A Comparison of Fracture Reductions Performed by Physician Extenders and Orthopaedic Residents in the Acute Pediatric Orthopaedic Practice

Background: The Accreditation Council on Graduate Medical Education-mandated 80-hour work week has led many teaching hospitals to find adequate replacements for residents. In addition, the subspecialty of pediatric orthopaedics is currently experiencing a workforce shortage. At the authors' institution, Level I emergency department and hospital on-call duties alternate between orthopaedic residents and orthopaedic-specific nurse practitioners. There are no studies looking at the quality of care rendered in the pediatric orthopaedic setting by physician extenders. Methods: A consecutive series of 139 pediatric patients with the diagnosis of closed both-bones diaphyseal forearm fracture underwent closed reduction and casting by either a trained nurse practitioner or orthopaedic resident in the emergency department from July 2006 through June 2007. Fifty-seven (41%) patients were treated by a nurse practitioner and 82 (59%) patients were treated by an orthopaedic resident. All patients were followed to completion of treatment by fellowship-trained pediatric orthopaedic staff. Results: There was no significant difference between the two groups in regard to the use of conscious sedation, cast characteristics, fracture characteristics, or length of follow up (P > 0.05). Patients treated by orthopaedic residents required more minor interventions (48% versus 35%), but this was not statistically significant (P = 0.17). However, patients treated by orthopaedic residents had a higher rate of requiring premedication and molding of a new cast in clinic for loss of reduction (33% versus 18%), and this did approach statistical significance (P = 0.052). In addition, patients treated by orthopaedic residents had slightly more major interventions, which necessitated operative intervention to restore alignment of the fracture (11% versus 8%), but this did not reach statistical significance (P = 0.56). Conclusions: Pediatric patients with closed both-bones diaphyseal forearm fractures were treated successfully by both trained orthopaedic nurse practitioners and orthopaedic residents with no statistically significant difference in interventions.