Socioeconomic Disparities in Secondary Procedures for Pediatric Distal Radius Fractures

Introduction Repeat reduction and surgical fixation are often performed in children with distal radius fractures failing initial closed reduction (CR). While socioeconomic disparities have been described in adult orthopaedic conditions, less is known about the pediatric population. The purpose of this investigation was to determine risk factors, if any, for differences in secondary procedure rates in children with distal radius fractures. Materials and Methods Of 2,072 patients in a multicenter prospective cohort of pediatric distal radius fractures, 270 had radiographic loss of reduction (LOR) following initial CR and casting. Rates of secondary intervention (e.g. repeat reduction, surgery) were compared by race, insurance status, childhood opportunity index (COI, lower score denotes greater opportunity), area deprivation index (ADI, lower score denotes less deprivation), and geographic distance to the treating center. Mixed-effects general linear modeling assessed associations between racial and socioeconomic characteristics on the likelihood of secondary intervention clustered by site. Odds ratios (OR) along with 95% confidence intervals (CI) are reported. Results Thirty-five patients (13%) underwent secondary procedures at a median 12 days following initial CR. Patients requiring secondary intervention demonstrated greater fracture angulation (21° vs. 16°, p=0.002) and translation (p=0.01) at initial LOR and experienced LOR earlier after CR (median 10 vs. 14 days, p=0.02). Furthermore, White patients (17% (30/179) vs. 5% (4/84) non-White patients), p=0.03), patients transferred from outside hospitals (p=0.01), patients with private insurance (p=0.02), and patients with lower COI (greater opportunity; p=0.006) were more likely to undergo secondary procedures. In the final multivariable model, each one-unit increase in COI (reflecting lower childhood opportunity) was associated with a 41% reduction in the odds of secondary intervention (OR 0.59, 95% CI 0.41-0.81; p=0.003), after adjustment for age and fracture angulation and translation at the time of LOR. Discussion In this multicenter cohort, secondary procedures after LOR were more likely to be performed in White patients, privately insured patients, and patients with lower social deprivation. After adjustment for fracture characteristics, greater childhood opportunity and fracture deformity remained independently associated with secondary intervention. Level of evidence II Key Concepts 1. Variations in secondary intervention rates for pediatric distal radius fractures are not well understood. 2. Patients with better childhood opportunity index, who have private insurance, and identify as White are more likely to receive secondary interventions for loss of reduction of pediatric distal radius fractures. 3. Further investigation is needed to delineate the root cause of these observed disparities.