The Impact of Social Determinants of Health on the Treatment of Distal Radius Fracture.

BACKGROUND: Disparities in social determinants of health (SDH) have been shown to play an increasingly important role in the equitable delivery of health care. Distal radius fractures (DRFs) are among the most common upper-extremity injuries encountered. This study aims to examine the influence of economic, educational, social, environmental, and healthcare disparities on management of these injuries. METHODS: PearlDiver Mariner insurance claims database was analyzed for treatment patterns of DRF in patients aged 18 to 65 years based on the presence or absence of social determinants of health disparities (SDHDs). Outcome variables included the primary mode of management of DRF, including operative versus non-operative, as well as concomitant procedures. Multivariate logistic regression was used to compare fracture management modality in patients with and without SDHDs. RESULTS: Of 161 704 patients identified with DRF, 38.3% had at least 1 reported SDHD. The majority of SDHDs were economic. Patients identified with 1 or more SDHDs had a higher medical comorbidity index. Patients with environmental SDHD were more likely to receive non-operative management. Within any SDHD and economic subgroups, odds of operative management were higher. No relationship was identified between SDHD and concomitant procedures. CONCLUSIONS: The presence of environmental disparities in SDH may predispose patients disproportionately to non-operative management. The presence of SDHDs may influence medical decision-making in favor of open reduction and internal fixation in patients with DRF treated operatively. In treating at-risk populations, providers should be aware of the potential for implicit bias associated with SDHDs and prioritize shared decision-making between patients and physicians.

Posterolateral Rotatory Instability Develops Following the Modified Kocher Approach and Does Not Resolve Following Interval Repair.

BACKGROUND: The modified Kocher and extensor digitorum communis (EDC)-splitting intervals are commonly utilized to approach the lateral elbow. Iatrogenic injury to the lateral ulnar collateral ligament may result in posterolateral rotatory instability (PLRI). in the present cadaveric study, we (1) evaluated lateral elbow stability following the use of these approaches and (2) assessed the accuracy of static lateral elbow radiographs as a diagnostic tool for PLRI. METHODS: Ten matched-pair cadaveric upper-extremity specimens (n = 20) were randomly assigned to Kocher or EDC-splitting approaches. Specimens underwent evaluation pre-dissection, post-dissection, and following repair of the surgical interval. Clinical evaluation of lateral elbow stability was performed with the lateral pivot-shift maneuver. Radiographic radiocapitellar displacement was evaluated with the fully extended hanging arm test and on lateral elbow 30° flexion radiographs. Paired Wilcoxon signed-rank tests with Bonferroni correction were utilized to compare groups. RESULTS: All Kocher group specimens (10 of 10) developed PLRI on the pivot-shift maneuver following dissection. No EDC-splitting group specimens (0 of 10) developed instability with pivot-shift testing. The fully extended hanging arm test showed no difference in radiocapitellar displacement between groups (p > 0.008). Lateral elbow 30° flexion radiographs in the Kocher group showed an increased radiocapitellar displacement difference (mean, 8.46 mm) following dissection compared with the pre-dissection baseline (p < 0.008). Following repair of the Kocher interval, the radiocapitellar displacement (mean, 6.43 mm) remained greater than pre-dissection (mean, 2.26 mm; p < 0.008). In the EDC-splitting group, no differences were detected in radiocapitellar displacement on lateral elbow radiographs with either the fully extended hanging arm or lateral elbow 30° flexion positions. CONCLUSIONS: The Kocher approach produced PLRI that did not return to baseline conditions following repair of the surgical interval. The EDC-splitting approach did not cause elbow instability clinically or radiographically. The hanging arm test was not reliable for the detection of PLRI. CLINICAL RELEVANCE: The Kocher interval for lateral elbow exposure results in iatrogenic PLRI that is not detectable on the hanging arm test and that does not return to baseline stability following repair of the surgical interval.

Effect of Race and Geography on Patient- and Parent-Reported Quality of Life for Children With Congenital Upper Limb Differences.

PURPOSE: Patient beliefs about health and disability are shaped by many social factors and are a key determinant in their ultimate outcome. We hypothesized that pediatric and parent-reported outcome measures regarding a child's congenital upper limb difference will be affected by geographic location, parent education, sex, ethnicity, race, age, and presence of additional medical comorbidities. METHODS: Patients enrolled in the multicenter Congenital Upper Limb Difference registry were included. Age, sex, race, ethnicity, medical comorbidities, highest level of parental education, area deprivation index, and geographic region were recorded. Patient-Reported Outcomes Measurement Information System (PROMIS) in the pediatric and parent-reported domains of upper extremity, anxiety, pain interference, peer relationships, and depressive symptoms were collected. RESULTS: The only difference between geographic regions in the United States in pediatric and parent-reported PROMIS was that parents in the Midwest reported higher upper extremity function scores in children with upper limb differences than the West. Black patients demonstrated higher scores in parent and child-reported domains of depression, pain, and anxiety, and lower scores in upper extremity function than White and Asian peers. Additionally, children with medical comorbidities also demonstrated worse outcomes in multiple PROMIS domains. There was no difference in scores based on sex, parent education, and ethnicity. CONCLUSIONS: In children with congenital upper limb differences, race and additional medical comorbidities have an impact on patient- and parent-reported PROMIS outcome measures in multiple domains, with Black children and those with additional medical comorbidities scoring lower than their peers. CLINICAL RELEVANCE: As we strive to develop a health care system that provides equitable care to all patients, providers who care for children with upper limb differences should be aware that race and additional medical comorbidities can negatively affect patient- and parent-reported PROMIS outcome measures.

Poor Outcomes of Pediatric Acute Compartment Syndrome in the Setting of Extracorporeal Membrane Oxygenation: A Multicenter Case Series.

BACKGROUND: Acute compartment syndrome (ACS) is a well-described condition that merits emergent surgical decompression. Peripheral arterial cannulation can increase the likelihood of ACS in patients requiring extracorporeal membranous oxygen (ECMO). Comorbidities in these critically ill patients may portend negative consequences of decompressive fasciotomy. This study investigated the clinical short-term and mid-term outcomes in pediatric patients with ECMO-associated ACS. METHODS: This is a retrospective case series at 3 pediatric hospitals from 2006 to 2019, including children ages 0 to 19 years who underwent peripheral arterial cannulation and developed ACS. RESULTS: Eighteen patients developed ACS after receiving peripheral cannulation ECMO. Mean time to diagnosis after cannulation was 63.1 hours. All patients were diagnosed clinically; the most common findings were tight compartments, swelling, and loss of peripheral pulses. Eight patients (44%) died due to underlying illness. Treating physicians decided against decompression for 5 patients due to their underlying illness, instability, and concern for infection. Thirteen patients (72%) underwent decompressive fasciotomies. Ten surgical patients required subsequent surgeries and 6 (33%) developed surgical site infections. Of the 7 surviving surgical patients, 4 (57%) required extremity amputations and 4 had lower extremity neurological deficits on follow-up. Two of 3 nonsurgical patients (66%) had functional lower extremity motor deficits on follow-up. No surviving nonoperative patients developed infections or required amputations. CONCLUSIONS: ACS on ECMO is associated with high rates of complications including neurologic deficits, infection, and amputation. Patients treated nonoperatively avoided complications such as infection and amputation, but had more functional neurological deficits than surgical patients. Orthopaedic surgeons should consider the high morbidity of compartment release in these critically ill patients and, with critical care teams, assess whether the potential benefits of surgery outweigh expected risks. LEVEL OF EVIDENCE: Level IV.

Potential Sex Bias Exists in Orthopaedic Basic Science and Translational Research.

BACKGROUND: Potential sex bias has been shown in general surgery basic science and translational research, with unequal representation of male and female specimens. Because basic science research forms the foundation for clinical studies on which patient care is based, it is important that this research equally consider both sexes. The purpose of this study was to determine if potential sex bias exists in the basic science and translational orthopaedic literature. METHODS: A systematic review was conducted of all articles published in 2014 in The Journal of Bone & Joint Surgery, Clinical Orthopaedics and Related Research, The Bone & Joint Journal, and the Journal of Orthopaedic Research (JOR). All original research articles utilizing animals, cells, or cadavers were included. The data abstracted included study type, sex of specimen studied, and presence of sex-based reporting of data. A second review was performed of all basic science articles published in JOR in 1994, 2004, and 2014 to compare sex bias trends across 3 decades. Distributions of variables were compared using the Fisher exact test, with significance defined as p < 0.05. RESULTS: Of 1,693 articles reviewed, 250 (15%) were included: 122 animal-based studies (49%), 71 cell-based studies (28%), and 57 human cadaver-based studies (23%). Overall, authors in 88 studies (35%) did not report the sex of animals, cells, or cadavers used. Of 162 studies in which the authors did report sex, 69 (43%) utilized male only, 40 (25%) utilized female only, and 53 (33%) utilized both sexes. Of those studies that used both sexes, authors in only 7 studies (13%) reported sex-based results. A subanalysis of JOR articles across 3 decades revealed a significant increase in studies specifying sex (p = 0.01) from 2004 to 2014. CONCLUSIONS: Potential sex bias exists in orthopaedic surgery basic science and translational research, with an overrepresentation of male specimens. CLINICAL RELEVANCE: Inequality in sex representation must be addressed as basic science and translational research creates the foundation for subsequent clinical research, which ultimately informs clinical care.