PEDIATRICS Vol. 114 No. 6 December 2004, pp. 1530-1533 (doi:10.1542/10.1542/peds.2004-0120)
Recognition and Management of Pediatric Fractures by Pediatric Residents
* Division of Emergency Medicine and Department of Pediatrics, Children's National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, DC
Division of Pediatric Emergency Medicine, Alfred I. duPont Hospital for Children, Wilmington, Delaware
Division of Pediatric Emergency Medicine, Mount Sinai Hospital Center, New York, New York
|| Division of Pediatric Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
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ABSTRACT |
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 TOP ABSTRACT METHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Background. Competence in basic orthopedic assessment and interpretation of radiographs is important for pediatricians because appropriate initial management of fractures can expedite therapy and minimize morbidity. However, requirements for training in orthopedics and radiology are poorly defined in pediatric residency programs.
Objective. To assess the ability of pediatric residents to recognize and to manage appropriately pediatric fractures.
Methods. This study involved administration of a case-based questionnaire with radiographs to volunteer categorical pediatric residents in 3 geographically diverse training programs. The diagnosis and management of 8 orthopedic complaints were evaluated. Responses were scored according to the number of features identified accurately, including the presence or absence of a fracture. Residents who were able to identify a fracture were assessed with respect to their ability to classify the fracture and to provide initial management. The study was pretested with a group of pediatric emergency medicine attending physicians, to establish the suitability of the cases.
Results. Among the 3 residency sites, 102 of 190 eligible pediatric residents (53.7%) participated, yielding 95 completed questionnaires. The mean number of cases in which a resident correctly answered the question, "Is a fracture present?" and correctly identified the fractured bone (if a fracture was present) was 6.5 ± 1.2 of 8 cases (81.6%; 95% confidence interval: 78.5–84.7%). The diagnostic accuracy of Salter-Harris classification in cases in which such fractures were present was 40.9%. The mean score of correctly identified features for the resident group was 38.5 ± 9.4, of a possible 64 points (proportion correct: 60.1%; 95% confidence interval: 57.2-63%). There was a small but significant difference in mean correct responses between first-year residents (proportion correct: 55.4%; 95% confidence interval: 50.8- 60.3%) and third-year residents (proportion correct: 65.1%; 95% confidence interval: 60.7-69.5%). There was no association between the proportion of correct responses and whether or not residents had taken radiology or orthopedics elective courses in medical school. Overall, 43% of cases were both identified and managed correctly by the pediatric residents.
Conclusions. For residents from the participating training programs, skills in recognizing and managing pediatric fractures were suboptimal. Additional review of training requirements is necessary to identify more clearly areas of improvement for current curricula.
Key Words: fractures • residency training
Musculoskeletal injuries are a common cause of pediatrician and emergency department visits, accounting for 
12% of all pediatric visits to emergency departments.1 Fractures account for a significant proportion of these injuries.2–4 Competence in basic orthopedic assessment and management is important for pediatric residents, because these injuries are prevalent and the pediatrician is often the first physician to examine an injured child. Appropriate initial management can minimize morbidity and long-term dysfunction.5
The Ambulatory Pediatric Association educational guidelines for pediatric residency programs include goals for resident competence in the diagnosis and management of fractures and joint sprains.6 These include the recognition and management of problems that generally require referral to the orthopedics department (slipped capital femoral epiphysis and fractures) and those that do not require referral (clavicular fractures and simple sprains). The Ambulatory Pediatric Association guidelines also require pediatric residents to interpret radiographs accurately and to treat patients effectively on the basis of extremity radiographs, including diagnosis of common fractures and Salter-Harris classification.6
Training in orthopedic medicine, sports medicine, and radiology is not well defined in pediatric residency programs, however, and subspecialty training in these areas remains elective.7 Specific requirements for attaining these expected competencies are not established. As a result, the skill of pediatric residents in recognizing and determining appropriate management of common pediatric fractures may be suboptimal.
The performance of resident trainees in cardiac auscultation,8 resuscitation,9 developmental pediatric evaluations,10 diagnosis of otitis media,11 and physical examinations of the ankle and knee12 has been evaluated. In each study, the results indicated suboptimal resident skills, which suggests that current pediatric residency training may not provide adequate experience in these areas. The ability of pediatric residents to recognize and to manage appropriately pediatric fractures has not been evaluated similarly.
The objective of this study was therefore to assess the ability of pediatric residents to recognize and to manage appropriately pediatric fractures. Secondary objectives were to determine whether the year of residency training and/or completion of elective training in orthopedics and radiology influenced performance. We hypothesized that resident performance in these skills would be suboptimal but would improve with advancing year of training and with elective experience.
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METHODS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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This study involved a case-based questionnaire with radiographs that was administered to volunteer categorical pediatric residents in 3 geographically diverse training programs (Children's National Medical Center, Washington, DC; University of Texas Southwestern Medical Center, Dallas, TX; and Mount Sinai Hospital, New York, NY), between September 1 and December 31, 2001. Each participant was asked to review brief, written, clinical scenarios and radiographs and to complete anonymously a questionnaire addressing diagnosis and management. The resident year of training was recorded. In addition, residents were asked to indicate whether they had taken a radiology or orthopedics elective course during medical school and/or residency.
Nine conditions encountered in the pediatric population were included in the cases, ie, 2 Salter-Harris extremity fractures (Salter-Harris II radius and Salter-Harris II tibia), a spiral fracture of the distal tibia, a slipped capital femoral epiphysis, a clavicular fracture, a rickets-associated femoral fracture, a buckle radial fracture, an ankle sprain, and a healing rib fracture. Radiographs were selected from radiology teaching files and emergency department cases. Diagnoses were confirmed with reviews by a pediatric radiology attending physician and a pediatric emergency medicine physician. The questionnaire was pretested with a group of pediatric emergency medicine attending physicians, to establish the suitability of the case questions.
Responses were scored on the basis of the number of features identified accurately, including initial determination of the presence or absence of a fracture and correct naming of the fractured bone. If naming of the fractured bone was omitted from 
2 cases, the questionnaire was considered incomplete and was not scored. Residents who were able to identify correctly the presence or absence of a fracture (and the affected bone) were assessed with respect to their ability to classify the fracture and to provide initial management; these additional features included anatomic location of the fracture, Salter-Harris classification, fracture pattern, and need for immobilization. Residents who were able to identify correctly the need for immobilization were assessed with respect to their ability to select an appropriate immobilization device. Upper-extremity options included a figure-eight harness, sugar tong splint, long arm splint, radial gutter splint, ulnar gutter splint, and sling and swathe. Lower-extremity options included a long leg splint, posterior short leg splint, stirrup splint (sugar tong), and hip spica. Immobilization devices were identified by name and with a picture. The questionnaire requested that all appropriate modes of immobilization appropriate for the injury be indicated; however, full credit was given if any acceptable device was selected.
The healing rib fracture case was not scored or included in the final results because it was determined that sharing of the content of this case had likely occurred in 1 program. The maximal final score attainable was therefore 64 points among 8 cases.
This study was approved by the institutional review board at each institution. Data analysis was performed with SPSS software, version 7.5 (SPSS Inc, Chicago, IL). Results are reported as the mean score ± 1 SD and the mean percentage correct, with 95% confidence intervals. Analysis of variance was used to analyze the differences in mean scores among groups. Comparisons of the proportions of cases correctly identified and managed were performed with the 
2 test. Statistical significance was established at P < .05.
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RESULTS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Among the 3 residency sites, 102 of 190 eligible pediatric residents (53.7%) voluntarily participated in the study. Among the 102 resident participants, 95 questionnaires were completed and scored. In the final group, there were 31 first-year residents, 28 second-year residents, and 36 third-year residents.
The mean number of cases in which the residents correctly answered the question, "Is a fracture present?" and correctly identified the fractured bone (if a fracture was present) was 6.5 ± 1.2 of 8 cases (81.6%; 95% confidence interval: 78.5-84.7%). As summarized in Table 1, the ankle sprain was the case most frequently misdiagnosed by residents.
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Immobilization was correctly identified by residents as initial management of the injury in 77% of cases in which the presence or absence of a fracture had been correctly determined. An appropriate immobilization device was selected in 64% of these cases. As depicted in Fig 1, 43% of all cases (331 of 760 cases) were correctly identified and managed by residents, with use of an appropriate immobilization device or immediate orthopedics consultation as indicated.
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The overall diagnostic accuracy of Salter-Harris classification by residents in cases in which such fractures were present was 40.9%. Radiographic findings consistent with rickets were correctly noted by 15.8% of the residents.
The mean total score of correctly identified features for the resident group was 38.5 ± 9.4, of a possible 64 points (proportion correct: 60.1%; 95% confidence interval: 57.2-63%). As outlined in Table 2, improvement in scores was noted as training progressed (P = .02). Specifically, there was a significant difference in mean correct responses between first-year and third-year residents (P = .004). There was no significant difference in mean scores between first-year and second-year residents (P = .44) or between second-year and third-year residents (P = .07).
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Forty-nine residents (51.6%) had taken an elective course in either radiology or orthopedics in medical school. Four residents (4.2%) had taken such an elective course during residency. Two residents (2.1%) had this elective experience in both medical school and residency; 40 residents (42.1%) had no elective experience in either setting.
There was no association between the proportion of correct responses and whether residents had or had not taken elective courses in radiology or orthopedics in medical school or residency (P = .48). The mean score for the 4 residents who had taken such an elective course during residency (score: 44.0 ± 5.83; proportion correct: 68.8%; 95% confidence interval: 53-84.5%) was higher than that for residents without this experience (score: 38.6 ± 10.2; proportion correct: 60.3%; 95% confidence interval: 52.1-65.2%), but the values were not statistically different (P = .31).
The study was pretested with 7 pediatric emergency medicine attending physicians. Among these, 6 questionnaires were completed and scored. The attending physician group obtained significantly higher scores than did the resident group in all noted areas except recognition of radiographic findings suggesting rickets.
The mean number of cases in which the attending physician group correctly determined the presence of a fractured bone was 7.7 ± 0.5 of 8 cases (96.2%; 95% confidence interval: 83.4-100%; P = .03). The attending physician group appropriately recognized immobilization as the initial management of the injury in 97.5% of cases in which the presence or absence of a fracture had been determined correctly. An appropriate immobilization device was selected in 82.1% of these cases. Overall, 79% of all cases (38 of 48 cases) were identified and managed correctly by attending physicians; this value was significantly higher than that for the resident group (P = .001).
The overall diagnostic accuracy of Salter-Harris classification in cases in which such fractures were present was 83.3% for attending physicians (P = .004). Radiographic findings consistent with rickets were correctly noted by 16.7% of the attending physicians (P = .96). The mean score for the pediatric emergency medicine attending physicians was 52.5 ± 5.6 (proportion correct: 82.0%; 95% confidence interval: 70.4-93.7%; P = .0005).
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DISCUSSION |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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This study suggests that the skills of this group of pediatric residents in the recognition and management of pediatric fractures are suboptimal. Overall, the entire resident group was unable to determine correctly whether a fracture was absent or present in nearly 20% of cases. When residents were assessed with respect to their ability to classify the identified fracture and provide initial management, performance worsened. Salter-Harris classification was not recognized or was incorrectly applied in 60% of cases. Difficulties in determining the need for immobilization and in selecting an appropriate immobilization device resulted in more than half of the cases being incorrectly identified and managed.
A small but significant improvement was observed when third-year residents and first-year residents were compared. Medical school or resident elective exposure to relevant subspecialties did not significantly improve performance, although the total number of residents who had completed resident elective training was small, which limited comparisons.
Similarly, the small number of attending physician participants limited direct comparison with the resident group. Because these physicians correctly identified the presence or absence of a fracture, the fractured bone, and the need for immobilization in nearly all of the cases, the questionnaire was considered appropriate. Attending physician participants also identified correctly the Salter-Harris classification and an appropriate immobilization device in >82% of cases. Because there were 6 completed pretests, such a value could reflect an incorrect response by 1 participant. Given the performance of the majority of pretesters, the questionnaire was considered a reasonable evaluation tool, particularly in the areas of fracture recognition and determination of the need for immobilization.
One limitation of this study was that the participants did not have actual patients to interview and examine. However, the written scenarios were realistic histories, with physical examination findings characteristic of each injury, and ensured uniformity of the cases. In addition, because previous studies showed suboptimal resident skills in physical examinations of the ankle and knee,12 it is unclear whether examination of actual patients would have yielded improved diagnostic and management performance.
Another limitation of any study involving distribution of a questionnaire is the potential for sharing of content among participants. Although the first page of the questionnaire requested that participants did not "discuss the topic or content of this questionnaire with other residents until the study is completed," there was no means by which to ensure that this did not happen. For example, we discovered that the diagnosis of a rib fracture had been shared; therefore, we did not include this case in our calculations.
Although many general pediatricians may have the benefit of subspecialists to assist in the diagnosis and management of fractures, competence in initial management principles (such as immobilization) for musculoskeletal injuries is important, because these injuries are common and timely intervention is crucial for ensuring good outcomes. The poor performance of the resident group in recognizing the need for immobilization suggests that this basic competence is not present. Interestingly, the ankle sprain (not a fracture) was the case most frequently misdiagnosed by residents. Although residents might have been biased in "looking for fractures" in this type of evaluation, such a bias does not explain the failure to immobilize injuries. Finally, the poor performance of both residents and attending physicians in recognizing radiographic findings consistent with rickets serves as a reminder to evaluate appropriately nontraumatic medical causes of fractures.
Formal training in radiology and orthopedics subspecialties during residency is elective. Few residents in this study had obtained elective training in these areas during residency, which may suggest insufficient experience in this area for pediatricians in training. However, the trend of the higher mean score for those who did have this additional experience is encouraging.
Other studies suggested that resident trainees may need to spend more time in subspecialty clinics as an essential part of training.8 Improved resident knowledge of the Denver II classification was noted after completion of a developmental pediatric rotation.10 Significant improvement in residents' performance in ankle and knee examinations occurred after a teaching intervention.12 This suggests that identification of educational deficiencies in residency training programs may facilitate development of effective educational interventions.
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CONCLUSIONS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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The skills of pediatric residents in the recognition and management of pediatric fractures appear to be suboptimal. Our results suggest that the goals for resident competence in these areas are not being met. Although few residents in this study had obtained relevant elective experience during residency, their trend toward higher scores may be encouraging. Additional critical study and review of training requirements are necessary to identify more clearly areas of improvement for current curricula.
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FOOTNOTES |
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Accepted Jun 14, 2004.
Reprint requests to (L.M.R.) Division of Emergency Medicine, Children's National Medical Center, 111 Michigan Ave NW, Washington, DC 20010. E-mail: lryan{at}cnmc.org
No conflict of interest declared.
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REFERENCES |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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PEDIATRICS (ISSN 1098-4275). ©2004 by the American Academy of Pediatrics
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