1 SUPPLEMENTAL FILE S1:
ORTHOPEDIC MANAGEMENT OF COMMON PEDIATRIC FRACTURES SURVEY A. DEMOGRAPHICS
1. Are you a practicing staff orthopedic surgeon that treats children?
Yes (survey will go to next question) No (survey will exit)
2. What country do you practice in?
US Canada
3. What state or province do you practice in?
Drop down list of all states and provinces
4. How many years have you been working as a staff orthopedic surgeon since you completed your clinical training?
Less than 5 years 5 - 10 years 11 - 15 years 16 - 20 years
> 20 years
5. Did you complete a fellowship in pediatric orthopedic surgery?
Yes No
6. How would you best describe your primary practice setting:
University affiliated general/community hospital University affiliated children's hospital
Non-university affiliated general/community hospital Non-university affiliated children's hospital
Other (please specify)
7. How many children with elbow, wrist and/or ankle fractures do you see on average per month?
Zero 1 - 20 21 - 40 41 - 60
Greater than 60
2 B. GARTLAND TYPE I SUPRACONDYLAR FRACTURE
8. What degree of concern do you have for this fracture regarding clinically important short and/or long term complications?
Very Low Low Moderate High Very High
9. What is your institution's preferred method of immobilization for the duration of therapy of the above fracture?
Sling and swathe Long arm splint
Long arm splint initially followed by long arm cast Long arm cast
Other ________________________
3 C. DISTAL RADIUS FRACTURES
I. Distal Radius Buckle Fracture
10. What degree of concern do you have for this fracture regarding clinically important short and/or long term complications?
Very Low Low Moderate High Very High
11. What is your institution's preferred method of immobilization for the duration of therapy of this type of fracture?
No immobilization
Removable prefabricated wrist brace Short arm splint
Short arm cast Long arm cast
Short arm wrist splint initially followed by a short arm cast Long arm wrist splint initially followed by a long arm cast Other ____________
4 II. Isolated Minimally Angulated (<15° on lateral radiograph) Greenstick Distal Radius Fracture in a Skeletally Immature Child Less Than 11 Years of Age
12. What degree of concern do you have for this fracture regarding clinically important short and/or long term complications?
Very Low Low Moderate High Very High
13. What your institution's preferred method of immobilization for the duration of therapy for this type of fracture?
Removable prefabricated wrist brace Short arm splint
Short arm cast Long arm cast
Short arm wrist splint initially followed by a short arm cast Long arm wrist splint initially followed by a long arm cast
Reduction to perfect alignment followed by short or long arm cast Other ____________
5 III. Isolated Minimally Angulated (<15° on lateral radiograph) Transverse/Complete Distal Radius Fracture in a Skeletally Immature Child Less Than 11 Years of Age
14. What degree of concern do you have for this fracture regarding clinically important short and/or long term complications?
Very Low Low Moderate High Very High
15. What your institution's preferred method of immobilization for the duration of therapy for this type of fracture?
Removable prefabricated wrist brace Short arm splint
Short arm cast Long arm cast
Short arm wrist splint initially followed by a short arm cast Long arm wrist splint initially followed by a long arm cast
Reduction to perfect alignment followed by short or long arm cast Other ____________
6 16. In skeletally immature children with minimally angulated/displaced distal radius fractures, a large multi-centre study is proposed that will compare a short arm pre-fabricated splint to a short arm cast with respect to certain outcomes. Please tell us your opinion on the importance of each of the following outcomes:
Functional recovery of the wrist
very important, moderately important, neither important or unimportant, moderately unimportant, very unimportant
Radiographic alignment at union
very important, moderately important, neither important or unimportant, moderately unimportant, very unimportant
Clinical appearance of wrist at 4-6 weeks
very important, moderately important, neither important or unimportant, moderately unimportant, very unimportant
Time to union
very important, moderately important, neither important or unimportant, moderately unimportant, very unimportant
Loss of reduction in follow up necessitating surgical intervention
very important, moderately important, neither important or unimportant, moderately unimportant, very unimportant Change in immobilization device due to complications / symptoms
very important, moderately important, neither important or unimportant, moderately unimportant, very unimportant Pain at 4 - 6 weeks
very important, moderately important, neither important or unimportant, moderately unimportant, very unimportant
7 D. DISTAL FIBULAR ANKLE FRACTURES
17. A 6 year old boy presents with an ankle injury after an inversion injury. He cannot walk and has tenderness and swelling isolated to the distal fibula which is maximal over the growth plate. His ankle x-rays do not show any fractures or displacement but demonstrate soft tissue swelling over the distal fibular growth plate.
What is your diagnosis for this injury?
Nondisplaced Salter-Harris I fracture of the distal fibula Ankle sprain
Other _________________________
I do not know
Soft tissue swelling over the distal fibular growth plate
8 18. What is your institution's preferred method of immobilization for the duration of therapy of the following fractures?
18A. Distal fibular avulsion fractures (growth plates open)
No immobilization - Rest, ice, compression and elevation with return to activities as tolerated
Removable ankle brace for approximately 1 week and then brace as needed for symptoms Posterior splint of lower leg for approximately 1 week and reassess the need for further immobilization
Posterior splint of lower leg Below knee cast
Other _________________________
18B. Nondisplaced Salter-Harris I of the distal fibula
No immobilization - Rest, ice, compression and elevation with return to activities as tolerated
Removable ankle brace for approximately 1 week and then brace as needed for symptoms Posterior splint of lower leg for approximately 1 week and reassess the need for further immobilization
Posterior splint of lower leg Below knee cast
Other _________________________
9 18C. Nondisplaced Salter-Harris II fracture of distal fibula
No immobilization - Rest, ice, compression and elevation with return to activities as tolerated
Removable ankle brace for approximately 1 week and then brace as needed for symptoms Posterior splint of lower leg for approximately 1 week and reassess the need for further immobilization
Posterior splint of lower leg Below knee cast
Other _________________________
10 There are three Level I evidence studies that compared a cast to a removable device (brace / splint) in approximately 100 patients with (1) isolated nondisplaced distal fibular SalterHarris
I, II, and avulsion fractures, (2) distal radius buckle fractures, or (3) minimally angulated distal radius greenstick and transverse fractures in skeletally immature children. All
three studies found that the removeable device was at least as effective as the cast with respect functional recovery, had superior patient preferences, and was costeffective.
[CMAJ 2010: 182(14):150712; Pediatrics 2007: 119(6): e125663; Pediatrics 2006: 117(3):6917]
19. To what degree would you feel comfortable managing these types of fractures with the immobilization device listed for the duration of therapy
Fracture and Immobilization Device
Very
comfortable Moderately
comfortable Neither
comfortable or uncomfortable
Moderately
uncomfortable Very
uncomfortable Distal Radius
Buckle Fracture:
short arm splint Minimally angulated distal radius
greenstick:
prefabricated short arm splint Minimally
anugulated distal radius transverse fracture:
prefabricated short arm splint Nondisplaced isolated distal fibular Salter- Harris I:
removable brace Isolated un or minimally displaced distal fibular Salter- Harris II:
removable brace Isolated distal fibular avulsions:
removable brace
11 20. If you would not consider using a prefabricated splint for distal radius buckle, minimally
angulated greenstick/transverse fractures or a removable brace for nondisplaced isolated distal fibular Salter Harris I, II avulsion fractures, please tell us why (check all that apply)
Distal radius fractures (buckle, minimally angulated greenstick / transverse)
Distal Fibular Fractures (nondisplaced isolated SH1,SH2, avulsions) Concerned about potential
complications
Medico-legal implications Cost/reimbursement issues Lack of availability in my practice Do not feel evidence is strong enough
My colleagues do not support this management choice
Concerned about patient compliance
Concerned about patient acceptance
Other:
12 21. Which venue do you think is the most appropriate for follow up for each of the following
fractures?
Pediatric orthopedic clinic
Orthopedic clinic
ED Minor Fracture Clinic
Primary care provider
Follow up as
needed
Other
Type I Gartland Supracondylar Fracture
Buckle Fracture of the distal radius Greenstick Fracture of Distal Radius (<
15° angulated) Transverse Fracture of Distal Radius (<
15° angulated) Distal Fibular Avulsion Fracture Nondisplaced Salter- Harris I Distal Fibula Nondisplaced Salter- Harris II Distal Fibula
22. Do you have any comments?
