Table VI.

Negotiating treatment decisions: illustrative quotations.

Theme 3: Negotiating treatment decisions
Category	Illustrative quotes
Striving for practice change involves: 1) believing in the study and non-surgical casting; 2) supporting parent choice; 3) encouraging practice change; and 4) anticipating reluctance	1) Believing in the study and nonoperative treatment: What it’s also raised with me personally is the fact that we have been very aggressive with these fractures. We’ve probably been operating and putting kids at risk of complications with surgery that we didn’t need to, in a number of cases. (Clinician9) I think this will be strong evidence to show that we don’t need to take every single child with just a bendy arm or just a little bit of displacement to theatre or do manipulation. So, I think this will make a massive difference in practice. (Clinician18)
	2) Supporting parent choice: I think that (after the study) the different treatment measures should be offered to the parents…. I think it’s a different journey that the patient takes and the parents need to be aware of that and there are still hurdles whichever treatment path you take. But the vast majority of patients do really well whichever treatment arm they take, it’s just a different way of doing it really. (Clinician15)
	3) Encouraging practice change: I think within our department attitudes to what can be managed nonoperatively has changed already which has affected the recruitment to the trial. Fractures that would always have been taken (for surgery) are now less likely to be so by the individuals who wanted to operate on it, which is amazing. (Clinician9) You see some of the really horrible ones and they’re doing okay and that is quite reassuring. I’ve used one or two of the pictures – “you’re worried about it, come and look at these” and you send it round to your colleagues and they say they think it’s a bit much and I’ll say “well, have a look at these pictures six weeks down the line, this is what happens”. (Clinician17) I think we’ve stopped operating on these fractures. Compared to other orthopaedic surgeons I am very conservative in the sense that I think it remodels pretty well and we over treat many of them. We look for perfection, we don’t let ‘Mother Nature’ do her job. My feeling is that once we have the outcomes most likely we will stop operating on them, especially for the very young so I would say less than eight (years old) for definite. (Clinician11)
	4) Anticipating reluctance: I know there are some of my colleagues that, no matter what you put in print, will not change their practice and that’s the difficult bit: “I’ve always done it this way” or “I know it says that, but it’s a bit (displaced/ angulated/ worse) beyond what they looked at”. Just publishing the paper isn’t going to be enough. If you find that nonoperative treatment is appropriate for all of them, or a sub-set or whatever it happens to be, you’re going to have to do more than just publish the paper to get the message out and get people to change their practice. Because finding the evidence and changing the practice are two totally different things. (Clincian17)
Concerns about nonoperative treatment involves understanding: 1) colleague’s concerns about nonoperative treatment; and 2) factors that influence surgeon’s preference for surgery	1) Colleague’s concerns about nonoperative treatment: Seeing a very bent forearm in a child, it is sometimes difficult to believe that remodelling will occur. I have concerns that children will end up with deformities or functional problems where the fractures are quite severe and they’re a bit older. So, I worry about the kids who are between ten (years old) and say ten and 364 days and so for me that’s the only clinical concern, about causing harm. (Clinician9) I suppose my only residual concern is around the very grossly deformed off-ended fractures and what happens with the distal radio-ulna joint (DRUJ) as the patient gets older. If they have any residual problems with the DRUJ when they’ve reached skeletal maturity - which won’t really be answered by the study for many, many years and it hasn’t really been addressed in the literature yet. That’s my only hesitancy. (Clinician13)
	2) Factors that influence surgeon’s preference for surgery: It has to be agreed by the parents and the consultant. The consultants are the ones who are carrying the responsibility and the ones to make the final decision, which I totally understand. It’s part of defensive medicine? (Clinician18) When you look at the classic paper from Hawaii, about the nonoperative treatment of overriding distal radial fractures, in that age group they were very particular in reducing the angulation. Although (the fractures) were still off-ended, and short, they were still ensuring the angulation was correct and the bones were roughly in the same direction. (Clinician15)