Abstract
Background
Repeat reduction and surgical fixation are often performed in children with distal radius fractures failing initial closed reduction (CR). While socioeconomic disparities have been described in adult orthopaedic conditions, less is known about the pediatric population. The purpose of this investigation was to determine risk factors, if any, for differences in secondary procedure rates in children with distal radius fractures.
Methods
Of 2,072 patients in a multicenter prospective cohort of pediatric distal radius fractures, 270 had radiographic loss of reduction (LOR) following initial CR and casting. Rates of secondary intervention (eg repeat reduction, surgery) were compared by race, insurance status, Childhood Opportunity Index (COI, lower score denotes greater opportunity), Area Deprivation Index (lower score denotes less deprivation), and geographic distance to the treating center. Mixed-effect general linear modeling was used to assess associations between racial and socioeconomic characteristics on the likelihood of secondary intervention clustered by site. Odds ratios (ORs) along with 95% confidence intervals (CIs) are reported.
Results
Thirty-five patients (13%) underwent secondary procedures at a median 12 days following the initial CR. Patients requiring secondary intervention demonstrated greater fracture angulation (21° vs 16°, P = .002) and translation (P = .01) at initial LOR and experienced LOR earlier after CR (median: 10 vs 14 days, P = .02). Furthermore, White patients [17% (30/179) vs 5% (4/84) non-White patients], P = .03), patients transferred from outside hospitals (P = .01), patients with private insurance (P = .02), and patients with a lower COI (greater opportunity; P = .006) were more likely to undergo secondary procedures. In the final multivariable model, each one-unit increase in the COI (reflecting lower childhood opportunity) was associated with a 41% reduction in the odds of secondary intervention (OR: 0.59, 95% CI: 0.41–0.81; P = .003) after adjustment for age and fracture angulation and translation at the time of LOR.
Conclusions
In this multicenter cohort, secondary procedures after LOR were more likely to be performed in White patients, privately insured patients, and patients with lower social deprivation. After adjustment for fracture characteristics, greater childhood opportunity and fracture deformity remained independently associated with secondary intervention.
Key Concepts
-
(1)
Variations in secondary intervention rates for pediatric distal radius fractures are not well understood.
-
(2)
Patients with a better Childhood Opportunity Index, who have private insurance, and who identify as White are more likely to receive secondary interventions for loss of reduction of pediatric distal radius fractures.
-
(3)
Further investigation is needed to delineate the root cause of these observed disparities.
Level of Evidence
II
Keywords: Distal radius fractures, Social deprivation, Childhood opportunity
Introduction
Distal radius fractures are among the most common fractures in children. Treatment is typically based on fracture pattern, magnitude of displacement, and potential for bony remodeling with continued skeletal growth. For more severely displaced fractures in older children, closed reduction (CR) and cast immobilization is typically recommended. However, given the risk of fracture instability following initial reduction, serial radiographic evaluation is recommended, and secondary CR and/or surgical fixation may be recommended for excessive late displacement [1,2].
Racial and socioeconomic treatment disparities have been widely reported in medicine, including orthopaedics [3]. While the etiologies of these disparities are complex and multifactorial, commonly cited factors include limited access to health care resources, financial barriers, provider biases, and patient notions of traditional health care delivery systems [4]. Indeed, historical accounts of medical research adversely targeting vulnerable populations have resulted in fear of the health care system by people who have been medically underserved and/or historically under-represented [5]. Furthermore, recent studies suggest that patients without insurance or who have public insurance are more likely to delay presentation [[6], [7], [8]]. In pediatric fracture care, delays in presentation are particularly relevant, given the additional morbidity of delayed fracture reduction and the potential for future, albeit incomplete, remodeling of bony deformity. All of these considerations may influence the treatment a patient seeks or receives.
The current investigation seeks to investigate the presence, if any, of socioeconomic differences in secondary procedure rates for loss of reduction (LOR) in children with distal radius fractures. In a previously published study from our multicenter registry, predominantly White patients were noted to undergo secondary procedures [2]. In this follow-up analysis, fracture characteristics, geographic distance from the hospital, clinical follow-up rates, and standardized indices of socioeconomic status were used to characterize any apparent differences in secondary fracture care.
Materials and methods
From 2018 to 2019, 2,072 children between the ages of 4 and 18 years were enrolled in a multicenter longitudinal prospective registry of pediatric distal radius fractures [9]. Of the 616 patients who underwent initial CR for displaced injuries, there were 270 patients (43.4%) who demonstrated radiographic LOR after initial CR and immobilization (Fig. 1). LOR was defined a priori as a change in angulation ≥10° in any plane or an increase in translation greater than or equal to two categories. Patient demographic information was prospectively collected, including age, sex, and self-identified race; fractures were characterized according to fracture pattern and displacement. Patients with torus fractures and open fractures were excluded from this analysis.
Figure 1.
Flow diagram of patient enrollment and analytic cohort selection. This diagram shows the number of patients enrolled, screened, and ultimately included in the final analysis. COI, Childhood Opportunity Index; DRF, Distal Radius Fracture.
In addition to assessing if there were racial differences in secondary procedure rates, the secondary aim of this investigation was to determine if socioeconomic factors and geographic distance to the treating health care facility influenced clinical follow-up and surgical rates.
Socioeconomic status was characterized using the Area Deprivation Index (ADI) and Childhood Opportunity Index (COI). The ADI is a measure of socioeconomic conditions by neighborhood based on the U.S. Census [10]. ADI values are presented as national percentile census block groups ranging from level 1 to 100, where a ranking of 1 denotes a lower level of disadvantage and a ranking of 100 indicates the highest level of disadvantage. The COI is a measure that maps the indicators that contribute to a child’s healthy development [11]. These indicators are then broken down into three domains: education, health and environment, and social and economic. For the purpose of this investigation, the COI scale, which was originally decided as ranging from very high to very low, was converted to a numerical scale from 1 to 5, where 1 was equal to “very high” on the COI scale.
The geographic distance from the patient’s home to the hospital at the time of injury was also estimated using the central location of the patient’s zip code to the central location of the hospital zip code. The patient’s insurance status was categorized as private or public and collected as another variable for comparative analysis.
Patient, injury, and treatment characteristics were summarized for the cohort and then compared across outcome groups (secondary intervention vs no secondary intervention). Due to heterogeneity in study characteristics including race, COI, national ADI, the distance from the hospital, as well as variability in insurance type and ethnicity across sites, analyses were adjusted for clustering by site. Mixed-effect general linear modeling was used to assess the effects of racial and socioeconomic factors on the likelihood of secondary intervention clustered by participating institution. Covariates considered for the multivariable analysis were selected based on clinical relevance and prior literature. Final model specification was guided by model fit (Akaike information criterion) while maintaining a parsimonious model appropriate for the number of outcome events. Multivariable analyses were conducted using complete-case analysis. Patients missing data for variables included in the final model were excluded from the corresponding analysis. For relevant factors, odds ratios (ORs) along with 95% confidence intervals (CIs) were reported.
This investigation was approved by the institutional review board of all participating centers; all patients in the registry had a parent or guardian’s consent, and assent was obtained from patients aged 8 years and older.
Results
Of the 270 patients with a loss of initial reduction, 35 patients underwent secondary procedures (35/270, 13%) at a median 12 days following initial CR (Table 1). The majority of secondary interventions consisted of CR with percutaneous pinning (18/35, 51%), followed by CR without fixation (5/35, 14%), plating (5/35, 14%), repeat CR in the emergency department or clinic (3/35, 9%), open reduction with percutaneous pinning (3/35, 9%), and C-wire with suture fixation (1/35, 3%) (Table 2).
Table 1.
Patient, injury, and treatment characteristics by secondary procedure group.
| Patient characteristics | Secondary procedure (N = 35) | No secondary procedure (N = 235) | Pa |
|---|---|---|---|
| Age at enrollment (mean; SD) | 10 (4.0) | 9.5 (3.3) | .16 |
| Sex (male; n (%)) | 25 (71%) | 156 (66%) | .55 |
| BMI group (N = 258a; n (%)) | .45 | ||
| Under weight | 1 (3%) | 3 (1%) | |
| Healthy weight | 21 (60%) | 118 (53%) | |
| Overweight | 5 (14%) | 47 (21%) | |
| Obese | 8 (23%) | 55 (25%) | |
| Race (N = 263a; n (%)) | .03 | ||
| Black | 2 (6%) | 57 (25%) | |
| White | 30 (88%) | 149 (65%) | |
| Mixed/Another | 2 (6%) | 23 (10%) | |
| Hispanic (N = 242a; n (%)) | 0 (0%) | 17 (8%) | .97 |
| Hospital admission (n (%)) | 5 (14%) | 5 (2%) | .002 |
| Outside hospital transfer (n (%)) | 27 (77%) | 124 (53%) | .01 |
| Insurance type (n (%)) | .02 | ||
| Public | 5 (14%) | 84 (36%) | |
| Private | 28 (80%) | 140 (59%) | |
| Unknown | 2 (6%) | 11 (5%) | |
| COI (median (IQR)) | 1 (1-2) | 2 (1-4) | .006 |
| ADI national (median (IQR)) | 22 (13-36) | 29 (13-56) | .05 |
| Distance from hospital (miles; median (IQR)) | 10 (6-20) | 9 (6-17) | .54 |
| Fracture characteristics | |||
| Fracture type (n (%)) | .76 | ||
| Bicortical | 30 (86%) | 192 (82%) | |
| Greenstick | 0 (0%) | 1 (0%) | |
| Intra-articular (physis closed) | 1 (3%) | 0 (0%) | |
| Physeal | 3 (8%) | 19 (8%) | |
| Unknown | 1 (3%) | 23 (10%) | |
| Ulna fracture (n (%)) | 29 (83%) | 206 (88%) | .40 |
| Worst pre-reduction angulation magnitude (AP; mean; SD) | 4 (4.1) | 2 (3.1) | .001 |
| Worst pre-reduction angulation magnitude (LAT; mean; SD) | 5 (5.0) | 3 (4.2) | .01 |
| Worst angulation magnitude at LOR (mean; SD) | 21 (9.7) | 16 (6.8) | .002 |
| Worst translation at LOR (n (%)) | .01 | ||
| 0% | 8 (22%) | 94 (40%) | |
| 1-25% | 15 (43%) | 97 (41%) | |
| 26-50% | 6 (17%) | 35 (15%) | |
| 51-100% | 3 (9%) | 6 (3%) | |
| >100% | 3 (9%) | 3 (1%) | |
| Time from CR to LOR (d; median (IQR)) | 10 (8-15) | 14 (9-28) | .02 |
BMI, body mass index; SD, standard deviation; IQR, interquartile range (25th-75th percentile); COI, Childhood Opportunity Index; ADI, Area Deprivation Index; AP, anteroposterior; LAT, lateral; CR, closed reduction; LOR, loss of reduction.
P values are based on general linear mixed modeling clustered on site. Bolded P values indicate statistical significance (P <0.05).
Categorical variables are presented as frequency (%). Continuous variables are presented as mean (SD) or median (IQR), as indicated for each variable.
The number in parentheses (N) represents the total number of patients with data for the given characteristic.
Table 2.
Summary of secondary procedures.
| Procedure | Frequency | (%) |
|---|---|---|
| Repeat closed reduction in the ED/clinic | 3 | (9%) |
| Closed reduction in the OR | ||
| No fixation | 5 | (14%) |
| Percutaneous pinning | 18 | (51%) |
| Open reduction | ||
| Percutaneous pinning | 3 | (9%) |
| Plating | 5 | (14%) |
| C-wire and suture fixation | 1 | (3%) |
ED, emergency department; OR, operating room.
Compared with patients who did not undergo secondary intervention, patients requiring secondary procedures were more likely to be White (88% vs 65%, P = .03), have private insurance (80% vs 60%, P = .02), and reside in neighborhoods with greater childhood opportunity as measured by the COI (median: 1 [interquartile range {IQR}: 1-2] vs 2 [IQR: 1-4], P = .006) (Table 1). They were also more likely to have been transferred from an outside hospital (77% vs 53%, P = .01) and admitted to the hospital (14% vs 2%, P = .002). There were no significant differences in age, sex, fracture type, ulna fracture, geographic distance from the treating hospital, or body mass index between groups.
Patients undergoing secondary intervention demonstrated greater fracture deformity at the time LOR was identified. Mean worst angulation at LOR was 21° (standard deviation [SD]: 9.7°) compared with 16° (SD: 6.8°) among patients managed without secondary intervention (P = .002). A greater translation at LOR was also associated with secondary intervention (P = .01), and patients undergoing secondary intervention experienced LOR earlier after CR (median: 10 vs 14 days, P = .02).
In unadjusted analyses, greater childhood opportunity, private insurance, outside hospital transfer, and increased fracture angulation and translation at the time of LOR were each associated with higher odds of secondary intervention (Table 3). In the final multivariable model, older age (OR: 1.13, 95% CI: 1.00-1.27; P = .05), greater childhood opportunity (OR: 0.59, 95% CI: 0.41-0.81; P = .003), greater translation at LOR (OR: 2.09, 95% CI: 1.42-3.16; P < .001), and greater angulation at LOR (OR: 1.09, 95% CI: 1.03-1.14; P = .002) remained independently associated with secondary intervention.
Table 3.
Unadjusted and adjusted associations with secondary intervention following loss of reduction.
| Characteristic | Unadjusteda | Adjustedb | ||||
|---|---|---|---|---|---|---|
| OR | 95% CI | P | OR | 95% CI | P | |
| Age (y) | 1.08 | (0.97-1.20) | .16 | 1.13 | (1.00-1.27) | .05 |
| Sex (% male) | 1.27 | (0.59-2.88) | .55 | |||
| Race | ||||||
| White race | 1.00 | Referent | ||||
| Black race | 0.17 | (0.03-0.60) | .02 | |||
| Mixed/another race | 0.43 | (0.07-1.57) | .27 | |||
| Outside hospital transfer | 3.02 | (1.37-7.37) | .009 | |||
| Private insurance | 3.36 | (1.35-10.19) | .02 | |||
| COI | 0.65 | (0.47-0.87) | .006 | 0.59 | (0.41-0.81) | .003 |
| ADI national | 0.98 | (0.97-1.00) | .05 | |||
| Distance from hospital | 1.01 | (0.98-1.02) | .54 | |||
| Worst translation at loss of reduction | 1.71 | (1.21-2.42) | .002 | 2.09 | (1.42-3.16) | <.001 |
| Worst angulation at loss of reduction | 1.07 | (1.03-1.12) | .002 | 1.09 | (1.03-1.14) | .002 |
ADI, Area Deprivation Index; COI, Childhood Opportunity Index; OR, odds ratio; CI, confidence interval.
Unadjusted results are from individual generalized linear mixed models clustered on site.
Adjusted results are from a multivariable generalized linear mixed model including all variables with reported effects clustered on site.
Discussion
Recently, there has been a greater awareness of potential racial disparities in orthopaedic care [12]. In a recent study of over 26,000 patients by Benitez et al., Hispanic and Black adults were found to be less likely to receive an operative treatment for distal radius fractures than the White patients [6]. Furthermore, the authors determined that these disparities remained even after patients reached the age of Medicare eligibility. In another study of pediatric orthopaedic patients, Kitchen et al. [13] found that 60.6% of children with public insurance experienced greater delays in fracture care than patients with private insurance. The authors also noted that patients with public insurance experienced more delays between injury and referral than patients with private insurance. These studies highlight the possible associations between race or socioeconomic status and fracture care.
The present investigation identifies differences in secondary procedure rates in children with distal radius fractures that align with much of the recent literature. In this multicenter prospective cohort, White pediatric patients were more likely to receive secondary operations for LOR of distal radius fractures than Black patients or patients of another race. In addition, patients with private insurance were more likely to receive secondary procedures. Interestingly, a novel finding was that the patients who received secondary procedures had better COIs than those who did not (Table 1).
The reasons for these observed differences are complex and likely multifactorial. Not all patients and families may have the medical literacy to understand the treatment decisions or potential benefits of secondary interventions [14]. Some demographic groups may have historical biases against surgical interventions [15]. In addition, the patient’s/family’s socioeconomic circumstances might influence their ability or willingness to follow-up at recommended time intervals or undergo surgical treatment. Furthermore, orthopaedic providers, while well intended, might hold unconscious biases [4]. Lastly, there may be systemic issues related to general infrastructure and social resources that might influence the ability for all patients to adhere to treatment recommendations or receive equitable care. For example, some parents may lack transportation, childcare, or leave time to make follow-up appointments or surgical dates. More robust analysis and further investigation is needed to determine the root causes of the disparities reported here.
It is important to recognize that the neither observed differences connote intent nor can any conclusion be made regarding optimal surgical rates or clinical best practices. Given the robust remodeling potential for pediatric fractures of the distal radius, the lower secondary intervention rates seen in patients identifying themselves as another race, publicly insured, and/or patients with lower childhood opportunity may actually be preferable, conferring desirable clinical outcomes while avoiding unnecessary surgical risk or associated health care costs. Further investigation of the longer-term, patient-centered outcomes within this multicenter cohort will help elucidate the cause(s) of observed differences in secondary procedure rate and improve the care of distal radius fractures in all children.
There were a number of limitations to this study. While our data were derived from a multicenter prospective registry of over 2,000 children, patients came largely from academic medical centers in the central and northeastern USA. Further analysis of patients from a broader geographic distribution, including private practice settings, is needed to corroborate the generalizability of these results. Additional information about clinical decision-making, as well as the influence of patient/family preference, is needed to understand the factors affecting secondary procedure rates. Finally, families were asked to self-identify their racial and ethnic backgrounds. These questions were not universally answered and do not account for multiracial patients or those not represented in the standard list of racial descriptions.
Despite these limitations, our results demonstrated that White patients, patients with private insurance, and patients with a better COI were more likely to undergo secondary procedures for late displacement following pediatric distal radius fractures. Even in the adjusted model, better childhood opportunity and greater fracture deformity remained independently associated with secondary intervention. Further investigation is needed to understand the root cause of these differences and the impact, if any, on longer-term patient outcomes.
Ethics approval and consent
Complete written informed consent was obtained from the patient, their guardian, or legal representative for the publication of this study and accompanying images.
Author contributions
Rebecca D. Aguiar: Writing – review & editing, Writing – original draft, Project administration, Methodology, Investigation, Data curation, Conceptualization. Apurva S. Shah: Writing – review & editing, Project administration, Methodology, Investigation, Data curation, Conceptualization. Mark L. Miller: Writing – review & editing, Project administration, Methodology, Investigation, Data curation, Conceptualization. Michael C. Willey: Writing – review & editing, Project administration, Methodology, Investigation, Data curation, Conceptualization. Susan T. Mahan: Writing – review & editing, Project administration, Methodology, Investigation, Data curation, Conceptualization. Ata Kiapour: Writing – review & editing, Investigation, Data curation. Patricia E. Miller: Writing – review & editing, Writing – original draft, Validation, Methodology, Investigation, Formal analysis. Donald S. Bae: Writing – review & editing, Writing – original draft, Project administration, Methodology, Investigation, Funding acquisition, Conceptualization.
Funding
This study received grant funding from the Pediatric Orthopaedic Society of North America.
Declaration of competing interests
The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: D.B. reports financial support was provided by Pediatric Orthopaedic Society of North America. The coauthor received royalties from Wolters Kluwer for a textbook. If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
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