Meghan Hughes1, Karan Dua2, Nathan N O'Hara1, Brian K Brighton3, Theodore J Ganley4, William L Hennrikus5, Martin J Herman6, Joshua E Hyman7, J Todd Lawrence4, Charles T Mehlman8, Kenneth J Noonan9, Norman Y Otsuka10, Richard M Schwend11, M Wade Shrader12, Brian G Smith13, Paul D Sponseller14, Joshua M Abzug1. 1. Department of Orthopaedics, University of Maryland School of Medicine. 2. Department of Orthopaedic Surgery & Rehabilitation Medicine, SUNY Downstate Medical Center, Brooklyn. 3. Department of Orthopaedic Surgery, Carolinas Healthcare System/Levine Children's Hospital, Charlotte, NC. 4. Department of Orthopaedic Surgery, The Children's Hospital of Philadelphia. 5. Department of Orthopaedics and Rehabilitation, Penn State Hershey Medical Center, Hershey, PA. 6. Department of Orthopaedic Surgery, St. Christopher's Hospital for Children, Philadelphia. 7. Department of Orthopaedic Surgery, New York-Presbyterian Morgan Stanley Children's Hospital, Columbia University Medical Center, New York. 8. Department of Orthopaedic Surgery, University of Cincinnati College of Medicine, Cincinnati, OH. 9. Department of Orthopaedics and Rehabilitation, University of Wisconsin and School of Public Health, Madison, WI. 10. Department of Orthopaedic Surgery, The Children's Hospital at Montefiore, Bronx, NY. 11. Department of Orthopaedic Surgery, Children's Mercy Hospital, Kansas City, MO. 12. Department of Orthopaedic Surgery, Children's of Mississippi, Jackson, MS. 13. Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT. 14. Department of Orthopaedic Surgery, Johns Hopkins Medicine, Baltimore, MD.
Abstract
BACKGROUND: Medial epicondyle fractures are a common pediatric and adolescent injury accounting for 11% to 20% of elbow fractures in this population. This purpose of this study was to determine the variability among pediatric orthopaedic surgeons when treating pediatric medial epicondyle fractures. METHODS: A discrete choice experiment was conducted to determine which patient and injury attributes influence the management of medial epicondyle fractures by pediatric orthopaedic surgeons. A convenience sample of 13 pediatric orthopaedic surgeons reviewed 60 case vignettes of medial epicondyle fractures that included elbow radiographs and patient/injury characteristics. Displacement was incorporated into the study model as a fixed effect. Surgeons were queried if they would treat the injury with immobilization alone or open reduction and internal fixation (ORIF). Statistical analysis was performed using a mixed effect regression model. In addition, surgeons filled out a demographic questionnaire and a risk assessment to determine if these factors affected clinical decision-making. RESULTS: Elbow dislocation and fracture displacement were the only attributes that significantly influenced surgeons to perform surgery (P<0.05). The presence of an elbow dislocation had the largest impact on surgeons when choosing operative care (β=-0.14; P=0.02). In addition, for every 1 mm increase in displacement, surgeons tended to favor ORIF by a factor of 0.09 (P<0.01). Sex, mechanism of injury, and sport participation did not influence decision-making. In total, 54% of the surgeons demonstrated a preference for ORIF for the included scenarios. On the basis of the personality Likert scale, participants were neither high-risk takers nor extremely risk adverse with an average-risk score of 2.24. Participant demographics did not influence decision-making. CONCLUSIONS: There is substantial variation among pediatric orthopaedic surgeons when treating medial epicondyle fractures. The decision to operate is significantly based on the degree of fracture displacement and if there is a concomitant elbow dislocation. There is no standardization regarding how to treat medial epicondyle fractures and better treatment algorithms are needed to provide better patient outcomes. LEVEL OF EVIDENCE: Level V.
BACKGROUND: Medial epicondyle fractures are a common pediatric and adolescent injury accounting for 11% to 20% of elbow fractures in this population. This purpose of this study was to determine the variability among pediatric orthopaedic surgeons when treating pediatric medial epicondyle fractures. METHODS: A discrete choice experiment was conducted to determine which patient and injury attributes influence the management of medial epicondyle fractures by pediatric orthopaedic surgeons. A convenience sample of 13 pediatric orthopaedic surgeons reviewed 60 case vignettes of medial epicondyle fractures that included elbow radiographs and patient/injury characteristics. Displacement was incorporated into the study model as a fixed effect. Surgeons were queried if they would treat the injury with immobilization alone or open reduction and internal fixation (ORIF). Statistical analysis was performed using a mixed effect regression model. In addition, surgeons filled out a demographic questionnaire and a risk assessment to determine if these factors affected clinical decision-making. RESULTS:Elbow dislocation and fracture displacement were the only attributes that significantly influenced surgeons to perform surgery (P<0.05). The presence of an elbow dislocation had the largest impact on surgeons when choosing operative care (β=-0.14; P=0.02). In addition, for every 1 mm increase in displacement, surgeons tended to favor ORIF by a factor of 0.09 (P<0.01). Sex, mechanism of injury, and sport participation did not influence decision-making. In total, 54% of the surgeons demonstrated a preference for ORIF for the included scenarios. On the basis of the personality Likert scale, participants were neither high-risk takers nor extremely risk adverse with an average-risk score of 2.24. Participant demographics did not influence decision-making. CONCLUSIONS: There is substantial variation among pediatric orthopaedic surgeons when treating medial epicondyle fractures. The decision to operate is significantly based on the degree of fracture displacement and if there is a concomitant elbow dislocation. There is no standardization regarding how to treat medial epicondyle fractures and better treatment algorithms are needed to provide better patient outcomes. LEVEL OF EVIDENCE: Level V.