ORIGINAL ARTICLE

The Inadequacy of Pediatric Fracture Care Information in Emergency Medicine and Pediatric Literature and Online Resources Kali Tileston, MD and Julius A. Bishop, MD

Background: Emergency medicine and pediatric physicians often provide initial pediatric fracture care. Therefore, basic knowledge of the various treatment options is essential. The purpose of this study was to determine the accuracy of information commonly available to these physicians in textbooks and online regarding the management of pediatric supracondylar humerus and femoral shaft fractures. Methods: The American Academy of Orthopaedic Surgeons Clinical Practice Guidelines for pediatric supracondylar humerus and femoral shaft fractures were used to assess the content of top selling emergency medicine and pediatric textbooks as well as the top returned Web sites after a Google search. Only guidelines that addressed initial patient management were included. Information provided in the texts was graded as consistent, inconsistent, or omitted. Results: Five emergency medicine textbooks, 4 pediatric textbooks, and 5 Web sites were assessed. Overall, these resources contained a mean 31.6% (SD = 32.5) complete and correct information, whereas 3.6 % of the information was incorrect or inconsistent, and 64.8% was omitted. Emergency medicine textbooks had a mean of 34.3% (SD = 28.3) correct and complete recommendations, 5.7% incorrect or incomplete recommendations, and 60% omissions. Pediatric textbooks were poor in addressing any of the American Academy of Orthopaedic Surgeons guidelines with an overall mean of 7.14% (SD = 18.9) complete and correct recommendations, a single incorrect/incomplete recommendation, and 91.1% omissions. Online resources had a mean of 48.6% (SD = 33.1) complete and correct recommendations, 5.72% incomplete or incorrect recommendations, and 45.7% omissions. Conclusions: This study highlights important deficiencies in resources available to pediatric and emergency medicine physicians seeking information on pediatric fracture management. Information in emergency medicine and pediatric textbooks as well as online is variable, with both inaccuracies and omissions being common. This lack of high-quality information could compromise patient care. Resources should be committed to ensuring accurate and complete information is readily available to all physicians providing pediatric fracture care. In addition, orthopaedic surgeons should take an active role to ensure that

From the Department of Orthopaedic Surgery, Stanford University, Redwood City, CA. None of the authors received financial support for this study. The authors declare no conflicts of interest. Reprints: Kali Tileston, MD, Department of Orthopaedic Surgery, Stanford University, 450 Broadway Street, Pavilion C, 4th Floor, Redwood City, CA 94063-6342. E-mail: [email protected] Copyright r 2014 Wolters Kluwer Health, Inc. All rights reserved.

J Pediatr Orthop



nonorthopaedic textbooks and online resources contain complete and accurate information. Level of Evidence: Level IV. Key Words: fracture care, education, Clinical Practice Guidelines, online resources (J Pediatr Orthop 2015;35:769–773)

E

mergency room physicians and pediatricians are commonly responsible for the initial evaluation and treatment of pediatric fracture patients. Although many pediatric fractures can be managed on an outpatient basis, some injuries require urgent or emergent evaluation and treatment. However, training in pediatric emergency medicine is variable, especially as it relates to orthopaedic care.1,2 For example, emergency medicine residents spend an average of 17 weeks performing pediatric care during their residency with only 23% of programs offering a specific pediatric orthopaedic rotation.3 Similarly, pediatric residency training only includes an average of 11 weeks of emergency care.4 The top 3 areas of weakness in pediatric training are cited as major trauma, minor trauma, and acute orthopaedic care.4 Simultaneously, there are ongoing challenges in providing injured children with urgent or emergent access to orthopaedic surgeons. Increasing numbers of patients are seeking emergency orthopaedic care, with children accounting for 25% to 35% of emergency room visits.3 Concurrently, there exists a shortage of orthopaedic surgeons available to cover emergency room call.5 Therefore, increasing pressure is placed on the emergency medicine and pediatric physicians to appropriately evaluate and treat orthopaedic injuries in children. In the setting of insufficient training in pediatric orthopaedics and the ongoing difficulty with obtaining pediatric orthopaedic call coverage, access to high-quality fracture care information in textbooks and online resources becomes increasingly important. The purpose of this study was to assess the quality of pediatric fracture care information in emergency medicine and pediatric textbooks and online resources.

METHODS The most commonly purchased emergency medicine (Textbook of Pediatric Emergency Medicine,6 The Atlas of

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Tileston and Bishop

Emergency Medicine,7 Rosen’s Emergency Medicine,8 Rosen & Barkin’s 5-Minute Emergency Medicine Consult,9 Tintinalli’s Emergency Medicine10) and pediatric textbooks (The Harriet Lane Handbook,11 CURRENT Diagnosis & Treatment: Pediatrics,12 Nelson Textbook of Pediatrics,13 Zitelli and Davis’ Atlas of Pediatric Physical Diagnosis14) from the medical bookstore at a quaternary care academic medical center along with 5 of the highest returned general medical Web sites on Google search (eORIF,15 MedScape,16 UpToDate,17 Wheeless’ Textbook of Orthopaedics,18 Wikipedia19) were evaluated for the completeness and accuracy of information relevant to the management of pediatric supracondylar and femoral shaft fractures. We excluded orthopaedic-specific Web sites as their information is aimed toward orthopaedic surgeons rather than the general medical population. Two reviewers (J.A.B., K.L.) examined the content of each resource and scored them, utilizing the American Academy of Orthopaedic Surgeons (AAOS) Clinical Practice Guidelines as a gold standard.20,21 These guidelines synthesize current evidence and expert opinion with the expressed goal of improving the diagnosis and treatment of various orthopaedic conditions.22 As the purpose of this study was to evaluate the quality of information available to nonorthopaedists, only guidelines that addressed the initial patient management were included in this study. Guidelines related to the technical aspects of surgery and postoperative care were excluded. The scores were based on the inclusion of the AAOS Clinical Practice Guidelines listed below. Supracondylar fracture guidelines20: (1) We suggest nonsurgical immobilization of the injured limb for patient with acute (eg, Gartland type I) or nondisplaced pediatric supracondylar fractures of the humerus or posterior fat pad sign. (2) We suggest closed reduction with pin fixation for patients with displaced (eg, Gartland types II and III and displaced flexion) pediatric supracondylar fractures of the humerus. (3) We are unable to recommend for or against a time threshold for reduction of displaced pediatric supracondylar fractures of the humerus without neurovascular injury. (4) In the absence of reliable evidence, the opinion of the work group is that emergent closed reduction of displaced pediatric supracondylar humerus fractures be performed in patients with decreased perfusion of the hand. Femoral shaft fracture guidelines21: (1) We recommend that children aged less than 36 months with a diaphyseal femur fracture be evaluated for child abuse. (2) Treatment with a Pavlik harness or a spica cast is an option for infants aged 6 months and younger with a diaphyseal femur fracture. (3) We suggest early spica casting for children aged 6 months to 5 years with a diaphyseal femur fracture with 2 cm of shortening. (5) We are unable to recommend for or against patient weight as a criterion for the use of spica casting in children aged 6 months to 5 years with a diaphyseal femur fracture. (6) It is an option for physicians to use flexible intramedullary nailing to treat children aged 5 to 11 years diagnosed with diaphyseal femur fractures. (7) Rigid trochanteric entry nailing, submuscular plating, and flexible intramedullary nails are treatment options for children aged 11 years to skeletal maturity with diaphyseal femur fractures, but piriformis or near-piriformis entry rigid nailing is not a treatment option. Information provided in the texts and Web sites was graded as Complete/Correct (C), Incorrect/Inconsistent (I), or Omitted (O). Incorrect or inconsistent information was defined as information that contradicted the AAOS Clinical Guidelines. Examples include contradictory information about the urgent or emergent nature of a problem or about the appropriate treatment strategy for a patient of a particular age. Omissions were identified if no mention of a particular guideline was present in the text. Each reference was reviewed independently. Any discrepancy was discussed among reviewers and a consensus reached.

RESULTS The scope and accuracy of the information in each textbook and Web site is summarized in Table 1. Overall, these resources contained a mean 31.6% (SD = 32.5) complete and correct information, whereas 3.6 % of the information was incorrect or inconsistent, and 64.8% was omitted. Emergency medicine textbooks had a mean of 34.3% (SD = 28.3) correct and complete recommendations, 5.7% incorrect or incomplete recommendations, and 60% omissions. They appropriately addressed a mean of 60% (SD = 1.22) of the guidelines for pediatric supracondylar humerus fractures while only addressing a mean of 8.58% (SD = 11.4) of guidelines for pediatric diaphyseal femur fractures. Pediatric textbooks were poor in addressing any of the AAOS guidelines with an overall mean of 7.14% (SD = 18.9) complete and correct recommendations. There were no complete and correct recommendations for pediatric supracondylar humerus fractures and a mean 14.3% (SD = 24.7) complete and correct recommendations for pediatric diaphyseal femur fractures. Only 1 pediatric textbook addressed any of the AAOS guidelines. There was 1 incorrect/incomplete recommendation, resulting in a mean 91.1% omissions of the information contained in the AAOS guidelines from pediatric textbooks. Online resources had a mean of 48.6% (SD = 33.1) complete and correct recommendations, 5.72% incomplete or incorrect recommendations, and 45.7% omissions. There was a mean 40% (SD = 33.9) and 57.1% (SD = 30) correct and complete recommendations in regards to supracondylar Copyright

r

2014 Wolters Kluwer Health, Inc. All rights reserved.

Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.

Copyright

r

2014 Wolters Kluwer Health, Inc. All rights reserved. O C 3/4 (75) I O O O O O O

O

O

(50)

C

I

C I

O

I O 0/7 (0)

C

C

(28.6)

C

C

C

O

O

C

0/7 (0)

O O

O

O O

O

O

O O

O

O O

O

O

2/4 (50)

C

O

C

O

1/7 (14.3) 0/7 (0)

O O

O

O O

O

C

3/4 (75) 2/4 (50)

C

O

C

C

0/7 (0)

O O

O

O O

O

O

0/4 (0)

O

O

O

O

O

O

O

O

C C

O

C O

I

C

0/7 (0) 4/7 (57.1)

O O

O

O O

O

O

0/4 (0) 0/4 (0)

O

O

O

O

0/7 (0)

O O

O

O O

O

O

0/4 (0)

O

O

O

O

C C

O

C I

I

C

3/4 (75)

O

C

C

C

C C

O

C C

C

C

3/4 (75)

C

O

C

C

C C

O

C C

I

C

2/4 (50)

O

O

C

C

5/7 (71.4) 4/7 (57.1) 6/7 (85.7) 5/7 (71.4)

C C

O

C I

C

C

0/4 (0)

O

O

O

O

eORIF

0/7 (0)

O O

O

O O

O

O

0/4 (0)

O

O

O

O

Wikipedia

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C indicates correct; I, incorrect/incomplete; O, omitted.

Supracondylar humerus fractures (1) Nonsurgical immobilization type I (2) Surgical treatment type II/III (3) No recommendation for reduction without N/V injury (4) Emergent closed reduction if vascular compromise Correct/[present+omitted] 2/4 (%) Femoral shaft fractures (1) Evaluate for child abuse if

The Inadequacy of Pediatric Fracture Care Information in Emergency Medicine and Pediatric Literature and Online Resources.

Emergency medicine and pediatric physicians often provide initial pediatric fracture care. Therefore, basic knowledge of the various treatment options...
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