ORIGINAL ARTICLE
Evidence into Practice: Pediatric Orthopaedic Surgeon Use of Removable Splints for Common Pediatric Fractures Kathy Boutis, MD, MSc,* Andrew Howard, MD, MSc,w Erika Constantine, MD,zy Anna Cuomo, MD,8 Zeeshanefatema Somji, BSc,* and Unni G. Narayanan, MBBS, MScw
Objectives: Removable splints when compared with circumferential casts in randomized trials have been shown to be a safe and cost-effective method of managing many common minor distal radius and fibular fractures. This study estimated the extent to which this evidence is being implemented in clinical practice, and determined the perceived barriers to the adoption of this evidence. Methods: A cross-sectional survey of practicing orthopaedic surgeon members of the Pediatric Orthopedic Surgeons of North America (POSNA) was conducted, using a 22-item online questionnaire, and distributed using a modified Dillman technique. Survey questions were derived from and validated by literature review, expert opinion, and pilot-testing on the targeted sample before implementation. Results: Of the 826 eligible participants, 558 (67.6%) responded to the survey. Of these, 505 (90.5%) had completed a fellowship in pediatric orthopaedics, 335 (60.0%) worked in a universityaffiliated setting, and 377 (67.6%) had been in practice for 60
Canada n = 40 8 8 3 3 18
United States n = 518
(20.0) (20.0) (7.5) (7.5) (45.0)
122 87 79 67 163
(23.6) (16.8) (15.3) (12.9) (31.5)
P*
0.21
40 (100)
465 (89.8)
0.06
39 (97.5)
296 (57.1)
0.001
2 8 5 10 15
14 140 169 81 114
(5.0) (20.0) (12.5) (25.0) (37.5)
(2.7) (27.0) (32.6) (15.6) (22.0)
0.17
*P-value reflects differences in distribution.
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Common Fractures POSNA Survey
TABLE 2. Immobilization Device Practice Patterns for the Duration of Therapy What is Your Institution’s Preferred Method of Immobilization for the Duration of Therapy for Each Fracture? (if no Institutional Standard, Please State Your Practice) Buckle fracture of the distal radius [n (%)] Removable splint (prefabricated, fiberglass, plaster) Short arm cast Long arm cast Minimally angulated greenstick fracture of distal radius [n (%)] Removable splint (prefabricated, fiberglass, plaster) Short arm cast Long arm cast Reduction to anatomic alignment followed by cast Minimally angulated transverse fracture of distal radius [n (%)] Removable splint (prefabricated, fiberglass, plaster) Short arm cast Long arm cast Reduction to anatomic alignment followed by case Salter-Harris I fracture of distal fibula [n (%)] Removable device (brace, splint, boot) Below knee walking cast for 3-4 wk Below knee boot/walker for 3-4 wk Salter-Harris II fracture of distal fibula [n (%)] Removable device (brace, splint, boot) Below knee walking cast for 3-4 wk Below knee boot/walker for 3-4 wk Avulsion fracture of the distal fibula [n (%)] Removable device (brace, splint, boot) Below knee walking cast for 3-4 wk Below knee boot/walker for 3-4 wk
(P = 0.004); 27.5% of Canadian POSNA reported a concern for cost/reimbursement and 11.2% do in the United States (P = 0.009). Of note, the quality of the evidence as a barrier to using removable devices was only reported by a relative minority of the respondents for distal radius and distal fibular fractures.
Clinical Significance of Fractures for Important Short-term and Long-term Complications Almost all the respondents reported a “very low/ low” level of concern for complications from distal radius buckle and greenstick fractures (Table 5). However, almost one third of respondents expressed at least a “moderate” level of concern for important complications from transverse distal radius fractures.
Canada n = 40
United States n = 503
P
22 (55.0) 17 (42.5) 1 (2.5)
136 (27.6) 348 (69.2) 19 (3.8)
< 0.001 0.04 0.91
7 25 7 1
(17.5) (62.5) (17.5) (2.5)
25 328 124 26
(5.0) (65.2) (24.7) (5.2)
0.001 0.42 0.43 0.72
2 21 14 3
(5.0) (52.5) (35.0) (7.5)
6 268 201 28
(1.2) (53.3) (40.0) (5.6)
0.005 0.71 0.42 0.40
8 (20.0) 23 (57.5) 9 (22.5)
49 (9.8) 318 (63.2) 136 (27.0)
0.27 1.00 1.00
5 (12.5) 29 (72.5) 6 (15.0)
24 (4.8) 400 (79.5) 79 (15.7)
0.27 1.00 1.00
8 (20.0) 23 (57.5) 9 (22.5)
114 (22.7) 275 (54.7) 114 (22.6)
0.53 1.00 0.73
In the distal fibular fracture group, no respondents reported a “very high/high” level of concern for important complications and only relatively small minority expressed a “moderate” level of concern for Salter-Harris I and II fractures of the distal fibula. Almost all respondents reported a “low/very low” potential for complications for distal fibular avulsion fractures.
DISCUSSION This survey revealed that a relatively small proportion of responding POSNA members treat common minor distal radius and fibular fractures with removable devices. However, most orthopaedic surgeons do consider these injuries at relatively low risk for short-term and long-term complications and reported being at least moderately comfortable managing these injuries (with the
TABLE 3. Comfort Level of Pediatric Orthopaedic Surgeons for Using Removable Devices for Specific Fractures n (%)
Fracture Type Distal radius buckle Minimally displaced greenstick of distal radius Minimally displaced transverse of distal radius Salter-Harris I of distal fibula Salter-Harris II of distal fibula Avulsion of distal fibula
r
Very Comfortable n = 540
Moderately Comfortable n = 540
Neither Comfortable/ Uncomfortable n = 540
Moderately Uncomfortable n = 540
Very Uncomfortable n = 540
300 (55.6) 114 (21.1)
131 (24.2) 191 (35.4)
44 (8.1) 74 (13.7)
42 (7.8) 123 (22.8)
23 (4.3) 38 (7.0)
53 (9.8)
118 (21.9)
74 (13.7)
221 (40.9)
72 (13.3)
258 (47.8) 161 (29.8) 244 (45.2)
155 (28.7) 161 (29.8) 138 (25.6)
57 (10.6) 72 (13.3) 65 (12.0)
53 (9.8) 110 (20.3) 67 (12.4)
22 (4.1) 36 (6.7) 27 (5.0)
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TABLE 4. Reported Barriers to the Use of Removable Devices n (%) What Barriers do You Distal Radius Face in Applying Fractures (Buckle, Distal Fibular Removable Devices Minimally Displaced Fractures for These Fractures? Greenstick/ (Nondisplaced Salter(Check All That Transverse) Harris I, II, Avulsion) Apply) n = 540 n = 540 Concerned about patient compliance Concerned about potential complications Medicolegal implications Cost/reimbursement issues Do not feel evidence is strong enough Lack of availability of commercial devices in my practice Orthopaedic colleagues do not support this treatment choice These do not apply to me, I prefer to use these devices in these cases
376 (69.6)
295 (54.6)
251 (46.5)
142 (26.3)
114 (21.1)
89 (16.4)
81 (15.0)
80 (14.5)
68 (12.6)
53 (9.8)
59 (10.9)
52 (9.6)
36 (6.6)
29 (5.4)
79 (14.6)
119 (22.0)
exception of transverse distal radius fractures) with removable splints. The most commonly reported perceived barriers to application of a removable device were concerns about patient compliance, potential complications, and medicolegal implications. In 2003, Plint et al23 reported that 12% of Canadian pediatric orthopaedic surgeons managed distal radius buckle fractures with a removable splint, and our results demonstrate that this has now increased to 55% in Canada and 27% in the United States, supporting some uptake of the evidence for this injury. In 2010, a randomized control trial demonstrated the cost-effectiveness of a removal splint versus cast for minimally displaced greenstick/transverse fractures,3,15 however, only 6% of POSNA members reported using splint treatment for these injuries. Further, about 40% of pediatric orthopaedic surgeons treat minimally displaced transverse fractures using a long arm circumferential
Volume 35, Number 1, January 2015
cast, despite level I evidence that demonstrates that there is no difference between long and short arm casts with respect to important clinical outcomes in the treatment of unstable distal radius fractures.24 Consistent with the current evidence that demonstrates that reduction has no clinical benefit over remodeling in minimally displaced distal radius fractures,25,26 95% of pediatric orthopaedic surgeons would not reduce minimally displaced distal radius fractures to anatomic alignment before immobilization. Use of removable devices to treat stable, low-risk distal fibular fractures2 is relatively low among pediatric orthopaedic surgeons. There are very little data in the literature about the use of immobilization strategies for these injuries by orthopaedic surgeons. In 2008, Dowling and Wishart27 reported that approximately 85% of emergency physicians immobilize Salter-Harris I fractures of the distal fibula with fiberglass/plaster immobilization and refer these to an orthopaedic surgeon. Our data demonstrate that about 90% of POSNA respondents prefer to use below knee immobilization with a cast or commercial boot for this injury. Similarly, about 95% treat Salter-Harris II fractures of the distal fibula with a strategy that immobilizes the ankle for 3 to 6 weeks. The use of a removable device was greatest for distal fibular avulsion fractures although still relatively low at about 20%. In this study, most orthopaedic surgeons reported that they consider these distal radius and fibular fractures at relatively low risk for future important short-term and long-term complications. Further, most would feel at least moderately comfortable managing these injuries with removable devices. Canadian pediatric surgeons were significantly more concerned about cost/reimbursement issues of these devices for their patients relative to surgeons in the United States. American orthopaedic surgeons were relatively more concerned about patient compliance, which may explain why Canadian orthopaedic surgeons have adopted removable devices more frequently than their American colleagues for distal radius fractures. Other issues to consider may include the availability of prefabricated commercial splints, and/or patient factors that may result in a preference for cast placement. This research is subject to the usual limitations of self-administered surveys. One issue with this survey’s results is the potential for self-selection bias. However, our response rate of 68% exceeds other similar published
TABLE 5. Potential for Complications for Specific Fractures Reported by Pediatric Orthopaedic Surgeons n (%) Fracture Type
Very Low n = 543
Distal radius buckle Minimally displaced greenstick of distal radius Minimally displaced transverse of distal radius Salter-Harris I of distal fibula Salter-Harris II of distal fibula Avulsion of distal fibula
448 161 101 438 256 442
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(82.5) (29.7) (18.6) (80.7) (47.2) (81.4)
Low n = 543 91 282 278 97 228 100
(16.8) (51.9) (51.2) (17.9) (42.0) (18.4)
Moderate n = 543
High n = 543
Very High n = 543
4 100 149 50 59 1
0 0 14 (2.6) 0 0 0
0 0 1 (0.2) 0 0 0
(0.7) (18.4) (27.4) (9.2) (9.2) (0.2)
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physician surveys (53% to 54%),28–30 respondents represented a wide geographic area in the United States and Canada, and nonrespondent/nonsampled surgeons working in the same clinic/institution are more likely to be similar than different from each other in their practices.28–31 It is difficult to separate out what respondents actually do versus what they say they do. Finally, because the respondents in this survey are based in Canada and the United States the extent to which these results can be generalized to our colleagues in other countries is uncertain. Although surgeons’ beliefs about the excellent prognosis for these fractures is consistent with the evidence that supports the use of removable devices for these injuries, the majority of pediatric orthopaedic surgeons treat low-risk distal radius and fibular fractures with circumferential casts. Perceived barriers and important clinical outcomes derived from this survey can be incorporated into future research that introduces knowledge translation strategies (eg, education) targeted at all the stakeholders to provide health care efficient, safe, and more convenient strategies for these common injuries. REFERENCES 1. Plint AC, Perry JJ, Correll R, et al. A randomized, controlled trial of removable splinting versus casting for wrist buckle fractures in children. Pediatrics. 2006;117:691–697. 2. Boutis K, Willan AR, Babyn P, et al. A randomized, controlled trial of a removable brace versus casting in children with low risk ankle fractures. Pediatrics. 2007;119:e1256–e1263. 3. Boutis K, Willan A, Babyn P, et al. A randomized controlled trial of cast versus wrist splint in children with acceptably angulated wrist fractures. CMAJ. 2010;182:1507–1512. 4. Carmichael KD, Westmoreland J. Effectiveness of ear protection in reducing anxiety during cast removal in children. Am J Orthop. 2005;34:43–46. 5. Katz K, Fogelman R, Attias J, et al. Anxiety reaction in children during removal of their plaster cast with a saw. J Bone Joint Surg Br. 2001;83:388–390. 6. Liu RW, Mehta P, Fortuna S, et al. A randomized prospective study of music therapy for reducing anxiety during cast room procedures. J Pediatr Orthop. 2007;27:831–833. 7. Boyd AS, Benjamin HJ, Asplund C. Principles of casting and splinting. Am Fam Physician. 2009;79:16–22. 8. Barnett PL, Lee MH, Oh L, et al. Functional outcome after airstirrup ankle brace or fiberglass backslab for pediatric low-risk ankle fractures: a randomized observer-blinded controlled trial. Pediatr Emerg Care. 2012;28:745–749. 9. Davidson JS, Brown DJ, Barnes SN, et al. Simple treatment for torus fractures of the distal radius. J Bone Joint Surg. 2001;83B:1173–1175. 10. Firmin F, Crouch R. Splinting versus casting of “torus” fractures to the distal radius in the paediatric patient presenting at the emergency department (ED): a literature review. Int Emerg Nurs. 2009;17: 173–178.
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11. Khan KS, Grufferty A, Gallagher O, et al. A randomized trial of’soft cast’ for distal radius buckle fractures in children. Acta Orthop Belg. 2007;73:594–597. 12. Oakley E, Ooi KS, Barnett PL. A randomized control trial of two methods of immobilizing torus fractures of the distal forearm. Pediatr Emerg Care. 2008;24:65–70. 13. West S, Andrews J, Bebbington A, et al. Buckle fractures of the distal radius are safely treated in a soft bandage: a randomized prospective trial of bandage versus plaster cast. J Pediatr Orthop. 2005;25:322–325. 14. Witney-Lagen C, Smith C, Walsh G. Soft cast versus rigid cast for treatment of distal radius buckle fractures in children. Injury. 2013;44:508–513. 15. Vonkeyserlingk C, Boutis K, Willan A, et al. Cost-effectiveness analysis of cast versus splint in children with acceptably angulated wrist fractures. Int J Technol Assess Health. 2011;27:101–107. 16. Willan A, Goeree R, Boutis K. Applying value of information methods in the evaluation of research evidence. J Clin Epidemiol. 2012;65:870–876. 17. Eysenbach G. Improving the quality of web surveys: the checklist for reporting results of internet e-surveys (CHERRIES). J Med Internet Res. 2004;6:e34. 18. Burns KE, Duffett M, Kho ME, et al. A guide for the design and conduct of self-administered surveys of clinicians. CMAJ. 2008;179:245–252. 19. Streiner DL, Norman GR. Health Measurement Scales: A Practical Guide to Their Development and Use. 2nd ed. Oxford, UK: Oxford University Press; 1998. 20. Erickson M, Frick S. Distal radius and ulna fractures. In: Beaty JH, Kasser JR, eds. Fractures in Children. Philadelphia: Lippincott Williams & Wilkins; 2010:405–444. 21. Wilkins KE. Principles of fracture remodeling in children. Injury. 2005;36(suppl 1):A3–A11. 22. Dillman DA. Mail and Internet Surveys: The Tailor Design Method. 2nd ed. New York, NY: John Wiley & Sons; 2000. 23. Plint A, Clifford T, Perry J, et al. Wrist buckle fractures: a survey of current practice patterns and attitudes toward immobilization. CJEM. 2003;5:95–100. 24. Bohm ER, Bubbar V, Yong Hing K, et al. Above and below-theelbow plaster casts for distal forearm fractures in children. A randomized controlled trial. J Bone Joint Surg Am. 2006;88:1–8. 25. Al Ansari K, Howard A, Seeto B, et al. Minimally angulated pediatric wrist fractures: is casting without manipulation enough? CJEM. 2007;9:9–15. 26. Do TT, Strub WM, Foad SL, et al. Reduction versus remodeling in pediatric distal forearm fractures: a preliminary cost analysis. Journal of Pediatric Orthopedics Part B. 2003;12:109–115. 27. Dowling S, Wishart I. The use of Ottawa Ankle Rules in children: a survey of physicians’ practice patterns. CJEM. 2011;13:333–338. E44-6. 28. Asch D, Jedrziewski K, Christakis N. Response rates to surveys published in medical journals. J Clin Epidemiol. 1997;10:1229–1236. 29. Boutis K, Constantine E, Schuh S, et al. Pediatric emergency physician opinions on ankle radiograph clinical decision rules. Acad Emerg Med. 2010;17:709–717. 30. Cummings S, Savitz L, Konrad T. Reported response rates to mailed physician questionnairs. Health Serv Res. 2001;35:1347–1355. 31. Graham ID, Stiell IG, Laupacis A, et al. Awareness and use of the Ottawa ankle and knee rules in 5 countries: can publication alone be enough to change practice? Ann Emerg Med. 2001;37:259–266.
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Evidence into Practice: Pediatric Orthopaedic Surgeon Use of Removable Splints for Common Pediatric Fractures Kathy Boutis, MD, MSc,* Andrew Howard, MD, MSc,w Erika Constantine, MD,zy Anna Cuomo, MD,8 Zeeshanefatema Somji, BSc,* and Unni G. Narayanan, MBBS, MScw
Objectives: Removable splints when compared with circumferential casts in randomized trials have been shown to be a safe and cost-effective method of managing many common minor distal radius and fibular fractures. This study estimated the extent to which this evidence is being implemented in clinical practice, and determined the perceived barriers to the adoption of this evidence. Methods: A cross-sectional survey of practicing orthopaedic surgeon members of the Pediatric Orthopedic Surgeons of North America (POSNA) was conducted, using a 22-item online questionnaire, and distributed using a modified Dillman technique. Survey questions were derived from and validated by literature review, expert opinion, and pilot-testing on the targeted sample before implementation. Results: Of the 826 eligible participants, 558 (67.6%) responded to the survey. Of these, 505 (90.5%) had completed a fellowship in pediatric orthopaedics, 335 (60.0%) worked in a universityaffiliated setting, and 377 (67.6%) had been in practice for 60
Canada n = 40 8 8 3 3 18
United States n = 518
(20.0) (20.0) (7.5) (7.5) (45.0)
122 87 79 67 163
(23.6) (16.8) (15.3) (12.9) (31.5)
P*
0.21
40 (100)
465 (89.8)
0.06
39 (97.5)
296 (57.1)
0.001
2 8 5 10 15
14 140 169 81 114
(5.0) (20.0) (12.5) (25.0) (37.5)
(2.7) (27.0) (32.6) (15.6) (22.0)
0.17
*P-value reflects differences in distribution.
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Common Fractures POSNA Survey
TABLE 2. Immobilization Device Practice Patterns for the Duration of Therapy What is Your Institution’s Preferred Method of Immobilization for the Duration of Therapy for Each Fracture? (if no Institutional Standard, Please State Your Practice) Buckle fracture of the distal radius [n (%)] Removable splint (prefabricated, fiberglass, plaster) Short arm cast Long arm cast Minimally angulated greenstick fracture of distal radius [n (%)] Removable splint (prefabricated, fiberglass, plaster) Short arm cast Long arm cast Reduction to anatomic alignment followed by cast Minimally angulated transverse fracture of distal radius [n (%)] Removable splint (prefabricated, fiberglass, plaster) Short arm cast Long arm cast Reduction to anatomic alignment followed by case Salter-Harris I fracture of distal fibula [n (%)] Removable device (brace, splint, boot) Below knee walking cast for 3-4 wk Below knee boot/walker for 3-4 wk Salter-Harris II fracture of distal fibula [n (%)] Removable device (brace, splint, boot) Below knee walking cast for 3-4 wk Below knee boot/walker for 3-4 wk Avulsion fracture of the distal fibula [n (%)] Removable device (brace, splint, boot) Below knee walking cast for 3-4 wk Below knee boot/walker for 3-4 wk
(P = 0.004); 27.5% of Canadian POSNA reported a concern for cost/reimbursement and 11.2% do in the United States (P = 0.009). Of note, the quality of the evidence as a barrier to using removable devices was only reported by a relative minority of the respondents for distal radius and distal fibular fractures.
Clinical Significance of Fractures for Important Short-term and Long-term Complications Almost all the respondents reported a “very low/ low” level of concern for complications from distal radius buckle and greenstick fractures (Table 5). However, almost one third of respondents expressed at least a “moderate” level of concern for important complications from transverse distal radius fractures.
Canada n = 40
United States n = 503
P
22 (55.0) 17 (42.5) 1 (2.5)
136 (27.6) 348 (69.2) 19 (3.8)
< 0.001 0.04 0.91
7 25 7 1
(17.5) (62.5) (17.5) (2.5)
25 328 124 26
(5.0) (65.2) (24.7) (5.2)
0.001 0.42 0.43 0.72
2 21 14 3
(5.0) (52.5) (35.0) (7.5)
6 268 201 28
(1.2) (53.3) (40.0) (5.6)
0.005 0.71 0.42 0.40
8 (20.0) 23 (57.5) 9 (22.5)
49 (9.8) 318 (63.2) 136 (27.0)
0.27 1.00 1.00
5 (12.5) 29 (72.5) 6 (15.0)
24 (4.8) 400 (79.5) 79 (15.7)
0.27 1.00 1.00
8 (20.0) 23 (57.5) 9 (22.5)
114 (22.7) 275 (54.7) 114 (22.6)
0.53 1.00 0.73
In the distal fibular fracture group, no respondents reported a “very high/high” level of concern for important complications and only relatively small minority expressed a “moderate” level of concern for Salter-Harris I and II fractures of the distal fibula. Almost all respondents reported a “low/very low” potential for complications for distal fibular avulsion fractures.
DISCUSSION This survey revealed that a relatively small proportion of responding POSNA members treat common minor distal radius and fibular fractures with removable devices. However, most orthopaedic surgeons do consider these injuries at relatively low risk for short-term and long-term complications and reported being at least moderately comfortable managing these injuries (with the
TABLE 3. Comfort Level of Pediatric Orthopaedic Surgeons for Using Removable Devices for Specific Fractures n (%)
Fracture Type Distal radius buckle Minimally displaced greenstick of distal radius Minimally displaced transverse of distal radius Salter-Harris I of distal fibula Salter-Harris II of distal fibula Avulsion of distal fibula
r
Very Comfortable n = 540
Moderately Comfortable n = 540
Neither Comfortable/ Uncomfortable n = 540
Moderately Uncomfortable n = 540
Very Uncomfortable n = 540
300 (55.6) 114 (21.1)
131 (24.2) 191 (35.4)
44 (8.1) 74 (13.7)
42 (7.8) 123 (22.8)
23 (4.3) 38 (7.0)
53 (9.8)
118 (21.9)
74 (13.7)
221 (40.9)
72 (13.3)
258 (47.8) 161 (29.8) 244 (45.2)
155 (28.7) 161 (29.8) 138 (25.6)
57 (10.6) 72 (13.3) 65 (12.0)
53 (9.8) 110 (20.3) 67 (12.4)
22 (4.1) 36 (6.7) 27 (5.0)
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TABLE 4. Reported Barriers to the Use of Removable Devices n (%) What Barriers do You Distal Radius Face in Applying Fractures (Buckle, Distal Fibular Removable Devices Minimally Displaced Fractures for These Fractures? Greenstick/ (Nondisplaced Salter(Check All That Transverse) Harris I, II, Avulsion) Apply) n = 540 n = 540 Concerned about patient compliance Concerned about potential complications Medicolegal implications Cost/reimbursement issues Do not feel evidence is strong enough Lack of availability of commercial devices in my practice Orthopaedic colleagues do not support this treatment choice These do not apply to me, I prefer to use these devices in these cases
376 (69.6)
295 (54.6)
251 (46.5)
142 (26.3)
114 (21.1)
89 (16.4)
81 (15.0)
80 (14.5)
68 (12.6)
53 (9.8)
59 (10.9)
52 (9.6)
36 (6.6)
29 (5.4)
79 (14.6)
119 (22.0)
exception of transverse distal radius fractures) with removable splints. The most commonly reported perceived barriers to application of a removable device were concerns about patient compliance, potential complications, and medicolegal implications. In 2003, Plint et al23 reported that 12% of Canadian pediatric orthopaedic surgeons managed distal radius buckle fractures with a removable splint, and our results demonstrate that this has now increased to 55% in Canada and 27% in the United States, supporting some uptake of the evidence for this injury. In 2010, a randomized control trial demonstrated the cost-effectiveness of a removal splint versus cast for minimally displaced greenstick/transverse fractures,3,15 however, only 6% of POSNA members reported using splint treatment for these injuries. Further, about 40% of pediatric orthopaedic surgeons treat minimally displaced transverse fractures using a long arm circumferential
Volume 35, Number 1, January 2015
cast, despite level I evidence that demonstrates that there is no difference between long and short arm casts with respect to important clinical outcomes in the treatment of unstable distal radius fractures.24 Consistent with the current evidence that demonstrates that reduction has no clinical benefit over remodeling in minimally displaced distal radius fractures,25,26 95% of pediatric orthopaedic surgeons would not reduce minimally displaced distal radius fractures to anatomic alignment before immobilization. Use of removable devices to treat stable, low-risk distal fibular fractures2 is relatively low among pediatric orthopaedic surgeons. There are very little data in the literature about the use of immobilization strategies for these injuries by orthopaedic surgeons. In 2008, Dowling and Wishart27 reported that approximately 85% of emergency physicians immobilize Salter-Harris I fractures of the distal fibula with fiberglass/plaster immobilization and refer these to an orthopaedic surgeon. Our data demonstrate that about 90% of POSNA respondents prefer to use below knee immobilization with a cast or commercial boot for this injury. Similarly, about 95% treat Salter-Harris II fractures of the distal fibula with a strategy that immobilizes the ankle for 3 to 6 weeks. The use of a removable device was greatest for distal fibular avulsion fractures although still relatively low at about 20%. In this study, most orthopaedic surgeons reported that they consider these distal radius and fibular fractures at relatively low risk for future important short-term and long-term complications. Further, most would feel at least moderately comfortable managing these injuries with removable devices. Canadian pediatric surgeons were significantly more concerned about cost/reimbursement issues of these devices for their patients relative to surgeons in the United States. American orthopaedic surgeons were relatively more concerned about patient compliance, which may explain why Canadian orthopaedic surgeons have adopted removable devices more frequently than their American colleagues for distal radius fractures. Other issues to consider may include the availability of prefabricated commercial splints, and/or patient factors that may result in a preference for cast placement. This research is subject to the usual limitations of self-administered surveys. One issue with this survey’s results is the potential for self-selection bias. However, our response rate of 68% exceeds other similar published
TABLE 5. Potential for Complications for Specific Fractures Reported by Pediatric Orthopaedic Surgeons n (%) Fracture Type
Very Low n = 543
Distal radius buckle Minimally displaced greenstick of distal radius Minimally displaced transverse of distal radius Salter-Harris I of distal fibula Salter-Harris II of distal fibula Avulsion of distal fibula
448 161 101 438 256 442
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(82.5) (29.7) (18.6) (80.7) (47.2) (81.4)
Low n = 543 91 282 278 97 228 100
(16.8) (51.9) (51.2) (17.9) (42.0) (18.4)
Moderate n = 543
High n = 543
Very High n = 543
4 100 149 50 59 1
0 0 14 (2.6) 0 0 0
0 0 1 (0.2) 0 0 0
(0.7) (18.4) (27.4) (9.2) (9.2) (0.2)
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J Pediatr Orthop
Volume 35, Number 1, January 2015
physician surveys (53% to 54%),28–30 respondents represented a wide geographic area in the United States and Canada, and nonrespondent/nonsampled surgeons working in the same clinic/institution are more likely to be similar than different from each other in their practices.28–31 It is difficult to separate out what respondents actually do versus what they say they do. Finally, because the respondents in this survey are based in Canada and the United States the extent to which these results can be generalized to our colleagues in other countries is uncertain. Although surgeons’ beliefs about the excellent prognosis for these fractures is consistent with the evidence that supports the use of removable devices for these injuries, the majority of pediatric orthopaedic surgeons treat low-risk distal radius and fibular fractures with circumferential casts. Perceived barriers and important clinical outcomes derived from this survey can be incorporated into future research that introduces knowledge translation strategies (eg, education) targeted at all the stakeholders to provide health care efficient, safe, and more convenient strategies for these common injuries. REFERENCES 1. Plint AC, Perry JJ, Correll R, et al. A randomized, controlled trial of removable splinting versus casting for wrist buckle fractures in children. Pediatrics. 2006;117:691–697. 2. Boutis K, Willan AR, Babyn P, et al. A randomized, controlled trial of a removable brace versus casting in children with low risk ankle fractures. Pediatrics. 2007;119:e1256–e1263. 3. Boutis K, Willan A, Babyn P, et al. A randomized controlled trial of cast versus wrist splint in children with acceptably angulated wrist fractures. CMAJ. 2010;182:1507–1512. 4. Carmichael KD, Westmoreland J. Effectiveness of ear protection in reducing anxiety during cast removal in children. Am J Orthop. 2005;34:43–46. 5. Katz K, Fogelman R, Attias J, et al. Anxiety reaction in children during removal of their plaster cast with a saw. J Bone Joint Surg Br. 2001;83:388–390. 6. Liu RW, Mehta P, Fortuna S, et al. A randomized prospective study of music therapy for reducing anxiety during cast room procedures. J Pediatr Orthop. 2007;27:831–833. 7. Boyd AS, Benjamin HJ, Asplund C. Principles of casting and splinting. Am Fam Physician. 2009;79:16–22. 8. Barnett PL, Lee MH, Oh L, et al. Functional outcome after airstirrup ankle brace or fiberglass backslab for pediatric low-risk ankle fractures: a randomized observer-blinded controlled trial. Pediatr Emerg Care. 2012;28:745–749. 9. Davidson JS, Brown DJ, Barnes SN, et al. Simple treatment for torus fractures of the distal radius. J Bone Joint Surg. 2001;83B:1173–1175. 10. Firmin F, Crouch R. Splinting versus casting of “torus” fractures to the distal radius in the paediatric patient presenting at the emergency department (ED): a literature review. Int Emerg Nurs. 2009;17: 173–178.
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2014 Lippincott Williams & Wilkins
Common Fractures POSNA Survey
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