Outcomes of Nonoperatively Treated Pediatric Supracondylar Humeral Fractures at the Nkhotakota District Hospital, Malawi

Abstract

Background: Displaced supracondylar humeral fractures (SCHFs) benefit from closed reduction and percutaneous pinning. In Malawi, many SCHFs are treated nonoperatively because of limited surgical capacity. We sought to assess clinical and functional outcomes of nonoperatively treated SCHFs in a resource-limited setting. Methods:We retrospectively reviewed all patients with SCHFs treated at Nkhotakota District Hospital (NKKDH) in Malawi between January 2014 and December 2016. Patients subsequently underwent clinical and functional followup assessment.Results: We identified 182 children (54% male, mean age of 7 years) with an SCHF; 151 (83%) of the fractures were due to a fall, and 178 (98%) were extension-type (Gartland class distribution: 63 [35%] type I, 52 [29%] type II, and 63 [35%] type III). Four patients with type-I fractures were treated with an arm sling alone, and 59 were treated with straight-arm traction to reduce swelling and then splint immobilization until union. All 119 of the patients with Gartland type-II and III or flexion-type injuries were treated with straight-arm traction, manipulation under anesthesia without fluoroscopy, and then splint immobilization until union. A total of 137 (75%) of the patients were available for follow-up, at a mean of 3.9 years after injury. The Flynn functional outcome was excellent for 39 (95%) with a type-I fracture, 30 (70%) with type-II, and 14 (29%) with type-III. The Flynn cosmetic outcome was excellent for 40 (98%) with a type-I fracture, 42 (98%) with type-II, and 41 (84%) with type-III. Forty (98%) of the children with a type-I fracture, 41 (95%) with type-II, and 32 (65%) with type-III returned to school without limitation. Controlling for sex, delayed presentation, medical comorbidities, injury mechanism, and skin blistering/superinfection during traction, patients with type-II fractures were 5.82-times more likely (95% confidence interval [CI], 1.71 to 19.85) and those with type-III fractures were 9.81-times more likely (95% CI, 3.00 to 32.04), to have a clinical complication or functional limitation compared with patients with type-I fractures.Conclusions: Nonoperative treatment of type-III SCHFs resulted in a high risk of clinical complications or functional impairment. These results illustrate the urgent need to increase surgical capacity in low-income countries like Malawi to improve pediatric fracture care.

Epidemiology and Management of Pediatric Fractures in Malawi

“… 37 , 38 In addition, nonsurgical treatment of displaced supracondylar humerus fractures results in unacceptably high rates of clinical complications and functional impairments but remains the standard of care in Malawi. 15 We observed that 95% of patients in our cohort with supracondylar humerus fractures were treated nonsurgically. Of note, less than 15% of supracondylar humerus fractures presented ≥2 days, and only 4% presented over 10 days from the time of fracture.…”

“… 11 Proper fracture care, including appropriate surgery, can prevent long-term disability. 12 13 14 15 However, Malawi has insufficient surgical capacity to provide basic orthopaedic surgery to all citizens who need it. 16 Fracture care in Malawi's public sector is provided free of charge to patients through government and donor funding at 25 district hospitals and four urban central hospitals, with >90% of fractures managed in rural district hospitals by orthopaedic clinical officers (OCOs).…”

“… 18 Recent studies have found that pediatric patients in Malawi with femur and pediatric supracondylar humerus (Gartland type II and III) fractures who are treated nonsurgically have notable rates of extended length of stay, malunion, chronic pain, and functional limitations. 15 , 22 Currently, the intended referral practices in Malawi involve all patients with fractures who present to primary health centers, which do not have radiograph machines, being referred to district hospitals for further assessment and initial nonsurgical treatment. Those with intraarticular fractures, severe open fractures, polytrauma, or disabling sequelae after nonsurgical management (nonunion, malunion, etc) are then referred from the district hospitals to central hospitals for treatment by orthopaedic surgeons.…”