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Study: Research supports less aggressive treatment for pediatric upper extremity fractures
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An analysis of research presented at the Pediatric Orthopaedic Society of North America and the American Academy of Orthopaedic Surgeons across 2 decades revealed recommendations for less aggressive treatments of pediatric upper extremity fractures, despite a trend toward more operative treatments.
“Even though clinical research has consistently favored less aggressive treatments over the past 20 years, it has not altered the trend toward more operative treatments,” Emily A. Eismann, MS, and colleagues wrote in the study. “This divergence between research and practice must be explored in our efforts to improve the quality, safety and value of the care that we provide to our pediatric patients.”
Eismann and colleagues analyzed the abstracts from the two annual meetings from 1993 until 2012, taking note of presentations that were more aggressive, less aggressive or neutral through an analysis by two surgeons, according to the abstract. Using Spearman correlations, the researchers examined differences in levels of evidence, treatment recommendations and fracture location.
Researchers found 47% of abstracts suggested less aggressive treatment, while 27% of abstracts recommended neutral action, according to the abstract. More aggressive treatment was recommended in 24% of studies with operative treatment and 11% of studies with nonoperative treatment.
Case studies recommended aggressive treatment more often than comparative studies, and studies with fewer patients recommended aggressive treatment more often than studies with a larger patient group. Overall, 91% of level I and level II, 81% of level III and 70% of level IV studies recommended less aggressive or neutral treatments, according to the abstract.
Disclosure: The authors have no relevant financial disclosures.
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Shital N. Parikh, MD, FACS
The study by Eismann and colleagues reinforces the logical thinking that several factors, besides clinical research, affect medical practice and physician preferences.
Despite increasing clinical research with more than 40 orthopedic journals and more than 45,000 orthopedic publications in the last 10 years, it may be a difficult, confusing and complex exercise to identify the best available evidence to support clinical practice. This could be seen in the 2011 American Academy of Orthopaedic Surgeons Clinical Practice Guideline on management of supracondylar fracture of the distal humerus in children, wherein 8 of 14 treatment recommendations based on existing literature were inconclusive due to lack of strong evidence. It is imperative for a physician to consider the level of evidence when analyzing the research literature as more than 80% of level IV case series, in the current study, recommended more aggressive treatment and 91% of level I or level II prospective randomized controlled trials recommended less aggressive or neutral treatment for pediatric upper extremity fractures.
Even when high level evidence favoring certain form of treatment is identified, there may be several impediments to its application into clinical practice. These factors include surgeon training and bias, family expectations, patient factors, financial implications and incentives, resources or lack thereof, social situation and treatment convenience. Also, with more emphasis on surgeons’ quality of life and restricted work hours, the newer generation of orthopedic surgeons may find it more valuable to “fix” things rather than “waste” time in casting and close follow-up. Without a regulatory body to oversee the clinical practice, it is up to the surgeon to decide on the most appropriate treatment for their patient, taking into consideration the best available evidence and the feasibility of its application in practice.
Reference:
http://www.aaos.org/research/guidelines/SupracondylarFracture/SupracondylarFracture_Guideline.asp
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Jeffrey R. Sawyer, MD
Although early operative treatment of pediatric upper extremity fractures, especially forearm fractures, is widely accepted as standard practice, this review of abstracts presented over the past 20 years at Pediatric Orthopaedic Society of North America or the American Academy of Orthopaedic Surgeons annual meetings found 74% recommended treatment that was less aggressive than (47%) or similar to (27%) that recommended in a well-known fracture text (Rockwood and Wilkins’ Fractures in Children). Also, they found only 24% of operative studies recommended more aggressive treatment.
This large body of evidence supporting less aggressive treatment has not produced a change in practice patterns, which may be attributable to several factors. The treatment chosen involves a complex interplay among numerous factors, including the social situation of the patient, parental and patient expectations, and the surgeon’s education/expertise. For certain patients and families, early surgery, considered more aggressive in this study, may in fact be less aggressive in terms of need for follow-up (physician visits, travel and radiographs) and time away from school and work. Additionally, with an increased volume of upper extremity surgery, younger surgeons may not be as comfortable with less aggressive (closed) treatment. These factors, as well as others yet to be identified, may explain the dichotomy between the scientific evidence and the practice patterns observed in the treatment of pediatric upper extremity fractures.
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