Reduction of radial-head subluxation in children by triage nurses in the emergency department: a cluster-randomized controlled trial

Background:

Radial-head subluxation is an easily identified and treated injury. We investigated whether triage nurses in the emergency department can safely reduce radial-head subluxation at rates that are not substantially lower than those of emergency department physicians.

Methods:

We performed an open, noninferiority, cluster-randomized control trial. Children aged 6 years and younger who presented to the emergency department with a presentation consistent with radial-head subluxation and who had sustained a known injury in the previous 12 hours were assigned to either nurse-initiated or physician-initiated treatment, depending on the day. The primary outcome was the proportion of children who had a successful reduction (return to normal arm usage). We used a noninferiority margin of 10%.

Results:

In total, 268 children were eligible for inclusion and 245 were included in the final analysis. Of the children assigned to receive physician-initiated care, 96.7% (117/121) had a successful reduction performed by a physician. Of the children assigned to receive nurse-treatment care, 84.7% (105/124) had a successful reduction performed by a nurse. The difference in the proportion of successful radial head subluxations between the groups was 12.0% (95% confidence interval [CI] 4.8% to 19.7%). Noninferiority of nurse-initiated radial head subluxation was not shown.

Interpretation:

In this trial, the rate of successful radial-head subluxation performed by nurses was inferior to the physician success rate. Although the success rate in the nurse-initiated care group did not meet the non-inferiority margin, nurses were able to reduce radial head subluxation for almost 85% of children who presented with probable radial-head subluxation. Trial registration: Clinical Trials.gov, no. {"type":"clinical-trial","attrs":{"text":"NCT00993954","term_id":"NCT00993954"}}NCT00993954.Radial-head subluxation is a common arm injury among young children and often results in a visit to the emergency department.¹ This type of injury occurs when forceful longitudinal traction is applied to an extended and pronated forearm.² Radial-head subluxation is easily recognized by its clinical presentation and can be treated by a simple reduction technique involving hyperpronation or supination and flexion of the injured arm.^3–7Despite the ease of diagnosis and treatment, children with radial-head subluxation often wait hours in the emergency department for a reduction that takes minutes to perform.⁸ These visits have direct health care costs and involve time and stress for the child and their family. Early treatment and shorter wait times correlate with patient satisfaction.^9,10 Patient satisfaction is comparable when minor injuries are cared for by a nurse instead of by a physician.^11–13 Nurse-initiated treatments are increasingly a focus of health care.^14–17Treatment of radial-head subluxation is an appropriate area to consider nurse-initiated care. Our objective was to determine whether triage nurses, trained in the recognition and treatment of radial-head subluxation, could successfully reduce radial-head subluxation at a rate similar to that of physicians.