Variability of orthopedic physician fracture location identification: Implications for bone stimulator treatment

Aseptic non-union is a significant complication in approximately 5% of long-bone fractures. External bone stimulation treatment is often attempted before more invasive surgical interventions. Bone stimulators can have favorable results, but have a limited 1.7cm therapeutic radius. This study evaluated the accuracy by which clinicians locate a fracture on a cadaveric model. This has implications for the clinician's ability to accurately counsel patients on daily bone stimulator placement. Additionally, physicians (orthopedic attending surgeons and residents) were compared with pre-clinical (M1 and M2) medical students to evaluate if higher levels of training improved accuracy.

Orthopedic physicians and pre-clinical medical students will localize a radiographic fracture within 1.7cm less than 100% of the time, which represents the ideal consistency for patient care. Furthermore, orthopedic physicians will achieve a higher percentage accuracy than pre-clinical medical students.

The sample included 20 orthopedic physicians and 16 pre-clinical medical students. Upper (radius) and lower (tibia) extremity cadaver models were prepared by inducing a single, transverse diaphyseal fracture. Plain reference radiographs of each model were obtained. Participants placed a radiopaque marker onto each model at the perceived fracture location, and radiographs were taken to document placement. Perpendicular marker-to-fracture distance was measured to the nearest mm along each bone's long axis using the PACS system.

Placement within the therapeutic radius was achieved by 70-80% of physicians, and 69-75% of medical students. In the remaining participants, improper placement distances were lower among physicians than among medical students (radius: 2.1±0.5 vs. 3.6±0.9cm, p=0.02; tibia: 2.6±0.5 vs 3.5±0.5cm, p=0.89).

In two cadaveric fracture models, up to 30% of orthopedic surgeons perceived a fracture location to be outside a bone stimulator's 1.7cm therapeutic radius. This finding suggests that physicians and their patients may benefit from additional methods for specifying the location of a non-union before commencing daily bone stimulator treatment.

Level IV, prospective cohort study-evidence from a well-designed prospective cohort study.