Simulation Training of Orthopaedic Residents Improves Patient Outcomes in Pediatric Distal Radius Fractures
Taylor J Jackson, BA1; Apurva S Shah, MD MBA1; J. Todd Lawrence, MD, PhD2; (1)Children's Hospital of Philadelphia, Philadelphia, PA, (2)Children's Hospital of Philadelphia, Wynnewood, PA
Background: In pediatric and adolescent patients, most distal radius fractures can be treated with closed reduction and casting. The quality of the initial reduction and plcement of a well-molded cast are important, modifiable factors for maintaining reduction. Orthopaedic residents often develop these skills treating real patients who may bear the burden of their inexperience. While simulation training with high-fidelity models has been shown to increase proficiency of trainees on the model, the impact of simulation training on patient outcomes has not been investigated.
Methods: A retrospective review of children (ages 4-18 years) with a distal radius fracture that underwent closed reduction and casting by a novice orthopaedic surgery resident was performed. Patients treated by residents who underwent simulation training were compared to patients treated by residents without simulation training. Only physeal or bicortical fractures, and only the first five distal radius fractures treated by a specific resident were included. Radiographs were evaluated to determine fracture pattern, angulation, translation, cast index, three-point indices, and loss of reduction.
Results: Seventy-eight patients were included, with a mean age of 10.5±3.0 years. Patients treated by simulation-trained residents had more physeal fractures (44.4% vs 20.8%, p=0.042) and greater initial angulation on the lateral radiograph (24.5¡ vs 17.8¡, p=0.018). Patients treated by simulation-trained residents demonstrated higher quality reductions, with less residual angulation in the anteroposterior radiograph (3.7¡ vs 6.3¡, p=0.006) and less residual translation on the lateral (14% vs 21%, p=0.040) and anteroposterior radiograph (10% vs 16%, p=0.029) (Table 1). The cast and three-point indices were similar between groups. The simulation-trained residents had significantly lower loss of reduction rates (50% vs 79%, p=0.016) (Figure 1).
Conclusions: While loss of reduction is common following closed reduction of a distal radius fracture, patients treated by young trainees with limited experience have a very high rate of loss of reduction. Simulation training significantly decreased the rate of loss of reduction and appears to be an important tool to maximize proficiency and improve patient outcomes.
Level of Evidence: III
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