Presentation and Referral Patterns in Pediatric Closed Hand Fractures

Although pediatric hand fractures are common and generally have good outcomes, they remain a considerable source of anxiety for non-hand surgeons, who are less familiar with these injuries. We hypothesized that this anxiety may manifest as inefficiency in referral patterns.

The records of pediatric patients with isolated, closed hand fractures without concurrent trauma seen at our institution by a hand surgeon between January 2017 and December 2018 were retrospectively reviewed.

There were 454 patients included; 62.1% were men, and the mean age was 9.6 years at initial encounter. Most patients (89.6%) were treated nonoperatively and incurred few complications (0.5%). Roughly half of all cases (n = 262) initially presented to an outside provider. Of these, 24.0% (n = 64 of 262) were evaluated by 2+ providers before a hand surgeon. Most commonly, these patients were referred from an outside emergency department (ED) to our ED before hand surgeon evaluation (n = 45 of 64). Forty-seven patients required surgery; however, none were performed urgently. Although a greater proportion of 7- to 11-year-old patients saw 2+ providers prior to a hand surgeon (P = .007), fewer required surgery (P < .001).

Pediatric closed hand fractures are mainly treated nonoperatively and nonemergently with generally excellent outcomes. Our data suggest that many patients continue to be referred through the ED or multiple EDs/providers for treatment. These inefficient referral patterns demonstrate the need for better education for ED and primary care providers, as well as better communication between these providers and local pediatric hand surgeons. Advancements in these areas are likely to improve efficiency of care and decrease costs.