Recommended Treatment for Pediatric Upper Extremity Fractures Varies Among Orthopaedic Surgeons and Trainees.

Abstract

Background: Given the breadth of findings and recommendations regarding the acceptable alignment and optimal management of pediatric fractures, pervasive questions remain about the current versus best practices. We aimed to identify patterns and assess agreement in the management of pediatric fractures among respondents at various levels of training and practice characteristics.

Methods: A cross-sectional survey containing 15 case vignettes of common pediatric fractures was distributed to attendings, fellows, and residents at various institutions. Each vignette included relevant imaging, alignment metrics, and patient age/sex. Participants were given four treatment options for each vignette: (1) no reduction/cast or splint in situ, (2) reduction attempt, will remodel (no need for OR), (3) reduction attempt, needs to be anatomic (possible OR), (4) no reduction attempt, splint for comfort, needs operative intervention. Respondents were separated into three distinct cohorts: individuals in training (i.e., residents/fellows), attending pediatric orthopaedists, and attending non-pediatric orthopaedists.

Results: 48 individuals completed the survey: 22 trainees (residents and fellows), 19 pediatric attendings, and 7 non-pediatric attendings. Among all subgroups, there was a significant poor-fair overall level of agreement (attendings (peds): K = 0.337, P < .001; attendings (non-peds): K = 0.299, P < .001, trainees K = 0.241, P < .001). Pediatric attendings generally opted for less invasive treatments than trainees in management of distal radius fractures (average response of 1.86 vs. 2.16; P < .05) and both bone fractures (1.92 vs. 2.24; P < .05). The differences in proximal humerus fractures (1.24 vs. 1.46; P = .095) and "other" fractures (2.34 vs. 2.51; P = .277) did not reach significance, though the same trend (trainees pursuing more aggressive treatment) persisted. Pediatric attendings reached ≥80% consensus on a single treatment option for 6/15 cases (1/5 DRF, 2/3 PHF, 3/7 other), and on grouped "non-operative" and "possible or certain OR" for 11/15 (3/5 DRF, 3/3 PHF, 5/7 other cases).

Conclusions: To our knowledge, this is the first cross-sectional survey investigating agreement on management of pediatric fractures and expectation of remodeling among attendings, fellows, and residents at various institutions. Overall agreement among attendings was poor-fair and higher than trainees. Trainees were more likely to recommend invasive/operative treatments. Further studies standardizing pediatric upper extremity fracture management, as well as resident education on the topic, are warranted.

Key concepts: (1)Treatment recommendations for pediatric upper extremity fractures are not standardized.(2)In comparing 15 case vignettes, agreement among attendings was poor-fair but higher than trainees.(3)Trainees were more likely to recommend invasive/operative treatments.

Level of evidence: V.