Pediatric Hand Fractures and Congenital Differences: An Analysis of Data From the American Board of Orthopaedic Surgery and the American Board of Plastic Surgery

Our study was submitted to and approved by the ABOS research committee and the ABPS. Blinded surgical logs submitted for ABOS and ABPS Part II (oral) examination were reviewed from 2004 to 2014 for trauma or congenital difference surgeries on pediatric patients. The orthopedic surgeons submitted a 6-month surgical log from April 1 to September 30 of the year prior to the examination, typically beginning 7 months after starting practice. The plastic surgeons submitted a 9-month surgical log collected from July 1 to March 31, beginning in the month of July after the completion of residency. Case numbers and trends were evaluated on a case volume per 6-month basis to reflect the varying case collection period between plastic and orthopedic surgery. During the 11-year period, there were 673 plastic surgery board applicants, including 443 general and 230 plastic surgeons with hand fellowship training and 1,780 orthopedic board applicants, including 889 general orthopedic applicants, 723 orthopedic surgeons with hand fellowship training, and 168 pediatric orthopedic fellowship-trained applicants. Board applicants by specialty each year are provided in Figure 1. To be included in this analysis, all applicants completed an upper-extremity procedure on a patient <18 years of age during the collection interval. Training varied for the 5 fields of surgeons. Peds Ortho, Hand Ortho, and Plastics Hand surgeons completed a fellowship in their field, whereas Gen Plastics and Gen Ortho surgeons did not complete a fellowship (or completed a fellowship not relevant to pediatric hand surgery).

We evaluated only specific Current Procedural Terminology (CPT) codes for surgeries performed on pediatric patients (<18 years of age). Specifically, we assessed patients treated surgically for congenital differences and fractures of the hand, evaluating a total of 20 CPT codes (Table 1). These specific codes were chosen to represent typical hand fracture surgeries and congenital difference hand surgeries. We primarily assessed the patient groups across all ages but also subdivided the patients into those <13 years of age. This was done to assess whether younger patients were more likely to be treated in the field of Peds Ortho.

A total of 6,835 surgeries for congenital differences or hand trauma were identified and reviewed for <18 years of age. There were 5,759 trauma and 1,076 congenital difference surgeries. The number of submitted hand surgery procedures for ABOS and ABPS Boards Part II increased annually over the 11 years of this study from 540 in 2004 to 739 in 2014.

Orthopedic surgeons performed 4,786 (70%) surgeries, and plastic surgeons performed 2,049 (30%) surgeries. Hand fellowship-trained surgeons (orthopedic and plastic) performed 3,809 (56%) surgeries. Surgeons in Peds Ortho performed 608 (9%) surgeries, including 413 trauma and 195 congenital difference surgeries. The other surgeries were performed by the surgeons in Gen Ortho and Gen Plastics.

Our study evaluated surgical volume from surgeons of different training backgrounds surgically treating children with congenital differences or traumatic conditions of the hand. By combining data from the ABOS and ABPS, we were able to assess trends in care by recent residency and fellowship graduates. These data confirm that for patients with congenital difference and traumatic surgeries of the hand, the majority of pediatric patients continue to be treated by orthopedic-trained hand surgeons.

Our data demonstrate several interesting trends. First, when surgeries are considered by specialty, there were 10.8 additional surgeries per year by board applicants in the field of Hand Ortho and 4.7 additional surgeries per year in Peds Ortho, whereas board applicants in Gen Ortho performed 4.2 fewer surgeries per year. In addition, the number of board applicants from the specialties changed: there were 3.1 fewer applicants each year submitting pediatric cases in Gen Ortho, an additional 3.6 applicants per year in Hand Ortho, and an additional 1.4 applicants per year in Peds Ortho. There were no significant changes in surgery number or board applicants for pediatric surgeries in Gen Plastics or Hand Plastics. Our hypothesis was that as more surgeons became fellowship trained in pediatric orthopedic surgery, a greater proportion of hand fracture and congenital difference surgeries would be performed by pediatric orthopedic surgeons. However, when our data were combined, there were indeed more surgeons performing more hand surgeries in the Peds Ortho (and Hand Ortho) specialty over the 11 years (and fewer surgeons and surgeries in the Gen Ortho group), but there were no statistically significant changes in the percentage of surgeries completed by the 5 groups of surgeons over the time course of this investigation.

These data differ from the previously published trends in caring for pediatric patients with traumatic and congenital difference conditions over the last 15 years. Hosseinzadeh et al showed that pediatric orthopedic surgeons cared for an increasing number of pediatric patients in a study evaluating submitted surgeries (all body locations) for the ABOS Part II examination. Overall, in 2004, 18% of pediatric patients were treated by fellowship-trained pediatric orthopedic surgeons whereas, in 2014, 47% were treated by pediatric orthopedic surgeons. There were notable increases in the percentage of pediatric patients cared for by pediatric orthopedic surgeons in various subspecialties including an 175% increase in the percentage of upper-extremity trauma surgeries over the 11 years of study (12% of submitted surgeries compared with 43% of submitted surgeries). These data may indicate changing surgical indications or simply may reflect a greater role of the pediatric orthopedic surgeon in hand trauma care. Nonetheless, this increase in surgical volume is important information for pediatric orthopedic surgery fellowships.

Understanding who is caring for patients with congenital differences of the upper extremity is challenging, and board databases provide helpful insights. These data help to inform the educational process for residency and fellowship programs in orthopedic and plastic surgery. A recent study by Mann et al examined the early practice patterns of hand surgeons in an effort to assess the ability to meet eligibility requirements for the ABOS Subspecialty Certificate in Orthopaedic Surgery of the Hand. A total of 125 surgeries were required with a minimum number of surgeries required in 5 of 9 categories. The case profiles showed limited diversity of surgeries, and few surgeons were able to meet the minium criteria for the congenital category (only 3 surgeries were required during the 6 months of collection). These data, together with ours, demonstrate that junior hand surgeons are, in general, not treating a large or increasing number of patients with congenital differences. However, Peds Ortho surgeons are the exception, with an increase in the number of congenital difference surgeries over the 11-year period. This information must inform the education of those surgeons. In addition, congenital differences may be treated by more senior surgeons, perhaps many in more focused centers and childrens’ hospitals.

We chose to evaluate the patients as a complete group but also further assessed the patients <13 years of age. This was done to address the concept that the care of the adolescents is often provided by “adult” surgeons, given the similar nature of the pathology and general safety of providing care in adult operating rooms. Our findings did show differences in these groups. Orthopedic hand surgeons were performing an increasing percentage of the surgeries in patients <13 years of age, an increase driven by additional trauma surgeries (congenital difference surgeries were stable over time). Interestingly, the trend was different for pediatric orthopedic surgeons who had an increased overall number of surgeries and percentage of surgeries. However, the Peds Ortho surgeons showed an increase in congenital difference surgeries, whereas trauma surgeries remained unchanged over time. The number of cases in patients <13 years of age did not change for general plastic surgeons and plastic hand surgeons; however, the number of cases decreased for general orthopedic surgeons.

This study has limitations. First, these data reflect the practice trends of recent graduates of residency and fellowship. Our findings may not reflect the practices of more senior surgeons or even the same surgeons later in practice. However, it is our opinion that the nature of specialized surgery on the pediatric hand is such that those operating on these patients early in their practice might reasonably be expected to continue to do so over time; similarly, those not choosing to operate on such patients early in their practice are presumably less likely to initiate the care of these patients in the future. However, it is important to note that young surgeons likely have access to trauma patients, but patients with congenital differences of the upper extremity may be less likely to seek care from surgeons who have recently completed training. Additionally, the database information provided by the ABOS and ABPS allows a unique look at surgeon practices via specific surgeries listed by CPT code. Second, surgeons self-identify for categorization and code their own surgeries by CPT code, and errors are possible. Third, the training pathways examined herein reflect the primary fellowship pathway. There are positions available for additional training in congenital hand surgery, with both official and unofficial fellowship positions of variable lengths of time. Such training is not reflected in this investigation. Finally, this study only evaluates surgical procedures and is, therefore, affected by surgical indications that may vary depending on training pathway.

In this analysis of early practice patterns, the majority of pediatric hand trauma and congenital difference surgeries continue to be performed by Ortho Hand surgeons, whereas there are there are an increased number of Peds Ortho and Ortho Hand surgeons treating an increasing number of these patients (with a decrease in Ortho Gen surgeons and surgeries). Our data demonstrate that these changes are related to an increased number of practicing pediatric orthopedic surgeons and we believe that the increased number of surgeons is accompanied by an increased interest in this field. It is imperative that all residency (orthopedic and plastics) and fellowship (plastic hand, orthopedic hand, and pediatric orthopedic) programs appropriately expose and teach residents and fellows to care for the pediatric patient with trauma or congenital differences of the upper extremity.