Recognition and management of pediatric fractures by pediatric residents

Background. Competence in basic orthopedic assessment and interpretation of radiographs is important for pediatricians because appropriate initial management of fractures can expedite therapy and minimize morbidity. However, requirements for training in orthopedics and radiology are poorly defined in pediatric residency programs. Objective. To assess the ability of pediatric residents to recognize and to manage appropriately pediatric fractures. Methods. This study involved administration of a case-based questionnaire with radiographs to volunteer categorical pediatric residents in 3 geographically diverse training programs. The diagnosis and management of 8 orthopedic complaints were evaluated. Responses were scored according to the number of features identified accurately, including the presence or absence of a fracture. Residents who were able to identify a fracture were assessed with respect to their ability to classify the fracture and to provide initial management. The study was pretested with a group of pediatric emergency medicine attending physicians, to establish the suitability of the cases. Results. Among the 3 residency sites, 102 of 190 eligible pediatric residents (53.7%) participated, yielding 95 completed questionnaires. The mean number of cases in which a resident correctly answered the question, "Is a fracture present?" and correctly identified the fractured bone (if a fracture was present) was 6.5 +/- 1.2 of 8 cases (81.6%; 95% confidence interval: 78.5-84.7%). The diagnostic accuracy of Salter-Harris classification in cases in which such fractures were present was 40.9%. The mean score of correctly identified features for the resident group was 38.5 +/- 9.4, of a possible 64 points (proportion correct: 60.1%; 95% confidence interval: 57.2-63%). There was a small but significant difference in mean correct responses between first-year residents (proportion correct: 55.4%; 95% confidence interval: 50.8-60.3%) and third-year residents (proportion correct: 65.1%; 95% confidence interval: 60.7-69.5%). There was no association between the proportion of correct responses and whether or not residents had taken radiology or orthopedics elective courses in medical school. Overall, 43% of cases were both identified and managed correctly by the pediatric residents. Conclusions. For residents from the participating training programs, skills in recognizing and managing pediatric fractures were suboptimal. Additional review of training requirements is necessary to identify more clearly areas of improvement for current curricula.