Operative Versus Nonoperative Treatment of Displaced Intra-Articular Calcaneal Fractures

Background: Recent years have seen a trend toward more operative treatment of upper extremity fractures in children. The current study examines clinical research regarding pediatric upper extremity fracture treatment over the past twenty years in an attempt to identify research-based support for the increasingly aggressive treatment of these fractures. Methods: Accepted abstracts on pediatric upper extremity fracture treatment presented at the Pediatric Orthopaedic Society of North America (POSNA) and the American Academy of Orthopaedic Surgeons (AAOS) annual meetings from 1993 through 2012 were reviewed. Abstracts were chosen rather than publications because of the larger number of abstracts that are available and because abstracts offer a more global representation of the research being performed by and presented to the members of these societies. The treatment recommendations of authors were classified as more aggressive, less aggressive, or neutral by two attending surgeons on the basis of which treatment was favored in comparative studies or how treatments in single-group studies compared with the standard of care at the time. Abstracts without treatment recommendations were excluded. Relationships between level of evidence, fracture location, and treatment recommendation were statistically evaluated with use of Spearman correlations and logistic regression analysis. Results: Overall, a higher proportion of studies gave less aggressive (47%, ninety of 190) or neutral (27%, fifty-one of 190) recommendations than more aggressive treatment recommendations (26%, forty-nine of 190). Only 24% of operative studies and 11% of nonoperative studies recommended more aggressive treatment (p = 0.001). Case series were more likely to recommend more aggressive treatments than comparative studies (30% versus 17%, p = 0.025). Also, studies with a smaller sample size were more likely to recommend more aggressive treatments (p = 0.006). The great majority of Level-I and Level-II (91%, ten of eleven), Level-III (81%, thirty-nine of forty-eight), and Level-IV (70%, ninety-two of 131) studies, however, provided either neutral or less-aggressive treatment recommendations. Conclusions: The majority of research presented at POSNA and AAOS meetings over the past two decades fails to support the trend toward increasingly aggressive treatment of pediatric upper extremity fractures. This dichotomy between clinical research and the direction of clinical treatment must be explored in our efforts to provide evidence-based care of pediatric upper extremity fractures.