511W hen a patient with an orthopedic complaint presents to the emergency department (ED), an emergency medicine (EM) physician or another primary care physician first evaluates the patient to determine whether the issue requires an urgent orthopedic consult or if the patient can be stabilized for elective follow-up care in an orthopedic clinic. Correct identification of orthopedic diagnoses requiring urgent care is particularly important, as on-call participation for orthopedic surgeons has declined nationally within the past several years.1 Neglecting to call for an urgent consultation for particular orthopedic diagnoses can lead to incomplete reduction, missed fractures, malunion, nonunion, avascular necrosis, increased infection rate, or growth disturbances. 2-5Understanding the key role of primary care and EM physicians, the authors investigated the decision-making process of orthopedic surgeons, pediatricians, and EM physicians to determine whether these 3 specialties reached different conclusions on the urgency of ED orthopedic consults. The authors also studied whether these decisions varied by year in training, to ascertain if variable or no musculoskeletal education during medical school was made up for during the residency training years. An online survey invitation was sent to orthopedic surgeons, pediatricians, and EM physicians at 3 institutions and remained accessible for a period of 3 months. The survey consisted of 16 ED presentations, 8 adult and 8 pediatric cases, with the pediatricians only having access to the 8 pediatric scenarios. Each scenario included a brief patient history, laboratory or physical examination findings, and selected radiographs. Each physician was asked to determine whether orthopedic consultation was required acutely, or whether the patient could be discharged with later orthopedic clinic follow-up.The authors' study proved that there was a significant difference in the consult choices between orthopedic surgeons, pediatricians, and EM physicians. Among the 8 pediatric scenarios, the largest differences were seen between specialties' perceptions of whether orthopedic consult was needed for lateral condyle fracture and slipped capital femoral epiphysis presentations. These 2 pathologies require both radiographic and clinical familiarity to recognize the diagnosis and therefore to make the correct decision regarding urgency of the consultation. A lateral condyle fracture or slipped capital femoral epiphysis, which were not identified as "requiring urgent orthopedic consult" by both pediatricians and EM physicians, can have grave consequences if not promptly treated. Additionally, both orthopedic surgeons and pediatricians showed a statistically significant difference compared with EM physicians in obtaining the correct consult for a patient with a Monteggia fracture.Differences in orthopedic consultation were also seen in adult cases. In the first case, EM physicians were more likely than orthopedic surgeons to request an ED consultation for a stable ankle fracture. In th...
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