Are outcomes comparable between emergency department and orthopaedic reduction of paediatric distal forearm fractures?

May 11, 2026

May 11, 2026

Tamzin Wild, Foundation Year 2 Doctor (Manchester Foundation Trust)

Pedro Osório, Junior Clinical Teaching Fellow

In (children with displaced upper-lib fractures, including forearm & wrist fractures) Is (reduction and immobilisation of the fracture by emergency medicine trained clinicians) Associated with (similar patient orientated outcomes to orthopaedic surgeons)

A 9 year old child presents to the ED after falling from a climbing frame, with a painful, swollen and visibly deformed forearm. X-rays confirm a displaced radial fracture requiring reduction. The department is busy and orthopaedic input may be delayed. Two emergency physicians trained in procedural sedation and fracture reduction are available. You consider whether ED led reduction and immobilisation provides comparable outcomes to orthopaedic led management in paediatric displaced upper limb fractures

MEDLINE and EMBRASE databases were searched from 1976-2026 using the Ovid interface. The following keywords were used: (upper limb OR forearm OR wrist OR radius OR ulna).ti,ab. AND (fracture*).ti,ab. AND (displaced OR reduction OR "closed reduction").ti,ab. AND (pediatric OR paediatric OR child* OR adolescent*).ti,ab. AND ("emergency department" OR "emergency room" OR "accident and emergency").ti,ab. AND (orthopaedic* OR orthopedic*).ti,ab.

A supplementary search was performed in the Cochrane Library using the same search terms. Google Scholars ‘cited by’ function was used to search for any additional studies that referenced the included studies. Reference lists of included studies were also reviewed to identify any additional relevant papers. Results were exported to Microsoft Excel and duplicates were removed.

Inclusion criteria were studies involving paediatric patients with displaced forearm or wrist fractures managed in the ED. Studies were excluded if there was no direct comparative data between both emergency and orthopaedic led groups or if they were conference abstracts, case reports and case series and non-peer reviewed publications.

Our search strategy resulted in 89 papers after removal of duplicates. 71 were excluded following title and abstract review as they did not meet the clinical three part question or were abstract-only publications.

18 papers underwent full text review, of which 13 were excluded due to lack of comparative data between emergency physicians and orthopaedic surgeons (n=11), not addressing the three-part question (n=1), or duplicate publication of the same dataset (n=1).

In total, five papers were included within the final analysis. One was a randomised controlled trial (RCT) and four were observational cohort studies, comprising two prospective and two retrospective designs. The results are summarised in Table 1.

Overall, the majority of studies found similar rates of successful initial fracture reduction between emergency physician and orthopaedic groups1-3, 6. The one RCT identified1 demonstrated comparable fracture alignment and long-term healing outcomes between groups, with lower remanipulation rates in the emergency physician led cohort. There is no evidence of additional benefit from orthopaedic involvement in reduction success or long-term outcomes.

A consistent finding across the studies was reduced time to reduction and shorter ED length of stay in emergency physician led care1,3,4,6, likely due to earlier clinician availability and reduced reliance on orthopaedic input. Supporting this, a recent trial, found evidence that these fractures heal well with conservative management7, but in select children who do require manipulation, orthopaedics may not always be necessary or optimal, and ED management appears to be more effective. Waiting for orthopaedic surgeons, particularly when surgeons are engaged in theatre or other duties, may prolong time to reduction and leave a child in severe pain for longer than necessary.

Emergency physician led reduction of paediatric distal forearm fractures should be performed as first line management in the emergency department when trained clinicians are available. Outcomes are equivalent to orthopaedic led management, with consistently reduced ED length of stay.

Level 1: Recent well-done systematic review was considered or a study of high quality is available

1. S. Khan, J. Sawyer, J. Pershad. Closed Reduction of Distal Forearm Fractures by Pediatric Emergency Physicians
2. Kristene M. Rimbaldo Emmanuelle Fauteux-Lamarre Franz E. Babl Carrie Kollias Sandy M. Hopper. Deformed pediatric forearm fractures: Predictors of successful reduction by emergency providers
3. D. Milner, E. Krause, K. Hamre, A. Flood. Outcome of Pediatric Forearm Fracture Reductions Performed by Pediatric Emergency Medicine Providers Compared With Reductions Performed by Orthopedic Surgeons
4. J. Pershad, S. Williams, J. Wan, J. Sawyer. Pediatric distal radial fractures treated by emergency physicians
5. H. Ulcer, A. Aydogdu, O. Ciloglu, A. Erenler. Comparison of outcomes of closed reduction in paediatric both-bone forearm fractures performed by emergency physicians and orthopedic surgeons
6. M. Bar-Hakim, H. Gur-Soferman. Comparison of treatment of forearm fractures by Pediatric emergency physicians versus orthopedic residents in a Pediatric emergency department