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Outcomes of Toddler's Fractures After Implementation of Comprehensive Care Management Protocol With Controlled Ankle
Sheena J Amin1, McKenna Noe2, Janet O'Rear2
1Department of Orthopaedic Surgery, University of Missouri Kansas City.
Insights
A new protocol using controlled ankle motion (CAM) boots for toddler's fractures (TF) reduced skin breakdown in internally managed patients. This approach also lowered treatment costs, though external facility management remains a challenge.
Area of Science:
- Pediatric Orthopedics
- Trauma Surgery
Background:
- Toddler's fractures (TF) are stable tibia fractures in children aged 1-4 years.
- Skin breakdown is a common complication of traditional casting and splinting for TF.
- A new treatment algorithm was developed to address skin breakdown issues.
Purpose of the Study:
- To evaluate the outcomes of a new treatment protocol for TF.
- To specifically assess the impact of the protocol on the incidence of skin breakdown.
- To analyze cost-effectiveness and fracture healing rates.
Main Methods:
- Implementation of a protocol involving controlled ankle motion (CAM) boots for immobilization.
- Education for emergency and urgent care teams on proper CAM boot use.
- Development of caregiver handouts emphasizing skin checks and boot removal.
- Retrospective chart review of 429 TF patients (358 pre-protocol, 71 post-protocol).
Main Results:
- The post-protocol group showed significantly higher CAM boot utilization (93% vs. 32.4%).
- Overall skin breakdown rates were not significantly different (9.9% vs. 17%), but all post-protocol cases originated from outside facilities.
- Internally managed patients had significantly less skin breakdown post-protocol (0% vs. 44.3%).
- Average cost savings of $187 per encounter were observed.
Conclusions:
- The CAM boot protocol effectively reduced skin breakdown in patients managed internally.
- Fracture healing rates were equivalent to traditional long leg casts (LLC).
- The protocol decreased healthcare costs for patients.
- Addressing skin breakdown in patients initially treated at outside facilities requires further intervention.
Background:
Toddler's fractures (TF) are stable tibia fractures in children 1 to 4 years of age. Skin breakdown is a complication associated with casting and splinting and has been a continued issue at our institution. Based on literature review, we implemented a new treatment algorithm for TF. The purpose of this study is to evaluate the outcomes of our protocol with a particular focus on skin breakdown.
Methods:
Our protocol included exclusive utilization of controlled ankle motion (CAM) boots for immobilization, coaching ED and urgent care teams on proper CAM boot application and wear, creation and dissemination of handouts for caregivers, with an emphasis on frequent boot removal and skin checks, and the standardization of clinic scheduling protocols. A retrospective chart review of 429 patients with TF between 2019 and 2023 was performed. This included 358 patients prior to implementation of the new protocol and 71 patients after. Patient demographics, immobilization method, and the degree of skin breakdown was recorded.
Results:
There was no difference in patient age or sex between the two groups. Significantly larger percentage of patients were treated in CAM boots in the post-protocol group (66/71 (93%)) as compared with the pre-protocol group (116/358 (32.4%), P =0.0001). In the pre-protocol group, 61/358 (17%) had skin breakdown, the majority of whom had been treated in a long leg cast (LLC) (85.2%). In the post-protocol group, 7/71 (9.9%) had skin breakdown. This was not statistically different as compared with the pre-protocol group ( P =0.208). However, in the post-protocol group, all incidences of skin breakdown occurred in patients who presented and were treated initially to an outside facility, with breakdown present at the time of initial presentation to our institution. When comparing wounds that developed during treatment at our institution, the post-protocol group had significantly less skin breakdown compared with the pre-protocol group, 0/7 (0%) vs. 27/61 (44.3%), P =0.037. Implementation of the new protocol yielded an average cost savings of $187 per encounter for patients and their families.
Conclusion:
A care management protocol using CAM boots for immobilization, provided at initial presentation, was successfully implemented at our institution. This protocol yielded decreased skin breakdown rates among internally managed patients and equivalent rates of fracture healing compared with those immobilized via traditional long leg casts. The protocol also reduced overall cost of the episode of care for the patient. Despite these internal improvements, skin breakdown continues to be encountered in patients initially treated at outside facilities unfamiliar with our protocol. Future directions will focus on early clinic follow-up to assess proper fitting of CAM boots, caregiver education, expansion of the protocol to include referral institutions, and further reduction of cost and radiation exposure to patients by eliminating unnecessary follow-up clinic visits and radiographs.
Level Of Evidence:
III: (retrospective cohort study).
