Postponing surgery of paediatric supracondylar humerus fractures to office hours increases consultant attendance in operations and saves operative room time

Abstract

PurposeTo assess if postponing surgery of paediatric supracondylar humerus fractures (SCHF) without compromised blood circulation to office hours can improve the quality of reduction and pin fixation and decrease complications.MethodsIn 2004, night-time (0am to 7am) surgery was allowed only for children with compromised blood circulation. Number of open reductions, surgeons experience, operation time, quality of reduction (Baumann angle, anterior humeral line crossing point with capitellum) and pin fixation as well as the number of complications were compared in 100 children before (A) and 100 after (B) the new protocol. Surgery was commenced during office hours (8am to 3pm) in 27% (A) versus 55% (B) and delay to surgery from admission exceeded six hours in 25% (A) versus 52% (B) of the children.ResultsOpen reduction was performed in eight (A) versus 11 (B) children. In group A, 40% were operated on by a registrar alone compared with 14% in group B. Mean operation room time decreased by 11 minutes in group B. Radiographic alignment was satisfactory at fracture union in 68% (A) versus 68% (B) and radiologically stable pin fixation in 42% (A) versus 55% (B) of children (p = 0.08). The was no statistical difference in admission time, re-reductions, infections, permanent iatrogenic nerve injuries or corrective osteotomies between the patient groups.ConclusionsNo statistical difference in quality of reduction or pin fixation or in number of complications was observed. Postponing operative treatment of SCHF without vascular compromise increased consultant attendance in operations and decreased operative room time.Level of EvidenceIII - retrospective comparative study

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

“…All six articles articles retrospectively compared postoperative outcomes of pediatric patients who had surgery for supracondylar humerus fractures at different times of the day. Primary outcomes in the studies were reduction quality [ 14 , 15 , 16 , 17 , 18 , 19 ], malunion rate [ 15 ], loss of reduction [ 17 ] and complications [ 16 ]. Also, functional outcomes in follow-up were assessed in three articles [ 14 , 15 , 16 ].…”

“…Tuomilehto et al [ 19 ] assessed 200 fractures (mean age 7.1 years, range 1.8 to 14.1, 15.5% Gartland type II, 83.5% Gartland type III). Of these fractures, timing of surgery for the first 100 patients depended on circumstances, and could therefore be during the night (24:00–7:00) (12% of surgeries).…”

Suprakondyläre Humerusfraktur im Kindesalter

“…Zwei Arbeiten aus dem Jahr 2018 erschienen in The Bone & Joint Journal und Journal of Pediatric Orthopedic weisen darauf hin, dass die verzögerte Versorgung keine schlechteren Ergebnisse aufweist -natürlich unter Einbeziehung einiger Limitationen und auch der Tatsache, dass all diese Studien nicht prospektiv und/oder in genügend großen Populationen durchgeführt wurden. Es wird hervorgehoben, dass das Ausmaß der Expertise des Behandlers tagsüber deutlich besser ist [14,15], was am Ende einen Vorteil für den Patient darstellt. Die Operation sollte am der Indikationsstellung folgenden Tag als Erste geplant werden.…”

“…Tage als feste Medikation und anschließend nach Bedarf. In einer Studie (Januar 2019) mit 81 Patienten, veröffentlicht in The Journal of Bone & Joint Surgery konnte gezeigt werden, dass die betreffenden Kinder meist nach 3 Tagen schmerzfrei sind und fast keine Schmerzmittel mehr benötigen[19,20]. Einer kontinuierlichen Therapie wird der Vorzug gegeben, um Schmerzspitzen zu vermeiden.Die Studie und eigene klinische Erfahrung weisen darauf hin, dass "outliners", die einen besonders hohen Schmerzmittelbedarf haben, ein Indiz dafür sein können, dass sich hinter einem hohen Schmerzmittelbedarf Komplikationen wie ein Kompartmentsyndrom oder eine Ischämie verstecken können.…”

Is there an optimal timing for surgical treatment of pediatric supracondylar humerus fractures in the first 24 hours?

“…Operating the pediatric SHF patients within working or non-working hours is still debating in the literature. In recent studies, mal-union rates were reported to be higher in pediatric SHFs operated in the night hour surgeries and mean operative duration was found to be shorter in daytime surgeries [ 6 , 7 ]. On the other hand, in a recent article, there was no difference in reduction quality, complications and outcomes between pediatric SHF patients operated during the night or the daytime [ 8 ].…”