Delayed surgery in displaced paediatric supracondylar fractures: a safe approach? Results from a large UK tertiary paediatric trauma centre

Interfacility Transfer of Pediatric Supracondylar Elbow Fractures: Transfer by Ambulance Shows No Advantage in Speed of Transfer or Prevention of Complications

BACKGROUND

The treatment of supracondylar humerus (SCH) fractures is increasingly centralized in tertiary centers. Interfacility transfer from other facilities may occur by ground ambulance or privately owned vehicle (POV). The objective of this study was to determine if interfacility transfer by POV is equivalent in transfer time and perioperative complications compared with ground ambulance.

METHODS

This was a single-institution, retrospective study of SCH fractures with an intact pulse transferred by POV or ground ambulance. Transfer time points were collected to determine transfer time and speed. Associated injuries of ipsilateral fracture, skin at risk, and motor nerve palsy were recorded from orthopaedic documentation at the presentation. Insurance status and the Area Deprivation Index (ADI) were used as measures of socioeconomic disparity.

RESULTS

676 "urgent" Type III, IV, and flexion type SCH fractures and 167 "nonurgent" Type II SCH fractures were transferred by ambulance or POV. Open reduction was similar between urgent transfers transported by ambulance or POV (10% vs. 9%, P =0.344). There was no difference in transfer time ( P =0.391) or transfer speed ( P =0.416) between transfer groups. POV transfers were independently associated with no skin at risk (OR 2.1; 95% CI: 1.3-3.3, P =0.003), neurovascularly intact (OR 2.5; 95% CI: 1.4-4.4, P =0.001), and patients in the low (OR 1.9; 95% CI: 1.3-2.5, P =0.041) and moderate deprivation (OR 1.9; 95% CI: 1.1-3.5, P =0.034) compared with the high deprivation group. Medicaid insurance was associated with a lower odds ratio of private transport compared with commercial insurance (OR 0.54; 95% CI: 0.38-0.76, P =<0.001).

CONCLUSIONS

Interfacility transfer of nonemergent SCH fractures by privately owned vehicles has a similar speed of transfer and perioperative complication rate to transfer by ground ambulance. Our findings allow the triaging of nonemergent SCH fractures for potential interfacility transfer by privately owned vehicles and bring attention to disparities in interfacility transfer methods.

LEVEL OF EVIDENCE

Level III- Retrospective cohort study.

Time of surgery and surgeon level in supracondylar humerus fractures in pediatric patients: A retrospective study

BACKGROUND

Supracondylar humerus fractures account for more than 60% of all elbow fractures and about 1/5 of all pediatric fractures. Unfortunately, these fractures can be associated with risk of complications including neurovascular injuries, malunions and limb deformities. Controversy exists regarding the effect of time of surgical intervention and/or level of surgeon performing the surgery on outcome of these fractures.

AIM

To determine whether time of surgical intervention and/or surgeon level influence the outcomes of surgically managed pediatric supracondylar humerus fractures.

METHODS

We retrospectively studied 155 pediatric patients presenting with a supracondylar humerus fracture in a level 1 trauma center from January 2006 to December 2019. The data extracted included demographic data, fracture characteristics, surgical data, and follow-up outcomes. The collected data was analyzed and P values of < 0.05 were considered statistically significant.

RESULTS

Of the cohort, 11% of patients had documented post-operative complications, of which the majority occurred in surgeries performed after day time working hours and in fractures requiring open reduction. While the lowest complication rate was found in surgeries performed by pediatric orthopaedic surgeons, this did not reach statistical significance.

CONCLUSION

In pediatric patients undergoing surgery for supracondylar fractures, we found a higher complication rate when surgeries were not performed during working hours. Surgeon level and training had no significant effect on the risk of post-operative complications.

The Effect of Delayed Closed Reduction of Supracondylar Fracture on Perioperative Complications

Background Supracondylar fracture is one of the most frequent pediatric traumas and surgically managed fractures. Multiple factors can contribute to delaying surgical management of supracondylar fracture, which is thought to lead to difficult reduction and more complications. Surgical treatment during the nighttime shift (from 20:00-8:00) might increase the complication rate including vascular injury, nerve injury, and the need to convert closed reduction to open due to multiple reasons including nontrained staff, exhausted on-call team, and other reasons. Objectives We are looking into the effect of delaying surgical intervention 24 hours from the trauma to the surgical intervention and the impact of daytime or night-time surgeries on perioperative complications. Methods A retrospective cohort study was conducted on all patients who presented with supracondylar fracture Gartland type 2 or 3 who required surgical intervention (63 patients) from 2018-2021 in an academic institute. All patients presented with unilateral injury. Patients were divided into an early surgical group where the surgery was done within the first 24 hours from the trauma and a delayed surgical group if performed after 24 hours. Additionally, patients were classified based on the time of the day surgery was performed into daytime or nighttime surgeries. The complication rate was compared between the groups. Results Most of the patients were male, and the mean age was 4.52 ± 2.28 years. No significant difference was found between the early and delayed groups in the complication rate. Nerve and vascular injury were statistically higher for cases operated at nighttime. Conclusion Delayed surgical treatment of supracondylar fracture doesn't affect the complication rate, whereas closed reduction of supracondylar fractures that were performed during nighttime duty was shown to lead to a higher rate of vascular and nerve injuries.

Are we staying up too late? Timing of surgery of displaced supracondylar fractures in children. Clinical audit in a paediatric tertiary UK trauma centre and literature review

INTRODUCTION

The British Orthopaedic Association (BOA) guidelines in managing supracondylar humerus fractures in children, outline indications for urgent fixation of these fractures. We present our data from a regional paediatric trauma centre before and after implementing a change in practice as per these guidelines.

MATERIALS AND METHODS

Retrospective clinical audit against BOA guidelines. Radiographs, admission clerking notes, operation notes, and clinic letters were all reviewed. We included all displaced supracondylar fractures of the extension type (Gartland Types 2b and 3). The first audit cycle occurred in 2017, subsequent cycles in 2018 & 2019.

RESULTS

172 patients reviewed across the three audit stages. In the first audit, almost quarter of patients were operated on in the same night without clear indication as per the guidelines. This dropped down to 7% after a change of practice in 2019. Rate of conversion to open reduction and nerve complications did not increase after delayed fixation.

CONCLUSION

When there is no indication for same night operating out of hours, delaying treatment until the next day seems to be a safe way of treating these difficult fractures. Our data show that there is no increase in complications when these fractures are managed the next day.

Early Versus Delayed Treatment for Gartland Type III Supracondylar Humeral Fractures in Children: A Systematic Review and Meta-analysis

PURPOSE

The timing of treatment for Gartland type III supracondylar fractures has been an area of contention as it was previously thought to be a surgical emergency. The aim of this systematic review and meta-analysis is to clarify whether there is a difference in perioperative outcomes between early and delayed treatment for Gartland type III supracondylar humeral fractures in children.

METHODS

Literature search and study selection were performed according to the PRISMA process. The early surgery (ES) and delayed surgery (DS) groups were defined by the authors of each study included, based on the time to surgery. The primary outcome was the risk of conversion to open reduction. The secondary outcome was perioperative complication risks.

RESULTS

A total of 14 studies met the eligibility criteria (n = 1263 patients), of which 665 (52.7%) patients had undergone early surgery, while 598 (47.3%) had delayed surgery. On meta-analysis, there was no significant difference between ES and DS for the outcome of open reduction conversion risk. There was also no significant difference for the secondary outcomes of post-operative compartment syndrome, iatrogenic nerve injury, vascular injury, and surgical site infection.

CONCLUSION

Despite the limitations in the literature, evidence exists to support the notion that a delayed approach to the surgical treatment of Gartland type III supracondylar humeral fractures in children does not result in an increased risk of converting to open reduction and perioperative complications.

Evaluating Perioperative Complications Surrounding Supracondylar Humerus Fractures: Expanding Indications for Outpatient Surgery

BACKGROUND

Supracondylar humerus (SCH) fractures are one of the most common pediatric orthopaedic injuries. Described using the Wilkins modification of the Gartland Classification system, current practice guidelines give moderate evidence for closed reduction and percutaneous pinning of type 2 and 3 injuries, but little evidence exists regarding the appropriate surgical setting for fixation. The goal of this study was to evaluate the perioperative complication profile of type 3 fractures with maintained metaphyseal contact and determine their suitability for outpatient surgery.

METHODS

Skeletally immature patients with type 2 and 3 SCH fractures treated at a single, Level-1 trauma institution from March 2019 to January 2000 were retrospectively reviewed. A total of 1126 subjects were identified. Open, concomitant injuries, incomplete physical examination, initial neurovascular compromise, flexion-type fractures, ecchymosis, skin compromise, and those managed nonoperatively were excluded. Type 3 fractures were categorized as either "3M" versus type "3" ("M" denoting metaphyseal bony contact). Demographic data, neurovascular changes, and postoperative complications were collected. Categorical variables were evaluated using χ2 or Fisher exact tests, and continuous variables analyzed using analysis of variance, with significance defined as a P-value <0.05.

RESULTS

A total of 485 patients (189 type 2, 164 type 3M, 132 type 3) met inclusion criteria. Sex and length of stay did not differ among groups. The incidence of neurovascular change between initial presentation and surgical fixation was significantly greater for type 3 fractures compared with other groups (P=0.02). No child in the 3M group had preoperative neurovascular examination changes, compared with 3 patients with type 3 injuries. When directly compared with the 3M group, type 3 fractures had a higher incidence of neurovascular examination changes that trended towards significance (P=0.08). There was no difference in postoperative complication rate between groups (P=0.61).

CONCLUSIONS

Our findings demonstrate that Gartland type 3 SCH fractures lacking metaphyseal bony contact, compared with types 3M and 2, are more likely to experience neurovascular examination changes between initial presentation and definitive surgical fixation. Type 3M fractures clinically behaved like type 2 injuries and, accordingly, could be considered for treatment on an outpatient basis.

LEVEL OF EVIDENCE

Level III-retrospective comparative study.

Management of acute paediatric fractures treated surgically in the UK: a cross-sectional study

INTRODUCTION

The epidemiology of acute paediatric orthopaedic trauma managed surgically across the NHS is poorly described. Compliance against national standards for the management of supracondylar humeral fractures is also unknown at a national level.

METHODS

Collaborators in 129 NHS hospitals prospectively collected data on surgically managed acute paediatric orthopaedic trauma cases. Data were collected over a seven-day period and included demographics, injury characteristics, operative details and timing of surgery. A national audit was also undertaken to evaluate compliance with the British Orthopaedic Association Standards for Trauma Guideline 11: Supracondylar Fractures of the Humerus in Children.

RESULTS

Data were captured on 770 surgically treated cases. The three most common injuries were forearm fractures of both bones (n = 235), distal radius fractures (n = 194) and supracondylar elbow fractures (n = 89). The mode day of injury was Friday (n = 136) and the mode day of surgery was Saturday (n = 138). 88% of supracondylar fractures received surgery on the day of presentation or the following day. Only 14% of supracondylar fractures were treated surgically after 8pm; 33/89 used 2.0mm Kirschner wires, 38/89 used 1.6mm wires and 2/89 used 1.2mm wires.

CONCLUSION

Forearm fractures of both bones, distal radius fractures and supracondylar humeral fractures were the three most common injuries treated surgically. There is wide variation in compliance against national standards in the management of supracondylar humeral fractures with 88% undertaking surgery on the day of or the day following presentation but only 37% using the recommended 2.0mm Kirschner wires.

Timing of osteosynthesis of fractures in children changes the outcome

PURPOSE

The search for optimal treatment strategies for fractures in children that require osteosynthesis is controversial and is still being debated. A major factor that has been under discussion is the impact of the timing of surgery: the time delay between the trauma and the operation, as well as the duration of the surgical procedure, and the time of day that the operation is performed are potential factors that might influence the outcome. Therefore, the aim of our study was to investigate the influence of these factors on the outcome after osteosynthesis of diverse fractures of the extremities in children.

METHODS

In a retrospective study, 387 patients aged 1-18 years who presented with fractures of the extremities that underwent surgery were included. Patient records including radiological studies were analyzed. The follow up period lasted at least 12 months or until recovery. Statistical significance was set at an alpha level of P ≤ 0.05.

RESULTS

Delayed surgery, as well as a prolonged duration of surgery, and the mode of transportation of the patient significantly were related to a higher rate of complications. However, in this study, the complication rate was not found to be influenced by the mode of reduction of the fracture, or the time of day or the day of the week. A further parameter that significantly changed the outcome was the mechanism of injury. However, the rate of complications was unchanged if a resident or a consulting was the performing surgeon so that a resident can safely perform the procedure in the presence of a consultant.

CONCLUSION

Timing of surgery for fractures of the extremities in children, including the time from trauma to surgery, the duration of the operation and the mode of transportation to the ER, were found to have a significant impact on the occurrence of complications in this study while the mode of reduction and the time of day did not change the outcome. Future studies with a focus on selected types of fractures are needed to further enlighten this topic.

LEVEL OF EVIDENCE

Retrospective comparative study, level III.

Timing of Surgery for Pediatric Supracondylar Humerus Fractures and Early Postoperative Results

Background: Pediatric supracondylar humerus fracture (PSHF) is one of the most common fractures of the elbow seen among boys aged between 5 and 7 years. The timing of surgical treatment for this type of fracture is still controversial. Thus, we aimed to investigate whether the timing of surgery for PSHFs affects the incidence of early postoperative complications and reduction of PSHFs. Methods: We retrospectively reviewed the medical records of PSHF patients who underwent surgery at our hospital between January 2007 and March 2019. We classified patients who underwent surgery within 12 h and more than 12 h after the fracture as the early and delayed groups, respectively. The outcome measures compared between the two groups were the incidence of postoperative early complications such as neurological deficits, including iatrogenic ulnar nerve injury, vascular compromise, compartment syndrome, K-wire migration, and unplanned returns to the operating room. We also examined surgical time, reduction procedure, and perioperative radiographic parameters. Results: There was no significant difference in the incidence of early complications between the early and delayed groups for either modified Gartland type II or type III fractures. There was also no significant difference in surgical time, reduction procedure, or perioperative radiographic parameters between the two groups. Conclusions: Delayed surgery was not associated with an increased rate of postoperative early complications in either type II or type III fractures. The timing of surgery does not affect the difficulty or quality of reduction.

Early versus delayed surgery for paediatric supracondylar humeral fractures in the absence of vascular compromise: a systematic review and meta-analysis

AIMS

We set out to determine if there is a difference in perioperative outcomes between early and delayed surgery in paediatric supracondylar humeral fractures in the absence of vascular compromise through a systematic review and meta-analysis.

MATERIALS AND METHODS

A literature search was performed, with search outputs screened for studies meeting the inclusion criteria. The groups of early surgery (ES) and delayed surgery (DS) were classified by study authors. The primary outcome measure was open reduction requirement. Meta-analysis was performed in the presence of sufficient study homogeneity. Individual study risk of bias was assessed using the Risk of Bias in Non-Randomised Studies - of Interventions (ROBINS-I) criteria, with the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) criteria used to evaluate outcomes independently.

RESULTS

A total of 12 studies met the inclusion criteria (1735 fractures). Pooled mean time to surgery from injury was and 10.7 hours for ES and 91.8 hours for DS. On meta-analysis there was no significant difference between ES versus DS for the outcome of open reduction requirement. There was also no significant difference for the outcomes: Iatrogenic nerve injury, pin site infection, and re-operation. The quality of evidence for all the individual outcomes was low or very low.

CONCLUSIONS

There is no evidence that delaying supracondylar fracture surgery negatively influences outcomes in the absence of vascular compromise. There are, however, notable limitations to the existing available literature.

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.

Utilization of Orthopaedic Trauma Surgical Time: An Evaluation of Three Different Models at a Level I Pediatric Trauma Center

OBJECTIVE

Over the past decade, our institution has instituted three different scheduling models in an attempt to care for pediatric trauma at our Level I Trauma Center. This has been in response to a number of factors, including a limited number of physicians covering the call schedule, increasing competition for operating room (OR) time after hours (pediatric surgery, urology, neurosurgery), an attempt to fully utilize OR time during the daytime, fully staffed hours, and optimizing patients' timeliness to surgery. We examined the three on-call systems in place at our institution to determine whether a more flexible approach to pediatric trauma call resulted in delays in treatment.

METHODS

We retrospectively reviewed patient records for three distinct 1-year periods with three different surgical call schedules: (i) a traditional call schedule in which the call physician was responsible for patients who presented to our emergency room; (ii) a half-day trauma block OR reserved the morning following call; and (iii) a full-day trauma block. Variables included date of injury, time of admission, admission diagnosis, cause of injury, and OR procedure and start time.

RESULTS

We reviewed 951 cases over the entire study, 268 during the traditional call schedule, 282 during the half-call block and 401 over the time period of the full-day block. Mechanisms of injury were similar among the three groups, with falls and motor vehicle accidents being the leading causes. The average delay time was 17:40 for the traditional call group, 15:10 for the half-block call group, and 15:09 for the full-day block group. Our findings suggest that there was a high incidence of cases performed on weekdays after peak staffing hours with a traditional call model (59%). In contrast, half-day and full-day block models saw only 4% and 1% of the cases performed after peak staffing hours, respectively. There was a statistically significant difference in the number of patients admitted to the OR among the three groups (χ(2) = 488.8449, P < 0.0001). The number of patients seen during Monday through Friday was also statistically significant among the three groups (χ(2) = 382.0576, P < 0.0001).

CONCLUSIONS

The institution of more flexible and physician-directed half-call and full-day blocks did result in delays in treatment. However, it also has demonstrated benefits to patients in reducing the number of operative cases performed after weekday peak staffing hours; helped our institution better manage its staffing and financial resources; and provided the treating surgeon flexibility in determining the timing of operative care.

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).