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Variation in Documentation of Pediatric Supracondylar Fractures
Carissa Meyer, MD; Lauren Rinaca, PA; Ebrahim Paryavi; Joshua Abzug, MD University of Maryland Medical Center, Baltimore, MD

Hypothesis: Supracondylar humerus fractures are the most common pediatric elbow fracture. As children can be difficult to examine and many may have associated neurovascular injuries that can alter timing of treatment, the purpose of this study was to assess adequacy and accuracy of documentation regarding these injuries.
Methods: A retrospective chart review was performed of all pediatric supracondylar fractures in children under the age of 15. Data collected included patient age, type of fracture (Type I, II, III extension, flexion), clinician type (Emergency Department or Orthopaedic surgeon) and level of training, motor exam documentation (anterior interosseous nerve, radial nerve and ulnar nerve function) and presence of nerve palsy. Linear regression was used to analyze documentation with regards to patient age and clinician level of training.
Results: Thirty patients were identified during the study period, including 3 patients with associated nerve palsies (2 AIN and 1 radial nerve palsy). In all cases, the nerve palsy was not recognized by the ED physicians or the orthopaedic resident(s) prior to the orthopaedic attending evaluation. In patients with a nerve palsy, motor documentation continued to be incomplete or failed to document a nerve palsy in >50% of notes even after attending documentation of the nerve palsy. Incomplete motor exam documentation, defined as failure to document function pertaining to a particular nerve, occurred in 97% of notes done by Emergency Department attendings or residents. There was no correlation between motor exam documentation and year of residency training. Improved documentation by orthopaedic residents was significantly improved as patients increased in age (p-value 0.046). Documentation was complete in 90% of patients aged 6 years or older. There was no correlation between improved motor documentation and correctly identifying a nerve palsy (odds ratio 0.88, p-value 0.43).
Summary:

  • Inadequate or incorrect documentation may occur at any step of the evaluation process and may persist despite appropriate documentation by an attending surgeon
  • Motor exam documentation improved with patient age and reached 90% for patients 6 and older, implying that barriers exist to appropriate neurologic examination in young children
  • Improved education of emergency department physicians and orthopaedic residents is important to provide specific and age-appropriate neurologic examinations in young children with skeletal trauma
  • Proper documentation is necessary to improve recognition and monitoring of neurologic status in pediatric patients with supracondylar humerus fractures

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