to a primary care provider (PCP) for follow-up of a distal radius buckle fracture who subsequently did not deviate from this reassessment strategy.

Transcription

1 Primary Care Physician Follow-up of Distal Radius Buckle Fractures Eric Koelink, MD, a Suzanne Schuh, MD, b Andrew Howard, MD, MSc, c Jennifer Stimec, MD, c Lorena Barra, MD, d Kathy Boutis, MD, MSc b OBJECTIVES: Our main objective was to determine the proportion of children referred to a primary care provider (PCP) for follow-up of a distal radius buckle fracture who subsequently did not deviate from this reassessment strategy. METHODS: This prospective cohort study was conducted at a tertiary care pediatric emergency department (ED). Eligible children were aged 2 to 17 years with a distal radius buckle fracture treated with a removable splint and referred to the PCP for reassessment. We telephoned families 28 days after their ED visit. The primary outcome was the proportion who received PCP follow-up exclusively. We also measured the proportion who received PCP anticipatory guidance and those children who reported returning to usual activities always by 4 weeks. RESULTS: We enrolled 200 children, and 180 (90.0%) received telephone follow-up. Of these, 157 (87.2% [95% confidence interval: 82.3 to 92.1]) received PCP follow-up exclusively. Specifically, 11 (6.1%) families opted out of physician follow-up, 5 (2.8%) self-referred to an ED, and the PCP requested specialty consultation in 7 (3.9%) cases. Of the 164 with a PCP visit, 77 (47.0%) parents received anticipatory guidance on return to activities for their child, and 162 (98.8%) reported return to usual activities within 4 weeks. CONCLUSIONS: The vast majority of children with distal radius buckle fractures presented to the PCP for follow-up and did not receive additional orthopedic surgeon or ED consultations. Despite a suboptimal rate of PCP advice on return to activities, almost all parents reported full return to usual activities within 4 weeks. abstract a Division of Emergency Medicine, Department of Pediatrics, McMaster University Medical Centre and McMaster University, Hamilton, Ontario, Canada; b Division of Emergency Medicine, Department of Pediatrics, c Division of Orthopedics, Department of Surgery, and d Department of Diagnostic Imaging, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada Dr Koelink was involved in the critical development of the research proposal, data collection tools, and research ethics approval; he oversaw all research operations in patient enrollment, as well as data collection and entry. Dr Koelink had full access to the data, significantly contributed to the interpretation of the analyses, and wrote initial drafts of the manuscript. Dr Schuh was primarily involved in the initial design of the work and development of the research proposal; she also contributed to interpretation of the results and intellectual input of key study results, and revised the article critically for important intellectual content. Dr Stimec was involved in the initial design of the research study and was the content expert in pediatric musculoskeletal radiology; she independently interpreted the images of all the enrolled cases, contributed to interpretation of results and intellectual input of key study results, and revised the article critically for important intellectual content. Dr Howard was primarily involved in the initial design of the study and development of the research proposal; he also contributed to the interpretation of study results and revised the article critically for important intellectual content. Dr Barra contributed to the study methodology and led the logistical operations of patient enrollment; she conducted all patient follow-up, instituted mechanisms in the study to ensure high follow-up capture, performed all data entry, and reviewed the manuscript. Dr Boutis is the responsible author and as such has full access to the data and has final responsibility for the decision to submit for publication. She WHAT'S KNOWN ON THIS SUBJECT: Distal radius buckle fractures have an excellent prognosis. They are often managed by orthopedic surgeons, but primary care providers (PCPs) may also be able to reassess these low-risk injuries. Currently, no data are available on PCP follow-up of this injury. WHAT THIS STUDY ADDS: The majority of children with distal radius buckle fractures presented to the PCP for follow-up and received no additional orthopedic or emergency department consultation. Almost all parents reported a full return to usual activities within 4 weeks for their child. To cite: Koelink E, Schuh S, Howard A, et al. Primary Care Physician Follow-up of Distal Radius Buckle Fractures. Pediatrics. 2016;137(1):e PEDIATRICS Volume 137, number 1, January 2016 :e ARTICLE

2 A buckle fracture of the distal radius is the most common type of fracture in childhood and represents 20% of all pediatric fractures. 1 Despite their high frequency, these fractures represent very stable injuries with excellent prognosis. 2 As a result, extensive evidence recommends their treatment with a removable wrist splint, rather than the traditional use of casting. 2 8 After the initial diagnosis and treatment, most of these fractures are managed by orthopedic surgeons. 9 Given that intervention by an orthopedic specialist is rarely required for these fractures, it may also be appropriate to have these low-risk injuries followed up by the primary care provider (PCP). However, some studies suggest there may be knowledge deficits in the management of this injury by PCPs because education in musculoskeletal injuries is often lacking in family practice and pediatrics residency training Thus, PCP follow-up may result in unwarranted referrals to orthopedic surgeons or emergency departments (EDs), as well as inappropriate anticipatory guidance for this injury regarding duration of splint use or readiness for return to activities. Because 90% of these injuries are currently managed by orthopedic surgeons, 9 and there are no studies demonstrating whether PCP follow-up is adequate for this common injury, it is important to examine the management outcomes of children with distal radius buckle fractures referred to the PCP for follow-up before implementing this strategy as a practice standard. The main objective of the present study was to determine the proportion of children referred to a PCP for follow-up of a distal radius buckle fracture who subsequently received PCP follow-up and were not referred to an orthopedic surgeon or ED physician. Based on the excellent prognosis of this fracture, 2 we hypothesized that 90% of participants would receive PCP follow-up exclusively for this injury. METHODS Study Design and Setting This prospective cohort study was conducted in an urban university affiliated tertiary care children's ED in Toronto, Canada. Study Population A convenience sample of children aged 2 to 17 years diagnosed with a distal radius buckle fracture 13 were enrolled and referred to the PCP for follow-up. Children were also eligible if the distal radius buckle fracture was associated with a distal ulnar buckle/styloid fracture. 2,14 Patients were excluded if image review resulted in a different diagnosis. Other exclusion criteria involved patients at risk for pathologic fractures, multiple injuries, developmental delay affecting assessment, history of fracture in the same forearm within 3 months, and those who could not complete follow-up due to lack of telephone access or an insurmountable language barrier. The study was approved by the Hospital for Sick Children Research Ethics Board. Patient Recruitment Research assistants present from 8:30 to 2:30 daily screened the ED electronic tracking system to identify children presenting with wrist injuries. In cases confirmed as having a distal radius buckle fracture and meeting eligibility criteria, the research assistant obtained informed consent and assent where applicable. Research assistants completed a study data collection sheet to capture demographic information, management, and type of PCP (family physician, pediatrician, or none). A PCP is the physician identified by the family who regularly sees the child for well-child and sick visits. At discharge, parents were provided with an information handout that discussed the diagnosis and recommended PCP follow-up in 2 weeks. At the study institution, follow-up of distal radius buckle fractures by the PCP is the standard of care, and thus these injuries are not routinely referred to an orthopedic surgeon. Upon implementation of this practice standard, there was no education outreach to the PCPs, and the management outcomes of this practice have never been examined. Follow-up All study radiographs were reviewed by a pediatric radiologist specializing in musculoskeletal injuries within 72 hours. Discordant interpretations from the ED interpretation and respective changes in management were reported to the family. All enrolled families were contacted by telephone at day 28 after the ED visit to allow adequate time for contact with the PCP. This time frame also allowed adequate recall of events by parents. 15 For those with continued symptoms, weekly telephone calls were made after day 28 until patients reached full recovery. We chose telephone contact (versus in-person contact) to maximize compliance with follow-up 2,16 and to remove the impact that a hospital visit may have on PCP and/or other physicians visits. Other rigorously designed studies support the use of parental recall via telephone follow-up with respect to reports on physician visits within the time frame used in this study.,17,18 Families were asked about the following details related to the index fracture: clinical status, pain (never, occasionally, often, or always) and return to usual activities (always, most of the time, some of the time, not very often, or never); type (if any) of physician follow-up; parent management of splint usage and return to activities; and physician 2 KOELINK et al

3 visits and diagnostic imaging taken after the ED visit, with respective changes in diagnosis/treatment. Families were also asked about their satisfaction with PCP follow-up and PCP-recommended time frames for splint usage and return to usual activities. Outcomes The primary study outcome was the proportion of participants referred to the PCP for follow-up of a distal radius buckle fracture who, after ED discharge, received PCP follow-up and did not have visits to other physicians for this injury (ie, exclusive PCP follow-up). This outcome is clinically relevant as a measure of physician ability and willingness to manage the injury without additional specialty consultation, and it also measures the feasibility of this follow-up strategy for parents. Although follow-up of this fracture was not routinely accepted at the study institution's orthopedic clinic, follow-up of distal radius buckle fractures are routinely accepted into several other orthopedic clinics in the study region; thus, PCPs do have the option of referring these children to fracture clinics at a different hospital. As secondary outcomes, we also reported the frequency of each type of deviation from exclusive PCP follow-up. To explore PCP management of these injuries, the following factors were examined: (1) mean number of physician visits; (2) proportion of children who received repeat radiographs at the PCP visit; (3) comparison of physician-recommended timelines on splint usage and return to activities versus those applied by the parents; and (4) variables that may be independently associated with lack of anticipatory guidance on return to activity provided at the PCP visit (pediatrician versus family physician; age 5 years versus >5 years; radius and ulna fractures versus isolated radius fracture). We also examined the proportion of children with a poor or prolonged recovery, defined as pain/limitation of activity >6 weeks 13,19 and re-injury that leads to re-fracture. To establish the convenience and satisfaction with PCP follow-up, the mean distance of a PCP clinic from the family home versus the mean distance of the hospital from the family home was determined. We also determined the proportion of families who reported being very satisfied/satisfied with PCP follow-up for this injury as measured by using a 5-point categorical scale. Data Analyses Based on PCP knowledge of managing these injuries, 7,10,20,21 we estimated that 90% of participants would receive follow-up with the PCP exclusively. Therefore, assuming a primary outcome proportion of 0.90 and a 95% confidence interval (CI) precision of ±0.05 yields a minimum number of 158 patients (PASS, 2011; NCSS, LLC, Kaysville, UT). Descriptive statistics were used to summarize responses. Proportions were compared by using a χ 2 test. Logistic regression was used to determine the association between variables and the binary outcome of anticipatory guidance on return to activities given in follow-up or the lack thereof. All variables were entered into a full (ie, saturated) multivariable logistic regression model. Odds of anticipatory guidance for a given variable were reported with respective 95% CIs. All analyses were completed by using SPSS version 20 (IBM SPSS Statistics, IBM Corporation, Armonk, NY). RESULTS Patients During the study period, 297 children were diagnosed with a distal radius buckle fracture, 247 met enrollment criteria in the ED, and 223 (90.3%) consented to participate (Fig 1). There were no significant differences in the mean age (P =.34) or gender (P =.12) of children who consented to participate versus those who declined. Upon image review, 23 (10.3%) of the 223 enrolled children were found to have ED physician diagnostic errors. Of the remaining 200 enrolled children, 109 (54.5%) were male, and the mean ± SD age was 8.4 ± 3.4 years. Specifically, 33 (16.5%) were aged 2 to 4 years, 65 (32.5%) were aged 5 to 7 years, 63 (31.5%) were aged 8 to 10 years, 25 (12.5%) were aged 11 to 12 years, and 14 (7.0%) were aged 14 years. There were 183 (91.5%) patients who demonstrated skeletal immaturity (open physes) on radiographs. In this cohort, 191 (95.5%) identified a regular PCP; 110 (55.0%) used a pediatrician. A total of 66 (33.0%) participants had buckle fractures of the ulna as well as the distal radius. Telephone follow-up was successful in 180 (90.0%) of the 200 enrolled children. Orthopedic Referral, ED Visits, and No Physician Follow-up Of the 180 children with distal radius buckle fractures who received the study telephone follow-up, 157 (87.2% [95% CI: 82.3 to 92.1]) received exclusive PCP follow-up (Fig 2). Specifically, 11 (6.1%) families opted out of any physician follow-up due to a reported lack of need; 5 (2.8%) self-referred to an ED for a second opinion; and the PCP referred 7 (3.9%) children for further ED care (3 for a broken splint) or orthopedic consultation (4 for a second opinion). None of the families who received a second opinion by the ED or an orthopedic surgeon were given a different diagnosis or management. If we assume that all 20 patients lost to follow-up either did not receive a PCP visit or received orthopedic/ ED consultation, the proportion of those who received exclusive PCP PEDIATRICS Volume 137, number 1, January

4 (2 minimally displaced at 15 degrees; 12 nondisplaced) that were managed with a removable splint for the duration of therapy. There were also 2 cases of minimally displaced Salter-Harris type II fractures of the distal radius that were immobilized with a cast and healed to anatomic alignment by 6 months. Figure 3 presents the ED radiographs of the children with the highest degree of displacement. In this subset of 16 cases, there was no further displacement on follow-up radiographs, and parents reported a full return to baseline activities by 4 weeks. Resource Use of PCP Visits FIGURE 1 Patient enrollment. a Exclusions total >50 because some patients had >1 exclusion criterion. Of the 164 patients with distal radius buckle fractures with PCP follow-up, 123 (75.0%) visited their PCP once after the index ED visit, 35 (21.3%) visited twice, and 6 (3.7%) were seen 3 times. In addition, 126 (76.8%) children followed up with their PCP at 2 to 3 weeks after the ED visit, 15 (9.1%) were seen within 1 week, and 23 (14.0%) were seen in 4 to 5 weeks due to scheduling issues. Seven (4.3%) patients had repeat wrist radiographs ordered by the PCP. Splint Use and Return to Activities FIGURE 2 Follow-up of children diagnosed with a distal radius buckle fracture in the ED. follow-up would be 157 of 200 (78.5% [95% CI: 72.3 to 83.6]). Of the 23 patients with ED physician diagnostic errors, 7 children had no fractures and were advised that splinting and follow-up were no longer required. The remaining 16 injuries represented subtle examples of more complex fractures. Fourteen of these were greenstick fractures of the distal radius metaphysis Parents reported <3 weeks of splint usage in 112 (68.3%) of 154 cases (Fig 4). According to parental report, duration of splint use was not discussed by the PCP with 77 (47.0%) parents. However, the reported frequency of splint usage in the group that did not receive specific physician advice on this topic was not significantly different from that reported by parents who did receive specific PCP advice on duration of splint use (P =.72). In contrast, the proportion of parents who opted for splint use for 3 weeks was 72.9% versus 54.0% of physicians who recommended this time frame to parents (P <.0001). 4 KOELINK et al

5 When asked about their PCPrecommended time to return to normal activities, 87 (53.1%) families stated lack of specific advice about this issue (Fig 5). There were no differences in reported return to activities in patients who received physician advice versus those who did not (P =.79). Family physicians versus pediatricians were more likely to provide activity anticipatory guidance on return to activities (odds ratio [OR]: 2.1 [95% CI: 1.1 to 4.1]). However, young age ( 5 years versus >5 years) and fracture of both radius and ulna were not likely to provide guidance (OR: 1.0 [95% CI: 0.4 to 2.4]; OR: 1.1 [95% CI: 0.5 to 2.2], respectively). Of the 75 families who received PCP anticipatory guidance advice, 59 (78.7%) opted for return to activities in <3 to 4 weeks versus 38.3% of the PCPs who reportedly recommended this time frame (P <.0001). Clinical Recovery and Parental Satisfaction In the 164 children with distal radius buckle fractures and PCP follow-up, 162 (98.8%) reported recovery to usual activities within 4 weeks; 2 patients had occasional pain until 6 weeks after injury. Parental satisfaction was reported as follows: 117 (71.3%), very satisfied; 39 (23.8%), satisfied; 5 (3.1%), neither satisfied/unsatisfied; 2 (1.3%), unsatisfied; and 1 (0.6%), very unsatisfied. The mean distance from a patient's home to the PCP was 7.8 ± 9.6 km, and the respective distance to the treatment hospital's orthopedic clinic was 12.7 ± 14.5 km, a mean difference of 4.9 km (95% CI: 7.2 to 2.6). DISCUSSION This study showed that the majority of children with distal radius buckle fractures were followed up exclusively by the PCP. Despite the suboptimal rate of PCP anticipatory guidance on splint use and return FIGURE 3 Injuries misdiagnosed as a distal radius buckle fracture by the ED physician. A, Greenstick fracture of distal radius. B, Salter-Harris type II fracture of the distal radius. to activities, parents reported a full return to usual activities within 4 weeks, which represents an expected time frame for this injury. 2 Considerable practice variation exists in the care of distal radius buckle fractures after the index ED visit. Approximately 99% of pediatric orthopedic respondents in a US-based survey reported these fractures to be at very low/low risk for future complications, but 90% still recommended an orthopedic reassessment of this fracture. 9 In Canada, 50% of patients with these injuries are referred from the ED to the PCP for follow-up. 22 The present study's findings support the premise that PCP care represents a safe and feasible follow-up option for this low-risk fracture. Despite previous reports that parents PEDIATRICS Volume 137, number 1, January

6 may prefer care by orthopedic surgeons, 20 our study found that parents reported a high degree of satisfaction with PCP follow-up, and PCP offices were significantly closer to patients homes. Importantly, most of the patients who saw a PCP only required 1 visit, and very few had repeat imaging. This finding contrasts with the practice in some orthopedic clinics in which several visits and repeat radiographs seem to be common, 23,24 leading to increased health care costs, loss of patient and provider time, and exposure to potentially unnecessary radiation. 23 Approximately 10% of injuries diagnosed by the ED physician as distal radius buckle fractures were subtle examples of more complex injuries. Other studies have found a similar frequency and type of FIGURE 4 Splint usage reported by parents. FIGURE 5 Return to activities reported by parents. misdiagnosis by ED physicians when considering this injury. 2,7 Nevertheless, healing of these more complex injuries is excellent because the distal radius has one of the highest capacities for remodeling. 25 An intervention by an orthopedic surgeon is rarely required, and these fractures can generally be safely treated by using a splint. However, these injuries may require longer immobilization and different anticipatory guidance. 13 Because diagnostic errors in radiograph interpretation by the ED physician can result in a change in management, we recommend a robust quality assurance system for ED physician image interpretation 34 to ensure errors are recognized and acted on. Only approximately one-half of participating parents reported receiving PCP recommendations with respect to 2 key elements of anticipatory guidance: duration of splint usage and return to normal activities. This relatively low rate 6 KOELINK et al

7 of PCP advice may be related to the limited PCP expertise in this area. A recent survey of pediatricians across Canada and the United States found that 45% of respondents reported perceived knowledge deficits in anticipatory guidance of minor common pediatric fractures. 20 Although 70% of these respondents supported PCP office management of this injury, they anticipated benefit from further related education. Interestingly, most parents removed the splint and returned their children to activities by 3 to 4 weeks, regardless of the PCP advice on this matter. The latter finding is consistent with the data reported by Plint et al, 2 in which families were advised to use the splint as needed, and 95% were no longer using it by 4 weeks. Given the excellent prognosis of this injury, lack of reported complications, and the conservative physician guidance compared with choices influenced by patient symptoms, PCPs would likely benefit from further related education while assuming primary responsibility of follow-up of these injuries. This study has limitations. There was no orthopedic surgeon comparator group, limiting comparisons of PCP versus orthopedic surgeon follow-up outcomes. Nevertheless, our study has value in demonstrating the feasibility of PCP follow-up without the need for further specialty consultation for this injury. Our outcomes were susceptible to the accuracy of parental recall and were not corroborated with physician records; functional recovery in particular was subject to parental interpretation and not validated by a scale 35 or health care professional. Our results may not be generalizable to areas in which many patients lack a PCP. However, 5% of our patients opted out of any follow-up care due to reported lack of need, a finding also present in other studies examining this population. 2,7 Although there is 1 study supporting no physician follow-up of distal radius buckle fractures, 36 future research examining this strategy may be warranted. Our reported rate of misdiagnosis may differ from other ED settings with different levels of expertise in pediatric musculoskeletal image interpretation. CONCLUSIONS The vast majority of children with distal radius buckle fractures presented to the PCP for follow-up and received no additional orthopedic surgeon or ED consultation. Many parents did not receive PCP anticipatory guidance on splint use and return to activities. Furthermore, when PCPs did provide this guidance, their timelines were more conservative than patientguided choices. The latter 2 findings suggest that PCPs may benefit from further education in this area, which echoes the desire for more education on office management of minor pediatric fractures previously reported by PCPs. 20 ACKNOWLEDGMENTS The authors acknowledge the Pediatric Research Academic Initiative at SickKids Emergency (PRAISE). This research would not have been possible without the superb efforts of the program manager, Johanna Crudden, and the participating PRAISE research assistants. ABBREVIATIONS CI: confidence interval ED: emergency department OR: odds ratio PCP: primary care provider lead and provided most input into the intellectual content of the research proposal, developed all data collection forms, performed all the analyses, and had the most major role in the interpretation of results. She contributed most significantly to the initial drafts and critical revisions of the manuscript and gave final approval of the submitted version. All authors gave final approval of the submitted version. DOI: /peds Accepted for publication Sep 28, 2015 Address correspondence to Kathy Boutis, MD, MSc, Hospital for Sick Children, 555 University Ave, Toronto, ON, M5G 1X8. kathy.boutis@sickkids.ca PEDIATRICS (ISSN Numbers: Print, ; Online, ). Copyright 2016 by the American Academy of Pediatrics FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose. FUNDING: The Hospital for Sick Children funded the research support received via the Pediatric Research Academic Initiative at SickKids Emergency (PRAISE) program. POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose. PEDIATRICS Volume 137, number 1, January

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9 of missed extremity fractures in emergency radiology. Acta Radiol. 2006;47(7): Espinosa JA, Nolan TW. Reducing errors made by emergency physicians in interpreting radiographs: longitudinal study. BMJ. 2000;320(7237): Young NL, Williams JI, Yoshida KK, Wright JG. Measurement properties of the activities scale for kids. J Clin Epidemiol. 2000;53(2): Symons S, Rowsell M, Bhowal B, Dias JJ. Hospital versus home management of children with buckle fractures of the distal radius. A prospective, randomised trial. J Bone Joint Surg Br. 2001;83(4): PEDIATRICS Volume 137, number 1, January

10 Primary Care Physician Follow-up of Distal Radius Buckle Fractures Eric Koelink, Suzanne Schuh, Andrew Howard, Jennifer Stimec, Lorena Barra and Kathy Boutis Pediatrics 2016;137; DOI: /peds originally published online December 10, 2015; Updated Information & Services References Subspecialty Collections Permissions & Licensing Reprints including high resolution figures, can be found at: This article cites 31 articles, 7 of which you can access for free at: This article, along with others on similar topics, appears in the following collection(s): Emergency Medicine sub Orthopaedic Medicine sub Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: Information about ordering reprints can be found online:

11 Primary Care Physician Follow-up of Distal Radius Buckle Fractures Eric Koelink, Suzanne Schuh, Andrew Howard, Jennifer Stimec, Lorena Barra and Kathy Boutis Pediatrics 2016;137; DOI: /peds originally published online December 10, 2015; The online version of this article, along with updated information and services, is located on the World Wide Web at: Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since Pediatrics is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, Copyright 2016 by the American Academy of Pediatrics. All rights reserved. Print ISSN: