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Management of Toddler's Fracture: A Systematic Review With Meta-Analysis
Ariane Boutin1, Amita Misir2, Kathy Boutis3
1From the Department of Pediatric Emergency Medicine, CHU Sainte-Justine and University of Montreal, Montreal.
Insights
For toddler's fractures (TF) in children, no immobilization appears safe, reducing healthcare visits. However, more high-quality studies are needed to confirm these findings for toddler's fractures.
Area of Science:
- Pediatric Orthopedics
- Musculoskeletal Injuries
Background:
- Toddler's fractures (TF) are common pediatric leg injuries.
- Current treatment often involves immobilization, but its necessity is debated.
Purpose of the Study:
- To compare fracture-related adverse outcomes between immobilization and no immobilization for toddler's fractures.
- To evaluate health services utilization differences between these treatment strategies.
Main Methods:
- Systematic literature search across major databases (MEDLINE, Embase, Cochrane).
- Inclusion of retrospective studies with quality assessment by two independent authors.
- No restrictions on language, publication status, or location.
Main Results:
- Four low-quality retrospective studies (355 participants) met inclusion criteria.
- No significant difference in fracture-related adverse outcomes between immobilization and no immobilization.
- No immobilization group showed fewer radiographs and outpatient visits, but a trend towards more repeat ED visits.
Conclusions:
- No immobilization may be a safe alternative for toddler's fractures.
- High-quality evidence is required to guide clinical decision-making.
- Future research should incorporate patient recovery, pain, and caregiver perspectives.
Objectives:
In studies that included children diagnosed with toddler's fractures (TFs), we determined the fracture-related adverse outcomes in those treated with immobilization versus no immobilization. Furthermore, we compared health services utilization between these 2 immobilization strategies.
Methods:
A search was done on Ovid MEDLINE(R), Embase Classic + Embase, and Cochrane Central Register of Controlled Trials along with reference lists as conference proceedings and abstracts. No language or publication status or location restrictions were used. All study steps, including the methodological quality assessment, were conducted independently and in duplicate by 2 authors.
Results:
Of the 490 references identified, 4 retrospective studies of low quality met inclusion criteria and collectively included 355 study participants. With respect to fracture-related adverse outcomes, there was no risk difference [0; 95% confidence interval (CI), -0.09 to 0.09] between the immobilization and no immobilization treatment strategies. Furthermore, in the immobilization versus no immobilization groups, there was a higher mean difference in the number of radiographs (0.69; 95% CI, 0.15-1.23) and scheduled outpatient orthopedic visits (0.96; 95% CI, 0.24-1.68), but a decreased relative risk (0.41; 95% CI, 0.05-3.19) of repeat emergency department visits. No data were reported on patient pain or caregiver satisfaction.
Conclusions:
In children with TF, this study suggests that no immobilization may be a safe alternative to immobilization for this minor fracture; however, high-quality evidence is needed to optimally inform clinical decision making. Future work should include validated measures of patient recovery, pain, and caregiver perspectives when comparing treatment strategies for this injury.
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