Woo Brandi M, Bastrom Tracey P, Dennis M Morgan, Pennock Andrew T, Upasani Vidyadhar V, Edmonds Eric W
Department of Orthopedic Surgery, University of California San Diego, CA, USA.
Pediatric Orthopedics & Scoliosis Center, Rady Children's Hospital, San Diego, CA, USA.
HSS J. 2022 Feb;18(1):122-129. doi: 10.1177/1556331621992259. Epub 2021 Feb 17.
The value of employing an orthopedic technician or advanced practice provider (OT/APP) to assist trainees during on-call hours has not been assessed. As the third most common pediatric long bone fracture, most tibial fractures can be managed with closed reduction and casting. We sought to determine whether clinical outcomes could be positively affected for traumatic childhood tibia fractures by using an experienced OT/APP to aid orthopedic surgery residents with closed reduction and casting. We performed a retrospective chart review of tibial shaft fractures that occurred between 2010 and January 2017. Fractures undergoing manipulation and closed reduction by orthopedic surgery residents (post-graduate year 2 to 4) in the emergency department were included and differentiated into 2 cohorts: (1) residents who performed the procedure alone and (2) residents who were assisted by an OT/APP. Comparisons in cast quality and treatment success were made using univariate statistics followed by a multivariate Classification and Regression Tree (CART) analysis. Of the 73 patients who met our criteria, 38 received treatment by a resident alone and 35 by a resident assisted by an OT/APP. Evidence to support our hypothesis was found with the resident-alone group "over" padding the casts posteriorly. Univariate analysis demonstrated that the rate of subsequent surgical intervention was more than double in the resident-alone group (31% vs 14%), yet OT/APP castings underwent more wedging at follow-up (17% vs 0%). CART analysis revealed initial fracture severity and lack of OT/APP assistance as predictors of surgical intervention with terminal nodes, in increasing order of risk of requiring surgical intervention: lower translation on sagittal and anteroposterior (AP), lower sagittal translation with greater AP translation, greater sagittal translation with OT/APP assistance, and greater sagittal translation without assistance. The initiation of a cast application-training program in 2015 decreased the need for surgical treatment in the resident-only group (pre-program 38.5% vs post-program 17%), although this was not statistically significant. When residents were assisted by OT/APP with initial tibia closed reduction and casting, subsequent loss of reduction was more likely to be managed with cast wedging; when this assistance was not available, there was a higher rate of fractures needing surgical intervention due, in part, to poor casting technique. The reduction in the rate of surgical intervention after an internal training program was implemented suggests that trainees may improve their casting ability without added help of an experienced assistant. Future study should be performed on distal radius fractures to determine if the presented findings are valid across casting types.
在值班时间雇佣一名骨科技术人员或高级执业提供者（OT/APP）来协助实习生的价值尚未得到评估。作为第三常见的小儿长骨骨折，大多数胫骨骨折可通过闭合复位和石膏固定进行处理。我们试图确定，通过使用经验丰富的OT/APP协助骨科手术住院医师进行闭合复位和石膏固定，是否会对儿童外伤性胫骨骨折的临床结果产生积极影响。我们对2010年至2017年1月期间发生的胫骨干骨折进行了回顾性病历审查。纳入了在急诊科由骨科手术住院医师（研究生二年级至四年级）进行手法操作和闭合复位的骨折病例，并将其分为两个队列：（1）独自进行操作的住院医师，（2）由OT/APP协助的住院医师。使用单变量统计进行石膏质量和治疗成功率的比较，随后进行多变量分类与回归树（CART）分析。在符合我们标准的73例患者中，38例由住院医师独自治疗，35例由OT/APP协助的住院医师治疗。在独自操作的住院医师组中发现了支持我们假设的证据，即他们在石膏后侧“过度”填充。单变量分析表明，独自操作的住院医师组后续手术干预率是另一组的两倍多（31%对14%），然而在随访时OT/APP辅助固定的石膏出现更多楔形（17%对0%）。CART分析显示，初始骨折严重程度和缺乏OT/APP协助是手术干预的预测因素，按需要手术干预风险增加的顺序排列的终端节点为：矢状面和前后位（AP）移位较小、矢状面移位较小但AP移位较大、有OT/APP协助时矢状面移位较大、无协助时矢状面移位较大。2015年启动的石膏应用培训项目降低了仅由住院医师治疗组的手术治疗需求（项目前为38.5%，项目后为17%），尽管这在统计学上不显著。当住院医师在初始胫骨闭合复位和石膏固定时得到OT/APP的协助，随后的复位丢失更有可能通过石膏楔形矫正来处理；当没有这种协助时，部分由于石膏技术不佳，需要手术干预的骨折发生率较高。内部培训项目实施后手术干预率的降低表明，实习生可能在没有经验丰富助手额外帮助的情况下提高他们的石膏固定能力。未来应针对桡骨远端骨折进行研究，以确定所呈现的结果是否适用于所有类型的石膏固定。
