Comparison of complications and results of early versus delayed surgery for Gartland type III supracondylar humeral fractures in pediatric patients

Double joystick technique - a modified method facilitates operation of Gartlend type-Ⅲ supracondylar humeral fractures in children

Gartland type-Ⅲ supracondylar humerus fracture (SCHF) is a severe lesion with the feature of difficult reduction. Due to the high failure rate of traditional reduction, a more practical and safer method is needed. This retrospective study aimed to explore the effectiveness of the double joystick technique during the closed reduction of children with type-III fractures. Forty-one children with Gartland type-Ⅲ SCHF underwent closed reduction and percutaneous fixation using the double joystick technique at our hospital between June 2020 and June 2022, and 36 (87.80%) patients were successfully followed up. The affected elbow was evaluated by the joint motion, radiographs, and Flynn's criteria then contrasted with the contralateral elbow at the last follow-up. A group of 29 boys and seven girls with an average age of 6.33 ± 2.68 years. The mean time of surgery and hospital stay was 26.61 ± 7.51 min and 4.64 ± 1.23 days, respectively. After a mean follow-up of 12.85 months, the average Baumann angle was 73.43 ± 3.78°, although the average carrying angle (11.33 ± 2.17°), flexion angle (143.03 ± 5.15°), and extension angle (0.89 ± 3.23°) of the affected elbow were less than those of the contralateral elbow ( P  < 0.05), the mean range of motion difference between two sides is only 3.39 ± 1.59°, with no complications. Furthermore, 100% of patients recovered satisfactorily, with excellent outcomes (91.67%) and good outcomes (8.33%). The double joystick technique is a safe and effective method that facilitates the closed reduction of Gartland type-Ⅲ SCHF in children without raising the risk of 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.

Effect of fracture location on rate of conversion to open reduction and clinical outcomes in pediatric Gartland type III supracondylar humerus fractures

BACKGROUND

Supracondylar humerus fractures are the most common form of elbow fracture in children and adolescents. At present, treatment planning is based on the Gartland classification. Reduction and percutaneous pinning are done for Gartland type III fractures. In cases where closed reduction is unsuccessful, the procedure is converted to open reduction. However, there is no consensus on which patients are more likely to require conversion to open reduction. The aim of this study was to investigate the effect of fracture location on the rate of conversion to open reduction and clinical outcomes.

METHODS

A total of 112 patients who underwent early surgery for Gartland type III supracondylar humerus fracture between August 2011 and August 2017 were evaluated. The patients' age, sex, facture location, post-operative loss of reduction, and complications were noted. The fractures were classified according to fracture level relative to isthmus (high level) or at/below the isthmus (low level). Closed reduction was initially preferred. Open reduction with percutaneous pinning was performed, when necessary. Flynn's criteria were used to evaluate elbow motion after treatment.

RESULTS

Mean follow-up time was 39 months (16-62 months). The mean age of the patients was 6.4±2 years (1.4-12 years). Thirty-nine of the patients were female, 73 were male; 32 fractures were in the dominant arm, 80 were in the non-dominant arm. Ninety of the fractures were classified as high level (proximal) and 22 as low level (distal). Patients with low-level fractures were significantly younger (p<0.01). Patients with low-level fractures also showed a significantly higher rate of conversion to open reduction compared to those with high-level fractures (p<0.01). Clinical outcomes evaluated with Flynn's criteria were statistically equivalent between the high and low fracture groups (p>0.05).

CONCLUSION

The Gartland classification provides important guidance for the treatment of supracondylar humerus fractures, but may have limitations. Our results suggest that revising the classification by incorporating fracture location may be more beneficial for pre-operative planning.

Predictors of early elbow function following paediatric humeral supracondylar fractures: A retrospective analysis

Background

Supracondylar fracture usually occurs as a result of fall on an outstretched hand. Prompt management is essential to prevent complications. Functional outcome after management of this fracture may be predicted by some factors.

Aims

The study aimed to review the management of supracondylar fractures and determine what factors have an impact on the functional outcome of the elbow using MEPS score in the early post-operative period.

Patients and Methods

This study was a retrospective study of all patients with supracondylar fractures that presented at the accident and emergency department of a tertiary institution over a 2-year period. Their relevant data were retrieved from their folders and analysis done using SPSS 20. The MEPS score at 6 months was calculated. Multiple linear regressions were used to determine factors that can predict early elbow function using the MEPS score at 6 months.

Results

In the study, 61.4% (35) patients were males and 38.6% (22) females. The commonest mechanism of injury was fall on the outstretched hand (FOOSH), 70.2%. The mean duration of presentation to the hospital was 38 h (SD = 56.9). Among treatment offered to the patients, a higher number had open reduction with pinning. The mean postoperative Mayo elbow score was 87.6. Age of patients, Gartland type and the duration of cast immobilization were significant predictors of the MEPS at 6 months after treatment.

Conclusion

The Gartland type and duration of cast immobilization are the most important predictors of the MEPS score at 6 months in this study.

Treatment and outcomes of pediatric supracondylar humeral fractures in Korle Bu Teaching Hospital

Objectives:

Supracondylar humeral fractures (SCHF) are the most common elbow injury in the pediatric population. The treatment, outcome, and health-related quality of life (HRQoL) following these injuries are described.

Methods:

Patients with SCHF who were treated depending on the fracture type were evaluated. Medical records stored in the REDCap database were reviewed to obtain information on demographics, mechanisms of injury, neurovascular status, infection rates, and postoperative complications. Outcomes were assessed using Flynn's criteria and Pediatric Quality of Life (PedsQL) version 4.0. Follow-up was for 6 months.

Results:

A total of 101 patients with a mean age of 5.2 years (SD ± 2.3) were seen. Most of the injuries occurred at home (64.3%). The left-arm (nondominant) was the most injured (62%), though 92% of patients were right hand dominant. Ninety-six percent of the fractures were the extension type. A total of 98% had satisfactory outcomes using Flynn's criteria and older patients were likely to sustain Gartland type III SCHF (P = .01). There was a significant difference in mean scores of PedsQL (all P values < .01) at 6 months.

Conclusions:

In this prospective study, the quality of life of patients following SCHF diminished at the time of the injury and returned to the population normal 6 months after. There was no significant difference in HRQoL scores between patients who presented early and those who presented late. The delayed presentation and management did not also affect the functional outcome and complications. Therefore, surgical management of these injuries after late presentation is still safe.

An Analysis of the Impact of Timing and Technique on Outcomes after Surgery for Distal Radius Fractures: The Wrist and Radius Injury Surgical Trial Collaborative Study

BACKGROUND

Surgical treatment of closed distal radius fractures varies based on treatment, surgeon schedule, and patient preferences. The authors examined how timing and technique impact surgeon-perceived procedural difficulty and quality of reduction, outcomes, and complications.

METHODS

This was a retrospective study of participants in the randomized, multicenter Wrist and Radius Injury Surgical Trial with isolated unstable distal radius fractures. Participants were randomized to treatment with a volar locking plate system, closed reduction and percutaneous pinning, or external fixation. The authors analyzed surgeon-perceived procedural difficulty and reduction quality based on time to operation.

RESULTS

Of 184 participants, 88 underwent surgery less than 7 days after fracture (mean, 4.6 days) and 96 underwent surgery at more than 7 days after fracture (mean, 12.3 days). Surgery performed at more than 7 days was rated more difficult versus surgery at less than 7 days [4.6 versus 3.8 of 10 (1 = easiest); p = 0.05]. When the volar locking plate technique was performed, there was no difference in surgeon-perceived difficulty or reduction quality between the groups; however, surgeons performing closed reduction and percutaneous pinning more than 7 days after injury reported greater procedure difficulty (4.1 versus 2.9; p = 0.05) and poorer reduction quality compared to less than 7 days (7.2 versus 8.1; p = 0.03). Participants who underwent surgery at less than 7 days scored 8 and 7 points greater on the Michigan Hand Outcomes Questionnaire Satisfaction (p = 0.05) and Activities of Daily Living (p = 0.03) domains, respectively.

CONCLUSIONS

Surgery performed less than 7 days after fracture leads to better surgeon-perceived reduction quality and less procedural difficulty. If surgery cannot be performed before 7 days, the authors recommend patients undergo treatment with the volar locking plate system, given the comparable level of surgeon-perceived procedural difficulty and reduction quality when surgery was performed less than 7 days after injury.

CLINICAL QUERSTION/LEVEL OF EVIDENCE

Therapeutic, III.

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.

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.

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.

Transfer Time After Acceptance to a Level I Trauma Center

Background

Timely treatment of pediatric orthopaedic emergencies at level I trauma centers is frequently dependent on transfers from neighboring centers.

Methods

Records were collected from our level I trauma center for patients with isolated orthopaedic issues accepted for transfer in 2015. Open fractures, compartment syndrome, septic arthritis, and supracondylar humerus fractures with ecchymosis or neurovascular compromise were emergent. The rush hour was 6 am to 10 am and 3 pm to 7 pm.

Results

Ninety-six patients met the inclusion criteria; 19% (18/96) were orthopaedic emergencies and 37% (35/96) occurred during the rush hour. The average time from transfer acceptance to accepting hospital admission was 203 minutes (range, 68 to 584 minutes; SD, 85.8 minutes). The average time from transfer acceptance to departure from the transferring facility was 114 minutes (range, 7 to 391 minutes; SD, 71.9 minutes). There was no correlation between the transfer time and rush hour (P = 0.40), emergent versus nonemergent (P = 0.42), or routed distance from the hospital (P = 0.46).

Conclusion

The average transfer time exceeded 3 hours and was independent of the distance, the rush hour, or urgency of patient condition. An average 2-hour delay was encountered for patients while leaving a medical facility after acceptance of transfer.

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.

[Clinical and epidemiological characteristics of humeral supracondylar fractures in pediatric patients in a Regional General Hospital]

BACKGROUND

Supracondylar humerus fractures are common in children between 5-7 years of age and more frequent in the males, 90-95% of these fractures are in extension mechanism, the urgency of immediate attention is to prevent complications and sequelae.

OBJECTIVE

To establish the clinical and epidemiological profile of supracondylar humerus fractures, in a General Regional Hospital from the Instituto Mexicano del Seguro Social in Yucatan Mexico, during 2011-2013.

MATERIAL AND METHODS

A cross-sectional study. Strength association was measured by odds ratios and statistical significance with chi(2) test, p value was considered in < 0.05 RESULTS: 56 cases were analyzed, the mean age was 2.6 ± 5.33 years, the mechanism of injury was falling over at home, male gender is associated with extent injure mechanism (OR 5.6, 95% CI 1.0-30.1, p = 0.03), we observed that at most time elapsed between injury and medical means more hospital days (r = 0.40; p = 0.002), surgical treatment was established in 44 cases (78.6%), 18 (40.9%) with closed technique and placement of cloves and 26 (59.1%) with open reduction, in 100% cross configuration was used, ten complications were reported.

CONCLUSIONS

Supracondylar humerus fractures are a common injury in children, males are more likely to be injured by extension, and the speed in medical treatment is an important issue.

Is lateral pin fixation for displaced supracondylar fractures of the humerus better than crossed pins in children?

BACKGROUND

Closed reduction and percutaneous pin fixation is considered standard management for displaced supracondylar fractures of the humerus in children. However, controversy exists regarding whether to use an isolated lateral entry or a crossed medial and lateral pinning technique.

QUESTIONS/PURPOSES

We performed a meta-analysis of randomized controlled trials (RCTs) to compare (1) the risk of iatrogenic ulnar nerve injury caused by pin fixation, (2) the quality of fracture reduction in terms of the radiographic outcomes, and (3) function in terms of criteria of Flynn et al. and elbow ROM, and other surgical complications caused by pin fixation.

METHODS

We searched PubMed, Embase, the Cochrane Library, and other unpublished studies without language restriction. Seven RCTs involving 521 patients were included. Two authors independently assessed the methodologic quality of the included studies with use of the Detsky score. The median Detsky quality score of the included trials was 15.7 points. Dichotomous variables were presented as risk ratios (RRs) or risk difference with 95% confidence intervals (CIs) and continuous data were measured as mean differences with 95% CI. Statistical heterogeneity between studies was formally tested with standard chi-square test and I(2) statistic. For the primary objective, a funnel plot of the primary end point and Egger's test were performed to detect publication bias.

RESULTS

The pooled RR suggested that iatrogenic ulnar nerve injury was higher with the crossed pinning technique than with the lateral entry technique (RR, 0.30; 95% CI, 0.10-0.89). No publication bias was further detected. There were no statistical differences in radiographic outcomes, function, and other surgical complications. No significant heterogeneity was found in these pooled results.

CONCLUSIONS

We conclude that the crossed pinning fixation is more at risk for iatrogenic ulnar nerve injury than the lateral pinning technique. Therefore, we recommend the lateral pinning technique for supracondylar fractures of the humerus in children.

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.

Is nonperforated pediatric appendicitis still considered a surgical emergency? A survey of pediatric surgeons

OBJECTIVE

To describe the beliefs and preferences of pediatric surgeons regarding the emergent nature of nonperforated appendicitis.

METHODS

An electronic mailing was sent to all 1052 members of the American Pediatric Surgical Association (APSA) inviting participation in a 26-item survey, which was administered by Survey Monkey (www.surveymonkey.com). Chi-square and Mann-Whitney tests were used for bivariate analysis. Spearman's rho was used for nonparametric correlation.

RESULTS

Four hundred eighty-four pediatric surgeons (46%) responded to the survey. Few respondents (4%) considered nonperforated appendicitis to be a surgical emergency. A minority (14%) would come in from home to perform an overnight appendectomy. Most (92%) believe that postponing overnight appendectomy until daytime does not result in a clinically significant increase in perforation. Respondents endorsed surgeon fatigue (56%) and limited operating room availability (56%) most often among factors that would make them more likely to postpone surgery. Sixty-eight percent reported no departmental guideline regarding delay of overnight appendectomy.

CONCLUSIONS

Most pediatric surgeons in our study believe nonperforated appendicitis is not a surgical emergency and prefer to postpone overnight appendectomy.

A retrospective analysis of loss of reduction in operated supracondylar humerus fractures

BACKGROUND

Loss of reduction following closed or open reduction of displaced supracondylar fractures of the humerus in children varies widely and is considered dependent on stability of the fracture pattern, Gartland type, number and configuration of pins for fixation, technical errors, adequacy of initial reduction, and timing of the surgery. This study was aimed to evaluate the factors responsible for failure of reduction in operated pediatric supracondylar fracture humerus.

MATERIALS AND METHODS

We retrospectively assessed loss of reduction by evaluating changes in Baumann's angle, change in lateral rotation percentage, and anterior humeral line in 77 consecutive children who were treated with multiple Kirschner wire fixation and were available for followup. The intraoperative radiographs were compared with those taken immediately after surgery and 3 weeks postoperatively. Multivariate logistic regression analysis was performed by STATA 10.

RESULTS

Reduction was lost in 18.2% of the patients. Technical errors were significantly higher in those who lost reduction (P = 0.001; Odds Ratio: 57.63). Lateral pins had a significantly higher risk of losing reduction than cross pins (P = 0.029; Odds Ratio: 7.73). Other factors including stability of fracture configuration were not significantly different in the two groups.

CONCLUSIONS

The stability of fracture fixation in supracondylar fractures in children is dependent on a technically good pinning. Cross pinning provides a more stable fixation than lateral entry pins. Fracture pattern and accuracy of reduction were not important factors in determining the stability of fixation.