O2103: Variation in the Treatment of Pediatric Lateral Condyle Fractures of the Humerus (PLCHF)

Background:

Background: Surgical fixation of PLCHF is achieved using K-wires or screws, although factors influencing surgeons’ choices remain unclear. The purpose of this study was to conduct a survey to determine surgeons’ preferences in the treatment of PLCHFs.

Methods:

Methods: A cross-sectional survey was electronically disseminated to the POSNA (Pediatric Orthopedic Society of North America) membership in January 2023. Respondents were asked to provide demographics including years of experience, practice type, and orthopedic subspecialty, followed by general preferences on classification, implant choice, and use of physical therapy. Respondents were given eleven PLCHF cases which were constructed to represent a spectrum of age, fragment displacement, and time elapsed since injury. Respondents also identified their willingness to randomize the implant used. Patient, fracture, and surgeon characteristics were analyzed to develop predictors of treatment recommendations. Multivariate logistic regression analyses were conducted to evaluate the association between predictors and outcomes.

Results:

Results: 159 surgeons responded (11% of membership). Respondents were appropriately distributed by years in practice and pediatric subspecialty, 73% male, and 74% academic. Of all respondents, 94% (150/159) use K-wires (47% exclusively), 54% use screw fixation (6% exclusively), and 48% use both. Screw preference was more common in surgeons with >30 years of experience (22/31) vs 30 years or less (63/128, p = 0.048). There was variability in implant choice among the cases, as no case reached a 90% consensus on the choice of implant while 5 cases had < 75% agreement. Screw fixation was more common for fractures presenting >2 weeks after injury (OR = 36.9, CI 12.8 – 106.2) and in older patients (per year, OR = 1.8, CI 1.5 – 2.2). 83% favored open treatment, although 3 cases had < 70% consensus on this option. Open treatment was more common with fractures assigned a higher grade (Jakob/Weiss grade 3, OR = 24.4, CI 9.1 – 65.6). Physical therapy is used infrequently, with 80% prescribing it in < 30% of the cases. 54% of respondents were willing to randomize some of the case scenarios, with 29% willing to randomize at least 8 cases. Respondents were most open to randomize if the case was classified as Jacob/Weiss grade 3 (47%) and least willing with grade 1 classifications (10%).

Conclusion:

Conclusion: While POSNA members primarily favor K-wires for stabilizing displaced PLCHFs, screw fixation was preferred for late-presenting PLCHFs and older patients. There is variability in implant choice among surgeons when provided specific case scenarios. More than half of the respondents were willing to randomize some of the clinical cases, more often with fractures assigned a higher severity. This survey therefore demonstrates the need to develop, and the equipoise necessary for a randomized, prospective trial comparing implantation types in the treatment of displaced PLCHFs.