Delaying treatment of supracondylar fractures in children

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.

Effectiveness of an early operating room start time in managing pediatric trauma

BACKGROUND

The timing of operative treatment for pediatric supracondylar humerus fractures (SCHF) and femoral shaft fractures (FSF) remains controversial. Many fractures previously considered to be surgical emergencies, such as SCHF and open fractures, are now commonly being treated the following day. When presented with an urgent fracture overnight needing operative treatment, the on-call surgeon must choose whether to mobilize resources for a late-night case or to add the case to an elective schedule of the following day.

AIM

To describe the effect of a program allowing an early operating room (OR) start for uncomplicated trauma prior to an elective day of surgery to decrease wait times for surgery for urgent fractures admitted overnight.

METHODS

Starting in October 2017, patients were eligible for the early slot in the OR at the discretion of the surgeon if they were admitted after 21:00 the previous night and before 05:00. We compared demographics and timing of treatment of SCHF and FSF treated one year before and after implementation as well as the survey responses from the surgical team.

RESULTS

Of the 44 SCHF meeting inclusion criteria, 16 received treatment before implementation while 28 were treated after. After implementation, the mean wait time for surgery decreased by 4.8 h or 35.4% (13.4 h vs 8.7 h; P = 0.001). There were no significant differences in the operative duration, time in the post anesthesia care unit, and wait time for discharge. Survey results demonstrated decreased popularity of the program among nurses and anesthesiologists relative to surgeons. Whereas 57% of the surgeons believed that the program was effective, only 9% of anesthesiologists and 16% of nurses agreed. The program was ultimately discontinued given the dissatisfaction.

CONCLUSION

Our findings demonstrate significantly reduced wait times for surgery for uncomplicated SCHF presenting overnight while discussing the importance of shared decision-making with the stakeholders. Although the program produced promising results, it also created new conflicts within the OR staff that led to its discontinuation at our institution. Future implementations of such programs should involve stakeholders early in the planning process to better address the needs of the OR staff.

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.

Forearm Compartment Pressure Change in Children Operated for Supracondylar Humerus Fracture

BACKGROUND

The aim of this study is to examine the preoperative and postoperative forearm compartment pressures in patients treated operatively for Gartland type III extension type supracondyler humerus fractures and understand the course of these values over postoperative period.

METHODS

Deep volar compartment pressure of 31 patients were measured in the proximal one third of the forearm preoperatively, and measurements were continued every 4 hours for the first 24 hours after the operation with a catheter. Type of the reduction technique (open reduction vs. closed reduction), duration of surgery, the time from the injury to surgery were all evaluated.

RESULTS

In the measurements made immediately after the operation (0 h), a sudden increase in the compartment pressure was detected in all patients (15.0±5.9 to 27.9±7.5 mm Hg) independent of the reduction technique and gradually decreased over time. The mean compartment pressure at the 12th hour postoperatively was higher in the open reduction group than in the CR group (24.5±3.4, 20.7±6.7 mm Hg, respectively) ( P =0.044). The mean preoperative compartment pressure was 17.7±5.8 mm Hg in patients with a time from injury to surgery longer than 12 hours, and 12.4±4.8 mm Hg in patients with 12 hours or less ( P =0.006). The postoperative 0-, 12-, and 20-hour pressure values were higher in the >1 hour operation time group than in the ≤1 hour group and the differences were statistically significant ( P =0.046, 0.016, and 0.032, respectively).

CONCLUSIONS

In pediatric supracondylar humeral fractures, those who underwent open reduction had higher preoperative and postoperative compartment pressures. The reduction attempt was found to be a factor that increased the compartment pressure and after the operation, the compartment pressure values decrease gradually. Prolonged operative time (>1 h) and increased time from injury to operative fixation (>12 h) were associated with higher compartment pressures.

LEVEL OF EVIDENCE

Level II-prospective study.

Social Disparities in Outpatient and Inpatient Management of Pediatric Supracondylar Humerus Fractures

Socioeconomic status, race, and insurance status are known factors affecting adult orthopaedic surgery care, but little is known about the influence of socioeconomic factors on pediatric orthopaedic care. The purpose of this study was to determine if demographic and socioeconomic related factors were associated with surgical management of pediatric supracondylar humerus fractures (SCHFs) in the inpatient versus outpatient setting. Pediatric patients (<13 years) who underwent surgery for SCHFs were identified in the New York Statewide Planning and Research Cooperative System database from 2009−2017. Inpatient and outpatient claims were identified by International Classification of Diseases-9-Clinical Modification (CM) and ICD-10-CM SCHF diagnosis codes. Claims were then filtered by ICD-9-CM, ICD-10-Procedural Classification System, or Current Procedural Terminology codes to isolate SCHF patients who underwent surgical intervention. Multivariable logistic regression analysis was performed to determine the effect of patient factors on the likelihood of having inpatient management versus outpatient management. A total of 7079 patients were included in the analysis with 4595 (64.9%) receiving inpatient treatment and 2484 (35.1%) receiving outpatient treatment. The logistic regression showed Hispanic (OR: 2.386, p < 0.0001), Asian (OR: 2.159, p < 0.0001) and African American (OR: 2.095, p < 0.0001) patients to have increased odds of inpatient treatment relative to White patients. Injury diagnosis on a weekend had increased odds of inpatient management (OR: 1.863, p = 0.0002). Higher social deprivation was also associated with increased odds of inpatient treatment (OR: 1.004, p < 0.0001). There are disparities among race and socioeconomic status in the surgical setting of SCHF management. Physicians and facilities should be aware of these disparities to optimize patient experience and to allow for equal access to care.

Is there an optimal timing for surgical treatment of pediatric supracondylar humerus fractures in the first 24 hours?

Background

We aimed to determine the ideal surgical timing in the first 24 hours after admission to the hospital of pediatric supracondylar humerus fractures (SHF) that do not require emergent intervention.

Materials and Methods

Patients who underwent surgery in our institution between January 2011 and January 2019 due to pediatric Gartland type 3 SHFs were evaluated retrospectively. Open fractures, fractures associated with vascular injury and compartment syndrome, flexion type fractures were excluded. A total of 150 Gartland type 3 were included. The effect of early (<12 hours) or late (>12 hours) surgical interventions, daytime or night-time surgeries, working or non-working hour surgeries on operative parameters (operative duration and open reduction rate, reduction quality on postoperative early radiographs) were evaluated in pediatric SHFs.

Results

Early (<12 hours) or late (>12 hours), daytime or nighttime, working or non-working hour surgeries were found to be similar in Gartland type 3 patients regarding early postoperative reduction quality, duration of surgery, open reduction rate (p>0.05). Mean times passed from first admission to hospital until surgery were longer in working hour, late (>12 hours) and daytime surgery groups than non-working hour, early (<12 hours) and night-time surgery groups (p<0.001).

Conclusion

Although delaying the operation to the working hours seems to prolong the time until surgery in pediatric Gartland type 3 SHF patients who do not require emergent intervention such as open fractures, neurovascular impairment and compartment syndrome, there may not be a time interval that makes a difference for the patients if surgery is performed within the first 24 hours, thus the surgery could be scheduled according to the surgeons’ preference.

Level of Evidence: Level 3, Retrospective cohort study

Compartment Syndrome in Children With a Supracondylar Fracture: Not Everyone has Risk Factors

OBJECTIVES

To clarify the incidence, associated conditions, and timing of fasciotomy for compartment syndrome (CS) in children with a supracondylar (SC) fracture of the humerus.

DESIGN

A retrospective trauma system database study.

SETTING

Accredited trauma centers in Pennsylvania.

PATIENTS

A statewide trauma database was searched for children 2-13 years of age admitted with a SC fracture between January 2001 and December 2015. Four thousand three hundred eight children met inclusion criteria.

INTERVENTION

Treatment of a SC fracture.

MAIN OUTCOME MEASUREMENT

Diagnosis of CS/performance of a fasciotomy.

RESULTS

During the study period, 21 (0.49%) children admitted with a SC fracture of the humerus were treated with fasciotomy. CS/fasciotomy was more likely in males (P = 0.031), those with a nerve injury (P = 0.049), and/or ipsilateral forearm fracture (P < 0.001). Vascular procedure, performed in 18 (0.42%) children, was strongly associated with CS/fasciotomy (P < 0.001). Closed reduction and fixation of a forearm fracture was associated with CS (P = 0.007). Timing of SC fracture treatment did not influence outcome. Fasciotomy was performed subsequent to reduction in 13 subjects; mean interval between procedures was 23.4 hours (r = 4.5-51.3).

CONCLUSIONS

Risk factors for CS exist; however, they are not required for the condition to develop. CS may develop subsequent to admission and/or SC fracture treatment. In timing of operative management and hospitalization, the results support contemporary practice.

LEVEL OF EVIDENCE

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

Appropriate Use Criteria for Treatment of Pediatric Supracondylar Humerus Fractures With Vascular Injury: Do Our Hospital Practice Patterns Agree With Current Recommendations?

BACKGROUND

Managing the pulseless pediatric supracondylar humerus fracture (PSHF) remains a significant clinical decision-making challenge for the treating surgeon. The purpose of the study is to determine frequency of the treatments according to the American Academy of Orthopaedic Surgeons (AAOS) Appropriate Use Criteria (AUC) for the PSHF with vascular injury and evaluate the appropriateness of these interventions.

METHODS

We identified all PSHF with concern for vascular injury at one high volume, level 1 trauma center managed by 6 fellowship-trained pediatric orthopaedic surgeons over 4.5 years. Demographic information and other injury and treatment variables were obtained. Each patient was classified as 1 of the 6 patient scenarios specified by the AAOS AUC. Each of the 18 interventions identified in the AUC were documented, including the level of "appropriateness" as specified by AAOS AUC.

RESULTS

A total of 638 PSHF were managed identified; of these, 52 were pink, pulseless, or dysvascular (8.2%). Only 7 of the 18 treatment options suggested by the AUC were used in this cohort. Across all 7 interventions used in this cohort, 20.2% (17/84) of interventions were "appropriate," 52.4% (44/84) were "maybe appropriate," 22.6% (19/84) were "rarely appropriate," and 4.8% (4/84) were not listed in treatment options.

CONCLUSIONS

Supracondylar fractures are the most common injury to the elbow seen in children and are variable in presentation and management. The pink, pulseless fracture continues to be a major topic for research and discussion due to the morbidity if not treated "appropriately." The AUC were created to help guide practitioners when strong evidence is lacking. In this study at a single, pediatric hospital, there was variation and disagreement with "appropriateness" of treatments that were performed but this discrepancy did not result in any poor outcomes. Although the AUC do offer valuable guidance, our findings highlight a need for continued research in this area to help validate the AUC and help strengthen the recommendations moving forward.

LEVEL OF EVIDENCE

Level III-retrospective.

Treatment of pediatric supracondylar humerus fractures accompanied with pink pulseless hands

Background

The optimal treatment for pediatric supracondylar humeral fractures accompanied with a pink pulseless hand is controversial. Some clinicians recommend close observation after closed reduction and percutaneous pinning of the fractures, while some recommend surgical exploration if the radial pulse is unpalpable. The present study aimed to analyze the benefits and outcomes of close observation for treating pediatric supracondylar humeral fractures with a pink pulseless hand.

Methods

Thirteen consecutive children presenting with a pink pulseless hand following supracondylar humeral fracture were enrolled in this study. Preoperative and postoperative color-flow Duplex ultrasound detection was used to assess brachial artery compromise in most cases. Urgent closed reduction and percutaneous pinning of the fractures were attempted first. Close observation was carried out when the hand was pink and pulseless with an absent radial pulse.

Results

Preoperative color-flow Duplex ultrasound showed no disruption of the brachial artery in cases detected. Compression of the artery by the proximal fragment was observed in most cases, with one case of entrapment of the artery between fragments, and thrombus considered in two cases. All cases underwent urgent surgery, after which nine experienced immediate return of the radial pulse. The remaining four without a palpable pulse were managed with close observation and no deterioration of the vascular status was observed; therefore, no surgical exploration was performed. Postoperative color-flow Duplex ultrasound revealed continuity of the artery and rich collateral circulation. Patients completed an average of 4.5 years of follow-up, during which no major complications occurred. All patients achieved excellent limb function.

Conclusions

Our study demonstrates that close observation after urgent closed reduction and percutaneous pinning is a sufficient approach for the treatment of pediatric supracondylar humeral fractures accompanied with a pink pulseless hand. Surgical exploration is not necessary as long as the hand is warm and well perfused. Color-flow Duplex ultrasound is beneficial for assessing vascular compromise and determining treatment strategies.

Open Reduction of Neglected Supracondylar Humeral Fractures With Callus Formation in Children

BACKGROUND

The standard treatment for supracondylar humeral fractures (SHFs) in children is closed reduction and percutaneous Kirschner (K)-wire fixation. In patients who present >14 days after injury and show callus formation, this procedure cannot be performed. There are 2 options in these cases: functional exercises with osteotomy performed at a later stage if cubitus varus is present, or immediate open reduction and percutaneous K-wire fixation. This study aimed to evaluate the outcomes of K-wire fixation through an anterior approach in children with neglected SHF and identify factors predicting the outcomes.

METHODS

This retrospective study assessed the files of 32 children treated for neglected SHF at our hospital between June 2015 and May 2018. An incision was made along the anterior transverse groove of the elbow. The callus was removed, the fracture was reduced, and K-wire fixation was performed. The outcome evaluation included the radiological Baumann angle, pin fixation construct, carrying angles, and the functional outcome was Mayo Elbow Performance Score and Flynn criteria. Binary regression analysis compared the functional outcome as the dependent variable with age, time from injury to operation, operation time, and the amount of callus.

RESULTS

The interval between injury and operation was 14 to 40 days (average, 22.4 d). Patients were followed for 12 to 36 months (average, 21.5 mo). Fracture healing took 5 to 8 weeks (average, 6.6 wk). No patient had a vascular injury or compartment syndrome. Twelve patients were intraoperatively assessed for radial and median nerve injury. No nerve repair was required. All nerve injuries recovered within 3 months. No iatrogenic ulnar nerve injury occurred. One patient had an infected incision. Binary regression analysis showed that the time elapsed between injury and operation (P=0.033) and Gartland type (P=0.008) were inversely correlated with outcomes; the longer the duration, the poorer the outcomes.

CONCLUSIONS

The functional outcomes after open reduction and K-wire fixation through an anterior approach were poorer with longer time to surgery and Gartland type.

LEVEL OF EVIDENCE

Level III.

Epidemiological Analysis of Displaced Supracondylar Fractures

INTRODUCTION

 Supracondylar fractures are one of the most common fracture patterns sustained by children, and one of the most common injuries requiring operative fixation. Understanding the complications associated with supracondylar fractures is vital for the practicing orthopedic surgeon. This analysis of supracondylar fractures examined the clinically important aspects including vascular injury, compartment syndrome, neurological injury, brachialis entrapment, associated injuries, and etiologies of injury. Recent advances in technology have resulted in a myriad of new forms of recreational equipment for children to play with. The purpose of this study is to compare the historical literature, the current literature, and a single surgeon's sample of supracondylar fractures. In addition, this study aims to evaluate if any changes in epidemiology or etiology have occurred due to the development of new recreational equipment.

OBJECTIVE

 The purpose of this study is to evaluate and provide a qualitative overview of the epidemiology of displaced supracondylar fractures, to compare historically reported numbers to more recent literature as well as a single surgeon sample, and to evaluate if changes in epidemiology or etiology have occurred due to the new recreational equipment that children use.

METHODS

Some 75 displaced supracondylar elbow fractures were reviewed. Data elements recorded from the electronic medical record (EMR) included patient age, gender, height, weight, handedness, date, time, location, mechanism, Gartland classification, concurrent injuries, and neurovascular status.  Results: In this study, there were 42 males and 33 females. The average age was six years. Some 70 of the 75 patients were older than the age three. One fracture was open, nine fractures had a pucker sign, seven presented with a nerve palsy, four presented without a pulse, and seven patients presented with an additional ipsilateral distal radius fracture. All fractures were the result of a fall. Falls from playground equipment resulted in 29 fractures. There were 10 from falls off of furniture, six from falls during sports, three from falls on the stairs, and three from fall off of bikes. The remaining fractures resulted from running, tripping, falling from a toy ball, sled, tree, wagon, fence, bounce house, van, deck, power wheels car, ATV, and a go-cart. Some 64 fractures were transferred from 27 different outside hospitals. Eleven fractures presented directly to the ED. Twenty-six fractures occurred during the summer, 20 occurred in the autumn, 6 occurred in the winter, and 23 occurred during the spring. Some 35 fractures occurred at home, 30 on the school grounds, four in a gymnasium, four in a park, one at a farm show, and one in a parking lot. Some 25 fractures were treated between midnight and 8 am, 16 were treated between 8 am and 5 pm, and 34 were treated between 5 pm and midnight.  Conclusion: Pediatric supracondylar fractures are common in children, and many of them require operative intervention. This study examined the most important aspects of supracondylar fractures. This update provides a look at the clinically important aspects of supracondylar fractures and compares them to previous teachings and canon. Despite the advancement and changes in recreational equipment that children are using, children are still sustaining supracondylar fractures in the most common ways including falls from playground equipment and falls from standing.

Inpatient Versus Outpatient Treatment of Gartland Type II Supracondylar Humerus Fractures: A Cost and Safety Comparison

BACKGROUND

In an effort to increase health care value, there has been a recent focus on the transition of traditionally inpatient procedures to an outpatient setting. We hypothesized that in the treatment of Gartland extension type II supracondylar humerus fractures (SCHF), outpatient surgery can be performed safely and with similar clinical and radiographic outcomes compared with urgent inpatient treatment with an overall reduction in cost.

METHODS

We compared a prospective cohort of Gartland type II SCHF treated primarily as outpatients (postprotocol) to a retrospective cohort treated primarily as urgent inpatients (preprotocol), excluding patients with preoperative neurovascular injury, open fracture, additional ipsilateral upper extremity fracture, and prior ipsilateral SCHF. Inpatient versus outpatient treatment was also compared. Outcomes including perioperative factors, complications, readmission, reoperation, postoperative radiographic measurements, and direct hospital costs underwent univariate and multivariate analyses.

RESULTS

A total of 220 patients in the postprotocol cohort (88 inpatients and 132 outpatients) and 129 in the preprotocol cohort (97 inpatients and 32 outpatients) were analyzed. There were no differences in operative times, number of pins, conversion to open reductions, readmissions, or reoperations between cohorts or groups, and no cases developed postoperative neurovascular injuries or compartment syndromes. Total complications did not differ between the preprotocol and postprotocol cohorts; however, were higher in the inpatient group (3.8% vs. 0%; P=0.016) in the univariate, but not multivariate analysis. There were no differences in Baumann angle or humerocondylar angle. Significantly more inpatients' anterior humeral line fell outside of the middle third of the capitellum in the univariate, but not multivariate analysis. There were significant reductions in total cost per patient between the preprotocol and postprotocol cohorts (marginal effect, -$215; P<0.0001) and between the inpatient and outpatient groups (marginal effect, -$444; P<0.0001).

CONCLUSIONS

Delayed treatment of Gartland type II SCHF in the outpatient setting can be performed safely and with similar clinical and radiographic outcomes to those treated urgently as inpatients with a significant cost reduction.

LEVEL OF EVIDENCE

Therapeutic level III-retrospective comparative study.

Delayed surgery leads to reduced elbow range of motion in children with supracondylar humeral fractures managed at a referral hospital in sub-Saharan Africa

Background

Supracondylar humeral fractures (SHFs) in children are associated with morbidity due to elbow stiffness. Timely operative management and/or physiotherapy are thought to reduce this complication, but pose challenges in settings with limited resources for health.

Methods

This prospective cohort study included 45 pediatric patients with isolated SHF at a large tertiary hospital in Nairobi, Kenya. Patients were managed non-operatively or operatively with varying wait times to surgery, with or without physiotherapy. The measurement of elbow ROM was done up to 12 weeks after removal of Kirshner wires and/or backslab.

Results

Elbow ROM increased in the follow-up period, yet residual restricted mobility in the flexion-extension plane was common. Delayed surgical management ≥7 days was associated with reduced elbow ROM in the flexion-extension plane at 12 weeks median IQR 105° 92°–118° vs 120° 108°–124°, p=0.029. Physiotherapy was associated with reduced ROM at 12 weeks p=0.003, possibly due to the use of prolonged immobilization.

Conclusion

In this study of pediatric SHFs at a resource-limited hospital, elbow flexion was restricted at 12 weeks follow-up and was associated with major delays in operative management. Quality of orthopedic surgical care and physiotherapy services in low-resource settings deserves further attention.

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.

Who Gets Compartment Syndrome?: A Retrospective Analysis of the National and Local Incidence of Compartment Syndrome in Patients With Supracondylar Humerus Fractures

PURPOSE

Although acute compartment syndrome (ACS) is associated with pediatric supracondylar humerus (SCH) fractures, there are limited data describing its incidence and risk factors. The purpose of our study was to report the local and national incidence of ACS with SCH and floating elbow (concomitant SCH and forearm) fracture patterns and the associated risk factors.

METHODS

We retrospectively queried data for SCH fracture patients over a 4-year period from our institution (a level I pediatric trauma center) and the National Trauma Data Bank (NTDB). Data on demographics, mechanism of injury, open versus closed fracture, length of stay, presence or absence of forearm fractures, and incidence of traumatic compartment syndrome were analyzed. The student t and χ tests were utilized for group comparisons of continuous and categorical variables, respectively. Logistic regression was used to identify risk factors for compartment syndrome. Results are summarized as means with SD or odds ratios (OR) with 95% confidence intervals (CI). Statistical significance was set at P<0.05.

RESULTS

At our institution, 839 patients with SCH fractures met inclusion criteria. In total, 814 (97.02%) patients (average age, 5.96±2.58 y) sustained isolated SCH fractures during the indicated timeframe. SCH fractures with an associated forearm fracture were identified in 25 (2.98%) patients (average age, 7.00±3.03 y). Three patients (0.36%) with isolated SCH fractures were observed to have compartment syndrome. No compartment syndromes were identified in the patients with floating elbows.Within the same time period, the NTDB identified 31,234 SCH fractures met inclusion criteria. Of those, 31,167 patients had isolated SCH fractures (average age, 5.5±2.7 y). In total, 67 of the SCH patients (0.2%, P<0.0001) had documented ACS (average age, 7.3±3.5 y). The NTDB identified 1565 patients with floating elbows, including 13 (0.8%, P≤0.0001) who developed compartment syndrome (average age, 6.47±2.71 y). The NTDB query also identified 530 patients with neurovascular injury (NVI), with 4.5% (n=24) that developed compartment syndrome. In the regression analysis, older age (OR, 1.1; 95% CI, 1.0-1.2; P<0.0092), male sex (OR, 2.7; 95% CI, 1.5-4.8; P=0.0005), floating elbow fracture pattern (OR, 3.2; 95% CI, 1.7-6.1; P=0.0003) and NVI (OR, 25.0; 95% CI, 14.6-42.8; P≤0.0001) were identified as risk factors for developing compartment syndrome.

CONCLUSIONS

Data from our institution and NTDB reveal that acute traumatic compartment syndrome is rare, occurring in ∼2 to 3 fractures of 1000. However, there is a significantly increased risk with NVI, floating elbow fractures, males, and older patients.

SIGNIFICANCE

Characterizing the incidence and associated risk factors of ACS with concomitant SCH and forearm fracture patterns can improve clinical understanding and management of pediatric patients.

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.

The Community Orthopaedic Surgeon Taking Trauma Call: Pediatric Supracondylar Humeral Fracture Pearls and Pitfalls

Supracondylar humeral fractures are the most common type of pediatric elbow fracture. With proper treatment, these injuries usually heal well and the patients return to full function. However, a small percentage of these injuries may result in devastating complications and, thus, provoke anxiety in many surgeons treating them. This article provides tips for successful management of these injuries without complications and provides references for further study.

Standardized Note Templates Improve Electronic Medical Record Documentation of Neurovascular Examinations for Pediatric Supracondylar Humeral Fractures

Background:

Optimization of the electronic medical record (EMR) is essential to support the clinician and to improve the quality and efficiency of patient care. The present report describes the development and implementation of a standardized template that is embedded in the EMR and is focused on a comprehensive physical examination during the evaluation of pediatric supracondylar humeral fractures. We compared the completeness of physical examinations as well as the timing of detection and documentation of neurovascular injuries before and after implementation of the template. We hypothesized that the use of a template would increase the completeness of examinations and would lead to earlier documentation of neurovascular injuries.

Methods:

A multidisciplinary quality-improvement task force was created to address neurovascular documentation practices for patients who underwent operative treatment of supracondylar humeral fractures. Following a series of formative and process evaluations, a standardized EMR template was implemented. Neurovascular examination documentation practices that were in use before (pre-template group, n = 224) and after (template group, n = 300) the implementation of the template were compared. Logistic regression analyses of the 2 groups were used to compare the likelihood of a complete neurovascular examination and the timing of neurovascular injury identification.

Results:

There was significant improvement in the documentation of the vascular (odds ratio [OR], 70.7; 95% confidence interval [CI], 39.5 to 126.6; p < 0.0001), motor (OR, 17.6; 95% CI, 9.5 to 32.7; p < 0.0001), and sensory (OR, 23.9; 95% CI, 12.9 to 44.4; p < 0.0001) examinations in the template group. Neurological injuries were more likely to be identified preoperatively in the template group compared with the pre-template group (OR, 6.8; 95% CI, 1.7 to 27.1; p = 0.0067).

Conclusions:

The incorporation of a standardized template in the EMR improved the completeness and timing of documentation of neurological injury. Standardized EMR templates developed by a clinically driven multidisciplinary task force have the potential to improve the quality of clinical documentation and to ease communication among providers.

Level of Evidence:

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

Cross Pinning Versus Lateral Pinning in the Management of Type III Supracondylar Humerus Fractures in Children

INTRODUCTION

Closed reduction of supracondylar humerus fractures with K-wires has become the standard line of management with different opinions regarding the technique that is utilized.

AIM

To compare the functional and radiological outcomes of lateral and cross pinning technique in supracondylar fractures of humerus in children.

MATERIALS AND METHODS

A prospective study with 57 cases of displaced fracture supracondylar humerus, treated by lateral (Group A n=28) and cross pinning (Group B n=29), was conducted between May 2013 and May 2015. Independent sample student's t-test was done to assess the parameters like age, follow-up and duration of surgery. The results were expressed as mean with standard deviation and p<0.05 was considered as statistically significant.

RESULTS

As per the Gartland classification system, 46 (80.7%) patients had Type IIIA and 11 (19.2%) patients had Type IIIB fracture. The average surgical time was 28.3±1.6 minutes in Group A and 30±3.6 minutes in Group B (p=0.02). About, 3.5% patients in Group A had pin loosening. As per the Flynn criteria, 78.6% in Group A and 79.3% in Group B had excellent results.

CONCLUSION

No significant difference in terms of functional and radiological outcome was observed between both the techniques. Thus, both the techniques have equal results.

The Effect of the Pucker Sign on Outcomes of Type III Extension Supracondylar Fractures in Children

BACKGROUND

The pucker sign, also called skin tenting, indicates significant displacement of the supracondylar fracture and can be a cause for alarm. The purpose of this study is to compare a cohort of patients with type III supracondylar fractures presenting with a pucker sign to a group without a pucker sign by evaluating neurovascular injury at presentation, need for open reduction, persistent neurovascular injury, range of motion, and carrying angle at final follow-up.

METHODS

A retrospective review was performed for Gartland type III extension type supracondylar fractures. Those with a pucker sign were identified and evaluated. Type III supracondylar fractures with a pucker sign were compared with a similar cohort without a pucker sign.

RESULTS

In total, 12 patients with a pucker sign at an average age of 5.2 years were evaluated. A total of 11 patients (92%) had diminished or absent pulses, and 2 (17%) had weakness in the median nerve distribution. Nine (75%) patients in this group were transferred to the university hospital. Average time to surgery was 8.9 hours with an average operating time of 25.1 minutes. Open reduction was not needed in any case. At an average follow-up of 4.7 months no patients had persistent neurovascular compromise. Two patients lacked <5 degrees of extension and 1 lacked 10 degrees of extension. One patient lacked 10 degrees of flexion. No patients had a change in carrying angle difference compared with the contralateral side. No statistical differences were observed between the 2 groups.

CONCLUSIONS

Pucker sign, in the context of a supracondylar fracture of the humerus, is a soft tissue defect with potential entrapment of median nerve and brachial artery. At a maximum time of 16 hours from injury to surgery we report excellent outcomes and no long-term complications. Using the techniques of gradual traction, and milking the soft tissue, the pucker sign can be eliminated. Closed reduction and percutaneous pinning were performed in all the cases.

LEVEL OF EVIDENCE

Level III-retrospective comparative study.

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.

A comparative study of two percutaneous pinning techniques (lateral vs medial-lateral) for Gartland type III pediatric supracondylar fracture of the humerus

BACKGROUND

The management of displaced supracondylar fracture of the humerus with closed reduction and percutaneous pin fixation is the most widely accepted method of treatment, but controversy continues regarding the pin fixation techniques. A prospective randomized controlled study was undertaken to compare the stability, functional outcome and iatrogenic ulnar nerve injury between lateral pin fixation and medial-lateral pin fixation.

MATERIAL AND METHOD

Sixty-two patients with Gartland type III supracondylar fracture of the humerus were randomized into two groups-lateral pin fixation (n = 31) and medial-lateral pin fixation (n = 31). Primary assessment was performed for major loss of reduction and iatrogenic ulnar nerve injury. Secondary assessment included clinical outcome, elbow range of motion, radiographic measurements, Flynn grade, and complications.

RESULTS

There were two (6.5 %) iatrogenic ulnar nerve injury cases in the medial-lateral entry group and two (6.5 %) cases with mild loss of reduction in the lateral entry group. No major loss of reduction was observed in either of the groups. There was no statistically significant difference in change of Baumann angle, metaphyseal-diaphyseal angle, Flynn grade, carrying angle, and the total elbow range of motion (P < 0.05) between the two groups.

CONCLUSIONS

Lateral pin fixation offers similar functional and radiological outcome and almost equal mechanical stability compared with medial-lateral pinning without the risk of iatrogenic ulnar nerve injury. LEVEL OF EVIDENCE [OCEBM 2011]: Level 2.

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).

A case of supracondylar humerus fracture with vascular impairment. Open it up?

Supracondylar humerus fracture is one of the most frequent fractures in childhood. A serious complication is an injury to the neurovascular structures which could potentially result in severe functional impairment. We are presenting the case of a 3-year-old girl with a supracondylar humerus fracture in our emergency department and highlight the diagnostic and therapeutic steps in managing this situation. Initially, the hand was well perfused but showed to be pulseless in the operating theater after preparation for surgery. After open reduction and internal pin fixation the neurovascular structures were explored and the brachial artery was repaired by means of a cephalic vein graft. On follow up the patient presented with normal hand function and without vascular or neurologic deficits. As concomitant vascular injuries after supracondylar humerus fractures are rare, it can be difficult to discriminate a pink pulseless hand from a patient with essential vascular injury. Our case also demonstrates the need for short-term reevaluation of the clinical status. When in doubt there should be no hesitation to perform open surgery and vascular repair.

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.

Crossed pinning in paediatric supracondylar humerus fractures: a retrospective cohort analysis

PURPOSE

The aim of this study was to analyse the management of displaced paediatric supracondylar humerus fractures at our Level I Trauma Centre and to determine clinical and radiographic long-term results following operative treatment.

METHODS

Clinical and radiological results of 78 paediatric patients (29 female, 49 male; mean age 5.1 years) with supracondylar humerus fractures, treated from 1992 to 2004, were evaluated. Gartland's classification yielded 32 type II, 44 type III and further two flexion injuries. In all patients the follow-up period exceeded 12 months. Assessment after an average of 8.1 years (1.1-19.5) included neurovascular examination, Flynn's criteria (elbow function and carrying angle), pain, complications (infections, growth disturbances or iatrogenic nerve injuries) and measurement of the humeroulnar angle.

RESULTS

According to Flynn's criteria 73 patients (93.5 %) had a satisfactory outcome, while five (6.4 %) were graded as unsatisfactory (two due to cubitus varus and three because of limited elbow motion). The visual analogue scale (VAS) score averaged 0 (range 0-1) and the mean carrying angle measured 8.4° (-8 to 20°), compared to 10.8° on the contralateral side (2-20°). Injury-related complications yielded absent pulses in four (5.1 %), five (6.4 %) primary median, two (2.6 %) primary radial and one (1.3 %) primary ulnar nerve injury. Treatment-related complications included a secondary displacement and one iatrogenic radial nerve palsy. Based on primary nerve lesion as a dependent variable, statistical analysis showed that age had a significant influence revealing that older paediatric patients had a significantly higher risk (p = 0.02). Functional outcome as a dependent variable revealed an indirect proportion to the clinical carrying angle, achieving statistical significance (p < 0.01).

CONCLUSIONS

Crossed pinning in paediatric supracondylar humerus fractures is an effective method. Evaluation of the outcome in our study group demonstrated good results with the treatment approach described.

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.

Controversial topics in the management of displaced supracondylar humerus fractures in children

The aim of our study was to review the literature looking for the up to date information regarding these controversial topics. An electronic literature search was performed using the Medline/PubMed database. A closed reduction attempt should always be done first. It is more important to engage both columns as well as divergence of the pins no matter whatever configuration is applied. Time to surgery seems to be not an important factor to increase the risk of complications as well as open reduction rate. Usually neurological injuries present a spontaneous recovery. If there is absent pulse, we should follow the algorithm associated with the perfusion of the hand.

[Supracondylar fractures of the humerus in children]

BACKGROUND

Supracondylar humerus fractures are common in children. Severe complications are rare. We present an overview of treatment options and prognosis.

MATERIAL AND METHODS

The article is based on a non-systematic search in PubMed and experience from our own clinical research.

RESULTS

The injury is usually caused by falling from a height with the arm in extension. The mean age is about 6 years. Undisplaced fractures are treated conservatively with a cast. Displaced fractures should not be treated with a cast alone, as this may cause malunions and permanent neurovascular complications. The rate of complications after traction of displaced fractures is substantially lower than for immobilisation in cast alone. Traction and percutaneous pinning yield similar results, but percutaneous pinning is less expensive--mainly because it shortens the hospital stay. In addition, the risk of cubitus varus deformity seems to be reduced. Today the treatment of choice is closed reduction and percutaneous pinning. Choice of pin configuration is at the surgeon's discretion. Crossed pins are more common than two lateral pins, although medial pins can affect the ulnar nerve. However, the affection is almost always transient. Deep infection after percutaneous pinning is very rare.

INTERPRETATION

Percutaneous pinning of displaced supracondylar humerus fractures in children is cheap and the results are good.

The effects of surgical delay on the outcome of pediatric supracondylar humeral fractures

BACKGROUND

Occasionally, the treatment of a pediatric supracondylar humeral fracture is delayed owing to lack of an available treating physician, necessitating transfer of the child, or delay in availability of an operating room. The purpose of this study is to prospectively evaluate whether delayed pinning of these fractures affects the outcome or number of complications.

METHODS

We reviewed information that was prospectively collected on 145 pediatric supracondylar humeral fractures that were treated by closed reduction and percutaneous pinning, with a minimum follow-up of 8 weeks. To determine the effect of delayed treatment, we compared a group of fractures that was treated within the first 21 hours after their presentation to our urgent care center (Group A) with a group that was treated after more than 21 hours (Group B). We compared the following variables: need for open reduction, length of surgery, length of hospitalization, the presence of neurologic complications, vascular complications including compartment syndrome, pin tract infection, loss of fixation, final carrying angle, range of motion, and outcome.

RESULTS

Overall, the mean time from presentation to surgery for both groups was 52 hours. This interval was greater for Gartland type II fractures (65 h) than for Gartland type III fractures (19 h) (P=0.00001). There was no need for an open reduction in either group. There were no significant differences between the groups regarding iatrogenic nerve injuries, vascular complications, compartment syndromes, surgical time, final carrying angle, range of motion, and outcome.

CONCLUSIONS

The results of this prospective study found that a delay in pinning closed supracondylar humeral fractures in children did not lead to a higher incidence of open reduction or a greater number of complications. Although the urgency of treating any child with a supracondylar fracture should be individualized, our study suggests that most of these injuries can be managed safely in a delayed fashion without compromising the clinical outcome. We recommend careful monitoring of any patient with type 3 injury whose treatment is delayed.

LEVEL OF EVIDENCE

II.

Review article: paediatric supracondylar humeral fractures: emergency assessment and management

Supracondylar humeral fractures in children are common presentations to the ED but might be challenging to both diagnose and assess clinically. The ED has a critical role in accurately assessing the child, the limb's neurovascular status and initiating treatment. A specific approach to the clinical assessment of such a child is required as failure to detect neurovascular compromise can delay appropriate treatment and result in serious consequences. Most children can be investigated with X-ray radiograph alone with further treatment directed by severity of the fracture, commonly described using the Gartland classification. Our review article provides an overview of supracondylar humeral fractures and a suggested clinical approach to leave the emergency physician better equipped to assess and manage these fractures.

The need for better analysis of observational studies in orthopedics. A retrospective study of elbow fractures in children

BACKGROUND AND PURPOSE

The conventional statistical methods employed in observational studies in orthopedics require the fundamental assumption that the outcomes are independent. However, fractures treated by the same surgeon cannot be regarded as being independent of each other and should be nested in the statistical analysis. If the effect on outcome of early rather than delayed surgery depends on the severity of the fracture, we have a case of interaction. This is rarely considered in orthopedic research, but could affect the conclusions drawn. The aim of this paper is to describe the concepts of multilevel modeling and interaction in orthopedics.

PATIENTS AND METHODS

In a cohort of 112 patients with single supracondylar humerus fractures, 78 patients were examined clinically on average 4 years after surgery. The range of motion was measured and the global satisfaction was assessed. The results were used to compare traditional least-squares regression analysis with a 2-level model with interactions.

RESULTS

We found that 25% of the variance in outcome could be attributed to between-surgeon variance. We identified an interaction between the surgeons' experience and the severity of the fractures that influenced the conclusions. The variable "number of pins" was not significant in the 2-level model (p = 0.07), while the ordinary least-squares analysis gave a result that was statistically significant (p = 0.01).

INTERPRETATION

Researchers should consider the need for a 2-level model and the presence of interactions. Standard statistical methods might lead to wrong conclusions.

Surgical approaches for open reduction and pinning in severely displaced supracondylar humerus fractures in children: a systematic review

PURPOSE

There is no clear evidence in the actual literature regarding which of the surgical approaches could bring about the best functional, cosmetic, and radiological outcomes, as well as fewer complications, when an open reduction and pinning of a severely displaced supracondylar humerus fracture is performed. We, therefore, performed a systematic review of the English literature to investigate the existing evidence regarding this issue.

METHODS

A MEDLINE and EMBASE databases search was performed to identify articles that focused on the functional, cosmetic, and radiological outcomes, as well as post-surgical complications, regarding different surgical approaches used for open reduction and pinning in severely displaced supracondylar humerus fractures in children. One hundred and ninety-four articles were identified, of which seven were included for review. Data analysis included weighted means for all contingency tables and the Chi-square test. Standardized residues were studied when the Chi-square test was statistically significant. Statistical analyses were conducted using Stata 9.1/SE (StataCorp., College Station, TX) and P-values lower than 0.05 were considered to be statistically significant for all analyses.

RESULTS

For functional outcome, a high frequency of excellent results was found within the lateral and medial approaches, and a high frequency of good results within the anterior approach. A high frequency of poor results was found within the posterior approach. For cosmetic outcome, there was a high frequency of fair results within the posterior and lateral approaches, and a high frequency of poor results within the posterior approach. No statistically significant difference regarding time to union, as well as complications, was found.

CONCLUSION

Our results suggest that a combined antero-medial approach could be the method which allows the achievement of better functional and cosmetic outcome according to Flynn's criteria. Time to union, as well as post-surgical complications, should not be an issue regarding surgical approaches used for open reduction and pinning in these fractures.

The effect of surgical timing on operative duration and quality of reduction in Type III supracondylar humeral fractures in children

PURPOSE

To determine the influence of the time from injury to surgery of Type III supracondylar fractures on operative duration and quality of reduction.

METHODS

A retrospective review of Type III supracondylar fractures treated by closed reduction and percutaneous pinning over a 3-year period was performed.

RESULTS

The subjects were divided into two groups based on the time from injury to surgery (IST): Group 1 (<8 h) 48 subjects and Group 2 (>8 h) 39 subjects. There was no difference in the mean age or gender ratio between the two groups. There were no cases of compartment syndrome or conversion to open reduction in either group. The mean IST was 669 min. The mean IST for Group 1 was 340 min and it was 1,074 min for Group 2. The operative duration for Group 1 was 32.56 min and for Group 2 it was 31.72 min (P = 0.77). There were no significant differences in the quality of reduction.

CONCLUSIONS

There was no difference in the operative duration demonstrated between IST <8 h and IST >8 h. This failure to demonstrate a difference should not be interpreted as demonstrating equivalence. This study does not conclude that all displaced supracondylar fractures should be delayed, though it does inform the surgeon that, if compelled to delay surgery, this series did not demonstrate an increased risk of complications, nor a worsened quality of reduction.

The pink, pulseless hand after supracondylar fracture of the humerus in children

This annotation discusses the findings of two papers in the current issue describing the management of the neurovascular complications of supracondylar fractures of the humerus in childhood, with particular reference to the indications for and the timing of exploration of the brachial artery and the affected nerves.

Ischaemia and the pink, pulseless hand complicating supracondylar fractures of the humerus in childhood

A series of 26 children was referred to our specialist unit with a ‘pink pulseless hand’ following a supracondylar fracture of the distal humerus after a mean period of three months (4 days to 12 months) except for one referred after almost three years. They were followed up for a mean of 15.5 years (4 to 26). The neurovascular injuries and resulting impairment in function and salvage procedures were recorded. The mean age at presentation was 8.6 years (2 to 12). There were eight girls and 18 boys.

Only four of the 26 patients had undergone immediate surgical exploration before referral and three of these four had a satisfactory outcome. In one child the brachial artery had been explored unsuccessfully at 48 hours. As a result 23 of the 26 children presented with established ischaemic contracture of the forearm and hand. Two responded to conservative stretching. In the remaining 21 the antecubital fossa was explored. The aim of surgery was to try to improve the function of the hand and forearm, to assess nerve, vessel and muscle damage, to relieve entrapment and to minimise future disturbance of growth.

Based on our results we recommend urgent exploration of the vessels and nerves in a child with a ‘pink pulseless hand’, not relieved by reduction of a supracondylar fracture of the distal humerus and presenting with persistent and increasing pain suggestive of a deepening nerve lesion and critical ischaemia.

Timing of surgical treatment for type III supracondylar humerus fractures in pediatric patients

BACKGROUND

Type III supracondylar humeral fracture is a common cause of emergency hospitalization among children requiring surgical treatment. The configuration of the internal fixation material, surgical technique, and optimal timing of surgery (TS) have always been popular topics of debate. The TS in uncomplicated cases is usually determined by surgeons.

METHODS

In this study, we prospectively followed children with type III supracondylar fractures. We aimed to clarify the effects of injury side, gender, and post-injury delay on switching to open surgery and the ease of the reduction.

RESULTS

Based on our results, the probability of switching to open surgery increased by a factor of 4 every 5 h beginning 15 h after injury. Open surgery was necessary after 32 h.

CONCLUSION

Reduction became technically more difficult as TS increased.