
==== Front
J Orthop Trauma
J Orthop Trauma
jot
Journal of Orthopaedic Trauma
0890-5339
1531-2291
Journal of Orthopaedic Trauma

39058354
JOT15499
10.1097/BOT.0000000000002875
00011
3
Original Articles
The Dangers of Distracted Driving: A Substudy of Patient Perception Data From the DRIVSAFE Observational Study
Gjorgjievski Marko MD
Petrisor Bradley MD
Williams Dale MD
Denkers Matthew MD
Rajaratnum Krishan MD
Johal Herman MD
Al-Asiri Jamal MD
Chaudhry Harman MD, MSc
Nauth Aaron MD, MSc
Hall Jeremy MD, Med
Whelan Daniel MD, MSc
Ward Sarah MD, MSc, MLA
Atrey Amit MD, MSc
Khoshbin Amir MD, MSc
Leighton Ross MD
Glazebrook Mark MD
Coady Catherine MD
Biddulph Michael MD
Morash Joel MD
Reardon Gerald MD
Oxner William MD
Coles Chad MD
Trenholm James MD
Dunbar Michael MD, PhD
Richardson Glen C. MD, MSc
Wong Ivan MD
Glennie Andrew MD
Johnston David MD
Duffy Paul MD
Schneider Prism MD, PhD
Korley Robert MD
Buckley Richard MD
Martin Ryan MD
Beals Lauren MD
Elgie Cameron MD
Ginsberg Lydia BSc
Mehdian Yasna BSc
McKay Paula BSc
Simunovic Nicole MSc
Ratcliffe Jenna BSc
Sprague Sheila PhD
Li Silvia MSc
Vicente Milena RN-CCRP
Scott Taryn MSc
Hidy Jennifer BSc
Suthar Paril BSc
Harrison Tanja MPA
Dillabough Kaitlyn MSc
Yee Stephanie BSC
Garibaldi Alisha MSc
Trask Kelly MSc
O’Connor Catherine MSc
Bhandari Mohit MD, PhD
Ristevski Bill MD
The DRIVSAFE Team
From Queen's University, Kingston, Ontario Canada
Reprints: Marko Gjorgjievski, MD, Victory 3, Kingston General Hospital, 76 Stuart St, Kingston, ON K7L 2V7, Canada (e-mail: markogjorgjievski@gmail.com).
10 2024
24 9 2024
38 10 e347e354
16 7 2024
Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc.
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

Supplemental Digital Content is Available in the Text.

OBJECTIVE:

To determine how fracture clinic patients perceive the dangers of distracted driving.

METHODS:

Design:

Analysis of patient perception subset data from the original DRIVSAFE study; a large, multicenter cross-sectional study, surveying fracture clinic patients about distracted driving.

Setting:

Four Level 1 Canadian trauma center fracture clinics.

Patient Selection Criteria:

English-speaking patients with a valid Canadian driver's license and a traumatic musculoskeletal injury sustained in the past 6 months.

Outcome Measures and Comparisons:

Primary outcome was patients' safety ratings of driving distractions. As per the original DRIVSAFE study, patients were categorized as distraction-prone or distraction-averse using their questionnaire responses and published crash-risk odds ratios (ORs). A regression analysis was performed to identify associations with unsafe driving perceptions.

RESULTS:

The study included 1378 patients, 749 (54.3%) male and 614 (44.6%) female. The average age was 45.8 ± 17.0 years (range 16–87). Sending electronic messages was perceived as unsafe by 92.9% (1242/1337) of patients, while reading them was seen as unsafe by 81.2% (1086/1337). Approximately three-quarters of patients viewed making (78.9%, 1061/1344) and accepting (74.8%, 998/1335) calls on handheld mobile phones as unsafe. However, 31.0% (421/1356) of patients believed that they had no differences in their driving ability when talking on the phone while 13.1% (175/1340) reported no driving differences when texting. Younger age (OR, 0.93 [95% confidence interval (CI) 0.90–0.96], P < 0.001), driving experience (OR, 1.06 [95% CI 1.02–1.09], P < 0.001), and distraction-prone drivers (OR, 3.79 [95% CI 2.91–4.94], P < 0.001) were associated with unsafe driving perceptions.

CONCLUSIONS:

There is a clear association between being prone to distractions and unsafe driving perceptions, with distraction-prone drivers being 3.8 times more likely to perceive driving distractions as safe. This information could potentially influence the appropriate delivery and content of future educational efforts to change the perception of driving distractions and thereby reduce distracted driving.

LEVEL OF EVIDENCE:

Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

KEY WORDS:

distracted driving
patient perception
mobile phones
orthopaedic trauma
Canadian Orthopaedic Research Legacy GrantN/A Bill RistevskiPhysicians' Services Incorporated FoundationN/A Bill RistevskiRegional Medical Associates of HamiltonN/A Bill RistevskiOPEN-ACCESSTRUE
SDCT
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pmcINTRODUCTION

Road traffic collisions are the leading cause of death in the first 3 decades of life.1 As distracted driving is a global phenomenon and contributes to many of these tragedies, it has become a priority for the World Health Organization.2 It is estimated that approximately 21% of fatalities and 27% of serious injuries resulting from motor vehicle collisions (MVCs) are due to distracted driving,3 with an estimated financial impact of $123 billion annually for direct and indirect costs in the United States alone.4

Engaging with mobile phones, eating or drinking, programming a navigation system, daydreaming, interacting with children, and reaching for objects while driving are all examples of distracted driving5 and can increase collision risk. Manipulating a car radio doubles the chance of collision, as does eating or drinking,6 and programming a navigation system, now a standard feature of almost every vehicle, has been identified as the most demanding and distracting task.7 According to a report compiled using data from the Fatality Analysis Reporting System, the most common driving distraction involved in MVC fatalities is daydreaming.8

The presence of in-vehicle electronic devices and the rapid increase in mobile phone usage have inadvertently contributed to the rise of distracted driving.9 Mobile phones have been extensively studied, and their adverse effects on driving performance, compliance with traffic regulations, and drivers' reaction times have been demonstrated in numerous studies.10–12 In general, phone use quadruples the crash risk,13,14 dialing on a handheld phone raises it by 12 times,6 and sending electronic messages increases the risk by 23 times.15 Furthermore, studies have demonstrated that talking on a handheld and a hands-free phone is associated with an almost identical crash risk16

There is room for improvement in some of the campaigns aimed at reducing distracted driving. Information available online on distracted driving focuses primarily on death.17,18 However, research has shown that fear-based content is less effective than efficacy-based content19 and that public health efforts should aim to correct misconceptions related to driver distraction and crash risk, as risk perception is a strong predictor of distracted driving behaviors in adolescents.20 Campaigns aside, most of Canada21 and the United States22 have some form of legislation regulating phone use while driving, but despite increased legislation, fines, and education, people still engage in distracted driving regularly.23

Understanding why distracted driving is so prevalent, despite the safety risks is crucial for developing effective strategies for reducing distracted driving. Examining drivers' perceptions of the safety of distractions will help understand if misinterpreting distractions as being safe is contributing to distracted driving. Therefore, the null hypothesis is that there are no differences in unsafe perceptions about distractions between drivers prone to distracted driving and drivers who are not. Considering that MVCs are responsible for a large portion of musculoskeletal injuries,24 this study set out to acquire information on distracted driving perceptions from patients attending fracture clinics.

METHODS

Study Design and Setting

This study was designed to evaluate patients' perceptions of the safety of clearly identified and proven driving distractions. This secondary substudy analysis data were derived from the previously published DRIVSAFE study, a cross-sectional study, which recruited 1378 patients from 4 level 1 trauma centers in Canada (Hamilton, ON; Toronto, ON; Calgary, AB; Halifax, NS).23 Details of the primary research questions and methods were previously reported.23 In the current secondary analysis, an anonymous questionnaire evaluating drivers' behaviors, experiences, and views on distracted driving was administered to the patients. Ethics approval was obtained from the Hamilton Integrated Research Ethics Board (reference REB #15-334) and local Research Ethics Boards for each site.

Participant Selection Criteria

The original study recruited patients with a valid Canadian driver's license, able to speak English, and who visited the Orthopaedic clinic for a traumatic musculoskeletal injury sustained within the past 6 months. Exclusion criteria included patients who had not driven in the past 12 months, were cognitively impaired, or those whose injuries prevented them from completing the questionnaire (Form, see Appendix A, Supplemental Digital Content 1, http://links.lww.com/JOT/C307, shows the study Screening Form). Selection bias was minimized by approaching patients consecutively for screening. Patients who were eligible, willing to participate, and who provided informed consent were given the questionnaire to complete. Patient questionnaires were collected by the treating physician, who then completed the final portion of the survey regarding injury demographics. Finally, the study coordinator collected the questionnaire and entered the responses into the data capture system.

Survey Methods and Outcomes

The questionnaire design was based on data from the current literature on traffic-related injuries and included consultations with Orthopaedic trauma surgeons regarding their experiences treating distracted-driving injuries. A Likert scale format was selected, and questions from the National Highway Traffic Safety Administration National Survey on Distracted Driving were incorporated.25 The questionnaire included 36 questions across 7 sections; the first 6 sections to be completed by the patient, and the last section to be completed by the treating surgeon (Survey, see Appendix B, Supplemental Digital Content 2, http://links.lww.com/JOT/C308, shows the Distracted Driving Questionnaire) The questionnaire collected data on demographics (age, sex, income, education, household income), current injuries (type, cause, severity), and driving history, including distracting behaviors (mobile phone-related and other distractions), current collisions, and collision history (past MVCs and near-crashes). The sixth section of the questionnaire focused on the patient's perceptions about distracted driving, which is the focus of the data presented in this article. The primary outcome was the patients' perceived safety ratings of driving distractions.

Sample Size

The sample size was based on the original DRIVSAFE study, which used regression analysis examining associations between demographic variables and distracted driving behaviors. A conservative event rate of 20% was used, which was derived from the percentage of the people acknowledging an injury sustained from a distracted driving crash, which ranges from 21% to 31% in the reported literature describing these injuries.26,27 To provide a stable model for 17 predictors with a 95% confidence interval (CI) (5% width around the anticipated event rate) with a 20% event rate and 15 events per predictor, a sample size of 1300 patients was calculated.

Statistical methods: Distracted driving scores for each patient were calculated using the crash-risk odds ratio (OR) for distractions taken from published studies (see Appendix C, Table, Supplemental Digital Content 3, http://links.lww.com/JOT/C309, shows ORs for distractions used in the distracted driving scores calculations)6,15,16,28–31 and patients' responses from questions 12 (a-q), 13 (a-e), and 15 (a-b, d-e). Descriptive statistics were presented as percentages. As per the original DRIVSAFE study, patients were categorized as distraction-prone or distraction-averse depending on whether they were above or below the median of the distracted driving score, respectively.23 Patients scoring above the median were considered distraction-prone. A multivariable logistic regression analysis was performed between independent variables (age, years of driving experience, gender, household income, highest education level, and risk groups) and unsafe perceptions about distracted driving. Patients' responses to questions 27 (a-q), 28 (a-g), and 29 (a-b, d-e) were used to define unsafe driving perceptions. These questions asked patients to rank distractions as “Safe”, “Somewhat Safe”, and “Unsafe”. An unsafe perception was coded when the patient ranked these proven driving distractions as “Safe”.

RESULTS

A total of 2517 patients were screened for inclusion, 1378 of whom agreed to participate (848 were ineligible, and 291 declined) with an overall response rate of 82.6% (1378 of 1669) (Chart, see Figure, Supplemental Digital Content 4, http://links.lww.com/JOT/C310, shows the total number of screened, enrolled, and ineligible patients). There were 749 male (54.3%) and 614 female patients (44.6%) (1.1% not disclosed). The average age was 45.8 years, and the average driving experience was 27.5 years (see Table, Supplemental Digital Content 5, http://links.lww.com/JOT/C312, shows the patients' demographic characteristics). When reviewing the results below, it should be noted that due to different number of patients answering each question, some of the data have different denominators.

Regarding situations involving talking on the phone (Fig. 1), the activity identified as the most unsafe was making a phone call on a handheld device while driving, with 78.9% of patients ranking this activity as unsafe (1061/1344), followed closely by accepting phone calls on a handheld phone (74.8%, 998/1335). Dialing or accepting phone calls on a hands-free device while driving was generally considered less dangerous, with 13.0% (175/1344) and 11.0% (145/1324) of the patients describing these activities as unsafe, respectively. Accepting a phone call only after pulling over to a secure location was viewed as a safe practice, with only 4.8% of patients ranking this as unsafe (65/1343).

FIGURE 1. Patients' perceptions on the “safety” of different driving distractions involving talking on the phone.

Assessing situations involving texting while driving (Fig. 2), the patients identified sending electronic messages while continuing to drive as the most unsafe activity (92.9%, 1242/1337), followed by reading electronic messages (81.2%, 1086/1337). Interestingly, regarding the use of the voice command feature to text, only 21.4% (284/1328) of patients considered this practice unsafe. Sending texts only after the driver pulled over to a secure location was considered the safest practice involving electronic messages, with only 12.9% (171/1326) of patients ranking this activity as unsafe.

FIGURE 2. Patients' perceptions on the “safety” of different driving distractions involving sending electronic messages.

For nonmobile phone distractions (Fig. 3), the most unsafe behaviors perceived by patients were reading a book (99.3%, 1322/1331 rating this unsafe), followed by using a laptop while driving (98.6%, 1314/1332 rating this unsafe) and browsing the web (98.2%, 1283/1306 rating as unsafe). Daydreaming was perceived as unsafe by 67.5% (902/1337). By contrast, very few patients felt that listening to the radio, talking with a passenger, and singing along to a song were dangerous, with only 2.9% (39/1340), 3.0% (40/1342), and 4.9% (62/1335) reporting these distractions as unsafe, respectively.

FIGURE 3. Patients' perceptions on the “safety” of different driving distractions.

When asked whether they experienced differences in their driving when engaging in distractions, 31.0% (421/1356) of patients stated that there were no differences for talking on a mobile phone, and 13.1% (175/1340) perceived no differences while texting (Table 1). However, 33.7% (457/1356) and 58.7% (786/1340) of patients reported never talking on the phone or texting when driving. Therefore, when excluding patients who reported never using a mobile device while driving, the percentage of drivers who felt unaffected by mobile phone usage while driving climbed to 46.8% (421/899) for talking and 31.6% (175/554) for texting, respectively.

TABLE 1. Patient Perception on Differences in Driving When Engaging in Mobile Phone Distractions

Variable	Talking on the phone (%)*	Sending Electronic Messages (%)*	
Differences in driving when using mobile phone	1,356 (100)	1340 (100)	
 Yes	478 (35.3)	379 (28.3)	
 No difference	421 (31.0)	175 (13.1)	
 Never do it while driving	457 (33.7)	786 (58.7)	
Patients that did use mobile phone while driving†	899 (66.3)	554 (41.3)	
 Yes	478 (53.2)	379 (68.4)	
 No difference	421 (46.8)	175 (31.6)	
* The values are given as the number of patients, with the percentage in parentheses.

† This group consists of patients who responded with Yes and No difference.

The average time patients believed that it was safe for a driver to take their eyes off the road was 2.5 seconds ± 0.21 (95% CI 2.29–2.71, SD 22.8%) (see Table, Supplemental Digital Content 6, http://links.lww.com/JOT/C313, shows the patients' perceptions on taking eyes of the road and prevalence of mobile phone distractions). In addition, patients believed that other drivers at least occasionally talked on a mobile phone or texted while driving 66.0% ± 1.23% (95% CI 64.8%–67.2%, SD 22.8%) and 57.5% ± 1.29% (95% CI 56.2%–58.8%, SD 23.8%), respectively. The patients' views on potential legislation regarding distracted driving were also examined, and the majority of them (84.2%, 1126/1338) answered that they would support a ban on handheld devices while driving (see Chart, Supplemental Digital Content 7, http://links.lww.com/JOT/C311, shows patients' view on legislation regarding handheld phone use while driving).

Distracted driving scores were calculated for 1249 patients. The scores ranged from 49.2 to 287.2 points. The median score (153.2 points) was used as a cutoff to classify patients as distraction-prone or distraction-averse. Patients with younger age (OR, 0.93 [95% CI 0.90–0.96], P < 0.001), more driving experience (OR, 1.06 [95% CI 1.02–1.09], P < 0.001), and distraction-prone drivers (OR, 3.79 [95% CI 2.91–4.94], P < 0.001) were associated with unsafe perceptions for distracted driving (Table 2). Interestingly, lower education level was inversely associated with unsafe distracted driving perceptions (OR, 0.27 [95% CI 0.10–0.77], P = 0.001).

TABLE 2. Multivariable Regression Analysis Results for Associations Between Independent Variables and Unsafe Perceptions

Variable*	No. of Patients†	OR‡	P §	
Age, per year		0.93 (0.90–0.96)	0.00	
Years of having a driver's license		1.06 (1.02–1.09)	0.00	
Gender				
 Male	605 (56.2%)	1.19 (0.92–1.54)	0.18	
 Female (reference)	702 (43.8%)	1.00	—	
Household income				
 ≥$100,000	357 (28.6%	1.03 (0.64–1.66)	0.90	
 $80,000–<$100,000	185 (14.8%)	0.94 (0.56–1.57)	0.80	
 $60,000–<$80,000	182 (14.6%)	0.89 (0.53–1.49)	0.66	
 $40,000–<$60,000	202 (16.2%)	0.88 (0.53–1.46)	0.61	
 $20,000–<$40,000	191 (15.3%)	0.76 (0.46–1.26)	0.29	
 <$20,000 (reference)	132 (10.6%)	1.00	—	
Highest level of education				
 University	434 (34.7%)	0.56 (0.22–1.41)	0.22	
 College or trade school	459 (36.7%)	0.39 (0.16–0.98)	0.05	
 High-school diploma	265 (21.2%)	0.39 (0.16–1.00)	0.05	
 Some high-school education	67 (5.4%)	0.27 (0.10–0.77)	0.01	
 No high-school education (reference)	24 (1.9%)	1.00	—	
Risk group				
 Distraction-prone	624 (50.0%)	3.79 (2.91–4.94)	0.00	
 Distraction-averse (reference)	625 (50.0%)	1.00	—	
* The reference category is the lowest-ranked group.

† The values are given as the number of patients, with the marginal percentage in parentheses.

‡ The values are given as the OR, with the 95% CI in parentheses.

§ Values <0.05 were considered as statistically significant.

DISCUSSION

Driver behavior is influenced by what the driver believes to be acceptable norms and what they perceive to be high-risk activity. Any driver education or public-service announcements should therefore be directed at changing these perceptions. The information presented in this study will hopefully inform future efforts to reduce the incidence of distracted driving.

The original DRIVSAFE study recruited 1378 fracture clinic patients, which provided information regarding their behaviors and perceptions about distracted driving. The findings of this substudy suggest that most patients recognized the dangers of distracted driving. For example, almost all patients (98.2%) identified browsing the web while driving as unsafe, and 67.5% also described daydreaming as not being safe. Conversely, 79.2% of the patients rated listening to the radio as safe, and two-thirds (66.5%) responded that talking to a passenger in the vehicle was safe. These answers show that the patients recognize that some distractions are more dangerous than others. Of note, although some studies have considered talking to a passenger while driving as a distraction,27,32 the impact of this activity on driving has been questioned, with other studies reporting positive effects.33,34

Patients also demonstrated a good understanding of the dangers related to mobile phone distractions. Eight of 10 (78.9%) patients responded that making a phone call on a handheld device while driving was unsafe, and three-quarters (74.8%) said the same for accepting calls on a handheld device. In addition, 92.9% and 81.2% of the patients viewed reading or sending electronic messages as unsafe. Patients also identified that the best practice for answering a phone call or sending a text would be to pull over to a secure location before engaging in these activities, with 88.8% and 76.8% describing this as safe. Previous studies examining the crash risks for mobile phone distractions support that patients in this study correctly recognized these distractions as highly dangerous.6,15

In the original DRIVSAFE study and this current study, by using a method of calculating reported engagement in distractions weighted by crash-risk odds ratios, patients more inclined to engage in distracted driving were classified as “distraction-prone”.23 Furthermore, the “distraction-prone” group of patients was significantly associated with having an MVC. The findings in this study show that “distraction-prone” patients were also associated with unsafe perceptions of distracted driving. This demonstrates a strong connection between unsafe distracted driving perceptions and distracted driving behaviors. Younger age and more driving experience were also associated with unsafe driving perceptions. These findings are in line with the current literature, as adolescents with more driving experience tend to have riskier beliefs about distracted driving, with younger drivers, in general, being more likely to engage in distracted driving and are more often involved in distraction-related MVCs.23,35,36

Even though the patients fundamentally recognized that distractions are dangerous, there still seems to be a lack of understanding of the true extent of the danger. In this study, the average time patients believed that it was safe for a driver to take their eyes off the road was 2.54 seconds. However, if a person driving 55 mph closed their eyes for that time, they would travel more than half the length of a football field without looking at the road.15

In addition, a substantial group of patients were overconfident in their driving abilities. Nearly half (46.8%) of all the patients who talk on mobile phones and almost a third (31.6%) of all the patients who send electronic messages while driving stated they perceived no differences in their driving. Studies show that the percentage of people who can successfully multitask while driving is substantially lower at approximately 2.5%,37 demonstrating a huge disconnect between perceived and actual abilities. In addition, when asked about the percentage of drivers who at least occasionally talk on a mobile phone or text while driving, patients estimated 66.0% and 57.5%, respectively, which is considerably higher than what data from observational studies show.38,39 This suggests patients perceive mobile device use while driving as “normal” activity, despite evidence to the contrary.

Legislation could also play a role in perceptions of acceptable behavior. Nearly every province in Canada21 and state in the United States22 have some form of legislation regulating handheld phone use while driving, while none ban the use of hands-free phones. That could explain why most patients believed that hands-free phone calls were a safer option than handheld, 38.5% versus 2.8% for making and 41.4% versus 3.9% for answering calls. A review of the literature on distracted driving, however, showed that there was reduction in risk while driving when comparing handheld and hands-free phone conversations.13,14,38 Furthermore, Strayer also reported that even using hands-free phones while driving led to delayed reaction times and increased the chance of a collision.40 Changes in legislation regarding the use of hands-free devices might also change driver perception of risk associated with the use of this technology.

One of the main limitations of this study was that data quality depended on the patients' ability to provide accurate and truthful answers. However, as the questions were assessing only the patients' perceptions of distracted driving and thus had no legal consequences, this effect was hopefully reduced, and by having a larger sample size, the effect of data skewing present with smaller sample sizes was further minimized. The large sample size and high response rate of this study likely helped to decrease some biases; however, recall bias is still a potential factor. Excluding patients who were too injured to complete the survey and not including people who were in a distracted driving MVC but did not present to the fracture clinics or who potentially succumbed to their injuries because of a distracted-driving event could also be considered a study limitation.

CONCLUSION

This study showed that there is a clear association between being prone to distractions and unsafe distracted driving perceptions. Distraction-prone drivers were 3.8 times more likely to perceive driving distractions as safe, confirming this strong connection. In addition, drivers substantially underestimated the deleterious effect talking and texting on mobile phones have on their own driving ability, despite the majority of drivers perceiving distracted driving as dangerous. Understanding how high-risk behavior is rooted in unsafe perceptions could influence the appropriate delivery and content of educational efforts to reduce distracted driving. Future studies should focus on changing driver perceptions and devising effective targeted educational content to reduce distracted driving, especially in younger distracted drivers.

Supplementary Material

SUPPLEMENTARY MATERIAL

APPENDIX. The DRIVSAFE Team

The DRIVSAFE Team consists of: Marko Gjorgjievski, MD (Queen's University, Kingston, ON, Canada); Bradley Petrisor, MD (McMaster University, Hamilton, ON, Canada); Dale Williams, MD (McMaster University, Hamilton, ON, Canada); Matthew Denkers, MD (McMaster University, Hamilton, ON, Canada); Krishan Rajaratnum, MD (McMaster University, Hamilton, ON, Canada); Herman Johal, MD (University of Calgary, Calgary, AB, Canada); Jamal Al-Asiri, MD (McMaster University, Hamilton, ON, Canada); Harman Chaudhry, MD, MSc (University of Toronto, Toronto, ON, Canada); Aaron Nauth, MD, MSc (University of Toronto, Toronto, ON, Canada); Jeremy Hall, MD (University of Toronto, Toronto, ON, Canada); Daniel Whelan, MD, MSc (University of Toronto, Toronto, ON, Canada); Sarah Ward, MD, MSc, MLA (University of Toronto, Toronto, ON, Canada); Amit Atrey, MD, MSc (University of Toronto, Toronto, ON, Canada); Amir Khoshbin, MD, MSc (University of Toronto, Toronto, ON, Canada); Ross Leighton, MD (Dalhousie University, Dalhousie, NS, Canada); Mark Glazebrook, MD (Dalhousie University, Dalhousie, NS, Canada); Catherine Coady, MD (Dalhousie University, Dalhousie, NS, Canada); Michael Biddulph, MD (Dalhousie University, Dalhousie, NS, Canada); Joel Morash, MD (Dalhousie University, Dalhousie, NS, Canada); Gerald Reardon, MD (Dalhousie University, Dalhousie, NS, Canada); William Oxner, MD (Dalhousie University, Dalhousie, NS, Canada); Chad Coles, MD (Dalhousie University, Dalhousie, NS, Canada); James Trenholm, MD (Dalhousie University, Dalhousie, NS, Canada); Michael Dunbar, MD, PhD (Dalhousie University, Dalhousie, NS, Canada); Glen C. Richardson, MD, MSc (Dalhousie University, Dalhousie, NS, Canada); Ivan Wong, MD (Dalhousie University, Dalhousie, NS, Canada); Andrew Glennie, MD (Dalhousie University, Dalhousie, NS, Canada); David Johnston, MD (Dalhousie University, Dalhousie, NS, Canada); Paul Duffy, MD (University of Calgary, Calgary, AB, Canada); Prism Schneider, MD, PhD (University of Calgary, Calgary, AB, Canada); Robert Korley, MD (University of Calgary, Calgary, AB, Canada); Richard Buckley, MD (University of Calgary, Calgary, AB, Canada); Ryan Martin, MD (University of Calgary, Calgary, AB, Canada); Lauren Beals, MD (University of Calgary, Calgary, AB, Canada); Cameron Elgie, MD (Northern Ontario School of Medicine, Thunder Bay, ON, Canada); Lydia Ginsberg, BSc (University of Calgary, Calgary, AB, Canada); Yasna Mehdian, BSc (University of Western Ontario, London, ON, Canada); Paula McKay, BSc (McMaster University, Hamilton, ON, Canada); Nicole Simunovic, MSc (McMaster University, Hamilton, ON, Canada); Jenna Ratcliffe, BSc (McMaster University, Hamilton, ON, Canada); Sheila Sprague, PhD (McMaster University, Hamilton, ON, Canada); Silvia Li, MSc (McMaster University, Hamilton, ON, Canada); Milena Vicente, RN-CCRP (University of Toronto, Toronto, ON, Canada); Taryn Scott, MSc (McMaster University, Hamilton, ON, Canada); Jennifer Hidy, BSc (University of Toronto, Toronto, ON, Canada); Paril Suthar, BSc (University of Toronto, Toronto, ON, Canada); Tanja Harrison, MPA (University of Calgary, Calgary, AB, Canada); Kaitlyn Dillabough, MSc (University of Calgary, Calgary, AB, Canada); Stephanie Yee, BSC (University of Calgary, Calgary, AB, Canada); Alisha Garibaldi, MSc (McMaster University, Hamilton, ON, Canada); Kelly Trask, MSc (Dalhousie University, Dalhousie, NS, Canada); Catherine O'Connor, MSc (Dalhousie University, Dalhousie, NS, Canada); Mohit Bhandari, MD, PhD (McMaster University, Hamilton, ON, Canada); Bill Ristevski, MD (McMaster University, Hamilton, ON, Canada).

Funding: Canadian Orthopaedic Research Legacy Grant, Physicians' Services Incorporated Foundation, Regional Medical Associates.

The authors report no conflict of interest.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.jorthotrauma.com).
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