ORIGINAL ARTICLE
Resident Versus Attending Surgeons in Achieving and Maintaining Fracture Reduction in Pediatric Distal Radius Fractures Simon Abson, MBBS, Nicole Williams, FRACS, Mark Inglis, FRACS, Georgia Antoniou, BSc(Hons), and Peter Cundy, FRACS
Background: Distal third forearm fractures are one of the most common orthopaedic injuries in the pediatric population with a reported risk of redisplacement in the range of up to a third following initial reduction. The aims of this study were to determine whether fracture redisplacement and adequacy of cast molding were associated with surgeon seniority in the treatment of displaced pediatric distal third radius fractures that required manipulation under anesthesia. Methods: This study prospectively randomized 143 pediatric patients presenting to a tertiary referral hospital with a fractured distal radius into 2 groups. We compared the surgeon seniority (resident vs. attending surgeon) with the cast index (CI) and amount of displacement/angulation postreduction. Results: Our results showed no significant difference in CI according to level of experience between resident and attending surgeon (P = 0.14). There was also no difference in redisplacement for fracture types relative to seniority. Median redisplacement for resident and attending, respectively, for type Arbeitsgemeinschaft fu¨r Osteosynthesefragen (AO) 23E was 6% (range, 0% to 42%) versus 6% (range, 0% to 41%) P = 0.98. For type AO 23M reangulation was 4 degrees (range, 0 to 29 degrees) versus 5 degrees (range, 0 to 18 degrees) P = 0.97, respectively. Conclusions: Our results indicate that the level of seniority does not influence the CI or redisplacement/angulation of fractures after closed reduction. Residents appear well trained in cast application. Level of Evidence: Level I—randomized-controlled trial. Key Words: pediatric, distal radius, fracture, treatment, cast material, surgeon seniority (J Pediatr Orthop 2016;36:478–482)
D
istal third forearm fractures are one of the most common orthopaedic injuries in the pediatric population1 with a reported risk of redisplacement in the From the Women’s and Children’s Hospital, Adelaide, Australia. The authors declare no conflicts of interest. Reprints: Simon Abson, MBBS, Orthopaedic Department, Royal Newcastle Centre, Lookout Road, New Lambton Heights, Newcastle, NSW 2305, Australia. E-mail: [email protected]. Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
478 | www.pedorthopaedics.com
range of up to a third following initial reduction.2 Distal radial physeal injuries that show redisplacement are often managed expectantly because of high remodeling potential and risk of growth arrest on remanipulation. Metaphyseal fractures are also well known to have a high remodeling capacity and complete bayonet apposition is acceptable, provided angulation and growth remaining is within appropriate limits.3 Despite the overall high potential for remodeling and good outcome, gross redisplacement in older children does occasionally need remanipulation, and even minor redisplacement can result in prolonged consultation with concerned parents and increased necessity for follow-up. A recent study of nonoperative management of overriding distal radial fractures reiterated the importance of patient doctor communication and counseling in obtaining a satisfactory outcome for all involved.4 Follow-up for distal radius injury requiring reduction is recommended, to ensure no further redisplacement, adequate remodeling, and normal growth. There are recommendations for repeat radiographic imaging5 with recent literature recommending imaging limited to 2 weeks postoperatively.6 There is also evidence that surgeon seniority ensures better fracture reduction and hence less risk of redisplacement.7 Modern development of casting materials has made treatment of closed fractures using synthetic casts (SYN) a practical and attractive option. SYN have been shown to have more desirable mechanical properties with regards to deformity resistance and longevity.8 Furthermore, recent studies have also alluded to the improved cost benefit of SYN due to increased strength and less need for cast revision.9 Convenience of waterproof materials also has appeal to the vigorous expectations of modern day life and decreased dermatological complications.10 Studies have indicated the benefit of SYN over Plaster of Paris casts (POP), in the treatment of undisplaced “stable” distal radius fractures11 and displaced forearm fractures.12 There are no high-level evidence trials comparing amount of redisplacement after fracture reduction, in pediatric distal forearm fractures, with synthetic casting, or the traditional POP.2 The aims of this study were to determine whether fracture redisplacement and adequacy J Pediatr Orthop
Volume 36, Number 5, July/August 2016
Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.
J Pediatr Orthop
Volume 36, Number 5, July/August 2016
Resident Versus Attending Surgeons
of cast molding were associated with surgeon seniority in the treatment of displaced pediatric distal third radius fractures that required manipulation under anesthesia.
METHODS Institutional Review Board approval was obtained for the study protocol. We received no funding and declare no conflict of interest in this study. Patients presenting to a tertiary referral pediatric center from February 2009 to December 2011 with distal radius fractures [Arbeitsgemeinschaft fu¨r Osteosynthesefragen (AO) Pediatric Comprehensive Classification of Long-Bone Fractures type 23M and 23E] requiring manipulation were included in this study. The entire series of patients recruited was larger and was previously reported by Inglis et al12 comparing clinical outcomes between synthetic and POP. The current study excluded patients from this group with mid-shaft or proximal shaft fractures to minimize variation in fracture reduction potential. Manipulation was performed for type 23M fractures with >20 degrees angulation or type 23E with displacement >20% physeal depth. Patients were randomized by closed envelope at the time of presentation to the emergency department into receiving either Plaster of Paris (Gypsona BSN Medical Pty Ltd., Mt Waverly, Australia) or synthetic casting (3M Scotchcast Plus, St Paul, MN). The under cast padding used in both groups was 3M “Wet n’ Dry” (St Paul, MN). The Inglis and colleague’s study demonstrated that clinical outcomes and patient satisfaction were superior with the use of SYN rather than Plaster of Paris.13 Fracture degree of displacement was measured on lateral radiographs as a percentage slip for physeal fractures (B/A 100%), (Fig. 1) and in degrees of angulation for metaphyseal fractures (angle A), (Fig. 2). All measurements were made by the primary author (S.A.). Patients were followed up at 10 to 14 days postfracture reduction with x-rays to check for loss of position. Measurements were taken at 3 timepoints,
FIGURE 2. Type 23M measurement of displacement [angle A (degrees)].
namely; at time of presentation, at time of reduction, and at final follow-up. Information regarding the operating surgeon seniority, resident (R) or attending (A), was obtained from case notes. Patients without private health insurance had treatment by the R group with 2 to 4 years of orthopaedic experience, whereas those with private insurance were treated personally by the A group with 10 to 35 years of orthopaedic experience. Patients without a complete set of x-rays were excluded from the study. To assess the adequacy of the cast in maintaining fracture reduction, the cast index (CI) was used. The CI is a measure of molding with an index >0.81 associated with increased risk of redisplacement. Fracture displacement is minimized by the application of a well-molded cast.14 The CI was measured on radiographs performed at time of initial fracture reduction and cast application.
Statistical Analyses Groups were compared on continuous variables using the 1-way analysis of variance or the Wilcoxon ranksum test if distributions were significantly skewed. The likelihood-ratio w2 test was used to compare groups on categorical variables. The w2 test was used to determine whether frequency of casting technique differed between residents and attendings, and whether this may have confounded results. Statistical analysis was undertaken using SPSS, version 22.0 (IBM Corp., Armonk, NY).
RESULTS
FIGURE 1. Type 23E measurement of displacement (B/A = %). Copyright
r
2015 Wolters Kluwer Health, Inc. All rights reserved.
There were 143 patients with distal radius fractures of AO classification 23M and 23E. Seventy-seven patients were treated with SYN and 66 with POP. Six patients from the SYN group and 7 patients from the POP group were excluded because of insufficient imaging. Therefore, 130 patients were included in the study (Fig. 3). No significant differences were observed between the POP and SYN groups for age, sex, side of fracture, or fracture type (Table 1). www.pedorthopaedics.com |
Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.
479
J Pediatr Orthop
Abson et al
Enrollment through Emergency
Volume 36, Number 5, July/August 2016
196 Patients with Forearm fractures
Randomized (n= 196)
Excluded (n= 53) ♦ Not meeting inclusion criteria (n= 53) ♦ Declined to participate (n/a )
Allocated to POP (n= 66)
Allocation by closed envelope
Allocated to SYN (n= 77)
♦ Received allocated intervention (n=66)
♦ Received allocated intervention (n= 77)
♦ Did not receive allocated intervention (n= 0)
♦ Did not receive allocated intervention(n= 0 )
Follow-Up Lost to follow-up (Follow up outside imaging not available) (n= 7)
Lost to follow-up (Follow up outside imaging not available) (n= 6)
Discontinued intervention (n=0)
Discontinued intervention (n= 0)
Analysis Analysed (n= 59)
Analysed (n= 71)
♦ Excluded from analysis (n=0)
♦ Excluded from analysis (n=0)
FIGURE 3. Patient enrollment algorithm flow diagram. POP indicates Plaster of Paris casts; SYN, synthetic casts.
There were 104 reductions performed by the R group compared with 26 reductions by the A group. The distribution of POP and SYN casting technique among R and A was 17.0% and 83.0% and 22.5% and 77.5%, respectively. There was no significant difference in frequency of casting technique between residents and attendings (P = 0.43). CI was not significantly different between the 2 levels of experience with the R group mean CI of 0.77 (SD = 0.08) compared with A mean CI of 0.80 (SD = 0.07) (P = 0.14) (Table 2).
Postreduction displacement at follow-up for the 23M and 23E type fractures showed no difference between the 2 groups. For the 23M type fractures, the median angulation for the R group was 4 degrees (range, 0 to 29 degrees) compared with a median of 5 degrees (range, 0 to 18 degrees) for the A group, (P = 0.97). For 23E type fractures the median postreduction displacement for the R group was 6% (range, 0% to 42%) compared with a median of 6% (range, 0% to 41%) for the A group, (P = 0.98) (Table 2).
TABLE 1. Patient Intergroup Demographics Total patients (n) Age [median (range)] (y) Sex (male) (%) Cast side (right) (%) AO fracture type 23E/23M (n)
480 | www.pedorthopaedics.com
Plaster of Paris
Synthetic
P
59 10.6 (4.2-15.5) 71.2 52.5 18/41
71 11.1 (4.1-17.5) 60.6 47.9 14/57
0.57 0.20 0.60 0.16
Copyright
r
2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.
J Pediatr Orthop
Volume 36, Number 5, July/August 2016
Resident Versus Attending Surgeons
TABLE 2. Displacement Postreduction According to Surgeon Experience Total patients (n) Cast application plaster/synthetic ratio (%) Cast index [mean (SD)] Displacement AO 23E [median (range)] (%) Displacement AO 23M [median (range)] (deg.)
An analysis of the effect of cast material was also performed with respect to the 2 fracture types. A statistically significant difference in CI was found between POP (mean CI = 0.76) and SYN (mean CI = 0.79) (P = 0.015). Metaphyseal fractures (N = 98) had a median angulation of 5 degrees postreduction in POP group (range, 0 to 26 degrees) and a median angulation of 4 degrees (range, 0 to 29 degrees) in the SYN group. This difference was not statistically significant (P = 0.39). Epiphyseal fractures (N = 32) had a median displacement of 5.5% (range, 0% to 41%) in the POP group and 7.5% (range, 0% to 42%) in the SYN group. Again, there was no statistically significant difference in displacement between the 2 groups (P = 0.47) A total of 5 (3.8%) patients required remanipulation for grossly displaced fractures postinitial reduction and casting. Three patients were from the POP group (5.1%) compared with 2 patients from the SYN group (2.8%). (Table 3)
DISCUSSION Previous studies have shown a direct correlation between increased CI and a higher rate of fracture redisplacement.14 This study has shown that the quality of the reduction and CI is not dependent on the seniority of the operating surgeon, with no statistical difference in radiographic outcomes at time of reduction or final followup. This was a surprising result given that cast application and fracture reduction is commonly believed to be an acquired skill. It could be argued that our resident staff have developed these skills early in their career or through years of nonformal training. The CI for the attending (A) group was not statistically different to the resident (R) group and both were under the accepted limit of 0.81.14 The observed slightly higher CI for SYN group compared with POP group
Resident
Attending
P
104 17/83 0.77 (0.08) 6 (0-42) 4 (0-29)
26 22.5/77.5 0.80 (0.07) 6 (0-41) 5 (0-18)
— 0.43 0.14 0.98 0.97
could be explained by synthetic materials having a higher modulus of elasticity and a shorter working time (on average 3 min) than Gypsona.13 This is well known to contribute to difficulty in cast conformity and mouldability. In addition, surgeon experience has been noted in previous studies to play a factor in fracture redisplacement after reduction.7 Despite these observations, it is noteworthy that the R group had no significant difference in CI to the A group (Table 2). Thus, opinions that surgeons with lesser experience using synthetic materials could result in a harmful CI were not supported by this study. The slightly better CI for residents (0.77) versus attendings (0.80) may alleviate concern regarding mouldability and level of surgical experience if residents/ junior doctors are using SYN. A limitation of our study was 13 (9.1%) patients from 143 being excluded due to insufficient imaging at follow-up. However, equal numbers were lost from both cast material groups. A lower number of attending cases (26) compared with registrar cases (104) were recorded such that conclusions regarding level of experience and CI lacked power. On the basis of the given sample sizes, the results obtained and a probability of 0.05 for significance, the power was estimated to be 0.36. Therefore, the null hypothesis of no difference in the mean CI between residents and attendings would be correctly rejected, when false, only 36% of the time. SYN casts, although statistically inferior in relation to having a higher CI, had redisplacement values, which were not significantly different, compared with POP casts. Overall rates of remanipulation for severe redisplacement were also similar in both SYN and POP groups with values of 2.8% and 5%, respectively. The paper by Inglis et al12 found that the rate of remanipulation was not significantly different between the SYN and POP groups. Our study correlates well with these findings in that the radiologically measured redisplacement is similar between the 2 casting materials.
TABLE 3. Post Reduction Displacement by Cast Type Nonsupervised cases (%) Displacement AO 23E [median (range)] (%) Displacement AO 23M [median (range)] (deg.) Cast index [mean (SD)] Fractures 23E/23M requiring remanipulation (%)
Copyright
r
2015 Wolters Kluwer Health, Inc. All rights reserved.
Plaster of Paris
Synthetic
P
83.1 5.5 (0-41) 5 (0-26) 0.76 (0.08) 5.1
77.5 7.5 (0-42) 4 (0-29) 0.79 (0.07) 2.8
0.43 0.42 0.39 0.015 0.50
www.pedorthopaedics.com |
Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.
481
J Pediatr Orthop
Abson et al
This study indicates similar rates of displacement and angulation postreduction by residents and attendings. Resident doctors appear to acquire the skills needed to apply well-moulded casts relatively early in their careers. This study also supports the use of SYN for the safe maintenance of reduction of pediatric distal radius fracture types 23E and 23M by the resident staff.
REFERENCES 1. Cheng JC, Ng BK, Ying SY, et al. A 10-year study of the changes in the pattern and treatment of 6,493 fractures. J Pediatr Orthop. 1999;19:344–350. 2. Waters PM, Bae DS. Fractures of the Distal Radius and Ulna. In: Beaty JH, Kasser JR, eds. Rockwood and Wilkins’ Fractures in Children. 7th ed. Philadelphia: Lippincott Williams & Wilkins; 2010:292–346. 3. Noonan KJ, Price CT. Forearm and distal radius fractures in children. J Am Acad Orthop Surg. 1998;6:146–156. 4. Crawford SN, Lee LSK, Izuka BH. Closed treatment of overriding distal radial fractures without reduction in children. J Bone Joint Surg Am. 2012;94:246–252. 5. Green JS, Williams SC, Finlay D, et al. Distal forearm fractures in children: the role of radiographs during follow up. Injury. 1998;29:309–312.
482 | www.pedorthopaedics.com
Volume 36, Number 5, July/August 2016
6. Bochang C, Katz K, Weigl D, et al. Are frequent radiographs necessary in the management of closed forearm fractures in children? J Child Orthop. 2008;2:217–220. 7. Haddad FS, Williams RL. Forearm fractures in children: avoiding redisplacement. Injury. 1995;26:691–692. 8. Berman AT, Parks BG. A comparison of the mechanical properties of fiberglass cast materials and their clinical relevance. J Orthop Trauma. 1990;4:85–92. 9. Marshall PD, Dibble AK, Walters TH, et al. When should a synthetic casting material be used in preference to plaster-ofParis? A cost analysis and guidance for casting departments. Injury. 1992;23:542–544. 10. Stevenson AW, Gahukamble AD, Antoniou G, et al. Waterproof cast liners in paediatric forearm fractures: a randomized trial. J Child Orthop. 2013;7:123–130. 11. Shannon EG, DiFazio R, Kasser J, et al. Waterproof casts for immobilization of children’s fractures and sprains. J Pediatr Orthop. 2005;25:56–59. 12. Inglis M, McClelland B, Sutherland LM, et al. Synthetic versus plaster of Paris casts in the treatment of fractures of the forearm in children: a randomised trial of clinical outcomes and patient satisfaction. Bone Joint J. 2013;95-B:1285–1289. 13. Wytch R, Mitchell CB, Wardlaw D, et al. Mechanical assessment of polyurethane impregnated fibreglass bandages for splinting. Prosthet Orthot Int. 1987;11:128–134. 14. Chess DG, Hyndman JC, Leahey JL, et al. Short arm plaster cast for distal pediatric forearm fractures. J Pediatr Orthop. 1994;14: 211–213.
Copyright
r
2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.
Resident Versus Attending Surgeons in Achieving and Maintaining Fracture Reduction in Pediatric Distal Radius Fractures Simon Abson, MBBS, Nicole Williams, FRACS, Mark Inglis, FRACS, Georgia Antoniou, BSc(Hons), and Peter Cundy, FRACS
Background: Distal third forearm fractures are one of the most common orthopaedic injuries in the pediatric population with a reported risk of redisplacement in the range of up to a third following initial reduction. The aims of this study were to determine whether fracture redisplacement and adequacy of cast molding were associated with surgeon seniority in the treatment of displaced pediatric distal third radius fractures that required manipulation under anesthesia. Methods: This study prospectively randomized 143 pediatric patients presenting to a tertiary referral hospital with a fractured distal radius into 2 groups. We compared the surgeon seniority (resident vs. attending surgeon) with the cast index (CI) and amount of displacement/angulation postreduction. Results: Our results showed no significant difference in CI according to level of experience between resident and attending surgeon (P = 0.14). There was also no difference in redisplacement for fracture types relative to seniority. Median redisplacement for resident and attending, respectively, for type Arbeitsgemeinschaft fu¨r Osteosynthesefragen (AO) 23E was 6% (range, 0% to 42%) versus 6% (range, 0% to 41%) P = 0.98. For type AO 23M reangulation was 4 degrees (range, 0 to 29 degrees) versus 5 degrees (range, 0 to 18 degrees) P = 0.97, respectively. Conclusions: Our results indicate that the level of seniority does not influence the CI or redisplacement/angulation of fractures after closed reduction. Residents appear well trained in cast application. Level of Evidence: Level I—randomized-controlled trial. Key Words: pediatric, distal radius, fracture, treatment, cast material, surgeon seniority (J Pediatr Orthop 2016;36:478–482)
D
istal third forearm fractures are one of the most common orthopaedic injuries in the pediatric population1 with a reported risk of redisplacement in the From the Women’s and Children’s Hospital, Adelaide, Australia. The authors declare no conflicts of interest. Reprints: Simon Abson, MBBS, Orthopaedic Department, Royal Newcastle Centre, Lookout Road, New Lambton Heights, Newcastle, NSW 2305, Australia. E-mail: [email protected]. Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
478 | www.pedorthopaedics.com
range of up to a third following initial reduction.2 Distal radial physeal injuries that show redisplacement are often managed expectantly because of high remodeling potential and risk of growth arrest on remanipulation. Metaphyseal fractures are also well known to have a high remodeling capacity and complete bayonet apposition is acceptable, provided angulation and growth remaining is within appropriate limits.3 Despite the overall high potential for remodeling and good outcome, gross redisplacement in older children does occasionally need remanipulation, and even minor redisplacement can result in prolonged consultation with concerned parents and increased necessity for follow-up. A recent study of nonoperative management of overriding distal radial fractures reiterated the importance of patient doctor communication and counseling in obtaining a satisfactory outcome for all involved.4 Follow-up for distal radius injury requiring reduction is recommended, to ensure no further redisplacement, adequate remodeling, and normal growth. There are recommendations for repeat radiographic imaging5 with recent literature recommending imaging limited to 2 weeks postoperatively.6 There is also evidence that surgeon seniority ensures better fracture reduction and hence less risk of redisplacement.7 Modern development of casting materials has made treatment of closed fractures using synthetic casts (SYN) a practical and attractive option. SYN have been shown to have more desirable mechanical properties with regards to deformity resistance and longevity.8 Furthermore, recent studies have also alluded to the improved cost benefit of SYN due to increased strength and less need for cast revision.9 Convenience of waterproof materials also has appeal to the vigorous expectations of modern day life and decreased dermatological complications.10 Studies have indicated the benefit of SYN over Plaster of Paris casts (POP), in the treatment of undisplaced “stable” distal radius fractures11 and displaced forearm fractures.12 There are no high-level evidence trials comparing amount of redisplacement after fracture reduction, in pediatric distal forearm fractures, with synthetic casting, or the traditional POP.2 The aims of this study were to determine whether fracture redisplacement and adequacy J Pediatr Orthop
Volume 36, Number 5, July/August 2016
Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.
J Pediatr Orthop
Volume 36, Number 5, July/August 2016
Resident Versus Attending Surgeons
of cast molding were associated with surgeon seniority in the treatment of displaced pediatric distal third radius fractures that required manipulation under anesthesia.
METHODS Institutional Review Board approval was obtained for the study protocol. We received no funding and declare no conflict of interest in this study. Patients presenting to a tertiary referral pediatric center from February 2009 to December 2011 with distal radius fractures [Arbeitsgemeinschaft fu¨r Osteosynthesefragen (AO) Pediatric Comprehensive Classification of Long-Bone Fractures type 23M and 23E] requiring manipulation were included in this study. The entire series of patients recruited was larger and was previously reported by Inglis et al12 comparing clinical outcomes between synthetic and POP. The current study excluded patients from this group with mid-shaft or proximal shaft fractures to minimize variation in fracture reduction potential. Manipulation was performed for type 23M fractures with >20 degrees angulation or type 23E with displacement >20% physeal depth. Patients were randomized by closed envelope at the time of presentation to the emergency department into receiving either Plaster of Paris (Gypsona BSN Medical Pty Ltd., Mt Waverly, Australia) or synthetic casting (3M Scotchcast Plus, St Paul, MN). The under cast padding used in both groups was 3M “Wet n’ Dry” (St Paul, MN). The Inglis and colleague’s study demonstrated that clinical outcomes and patient satisfaction were superior with the use of SYN rather than Plaster of Paris.13 Fracture degree of displacement was measured on lateral radiographs as a percentage slip for physeal fractures (B/A 100%), (Fig. 1) and in degrees of angulation for metaphyseal fractures (angle A), (Fig. 2). All measurements were made by the primary author (S.A.). Patients were followed up at 10 to 14 days postfracture reduction with x-rays to check for loss of position. Measurements were taken at 3 timepoints,
FIGURE 2. Type 23M measurement of displacement [angle A (degrees)].
namely; at time of presentation, at time of reduction, and at final follow-up. Information regarding the operating surgeon seniority, resident (R) or attending (A), was obtained from case notes. Patients without private health insurance had treatment by the R group with 2 to 4 years of orthopaedic experience, whereas those with private insurance were treated personally by the A group with 10 to 35 years of orthopaedic experience. Patients without a complete set of x-rays were excluded from the study. To assess the adequacy of the cast in maintaining fracture reduction, the cast index (CI) was used. The CI is a measure of molding with an index >0.81 associated with increased risk of redisplacement. Fracture displacement is minimized by the application of a well-molded cast.14 The CI was measured on radiographs performed at time of initial fracture reduction and cast application.
Statistical Analyses Groups were compared on continuous variables using the 1-way analysis of variance or the Wilcoxon ranksum test if distributions were significantly skewed. The likelihood-ratio w2 test was used to compare groups on categorical variables. The w2 test was used to determine whether frequency of casting technique differed between residents and attendings, and whether this may have confounded results. Statistical analysis was undertaken using SPSS, version 22.0 (IBM Corp., Armonk, NY).
RESULTS
FIGURE 1. Type 23E measurement of displacement (B/A = %). Copyright
r
2015 Wolters Kluwer Health, Inc. All rights reserved.
There were 143 patients with distal radius fractures of AO classification 23M and 23E. Seventy-seven patients were treated with SYN and 66 with POP. Six patients from the SYN group and 7 patients from the POP group were excluded because of insufficient imaging. Therefore, 130 patients were included in the study (Fig. 3). No significant differences were observed between the POP and SYN groups for age, sex, side of fracture, or fracture type (Table 1). www.pedorthopaedics.com |
Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.
479
J Pediatr Orthop
Abson et al
Enrollment through Emergency
Volume 36, Number 5, July/August 2016
196 Patients with Forearm fractures
Randomized (n= 196)
Excluded (n= 53) ♦ Not meeting inclusion criteria (n= 53) ♦ Declined to participate (n/a )
Allocated to POP (n= 66)
Allocation by closed envelope
Allocated to SYN (n= 77)
♦ Received allocated intervention (n=66)
♦ Received allocated intervention (n= 77)
♦ Did not receive allocated intervention (n= 0)
♦ Did not receive allocated intervention(n= 0 )
Follow-Up Lost to follow-up (Follow up outside imaging not available) (n= 7)
Lost to follow-up (Follow up outside imaging not available) (n= 6)
Discontinued intervention (n=0)
Discontinued intervention (n= 0)
Analysis Analysed (n= 59)
Analysed (n= 71)
♦ Excluded from analysis (n=0)
♦ Excluded from analysis (n=0)
FIGURE 3. Patient enrollment algorithm flow diagram. POP indicates Plaster of Paris casts; SYN, synthetic casts.
There were 104 reductions performed by the R group compared with 26 reductions by the A group. The distribution of POP and SYN casting technique among R and A was 17.0% and 83.0% and 22.5% and 77.5%, respectively. There was no significant difference in frequency of casting technique between residents and attendings (P = 0.43). CI was not significantly different between the 2 levels of experience with the R group mean CI of 0.77 (SD = 0.08) compared with A mean CI of 0.80 (SD = 0.07) (P = 0.14) (Table 2).
Postreduction displacement at follow-up for the 23M and 23E type fractures showed no difference between the 2 groups. For the 23M type fractures, the median angulation for the R group was 4 degrees (range, 0 to 29 degrees) compared with a median of 5 degrees (range, 0 to 18 degrees) for the A group, (P = 0.97). For 23E type fractures the median postreduction displacement for the R group was 6% (range, 0% to 42%) compared with a median of 6% (range, 0% to 41%) for the A group, (P = 0.98) (Table 2).
TABLE 1. Patient Intergroup Demographics Total patients (n) Age [median (range)] (y) Sex (male) (%) Cast side (right) (%) AO fracture type 23E/23M (n)
480 | www.pedorthopaedics.com
Plaster of Paris
Synthetic
P
59 10.6 (4.2-15.5) 71.2 52.5 18/41
71 11.1 (4.1-17.5) 60.6 47.9 14/57
0.57 0.20 0.60 0.16
Copyright
r
2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.
J Pediatr Orthop
Volume 36, Number 5, July/August 2016
Resident Versus Attending Surgeons
TABLE 2. Displacement Postreduction According to Surgeon Experience Total patients (n) Cast application plaster/synthetic ratio (%) Cast index [mean (SD)] Displacement AO 23E [median (range)] (%) Displacement AO 23M [median (range)] (deg.)
An analysis of the effect of cast material was also performed with respect to the 2 fracture types. A statistically significant difference in CI was found between POP (mean CI = 0.76) and SYN (mean CI = 0.79) (P = 0.015). Metaphyseal fractures (N = 98) had a median angulation of 5 degrees postreduction in POP group (range, 0 to 26 degrees) and a median angulation of 4 degrees (range, 0 to 29 degrees) in the SYN group. This difference was not statistically significant (P = 0.39). Epiphyseal fractures (N = 32) had a median displacement of 5.5% (range, 0% to 41%) in the POP group and 7.5% (range, 0% to 42%) in the SYN group. Again, there was no statistically significant difference in displacement between the 2 groups (P = 0.47) A total of 5 (3.8%) patients required remanipulation for grossly displaced fractures postinitial reduction and casting. Three patients were from the POP group (5.1%) compared with 2 patients from the SYN group (2.8%). (Table 3)
DISCUSSION Previous studies have shown a direct correlation between increased CI and a higher rate of fracture redisplacement.14 This study has shown that the quality of the reduction and CI is not dependent on the seniority of the operating surgeon, with no statistical difference in radiographic outcomes at time of reduction or final followup. This was a surprising result given that cast application and fracture reduction is commonly believed to be an acquired skill. It could be argued that our resident staff have developed these skills early in their career or through years of nonformal training. The CI for the attending (A) group was not statistically different to the resident (R) group and both were under the accepted limit of 0.81.14 The observed slightly higher CI for SYN group compared with POP group
Resident
Attending
P
104 17/83 0.77 (0.08) 6 (0-42) 4 (0-29)
26 22.5/77.5 0.80 (0.07) 6 (0-41) 5 (0-18)
— 0.43 0.14 0.98 0.97
could be explained by synthetic materials having a higher modulus of elasticity and a shorter working time (on average 3 min) than Gypsona.13 This is well known to contribute to difficulty in cast conformity and mouldability. In addition, surgeon experience has been noted in previous studies to play a factor in fracture redisplacement after reduction.7 Despite these observations, it is noteworthy that the R group had no significant difference in CI to the A group (Table 2). Thus, opinions that surgeons with lesser experience using synthetic materials could result in a harmful CI were not supported by this study. The slightly better CI for residents (0.77) versus attendings (0.80) may alleviate concern regarding mouldability and level of surgical experience if residents/ junior doctors are using SYN. A limitation of our study was 13 (9.1%) patients from 143 being excluded due to insufficient imaging at follow-up. However, equal numbers were lost from both cast material groups. A lower number of attending cases (26) compared with registrar cases (104) were recorded such that conclusions regarding level of experience and CI lacked power. On the basis of the given sample sizes, the results obtained and a probability of 0.05 for significance, the power was estimated to be 0.36. Therefore, the null hypothesis of no difference in the mean CI between residents and attendings would be correctly rejected, when false, only 36% of the time. SYN casts, although statistically inferior in relation to having a higher CI, had redisplacement values, which were not significantly different, compared with POP casts. Overall rates of remanipulation for severe redisplacement were also similar in both SYN and POP groups with values of 2.8% and 5%, respectively. The paper by Inglis et al12 found that the rate of remanipulation was not significantly different between the SYN and POP groups. Our study correlates well with these findings in that the radiologically measured redisplacement is similar between the 2 casting materials.
TABLE 3. Post Reduction Displacement by Cast Type Nonsupervised cases (%) Displacement AO 23E [median (range)] (%) Displacement AO 23M [median (range)] (deg.) Cast index [mean (SD)] Fractures 23E/23M requiring remanipulation (%)
Copyright
r
2015 Wolters Kluwer Health, Inc. All rights reserved.
Plaster of Paris
Synthetic
P
83.1 5.5 (0-41) 5 (0-26) 0.76 (0.08) 5.1
77.5 7.5 (0-42) 4 (0-29) 0.79 (0.07) 2.8
0.43 0.42 0.39 0.015 0.50
www.pedorthopaedics.com |
Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.
481
J Pediatr Orthop
Abson et al
This study indicates similar rates of displacement and angulation postreduction by residents and attendings. Resident doctors appear to acquire the skills needed to apply well-moulded casts relatively early in their careers. This study also supports the use of SYN for the safe maintenance of reduction of pediatric distal radius fracture types 23E and 23M by the resident staff.
REFERENCES 1. Cheng JC, Ng BK, Ying SY, et al. A 10-year study of the changes in the pattern and treatment of 6,493 fractures. J Pediatr Orthop. 1999;19:344–350. 2. Waters PM, Bae DS. Fractures of the Distal Radius and Ulna. In: Beaty JH, Kasser JR, eds. Rockwood and Wilkins’ Fractures in Children. 7th ed. Philadelphia: Lippincott Williams & Wilkins; 2010:292–346. 3. Noonan KJ, Price CT. Forearm and distal radius fractures in children. J Am Acad Orthop Surg. 1998;6:146–156. 4. Crawford SN, Lee LSK, Izuka BH. Closed treatment of overriding distal radial fractures without reduction in children. J Bone Joint Surg Am. 2012;94:246–252. 5. Green JS, Williams SC, Finlay D, et al. Distal forearm fractures in children: the role of radiographs during follow up. Injury. 1998;29:309–312.
482 | www.pedorthopaedics.com
Volume 36, Number 5, July/August 2016
6. Bochang C, Katz K, Weigl D, et al. Are frequent radiographs necessary in the management of closed forearm fractures in children? J Child Orthop. 2008;2:217–220. 7. Haddad FS, Williams RL. Forearm fractures in children: avoiding redisplacement. Injury. 1995;26:691–692. 8. Berman AT, Parks BG. A comparison of the mechanical properties of fiberglass cast materials and their clinical relevance. J Orthop Trauma. 1990;4:85–92. 9. Marshall PD, Dibble AK, Walters TH, et al. When should a synthetic casting material be used in preference to plaster-ofParis? A cost analysis and guidance for casting departments. Injury. 1992;23:542–544. 10. Stevenson AW, Gahukamble AD, Antoniou G, et al. Waterproof cast liners in paediatric forearm fractures: a randomized trial. J Child Orthop. 2013;7:123–130. 11. Shannon EG, DiFazio R, Kasser J, et al. Waterproof casts for immobilization of children’s fractures and sprains. J Pediatr Orthop. 2005;25:56–59. 12. Inglis M, McClelland B, Sutherland LM, et al. Synthetic versus plaster of Paris casts in the treatment of fractures of the forearm in children: a randomised trial of clinical outcomes and patient satisfaction. Bone Joint J. 2013;95-B:1285–1289. 13. Wytch R, Mitchell CB, Wardlaw D, et al. Mechanical assessment of polyurethane impregnated fibreglass bandages for splinting. Prosthet Orthot Int. 1987;11:128–134. 14. Chess DG, Hyndman JC, Leahey JL, et al. Short arm plaster cast for distal pediatric forearm fractures. J Pediatr Orthop. 1994;14: 211–213.
Copyright
r
2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.
