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Fig. 1 AP radiographs of a type II supracondylar fracture before (A) and after (B) fixation with closed reduction and pinning. Reproduced from Pring ME and Wallaace CD: Shoulder and Elbow Trauma in Song KM (ed) Orthopaedic Knowledge Update Pediatrics 4, Rosemont, Ill. American Academy of Orthopaedic Surgeons, 2011, pp 329-345

AAOS Now

Published 6/1/2011
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Mary Ann Porucznik

Does time to surgery matter for type 2 supracondylar humerus fractures?

Study finds no increase in complications for pediatric patients

A broken elbow—specifically a supracondylar humerus fracture—is a common pediatric injury. Gartland type II supracondylar humerus fractures are displaced fractures with the posterior cortex intact (Fig. 1). Based on an analysis of nearly 400 of these fractures treated at a level 1 pediatric trauma center, children treated with closed reduction and percutaneous pinning did not experience any increase in complications, even if surgical treatment was delayed more than 5 days after the injury (typically due to delayed presentation).

“Changing patterns in referrals and insurance coverage mean that more pediatric trauma cases are being treated at large tertiary medical centers,” said presenter A. Noelle Larson, MD, of the Mayo Clinic in Rochester, Minn. “To expedite patient flow, type 2 fractures are sometimes pinned in a delayed fashion or in an outpatient setting.”

Dr. Larson and her colleagues wanted to determine whether a delay in surgical treatment of these fractures would have an impact on outcomes. The study was performed at Children’s Medical Center of Dallas and Texas Scottish Rite Hospital for Children, with Sumeet Garg, MD, as the lead investigator.

Retrospective review
This retrospective review of 1,297 supracondylar fractures surgically treated at a tertiary referral center during a 4-year period found 399 Gartland type 2 fractures (mean patient age of 5 years; range, 1–15 years). Of these, nearly half (48 percent) were pinned within 24 hours, one quarter (25 percent) were pinned from 1 to 5 days after injury, and the remaining fractures were pinned 5 days or more after the injury. The mean time from injury to surgery was 82 hours (range, 4.8 to 331 hours).

No patient sustained an open fracture or vascular injury, although 18 patients also had an ipsilateral radius or ulna fracture.

The fracture classification was based on surgeon’s intraoperative findings. Operative notes were also reviewed to determine preoperative antibiotics, pin configuration, need for vascular surgery, and need for open reduction.

A complication was defined as return to the operating room for any reason, infection, nerve injury, vascular exploration, compartment syndrome, loss of fixation, broken hardware, refracture after pin removal, or referral to physical therapy (also used as a surrogate for elbow stiffness).

Although 16 patients (4 percent) experienced complications (including three nerve injuries, which were resolved by latest follow-up), researchers could find no association between complications and time to surgery. “In fact, the cohort of fractures pinned within 24 hours had the highest rate of complications,” noted Dr. Larson.

No fractures required open reduction or vascular repair, nor were any episodes of compartment syndrome found. Five patients required additional surgery—one for loss of fixation and four for deep infection. Overall, the most common complication was infection (six patients), despite the administration of preoperative antibiotics, the use of sterile surgical techniques, and timely pin removal.

Limitations and conclustion
Researchers were unable to report on the rates of malunion or angular deformity following pinning of type II supracondylar humerus fractures, due to the retrospective nature of the study. Additionally, reliable range-of-motion data were limited.

“This study establishes benchmark figures for complications,” noted Dr. Larson, “and will serve as useful reference for further prospective work to improve outcomes and reduce complications following the surgical treatment of type II supracondylar humerus fractures. Based on our results, with the use of careful clinical judgment, we believe that outpatient pinning of selected type II supracondylar humerus fractures appears to be a safe and reasonable measure to improve practice efficiency.”

Dr. Larson’s coauthors for “Type 2 Supracondylar Fractures: Does Time to Surgery Matter?” include Sumeet Garg, MD; Nicholas D. Fletcher, MD; Jonathan R. Schiller, MD; Michael S. Kwon, MD; Lawson A.B. Copley, MD; and Christine A. Ho, MD.

Disclosure information: All of the authors report no conflicts.

Mary Ann Porucznik is managing editor of AAOS Now. She can be reached at porucznik@aaos.org

Bottom Line

  • This retrospective study of 399 Gartland type 2 supracondylar humerus fractures in children found that delay in surgery did not result in increased complications following closed reduction and percutaneous pinning.
  • Although 4 percent of patients experienced a complication, no association was found between complications and time to surgery.
  • The most common complication was infection; no patient experienced compartment syndromes, vascular injuries, or permanent nerve injuries.
  • Study limitations include an inability to report on rates of malunion or deformity and range of motion. Further prospective studies are needed to see if emergent treatment of these fractures results in subtle functional benefits.