (31.3%)
  Distal9 (34.6%)16 (33.3%)
Metaphyseal fractures, No.10 (38.6%)16 (33.3%)
  Proximal9 (32.1%)15 (31.3%)
  Middle1 (3.8%)1 (2.0%)
Radius displacement, No.
  Anteroposterior13 (50.0%)18 (37.5%)
    Medial7 (26.9%)13 (27.8%)
    Lateral6 (23.1%)5 (10.4%)
  Lateral16 (61.5%)25 (52.1%)
    Dorsal13 (50.0%)16 (33.3%)
    Volar3 (11.5%)7 (14.5%)
Ulna displacement, No.
  Anteroposterior5 (19.2%)9 (18.8%)
    Medial3 (11.5%)7 (14.5%)
    Lateral2 (7.7%)2 (4.2%)
  Lateral7 (26.9%)13 (27.0%)
    Dorsal5 (19.2%)8 (16.7%)
    Volar2 (7.7%)5 (10.4%)
Radius shortening, No.11 (42.3%)30 (62.5%)
Ulna shortening, No.22 (84.6%)37 (77.0%)
Radius angulation, median (range)43° (20°–78°)29° (4°–69°)
Ulna angulation, median (range)31° (13°–120°)23° (4°–53°)

Fracture Angulation Outcomes After Closed Reduction and After at Least 4 Weeks of Follow-up

Outcome MeasurementKetamine (n=26)Propofol (n=48)P
Radius angulation at reduction, median (range)10° (6°–25°)7° (3°–18°)<.05a
Ulna angulation at reduction, median (range)4° (2°–25°)4° (1°–36°).71
Unacceptable angulation at reduction, No.4 (15.4%)7 (14.6%).59
Padding index, median (range)0.39 (0.11–1.59)0.24 (0.09–0.83)<.05a
Follow-up, median (range), wk6.5 (4.1–14.7)6.0 (4.0–14.0).91
Radius angulation at follow-up, median (range)9° (1°–21°)11° (2°–57°).46
Ulna angulation at follow-up, median (range)5° (2°–9°)7° (1°–21°).15
Unacceptable angulation at follow-up, No.9 (34.6%)23 (47.9%).20
Intervention at follow-up, No.3 (11.5%)3 (6.3%).35

Characteristics of Fractures With Acceptable or Unacceptable Alignment at 4 Weeks or More of Follow-up

Fracture CharacteristicAcceptable AlignmentUnacceptable AlignmentP
Postreduction, No.6410
  Resident performing reduction, No.
    Postgraduate year 11 (1.6%)1 (10%)
    Postgraduate year 256 (87.5%)8 (80%).36
    Postgraduate year 37 (10.9%)1 (10%)
  Age, median (range), y7.1 (2.4–16.6)10.9 (5.2–15.7)<.05a
  Diaphyseal fractures, No.44 (68.8%)4 (40%).08
    Proximal1 (1.6%)1 (10%)
    Middle20 (31.3%)1 (10%)
    Distal23 (35.9%)2 (20%)
  Metaphyseal fractures, No.20 (35.9%)6 (60%).24
    Proximal19 (29.6%)5 (50%)
    Middle1 (1.6%)1 (10%)
  Padding index, median (range)0.27 (0.09–0.83)0.34 (0.18–1.59)<.05a
Follow-up, No.4232
  Resident performing reduction, No.
    Postgraduate year 11 (2.4%)1 (3.1%)
    Postgraduate year 236 (85.7%)28 (87.5%).93
    Postgraduate year 35 (11.9%)3 (9.4%)
  Age, median (range), y6.8 (2.4–16.6)9.2 (3.6–15.7)<.05a
  Diaphyseal fractures, No.29 (69.0%)19 (59.3%).73
    Proximal1 (2.3%)1 (3.1%)
    Middle14 (33.3%)7 (21.9%)
    Distal14 (33.3%)11 (34.3%)
  Metaphyseal fractures, No.13 (30.9%)13 (40.6%).52
    Proximal12 (28.6%)12 (37.5%)
    Middle1 (2.3%)1 (3.1%)
Authors

The authors are from the Department of Pediatric Orthopaedic Surgery (TM, RWL) and the Department of Pediatric Emergency Medicine Surgery (BK), Rainbow Babies and Children's Hospital, University Hospitals Cleveland Medical Center; and Case Western Reserve University School of Medicine (CC), Cleveland, Ohio.

Dr Morrison, Mr Carender, and Dr Kilbane have no relevant financial relationships to disclose. Dr Liu receives research support from Orthopaediatrics Corporation.

Correspondence should be addressed to: Todd Morrison, MD, Department of Pediatric Orthopaedic Surgery, Rainbow Babies and Children's Hospital, University Hospitals Cleveland Medical Center, 11100 Euclid Ave, Cleveland, OH 44116 ( toddamorrison@gmail.com).

Received: May 26, 2017
Accepted: July 26, 2017
Posted Online: September 07, 2017

10.3928/01477447-20170824-01

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