Incidence and treatment modality trends in pediatric tibial fractures: a PHIS database study
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Abstract
BACKGROUND: Tibial shaft fractures are a common pediatric musculoskeletal injury. Most tibial shaft fractures in the pediatric population are managed conservatively through closed reduction and casting. Surgical alternatives include intramedullary (IM) nailing, open reduction and internal fixation (ORIF), and external fixation. The use of operative treatment for pediatric tibial shaft fractures is indicated for older skeletally mature patients and for complex injury presentations. In recent years, with technological and procedural advancements, there has been a growing interest in the use of surgical management for pediatric fractures that historically have been treated conservatively. Studies have found evidence of this increasing trend in the management of pediatric tibial shaft fractures. However, there remains a sparsity of evidence analyzing this trend in the United States (US). In addition, studies have discovered discrepancies in injury management and outcomes across various patient specific factors. The impact of patient demographics and socioeconomic status on the management of pediatric tibial shaft fractures is not well understood.
OBJECTIVE: The study objective was to evaluate incidence and operative treatment trends for closed tibial shaft fractures in the US stratified by geographic region between 2010 and 2020. There was also interest in elucidating the impact patient-specific factors, such as insurance coverage and socioeconomic status, on the type of operative modality received.
METHODS: The Pediatric Health Information System (PHIS) was utilized to analyze a study sample of 2,211 patients, aged 0–18, presenting to a PHIS member site between 2010 and 2020 for closed tibial shaft fracture management. The incidence rate and injury management type were assessed through International Classification of Diseases (ICD) coding and Current Procedural Terminology (CPT) coding. Incidence data were stratified across four geographic regions to analyze possible associations. Reported cases of operative management were analyzed separately across various patient-specific factors reported in PHIS. These factors included sex, age, race/ethnicity, insurance type, urban/rural residency, region of care, and family income level. The impact of patient-specific factors on trends in operative management was analyzed by statistical comparison.
RESULTS: The overall incidence of closed tibial shaft fractures cases with procedural coding was estimated to be approximately 0.48% (95% CI, 0.46–0.50) across 459,209 total orthopedic cases. Closed tibial shaft fracture cases managed with some form of operative treatment as a proportion of total orthopedic cases decreased 0.92-fold between 2010 and 2020. For patients with surgically managed tibial shaft fracture cases, 75% were male and 81% were aged 11 or older. IM nailing was determined to be the most prevalent form of operative fixation accounting for 62% of all operative cases (95% CI, 59.5–65.0), and ORIF was the second most prevalent form, accounting for 24% (95% CI, 21.6–26.5). The least prevalent operative management modality utilized was external fixation at 14% (95% CI, 12.0–16.0). The proportion of IM nailing out of all operative cases in the sample was found to increase 1.2-fold between 2010 and 2020. Both ORIF and external fixation had decreasing trends over this study period, with 0.95-fold change for ORIF and 0.37-fold change for external fixation. The rate of IM nailing was found to be significantly higher in the Midwest region and lower in the West region in comparison with ORIF (p<.001). Both IM nailing and ORIF were significantly associated with increases in age in comparison with external fixation (p<.01). No significant associations were found between operative modality and biological sex, race/ethnicity, insurance type, urban/rural residency, or income level.
CONCLUSIONS: This study establishes the overall incidence rate of closed tibial shaft cases as a component of all orthopedic cases at 22 pediatric hospitals across the US. This information provides insight on the impact that these injuries have on the population and the US health system. The rate of IM nailing, found to increase across this study period, supports prior evidence toward increasing rates of operative pediatric fracture management with this modality. The association between geographic region and operative modality indicates that IM nailing is occurring at higher rates in the Midwest region and lower rates in the West region in comparison with ORIF. There is also evidence of a significantly larger percentage of IM nailing and ORIF in comparison with external fixation with increasing patient age. Contrary to past studies outlining discrepancies in care across socioeconomic factors, these findings provide evidence of no significant association between the included socioeconomic factors and the operative modality utilized in closed tibial shaft fracture cases.
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2024