The effect of surgical timing on the perioperative complications of treatment of supracondylar humeral fractures in children

Rate of Open Reduction for Supracondylar Humerus Fractures Varies Across Pediatric Orthopaedic Surgeons: A Single-Institution Analysis

OBJECTIVES

To (1) define a single institution's rate of open reduction for operative pediatric supracondylar humerus (SCH) fractures; (2) describe variability by surgeon in rates of irreducible fracture (IRF) and open reduction; and (3) determine whether variation in opening rate correlated with surgeon experience.

DESIGN

Retrospective analytic study.

SETTING

Urban tertiary care Level 1 trauma center.

PATIENTS/PARTICIPANTS

Twelve fellowship-trained pediatric orthopaedists.

MAIN OUTCOME MEASUREMENTS

Rate of open reduction for operatively treated SCH fractures (OTA/AO 13-M/3).

RESULTS

One thousand two hundred twenty-nine type II SCH fractures (none of which required open reduction) were excluded from the analysis. A total of 1365 other SCH fractures were included: 1302 type III fractures, 27 type IV fractures, and 36 fractures with unspecified type. 2.9% of type III and 22.2% of type IV fractures required open reduction. None of the injuries with unspecified type required open reduction. The rate of open reduction among 11 surgeons ranged from 0% to 15.0% in type III-IV fractures (P = 0.001). 86% (38/44) of open reductions were performed for IRF. In regression analysis, patient age was associated with open reduction for IRF (odds ratio 1.22, P = 0.001), but surgeon years-in-practice (0.321) and number of previous cases (0.327) were not associated with open reduction. Other indications for opening included suspected vascular or neurologic injury.

CONCLUSIONS

Open reduction was rarely performed in this sample, but IRF was the dominant indication for opening. We found true variation in surgeons' rates of performing open reductions. More experience was not correlated with decreased likelihood of open reduction.

LEVEL OF EVIDENCE

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

Management of supracondylar fractures of the humerus in children

Supracondylar fractures of the humerus are the most frequent fractures of the paediatric elbow, with a peak incidence at the ages of five to eight years.

Extension-type fractures represent 97% to 99% of cases. Posteromedial displacement of the distal fragment is the most frequent; however, the radial and median nerves are equally affected. Flexion-type fractures are more commonly associated with ulnar nerve injuries.

Concomitant upper-limb fractures should always be excluded. To manage the vascular status, distal pulse and hand perfusion should be monitored. Compartment syndrome should always be borne in mind, especially when skin puckering, severe ecchymosis/swelling, vascular alterations or concomitant forearm fractures are present.

Gartland’s classification shows high intra- and inter-observer reliability. Type I is treated with casting. Surgical treatment is the standard for almost all displaced fractures. Type IV fractures can only be diagnosed intra-operatively.

Closed reduction and percutaneous pinning is the gold standard surgical treatment. Open reduction via the anterior approach is indicated for open fractures, absence of the distal vascular flow for > 10 to 15 minutes after closed reduction, and failed closed reduction.

Lateral entry pins provide stable fixation, avoiding the risk of iatrogenic ulnar nerve injury.

About 10% to 20% of displaced supracondylar fractures present with alterations in vascular status. In most cases, fracture reduction restores perfusion.

Neural injuries occur in 6.5% to 19% of cases involving displaced fractures. Most of them are neurapraxias and it is not routinely indicated to explore the nerve surgically.

Cite this article: EFORT Open Rev 2018;3:526-540. DOI: 10.1302/2058-5241.3.170049

Postponing surgery of paediatric supracondylar humerus fractures to office hours increases consultant attendance in operations and saves operative room time

PURPOSE

To assess if postponing surgery of paediatric supracondylar humerus fractures (SCHF) without compromised blood circulation to office hours can improve the quality of reduction and pin fixation and decrease complications.

METHODS

In 2004, night-time (0am to 7am) surgery was allowed only for children with compromised blood circulation. Number of open reductions, surgeons experience, operation time, quality of reduction (Baumann angle, anterior humeral line crossing point with capitellum) and pin fixation as well as the number of complications were compared in 100 children before (A) and 100 after (B) the new protocol. Surgery was commenced during office hours (8am to 3pm) in 27% (A) versus 55% (B) and delay to surgery from admission exceeded six hours in 25% (A) versus 52% (B) of the children.

RESULTS

Open reduction was performed in eight (A) versus 11 (B) children. In group A, 40% were operated on by a registrar alone compared with 14% in group B. Mean operation room time decreased by 11 minutes in group B. Radiographic alignment was satisfactory at fracture union in 68% (A) versus 68% (B) and radiologically stable pin fixation in 42% (A) versus 55% (B) of children (p = 0.08). The was no statistical difference in admission time, re-reductions, infections, permanent iatrogenic nerve injuries or corrective osteotomies between the patient groups.

CONCLUSIONS

No statistical difference in quality of reduction or pin fixation or in number of complications was observed. Postponing operative treatment of SCHF without vascular compromise increased consultant attendance in operations and decreased operative room time.

LEVEL OF EVIDENCE

III - retrospective comparative study.

Pediatric Supracondylar Humerus Fractures: Does After-Hours Treatment Influence Outcomes?

OBJECTIVE

To compare the outcomes of pediatric supracondylar humerus fractures treated during daytime hours to those treated after-hours.

DESIGN

Retrospective.

SETTING

Academic Level I trauma center.

PATIENTS/PARTICIPANTS

Two hundred ninety-eight pediatric patients treated with surgical reduction and fixation of closed supracondylar fractures were included.

INTERVENTION

Seventy-seven patients underwent surgery during daytime hours (06:00-15:59 on weekdays). One hundred eighty-six patients underwent surgery after-hours (16:00-05:59 on weekdays and any surgery on weekends or holidays).

MAIN OUTCOME MEASURES

Surgeon subspecialty, operative duration, and radiographic and clinical outcomes, including range of motion and carrying angle, were extracted from the patient medical records.

RESULTS

There were no patient-related demographic differences between the daytime hours and after-hours groups. Daytime surgery was more likely to be performed by a pediatric orthopaedic surgeon than after-hours surgery. Fractures treated after-hours had more severe injury patterns. After-hours surgery was not independently associated with rate of open reduction, operative times, complications, achievement of functional range of motion, or radiographic alignment. A late-night surgery subgroup analysis demonstrated an increased rate of malunion in patients undergoing surgery between the hours of 23:00 and 05:59.

CONCLUSIONS

There is no difference in the operative duration or outcomes after surgical treatment of pediatric supracondylar humerus fractures performed after-hours when compared with daytime surgery. However, late-night surgery performed between 23:00 and 05:59 may be associated with a higher rate of malunion. Surgeons can use these data to make better-informed decisions about the timing of surgery in this patient population.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Pediatric Orthopedic Trauma: An Evidence-Based Approach

The management of pediatric fractures has evolved over the past several decades, and many injuries that were previously being managed nonoperatively are now being treated surgically. The American Academy of Orthopaedic Surgeons has developed clinical guidelines to help guide decision making and streamline patient care for certain injuries, but many topics remain controversial. This article analyzes the evidence regarding management of 5 of the most common and controversial injuries in pediatric orthopedics today.

Does the surgery time affect the final outcome of type III supracondylar humeral fractures?

INTRODUCTION

Supracondylar humeral fractures are common in the pediatric population, with displaced fractures requiring operative intervention. The purpose of this study was to look at our practice and assess whether a difference in clinical outcomes and requirement for open reduction was observed if surgery was delayed.

METHODS

This was a retrospective medical record and plain radiograph review of patients admitted with type III Gartland supracondylar fractures between January 2014 and December 2015. The patients were seen for up to 12 months postoperatively, and clinical assessment was performed at this stage.

RESULTS

There were 116 supracondylar humeral fractures admitted between January 2014 and December 2015, 23 of which were Gartland type III. The mean age of the patients was 6 years, and the mean time from emergency department presentation to surgery was 14 h. Seven of the 23 patients required conversion to open reduction. There were no reported complications and all fractures demonstrated radiographic union. The length of time to surgery did not increase the number of cases requiring open reduction. The results demonstrated that there was no difference in clinical outcomes found between those that had closed manipulation or required conversion to open reduction, nor the time taken to surgery.

CONCLUSION

This study suggest that patients who present with type III supracondylar humeral fractures and have no neurovascular deficit, a delay in pinning of 12 h or more may not result in a significant difference in the need for open reduction or clinical outcomes.

LEVEL OF EVIDENCE

Level IV.

Closed Versus Open Supracondylar Fractures of the Humerus in Children: A Comparison of Clinical and Radiographic Presentation and Results

BACKGROUND

The purpose of this investigation was to compare the presentation and postoperative results of children treated for open and closed, completely displaced type III supracondylar humerus fractures (SCFs).

METHODS

Thirty patients with open and 66 patients with closed, completely displaced type III SCFs were evaluated. Open fractures underwent irrigation and debridement, and all patients were treated by open or closed reduction and pin fixation. Medical records were reviewed to obtain demographic information as well as preoperative and postoperative clinical data regarding mechanism of injury, neurovascular status, associated injuries, postoperative range of motion, infections, and pain. Radiographs were evaluated to quantify displacement, Baumann's angle, humeral capitellar angle, position of the anterior humeral line, and adequacy of reduction. Outcomes were assessed using Flynn criteria. Mean clinical follow-up for the open and closed fracture groups was 8.9 and 5.7 months, respectively.

RESULTS

Both groups were similar with respect to age, sex distribution, weight and body mass index, laterality of involvement, and mechanism of injury. At presentation, 35% of closed SCFs and 23% of open SCFs presented with abnormal neurovascular status. There was a higher prevalence of diminished/absent pulses or distal limb ischemia in patients with open injuries (27%) compared with closed fractures (18%). Conversely, severely displaced closed fractures were more commonly associated with nerve injury/palsy at presentation (35%) than those with open fractures (23%). Spontaneous nerve recovery was seen in 87% within 3 to 6 months. Postoperative loss of reduction and malunion were more common in the closed fracture group. However, 84% of patients achieved good-to-excellent results by Flynn criteria, with no appreciable difference based upon open versus closed fractures.

CONCLUSIONS

With timely wound and fracture treatment, the clinical and radiographic results of children treated for open SCFs is similar to those with closed type III injuries, with little increased risk for infection, malunion, or neurovascular compromise.

LEVEL OF EVIDENCE

Level III.

Common Paediatric Elbow Injuries

Background:

Paediatric elbow injuries account for a large proportion of childrens’ fractures. Knowledge of common injuries is essential to understanding their assessment and correct management.

Methods:

A selective literature search was performed and personal surgical experiences are reported.

Results:

We have described the assessment and management of the five most common paediatric elbow injuries: supracondylar humeral fractures; lateral condyle fractures; medial epicondyle fractures; radial head and neck fractures; radial head subluxation.

Conclusion:

Understanding of the ossification centres around the paediatric elbow is essential to correctly assessing and managing the common injuries that we have discussed in the review. Outcomes after these injuries are usually favourable with restoration of normal anatomy.

Flexion-Type Supracondylar Humeral Fractures: Ulnar Nerve Injury Increases Risk of Open Reduction

BACKGROUND

The vast majority of displaced pediatric supracondylar humeral fractures can be treated successfully with closed reduction and percutaneous pinning. The need for open reduction is difficult to determine a priori and is typically due to the failure of closed reduction attempts or persistent limb ischemia. The aims of this study were to determine the prevalence of flexion-type supracondylar humeral fractures, the rate of open reduction for flexion-type fractures, and the predictive impact of ulnar nerve injury on the need for open reduction for flexion-type supracondylar humeral fractures.

METHODS

We developed a database of consecutive pediatric supracondylar humeral fractures treated operatively at a tertiary care pediatric trauma center from 2000 to 2015. Data recorded included age, mechanism of injury, fracture type (open or closed), fracture pattern (flexion-type or extension-type), concomitant skeletal injury, neurovascular injury, treatment, and surgeon. Radiographs of all flexion-type supracondylar humeral fractures were reviewed in order to confirm the classification of the injury pattern. The rate of open reduction for fractures with a flexion-type injury pattern and for such fractures with and without ulnar nerve injury at presentation was assessed.

RESULTS

Of 2,783 consecutive pediatric supracondylar humeral fractures treated by surgeons at our center, 95 (3.4%) were flexion-type fractures. Ulnar nerve injury was noted for 10 (10.5%) of the 95 flexion-type fractures. Open injuries were identified at presentation in 3 (3.2%) of the 95 cases. Among closed fractures, 21 (22.8%) of 92 flexion-type fractures required open reduction compared with 50 (1.9%) of 2,647 extension-type fractures (odds ratio [OR] = 15.4; 95% confidence interval [CI] = 8.8 to 27.0; p < 0.001). Among closed flexion-type fractures, open reduction was performed in 6 (60%) of 10 fractures with associated ulnar nerve injury and in 15 (18.3%) of 82 fractures without ulnar nerve injury (OR = 6.7; 95% CI = 1.7 to 26.7; p = 0.003).

CONCLUSIONS

Among closed supracondylar humeral fractures, the flexion-type injury pattern was associated with a 15.4-fold increase in the odds of open reduction. The presence of an ulnar nerve injury at presentation resulted in an additional 6.7-fold higher risk of open reduction among flexion-type supracondylar humeral fractures. Patients and families should be counseled regarding the high rate of open reduction for flexion-type supracondylar humeral fractures, particularly those with an associated ulnar nerve injury.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Comparison of daytime and after-hours surgical treatment of supracondylar humeral fractures in children

Reports on different types of surgical procedures show that night-time surgeries are often associated with a high number of complications than daytime surgeries. However, there are no data, and hence evidence that relate the outcome of supracondylar humeral fractures in children to the time of the day when the respective surgical procedure is implemented. In this study, we analyze the clinical and radiological outcomes of pediatric supracondylar humeral fractures surgically treated during daytime and night-time hours. In total, 91 patients with Gartland type-3 fractures were included; 47 patients treated between 0800 and 1700 h were defined as the daytime group and 44 patients treated between 1701 and 0759 h were defined as the after-hours group. Age, sex, affected side, fracture type, and day and time of operation were recorded. Any preoperative neurovascular injuries, open fractures, or ipsilateral fractures were noted. The surgical method, use of a medial pin or pins, operation time, any postoperative neurovascular complications, extent of successful reduction, fixation rate, any resultant deformity, and functional loss rate were evaluated. The two groups did not differ significantly in terms of operation time, open reduction rate, rate of poor reduction, extent of poor functional outcomes, or induction of deformity (P>0.05). The poor fixation rate was significantly greater in the after-hours group than in the daytime group (P<0.05). No significant between-group differences were evident in age, sex, affected side, or length of postoperative follow-up (all P-values>0.05). After-hours treatment of displaced supracondylar humeral fractures in children is associated with a higher poor fixation rate compared with daytime procedures.

LEVEL OF EVIDENCE

therapeutic study (retrospective comparative study), Level III.

Utility of Postoperative Antibiotics After Percutaneous Pinning of Pediatric Supracondylar Humerus Fractures

BACKGROUND

Pediatric supracondylar humerus fractures are common injuries that are often treated surgically with closed reduction and percutaneous pinning. Although surgical-site infections are rare, postoperative antibiotics are frequently administered without evidence or guidelines for their use. With the increasing prevalence of antibiotic-resistant organisms and heightened focus on health care costs, appropriate and evidence-based use of antibiotics is needed. We hypothesized that postoperative antibiotic administration would not decrease the rate of surgical-site infection.

METHODS

A billing query identified 951 patients with operatively treated supracondylar humerus fractures at our institution over a 15-year period. Records were reviewed for demographic data, perioperative antibiotic use, and the presence of surgical-site infection. Exclusion criteria were open fractures, open reduction, pathologic fractures, metabolic bone disease, the presence of other injuries that required operative treatment, and follow-up <2 weeks after pin removal. χ and Fisher exact test were used to compare antibiotic use to the incidence of surgical-site infection.

RESULTS

Six hundred eighteen patients met our inclusion criteria. Two hundred thirty-eight patients (38.5%) received postoperative antibiotics. Eleven surgical-site infections were identified for an overall rate of 1.8%. The use of postoperative antibiotics was not associated with a lower rate of surgical-site infection (P=0.883). Patients with a type III fracture (P<0.001), diminished preoperative vascular (P=0.001) and neurological status (P=0.019), and postoperative hospital admission (P<0.001) were significantly more likely to receive postoperative antibiotics.

CONCLUSIONS

Administration of postoperative antibiotics after closed reduction and percutaneous pinning of pediatric supracondylar humerus fractures does not decrease the rate of surgical-site infection.

LEVEL OF EVIDENCE

Level III-therapeutic.

Fracture Classification Does Not Predict Functional Outcomes in Supracondylar Humerus Fractures: A Prospective Study

BACKGROUND

Few studies have prospectively assessed functional outcomes after the surgical management of supracondylar humerus fractures (SCHFXs) and the relationship between fracture pattern and ultimate patient outcome has never been prospectively evaluated. The purpose of this study was to prospectively evaluate fracture classification and functional outcome in children with extension SCHFXs using validated outcome measures.

METHODS

An Institutional Review Board-approved prospective enrollment of consecutive patients with operative SCHFX was performed over a 3-year period. Fractures were classified by the treating surgeon using the modified Gartland classification. Functional outcome was assessed at final follow-up using the Pediatric Outcomes Data Collection Instruments (PODCI) and the Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) outcome measure. Patients with flexion-type fractures, multidirectionally unstable fractures and those with <10 weeks follow-up were excluded from analysis. Statistical analysis was used to determine the relationship between fracture classification/pattern and functional outcome.

RESULTS

Seven hundred fifty-two patients were enrolled during the study period. One hundred thirty-two patients with extension-type injuries (average age 6.7 y) completed functional outcome measures at an average follow-up of 12.4 weeks. Forty-five (34%) were type II fractures and 87 (66%) were type III fractures. Forty-five (34%) of the fractures were posteromedially displaced, 43 (33%) were posterolaterally displaced, and 44 (33%) were posteriorly displaced without coronal plane deformity. The average PODCI global functioning scale score and QuickDASH scores for the entire cohort were 93.6 and 11.4, respectively, indicating excellent function. No differences in outcome scores were noted between patients with type II and III fractures. No difference in outcome was identified based upon direction of fracture displacement.

CONCLUSIONS

This is the first study to prospectively analyze fracture classification and functional outcome using validated outcome measures following the operative treatment of pediatric extension-type SCHFX. Children generally have excellent functional outcomes following the operative treatment of SCHFX. Garland classification and direction of displacement do not influence functional outcomes.

LEVEL OF EVIDENCE

Level II-therapeutic.

Emerging U.S. National Trends in the Treatment of Pediatric Supracondylar Humeral Fractures

BACKGROUND

Understanding national trends in the treatment of pediatric supracondylar humeral fractures will provide important insight into variations in regional treatment and identify areas for improving value and quality in care delivery in the U.S.

METHODS

U.S. national trends in the treatment of supracondylar humeral fractures were evaluated through query of the Humana (2007 to 2014) and ING (2007 to 2011) administrative claims databases. Geographic variation and changes in surgical and transfer rates over time were further explored through the Nationwide Emergency Department Sample (NEDS) database (2006 to 2011). Hospital characteristics impacting treatment decisions were identified.

RESULTS

A total of 29,642 pediatric patients with supracondylar humeral fractures were identified in the administrative claims databases and a projected 63,348 encounters for supracondylar humeral fracture were identified in the NEDS database. The majority of the patients (76.1%; 22,563 of 29,642) were treated definitively with cast immobilization. Operative treatment was performed in 23.9% of the patients (7,079 of 29,642), with no change observed in the operative rate over time (p = 0.055). Of patients undergoing operative treatment, closed reduction and percutaneous pinning (CRPP) was performed in 87.3%, with a significant increase noted in the rate of CRPP over time (p = 0.0001); open reduction was performed in 12.7%, with a significant decrease noted in the rate of open reduction over time (p < 0.0001). Regional surgical rates generally showed significant variation from 2006 to 2010, followed by a convergence in the surgical rate among all geographic regions in 2011. These trends occurred simultaneous to a significant increase in transfer rates nationwide, from 5.6% in 2006 to 9.1% in 2011 (p = 0.0011). Transfer rates were significantly higher (p < 0.0001) for nontrauma, nonteaching, and nonmetropolitan centers while surgical rates were significantly higher (p < 0.0001) for trauma, teaching, and metropolitan centers when rates were analyzed by hospital designation.

CONCLUSIONS

Operative treatment was performed in 24% of pediatric patients with supracondylar humeral fractures from 2007 to 2014. There was a convergence of surgical rates across geographic regions, suggesting that a "standard of care" in the treatment of supracondylar humeral fractures is being established nationally.

CLINICAL RELEVANCE

Cases of pediatric supracondylar humeral fracture are increasingly being transferred to and, when managed surgically, receiving care at metropolitan facilities designated as trauma centers or teaching hospitals, with a corresponding decrease observed in the rate of open reduction. The optimization of nationwide referral and treatment patterns may improve value in care delivery.

Postoperative brachial artery entrapment associated with pediatric supracondylar fracture of the humerus: a case report

BACKGROUND

Severely displaced supracondylar fractures of the humerus in children are frequently associated with complications including neurovascular injuries, non-union, or compartment syndrome. In the current literature, no report exists about postoperative brachial artery entrapment in combination with an inconspicuous preoperative neurovascular examination.

CASE PRESENTATION

We present a case of a 6-year-old white boy with a pulseless radial and ulnar artery after open reduction and internal fixation of a severely displaced supracondylar fracture of his right humerus (Gartland type III) using four K-wires. Remarkably, the preoperative neurovascular examination was inconspicuous. Doppler ultrasound of his brachial artery revealed no pulse when his elbow was in flexion and a faint pulse when it was in full extension 10 hours postoperatively. Revision surgery was performed immediately. On intraoperative examination, a kinking of his brachial artery caused by an entrapment of the tunica externa in the reduced fracture was seen and the artery was released by microsurgical arteriolysis immediately. At the final follow-up examination, positive palpable pulse with good capillary filling and, according to Flynn's criteria, an excellent recovery of elbow function was observed 3 months postoperatively.

CONCLUSIONS

This case demonstrates a rare complication of postoperative artery entrapment with inconspicuous preoperative neurovascular examination. It strongly emphasizes the need for a standardized postoperative neurovascular assessment with fully flexed as well as fully extended elbow.

Surgical management of delayed irreducible Gartland III supracondylar fractures in children: open reduction and internal fixation versus external fixation

BACKGROUND

Percutaneous pinning has been accepted as the "gold standard" for displaced supracondylar humeral fracture (SHF) in children. However, to secure an anatomic reduction and to reduce the rotated fragment, open reduction is often necessary when there is inadequate stabilization or a satisfactory reduction has failed to be achieved. The study aimed to compare the efficacy of the open reduction and bioabsorbable poly-d,l-lactic acid (PDLLA) pin fixation method with the closed reduction and lateral external fixation method in irreducible delayed Gartland type III SHF in children.

METHODS

In this study, 124 consecutive patients with irreducible delayed Gartland type III SHF were included between 2005 and 2013. Two different surgical methods were performed in patients separately. Group I had 64 patients undergoing bioabsorbable PDLLA pin fixation after open reduction, whereas group II had 60 patients treated by lateral external fixation after closed reduction. The outcome of treatment was evaluated by the Mayo Elbow Performance Score and the criteria of Flynn.

RESULTS

Operation duration was longer in group I than in group II. Scoring of function showed that all patients had satisfactory results in both groups. The cosmetic result was satisfactory in all patients except 1 in group I.

CONCLUSIONS

Both bioabsorbable PDLLA pin fixation and lateral external fixation are reliable, safe treatment alternatives for irreducible delayed SHF. Neither open nor closed reduction is linked to an increased rate of perioperative complications or unsatisfactory functional results.

Gartland Type 3 Supracondylar Humeral Fractures in Children: Which Open Reduction Approach Should Be Used After Failed Closed Reduction?

OBJECTIVES

For displaced supracondylar humeral fractures in children, in the event of closed reduction failure, anatomic reduction is achieved via open reduction techniques; however, there are no confirmative reports among the published open reduction approaches that deliver the best functional and cosmetic results. Here, we compared long-term functional and cosmetic results of different surgical approaches.

DESIGN

Retrospective cohort study.

SETTING

Ankara Education and Research Hospital/Turkey. Secondary care hospital and trauma center.

PATIENTS/PARTICIPANTS

We evaluated 70 surgically treated Gartland type 3 supracondylar humeral fractures. Patients, with detailed history record, were divided into 5 groups with respect to surgery methods.

INTERVENTION

All patients were treated surgically using closed reduction and percutaneous pinning or 4 different open reduction approaches and percutaneous pinning.

MAIN OUTCOME MEASURES

Flynn cosmetic and functional score results were compared between surgical groups.

RESULTS

Posterior open reduction and triceps transection groups showed worst results, whereas medial and lateral open reduction groups showed good to excellent results similar to closed reduction group.

CONCLUSION

Medial and lateral approaches demonstrated better functional results than posterior and triceps transection approaches. Posterior approaches lead to restrictions in extension and poor functional results. In the posterior approach, transecting triceps from olecranon does not benefit from fracture reduction but results in loss of triceps strength and should be avoided. In failed closed reduction, medial and lateral open reduction approaches lead to similar cosmetic outcomes and functional results that are only slightly worse compared with those in closed reduction.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Fracture Supracondylar Humerus: A Review

Fracture supracondylar humerus is one of the most common fractures encountered in pediatric age group at all levels (both rural and urban). Thus it needs a special review in its management protocol as per the changing trend. Modified Gartland classification is the most accepted classification and has its importance in decision making regarding management and prognosis. Neurovascular complications are mostly associated with Type III A, III B and Type IV variety and they most of the time need surgical intervention for stabilization, exploration of brachial artery, sometimes median nerve exploration and reduction of fracture. Cubitus varus is the most common associated deformity associated with this fracture (especially in Type III A). The aim of the review was to develop an insight for the understanding of variations in presentation and management of supracondylar fracture of the humerus (both simplicity and complexity) and the flowing trend in addition to the recent advances to deal with this particular pediatric orthopaedic entity which often presents as an emergency.

Off-Hour Surgery Among Orthopedic Subspecialties at an Urban, Quaternary-Care, Level 1 Trauma Center

PURPOSE

We sought to determine and quantify which subspecialties of orthopedic surgeons are operating off hours in an urban, quaternary-care, level 1 trauma center.

MATERIALS AND METHODS

We used our clinical registry to identify 43,211 orthopedic surgeries performed between January 2008 and December 2011. Our outcome measures were the number and proportion of off-hour surgeries performed as well as the number and proportion of off-hours per subspecialty. The denominators were the total number of surgeries and the total number of surgical hours worked per subspecialty. Subspecialties-based on the primary surgeon who performed the surgery-were arthroplasty, foot and ankle, hand, pediatrics, shoulder, spine, sports, orthopedic trauma, and orthopedic oncology.

RESULTS

A total of 2,431 (5.6%) surgeries were off-hours; the overall ratio of off-hour to on-hour surgeries was 1 to 17. There was a difference in the proportion of off-hour surgeries performed among orthopedic subspecialties: trauma (ratio, 1:5) and pediatric specialists (ratio, 1:5) had the lowest ratio, and shoulder (ratio, 1:152) and sports (ratio, 1:98) specialists the highest. The total number of surgical hours among all specialties was 59,026; of these hours, 3,833 (6.5%) were off-hour. The ratio of off-hour to on-hour surgical hours was 1 to 14. There was a difference in proportion of hours worked off-hour among orthopedic subspecialties; the ratios were greatest for trauma (1:5) and hand (1:5) specialists and the least for shoulder (1:157) and sports (1:92) specialists. Seven percent of hand surgery cases were off-hour, and 16% of the total surgical hours worked by hand surgeons were off-hour.

CONCLUSIONS

In an urban, academic, level 1 trauma and microvascular replantation regional referral hospital, there is a large difference in off-hour surgical volume and duration among orthopedic subspecialties: trauma, pediatric, and hand surgeons performed more off-hour work than their colleagues, with hand and pediatric surgeons the most likely to be working at night.

CLINICAL RELEVANCE

These data can inform how we organize, value, and incentivize off-hour care.

Impact of insurance status on ability to return for outpatient management of pediatric supracondylar humerus fractures

PURPOSE

Outcomes are excellent following surgical management of displaced supracondylar humerus fractures. Short delays until surgical fixation have been shown to be equivalent to immediate fixation with regards to complications. We hypothesized that insurance coverage may impact access to care and the patient's ability to return to the operating room for outpatient surgery.

METHODS

A retrospective review of supracondylar humerus fractures treated at a large urban pediatric hospital from 2008 to 2012 was performed. Fractures were classified by the modified Gartland classification and baseline demographics were collected. Time from discharge to office visits and subsequent surgical fixation was calculated for all type II fractures discharged from the emergency department. Insurance status and primary carrier were collected for all patients.

RESULTS

2584 supracondylar humerus fractures were reviewed, of which 584 were type II fractures. Of the 577 type II fractures with complete records, 383 patients (61 %) were admitted for surgery and the remaining 194 were discharged with plans for outpatient follow-up. There was no difference in insurance status between patients admitted for immediate surgery. Of the 194 patients who were discharged with type 2 fractures after gentle reduction, 59 patients (30.4 %) ultimately underwent surgical fixation. Of these, 42 patients were privately insured (58.3 % of patients with private insurance), 16 had governmental insurance (15.1 %), and 1 was uninsured (6.3 %). Patients with private insurance were 2.46 times more likely to have surgery than patients with public or no insurance (p = 0.005). Of the 135 patients who did not eventually have surgery, 92 (68.1 %) were seen in the clinic. Patients with private insurance were 2.78 times more likely to be seen back in the clinic when compared to publicly insured or uninsured patients (p = 0.0152).

CONCLUSIONS

Despite an equivalent number of privately insured and publicly insured patients undergoing immediate surgery for type II fractures, those with public or no insurance who were discharged were 2.46 times less likely to obtain outpatient surgery when compared to privately insured patients. Patient insurance status and the ability to follow up in a timely manner should be assessed at the time of initial evaluation in the emergency department. Level of evidence Level 3.

Delayed Open Reduction and K-Wire Fixation of Widely Displaced Supracondylar Fractures of Humerus in Children using Medial Approach

INTRODUCTION

Supracondylar fractures of humerus in children are usually treated with percutaneous pinning on emergency basis. When the operating time is delayed, percutaneous pinning is difficult due to massive swelling. Late presentation is common in developing countries.

AIM

To assess the outcome of open reduction and internal fixation with K-wire of widely displaced supracondylar fracture when operated later than 2 days after the injury.

MATERIALS AND METHODS

A total of 52 children (aged 3-12 years) with widely displaced supracondylar fracture of humerus (Gartland type-III) who presented later than 2 days after injury were treated with open reduction through medial approach and fixation with cross K-wires. RESULTs were assessed with Flynn's criteria.

RESULT

A total of 40 patients completed follow-up. Mean age of all (n=52) patients was 4.8 years (range 3-12 years). Mean delay of presentation was 7.5 days (range 2-14 days). Hundred percent patients had satisfactory results according to Flynn's criteria. Two patients had pin infections.

CONCLUSION

Open reduction through medial approach and fixation with two cross K-wires is a reliable method of treatment for supracondylar fractures of humerus in children when the operation is delayed.

When is the best time to fix fractures?

The best time to operate on a fracture is governed in part by the nature of the fracture itself. It is also influenced by the premorbid condition of the patient and by the degree that associated injuries have disrupted normal processes. It is likely that some patients have a period of increased physiological risk for intervention, during which a second insult will result in further harm. The picture is not yet fully clear but relates to variations in the inflammatory response to trauma. One consistent lesson appears to resonate throughout the published literature. The most predictable risk factor for iatrogenic physiological disturbance is transfer to the operating theatre before adequate resuscitation of the patient has taken place.

Posterolaterally displaced and flexion-type supracondylar fractures are associated with a higher risk of open reduction

To identify factors predictive of the risk of conversion from closed to open reduction. International Classification of Disease-9 codes were used to identify completely displaced pediatric supracondylar humerus fractures that were subjected to planned closed reduction and percutaneous pinning. Clinical and radiographic variables were retrospectively collected. Compared with posterior extension fractures, flexion (risk ratio: 34.1, 95% confidence interval: 8.1-143.6, P<0.0001) and posterolateral extension (risk ratio: 6.0, 95% confidence interval: 1.3-27.5, P=0.0221) fractures were significantly more likely to undergo conversion from closed to open reduction. The direction of displacement should be considered during the preoperative evaluation of supracondylar fractures.

Compartment Syndrome in Children

Compartment syndrome in children can present differently than adults. Increased analgesic need should be considered the first sign of evolving compartment syndrome in children. Children with supracondylar humerus fractures, floating elbow injuries, operatively treated forearm fractures, and tibia fractures are at high risk for developing compartment syndrome. Elbow flexion beyond 90° in supracondylar humerus fractures and closed treatment of forearm fractures in floating elbow injuries are associated with increased risk of compartment syndrome. Prompt diagnosis and treatment with fasciotomy in children result in excellent long-term outcomes.

Fractures of the elbow: supracondylar fractures

Fractures about the elbow are second in frequency only to the distal radius. Trauma specialists should be familiar with the range of possible injuries, complications, and be confident in their diagnosis and management.

Pin tract infection of operatively treated supracondylar fractures in children: long-term functional outcomes and anatomical study

PURPOSE

The purpose of our study was to determine the long-term functional outcomes of pin tract infection after percutaneous pinning of displaced supracondylar humeral fractures in children, and to evaluate the potential for intracapsular pin placement based on pin configuration in cadaveric elbows.

METHODS

We conducted a retrospective review of all patients requiring percutaneous pinning in a single institution over a 19-year period. The functional outcome assessment consisted of a telephone interview using the Disabilities of the Arm, Shoulder and Hand (DASH)] Outcome Measure and the Patient-Rated Elbow Evaluation (PREE) questionnaires. The risk of intracapsular pin placement was studied in cadaveric elbows for the three most common pin configurations: divergent lateral, parallel lateral, and medial and lateral crossed pins.

RESULTS

Of 490 children, 21 (4.3 %) developed pin tract infection. There were 15 (3.1 %) superficial and six (1.2 %) deep infections (osteomyelitis and septic arthritis). Both DASH and PREE scores were excellent at a mean of 18 years post-surgery. The risk of intracapsular pin placement using parallel lateral pins was found to be greater (p < 0.05) than either crossed or divergent lateral pinning configurations.

CONCLUSIONS

Most infections after pinning of supracondylar humerus fractures are superficial and can be managed with pin removal, oral antibiotics, and local wound care. Septic arthritis and osteomyelitis are rare complications; when they do occur, they seem to be associated with parallel lateral pin configuration, though a causal relationship could not be established from the current study. Satisfactory long-term outcomes of these deep infections can be expected when treated aggressively with surgical debridement and intravenous antibiotics.

Displaced supracondylar humeral fractures: influence of delay of surgery on the incidence of open reduction, complications and outcome

BACKGROUND

Closed reduction and pinning is the accepted treatment choice for dislocated supracondylar humeral fractures in children (SCHF). Rates of open reduction, complications and outcome are reported to be dependent on delay of surgery. We investigated whether delay of surgery had influence on the incidence of open reduction, complications and outcome of surgical treatment of SCHFs in the authors' institution.

METHODS

Three hundred and forty-one children with 343 supracondylar humeral fractures (Gartland II: 144; Gartland III: 199) who underwent surgery between 2000 and 2009 were retrospectively analysed. The group consisted of 194 males and 149 females. The average age was 6.3 years. Mean follow-up was 6.2 months. Time interval between trauma and surgical intervention was determined using our institutional database. Clinical and radiographical data were collected for each group. Influence of delay of treatment on rates of open reduction, complications and outcome was calculated using logistic regression analysis. Furthermore, patients were grouped into 4 groups of delay (<6 h, n = 166; 6-12 h, n = 95; 12-24 h, n = 68; >24 h, n = 14) and the aforementioned variables were compared among these groups.

RESULTS

The incidence of open procedures in 343 supracondylar humeral fractures was 2.6 %. Complication rates were similar to the literature (10.8 %) primarily consisting of transient neurological impairments (9.0 %) which all were fully reversible by conservative treatment. Poor outcome was seen in 1.7 % of the patients. Delay of surgical treatment had no influence on rates of open surgery (p = 0.662), complications (p = 0.365) or poor outcome (p = 0.942).

CONCLUSIONS

In this retrospective study delay of treatment of SCHF did not have significant influence on the incidence of open reduction, complications, and outcome. Therefore, in SCHF with sufficient blood perfusion and nerve function, elective treatment is reasonable to avoid surgical interventions in the middle of the night which are stressful and wearing both for patients and for surgeons.

LEVEL OF EVIDENCE

III (retrospective comparative study).

Changing trends in the management of children's fractures

The management of children's fractures has evolved as a result of better health education, changes in lifestyle, improved implant technology and the changing expectations of society. This review focuses on the changes seen in paediatric fractures, including epidemiology, the increasing problems of obesity, the mechanisms of injury, non-accidental injuries and litigation. We also examine the changes in the management of fractures at three specific sites: the supracondylar humerus, femoral shaft and forearm. There has been an increasing trend towards surgical stabilisation of these fractures. The reasons for this are multifactorial, including societal expectations of a perfect result and reduced hospital stay. Reduced hospital stay is beneficial to the social, educational and psychological needs of the child and beneficial to society as a whole, due to reduced costs.

Complications and Predictors of Need for Return to the Operating Room in the Treatment of Supracondylar Humerus Fractures in Children

Supracondylar humerus fractures are common pediatric injuries. Little is known about the risk factors for repeat operative procedures. A retrospective chart review of 709 patients treated for a displaced supracondylar humerus fracture was performed to identify risk factors for return to the operating room during the initial post-operative period. Deviations of routine fracture care were recorded and complication rates were compared between Gartland type 2 and 3 fractures using logistic regression. Type 3 fractures were found to have a higher complication rate, and, specifically, more peri-operative nerve palsies, more likely to need to return to the operating room for hardware removal, to lose fracture reduction, and require a return to the operating room for any reason. Five risk factors which may require returning to the operating room were identified: younger patient age, left sided fractures, type 3 fractures, peri-operative nerve palsy, and post-operative infection. In conclusion, Gartland type 3 supracondylar humerus fractures are associated with more complications then type 2 fractures. Risk factors for the need to return to the operating room in the post-operative period include: younger patient age, left sided fractures, type 3 fractures, peri-operative nerve palsy, and post-operative infection. Patients with these risk factors should be considered at risk for return to the OR and fracture fixation and follow up protocols should be adjusted for this risk.

Clinical and radiographic outcomes of supracondylar humerus fractures treated surgically by pediatric and non-pediatric orthopedic surgeons

PURPOSE

This study compares clinical and radiographic outcomes of operatively managed pediatric supracondylar humerus fractures between patients treated by pediatric orthopedists (POs) and patients treated by non-pediatric orthopedists (NPOs).

PATIENTS AND METHODS

A retrospective cohort study of pediatric patients with surgically managed supracondylar humerus fractures was conducted. For clinical outcomes analyses, 3 months of clinical follow-up were required, resulting in a sample size of 90 patients (33 treated by NPOs, 57 by POs). For radiographic outcomes analyses, 3 months of both clinical and radiographic follow-up were required, resulting in a sample size of 57 patients (23 treated by NPOs, 34 by POs).

RESULTS

The rate of inadequate fracture fixation was higher for patients treated by NPOs (43.5 %) than for patients treated by POs (14.7 %; p = 0.030), but rates of clinical complications, malreduction, and postoperative loss of reduction did not differ. Treatment with open reduction was more common for patients treated by NPOs (33.3 %) than for patients treated by POs (3.5 %; p < 0.001). Total operating room time was longer for patients treated by NPOs (110.9 min) than for patients treated by POs (82.9 min; p < 0.001).

CONCLUSIONS

While patients treated by POs differed from patients treated by NPOs with respect to several intermediate outcomes, including having a lower rate of open reduction and a lower rate of inadequate fracture fixation, there were no differences between POs and NPOs in the rates of the more meaningful and definitive outcomes, including clinical complications, malreduction, and postoperative loss of reduction.

Gartland type III supracondylar humerus fractures: outcome and complications as related to operative timing and pin configuration

PURPOSE

Supracondylar fractures of the humerus are the most common fracture of the elbow in children. The purpose of this study was to evaluate, in terms of outcomes and complications, Gartland type III pediatric supracondylar humerus fractures treated at a pediatric level-one trauma center over a 7-year period, specifically addressing the impact of time to surgery on the incidence of complications and conversion to open reduction.

METHODS

We retrospectively reviewed 297 pediatric patients that sustained a closed Gartland type III supracondylar humerus fracture treated between December 2004 and December 2011. The time to the operating room was calculated from the medical records for each patient. The outcome measures evaluated were operative time, conversion to open procedure, and perioperative and postoperative complications.

RESULTS

In our study, there were 30 complications in 25 children (8.4%). Conversion to open reduction occurred in 28 children (9.4%). The time from the emergency department to the operating room was not significantly correlated with increased complications, increased operative time, or conversion to open reduction (p > 0.05). Crossed pinning resulted in an increased risk of overall complications [odds ratio (OR) = 2.6] and iatrogenic nerve injuries (OR = 9.3). Complications also occurred more commonly in boys (OR = 3.3) and in older patients (p = 0.0069) CONCLUSIONS: We found no significant correlation between the time to surgery and complications, operative time, or need for open reduction. These findings support the trend of treating Gartland type III supracondylar humerus fractures in a less urgent manner. In addition, our study supports the concept that cross pinning leads to more complications than lateral pinning, including an 8-fold increase in iatrogenic nerve injury.

The cost of after-hours operative debridement of open tibia fractures

OBJECTIVES

The aim of this study was to evaluate the additional cost associated with performing after-hours operative debridement of open fractures within 6 hours of injury.

DATA SOURCES

The economic model is based on population estimates obtained from the National Trauma Database and the National Inpatient Sample on the number of open tibia fractures that occur annually in the United States and the number that present after-hours (between 6 PM and 2 AM) that undergo operative debridement within 6 hours. This model estimates incremental cost for after-hours surgery based on overtime wages for on-call personnel (nurses and surgical technicians) required to staff after-hours cases as published by the US Department of Labor and data from our own institution. As many level 1 hospitals are capable of performing after-hours cases without additional cost, a sensitivity analysis was performed to determine the effect of designated level of care of the trauma hospital.

DATA EXTRACTION AND SYNTHESIS

A total of 17,414 open tibia fractures were recorded in the National Inpatient Sample for 2009, and an estimated 7485 open tibia fractures presented after-hours, 4242 of which underwent operative debridement within 6 hours of presentation. Based on wage statistics from the US Department of Labor and our own institution, the estimated total additional cost for after-hours operative debridement of open tibia fractures within 6 hours is from $2,210,895 to $4,046,648 annually, respectively. For level 2 hospitals and below, the cost of performing after-hours operative debridement of open tibia fractures is calculated as from $1,532,980 to $2,805,846 annually.

CONCLUSIONS

The data indicated an increased overall financial cost of performing after-hours operative debridement of open tibia fractures. Given that there is minimal documented benefit to this practice, and with increased pressure to practice cost containment, elective delay of operative debridement of open fractures and/or transfer to a higher level of care trauma hospital may be an acceptable way to address these issues.

LEVEL OF EVIDENCE

Economic analysis level III. See instructions for authors for a complete description of levels of evidence.

Factors associated with a failed closed reduction for supracondylar fractures in children

PURPOSE OF THE STUDY

The aim of this retrospective study is to analyze the risk factors causing the failure of closed reduction of children supracondylar fracture.

PATIENTS AND METHODS

The children with supracondylar humerus fractures who were treated in our hospital from February 2008 to February 2013, were recorded as well as their age, sex, BMI, injured side, mechanism of injury, associated injuries, fracture type, delay from injury to surgery. Mean comparisons or Chi(2) test were used for univariate analysis of the above factors, and then multivariate logistic regression analysis was used to analyse the possible risk factors, in order to elicit the risk factors associated with a failed closed reduction for supracondylar fractures in children.

RESULTS

Univariate analysis showed that BMI, fracture type, duration from injury to surgery, and mechanism of injury had statistically significant association with the failure of closed reduction for children supracondylar fracture (*P=0.021, 0.044, 0.000 and 0.037 respectively). Multivariate logistic regression analysis demonstrated that fracture type (P=0.027, OR=1.177), time from injury to surgery (P=0.022, OR=2.003), and mechanism of injury (P=0.044, OR=4.182) were independent risk factors of a failed closed reduction for paediatric supracondylar fractures.

DISCUSSIONS

Gartland type III supracondylar fractures, the peak period of soft tissue swelling and high-energy injury are significant risk factors to warrant open reduction. Treating surgeons should preoperatively carefully evaluate these risk factors and be prepared to treat these injuries accordingly.

LEVEL OF EVIDENCE

Level IV retrospective study.

Factors delaying recovery after volar plate fixation of distal radius fractures

PURPOSE

To evaluate the factors influencing delayed functional recovery in patients with a distal radius fracture treated by volar plate fixation.

METHODS

A total of 122 patients with a distal radius fracture treated by volar locking plate were enrolled. The wrist range of motion, grip strength, and functional outcome by the Michigan hand score were assessed 3, 6, and 12 months after surgery. The factors assessed for their influence on delayed functional recovery include age, sex, bone mineral density (BMD), hand dominance, the type of fracture, the energy of trauma, the time to surgery, and the duration of immobilization. A multivariate regression analysis was conducted to identify independent predictors of delayed functional recovery in terms of the Michigan hand score.

RESULTS

There was a significant decrease in the wrist range of motion in patients with a high-energy trauma, severe type fracture, or increase in duration of immobilization at month 3, whereas only a severe fracture type was associated with a decreased range of motion after 6 and 12 months. An increase in age, a decrease in BMD, and high-energy trauma reduced grip strength at months 3 and 6, whereas only an increase in age and a decrease in BMD reduced grip strength at month 12. According to the multivariate regression analysis, severe type fracture and high-energy trauma reduced functional outcomes at months 3 and 6. Conversely, at month 12, an increase in age and a decrease in BMD reduced functional outcome.

CONCLUSIONS

An increase in age and a decrease in BMD were important risk factors influencing delayed functional recovery up to 12 months after distal radius fracture surgery, whereas fracture severity and high-energy trauma were associated with decreased functional outcomes up to 6 months after surgery.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Elbow fractures and dislocations

Elbow fractures are common in pediatric patients. Most injuries to the pediatric elbow are stable and require simple immobilization; however, more severe fractures can occur, often requiring operative stabilization and/or close monitoring. This article highlights the common fractures and dislocations about the pediatric elbow and discusses the history, evaluation, and treatment options for specific injuries.

The epidemiology of paediatric supracondylar fracture fixation: a population-based study

INTRODUCTION

The epidemiology of paediatric supracondylar fracture (SCF) fixation has not been evaluated at a population level. The purpose of this study was to: (1) determine the incidence density rate (IDR) of SCF fixation and (2) determine the rate of and risk factors for re-operation.

METHODS

Using administrative databases, all patients who underwent SCF fixation (closed reduction percutaneous pinning (CRPP) or open reduction (OR)) in Ontario between April 2002 and March 2010 were identified. Exclusion criteria included age (>12 years), a prior or concurrent non-SCF elbow fracture or previous humeral osteotomy. The overall IDR of SCF fixation and for subgroups of age, sex and season were calculated. A multivariate regression (immediate and short-term re-operation) and a Cox proportional hazards model (long-term re-operation) were used to identify patient, injury and provider factors that influenced re-operation risk and were reported as odds ratios or hazard ratios (HRs) with 95% confidence intervals (CIs), respectively.

RESULTS

A total of 3235 patients with a median age of 6.0 years (interquartile range (IQR): 3.0) underwent SCF fixation. The median follow-up was 6.0 years (IQR: 3.7). The majority underwent a CRPP (78.7%) which were performed after hours (75.6%). The overall IDR was 20.7/100,000 person-years (py), but it varied significantly by season and age. Re-operation was uncommon in the immediate (1.0%), short-term (1.4%) and long-term (0.3%) follow-up period. As compared to CRPP, patients who underwent OR were more likely to undergo early nerve exploration (odds ratio: 7.8 (CI: 3.0-20.6)) and re-operation in the long term (HR: 3.0 (CI: 1.0-8.7)). Increased surgeon volume of SCF fixation was protective against repeat fixation (odds ratio: 0.9 (CI: 0.9-1.0)) and re-operation in the long term (HR: 0.9 (CI: 0.8-1.0)).

CONCLUSIONS

While SCF fixation is common, the rate of re-operation is low. No differences existed between the sexes and a higher volume of fixations occurred during the summer months.

Dislocated Extension – Type Supracondylar Humerus Fractures in Children: Single Centre Experience

Aim: The aim of this study is to show our experience in cases of dislocated extension type – supracondylar humeral fractures and evaluate the results of their treatment in the period from 2000 to 2010 with a follow up of a maximum six months.Material and Methods: A retrospective analysis of the clinical cases for the period 2000 – 2010 was done. Children from 4 to 14 years of age with supracondylar fractures of the humerus – extension type are included. The total number of patients treated at the Clinic for Pediatric Surgery was 230.Results: The results of the treatment were evaluated after the last control examination six months later. We noticed postoperative neurological damage in 10 cases (4.85%). In 14 patients (6.8%) we noticed long term deformities such as cubitus varus or cubitus valgus. Infection at the entering place of the needles occurred in 4 patients (1.94%), which did not indicate premature extraction of the needles and conversion of the treatment.Conclusion: As a conclusion, we can stress that our outcomes in treatment of dislocated suparacondylar fractures of the humerus in children meet the world standards.

Obesity and its effects on pediatric supracondylar humeral fractures

BACKGROUND

This study evaluates the effects of childhood obesity on fracture complexity and associated injuries in pediatric supracondylar humeral fractures.

METHODS

A billing query identified all patients who were two to eleven years of age and had undergone operative treatment for extension-type supracondylar humeral fractures over a 12.5-year period. Records were reviewed for demographic data, body mass index percentile, and injury data. Complex fractures were defined as type-3 supracondylar humeral fractures, supracondylar humeral fractures with intercondylar extension, or supracondylar humeral fractures with ipsilateral upper-extremity fractures. Logistic regression analyses were used to test relationships among body mass index subgroups, fracture complexity, elbow motion, preoperative and postoperative neurovascular status, and complications.

RESULTS

Three hundred and fifty-four patients met our inclusion criteria. Forty-one children were underweight (BMI in the <5th percentile), 182 were normal weight (BMI in the 5th to 85th percentile), sixty-three were overweight (BMI in the >85th to 95th percentile), and sixty-eight were obese (BMI in the >95th percentile). There were 149 patients, eleven of whom were obese, with isolated type-2 fractures and 205 patients, fifty-seven of whom were obese, with complex fractures. Thirty-two patients had preoperative nerve palsies and twenty-eight patients had postoperative nerve palsies. Using logistic regression, obesity was associated with complex fractures (odds ratio, 9.19 [95% confidence interval, 4.25 to 19.92]; p < 0.001), preoperative nerve palsies (odds ratio, 2.69 [95% confidence interval, 1.15 to 6.29]; p = 0.02), postoperative nerve palsies (odds ratio, 7.69 [95% confidence interval, 2.66 to 22.31]; p < 0.001), and postoperative complications (odds ratio, 4.03 [95% confidence interval, 1.72 to 9.46]; p < 0.001). Additionally, obese patients were more likely to sustain complex fractures from a fall on an outstretched hand than normal-weight patients (odds ratio, 13.00 [95% confidence interval, 3.44 to 49.19]; p < 0.001).

CONCLUSIONS

Obesity is associated with more complex supracondylar humeral fractures, preoperative and postoperative nerve palsies, and postoperative complications. To our knowledge, this study is the first to assess the implications of obesity on supracondylar humeral fracture complexity and associated injuries and it validates public health efforts in combating childhood obesity.

The perfused, pulseless supracondylar humeral fracture: intermediate-term follow-up of vascular status and function

BACKGROUND

This study provides intermediate-term follow-up data on the vascular status of a cohort of children with a perfused, pulseless supracondylar humeral fracture who were managed with closed reduction, percutaneous pinning, and observation.

METHODS

Pediatric patients who sustained a perfused, pulseless supracondylar humeral fracture in the period from 2007 to 2011 and who had at least six months of clinical follow-up were identified and returned for evaluation. The primary outcome was vascular status as indicated by palpation of the radial pulse, the wrist brachial index, and arterial patency on duplex ultrasound. Secondary outcomes included functional parameters assessed with the Pediatric Outcomes Data Collection Instrument (PODCI), arm circumference, arm length, elbow motion, neurologic findings, muscle endurance, grip strength, and intolerance to cold.

RESULTS

Follow-up data were obtained for twenty of thirty-six patients with a Gartland type-III fracture who had been managed with closed reduction and percutaneous pinning. Five patients had a return of a palpable pulse in the operating room after closed reduction and percutaneous pinning. All twenty had a palpable radial pulse at the time of the latest follow-up, and all nerve palsies resolved. Duplex ultrasound performed at the time of follow-up showed that fourteen patients had a patent brachial artery, five had brachial artery occlusion with large collateral vessels, and one had severe arterial stenosis. All fourteen patients with a patent brachial artery, two of the five with an occluded brachial artery, and the patient with a stenotic brachial artery had a normal wrist brachial index. Three patients with an occluded brachial artery had an abnormal wrist brachial index (0.73, 0.71, and 0.80). No differences between the injured and uninjured sides were observed with regard to arm circumference, arm length, elbow motion, muscle endurance, or grip strength. Thirteen of the twenty patients had higher functioning in all domains of the PODCI questionnaire compared with the general population. Two patients (one with an occluded artery and one with a patent artery) had lower values on the global functioning score.

CONCLUSIONS

After an average of twenty months of follow-up, children with a perfused, pulseless supracondylar humeral fracture that had been treated with closed reduction, percutaneous pinning, and observation demonstrated a palpable distal radial pulse, normal growth of the arm, and good/excellent functional outcomes, although five of the twenty patients had an occluded brachial artery.

LEVEL OF EVIDENCE

Therapeutic level IV. See Instructions for Authors for a complete description of levels of evidence.

Managing supracondylar fractures of the distal humerus in children in a district general hospital

Introduction

Controversy exists regarding the timing of surgery in children with displaced supracondylar fractures of the humerus.

Methods

We reviewed retrospectively the postoperative outcomes and complications in these children managed in a district general hospital.

Results

There were 81 children with displaced supracondylar fractures (64 Gartland type III and 17 type IIA). Of these, 46 children were treated within 6 hours of presentation and 35 were treated later. The rate of open reduction was higher in children treated early (23%) than in late cases (11%). There was no significant difference in the postoperative outcomes and complications between the groups.

Conclusions

In children with a supracondylar fracture, the timing of surgical treatment (before or after six hours from presentation to hospital) had no effect on postoperative complications and outcomes.

Managing supracondylar fractures of the distal humerus in children in a district general hospital

INTRODUCTION

Controversy exists regarding the timing of surgery in children with displaced supracondylar fractures of the humerus.

METHODS

We reviewed retrospectively the postoperative outcomes and complications in these children managed in a district general hospital.

RESULTS

There were 81 children with displaced supracondylar fractures (64 Gartland type III and 17 type IIA). Of these, 46 children were treated within 6 hours of presentation and 35 were treated later. The rate of open reduction was higher in children treated early (23%) than in late cases (11%). There was no significant difference in the postoperative outcomes and complications between the groups.

CONCLUSIONS

In children with a supracondylar fracture, the timing of surgical treatment (before or after six hours from presentation to hospital) had no effect on postoperative complications and outcomes.

The value of ultrasonic diagnosis in the management of vascular complications of supracondylar fractures of the humerus in children

Of 48 consecutive children with Gartland III supracondylar fractures, 11 (23%) had evidence of vascular injury, with an absent radial pulse. The hand was pink and warm in eight and white and cold in the other three patients. They underwent colour-coded duplex scanning (CCDS) and ultrasound velocimetry (UV) to investigate the patency of the brachial artery and arterial blood flow. In seven patients with a pink pulseless hand, CCDS showed a displaced, kinked and spastic brachial artery and a thrombosis was present in the other. In all cases UV showed reduced blood flow in the hand. In three patients with a white pulseless hand, scanning demonstrated a laceration in the brachial artery and/or thrombosis. In all cases, the fracture was reduced under general anaesthesia and fixed with Kirschner wires. Of the seven patients with a pink pulseless hand without thrombosis, the radial pulse returned after reduction in four cases. The remaining three underwent exploration, along with the patients with laceration in the brachial artery and/or thrombosis.

We believe that the traditional strategy of watchful waiting in children in whom the radial pulse remains absent in spite of good peripheral perfusion should be revisited. Vascular investigation using these non-invasive techniques that are quick and reliable is recommended in the management of these patients.

Cite this article: Bone Joint J 2013;95-B:694–98.

An evaluation of supracondylar humerus fractures: is there a correlation between postponing treatment and the need for open surgical intervention?

PURPOSE

The goal of this study was to evaluate the treatment and recovery of patients treated for Gartland type III supracondylar humerus fractures in order to determine if postponing treatment leads to a higher rate of open surgical treatment or complications.

METHODS

A retrospective study was conducted examining the medical records of children with Gartland type III supracondylar humerus fractures at our institution for a two-year period. The patients included in the study were treated with closed reduction and percutaneous pinning (CRPP) or open reduction and internal fixation (ORIF).

RESULTS

After exclusions, 134 patients were included in the study, with an average age of 5.6 years. The patients were grouped according to whether their treatment was postponed (39.6 %) or immediate (60.4 %). The majority of all patients were treated using CRPP: 46 (86.8 %) of the postponed patients and 75 (92.6 %) of the immediate patients. Very few postsurgical complications occurred in the patients; there was only one (1.6 %) case of iatrogenic nerve injury in a postponed patient as well as four (3.8 %) cases of loss of carrying angle: one (2.3 %) in postponed patients and three (4.8 %) in immediate patients.

CONCLUSIONS

Postponing treatment of type III supracondylar humerus fractures in children did not lead to an increase in open surgical treatment; nor did it lead to an increase in complications.

The use of a joystick technique facilitates closed reduction and percutaneous fixation of multidirectionally unstable supracondylar humeral fractures in children

BACKGROUND

Multidirectionally unstable supracondylar fracture of the distal humerus presents with severe instability in both flexion and extension. Closed reduction and percutaneous fixation is challenging and may not be obtained by the traditional reduction maneuver.

METHODS

We retrospectively evaluated 8 children (4 boys and 4 girls) with a mean age at presentation of 7.6 years (range, 5.3 to 10.9 y) who underwent closed reduction and percutaneous fixation using a joystick technique for the treatment of multidirectionally unstable supracondylar fractures. Clinical and functional results were assessed by the system described by Flynn. Radiographs at last follow-up were compared with those taken immediate after pinning as well as with normal contralateral elbow radiographs at final follow-up.

RESULTS

After an average follow-up of 14.5 months (range, 12 to 24 mo), there was no difference between the injured upper extremity and the contralateral side according to cosmetic, functional, and radiographic evaluation. There was no complication such as pin-site infection, loss of fixation, malunion, cubitus varus, iatrogenic nerve injury, or need for further surgery.

CONCLUSIONS

The joystick technique is a safe and effective method that can avoid aggressive and frustrating attempts of closed reduction and further open reduction of multidirectionally unstable supracondylar fractures of the humerus in children.

LEVEL OF EVIDENCE

Level IV-case series.

Delayed treatment of supracondylar elbow fractures in children

BACKGROUND

Supracondylar fractures are the most common elbow fractures in children and are usually treated on an emergency basis, using percutaneous pinning. However, the treatment is often delayed in areas where healthcare resources are scarce.

HYPOTHESIS

Delaying treatment does not influence the perioperative complication rate.

MATERIALS AND METHOD

We retrospectively reviewed the medical charts of 89 children aged 2 to 15 years in whom surgery for extension-type supracondylar elbow fractures was delayed by more than 48 hours. The 53 boys and 36 girls with a mean age of 6 years 9 months had severe fracture displacement (28 stage III and 61 stage IV according to Lagrange and Rigault classification scheme). Mean time to treatment was 4.5 days (range: 2-17 days). Open reduction and crossed K-wire fixation via the posterior approach were performed in all 89 patients. Postoperative complications and sequelae were collected. Functional outcomes were evaluated using Flynn's criteria.

RESULTS

Outcomes were satisfactory in 74 (83.2%) of patients. Postoperative complications occurred in 13 (14.6%) patients and consisted of surgical site infection (n=7, 7.8%), iatrogenic nerve injury (n=3, 3.4%), and reoperation (n=3, 3.4%). At last follow-up after a mean of 5 months, three (3.4%) patients had cubitus varus and one had a recurrent fracture due to massaging. Elbow motion was limited in 11 (12.4%) patients. No case of compartment syndrome was recorded.

DISCUSSION

Despite an average time to surgery of 4.5 days, the outcome was satisfactory in 83% of cases. Delayed treatment was not associated with an increased rate of perioperative complications.

LEVEL OF EVIDENCE

Level IV, retrospective study.

Risk factors for failed closed reduction of pediatric supracondylar humerus fractures

The purpose of this retrospective study was to examine pediatric supracondylar humerus fractures at a Level I trauma center. Data were analyzed to identify risk factors associated with closed reduction failure. Closed pediatric supracondylar humerus fractures that were treated at the authors' trauma center between October 1997 and January 2009 were reviewed. The main outcome variable was necessity of open reduction. To determine which factors were independently associated with a failed closed reduction, a multivariate logistic model was fit predicting open reduction status.A total of 174 patients required operative treatment. Of these, 23 underwent open reduction and 151 underwent with closed reduction and percutaneous pinning. For patients who required open reduction, 39.1% had an associated injury compared with 14.6% of patients treated with closed reduction (P=.008). Average time from presentation to surgery was 4.1 hours in the open reduction and 6.3 hours in the closed reduction group (P=.049). Risk factors that significantly predicted failure of closed reduction were the presence of an associated injury, initial fracture displacement, and Gartland type III fracture (P=.008, .03, and .023, respectively).Associated injury, large initial fracture displacement, and Gartland type III factures were statistically significant independent risk factors for closed reduction failure. Increased time from injury to presentation demonstrated a trend toward open reduction. Consideration should be given to the expedient transfer of patients with type III supracondylar humerus fractures with associated injuries when definitive care will be provided at another institution.