Pediatric Hand Fracture Outcomes: How Often Do We Need to Operate?

Purpose: Pediatric hand fractures are frequent presentations to the emergency department. This study set out to evaluate the epidemiology, management, and outcomes, where care was imparted and by whom, and offer resource utilization suggestions regarding pediatric fractures presenting to a Canadian pediatric hospital. Methods: Records of patients from 0 to 18 years of age who presented to the British Columbia Children's Hospital Emergency Department between November 1, 2016, and January 31, 2021, with metacarpal or phalangeal fractures were analyzed. Results: A total of 524 hand fractures were identified in 499 patients. Over 60% of fractures occurred in boys. The number of fractures peaked at the age of 11 years for girls and 12 years for boys. Open fractures accounted for only 4.0% of all fractures. Approximately 40% of fractures were epiphyseal growth plate fractures, with Salter-Harris II fractures being the most common diagnosis overall. Management was primarily nonsurgical, with 75% of fractures managed with immobilization alone and 23% of fractures managed with bedside closed reduction and immobilization. Of the fractures requiring closed reduction, the majority were performed by the emergency physician with a success rate of 82%. Only 2.3% of all fractures required surgery. Conclusions: Hand fractures are common pediatric injuries and make up a large proportion of emergency room visits. The majority of fractures do not require formal surgery and are well managed with immobilization alone or closed reduction by an emergency room physician and immobilization. Nonsurgical treatment offers very encouraging outcomes. A certain percentage of these simple fractures would likely benefit from primary care management alone and not require specialist intervention.

Objectif : Les fractures de main de l'enfant sont des situations fréquemment rencontrées dans les services d'urgence. Cette étude a été menée pour évaluer l'épidémiologie, la gestion et les résultats, où les soins ont été transmis et par qui, et pour offrir des suggestions d'utilisation des ressources concernant les fractures pédiatriques arrivant dans un hôpital canadien pour enfants. Méthodes : Les dossiers des patients âgés de 0 à 18 ans arrivés au service des urgences de l'hôpital pour enfants de Colombie-Britannique avec une fracture métacarpienne ou phalangienne entre le 1er nov. 2016 et le 31 janvier 2021 ont été analysés. Résultats : Un total de 524 fractures de la main a été identifié chez 499 patients. Plus de 60 % des fractures concernaient des garçons. Le nombre de fractures était maximum à l'âge de 11 ans pour les filles et de 12 ans pour les garçons. Les fractures ouvertes représentaient seulement 4,0 % de toutes les fractures. Approximativement 40 % des fractures concernaient la plaque de croissance épiphysaire avec les fractures Salter-Harris II constituant globalement le diagnostic le plus fréquent. La gestion a été principalement non chirurgicale : 75 % des fractures ont été gérées par immobilisation seule et 23 % des fractures ont été gérées par réduction fermée au chevet des patients et immobilisation. La majorité des réductions fermées pour fracture a été réalisée par le médecin des urgences avec un taux de succès de 82 %. Seulement 2,3 % de toutes les fractures ont nécessité une intervention chirurgicale. Conclusions : Les fractures de la main sont des blessures pédiatriques fréquentes et constituent une proportion importante des visites aux urgences. La majorité des fractures ne nécessite pas de chirurgie et est bien gérée avec seulement une immobilisation ou une réduction fermée suivie d'une immobilisation par le médecin des urgences. Le traitement non chirurgical obtient des résultats très encourageants. Un certain pourcentage de ces fractures simples relèverait probablement d'une gestion en soins primaires uniquement et ne nécessitent pas l'intervention d'un spécialiste.

Prospective Validation of the Calgary Kids' Hand Rule: A Clinical Prediction Rule for Pediatric Hand Fracture Triage.

Introduction: Pediatric hand fractures are common and routinely referred to surgeons, yet most heal well without surgical intervention. This trend inspired the development of the Calgary Kids' Hand Rule (CKHR), a clinical prediction rule designed to predict "complex" fractures that require surgical referral. The CKHR was adapted into a checklist whereby the presence of any 1 of 6 clinically or radiologically identifiable fracture characteristics predicts a complex fracture. The aim of this study was to assess the accuracy of the CKHR in a prospective sample of children with hand fractures. Methods: Physicians were asked to complete the CKHR checklist when referring pediatric patients (< 18 years) to hand surgeons at a Canadian pediatric hospital (April 2019-September 2020). Completed checklists represented predicted outcomes and were compared to observed outcomes (determined via chart review). Predictive accuracy (primary outcome) was evaluated based on sensitivity and specificity. Secondary outcomes were interrater reliability between referring physicians and surgeons, and survey assessment of CKHR user satisfaction. Results: In total 365 fractures were included, with only 16 requiring surgical intervention. Overall performance of the CKHR was good with 84% sensitivity and 71% specificity. Percent agreement between referring physicians and surgeons ranged from 84.1% to 96.3% on individual predictors, with 78.1% agreement on the presence of any predictors. Survey results showed general user satisfaction but also identified areas for improvement. Conclusion: This study posits the CKHR as an accurate and clinically useful prediction rule and highlights the importance of education for its effective use and eventual scale and spread.

Introduction : Les fractures pédiatriques de la main sont fréquentes et régulièrement orientées vers les chirurgiens. Néanmoins, la plupart guérissent bien sans intervention chirurgicale. Cette tendance a inspiré l'élaboration de la Calgary Kids' Hand Rule (CKHR), un outil de prédiction clinique conçu pour prédire quelles fractures « complexes ¼ doivent être orientées vers un chirurgien. La CKHR a été adaptée sous forme de liste de contrôle où la présence de l'une quelconque de six caractéristiques cliniques ou radiologiques identifiables de fracture permet de conclure à une fracture complexe. Le but de cette étude était d'évaluer l'exactitude de la CKHR dans un échantillon prospectif d'enfants ayant une fracture de la main. Methodes : Les médecins ont été invités à remplir la liste de contrôle CKHR quand ils orientaient des patients pédiatriques (< 18 ans) à des chirurgiens de la main dans un hôpital pédiatrique canadien (avril 2019 à septembre 2020). Les listes de contrôle remplies représentaient les aboutissements prédits et elles ont été comparées aux aboutissements observés (établis par une revue des dossiers). La précision de la prédiction (critère d'évaluation principal) a été évaluée en termes de sensibilité et de spécificité. Les critères d'évaluation secondaires étaient la fiabilité inter-évaluateurs entre médecins référents et chirurgiens et l'évaluation de la satisfaction de l'utilisateur de la CKHR dans le cadre d'une enquête. Résultats : Au total, 365 fractures ont été incluses; seulement 16 d'entre elles ont nécessité une intervention chirurgicale. La performance globale de la CKHR a été bonne avec une sensibilité de 84% et une spécificité de 71%. Le pourcentage de concordance entre médecins référents et chirurgiens était compris entre 84,1% et 96,3% selon les éléments prédictifs individuels, avec une concordance de 78,1% sur la présence de l'un quelconque des éléments prédictifs. Les résultats de l'enquête ont montré une satisfaction globale des utilisateurs, mais ont aussi mis en évidence des domaines à améliorer. Conclusion : Cette étude assoit la CKHR comme règle de prédiction exacte et cliniquement utile; elle souligne aussi l'importance de l'éducation pour son utilisation efficace et une éventuelle plus grande diffusion.

Derivation and Internal Validation of a Prediction Model for Pediatric Hand Fracture Triage.

BACKGROUND: Pediatric hand fractures are common, and most can be managed by a period of immobilization. However, it remains challenging to identify those more complex fractures requiring the expertise of a hand surgeon to ensure a good outcome. The purpose of this study was to develop a prediction model for identification of complex pediatric hand fractures requiring care by a hand surgeon. METHODS: A 2-year retrospective cohort study of consecutively referred pediatric (<18 years) hand fracture patients was used to derive and internally validate a prediction model for identification of complex fractures requiring the expertise of a hand surgeon. These complex fractures were defined as those that required surgery, closed reduction, or four or more appointments with a hand surgeon. The model, derived by multivariable logistic regression analysis, was internally validated using bootstrapping and then translated into a risk index. RESULTS: Of 1170 fractures, 416 (35.6%) met criteria for a complex fracture. Multivariable regression analysis identified six significant predictors of complex fracture: open fracture, rotational deformity, angulation, condylar involvement, dislocation or subluxation, and displacement. Internal validation demonstrated good performance of the model (C-statistic = 0.88, calibration curve p = 0.935). A threshold of ≥1 point (ie, any one of the predictors) resulted in a simple, easy-to-use tool with 96.4% sensitivity and 45.5% specificity. CONCLUSIONS: A high-performing and clinically useful decision support tool was developed for emergency and urgent care physicians providing initial assessment for children with hand fractures. This tool will provide the basis for development of a clinical care pathway for pediatric hand fractures.

Estimated GFR and Incidence of Major Surgery: A Population-Based Cohort Study.

RATIONALE & OBJECTIVE: Kidney disease is associated with an increased risk for postoperative morbidity and mortality. However, the incidence of major surgery on a population level is unknown. We aimed to determine the incidence of major surgery by level of kidney function. STUDY DESIGN: Retrospective cohort study with entry from January 1, 2008, through December 31, 2009, and outcome surveillance from January 1, 2010, through December 31, 2016. SETTING & PARTICIPANTS: Population-based study using administrative health data from Alberta, Canada; adults with an outpatient serum creatinine measurement or receiving maintenance dialysis formed the study cohort. EXPOSURE: Participants were categorized into 6 estimated glomerular filtration rate (eGFR) categories: ≥60 (G1-G2), 45 to 59 (G3a), 30 to 44 (G3b), 15 to 29 (G4), and<15mL/min/1.73m2 with (G5D) and without (G5) dialysis. eGFR was examined as a time-varying exposure based on means of measurements within 3-month ascertainment periods throughout the study period. OUTCOME: Major surgery defined as surgery requiring admission to the hospital for at least 24 hours. ANALYTICAL APPROACH: Incidence rates (IRs) for overall major surgery were estimated using quasi-Poisson regression and adjusted for age, sex, income, location of residence, albuminuria, and Charlson comorbid conditions. Age- and sex-stratified IRs of 13 surgery subtypes were also estimated. RESULTS: 1,455,512 cohort participants were followed up for a median of 7.0 (IQR, 5.3) years, during which time 241,989 (16.6%) underwent a major surgery. Age and sex modified the relationship between eGFR and incidence of surgery. Men younger than 65 years receiving maintenance dialysis experienced the highest rates of major surgery, with an adjusted IR of 243.8 (95% CI, 179.8-330.6) per 1,000 person-years. There was a consistent trend of increasing surgery rates at lower eGFRs for most subtypes of surgery. LIMITATIONS: Outpatient preoperative serum creatinine measurement was necessary for inclusion and outpatient surgical procedures were not included. CONCLUSIONS: People with reduced eGFR have a significantly higher incidence of major surgery compared with those with normal eGFR, and age and sex modify this increased risk. This study informs our understanding of how surgical burden changes with differing levels of kidney function.

Surgical and Nonsurgical Pediatric Hand Fractures: A Cohort Study.

Pediatric hand fractures are common and approximately 10% require surgery. METHODS: This retrospective cohort study reports on hand fractures in a large pediatric population and identifies the characteristics and patterns of fractures that required surgical correction. A χ2 analysis was done to evaluate the association between individual fracture variables and surgery. The STROBE checklist was applied. RESULTS: One thousand one-hundred seventy-three hand fractures were reviewed. Peak age was 16 years for boys and 14 years for girls. Most fractures were closed (96.0%) and nonrotated (91.3%), and had no concomitant soft tissue injury (72.7%). More than half (56.3%) were nonepiphyseal plate fractures; yet as a single diagnosis, Salter-Harris II fractures were most common (30.2%). The following variables were significantly associated with surgery: open fractures, rotational deformity, distal phalangeal fracture location, multiple fractures, oblique pattern, comminution, displacement >2 mm, intra-articular involvement, and angulation >15°. Most fractures required only immobilization and early range of motion (64.3%). Closed reduction was required in 22.7%. Minor surgery by the primary provider was performed in 3.2% of fractures. Surgery by a hand surgeon was performed in 9.8%. The most common patterns requiring surgery were proximal or middle phalanx head or neck fractures (38.2%) and metacarpal midshaft fractures (20.9%). The most common operation was open reduction internal fixation (52.2%). CONCLUSIONS: Pediatric hand fractures are common, but 90.2% do not require surgery and, as such, primary providers play a key role in management. Certain fracture variables and patterns are more likely to lead to surgery.

Pediatric Hand Fracture Referring Practices: A Scoping Review.

BACKGROUND: Pediatric hand fractures are common, but few require surgery; therefore, these fractures are often perceived to be overreferred. Our objective is to systematically identify and describe pediatric hand fracture referring practices. METHOD: A scoping review was performed, searching electronic databases and grey literature up to January 2018 to identify referring practices for children (17 years and younger) with hand fractures (defined as radiographically confirmed fractures distal to the carpus) to hand surgeons. All study designs were included, and study selection and data extraction were independently performed in duplicate by 2 reviewers. Outcomes included referring rates, necessity of referral, referring criteria, and management of fractures. RESULTS: Twenty (10 cross-sectional, 7 prospective cohorts, and 3 narrative reviews) studies reporting on referring practices or management of 21,624 pediatric hand fractures were included. Proportion of pediatric hand fractures referred to hand surgeons ranged from 6.5% to 100%. Unnecessary referral, defined as those fractures within the scope of primary care management, ranged from 27% to 78.1%. Ten studies reported referring criteria, with 14 unique criteria identified. The most common referring criteria were displacement (36.4%), loss of joint congruity (36.4%), and instability (36.4%). The most common justification for these criteria was increased likelihood of requiring surgery. The most common initial management was immobilization (66%-100%). Final management was provided by orthopedic or plastic hand surgeons with 0% to 32.9% of fractures requiring surgery. CONCLUSION: Referring practices vary widely in the literature. Major gaps in the literature include objective measures and justification for referring criteria and primary care education on hand fracture referring practices.

HISTORIQUE: Les fractures de la main sont courantes en pédiatrie, mais rares sont celles qui exigent une opération. C'est pourquoi on a souvent l'impression qu'elles sont trop envoyées en consultation. Les chercheurs avaient comme objectif de déterminer et de décrire systématiquement les pratiques de consultation à cause d'une fracture de la main en pédiatrie. MÉTHODOLOGIE: En janvier 2018, dans le cadre d'une analyse exploratoire, les chercheurs ont fouillé les bases de données électroniques et la documentation parallèle pour déterminer les pratiques de consultation de chirurgiens de la main pour les enfants (de 17 ans et moins) victimes de fractures de la main (définies comme des fractures de la partie distale du carpe, confirmées par radiographie). Ils ont inclus toutes les méthodologies, et deux analystes ont chacun effectué toute l'extraction des données. Les résultats incluaient le taux, la nécessité et les critères de consultation ainsi que le traitement des fractures. RÉSULTATS: Les chercheurs ont inclus 20 études (dix transversales, sept cohortes prospectives, trois examens narratifs) sur les pratiques de consultation ou de prise en charge de 21,624 fractures de la main en pédiatrie. De 6,5 % à 100 % de ces fractures étaient envoyées en consultation à un chirurgien de la main. De 27 % à 78,1 % des consultations étaient inutiles, c'est-à-dire qu'elles pouvaient être traitées en soins primaires. Dix études faisaient état de critères de consultation, pour un total de 14 critères uniques. Ainsi, les principaux critères de consultation étaient un déplacement (36,4 %), la perte de la congruence articulaire (36,4 %) et l'instabilité (36,4 %). La principale justification de ces critères était une plus grande probabilité d'opération. L'immobilisation (66 % à 100 %) demeurait le traitement initial le plus courant. Un chirurgien orthopédique ou plastique de la main effectuait le traitement définitif, et de 0 % à 32,9 % des fractures devaient être opérées. CONCLUSION: Les publications font état de pratiques de consultation très variables. Elles comportent de grandes lacunes, soit l'objectivité des mesures, la justification des critères de consultation retenus et la formation en soins primaires sur les pratiques de consultation en cas de fracture de la main.

Preoperative predictors of poor acute postoperative pain control: a systematic review and meta-analysis.

OBJECTIVES: Inadequate postoperative pain control is common and is associated with poor clinical outcomes. This study aimed to identify preoperative predictors of poor postoperative pain control in adults undergoing inpatient surgery. DESIGN: Systematic review and meta-analysis DATA SOURCES: MEDLINE, Embase, CINAHL and PsycINFO were searched through October 2017. ELIGIBILITY CRITERIA: Studies in any language were included if they evaluated postoperative pain using a validated instrument in adults (≥18 years) and reported a measure of association between poor postoperative pain control (defined by study authors) and at least one preoperative predictor during the hospital stay. DATA EXTRACTION AND SYNTHESIS: Two reviewers screened articles, extracted data and assessed study quality. Measures of association for each preoperative predictor were pooled using random effects models. RESULTS: Thirty-three studies representing 53 362 patients were included in this review. Significant preoperative predictors of poor postoperative pain control included younger age (OR 1.18 [95% CI 1.05 to 1.32], number of studies, n=14), female sex (OR 1.29 [95% CI 1.17 to 1.43], n=20), smoking (OR 1.33 [95% CI 1.09 to 1.61], n=9), history of depressive symptoms (OR 1.71 [95% CI 1.32 to 2.22], n=8), history of anxiety symptoms (OR 1.22 [95% CI 1.09 to 1.36], n=10), sleep difficulties (OR 2.32 [95% CI 1.46 to 3.69], n=2), higher body mass index (OR 1.02 [95% CI 1.01 to 1.03], n=2), presence of preoperative pain (OR 1.21 [95% CI 1.10 to 1.32], n=13) and use of preoperative analgesia (OR 1.54 [95% CI 1.18 to 2.03], n=6). Pain catastrophising, American Society of Anesthesiologists status, chronic pain, marital status, socioeconomic status, education, surgical history, preoperative pressure pain tolerance and orthopaedic surgery (vs abdominal surgery) were not associated with increased odds of poor pain control. Study quality was generally high, although appropriate blinding of predictor during outcome ascertainment was often limited. CONCLUSIONS: Nine predictors of poor postoperative pain control were identified. These should be recognised as potentially important factors when developing discipline-specific clinical care pathways to improve pain outcomes and to guide future surgical pain research. PROSPERO REGISTRATION NUMBER: CRD42017080682.

Epidemiological analysis of pediatric burns in the Dominican Republic reveals a demographic profile at significant risk for electrical burns.

OBJECTIVE: Pediatric burns are preventable with legislative and infrastructural changes. Although retrospective audits of many low- and middle-income countries have aided preventative efforts, the epidemiological status of burns in the Caribbean is not known. This study characterizes pediatric burns in the Dominican Republic (DR) and compares these to age-matched North American records captured by the National Burn Repository. METHODS: A retrospective audit of 1600 patients admitted to the Unidad de Niños Quemados Dra. Thelma Rosario Hospital, the island's only major pediatric burn center, between January 2010 to March 2017 was performed. Epidemiological variables analyzed included age, gender, burn mechanism, year, month, city, admission duration, nationality, mortality, and %TBSA. RESULTS: Pediatric burn patients in the DR sustained larger burns (8.2% vs. 6.5% TBSA) and spent more days in the hospital (10 vs. 6 days). Females were overrepresented (M:F=1:1.5) and mortality amongst admitted patients was 4-fold higher (2.8% vs. 0.7%). Electrical burns were significantly overrepresented in DR (21%) compared to age-matched North American patients (2%). Although electrical burns were smaller (4% TBSA), compared to scald (14% TBSA), and flame (19% TBSA), these burns preferred hands and had a high mortality rate (3%). No significant seasonality in burn mechanisms were observed. Finally, we report geographical and age group differences in the distribution of burn mechanisms and highlight particularly vulnerable subpopulations. CONCLUSION: This investigation identifies a demographical profile where electrical burns account for a significant percentage of the burn population. This provides a basis for concentrating preventative efforts in vulnerable populations.

Breast cancer in transgender patients: A systematic review. Part 1: Male to female.

Male-to-Female (MtF) breast cancer events have been reported since 1968 however, MtF patients' risk of breast cancer remain unclear. Following PRISMA guidelines, electronic databases and grey literature were searched April 2018 to identify breast cancer events in MtF transgender persons. Screening and data extraction were independently performed in duplicate by two reviewers. Study quality was assessed using a component-based system. Qualitative analysis was performed on study characteristics, patient demographics, breast cancer characteristics, and breast cancer presentation and management. Eighteen articles met inclusion criteria representing 22 breast cancer events. Median age at breast cancer diagnosis was 51.5 years. The most common breast cancer type was adenocarcinomas (59.1%) and half of the breast cancers were hormone sensitive, with estrogen receptor positive status in 10 of 19 tested and progesterone receptor positive status in 5 of 14 tested. The most common presentation was breast lump (n = 6, 42.9%), two patients had palpable lymph nodes at presentation (14.3%), and six patients eventually developed metastases (42.9%). Seven patients had a recorded positive breast cancer family history and one was BRCA2 positive. Breast cancers were treated with mastectomies (simple, modified radical, and radical), wide local excision, lumpectomy, or were unclear. Four patients received hormone therapy (23.5%), two received radiation (11.8%), and seven received chemotherapy (41.2%). Breast cancer is present in MtF patients and commonly presents at a younger age with a palpable mass. Major gaps in the literature include lack of transgender population data and long term follow-up. This work highlights the need for screening recommendations.

Breast cancer in transgender patients: A systematic review. Part 2: Female to Male.

Transgender men or Female-to-Male (FtM) patients' risk of breast cancer and screening recommendations remain unclear. The objective of this study is to perform a systematic review of the literature and document all reported cases of FtM breast cancer as well as provide research recommendations. Following PRISMA guidelines, MEDLINE, ProQuest, PubMed, and Cochrane Database of Systematic Reviews were searched from inception until September 15, 2016. Screening and data extraction were performed in duplicate by two independent reviewers (RH and JS). Study quality was assessed using a component-based system. Study characteristics, patient demographics, breast cancer characteristics, presentation and management are reported. Eight articles met inclusion criteria representing 17 transgender men with breast cancer. Median age at diagnosis was 44.5 years. Breast cancer types included: 8 invasive ductal carcinomas, two tubular carcinomas and seven unrecorded. Twelve of the 14 known hormone status tumours were estrogen receptor positive (85.7%), of which nine were also progesterone positive. The most common was breast lump (n = 6) and four patients had local regional or distant disease at presentation. Management was reported for ten patients: six patients underwent mastectomy (60.0%), three radiation (30.0%), and five chemotherapy (50.0%). Breast cancer is present in transgender men and the risk is dependent on top surgery; those with top surgery appear to be lower risk than natal females. More longitudinal studies and better population data are required to contribute to evidence-based screening recommendations.