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

Evaluating safe time to discharge after closed reduction and percutaneous pinning of uncomplicated type III supracondylar humerus fractures: a single-center retrospective review

The purpose of this retrospective study was to review complications following closed reduction, percutaneous pinning of isolated, type III supracondylar fractures without associated injuries to evaluate if patients may be discharged safely on the day of surgery. We performed a retrospective chart and radiographic review of patients with isolated Gartland type III supracondylar humerus fractures who underwent closed reduction and percutaneous pinning over a 4-year period. We reviewed admission time to the emergency department, time and length of surgery, time to discharge, postoperative complications, readmission rate and office visits. Of the 110 patients included, 19 patients were discharged in less than 6 h, 45 patients between 6 and 12 h and 46 patients greater than 12 h. A total of 61 patients were discharged on the same day as surgery and 49 were discharged the next day. There were 11 postoperative complications. No postoperative complications were found in patients discharged less than 6 hours from surgery. For patients discharged between 6 and 12 hours postoperatively, one patient returned to the office earlier than scheduled. The result of our review suggests that patients can be safely discharged within the 12-h postoperative period with no increased risk of complications. This is contingent upon the patient having a stable neurovascular examination, pain control and caregiver's comfort level. This can decrease medical cost, family stress and burden to the hospital system. Time to discharge should still be evaluated on a case-by-case basis after evaluating medical and social barriers.

Retrospective Mid-Term Follow-Up of Posttraumatic and Iatrogenic Neurovascular Complications in Surgically Treated Paediatric Patients with Distal Humerus Fracture

BACKGROUND

The purpose of the study was to investigate and describe neurovascular complications and mid-term clinical outcomes of operatively managed fractures of the distal humerus in a paediatric population. Neurovascular injuries are common in these fractures, but reports about their implications for mid-term clinical outcomes is sparse.

METHODS

A single-centre retrospective study was conducted at a university teaching hospital investigating paediatric patients who underwent operative management of a distal humerus fracture between 2014 and 2018. Patient demographics, fracture classification, pre-, peri- and postoperative neurovascular complications were investigated. Mid-term follow up clinical examination and functional scoring using QuickDASH, the Broberg and Morrey Score (BMS), the Mayo Elbow Performance Score (MEPS) and the Numeric Rating Scale were performed.

RESULTS

A total of 84 patients were identified, of which 34 met the inclusion criteria and were available for follow-up clinical examination. The average time to follow-up was 150 weeks (1049.44 days ± 448.54). Ten primary traumatic neurovascular complications were identified, the majority of which involved the median nerve. Primary traumatic dissection of the brachial artery was recorded in three patients. Secondary iatrogenic nerve injury was documented in five patients after previously normal clinical examination. At follow-up, the average QuickDASH score was 3.0 ± 4.3, BMS was 98.6 ± 3.4 and MEPS was 97.1 ± 3.3 points.

CONCLUSIONS

The mid-term clinical outcome following surgical management of distal humerus fractures is excellent. There is, however, a considerable frequency of both primary and secondary neurovascular complications, which must be considered when opting to treat these injuries surgically.

Pediatric Supracondylar Humerus Fractures: Should We Avoid Surgery during After-Hours?

Pediatric supracondylar humerus fractures occur frequently. Often, the decision has to be made whether to operate immediately, e.g., during after-hours, or to postpone until office hours. However, the effect of timing of surgery on radiological and clinical outcomes is unclear. This literature review with the PICO methodology found six relevant articles that compared the results of office-hours and after-hours surgery for pediatric supracondylar humerus fractures. The surgical outcomes of both groups in these studies were assessed. One of the articles found a significantly higher “poor fixation rate” in the after-hours group, compared with office hours. Another article found more malunions in the “night” subgroup vs. the “all groups but night” group. A third article found a higher risk of postoperative paresthesia in the “late night” subgroup vs. the “day” group. Lastly, one article reported increased consultant attendance and decreased operative time when postponing to office hours more often. No differences were reported for functional outcomes in any of the articles. Consequently, no strong risks or benefits from surgical treatment during office hours vs. after-hours were found. It appears safe to postpone surgery to office hours if circumstances are not optimal for acute surgery, and if there is no medical contraindication. However, research with a higher level-of-evidence is needed make more definite recommendations.

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

Comprehensive Analysis of Pediatric Supracondylar Fractures in the Emergency Department; A Single Center Experience

Objective:

To describe the demographic characteristics and to assess possible risk factors related to the moment of presentation at Emergency Department (ED) for pediatric humeral supracondylar fractures.

Methods:

This was cross-sectional study being conducted during 5-year period from 2013 to 2017 at ED of a regional hospital in Spain. We have included all the pediatric patients (<14 years) with supracondylar fractures referring to our center during the study period. The demographic, clinical and radiological characteristics of the patients were recorded. The outcome and treatment strategies were also recorded. The risk factors of the pediatric supracondylar fracture was also assessed in our series.

Results:

We have included 52 pediatric patients with supracondylar fractures in this series. The mean age was 7.48 ± 2.97 years with a minimum age of 2 years and a maximum of 14 years. Among the patients there were 32 (61.54%) male and 20 (38.46%) female. Age less than 7 years found to be a protective factor against unstable fractures [OR 0.33 (0.10 - 1.02)]. Fractures presented during daytime hours showed a greater instability [OR 3.49 (1.07-11.39)]. However, the risk of presentation at nighttime was higher during the summer months (June to September).

Conclusion:

The older is the child, the greater is the risk of suffering an unstable fracture, which increases the need for surgery. This risk is greater during the daytime. Otherwise, during the summer months, there is a higher risk of patient presentation at nighttime.

Independent predictors affecting the reduction of pediatric supracondylar humerus fractures: a retrospective cohort study

BACKGROUND

Although it is important to understand the risk factors affecting the reduction of pediatric supracondylar humerus fractures (PSHFs), no inclusive study has been conducted so far. We performed a retrospective cohort study to identify the risk factors affecting the quality and difficulty of reduction for PSHFs.

METHODS

We reviewed 160 cases with a PSHF that had been surgically treated in our hospital between January 2007 and December 2019. We investigated age, sex, injured side, body mass index (BMI), modified Gartland classification, neurological deficit or an absent radial artery pulse at an initial examination, start time of the operation, waiting time from injury to surgery, operative time, reduction technique, and perioperative radiographic parameters. We calculated independent predictors of unsuccessful closed reduction, prolonged operative time, and malreduction using multivariate analyses.

RESULTS

In a logistic regression analysis, modified Gartland type III was a significant predictor of unsuccessful closed reduction (OR 14.50 [95% CI 4.03-51.90]; P < 0.01) and BMI was a significant predictor of malrotation (OR 1.59 [95% CI 1.06-2.39]; P = 0.025). In a multiple linear regression analysis, BMI and open reduction were significant predictors of prolonged operative time (BMI, P = 0.011; open reduction, P < 0.01).

CONCLUSIONS

If closed reduction fails, we should not hesitate to immediately switch to other methods. Obesity was an independent predictor of both prolonged operative time and malrotation, a finding that has not been previously reported. Rotational alignment should be carefully checked, especially for obese children, and accurately be reduced. Open reduction also extended operative time.

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.

[Supracondylar humeral fractures in childhood]

The classification of supracondylar humeral fractures in German-speaking areas is carried out according to von Laer, which has been appropriated from the AO system and has the advantage that it can be used to derive the treatment. When indicated immediate surgery is given preference over a delayed treatment. The result is controlled by functional tests directly during the operation. Instability of the fracture and correct placement of the Kirschner (K) wires are challenging. Alternatives are an external fixator and elastically stable intramedullary nailing (ESIN). Concomitant injuries initially affect the median nerve and the brachial artery and secondarily the radial nerve. Lesions of the ulnar nerve are mostly a postoperative complication. The bony consolidation is achieved after 3-4 weeks and afterwards implant removal can be safely carried out. Embedded K‑wires and ESIN are removed after 3-6 months, depending on the surgical capacity and complaints of the patient.