In "The Effect of Surgical Timing on the Perioperative Complications Associated With Treatment of Supracondylar Humeral Fractures in Children" authored by Mehlman et al., that appears in this edition of the Journal, the authors ask whether timing of the treatment of supracondylar fractures affects complication rates. Their conclusion states, "We were unable to find any statistically significant difference in perioperative complication rate for displaced supracondylar humeral fractures treated early versus those treated in a delayed fashion. We feel that the timing of surgical intervention can be either early or delayed when deemed appropriate by the surgeon." If one reads no further in the article, and simply changes his or her practice based on this single sentence, a decidedly negative impact upon patient outcome could result.

The decision to take a patient to the operating room early versus late is not based simply on matters of surgeon convenience or operating room availability. In the Discussion, the authors clearly state that in certain instances following supracondylar fracture, such as the pulseless presentation of an upper extremity, which occurs in up to 17% to 38% of type III fractures^1,2 or open fractures, early intervention is mandatory. In looking at their data further, 94 % of the early-pinned fractures were type III whereas only 70% of the delayed fractures were type III. While there is wide variation in type III fracture classifications, one wonders whether the degree of displacement and soft tissue injury were equivalent in the two groups. I think they were not. The incidence of open reduction was 14% in those done early and 3% in the late group. This further suggests that either the delay in treatment made the reduction easier by decreasing the swelling or soft tissue injury or more likely that the more severe fractures were treated early.

There are limitations in all retrospective studies and I am sure that the authors would agree that this retrospective study is limited to the degree that the early versus the late group are not totally comparable.

What then have we learned from this article? There are many cases of type II and type III supracondylar fractures in which delayed treatment would ease the stress on the medical system, surgeon and operating facility. We now have evidence that this is a safe course of management when used judiciously. However, these data do not support converting the treatment of all of these patients to elective ambulatory care. I believe this article does show that in selected cases of type II and type III supracondylar fractures treatment can be delayed with no increased incidence of certain specific complication rates:

1) conversion to open reduction
2) iatrogenic nerve injury
3) Volkmann's ischemic contracture.

The last of these is the most critical. The incidence of Volkmann's ischemic contracture in the modern era is extremely low. There is not sufficient power in this study to be certain that there is no increase in compartment syndrome with a delayed approach. However, I am concerned that if patients are not watched very closely with frequent neurovascular checks until the time of pinning, we will see an increased incidence in this relatively rare but tragic event.

To assume that one could place a child in a splint in the emergency room, send them home and delay definitive stabilization of a supracondylar fracture until a time convenient for family, surgeon and hospital is certainly not what Drs. Mehlman, et al meant nor what we should take away from this article. We are thankful to the authors for demonstrating that it is not necessary in selected supracondylar fractures to proceed with treatment on an emergent basis, if care is taken in patient selection and proper monitoring can be assured.

I thank the authors for their contribution to the literature and the editors of JBJS for the opportunity to comment on this paper.

1. Campbell CC, Waters PW, Emans JB, Kasser JR and Millis MB: Neurovascular Injury and Displacement in Type III Supracondylar Humerus Fractures. J Pediatr Orthop. 1995;15:47-52

2. Shaw BA, Kasser JR, Emans JB and Rand FF: Management of Vascular Injuries in Displaced Supracondylar Humerus Fractures without Arteriography. J. Orthop Trauma. 1990;4:25-9.