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Referral Patterns Of Pediatric Closed Hand Fractures: A Case Of Inefficiency
Landis R. Walsh, BA, Laura C. Nuzzi, BA, Catherine T. McNamara, BS, Joseph M. Firriolo, MD, Amir H. Taghinia, MD, MPH, MBA, Brian I. Labow, MD.
Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.

PURPOSE: Pediatric hand fractures are common. Yet, the pathways by which these injuries are referred from initial assessment to hand specialists remain understudied. This study explores the routes by which cases of pediatric closed hand fractures reach hand specialists and their corresponding need for surgical intervention.
METHODS: The records of pediatric patients with isolated, closed hand fractures seen between 01/2017 - 12/2018 were retrospectively reviewed for referral history, transfer of care, and surgical intervention. Exclusion criteria include: open fractures, nailbed injuries, and concurrent trauma.
RESULTS: A total of 504 patients were included in analyses (mean age at initial encounter: 9.4 years). Roughly half of all cases (n=271) were referred to Boston Children's Hospital (BCH) from outside providers. Of these cases, 25% (69/271) were directly referred to the BCH Emergency Department (ED). Additionally, 90% (62/69) of these referred ED cases were then subsequently referred to a hand surgeon for management; however, only 13% (8/62) of these indirect referrals required surgery. Despite younger patients (n=188, 0-11 years) having a significantly higher referral rate from outside providers to the BCH ED than their older counterparts (n=83, 12-17 years) (29% vs 17%, p<0.05), these younger patients required surgical intervention significantly less often (5% vs 36%, p<0.01).
CONCLUSIONS: A considerable number of pediatric isolated, closed hand fractures are referred from outside providers to tertiary hospital emergency departments before they receive attention from hand surgeons. This extra referral step places a financial and time burden upon families seeking treatment for often non-emergent injuries, and surgeons alike.


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