Racial Equity in Pediatric Mandible Fracture Treatment and Outcomes: A 30 Year Analysis
Alisa O. Girard, MBS1, Lekha V. Yesantharao, BS1, Christopher D. Lopez, MD1, Cynthia T. Yusuf, BS2, Alexander K. Karius, BS1, Isabel V. Lake, BS1, Richard J. Redett, MD1, Paul N. Manson MD1, Joseph Lopez, MD MBA1, Robin Yang, MD DDS1
1Johns Hopkins University School of Medicine, Baltimore, Maryland2University of Maryland School of Medicine, Baltimore, Maryland
Background: Pediatric mandible fractures are often the consequence of severe, traumatic injuries. In this population, nonoperative management is often favored to avoid hardware-associated disruptions in growth and development. Beyond pattern of injury and management strategy, outcomes in various pediatric conditions and injuries are further influenced by factors outside of clinical judgement, such as race, sex, and socioeconomic status. To expand current knowledge of pediatric health disparities, an in-depth investigation of race as related to mandibular fractures in the pediatric patient population is warranted.
Methods: This was a 30-year retrospective, longitudinal cohort study of pediatric patients who presented to a single institution with mandibular fractures. This study included patients 15 years and younger with mandibular fractures in isolation or in combination with other facial fractures. Patient data were abstracted from medical records and compared between patients of different races. Predictor variables included patient demographics (e.g., sex, race, SES, dentition stage), injury characteristics, and approach to surgical (open reduction with internal fixation) vs. conservative (soft diet and rest, or mandibulomaxillary fixation) treatment.
Results: 176 patients met inclusion criteria and 51.1% were non-White. Non-White patients were more likely than White patients to be injured as pedestrians hit by motor vehicles than through fall-, sports-, or animal-related incidents (p=0.0008, 0.0003, and 0.0013, respectively). Non-White patients were also more likely than White patients to be injured in assault incidents than by sports- or animal-related incidents (p=0.0007 and 0.0023, respectively). White patients were more likely to present with condylar (p=0.016) and sub-condylar fractures (p=0.014), whereas significantly more non-White patients had fractures of the mandibular angle (p=0.001). The post-treatment complication rate was 26.7% among White patients and 22.2% among non-White patients. The most common complication overall was malocclusion (18.3%). Race was not found to be a predictor of median time to treatment (1 day, IQR 1-3 days vs. 1 day, IQR 0-2 days, p=0.235), choice of surgical vs. conservative treatment (p=0.524), median follow-up (p=0.758) or a variety of post-treatment complications (p=0.203 - 0.743). Maryland’s transition to an All-Payer model in 2014 also had no impact.
Conclusions: Race correlated with mechanism of injury and mandible fracture pattern. Despite this, there was no racial difference in treatment approach (operative vs. conservative) or treatment outcomes at our institution. This equity in care may be attributed to institutional ideology endorsing rapid time to treatment and/or a robust experience caring for a predominantly non-white patient population.
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