title: Evidence into practice: pediatric orthopaedic surgeon use of removable splints for common pediatric fractures.
abstract: OBJECTIVE
  Removable splints when compared with circumferential casts in randomized trials have been shown to be a safe and cost-effective method of managing many common minor distal radius and fibular fractures. This study estimated the extent to which this evidence is being implemented in clinical practice, and determined the perceived barriers to the adoption of this evidence.
  
  
  METHODS
  A cross-sectional survey of practicing orthopaedic surgeon members of the Pediatric Orthopedic Surgeons of North America (POSNA) was conducted, using a 22-item online questionnaire, and distributed using a modified Dillman technique. Survey questions were derived from and validated by literature review, expert opinion, and pilot-testing on the targeted sample before implementation.
  
  
  RESULTS
  Of the 826 eligible participants, 558 (67.6%) responded to the survey. Of these, 505 (90.5%) had completed a fellowship in pediatric orthopaedics, 335 (60.0%) worked in a university-affiliated setting, and 377 (67.6%) had been in practice for <20 years. Only 158/543 [29.1%; 95% confidence interval (CI), 25.28, 32.92] reported using a removable splint to treat buckle fractures of the distal radius; 32 (5.9%; 95% CI, 3.9, 7.9) and 8 (1.5%; 95% CI, 0.5, 2.5) would use such splints for minimally displaced greenstick and transverse fractures of the distal radius, respectively. For distal fibular avulsion fractures, 122 (22.5%; 95% CI, 19.0, 26.0) would use a removable splint; 57 (10.5%; 95% CI, 7.9, 13.1) and 28 (5.6%; 95% CI, 3.7, 7.5) would do so for nondisplaced Salter-Harris I and II fractures of the distal fibula, respectively. The most commonly reported perceived barriers to application of a removable device were concerns about patient compliance, potential complications, and possible medicolegal implications.
  
  
  CONCLUSIONS
  Only a relatively small proportion of practicing POSNA use such splints for minor distal radius and distal fibular fractures. These data support the need for implementation of knowledge translation strategies (eg, education) targeted at all the stakeholders to encourage pediatric orthopaedic surgeons to change practice in keeping with the best evidence for these common and stable injuries.
  
  
  METHODS
  Level II.
authors.affiliation: *Department of Pediatrics, Division of Emergency Medicine †Division of Orthopaedic Surgery, Department of Surgery, The Hospital for Sick Children and University of Toronto, Toronto, ON ‡Departments of Emergency Medicine and Pediatrics, Section of Pediatric Emergency Medicine, Alpert Medical School of Brown University §Rhode Island Hospital/Hasbro Children's Hospital, Providence, RI ∥Department of Orthopedic Surgery, Shriners Hospital for Children (Los Angeles), University of California, Los Angeles, CA.
authors.forename: Kathy
authors.initials: K
authors.lastname: Boutis
authors.forename: Andrew
authors.initials: A
authors.lastname: Howard
authors.forename: Erika
authors.initials: E
authors.lastname: Constantine
authors.forename: Anna
authors.initials: A
authors.lastname: Cuomo
authors.forename: Zeeshanefatema
authors.initials: Z
authors.lastname: Somji
authors.forename: Unni G
authors.initials: UG
authors.lastname: Narayanan
mesh_terms: D002370:Casts, Surgical / Q000706:statistics & numerical data*; D002648:Child; D003430:Cross-Sectional Studies; D055317:Evidence-Based Practice; D005260:Female; D005360:Fibula / Q000293:injuries / Q000601:surgery; D005592:Fracture Fixation / Q000295:instrumentation / Q000379:methods / Q000706:statistics & numerical data; D006301:Health Services Needs and Demand; D006801:Humans; D008297:Male; D009656:North America; D009985:Orthopedics / Q000706:statistics & numerical data; D010349:Patient Compliance; D010372:Pediatrics / Q000706:statistics & numerical data; D010818:Practice Patterns, Physicians'; D011364:Professional Practice / Q000706:statistics & numerical data*; D011885:Radius Fractures / Q000601:surgery*; D015203:Reproducibility of Results; D013165:Splints / Q000706:statistics & numerical data*; D011795:Surveys and Questionnaires