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Pediatric Hand Fractures: Predicting Which Fractures Require Specialized Care by a Hand Surgeon
Rebecca L Hartley, MD; Ceilidh Anne Kinlin, MScPT; Josh Lam, MD; Karen Hulin-Poli, MScOT; Claire Temple-Oberle, MD, MSc, FRCSC; Rob Harrop, MD, MSc, FRCSC, FACS; Frankie OG Fraulin, MD, FRCSC
University of Calgary, Calgary, AB, Canada

Introduction: Most pediatric hand fractures can be managed non-operatively without consequence. There are no evidence-based guidelines to identify which fractures will require specialized care by a hand surgeon and current referral systems are based on primary care discretion. Our study's purpose is to determine which pediatric hand fractures require specialized care by a hand surgeon.

Materials & Methods: A retrospective chart review was conducted on all patients referred to plastic surgeons at a large tertiary pediatric hospital in 2013 with a diagnosis of a hand fracture. Patients' medical charts and radiographs were examined and data was collected into categories derived from both the literature and expert opinion. The fractures were then divided into two categories: metacarpal (MC) and phalangeal. Univariate analysis screened the categories for significant variables (screening cut-off p-value<0.2). We performed a logistic regression using the significant variables from the univariate screening as our independent (predictor) variables and "requiring specialized care by a hand surgeon" as our dependent (outcome) variable (defined as fractures that needed reduction, surgery or more than 3 follow-up visits by a hand surgeon). Goodness of fit testing for the model as well as beta values for the predictor variables were calculated with a p-value<0.05.

Results: 608 charts were reviewed, identifying 559 fractures, 185 MC (33.1%) and 374 phalangeal (66.9%). Management of all fractures included: immobilization alone (369, 66.0%), closed reduction and immobilization (119, 21.3%), surgical intervention in the operating room (57, 10.2%) and surgical intervention in the emergency department (14, 2.5%). The MC logistic regression model explained 85.9% of the observed outcomes with a Hosmer and Lemeshow test (HL) value of 0.869. Displacement (p-value 0.016, beta 1.638) and rotation (0.012, 2.199) were important predictors. The phalangeal logistic regression model explained 83.2% of observed outcomes with a HL value of 0.284. Condylar involvement (0.016, 1.290), displacement over 2 millimeters (0.042, 0.694), anterior-posterior angulation over 15 degrees (0.012, 1.238), and lateral angulation over 15 degrees (0.036, 0.955) were important predictors.

Discussion: Relatively few variables predict whether pediatric hand fractures will require specialized care by a hand surgeon. Knowledge of these variables will be an essential first step in devising strategies to better manage pediatric hand fractures. This data will be used to develop a clinical prediction tool and management pathway for pediatric hand fractures.

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