https://orcid.org/0009-0009-8591-8884
Figures
Abstract
Orthopedic trauma disproportionately affects vulnerable populations in the United States, yet the influence of social determinants of health (SDOH) on patient outcomes remains underexplored. This scoping review aims to map and evaluate existing literature on the relationship between SDOH and adult orthopedic trauma outcomes in the U.S., with the goal of identifying research trends, gaps, and priorities for future investigation. Following the JBI methodology for scoping reviews and reported according to PRISMA-ScR guidelines, seven databases were systematically searched. Eligible studies included adult patients (≥18 years) treated for orthopedic trauma in U.S. trauma centers and examined outcomes in relation to SDOH domains. From 8,105 initial records, 40 studies met inclusion criteria. The majority employed retrospective designs (70%) and were conducted at single institutions (52.5%). Social and community context (80%) and healthcare access (57.5%) were the most frequently studied SDOH domains, whereas education access and quality was rarely addressed (7.5%). Lower extremity (35%) and hip (22.5%) injuries were most studied, with surgical management predominating (70%). Reported outcomes varied widely, with mortality (32.5%), length of stay (30%), infection (22.5%), and re-operation (22.5%) being most common. This review highlights both the breadth and fragmentation of current evidence, revealing significant gaps in the study of underrepresented SDOH domains and non-surgical trauma care. Future research should prioritize standardized SDOH data collection and increased investigation of non-surgical trauma outcomes in order to inform equitable clinical practice and guide policy in US orthopedic trauma care.
Citation: Rumana R, Mosher H, Landau R, Hneiny L, Hernandez G (2025) The influence of social determinants of health on orthopedic trauma outcomes in the United States: A scoping review. PLOS Glob Public Health 5(12): e0005573. https://doi.org/10.1371/journal.pgph.0005573
Editor: Julia Robinson, PLOS: Public Library of Science, UNITED STATES OF AMERICA
Received: August 20, 2025; Accepted: December 11, 2025; Published: December 29, 2025
Copyright: © 2025 Rumana et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: All data are in the paper and the Supporting Information files.
Funding: The author(s) received no specific funding for this work.
Competing interests: The authors have declared that no competing interests exist.
Introduction
The United States is home to a racially, ethnically, and socioeconomically diverse population; however, this diversity is not always adequately reflected in clinical research, particularly in fields like orthopedic trauma that depend heavily on equitable access to care and consistent follow-up for recovery. Numerous barriers, such as limited awareness of research opportunities, cultural stigma, and mistrust in clinical institutions, contribute to the underrepresentation of marginalized groups [1,2]. In addition to these patient-level barriers, limited access to research and training mentorship for investigators from historically underrepresented backgrounds contribute to a research workforce that does not fully reflect the diversity of the US population [3,4]. This lack of diversity influences which questions are prioritized and can reduce cultural relevance and trust during study recruitment [5]. As a result, inequitable research opportunities for diverse investigators indirectly perpetuate the under-representation of marginalized groups in orthopedic trauma studies. Together, these factors highlight the importance of examining how structural and social determinants shape participation and outcomes in orthopedic trauma research.
These disparities are closely linked to social determinants of health (SDOH), which are defined as the non-medical factors that influence health outcomes [6]. The key domains of SDOH include healthcare access and quality, neighborhood and built environment, economic stability, education access and quality, and social and community context. Each of these domains contains a range of interrelated factors that can significantly influence individual health outcomes. Healthcare access and quality involves the availability, affordability, and quality of medical services. Neighborhood and built environment encompass physical surroundings such as housing, transportation, and infrastructure. Economic stability includes income, employment, and financial security. Education access and quality refers to the availability and standard of early childhood, primary, secondary, and higher education. Social and community context includes gender, sex, race, ethnicity, social relationships, and community support systems. Many of these social determinants are deeply interconnected. For example, education, employment, and housing collectively contribute to a person’s socioeconomic status. While some factors, such as race and ethnicity, are unchangeable demographic characteristics that are markers of structural and systemic inequities, others can be modified through policy and healthcare interventions.
In the context of orthopedic trauma, these social determinants play a critical role. Orthopedic trauma injuries—ranging from isolated fractures to complex, multi-system injuries—can be life-altering, requiring patients to navigate complex treatment and rehabilitation processes [7]. Effective recovery often depends on patients’ ability to understand and adhere to treatment plans, which may be influenced by their educational background, economic situation, social support, and access to care [8–12]. Understanding these relationships are essential for developing effective orthopedic trauma care strategies.
Existing literature has shown that orthopedic trauma can profoundly impact a person’s socioeconomic status, psychological well-being, and overall quality of life [13]. Key social factors such as race and ethnicity, housing stability, education level, employment status, and availability of social support have been identified as influential to patient outcomes [14]. Social support—while fluid—can significantly deteriorate following a traumatic injury, potentially complicating recovery [15]. Orthopedic trauma is a broad field whereas it encompasses both the surgical and nonoperative management of injuries affecting many parts of the body including the upper and lower extremities, hip, and pelvis. While there is existing literature on specific aspects of SDOH and their impact in orthopedic trauma, there is much to still be explored.
Specifically, there is a lack of consolidated evidence examining how these factors influence adult orthopedic trauma outcomes in the United States. We restricted our review to the US to ensure that included studies reflected a consistent healthcare system and sociocultural context. Differences in healthcare delivery, access to care, and social determinants in other countries could bias comparisons, so this focus allows for a more accurate assessment of the existing literature and identification gaps relevant to US populations. In particular, previous studies have shown that the US differs from other high-income nations in geographic health disparities, income-related inequities, and how social services and healthcare are funded and delivered [16–18]. To our knowledge, no existing scoping review has addressed this intersection. The aim of this project is to map the extent, nature, and scope of existing literature on the influence of social determinants of health on orthopedic trauma outcomes in adults. Given the broad and varied nature of both orthopedic trauma and SDOH, a scoping review is the most appropriate methodology. This approach allows for the inclusion of diverse study designs and outcome measures and is well suited to identify research gaps and guide future investigations. Ultimately, this work intends to serve as a foundation for further research and contribute to efforts to advance equity in trauma care.
Methods
A scoping review was chosen due to the broad nature of the research topic. Scoping reviews are a type of evidence synthesis reviews that present a broad overview of the evidence on a particular topic, regardless of study quality. This makes them useful in clarifying key concepts and thus identifying gaps [19]. This was conducted in accordance with the JBI methodology for scoping reviews and reported according to the PRISMA-ScR extension for scoping reviews in S1 Data [20,21]. There was no review protocol.
Research question
What is the extent of literature in addressing how SDOH affect adult orthopedic trauma outcomes in the United States, and what should future research focus on?
Search strategy
The search strategy was developed by an academic health science librarian (L.H.) in consultation with members of the project team (R.R. and R.L.). The search strategy was guided by CDC framework for social determinants of health, with search terms mapped to its five domains mentioned in the introduction and relevant orthopedic trauma outcomes to ensure comprehensive literature capture. The search strategy was structed around four key concepts: SDOH, orthopedic trauma injuries, outcomes such as mortality, length of stay, and post-operative complications, and US studies to ensure relevance to comparable healthcare and sociocultural contexts. This was initially done on OVID Medline and then translated using each database’s syntax, search fields, and controlled vocabulary to six other databases. The controlled vocabulary across OVID Medline & Cochrane Central, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL) Plus, SportDiscuss which are: Medical Subject Headings (MeSH), Emtree, CINAHL Headings, and SportDiscuss. We searched Ovid MEDLINE(R) ALL (United States National Library of Medicine), EMBASE (Elsevier, Embase.com), Cochrane Library (Wiley), CINAHL Plus with Full Text (Ebsco), SPORTDiscus with Full Text(Ebsco), SCOPUS (Elsevier), and Web of Science platform (Clarivate: Science Citation Index Expanded, Social Sciences Citation Index, Arts & Humanities Citation Index, Conference Proceedings Citation Index-Science, Conference Proceedings Citation Index-Social Science & Humanities, Emerging Sources Citation Index). On November 21–22, 2024, all the six databases were searched.
The records of Ovid Medline, Cochrane Library & Web of Science database records were downloaded to EndNote 20 [4] and then uploaded to Covidence web-based software. As for the remaining databases: Embase, Scopus, Plus with Full Text, and SPORTDiscus with Full Text, their records were uploaded directly to Covidence which is the tool used for deduplication, title-abstract screening, and full text evaluation [5] of all the records of the seven databases. For the full text screening, EndNote 20 was utilized to retrieve PDFs from University of Miami (UM)’s knowledgebase and then uploaded in bulk to covidence. The uncaptured records by EndNote Library were ordered through UM’s Interlibrary Loan.
Study selection
Two reviewers (R.R. and H.M.) independently reviewed all titles and abstracts for assessment against the inclusion criteria. Potentially relevant sources were moved onto full text screening, and the full text was assessed against the inclusion criteria by the same two independent reviewers. Reasons for exclusion of sources of evidence at full text were recorded and reported. Any disagreements that arose between the reviewers at any stage of the selection process were resolved by a third reviewer (R.L.).
Inclusion and exclusion criteria
This scoping review included studies focused on orthopedic trauma outcomes—both surgical and nonoperative—in adults aged 18 and older. For the purposes of this review, orthopedic trauma was defined as acute appendicular and pelvic musculoskeletal injuries requiring or nonoperative management in adults, typically resulting from high- or low- energy trauma. This included but was not limited to fractures of the proximal humerus, clavicle, elbow, pelvis, hip, femur, patella, and tibia. Spinal, hand, and foot fractures were excluded. Only studies that addressed variations in these outcomes based on social determinants of health (SDOH)—such as race/ethnicity, marital status, housing insecurity, sex, and educational status—were included. Studies were included only if a given SDOH domain was explicitly analyzed in relation to orthopedic trauma outcomes; reporting SDOH variables in baseline demographics alone were not sufficient. The review was limited to research conducted in U.S.-based trauma centers and emergency departments to ensure consistency in sociocultural and healthcare contexts. A wide range of study designs were considered, including experimental, quasi-experimental, analytical and descriptive observational studies, case reports, and qualitative research. Systematic reviews and opinion pieces that aligned with the inclusion criteria were also included. Studies involving participants under 18 years old or non-traumatic injuries, or those conducted outside the United States, were excluded. There were no limitations for language or date.
Data charting
Eligible studies were summarized and reported by two independent reviewers in Covidence. The following information was recorded for each article: title, author, journal, year of publication, study type, and setting (single institution, multiple institutions, regional database, national database, or other). Each study was further categorized based on orthopedic treatment as surgical, nonoperative, or combination. Due to the heterogeneity of the data, SDOH factors were categorized into the following domains: healthcare access, neighborhood and built environment, economic stability, social and community context, and education access and quality. Treatment outcome in relation to SDOH was also recorded. Because this is a scoping review, qualitative findings were summarized descriptively rather than synthesized. Counts or percentages of study characteristics, SDOH factors, and outcomes were used to map patterns across studies. All studies were weighted equally regardless of sample size.
Results
Study selection
Based on the PRISMA guidelines, the initial search strategy yielded 8,105 publications. After removing duplicates, 4,654 studies remained for title/abstract screening. 51 studies subsequently met inclusion criteria, with 40 studies ultimately included after full-text review (Fig 1). Articles were excluded for various reasons including wrong setting (n = 1), wrong outcomes (n = 6), wrong study design (n = 1), and wrong patient population (n = 3). An overview of the studies included is summarized in Table 1.
Research methodology and study setting
As shown in Table 1, most studies were retrospective in nature, with 28 (70%) employing a retrospective cohort design and 8 (20%) categorized as retrospective reviews. Only a small proportion of studies used prospective (2.5%) or prognostic (2.5%) designs, with brief reports and abstract-only publications each accounting for (2.5%) of the total. Regarding study setting (Table 1), most studies were conducted at a single institution (52.5%), followed by those using national databases (25%). Fewer studies involved multiple institutions (12.5%) or regional databases (10%).
SDOH domains
As presented in Table 1, Social and Community Context was the most frequently referenced social determinant of health (SDOH), mentioned in 32 studies (80%). Healthcare Access appeared in 23 studies (57.5%), followed by Neighborhood and Built Environment in 13 studies (32.5%) and Economic Stability in 11 studies (27.5%). Education Access and Quality was the least represented domain, cited in only 3 studies (7.5%).
Orthopedic trauma injury – location and treatment
Table 2 shows the most studied injury locations were the lower extremity (35%) and hip (22.5%), followed by the pelvis (17.5%). Upper extremity and other injury locations each accounted for 12.5% of the studies. As shown in Table 3, surgical treatment was the predominant management approach, reported in 28 studies (70%). A combination of surgical and non-surgical treatments were described in 9 studies (22.5%), while non-surgical treatment alone was reported in just 1 study (2.5%). In 2 studies (5%), the treatment type was not specified.
Treatment outcomes
As shown in Table 4, the most reported treatment outcomes were categorized as “other,” appearing in 27 studies (67.5%). All outcomes grouped under “other” are detailed in Table 1, which provides a comprehensive summary of each study’s reported measures. Mortality was reported in 13 studies (32.5%), followed closely by length of stay in 12 studies (30%). Infection and re-operation were each mentioned in 9 studies (22.5%), while emergency department visits were the least frequently reported outcome, cited in 4 studies (10%).
Discussion
This scoping review highlights both the breadth and the limitations in the investigation of orthopedic trauma outcomes in the context of social determinants of health in the United States. For the SDOH domains included in this study, social and community context was the most investigated, followed in order of decreasing frequency by healthcare access, neighborhood and built environment, economic stability, and education access and quality. This result is not surprising, as these variables are commonly included in chart reviews, such as gender, race, and ethnicity, which fall under the domain of social and community context. Healthcare access includes insurance status, which is another variable that can easily be pulled from a patient’s medical chart. The other domains require researchers to retrieve the information from the patients themselves, which adds a level of difficulty and may prevent researchers from including such domains as variables of interest. The introduction of standardized data collection of SDOH-related information could allow for these aspects to be studied more systematically. It is also possible that other factors, such as lack of funding and prioritization, limited interdisciplinary collaboration, and methodological complexity, contribute to the disparity in domain count. These features would require more complicated solutions, such as creating structured interdisciplinary partnerships and advocating for targeted funding.
Orthopedic trauma is a very large sub-specialty that includes many different orthopedic injuries and treatment options. In this review, we determined that the most popular injury location was lower extremity, followed by hip, pelvis, upper extremity, and multiple locations. We also determined that the included papers focused mainly on surgical treatment options, with fewer papers including combination of surgical and non-surgical treatment options and only one paper focusing on non-surgical treatments. As highlighted by these results, the current body of literature is spread over many different injuries and treatments. Further, each injury type has differences in surgical and nonoperative treatment options available. Thus, it is difficult to group these studies and thus their outcomes by generalized location or treatment options. This spread in data does reveal, however, that there are still vast possibilities for future research on orthopedic trauma conditions and treatment options, specifically in pelvic and upper extremity injuries and non-surgical treatments.
Over 30 orthopedic trauma treatment outcomes viewed in relation to SDOH were pulled from the included studies. The most common outcomes (mortality, length of stay, infection, re-operation, and following ED visit) were included in the Covidence data charting form. Due to a large variability in time since surgery for the outcomes mortality and infection rates, time was not included in Table 4. 67.5% of the studies also included other outcomes, such as overall complications, deep vein thrombosis, hardware failure and nonunion, and delayed healing. The variety in reported outcomes would make any systemic conclusion on the included studies difficult. Future research could focus on any outcome summarized in Table 1, especially ED visits and any outcome included in others.
Although the existing evidence remains limited and heterogenous, several practical implications emerge from this review for the US. Trauma centers could integrate SDOH factors, such as insurance status and race, into discharge planning to identify patients who may require enhanced care coordination or transportation assistance. SDOH data could also inform risk stratification models to identify patients at higher risk for complications or loss to follow-up, allowing trauma programs to allocate resources more efficiently. At the policy level, these findings highlight the importance of supporting reimbursement models and community-based partnerships that facilitate the integration of social services into trauma care. Strengthening both the clinical and policy pathways may help mitigate disparities and improve recovery trajectories for socially vulnerable patients.
This study has several limitations. The wide heterogeneity and broad scope of the studies included prevent this review from including a detailed analysis and answering specific clinical or policy questions. This also prohibits the paper from including a meta-analysis or other quantitative synthesis. The study design also does not allow for the quality of the studies to be investigated. A large proportion of the studies were retrospective and single center, which limits their generalizability. Additionally, SDOH variables were inconsistently defined and frequently obtained through chart review, relying on proxies such as insurance status or race rather than standardized measures. The methodological constraints within the existing evidence base should be considered when interpreting the findings and highlight the need for future prospective, multicenter studies with uniform SDOH data collection. Furthermore, publication bias limits the studies that were accepted to journals and made readily available in the databases. Additionally, a formal protocol was not registered prior to conducting this review, which we acknowledge as a limitation. We have tried to decrease the effects of this limitation by providing the full search strategy in S1 File to support transparency and reproducibility. Finally, this scoping review is limited to studies inside of the US, which limits the generalizability worldwide We believe that this decrease in generalizability is warranted, as including studies not based in the US would introduce biases due to differences in healthcare systems and sociocultural contexts. Even with these limitations, we believe that this study is a valuable exploration into the current state of literature on how orthopedic trauma outcomes are affected by SDOH.
Conclusion
This scoping review identifies a growing but still fragmented body of literature examining how social determinants of health influence orthopedic trauma outcomes in the United States. The predominance of retrospective studies focused on limited SDOH domains, specifically social and community context and healthcare access, highlights both the feasibility and constraints of relying on existing clinical data. Significant gaps remain in evaluating the other domains, especially education access and quality. Additionally, drawing systematic conclusions is prevented by the wide variability in orthopedic trauma injuries, treatment options, and reported outcomes. These findings underscore the need for prospective, multidisciplinary research that incorporates consistent SDOH data collection and prioritizes health equity in orthopedic trauma care. By addressing these gaps, future work can help inform targeted interventions and policies to improve outcomes for vulnerable populations affected by orthopedic trauma.
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