• Katia C Genadry, Michael C Monuteaux, Mark I Neuman, and Susan C Lipsett.
• Department of Pediatrics, Boston Children's Hospital, Boston, MA. Electronic address: katia.genadry@childrens.harvard.edu.
• Ann Emerg Med. 2021 Feb 1; 77 (2): 154-162.

Study ObjectiveWe identify the incidence and predictors of missed fracture and characterize patterns of radiography performance in children with a diagnosis of radial head subluxation in the emergency department (ED) setting.MethodsWe queried the Pediatric Health Information System database for visits by children younger than 10 years and with a diagnosis of radial head subluxation at 1 of 45 pediatric EDs from 2010 to 2018. The frequency of radiography use was assessed overall and between hospitals. Multivariable logistic regression was used to evaluate associations between patient-level characteristics and the outcome of missed fracture (return visit for upper extremity fracture within 7 days of the index visit).ResultsWe identified 88,466 eligible visits; the median patient age was 2.1 years, 59% of visits were by female patients, and in visits in which laterality was noted, 60% of cases occurred in the left arm. Radiography was performed at 28.5% of visits; hospital rates of radiography performance ranged from 19.8% to 41.7%. Missed upper extremity fractures were observed in 247 cases (0.3% of the cohort). The odds of missed fracture were higher in children older than 6 years (adjusted odds ratio 2.32; 95% confidence interval 1.12 to 4.81), children who underwent radiography at the index visit (adjusted odds ratio 2.52; 95% confidence interval 1.84 to 3.43), and children receiving acetaminophen or ibuprofen (adjusted odds ratio 1.54; 95% confidence interval 1.15 to 2.06).ConclusionRadiographs were obtained for greater than one quarter of children presenting to a pediatric ED with radial head subluxation, with wide variation between hospitals. Missed fractures were rare. Future efforts should aim to reduce unnecessary radiography in this population.Copyright © 2020 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.

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