Elsevier

Injury

Volume 42, Issue 4, April 2011, Pages 403-407
Injury

Practice variation in common fracture presentations: A survey of orthopaedic surgeons

https://doi.org/10.1016/j.injury.2010.11.011Get rights and content

Abstract

Background

Practice variation may indicate a lack of clear evidence to guide treatment. This study aims to quantify practice variation for common orthopaedic fractures, and to explore possible predictors of the variation.

Materials and methods

A nationwide electronic survey of Australian orthopaedic surgeons was performed. Five common fractures (ankle, scaphoid, distal radius, neck of humerus, and clavicle) were presented. Data on management preferences and surgeon background were gathered. Potential predictors of operative (vs. non-operative) treatment were explored.

Results

358 of 760 (47%) surgeons responded. For the ankle, undisplaced scaphoid, distal radius, neck of humerus and clavicle fractures, operative treatment was chosen in 40%, 44%, 77%, 26% and 38%, respectively. Operative treatment was significantly more likely to be chosen by more junior surgeons, and by surgeons specialising in the affected area (i.e., shoulder surgeons for clavicle and neck of humerus fractures, and hand surgeons for scaphoid and distal radius fractures).

Conclusions

Variations exist in the management of common fractures. Variation may represent legitimate improvisation for varying clinical scenarios, but it may reflect clinician bias, which in turn, may contribute to varying standards of care for the management of common conditions.

Introduction

It is generally accepted that systematic reviews of large randomised controlled trials (RCTs) offer the best evidence to guide management decisions. However, surgical trials are challenging as they can involve complex surgical procedures, must accommodate surgeon learning curves (making standardization difficult),1 and use heterogeneous patients, often with urgent surgical problems.19, 24 Well designed trials in orthopaedic surgery are sparse,27 and therefore, the management of common orthopaedic presentations may not be informed by a high level of evidence. Practice variation is a likely corollary of this and variation in orthopaedic as well as non-orthopaedic settings,6, 22, 30, 31, 32 is already well recognized. Whilst practice variation may represent legitimate improvisation for varying clinical scenarios, it may also reflect clinician bias, which may in turn contribute to varying standards of care for the management of common conditions.

The purpose of this study is to describe the management of common fractures amongst orthopaedic surgeons and to explore factors that may explain any observed variation.

Section snippets

Materials and methods

An electronic survey was sent by email to members of the Australian Orthopaedic Association (AOA), all of whom were consultant orthopaedic surgeons. The survey included nine multiple choice questions in total and was divided into two sections.

Section 1 had four questions pertaining to general information about the background of the surgeon: number of years experience as an orthopaedic consultant (0–5, 6–10, 11–15, and 16 and above years); sub-specialities that the surgeon self-identified with;

Results

A total of 803 surveys were sent by email to members of the AOA. Forty three email addresses were not found, and 5 surgeons were unable to complete the survey due to technical problems. A total of 358 responses were received (response rate 47%). 339 responders answered both sections. Most surgeons had experience 16 years and above (41%), with all other respondents divided between 0 to 5, 6 to 10, and 11 to 15 years experience (23%, 20%, and 16% respectively). 67% participated in an on-call

Discussion and conclusions

Our survey demonstrated considerable practice variation in the reported treatment of common fractures amongst orthopaedic surgeons in Australia. The survey participants were divided in their preferences between operative and non-operative management for the case presentations in this survey. Surgeons with a sub-specialty interest, such as hand surgeons and shoulder surgeons, were more likely to operate on fractures within their area of sub-specialty. Overall, less experienced orthopaedic

Conflicts of interest

No author is a recipient of a research scholarship or funding from any source. The paper is not based on a previous communication to a society or meeting.

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