Variation Among Pediatric Hand Surgeons When Diagnosing and Treating Distal Radius Fractures
Karan Dua, MD1; Nathan N. O'Hara, MHA2; Joshua M. Abzug, MD3
1State University of New York, Downstate Medical Center, Brooklyn, NY; 2University of Maryland School of Medicine, Baltimore, MD; 3Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD
Introduction Distal radius fractures are the most common injury in the pediatric population, but radiographic examination and classification of these fractures are not standardized. A recent study found poor agreement among pediatric orthopaedic surgeons when diagnosing and treating these fractures. The authors predict substantial variation also exists among pediatric hand surgeons when diagnosing and treating pediatric distal radius fractures.
Materials and Methods Ten pediatric hand surgeons who commonly treat pediatric distal radius fractures at different institutions reviewed 100 sets of posteroanterior (PA) and lateral pediatric wrist radiographs. The surgeons were asked to complete a questionnaire describing the fractures, the type of treatment they would recommend and the recommended length of immobilization. Additionally, the surgeons were asked when the next follow-up visit would be scheduled for, and whether or not they would obtain new radiographs at the subsequent and final follow-up visits.
Kappa statistics were performed to assess the agreement amongst examiners with the chance agreement removed. Strength of agreement was determined based on guidelines outlined by Landis and Koch. Kappa values of <0.00 were considered poor agreement, 0.00 to 0.20 slight agreement, 0.21 to 0.40 fair agreement, 0.41 to 0.60 moderate agreement, 0.61 to 0.80 substantial agreement, and 0.81 to 1.00 almost perfect agreement.
Results Fair agreement was present when diagnosing and classifying the distal radius fractures (K = 0.312). Diagnoses included torus, greenstick, Salter-Harris II, and extra-physeal fractures. There was also only fair agreement regarding the type of treatment that would be recommended (K = .242) and slight agreement regarding the length of immobilization (K = .187).
Slight agreement was present regarding when the first follow-up visit should occur (K = .188), and fair agreement on whether or not new radiographs should be obtained at the first follow-up visit (K = .396), and if radiographs were necessary at the final follow-up visit (K = .368). Surgeons had slight agreement regarding stability of the fracture (K = .139).
Conclusion The inter-reliability among pediatric hand surgeons of diagnosing pediatric distal radius fractures showed only fair agreement. Both pediatric orthopaedic surgeons and hand surgeons have wide variation in the treatment of pediatric distal radius fractures. Better classification systems of pediatric distal radius fractures are needed that standardize the treatment of these injuries in order to provide the best health outcomes.
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