P087: A comparison of how emergency physicians and plastic surgeons evaluate and triage pediatric hand fractures: a prospective trial of the Calgary Kids’ Hand Rule

Abstract

Introduction: Hand fractures in children are common and most are adequately managed with immobilization alone. There is a subset of fractures that require surgery as well as a fear of growth plate disturbance. For these reasons, triaging the so-called “complex” fractures that require specialized care by a hand surgeon is critical. In an effort to improve triaging for pediatric hand fractures, we previously derived and internally validated a prediction model for pediatric hand fracture triage using multivariable logistic regression with bootstrapping. The primary outcome was “complex fracture”, a definition we assigned to any fractures that required surgery, closed reduction or more than four appointments with a plastic surgeon. The model identified six significant predictors of complex fractures: angulation, condylar involvement, dislocation or subluxation, displacement, open fracture, and malrotation with strong performance (C-statistic 0.88) and was named the Calgary Kids’ Hand Rule (CKHR). Methods: A prospective cohort study was conducted at the Alberta Children's Hospital from April 1 until December 31, 2019. Eligible patients included children 17 years and younger with a radiographically confirmed hand fracture. Both emergency physicians and plastic surgeons completed independent CKHR forms for each new hand fracture. The fracture was predicted as “complex” if any one of the six predictors were present on the form. If none of the six predictors were present, the predicted outcome was “simple”. The observed outcome was “complex” if the fracture required surgery, closed reduction, or four or more appointments with a plastic surgeon at three months follow-up. All other fractures were observed outcome “simple”. The classification performance of the CKHR was assessed via sensitivity, specificity, and C-statistic. The kappa coefficient for inter-rater reliability between emergency physicians and plastic surgeons was calculated for each predictor. Results: To date, 102 pediatric hand fractures have been included in this prospective cohort study. Of the 74 observed simple fractures, 49 were predicted as “simple” and 25 were predicted as “complex”. Of the 28 observed “complex” fractures, 25 were predicted as “complex” and 3 were predicted as “simple”. These findings correspond to a sensitivity of 89%, specificity of 66%, and a C-statistic of 0.78. Of the 3 observed “complex” fractures that were predicted as “simple”, i.e. the 3 false negatives, one was a Seymour fracture of the fourth distal phalanx for which the emergency physician did not tick any boxes on the form. Upon further investigation, we learned that the physician had commented that the fracture was open, thus alluding to their acknowledgement of the predictor “open fracture” as being present). This fracture went on to require surgery. The second false-negative fracture was a non-displaced, intra-articular fracture of the fourth metacarpal head that required multiple appointments with the plastic surgeon. The third false-negative fracture was a non-displaced Salter-Harris II fracture of the thumb proximal phalanx without malrotation that received a closed reduction by the emergency physician. The kappa coefficient for inter-rater reliability between emergency physician and plastic surgeon evaluation of predictors varied by predictor from fair to almost perfect agreement. Condylar involvement had the highest kappa coefficient (kappa = 0.85) followed by malrotation (kappa = 0.65) and dislocation (kappa = 0.64). The predictors with the lowest kappa coefficients were displacement (kappa = 0.42), open fractures (kappa = 0.50), and angulation (kappa = 0.53). Conclusion: The Calgary Kids’ Hand Rule had a sensitivity of 89% in a prospective cohort of pediatric hand fractures referred to the Alberta Children's Hospital. The sensitivity could likely be improved with knowledge translation and specific education regarding use of the prediction tool. Emergency physicians and plastic surgeons displayed the lowest inter-rater reliability when assessing displacement, open fractures, and angulation. These predictors may represent areas of future research and physician education to delineate and decrease the discordance between emergency physicians and plastic surgeons.