Evaluating Perioperative Complications Surrounding Supracondylar Humerus Fractures: Expanding Indications for Outpatient Surgery

Abstract

Background: Supracondylar humerus (SCH) fractures are one of the most common pediatric orthopaedic injuries. Described using the Wilkins modification of the Gartland Classification system, current practice guidelines give moderate evidence for closed reduction and percutaneous pinning of type 2 and 3 injuries, but little evidence exists regarding the appropriate surgical setting for fixation. The goal of this study was to evaluate the perioperative complication profile of type 3 fractures with maintained metaphyseal contact and determine their suitability for outpatient surgery. Methods: Skeletally immature patients with type 2 and 3 SCH fractures treated at a single, Level-1 trauma institution from March 2019 to January 2000 were retrospectively reviewed. A total of 1126 subjects were identified. Open, concomitant injuries, incomplete physical examination, initial neurovascular compromise, flexion-type fractures, ecchymosis, skin compromise, and those managed nonoperatively were excluded. Type 3 fractures were categorized as either "3M" versus type "3" ("M" denoting metaphyseal bony contact). Demographic data, neurovascular changes, and postoperative complications were collected. Categorical variables were evaluated using χ 2 or Fisher exact tests, and continuous variables analyzed using analysis of variance, with significance defined as a P-value < 0.05. Results: A total of 485 patients (189 type 2, 164 type 3M, 132 type 3) met inclusion criteria. Sex and length of stay did not differ among groups. The incidence of neurovascular change between initial presentation and surgical fixation was significantly greater for type 3 fractures compared with other groups (P = 0.02). No child in the 3M group had preoperative neurovascular examination changes, compared with 3 patients with type 3 injuries. When directly compared with the 3M group, type 3 fractures had a higher incidence of neurovascular examination changes that trended towards significance (P = 0.08). There was no difference in postoperative complication rate between groups (P = 0.61). Conclusions:Our findings demonstrate that Gartland type 3 SCH fractures lacking metaphyseal bony contact, compared with types 3M and 2, are more likely to experience neurovascular examination changes between initial presentation and definitive surgical fixation. Type 3M fractures clinically behaved like type 2 injuries and, accordingly, could be considered for treatment on an outpatient basis.

Impact of the COVID-19 Pandemic on Pediatric Elbow Fractures: Marked Change in Management and Resource Utilization, Without a Change in Incidence

“…Although long-term outcomes data for this cohort are currently unavailable, the increased rate of presentation to outpatient clinics could provide a valuable analysis of outpatient elbow injury fixation, especially in light of recent trends toward outpatient fracture fixation with increasingly more severe fractures. 16 This study likewise observed that the proportion of patients treated for elbow injury that were transferred from another clinic or hospital increased during the COVID-19 period. Although we hypothesized this may be to limitations and increased volume at local hospitals secondary to the pandemic, given the multiple points of entry for patients to our tertiary care center and the variety of medical professional involved in this process, the specific causes for a change in transfer protocols remain difficult to assess.…”

“…This increased rate of presentation in the outpatient setting also likely contributes to the overall decreased proportion of hospital admissions for operative elbow injuries. Although long-term outcomes data for this cohort are currently unavailable, the increased rate of presentation to outpatient clinics could provide a valuable analysis of outpatient elbow injury fixation, especially in light of recent trends toward outpatient fracture fixation with increasingly more severe fractures 16…”

“…Although long-term outcomes data for this cohort are currently unavailable, the increased rate of presentation to outpatient clinics could provide a valuable analysis of outpatient elbow injury fixation, especially in light of recent trends toward outpatient fracture fixation with increasingly more severe fractures. 16 …”

The Frequency and Outcomes of Nerve Palsies in Operatively Treated Supracondylar Humerus Fractures

“…Medial pins are more likely to be used in displaced and unstable SCHFs, suggesting the severity of injury and unstable nature of the fracture may better explain the increased rate of nerve palsy in patients who receive a medial pin. The possibility of evolving nerve palsy should also be considered 31,32. Prolonged tension across the neurovascular structures in displaced fractures likely contributes to the development of a nerve palsy and patient exams were not consistently documented immediately before surgery, which is a limitation of the retrospective nature of this study.…”

“…The possibility of evolving nerve palsy should also be considered. 31,32 Prolonged tension across the neurovascular structures in displaced fractures likely contributes to the development of a nerve palsy and patient exams were not consistently documented immediately before surgery, which is a limitation of the retrospective nature of this study.…”