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Derivation and Internal Validation of a Prediction Model for Pediatric Hand Fracture Triage
Rebecca L Hartley1, Frankie O G Fraulin1,2, A Robertson Harrop1,2
1Section of Plastic Surgery, Department of Surgery, University of Calgary, Calgary, Alberta, Canada.
Insights
A new model helps identify complex pediatric hand fractures needing specialist care. This tool aids emergency physicians in determining which children require a hand surgeon
Area of Science:
- Orthopedic Surgery
- Pediatric Emergency Medicine
- Clinical Decision Support
Background:
- Pediatric hand fractures are common, with most managed non-operatively.
- Identifying complex fractures needing specialist hand surgeon intervention is challenging.
- Accurate identification ensures optimal outcomes for pediatric hand injuries.
Purpose of the Study:
- To develop and validate a prediction model for identifying complex pediatric hand fractures.
- To aid emergency and urgent care physicians in initial fracture assessment.
- To guide referral decisions to hand surgeons.
Main Methods:
- Retrospective cohort study of 1170 pediatric hand fracture patients.
- Multivariable logistic regression used to derive a prediction model.
- Internal validation via bootstrapping and translation into a risk index.
Main Results:
- 35.6% of fractures were classified as complex.
- Six predictors identified: open fracture, rotational deformity, angulation, condylar involvement, dislocation/subluxation, displacement.
- Model achieved high performance (C-statistic = 0.88) with a simple risk index (≥1 point) yielding 96.4% sensitivity.
Conclusions:
- A clinically useful decision support tool for pediatric hand fractures was developed.
- The tool assists emergency physicians in identifying fractures requiring hand surgeon expertise.
- This model can form the basis for a clinical care pathway for pediatric hand fractures.
Background:
Pediatric hand fractures are common, and most can be managed by a period of immobilization. However, it remains challenging to identify those more complex fractures requiring the expertise of a hand surgeon to ensure a good outcome. The purpose of this study was to develop a prediction model for identification of complex pediatric hand fractures requiring care by a hand surgeon.
Methods:
A 2-year retrospective cohort study of consecutively referred pediatric (<18 years) hand fracture patients was used to derive and internally validate a prediction model for identification of complex fractures requiring the expertise of a hand surgeon. These complex fractures were defined as those that required surgery, closed reduction, or four or more appointments with a hand surgeon. The model, derived by multivariable logistic regression analysis, was internally validated using bootstrapping and then translated into a risk index.
Results:
Of 1170 fractures, 416 (35.6%) met criteria for a complex fracture. Multivariable regression analysis identified six significant predictors of complex fracture: open fracture, rotational deformity, angulation, condylar involvement, dislocation or subluxation, and displacement. Internal validation demonstrated good performance of the model (C-statistic = 0.88, calibration curve p = 0.935). A threshold of ≥1 point (ie, any one of the predictors) resulted in a simple, easy-to-use tool with 96.4% sensitivity and 45.5% specificity.
Conclusions:
A high-performing and clinically useful decision support tool was developed for emergency and urgent care physicians providing initial assessment for children with hand fractures. This tool will provide the basis for development of a clinical care pathway for pediatric hand fractures.
