JBJS | The Effect of Surgical Timing on the Perioperative Complications of Treatment of Supracondylar Humeral Fractures in Children

The Journal of Bone & Joint Surgery, Volume 83, Issue 3

Articles | March 01, 2001

The Effect of Surgical Timing on the Perioperative Complications of Treatment of Supracondylar Humeral Fractures in Children

Charles T. Mehlman, DO, MPH; William M. Strub, BA; Dennis R. Roy, MD; Eric J. Wall, MD; Alvin H. Crawford, MD

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Investigation performed at the Division of Pediatric Orthopaedic Surgery, Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
Charles T. Mehlman, DO, MPH William M. Strub, BA Dennis R. Roy, MD Eric J. Wall, MD Alvin H. Crawford, MD Division of Pediatric Orthopaedic Surgery, Children’s Hospital Medical Center, University of Cincinnati College of Medicine, 3333 Burnet Avenue, Cincinnati, OH 45229-3039
No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.

The Journal of Bone & Joint Surgery. 2001; 83:323-323

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Abstract

Background: The purpose of this study was to evaluate the perioperative complication rates associated with early surgical treatment (eight hours or less following injury) and delayed surgical treatment (more than eight hours following injury) of displaced supracondylar humeral fractures in children.

Methods: Fifty-two patients had early surgical treatment and 146 patients had delayed surgical treatment of a displaced supracondylar humeral fracture. The perioperative complication rates of the two groups were compared with the use of bivariate and multivariate statistical methods.

Results: There was no significant difference between the two groups with respect to the need for conversion to formal open reduction and internal fixation (p = 0.56), pin-track infection (p = 0.12), or iatrogenic nerve injury (p = 0.72). No compartment syndromes occurred in either group. Power analysis revealed that our study had an 86% power to detect a 20% difference between the two groups if one existed.

Conclusions: We were unable to identify any significant difference, with regard to perioperative complication rates, between early and delayed treatment of displaced supracondylar humeral fractures. Within the parameters outlined in our study, we think that the timing of surgical intervention can be either early or delayed as deemed appropriate by the surgeon.

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Introduction

Introduction | Materials and Methods | Results | Discussion | References

The preferred treatment for displaced supracondylar humeral fractures in children is closed reduction and percutaneous pinning^1-11, with many authors recommending emergent treatment^12-20. The rationale offered to justify such emergent treatment has traditionally been to minimize swelling in an effort to decrease the risk of perioperative complications, such as compartment syndrome, infection, and nerve injuries, and to reduce the likelihood that a conversion to an open reduction will be needed^15,18,21,22. This concept, while intuitively attractive to orthopaedic surgeons, has been perpetuated only as stated opinion^12-20,22. To the best of our knowledge, there is no published study that supports this contention in a scientific fashion. One previous study demonstrated evidence that the timing of surgical treatment of a supracondylar fracture does not influence complication rates²³.

At our institution, closed supracondylar humeral fractures with adequate perfusion of the limb are immobilized in a position of comfort and are treated with closed reduction and percutaneous pinning in the next available time slot in the operating room. Some fractures with marked displacement may be provisionally reduced to improve patient comfort prior to splinting. Thus, because of random factors such as the availability of the operating room and surgeon, we were able to evaluate a series of children with displaced supracondylar humeral fracture in which some were treated soon after the injury and some were treated at a later time. The purpose of this study was to evaluate the perioperative complication rate for patients treated early (eight hours or less after injury) with that for patients treated in a delayed fashion (more than eight hours after injury).

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TABLE I: Patient Demographics

*The values are given as the percentage of patients, with the number of patients in parentheses.

	Early-Treatment Group (£8 Hours) (N = 52)	Delayed-Treatment Group (>8 Hours) (N = 146)
Average age (range) (yr + mo)	6 + 9 (1 + 4 to 14 + 4)	6 + 1 (1 + 5 to 13 + 10)
Average time (range) until surgery (hr + min)	5 (2 + 6 to 7 + 50)	23 (8 + 10 to 72)
Male*	56% (29)	46% (67)
Female*	44% (23)	54% (79)
Right side*	54% (28)	40% (59)
Left side*	46% (24)	60% (87)
Type-III fracture*	94% (49)	?70% (102)
Type-II fracture*	6% (3)	30% (44)
Medial pin used*	44% (23)	55% (80)

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TABLE I: Patient Demographics

*The values are given as the percentage of patients, with the number of patients in parentheses.

	Early-Treatment Group (£8 Hours) (N = 52)	Delayed-Treatment Group (>8 Hours) (N = 146)
Average age (range) (yr + mo)	6 + 9 (1 + 4 to 14 + 4)	6 + 1 (1 + 5 to 13 + 10)
Average time (range) until surgery (hr + min)	5 (2 + 6 to 7 + 50)	23 (8 + 10 to 72)
Male*	56% (29)	46% (67)
Female*	44% (23)	54% (79)
Right side*	54% (28)	40% (59)
Left side*	46% (24)	60% (87)
Type-III fracture*	94% (49)	?70% (102)
Type-II fracture*	6% (3)	30% (44)
Medial pin used*	44% (23)	55% (80)

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TABLE II: Complication Rates

*The values are given as the percentage of patients, with the number of patients in parentheses.

	Early-Treatment Group (£8 Hours)* (N = 52)	Delayed-Treatment Group (>8 Hours)* (N = 146)
Open reduction	13% (7)	3% (5)
Pin-track infection	?4% (2)	2% (3)
Iatrogenic nerve injury	?4% (2)	2% (3)
Compartment syndrome	?0% (0)	0% (0)

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TABLE II: Complication Rates

*The values are given as the percentage of patients, with the number of patients in parentheses.

	Early-Treatment Group (£8 Hours)* (N = 52)	Delayed-Treatment Group (>8 Hours)* (N = 146)
Open reduction	13% (7)	3% (5)
Pin-track infection	?4% (2)	2% (3)
Iatrogenic nerve injury	?4% (2)	2% (3)
Compartment syndrome	?0% (0)	0% (0)

Materials and Methods

Introduction | Materials and Methods | Results | Discussion | References

A computerized medical records search was conducted to identify all children with operatively treated supracondylar humeral fracture between January 1, 1983, and May 31, 1998, at Children’s Hospital Medical Center Cincinnati. Inpatient charts, outpatient charts, and emergency department records were examined to determine the age and gender of the patient, side of the fracture, time and date of injury, and time and date of surgery. If the precise time of injury could not be determined, the triage time in the emergency department was used as the time of injury. The presence or absence of a vascular deficit, open fracture, metabolic bone disease, or concurrent fracture was recorded. Documentation of the following perioperative complications was also sought from each patient’s record: failure of an attempt at closed reduction in the operating room that resulted in a formal open reduction, postoperative infection, treatment-related nerve injury, and compartment syndrome. The radiographs made at the time of injury were used to classify fractures according to the Gartland classification system²⁴. Other radiographic and clinical data such as malunion, neuropathy or neurapraxia at the time of presentation, and functional outcome were not collected as part of this study. Exclusion criteria were an age of greater than eighteen years, open fracture, nondisplaced fracture, metabolic bone disease, a dysvascular extremity, and ipsilateral upper-extremity fracture.

Our search identified 220 consecutive patients in whom a displaced supracondylar humeral fracture had been treated operatively. All patients had a unilateral injury. No patient had a progressive neurologic deficit or compartment syndrome at the time of presentation. Sixty-five patients were treated eight hours or less after injury. Of these patients, six presented with an open fracture, six had an ipsilateral forearm fracture, and one arrived in the emergency department without a palpable radial pulse. The remaining 155 patients had surgical treatment more than eight hours after injury. Nine of these patients had an ipsilateral upper-extremity fracture. No patient with an open fracture or no pulse at presentation was treated in a delayed manner. Thus, after we applied our exclusion criteria, there were fifty-two patients in the early-treatment group and 146 in the delayed-treatment group.

Demographic data for both groups are presented in Table I. Due to extreme displacement with or without markedly tented skin, approximately 50% of the patients in the delayed-treatment group underwent an initial closed reduction in the emergency department. None of the patients in the early-treatment group underwent such a reduction. It should also be noted that there was a higher percentage of more severely displaced (type-III) fractures in the early-treatment group (94%) than in the late-treatment group (70%).

Statistical methods utilized in this study included power analysis, the Fisher exact test, and logistic regression analysis. A two-group power-analysis method was utilized in order to determine the power of our study to detect a difference if one existed²⁵. An alpha value of 0.05 was used for this calculation. The Fisher exact test was used for bivariate analysis, and logistic regression was used for multivariate analysis in order to control for identified differences between the two groups. Probability values (p values) of 0.05 or less were considered to be significant, and a power of 80% or more was considered to be desirable²⁶.

Results

Introduction | Materials and Methods | Results | Discussion | References

In the early-treatment group, attempted closed reduction and percutaneous pinning failed to achieve satisfactory reduction in ten patients, seven of whom were treated by open reduction and internal fixation. Five of these patients had an immediate conversion to open reduction under the same anesthetic, and the other two were treated with traction for forty-eight hours, followed by open reduction and internal fixation. Three other patients were also treated with traction for forty-eight hours, followed by a successful second attempt at closed reduction and percutaneous pinning. Of the fifty-two patients, two had a superficial pin-track infection that resolved with oral antibiotic treatment and none had a compartment syndrome. Additionally, there were two iatrogenic nerve injuries: one of the median nerve and one of the ulnar nerve. The injury to the median nerve occurred in a ten-year-old girl who fell while roller skating. She underwent an initial attempt at reduction of a type-III fracture in the emergency department before being treated with a crossed pin configuration in which the medial pin was smooth and the lateral pin was threaded. A median nerve sensory and motor deficit was noted following the closed reduction performed in the emergency department. The ulnar nerve injury occurred in a four-year-old boy who fell down a grassy embankment and sustained a type-III fracture. Following successful closed reduction in the operating room, three smooth wires were placed. Two of these wires were medial and one was lateral. This patient also had a pin-track infection. Postoperatively, the patient had an ulnar nerve sensory deficit. The pins were maintained in place until osseous healing was complete, at four weeks. By the fourth postoperative month, both nerve injuries had completely resolved. The complication rates in the early-surgery group are listed in Table II.

Initial attempts at closed reduction in the operating room were successful in 141 of the 146 patients in the delayed-treatment group. Five patients had unsuccessful closed reduction and were treated by open reduction and internal fixation. Unlike in the early-treatment group, no patient was treated with traction after the initial attempt at closed reduction failed. There were three superficial pin-track infections that resolved with oral antibiotic treatment, and no patient had a compartment syndrome. Finally, three patients sustained an iatrogenic nerve injury: two involved the ulnar nerve and one, the median nerve. One ulnar nerve palsy occurred in a seven-year-old boy who sustained a type-III fracture secondary to a fall on wet grass. Following closed reduction and percutaneous pinning with three lateral pins, he was noted to have an ulnar nerve motor and sensory neurapraxia. The nerve was explored and noted to be structurally intact and not to be trapped in the fracture site. The other ulnar nerve injury occurred in a five-year-old girl who sustained a type-III fracture when she tripped and fell while running. She was treated with two smooth pins in a crossed configuration. Postoperatively, she was noted to have an ulnar nerve motor and sensory deficit. The pins were maintained until complete osseous healing had occurred. The median nerve injury occurred in a five-year-old girl who fell from monkey bars (a metal structure for climbing). She sustained a type-III fracture, which was treated with open reduction and internal fixation with a crossed smooth-pin configuration. In the postoperative setting, she was noted to have a sensory and motor deficit of the median nerve. By the fifth postoperative month, all three of these patients had a documented full return of nerve function. The complication rates for the patients treated more than eight hours after injury are listed in Table II.

Our power analysis revealed that our study had an 86% power to detect a 20% difference in complication rates between the groups if one existed. Bivariate analysis of our data with the Fisher exact test revealed no significant difference between the two groups with respect to the rate of either infection (p = 0.608) or iatrogenic nerve injury (p = 0.72). However, this test revealed a significant difference (p = 0.015) between the two groups concerning the need to convert to an open reduction, with the higher rate of conversion in the early-surgery group (13%). Because of concern about differences between the two groups regarding age, gender, and fracture severity, multivariate analysis (logistic regression) was performed to control for these observed differences. Such statistical analysis is appropriate when the outcome variable (dependent variable) is discrete (binary data such as yes or no, success or failure, and so on) and one wishes to simultaneously analyze multiple predictor variables (independent variables) that may be a mixture of discrete variables (such as Gartland type II or III and male or female) and continuous variables (such as age)^27,28. The logistic regression analysis revealed no significant difference between the two groups with respect to the rates of infection (p = 0.12), nerve injury (p = 0.72), or conversion to open reduction (p = 0.56).

Discussion

Introduction | Materials and Methods | Results | Discussion | References

Displaced supracondylar humeral fractures in children may be associated with infectious, vascular, and neurological complications in addition to difficulties in achieving and maintaining a satisfactory reduction^29-33. Many previous authors have expressed the opinion that emergent treatment of these fractures is necessary to avoid such complications^12-20. Our findings do not support this contention. We were unable to identify a difference with regard to the rates of open reduction, infection, iatrogenic nerve injury, or Volkmann ischemic contracture between patients treated eight hours or less after injury and those treated more than eight hours after injury.

A logical concern about delayed treatment is the inability to achieve a satisfactory closed reduction of the fracture due to continued swelling. It would therefore follow that the need for open reduction and internal fixation would increase as the time until the surgery increased. The rate of conversion to open reduction has been reported as ranging from less than 3% to about 46%^9,31,34-37. The precise timing of surgery has not always been clearly stated in these reports, however. In their series of 180 patients with type-III supracondylar fracture, Cheng et al.² reported a rate of open reduction approaching 38%, but it is important to note that in their series only 17% of the fractures presented on the day of injury. Other extraneous factors such as exactly what constitutes an acceptable reduction to individual authors have not been frequently discussed in the literature³⁵. Some authors have also developed intraoperative strategies aimed at decreasing the need for open reduction⁹. The rates of conversion to open reduction in both of our study groups lie well within the range reported by these other authors.

Infection following treatment of displaced supracondylar humeral fractures is almost always in a pin track; deep infection and osteomyelitis are rare^7,36. Recently reported rates of infection associated with percutaneous fixation have ranged from 2.4% to 6.6%^1,2,31,36. In our study, the infection rate for the patients treated eight hours or less after injury was 4%, whereas the rate in the group treated more than eight hours after injury was 2%. All of these infections resolved with a course of oral antibiotics followed by pin removal after adequate osseous healing. The percutaneous surgical approach to these fractures certainly plays a major role in achieving such low rates of infection, and we did not find that early surgery had any clear advantage over delayed surgery.

Nerve injuries associated with displaced supracondylar humeral fractures may be divided into those associated with the injury itself and those associated with treatment of the injury³⁸. Our study focused on the latter. Although a crossed Kirschner-wire configuration has been shown to be biomechanically superior³⁹, recent approaches to treatment have deemphasized the need for medial pins in the treatment of these fractures because of the increased morbidity associated with such pins^40-42. The rate of medial pin usage was higher in our delayed-treatment group (55%) than it was in our early-treatment group (44%), yet the delayed-treatment group had a lower observed rate of nerve injury (2% compared with 4% in the early-treatment group). A literature review of other published studies of closed reduction and percutaneous pinning (including a total of 1206 patients with displaced supracondylar fracture) revealed forty-three iatrogenic nerve injuries^{10,13,29,38,40-44}. This translates into a rate of iatrogenic nerve injury of 3.6% (forty-three of 1206), with the ulnar nerve being involved in 81% (thirty-five) of the forty-three cases. It has also been shown that there are multiple mechanisms of ulnar nerve injury in addition to direct nerve penetration⁴⁵. We think that differences in fracture severity, adequacy of pretreatment evaluation, experience of the surgeon, and pin configuration may lead to observed differences in the rates of iatrogenic nerve injury. Some authors have developed strategies for identifying children who may be at increased risk for ulnar nerve injury by medial pin placement⁴⁶. We did not specifically analyze surgeon experience in our study, but we can state that all procedures were either performed or directly supervised by an attending orthopaedic surgeon.

Volkmann ischemic contracture is a rare event, with a prevalence of 0.5% or less⁴⁷. In our study, we found no cases of compartment syndrome. Historically this has been one of the most feared complications of supracondylar fracture and probably is the reason why the fracture is treated as an emergency by many surgeons. It does not appear from our study that waiting longer to operate increases the risk of compartment syndrome. This may be largely due to the avoidance of hyperflexed positions of the elbow aimed at holding closed reductions of these fractures. We would thus emphasize that an adequately perfused limb should simply be splinted in an extended position to optimize the patient’s comfort while he or she awaits definitive surgical treatment. It is possible that our study was too small for us to identify and analyze true differences in rates of compartment syndrome between the two groups.

Our study is consistent with and builds on the study by Iyengar et al.²³, who also addressed the issue of surgical timing as it relates to complications following supracondylar fracture surgery. Those authors focused on several clinical parameters, including the need to convert to open reduction, nerve injury, and signs of compartment syndrome such as decreased grip strength. Their main outcome variable was the need to convert to open reduction, which occurred in 13% (three) of the twenty-three patients in their early-treatment group compared with 17% (six) of the thirty-five patients in their delayed-treatment group. There were no treatment-associated nerve injuries in their early-treatment group, whereas there was one (a radial nerve palsy) in their delayed-treatment group. They were unable to identify any significant differences between their early and delayed surgical groups concerning their measured parameters. The size of the patient groups evaluated by Iyengar et al. raises concern about the power of their study to demonstrate a difference if one existed. In fact, we estimated that their study had less than a 50% power to identify a 20% difference between the groups. Thus, our results support those of Iyengar et al. while offering substantially greater power.

The results of our study must be interpreted within the context of our study design. We performed a retrospective double-cohort study of patients treated by multiple surgeons at one institution during a long period. The early part of the study period was also a time when other methods, such as traction, were more commonly used than they were in more recent years. Despite our efforts to control for differences in our study groups with the use of multivariate statistical techniques, there still may have been differences between the two groups for which we did not adequately control. It is also possible that, despite our study having what is commonly considered to be adequate power (80%)²⁶, a larger study might still reveal significant differences in complication rates of such early and delayed-treatment groups.

In summary, we were unable to identify any significant difference in perioperative complication rates between displaced supracondylar humeral fractures treated early and those treated in a delayed fashion. Our study specifically excluded two of the most common scenarios that prompt emergent treatment of supracondylar humeral fractures: open fractures and pulseless extremities. We do not recommend delayed treatment in these situations. In addition, there are several other patient-related factors that may influence a surgeon’s decision to operate early. These include fracture patterns with sharp osseous spikes that may injure neurovascular structures, multiple fractures in the same extremity, skin-tenting that could progress to an open fracture, and severe fracture displacement. In such circumstances, a study such as ours can never serve as a substitute for the judgment of the attending orthopaedic surgeon. However, we believe that, within the parameters outlined in our study, the timing of surgical intervention can be either early or delayed as deemed appropriate by the surgeon.

Note: The authors thank Peter Gartside, PhD, for his assistance with the statistical analysis.

References

Introduction | Materials and Methods | Results | Discussion | References

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Topics

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TABLE I: Patient Demographics

*The values are given as the percentage of patients, with the number of patients in parentheses.

	Early-Treatment Group (£8 Hours) (N = 52)	Delayed-Treatment Group (>8 Hours) (N = 146)
Average age (range) (yr + mo)	6 + 9 (1 + 4 to 14 + 4)	6 + 1 (1 + 5 to 13 + 10)
Average time (range) until surgery (hr + min)	5 (2 + 6 to 7 + 50)	23 (8 + 10 to 72)
Male*	56% (29)	46% (67)
Female*	44% (23)	54% (79)
Right side*	54% (28)	40% (59)
Left side*	46% (24)	60% (87)
Type-III fracture*	94% (49)	?70% (102)
Type-II fracture*	6% (3)	30% (44)
Medial pin used*	44% (23)	55% (80)

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TABLE I: Patient Demographics

*The values are given as the percentage of patients, with the number of patients in parentheses.

	Early-Treatment Group (£8 Hours) (N = 52)	Delayed-Treatment Group (>8 Hours) (N = 146)
Average age (range) (yr + mo)	6 + 9 (1 + 4 to 14 + 4)	6 + 1 (1 + 5 to 13 + 10)
Average time (range) until surgery (hr + min)	5 (2 + 6 to 7 + 50)	23 (8 + 10 to 72)
Male*	56% (29)	46% (67)
Female*	44% (23)	54% (79)
Right side*	54% (28)	40% (59)
Left side*	46% (24)	60% (87)
Type-III fracture*	94% (49)	?70% (102)
Type-II fracture*	6% (3)	30% (44)
Medial pin used*	44% (23)	55% (80)

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TABLE II: Complication Rates

*The values are given as the percentage of patients, with the number of patients in parentheses.

	Early-Treatment Group (£8 Hours)* (N = 52)	Delayed-Treatment Group (>8 Hours)* (N = 146)
Open reduction	13% (7)	3% (5)
Pin-track infection	?4% (2)	2% (3)
Iatrogenic nerve injury	?4% (2)	2% (3)
Compartment syndrome	?0% (0)	0% (0)

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TABLE II: Complication Rates

*The values are given as the percentage of patients, with the number of patients in parentheses.

	Early-Treatment Group (£8 Hours)* (N = 52)	Delayed-Treatment Group (>8 Hours)* (N = 146)
Open reduction	13% (7)	3% (5)
Pin-track infection	?4% (2)	2% (3)
Iatrogenic nerve injury	?4% (2)	2% (3)
Compartment syndrome	?0% (0)	0% (0)