Variation Among Surgeons When Treating Medial Epicondyle Fractures
Meghan Hughes, MPH; University of Maryland School of Medicine, Balitmore, MD; Karan Dua, MD; State University of New York, Downstate Medical Center, Brooklyn, NY; Nathan N. O'Hara, MHA; University of Maryland School of Medicine, Baltimore, MD; Joshua M. Abzug, MD; Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD
Medial epicondyle fractures account for 11-20% of elbow fractures in the pediatric population. The relative indications for surgical intervention are currently evolving. This purpose of this study was to determine the variability among surgeons when treating pediatric and adolescent medial epicondyle fractures.
Materials and Methods
A discrete choice experiment was conducted to determine which patient and injury attributes influence the management of medial epicondyle fractures. An orthogonal and balanced fractional factorial design combined patient attributes and levels based on a Bayesian D-Optimal design. A convenience sample of 13 surgeons reviewed 60 case vignettes of medial epicondyle fractures that included anteroposterior and lateral elbow radiographs and patient/injury characteristics (gender, mechanism of injury, type of sport participation, and presence of concurrent elbow dislocation). Displacement was incorporated into the study model as a fixed effect. Surgeons were queried if they would treat the injury with immobilization alone or open reduction and internal fixation (ORIF). Statistical analysis was performed using a mixed effect regression model.
Surgeons also filled out a demographic questionnaire (age, gender, years in practice after fellowship, subspecialty, and frequency of being on-call) and a risk assessment (Jackson Personality Inventory Risk-taking Likert Subscale) to determine if these factors affected clinical decision-making.
Elbow dislocation and fracture displacement were the only attributes that significantly influenced surgeons to perform an operation (p < 0.05). The presence of an elbow dislocation had the largest impact on surgeons when choosing operative care (? = -0.14; p = 0.02). For every 1 mm increase in displacement, surgeons tended to favor ORIF by a factor of 0.09 (p < 0.01). ). Surgeons unanimously began favoring ORIF at 8.16 mm of displacement (95% CI: 2.05 – 14.1). Gender, mechanism of injury, and sport participation did not influence decision-making.
54% of the surgeons favored ORIF. Based on the personality Likert-scale, participants were neither high-risk takers nor extremely risk adverse with an average risk score of 2.24. Participant demographics did not influence clinical decision-making.
There is substantial variation among surgeons when treating medial epicondyle fractures. The decision to operate is significantly based on fracture displacement and the presence of an elbow dislocation. There is no standardization regarding how to treat medial epicondyle fractures in the pediatric and adolescent population. Treatment algorithms are needed in order to provide optimal patient outcomes with the least morbidity.
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