Pediatric Hand Fracture Outcomes: How Often Do We Need to Operate?

Purpose: Pediatric hand fractures are frequent presentations to the emergency department. This study set out to evaluate the epidemiology, management, and outcomes, where care was imparted and by whom, and offer resource utilization suggestions regarding pediatric fractures presenting to a Canadian pediatric hospital. Methods: Records of patients from 0 to 18 years of age who presented to the British Columbia Children's Hospital Emergency Department between November 1, 2016, and January 31, 2021, with metacarpal or phalangeal fractures were analyzed. Results: A total of 524 hand fractures were identified in 499 patients. Over 60% of fractures occurred in boys. The number of fractures peaked at the age of 11 years for girls and 12 years for boys. Open fractures accounted for only 4.0% of all fractures. Approximately 40% of fractures were epiphyseal growth plate fractures, with Salter-Harris II fractures being the most common diagnosis overall. Management was primarily nonsurgical, with 75% of fractures managed with immobilization alone and 23% of fractures managed with bedside closed reduction and immobilization. Of the fractures requiring closed reduction, the majority were performed by the emergency physician with a success rate of 82%. Only 2.3% of all fractures required surgery. Conclusions: Hand fractures are common pediatric injuries and make up a large proportion of emergency room visits. The majority of fractures do not require formal surgery and are well managed with immobilization alone or closed reduction by an emergency room physician and immobilization. Nonsurgical treatment offers very encouraging outcomes. A certain percentage of these simple fractures would likely benefit from primary care management alone and not require specialist intervention.

Prospective Validation of the Calgary Kids' Hand Rule: A Clinical Prediction Rule for Pediatric Hand Fracture Triage

Introduction: Pediatric hand fractures are common and routinely referred to surgeons, yet most heal well without surgical intervention. This trend inspired the development of the Calgary Kids' Hand Rule (CKHR), a clinical prediction rule designed to predict "complex" fractures that require surgical referral. The CKHR was adapted into a checklist whereby the presence of any 1 of 6 clinically or radiologically identifiable fracture characteristics predicts a complex fracture. The aim of this study was to assess the accuracy of the CKHR in a prospective sample of children with hand fractures. Methods: Physicians were asked to complete the CKHR checklist when referring pediatric patients (< 18 years) to hand surgeons at a Canadian pediatric hospital (April 2019-September 2020). Completed checklists represented predicted outcomes and were compared to observed outcomes (determined via chart review). Predictive accuracy (primary outcome) was evaluated based on sensitivity and specificity. Secondary outcomes were interrater reliability between referring physicians and surgeons, and survey assessment of CKHR user satisfaction. Results: In total 365 fractures were included, with only 16 requiring surgical intervention. Overall performance of the CKHR was good with 84% sensitivity and 71% specificity. Percent agreement between referring physicians and surgeons ranged from 84.1% to 96.3% on individual predictors, with 78.1% agreement on the presence of any predictors. Survey results showed general user satisfaction but also identified areas for improvement. Conclusion: This study posits the CKHR as an accurate and clinically useful prediction rule and highlights the importance of education for its effective use and eventual scale and spread.

Estimated GFR and Incidence of Major Surgery: A Population-Based Cohort Study

RATIONALE & OBJECTIVE

Kidney disease is associated with an increased risk for postoperative morbidity and mortality. However, the incidence of major surgery on a population level is unknown. We aimed to determine the incidence of major surgery by level of kidney function.

STUDY DESIGN

Retrospective cohort study with entry from January 1, 2008, through December 31, 2009, and outcome surveillance from January 1, 2010, through December 31, 2016.

SETTING & PARTICIPANTS

Population-based study using administrative health data from Alberta, Canada; adults with an outpatient serum creatinine measurement or receiving maintenance dialysis formed the study cohort.

EXPOSURE

Participants were categorized into 6 estimated glomerular filtration rate (eGFR) categories: ≥60 (G1-G2), 45 to 59 (G3a), 30 to 44 (G3b), 15 to 29 (G4), and<15mL/min/1.73m² with (G5D) and without (G5) dialysis. eGFR was examined as a time-varying exposure based on means of measurements within 3-month ascertainment periods throughout the study period.

OUTCOME

Major surgery defined as surgery requiring admission to the hospital for at least 24 hours.

ANALYTICAL APPROACH

Incidence rates (IRs) for overall major surgery were estimated using quasi-Poisson regression and adjusted for age, sex, income, location of residence, albuminuria, and Charlson comorbid conditions. Age- and sex-stratified IRs of 13 surgery subtypes were also estimated.

RESULTS

1,455,512 cohort participants were followed up for a median of 7.0 (IQR, 5.3) years, during which time 241,989 (16.6%) underwent a major surgery. Age and sex modified the relationship between eGFR and incidence of surgery. Men younger than 65 years receiving maintenance dialysis experienced the highest rates of major surgery, with an adjusted IR of 243.8 (95% CI, 179.8-330.6) per 1,000 person-years. There was a consistent trend of increasing surgery rates at lower eGFRs for most subtypes of surgery.

LIMITATIONS

Outpatient preoperative serum creatinine measurement was necessary for inclusion and outpatient surgical procedures were not included.

CONCLUSIONS

People with reduced eGFR have a significantly higher incidence of major surgery compared with those with normal eGFR, and age and sex modify this increased risk. This study informs our understanding of how surgical burden changes with differing levels of kidney function.

Surgical and Nonsurgical Pediatric Hand Fractures: A Cohort Study

Pediatric hand fractures are common and approximately 10% require surgery.

METHODS

This retrospective cohort study reports on hand fractures in a large pediatric population and identifies the characteristics and patterns of fractures that required surgical correction. A χ2 analysis was done to evaluate the association between individual fracture variables and surgery. The STROBE checklist was applied.

RESULTS

One thousand one-hundred seventy-three hand fractures were reviewed. Peak age was 16 years for boys and 14 years for girls. Most fractures were closed (96.0%) and nonrotated (91.3%), and had no concomitant soft tissue injury (72.7%). More than half (56.3%) were nonepiphyseal plate fractures; yet as a single diagnosis, Salter-Harris II fractures were most common (30.2%). The following variables were significantly associated with surgery: open fractures, rotational deformity, distal phalangeal fracture location, multiple fractures, oblique pattern, comminution, displacement >2 mm, intra-articular involvement, and angulation >15°. Most fractures required only immobilization and early range of motion (64.3%). Closed reduction was required in 22.7%. Minor surgery by the primary provider was performed in 3.2% of fractures. Surgery by a hand surgeon was performed in 9.8%. The most common patterns requiring surgery were proximal or middle phalanx head or neck fractures (38.2%) and metacarpal midshaft fractures (20.9%). The most common operation was open reduction internal fixation (52.2%).

CONCLUSIONS

Pediatric hand fractures are common, but 90.2% do not require surgery and, as such, primary providers play a key role in management. Certain fracture variables and patterns are more likely to lead to surgery.

Pediatric Hand Fracture Referring Practices: A Scoping Review

Background

Pediatric hand fractures are common, but few require surgery; therefore, these fractures are often perceived to be overreferred. Our objective is to systematically identify and describe pediatric hand fracture referring practices.

Method

A scoping review was performed, searching electronic databases and grey literature up to January 2018 to identify referring practices for children (17 years and younger) with hand fractures (defined as radiographically confirmed fractures distal to the carpus) to hand surgeons. All study designs were included, and study selection and data extraction were independently performed in duplicate by 2 reviewers. Outcomes included referring rates, necessity of referral, referring criteria, and management of fractures.

Results

Twenty (10 cross-sectional, 7 prospective cohorts, and 3 narrative reviews) studies reporting on referring practices or management of 21,624 pediatric hand fractures were included. Proportion of pediatric hand fractures referred to hand surgeons ranged from 6.5% to 100%. Unnecessary referral, defined as those fractures within the scope of primary care management, ranged from 27% to 78.1%. Ten studies reported referring criteria, with 14 unique criteria identified. The most common referring criteria were displacement (36.4%), loss of joint congruity (36.4%), and instability (36.4%). The most common justification for these criteria was increased likelihood of requiring surgery. The most common initial management was immobilization (66%-100%). Final management was provided by orthopedic or plastic hand surgeons with 0% to 32.9% of fractures requiring surgery.

Conclusion

Referring practices vary widely in the literature. Major gaps in the literature include objective measures and justification for referring criteria and primary care education on hand fracture referring practices.

Preoperative predictors of poor acute postoperative pain control: a systematic review and meta-analysis

OBJECTIVES

Inadequate postoperative pain control is common and is associated with poor clinical outcomes. This study aimed to identify preoperative predictors of poor postoperative pain control in adults undergoing inpatient surgery.

DESIGN

Systematic review and meta-analysis DATA SOURCES: MEDLINE, Embase, CINAHL and PsycINFO were searched through October 2017.

ELIGIBILITY CRITERIA

Studies in any language were included if they evaluated postoperative pain using a validated instrument in adults (≥18 years) and reported a measure of association between poor postoperative pain control (defined by study authors) and at least one preoperative predictor during the hospital stay.

DATA EXTRACTION AND SYNTHESIS

Two reviewers screened articles, extracted data and assessed study quality. Measures of association for each preoperative predictor were pooled using random effects models.

RESULTS

Thirty-three studies representing 53 362 patients were included in this review. Significant preoperative predictors of poor postoperative pain control included younger age (OR 1.18 [95% CI 1.05 to 1.32], number of studies, n=14), female sex (OR 1.29 [95% CI 1.17 to 1.43], n=20), smoking (OR 1.33 [95% CI 1.09 to 1.61], n=9), history of depressive symptoms (OR 1.71 [95% CI 1.32 to 2.22], n=8), history of anxiety symptoms (OR 1.22 [95% CI 1.09 to 1.36], n=10), sleep difficulties (OR 2.32 [95% CI 1.46 to 3.69], n=2), higher body mass index (OR 1.02 [95% CI 1.01 to 1.03], n=2), presence of preoperative pain (OR 1.21 [95% CI 1.10 to 1.32], n=13) and use of preoperative analgesia (OR 1.54 [95% CI 1.18 to 2.03], n=6). Pain catastrophising, American Society of Anesthesiologists status, chronic pain, marital status, socioeconomic status, education, surgical history, preoperative pressure pain tolerance and orthopaedic surgery (vs abdominal surgery) were not associated with increased odds of poor pain control. Study quality was generally high, although appropriate blinding of predictor during outcome ascertainment was often limited.

CONCLUSIONS

Nine predictors of poor postoperative pain control were identified. These should be recognised as potentially important factors when developing discipline-specific clinical care pathways to improve pain outcomes and to guide future surgical pain research.

PROSPERO REGISTRATION NUMBER

CRD42017080682.

Epidemiological analysis of pediatric burns in the Dominican Republic reveals a demographic profile at significant risk for electrical burns

OBJECTIVE

Pediatric burns are preventable with legislative and infrastructural changes. Although retrospective audits of many low- and middle-income countries have aided preventative efforts, the epidemiological status of burns in the Caribbean is not known. This study characterizes pediatric burns in the Dominican Republic (DR) and compares these to age-matched North American records captured by the National Burn Repository.

METHODS

A retrospective audit of 1600 patients admitted to the Unidad de Niños Quemados Dra. Thelma Rosario Hospital, the island's only major pediatric burn center, between January 2010 to March 2017 was performed. Epidemiological variables analyzed included age, gender, burn mechanism, year, month, city, admission duration, nationality, mortality, and %TBSA.

RESULTS

Pediatric burn patients in the DR sustained larger burns (8.2% vs. 6.5% TBSA) and spent more days in the hospital (10 vs. 6 days). Females were overrepresented (M:F=1:1.5) and mortality amongst admitted patients was 4-fold higher (2.8% vs. 0.7%). Electrical burns were significantly overrepresented in DR (21%) compared to age-matched North American patients (2%). Although electrical burns were smaller (4% TBSA), compared to scald (14% TBSA), and flame (19% TBSA), these burns preferred hands and had a high mortality rate (3%). No significant seasonality in burn mechanisms were observed. Finally, we report geographical and age group differences in the distribution of burn mechanisms and highlight particularly vulnerable subpopulations.

CONCLUSION

This investigation identifies a demographical profile where electrical burns account for a significant percentage of the burn population. This provides a basis for concentrating preventative efforts in vulnerable populations.