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. 2021 Nov;141(11):2011-2018.
doi: 10.1007/s00402-021-04062-0. Epub 2021 Jul 24.

Factors associated with surgeon recommendation for additional cast immobilization of a CT-verified nondisplaced scaphoid waist fracture

Anne Eva J Bulstra  1   2 , Tom J Crijns  3 , Stein J Janssen  4 , Geert A Buijze  5 , David Ring  3 , Ruurd L Jaarsma  6 , Gino M M J Kerkhoffs  4 , Miryam C Obdeijn  7 , Job N Doornberg  6   4 ; Science of Variation Group
Collaborators, Affiliations

Factors associated with surgeon recommendation for additional cast immobilization of a CT-verified nondisplaced scaphoid waist fracture

Anne Eva J Bulstra et al. Arch Orthop Trauma Surg. 2021 Nov.

Abstract

Introduction: Data from clinical trials suggest that CT-confirmed nondisplaced scaphoid waist fractures heal with less than the conventional 8-12 weeks of immobilization. Barriers to adopting shorter immobilization times in clinical practice may include a strong influence of fracture tenderness and radiographic appearance on decision-making. This study aimed to investigate (1) the degree to which surgeons use fracture tenderness and radiographic appearance of union, among other factors, to decide whether or not to recommend additional cast immobilization after 8 or 12 weeks of immobilization; (2) identify surgeon factors associated with the decision to continue cast immobilization after 8 or 12 weeks.

Materials and methods: In a survey-based study, 218 surgeons reviewed 16 patient scenarios of CT-confirmed nondisplaced waist fractures treated with cast immobilization for 8 or 12 weeks and recommended for or against additional cast immobilization. Clinical variables included patient sex, age, a description of radiographic fracture consolidation, fracture tenderness and duration of cast immobilization completed (8 versus 12 weeks). To assess the impact of clinical factors on recommendation to continue immobilization we calculated posterior probabilities and determined variable importance using a random forest algorithm. Multilevel logistic mixed regression analysis was used to identify surgeon characteristics associated with recommendation for additional cast immobilization.

Results: Unclear fracture healing on radiographs, fracture tenderness and 8 (versus 12) weeks of completed cast immobilization were the most important factors influencing surgeons' decision to recommend continued cast immobilization. Women surgeons (OR 2.96; 95% CI 1.28-6.81, p = 0.011), surgeons not specialized in orthopedic trauma, hand and wrist or shoulder and elbow surgery (categorized as 'other') (OR 2.64; 95% CI 1.31-5.33, p = 0.007) and surgeons practicing in the United States (OR 6.53, 95% CI 2.18-19.52, p = 0.01 versus Europe) were more likely to recommend continued immobilization.

Conclusion: Adoption of shorter immobilization times for CT-confirmed nondisplaced scaphoid waist fractures may be hindered by surgeon attention to fracture tenderness and radiographic appearance.

Keywords: Cast; Decision-making; Fracture; Immobilization; Scaphoid.

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Conflict of interest statement

One or more of the authors has received personal research grants from Marti-Keuning Eckhardt Stichting (AEB), Prins Bernhard Cultuurfonds (AEB), Jo Kolk Studiefonds (AEB). One or more authors (GB) certifies that that he or she has received editorial fees from Elsevier publisher unrelated to this work.

Figures

Fig. 1
Fig. 1
random forest variable importance score of predictor patient variables for surgeon recommendation to continue or not continue cast immobilization. Ranked importance score of each patient variable as a predictor for surgeon recommendation to continue cast immobilization. The variable importance score is normalized to the most important variable having an importance score of one
See this image and copyright information in PMC

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