O1060: Does Patient Race, Ethnicity, or Socioeconomic Status Impact Surgical Decision Making? Analysis of Casting vs. Surgery for an Archetypal Pediatric Fracture

Background: Evidence of racial and socioeconomic disparity in the orthopaedic field has been increasingly demonstrated in recent decades, however there is a lack of current literature evaluating racial and ethnic disparities in outpatient surgical decision making for common pediatric fractures. This study aims to determine if racial and economic disparities exist in surgical indications for a common pediatric upper extremity fracture that can be variably treated with operative or non-operative management.

Methods: This retrospective cohort study compared the rate of operative intervention for patients who were treated for type II supracondylar humerus fractures at a single tertiary pediatric hospital based on self-reported race or ethnicity and insurance status. Patients between the ages of 2-12 years old who were initially evaluated at an outpatient orthopedic clinic visit between 2013-2021 were included. Patients with type I or III fracture patterns, open injuries, polytrauma, vascular injuries, or underlying metabolic bone disorders were excluded.

Demographic and injury characteristics were collected for each patient including sex, race, ethnicity, insurance status, and date and mechanism of injury. The treating physician’s race was documented and grouped into white versus non-white categories. Surgical treatment, as defined by closed reduction with percutaneous pinning (CRPP) or open reduction with internal fixation (ORIF), was grouped as a single cohort and compared with the cohort of fractures that were treated nonoperatively.

Categorical variables were compared utilizing χ2 and Fisher exact tests. A significance threshold of P < 0.05 was applied in all cases.

Results: A total of 1539 patients with type II supracondylar humerus fractures were included with a mean age of 5.8+/-2.6 years (Table 1). The overall operative rate was 10.1% (155/1539). There was no difference in the operative rate based on patient race, ethnicity, or insurance status (Table 2). There was a significant difference in the operative rate based on surgeon race with non-white surgeons (5/14) having a higher operative rate than white (9/14) surgeons (14% [62/436] versus 8% [93/1103], p=0.001).

Conclusion: Given that type II supracondylar humerus fractures can be variably treated operatively or nonoperatively, there is greater potential for bias in decision making. This study suggests that surgical decision making for type II fractures is not disproportionately influenced by patient race, ethnicity, or insurance status. Since outpatient surgical decision making may represent a significant number of supracondylar humerus fractures, our results are necessary to elucidate the decision making in this area to be more representative of the entire population of patients with these injuries. Other common pediatric fractures with equivocal surgical indications should be further evaluated to understand potential for bias in decision making. It is paramount that surgeons continue efforts to eliminate disparities in surgical indications based on race and socioeconomic status.