Hartley Rebecca L, Todd Anna R, Harrop Alan R, Fraulin Frankie O G
Department of Surgery, Section of Plastic Surgery, University of Calgary, Calgary, Alberta, Canada.
Alberta Children's Hospital, Calgary, Alberta, Canada.
Plast Surg (Oakv). 2019 Nov;27(4):340-347. doi: 10.1177/2292550319876659. Epub 2019 Sep 24.
Pediatric hand fractures are common, but few require surgery; therefore, these fractures are often perceived to be overreferred. Our objective is to systematically identify and describe pediatric hand fracture referring practices.
A scoping review was performed, searching electronic databases and grey literature up to January 2018 to identify referring practices for children (17 years and younger) with hand fractures (defined as radiographically confirmed fractures distal to the carpus) to hand surgeons. All study designs were included, and study selection and data extraction were independently performed in duplicate by 2 reviewers. Outcomes included referring rates, necessity of referral, referring criteria, and management of fractures.
Twenty (10 cross-sectional, 7 prospective cohorts, and 3 narrative reviews) studies reporting on referring practices or management of 21,624 pediatric hand fractures were included. Proportion of pediatric hand fractures referred to hand surgeons ranged from 6.5% to 100%. Unnecessary referral, defined as those fractures within the scope of primary care management, ranged from 27% to 78.1%. Ten studies reported referring criteria, with 14 unique criteria identified. The most common referring criteria were displacement (36.4%), loss of joint congruity (36.4%), and instability (36.4%). The most common justification for these criteria was increased likelihood of requiring surgery. The most common initial management was immobilization (66%-100%). Final management was provided by orthopedic or plastic hand surgeons with 0% to 32.9% of fractures requiring surgery.
Referring practices vary widely in the literature. Major gaps in the literature include objective measures and justification for referring criteria and primary care education on hand fracture referring practices.
小儿手部骨折很常见，但很少需要手术治疗；因此，这些骨折常被认为转诊过度。我们的目的是系统地识别和描述小儿手部骨折的转诊情况。
进行了一项范围综述，检索截至2018年1月的电子数据库和灰色文献，以确定手部骨折（定义为腕骨远端经影像学证实的骨折）的儿童（17岁及以下）转诊至手外科医生的情况。纳入所有研究设计，研究选择和数据提取由两名审阅者独立重复进行。结果包括转诊率、转诊必要性、转诊标准和骨折处理。
纳入了20项（10项横断面研究、7项前瞻性队列研究和3篇叙述性综述）报告21,624例小儿手部骨折转诊情况或处理的研究。转诊至手外科医生的小儿手部骨折比例为6.5%至100%。不必要的转诊（定义为初级保健管理范围内的骨折）比例为27%至78.1%。10项研究报告了转诊标准，共确定了14条独特的标准。最常见的转诊标准是移位（36.4%）、关节一致性丧失（36.4%）和不稳定（36.4%）。这些标准最常见的理由是需要手术的可能性增加。最常见的初始处理是固定（66% - 100%）。最终处理由骨科或整形手外科医生提供，0%至32.9%的骨折需要手术。
文献中转诊情况差异很大。文献中的主要差距包括转诊标准的客观测量和理由，以及关于手部骨折转诊情况的初级保健教育。
