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

      Purpose

      Pediatric patients with hand trauma and congenital differences are treated across multiple surgical subspecialties. The purpose of this study was to assess operative trends over an 11-year period using the American Board of Orthopaedic Surgery and the American Board of Plastic Surgery databases to better understand which surgeons were caring for pediatric hand fractures and birth differences in the first 2 years of their practice.

      Methods

      We queried the American Board of Orthopaedic Surgery and the American Board of Plastic Surgery databases for surgical procedures performed by applicants for the oral examinations between 2004 and 2014. Candidates self-identified as general orthopedic surgeon, pediatric orthopedic surgeon, hand surgeon (orthopedic and plastic), and general plastic surgeon. This included a total of 2,453 Board applicants. A total of 6,835 surgeries for birth differences or hand trauma were identified and reviewed for patients <18 years of age.

      Results

      There were 5,759 trauma and 1,076 congenital difference surgeries. A total of 4,786 (70%) surgeries were performed by orthopedic surgeons. Fellowship-trained hand surgeons (orthopedic and plastic) performed 3,809 (56%) surgeries. Pediatric orthopedic surgeons performed 608 (9%) surgeries. Over the 11 years, general orthopedic surgeons performed 4.2 fewer surgeries per year, whereas surgeons in hand orthopedics and pediatric orthopedics performed 10.8 and 4.7 additional surgeries per year. There were 3.1 fewer general orthopedic surgeons per year, whereas there were 3.6 and 1.4 additional surgeons in hand orthopedics and pediatric orthopedics each year, respectively. The number of surgeries and the number of surgeons submitting surgeries did not significantly change for those in general plastics or hand plastics.

      Conclusions

      This analysis of early practice patterns over 11 years demonstrates that the increasing numbers of surgeons in pediatric orthopedics and hand orthopedics are performing more surgeries compared with other fields.

      Clinical relevance

      The care of children with hand injuries and congenital differences is evolving, with direct implications for residency and fellowship education.

      Key words

      Pediatric and adolescent trauma and congenital differences of the hand and wrist have historically been managed by several different types of surgeons including hand surgeons (orthopedic surgeons and plastic surgeons), pediatric orthopedic surgeons, general orthopedic surgeons, general plastic surgeons, and general surgeons. Referral tendencies are influenced by local practice patterns, but the interest and expertise in caring for these injuries and differences are evolving. There is an increasing number of surgeons with post-residency training in both pediatric orthopedic surgery and hand surgery, highlighting what we believe is a growing interest in this field and a need for more specialized training.
      • Hosseinzadeh P.
      • Obey M.R.
      • Nielsen E.
      • et al.
      Orthopaedic care for children: who provides it? how has it changed over the past decade? analysis of the database of the American Board of Orthopaedic Surgery.
      The growth in the number of pediatric orthopedic surgeons is demonstrated by the 59% increase in the number of members of the Pediatric Orthopedic Society of North America between 1993 and 2014.
      • Minaie A.
      • Shlykov M.A.
      • Hosseinzadeh P.
      Pediatric orthopedic workforce: a review of recent trends.
      The purpose of this study was to assess the trends over an 11-year period using the databases of the American Board of Orthopaedic Surgery (ABOS) and the American Board of Plastic Surgery (ABPS) to better understand who, among surgeons in the 5 fields of surgery, cared for pediatric hand fractures and birth differences of the upper extremity in the first 2 years of their practice. The fields included pediatric orthopedic (Peds Ortho), orthopedic general (Gen Ortho), hand orthopedic (Hand Ortho), hand plastics (Hand Plastics), and plastics general (Gen Plastics). It is important to regularly assess and understand data on post-fellowship practice patterns to ensure that training programs are providing the needed education for residents and fellows so that graduates can deliver the best patient care. We hypothesized 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.

      Materials and Methods

      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).
      Figure thumbnail gr1
      Figure 1Board applicants per year by specialty.
      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.
      Table 1Current Procedure Terminology Codes
      ConditionCPT Codes Included
      Phalanx fractures26727- Percutaneous skeletal fixation of proximal/ middle phalanx fracture

      26735- Open treatment of phalanx shaft fracture, includes internal fixation

      26746- Open treatment of intra articular phalanx fracture, includes internal fixation

      26756- Percutaneous skeletal fixation of distal phalanx fracture

      26765- Open treatment of distal phalanx fracture, includes internal fixation

      26608- Percutaneous fixation of metacarpal fracture

      26615- Open treatment of metacarpal fracture, to include internal fixation
      Metacarpal fractures
      Congenital conditions26650- Pollicization

      26555- Positional change of other finger (ray transfer of index to long)

      26560- Repair syndactyly

      26561- Repair syndactyly with skin grafts, flaps

      26562- Repair complex syndactyly

      26565- Osteotomy for correction of deformity; metacarpal

      26567- Osteotomy for correction of deformity; phalanx

      26568- Osteoplasty for lengthening of metacarpal or phalanx

      26580- Repair cleft hand

      26587- Reconstruction of polydactylous digit, soft tissue and bone

      26590- Repair macrodactylia, each digit

      26593- Release, intrinsic muscles of hand

      26596- Excision of constricting ring with multiple z-plasties

      Statistical analysis

      Data were compiled into spreadsheets for basic statistical analyses, generation of surgery percentages and bar graphs analyses. We assessed overall trends in and across specialties, including case numbers and surgeon numbers to assess linear change over time by computing a simple linear regression with time and by testing whether the slope coefficient is significantly different from 0. We used a response variable of year and predictor variables of either number of surgeries, number of applicants, and number of surgeries done per applicant. In this case, a non-zero slope coefficient indicated a significant change in these variables over the study time period. In addition, significant relationships between linear regression slopes were assessed as the interaction between time (year) and specialties in a statistical model combining analysis of all the data as a function of time (year), specialty, and the interaction of time and specialty (year∗specialty). In this linear regression model, the response variable was the number of cases done per month, and the predictor variables were the types of fellowship training received by the operating surgeons and the year the data were collected. A slope coefficient that significantly differed from 0 would indicate a change in the number of cases done per month by a given specialty over the study time period.

      Results

      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.

      Changes in the number of surgeries

      Figures 2 and 3 demonstrate surgeries by specialty over the 6-month board collection period (plastic surgery applicants were normalized to 6 months for comparison) over the 11 years of data collection. When assessing the number of surgeries performed within each specialty without considering the number of surgeons within each specialty, there were significant changes by linear regression (P < .05). Board applicants in Gen Ortho had 4.2 fewer surgeries per year, whereas there were 10.8 additional surgeries per year in Hand Ortho and 4.7 additional surgeries per year in Peds Ortho. There were no significant changes in the number of surgeries for Plastics Hand or Gen Plastics over the 11-year period (P < .05).
      Figure thumbnail gr2
      Figure 2Surgeries per 6 months by specialty. Plastic surgery applicant case logs are normalized to 6 months.
      Figure thumbnail gr3
      Figure 3Percentage of surgeries per 6 months by specialty. Plastic surgery applicant case logs are normalized to 6 months.

      Changes among specialty applicants

      The total number of board applicants per specialty per year submitting pediatric hand surgeries was variable (Fig. 1) but demonstrated several important trends. Over the 11 years of available data, there were 3.1 (± 1.02) fewer applicants submitting surgeries in Gen Ortho (P < .05), whereas there were an additional 3.6 (± 0.95) applicants per year in Hand Ortho (P < .05) and an additional 1.4 (± 0.44) applicants per year in Peds Ortho (P < .05). There were no significant changes in surgeries for Gen Plastics or Hand Plastics (P > .05).

      Changes between specialties over time

      When normalizing surgeries per specialty for the number of surgeons each year, there were no significant trends in comparison to Peds Ortho (P > .05). This relative consistency across specialties (when considering the number of cases and number of surgeons within a specialty) is demonstrated in Figure 4.
      Figure thumbnail gr4
      Figure 4Surgeries per 6 months per surgeon by specialty, normalized for 6 months of surgery submissions.

      Patients <13 years of age

      We performed a specific assessment of surgical volume for congenital differences and fractures of the hand in patients <13 years of age. The percentage of total surgeries and the number of surgeries on patients <13 years of age completed by surgeons in the field of Hand Ortho both increased (P < .05, r2 = 0.36 and P < .05, r2 = 0.52, respectively). The percentage of the total number of congenital difference surgeries remained stable, whereas the percentage of the total number of hand fracture surgeries increased (P = .05, r2 = 0.27). The percentage of total surgeries and surgeries in patients <13 years of age completed by surgeons in the field of Peds Ortho both increased (P < .05, r2 = 0.32 and P < .05, r2 = 0.32, respectively). The percentage of the total number of congenital difference surgeries increased (P < .05, r2 = 0.39), whereas the number and percentage of trauma surgeries were unchanged. There were no significant changes in the number of surgeries in patients <13 years of age (including both congenital difference surgeries and trauma surgeries) for Gen Ortho, Gen Plastics, or Hand Plastics (P > .05).

      Discussion

      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
      • Hosseinzadeh P.
      • Obey M.R.
      • Nielsen E.
      • et al.
      Orthopaedic care for children: who provides it? how has it changed over the past decade? analysis of the database of the American Board of Orthopaedic Surgery.
      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
      • Mann T.R.
      • James M.A.
      • Harrast J.
      • Kaplan F.T.D.
      Early practice patterns of hand surgeons: an American Board of Orthopaedic Surgery database study.
      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.

      References

        • Hosseinzadeh P.
        • Obey M.R.
        • Nielsen E.
        • et al.
        Orthopaedic care for children: who provides it? how has it changed over the past decade? analysis of the database of the American Board of Orthopaedic Surgery.
        J Pediatr Orthop. 2019; 39: e227-e231
        • Minaie A.
        • Shlykov M.A.
        • Hosseinzadeh P.
        Pediatric orthopedic workforce: a review of recent trends.
        Orthop Clin North Am. 2019; 50: 315-325
        • Mann T.R.
        • James M.A.
        • Harrast J.
        • Kaplan F.T.D.
        Early practice patterns of hand surgeons: an American Board of Orthopaedic Surgery database study.
        J Hand Surg Am. 2019; 44 (e17): 819-828