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Variation in practice habits in the treatment of pediatric distal radius fractures
Nicholas M Bernthal1, Scott Mitchell, Joshua G Bales
1aDepartment of Orthopaedics, UCLA/Orthopaedic Hospital, David Geffen School of Medicine at UCLA, University of California bOrthopaedic Institute for Children, Los Angeles, California cKedlec Hospital, Richland, Washington dDepartment of Orthopaedic Surgery, Baylor College of Medicine, Houston, Texas, USA.
Insights
Treatment for pediatric distal radius fractures varies significantly among surgeons, with practice patterns differing from theoretical guidelines. Subspecialty training and practice setting influence treatment recommendations for these common childhood injuries.
Area of Science:
- Orthopedic Surgery
- Pediatric Orthopedics
- Traumatology
Background:
- Distal radius fractures are common in children, but standardized treatment protocols are lacking.
- Current management strategies exhibit considerable variability among orthopedic surgeons.
Purpose of the Study:
- To investigate practice patterns and treatment variations for pediatric distal radius fractures.
- To assess the alignment criteria considered acceptable by surgeons for these injuries.
Main Methods:
- An internet-based questionnaire surveyed 781 hand, pediatric, and general orthopedic surgeons.
- Surgeons defined acceptable alignment criteria and selected treatments for 10 diverse pediatric distal radius fracture cases.
- Responses were analyzed based on patient age, injury pattern, and surgeon subspecialty/practice setting.
Main Results:
- Acceptable alignment criteria differed significantly between younger (<9 years) and older pediatric patients.
- A notable percentage of surgeons (20.3%) recommended treatments inconsistent with their stated acceptable criteria.
- Hand and general orthopedic surgeons were more likely to recommend surgery than pediatric surgeons; private practice surgeons favored surgery over academic surgeons.
Conclusions:
- Significant discordance exists between surgeons' theoretical acceptable criteria and their actual treatment recommendations for pediatric distal radius fractures.
- Subspecialty training and practice type influence treatment decisions, highlighting a lack of standardized care.
- Further research is needed to correlate these treatment variations with patient outcomes.
Abstract:
Distal radius fractures are widespread in the pediatric population. Standardized treatment protocols have not been well defined. We sought to examine the diversity of current practice patterns in the treatment of these fractures by surveying hand, pediatric, and general orthopedic surgeons. Hand, pediatric, and general orthopedic surgeons were surveyed using an internet-based questionnaire on the management of pediatric distal radius fractures. Each surgeon was asked to select a criterion from among choices of 'acceptable' alignment criteria at the onset of the survey. Ten cases were then provided to represent a broad spectrum of injuries from minimally angulated torus fractures to complete, displaced fractures. In addition to the variation in injury pattern, the patients in the survey differed in age at the time of injury (3-15 years of age). For each case, surgeons were asked to select a preferred treatment, first on the basis of injury films, and then again after reviewing 1-week follow-up radiographs. A total of 781 surgeons completed the survey. In patients younger than 9 years of age, a residual sagittal angulation of 20° or less, coronal angulation of 10° or less, and 1 cm or less of bayonet apposition was deemed 'acceptable' by 88, 90, and 69% of respondents, respectively. In older patients, these percentages were 58, 64, and 29%, respectively. When specific cases were reviewed, 20.3% of surgeons recommended treatment different from their own theoretical 'acceptable' criteria. When subspecialty training was analyzed, hand surgeons and general orthopedic surgeons were 2.9 and 1.6 times more likely to recommend surgery, respectively, as compared with pediatric surgeons after viewing the initial radiograph. Private practice surgeons were 1.5 times more likely to recommend surgery compared with academic surgeons based on the initial injury radiographs. Our survey highlights the discordance between theoretical acceptable criteria of surgeons and their practice habits, as well as the substantial disparities in treatment recommendations based on subspecialty training. Further study is warranted to determine whether these variations in treatment affect patient outcomes. This survey is a level IV observational study.
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