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

Terpstra, S.; Burgers, P.T.P.W.; Heide, Huub J. L. van der; Witte, Pieter Bas de

doi:10.3390/children9020189

Cited by 9 publications

(8 citation statements)

References 19 publications

(42 reference statements)

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“…Terpstra et al found that the incidence of paresthesia complicating ScHF treated between 9 p.m. and 2 a.m. was higher when compared to the incidence of nerve injuries observed in ScHF treated during office hours [11]. According to their literature review, it appears safe to postpone surgery to office hours, if circumstances are not optimal for acute surgery at nighttime and if there is no medical contraindication [11].…”

Section: Introductionmentioning

confidence: 99%

Supracondylar Fractures of the Humerus: Association of Neurovascular Lesions with Degree of Fracture Displacement in Children—A Retrospective Study

Tomaszewski

Pethe²,

Kler³

et al. 2022

Children

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Supracondylar humerus fractures (ScHF) account for 60% of fractures of the elbow region in children. We assessed the relationship between neurovascular complications and the degree of fracture displacement as rated on the basis of modified Gartland classification. Moreover, we aimed to evaluate predisposing factors, e.g., age and gender, and outcomes of neurovascular complications in ScHF. Between 2004 and 2019, we treated 329 patients with ScHF at the Department of Traumatology and Orthopedics of the Upper Silesian Child Centre, Katowice, Poland. Mean age of patients (189 boys and 140 girls) was 7.2 years (Confidence interval: 6.89, 7.45). Undisplaced fractures were treated conservatively with a cast. Displaced fractures were managed by closed reduction and percutaneous Kirschner wire fixation using two pins inserted laterally. We retrospectively assessed the number of neurovascular lesions at baseline and recorded any iatrogenic injury resulting from the surgical intervention. Acute neurovascular lesions occurred in 44 of 329 ScHF patients (13.4%). The incidence of accompanying neurovascular injuries was positively associated with the severity of fracture displacement characterized by Gartland score. Vascular injuries occurred mainly in Gartland type IV ScHF, while nerve lesions occurred in both Gartland type III and IV ScHF. We noted a significantly higher mean Gartland score and mean age at injury in the group of children suffering from neurovascular injuries when compared to those in the group without such injuries (p = 0.045 and p = 0.04, respectively). We observed no secondary nerve lesions after surgical treatment. For the treatment of ScHF in children, we recommend closed reduction and stabilization of displaced fractures with K-wires inserted percutaneously from the lateral aspect of the upper arm. We advocate vessel exploration in case of absent distal pulses after closed reduction but do not consider primary nerve exploration necessary, unless a complete primary sensomotoric nerve lesion is present.

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Section: Introductionmentioning

confidence: 99%

Supracondylar Fractures of the Humerus: Association of Neurovascular Lesions with Degree of Fracture Displacement in Children—A Retrospective Study

Tomaszewski

Pethe²,

Kler³

et al. 2022

Children

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“…The timing of treatment of fully displaced SCH fractures remains controversial. While many of these injuries can be safely postponed until the next day, 3,[24][25][26][27][28] all series have some fractures that still had overnight treatment, indicating that there are some of these fractures severe enough to warrant evening or overnight surgery. However, the guidance on which of these fully displaced modified Gartland type 3 or 4 injuries are best treated at night, and which can safely be postponed until the next day is less clear.…”

Section: Discussionmentioning

confidence: 99%

“…Baumann's angle [17][18][19][20] lateral rotation percentage, 18,21,22 location of the anterior humeral line as it crosses the capitellum (not touching, anterior edge, anterior third, middle third, posterior third; 18.22) were assessed. A "loss of reduction" was determined if any of the above metrics changed between the intraoperative and postoperative radiographs: (1) change of Baumann's angle > 12°1 3,23 (2) change of lateral rotation percentage of >25% 21 and (3) change of position of the anterior humeral line by at least two steps. 12…”

Section: Methodsmentioning

confidence: 99%

“…Mildly displaced fractures (modified Gartland type 2) can be safely postponed until daylight hours or even for a few days, 1 and some of the fully displaced fractures (modified Gartland type 3) can also be postponed safely until the next day. 2 , 3 Yet, experts tend to agree that some pediatric SCH fractures are best not to leave until the next day. 4 However, it has been difficult to universally identify the fractures that require more urgent reduction and fixation.…”

Section: Introductionmentioning

confidence: 99%

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Fully displaced pediatric supracondylar humerus fractures: Which ones need to go at night?

Mahan

Miller

Park

et al. 2022

Journal of Children's Orthopaedics

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Background: Challenges remain in determining which displaced supracondylar humerus fractures are safe to postpone surgical treatment until daylight hours. The purpose of this study is to determine which characteristics can be identified to guide the timing of treatment of supracondylar humerus fractures. Methods: 225 completely displaced Gartland extension type 3/4 supracondylar humerus fractures in healthy patients that presented between 6 am and 7 am were identified. Data were collected retrospectively. Data analysis included univariate, multivariable logistic regression and classification and regression tree analysis. Results: 5% (78/225) underwent surgical treatment the night they presented, while 65% (147/225) were treated the next day. Overall complication rate was 6%, with no difference based on timing of surgery. 12% (28/225) presented with a motor nerve injury, while 6% (14/225) a “pink pulseless” extremity. Statistical analysis found the most reliable radiographic predictor to be the maximum displacement on the anterior–posterior or lateral view. Classification and regression tree analysis developed a clinical algorithm; patients with a “pink pulseless” extremity or motor nerve injury were recommended for surgery overnight, while those with an anterior–posterior or lateral view < 25 mm were recommended for surgery the next day. Conclusion: This study provides guidance on the timing of treatment for displaced supracondylar humerus fractures that present overnight. We provide a simple algorithm with three key clinical predictors for timing of treatment: presence of a “pink pulseless” arm, presence of a motor nerve injury, and displacement of any cortex by at least 25 mm (anterior–posterior or lateral view). This provides a step forward to help practitioners make safer evidenced-based timing decisions for their patients. Level of evidence: Prognostic Study, Level II.

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“…However, contradicting reports exist. Farrow et al [ 20 ] and Schmid et al [ 21 ] suggested that postponing surgery is a safe method, and no difference in outcomes has been reported between daytime and night-time surgical treatment [ 22 ]. Accepted general practice involves fast-tracking operative treatment to avoid complications related to delayed management and subsequent soft tissue swelling.…”

Section: Discussionmentioning

confidence: 99%

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

Gutwerk

Behrendt

Vetter³

et al. 2022

Children

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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.

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

Cited by 9 publications

References 19 publications

Supracondylar Fractures of the Humerus: Association of Neurovascular Lesions with Degree of Fracture Displacement in Children—A Retrospective Study

Supracondylar Fractures of the Humerus: Association of Neurovascular Lesions with Degree of Fracture Displacement in Children—A Retrospective Study

Fully displaced pediatric supracondylar humerus fractures: Which ones need to go at night?

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

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