'Does compliance with BOAST guidelines matter for displaced supracondylar fractures in children?': the experience of a tertiary referral major trauma centre over a 3.5-year period

Postoperative Immobilization Period for Pediatric Supracondylar Fractures: The Shorter the Better?

BACKGROUND

There are now recognized standards of care published by the British and American Orthopaedic Associations which detail key areas of evidence-based recommendations for the treatment of children with displaced supracondylar humerus fractures. Although many aspects of treatment are covered in these recommendations, both the American and British Orthopaedic Associations do not recommend the exact duration of immobilization postoperatively.

METHODS

This study retrospectively compared outcomes of operatively managed supracondylar fractures immobilized postoperatively for short immobilization (SI) defined as 28 days or less, with long immobilization (LI) defined as more than 28 days. The outcomes measured were clinical (deformity, range of motion, and pin site infection) and radiologic (loss of position after the removal of K-wires, Baumann's angle, anterior humeral line, refracture, and signs of osteomyelitis). Demographic data were recorded to evaluate and ensure satisfactory matching of the 2 groups for analysis.

RESULTS

The study included 193 pediatric supracondylar fractures over a 4-year period which were treated with manipulation under anesthetic and K-wire fixation. The difference in average time in plaster between the 2 groups was statistically significant (SI: n=27.5 d, SD 1.23; LI: n=43.9 d, SD 15.29, P =0.0001). Data for operative techniques-closed or open reduction (SI: n=66, LI: n=78, P =0.59), and crossed wires (SI: n=37, LI: n=50, P =0.57) between the two groups showed no statistical significance. There was no statistical difference between the groups for the average number of days postoperatively at which wires were taken out (SI: n=28.9 d, SD 5.95, LI: n=30.1 d, SD 5.57, P =0.15), number of pin site infections requiring antibiotic treatment (SI: n=3, LI: n=5, P =0.70), or children from each group who were recorded to have regained full range of motion symmetrical to their contralateral arm (SI: n=79, LI: n=99, P =0.74).

CONCLUSIONS

Our study therefore suggests that shorter immobilization of these patients (SI group) does not yield a higher rate of complications including refracture and malunion.

Preoperative vascular assessment of patients with a supracondylar humeral fracture and a perfused, pulseless limb

The 'pink, pulseless hand' is often used to describe the clinical situation in which a child with a supracondylar fracture of the humerus has normal distal perfusion in the absence of a palpable peripheral pulse. The management guidelines are based on the assessment of perfusion, which is difficult to undertake and poorly evaluated objectively. The aim of this study was to review the available literature in order to explore the techniques available for the preoperative clinical assessment of perfusion in these patients and to evaluate the clinical implications. A systematic literature review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and registered prospectively with the International Prospective Register of Systematic Reviews. Databases were explored in June 2022 with the search terms (pulseless OR dysvascular OR ischaemic OR perfused OR vascular injury) AND supracondylar AND (fracture OR fractures). A total of 573 papers were identified as being suitable for further study, and 25 met the inclusion criteria for detailed analysis. These studies included a total of 504 patients with a perfused, pulseless limb associated with a supracondylar humeral fracture. Clinical examination included skin colour (23 studies (92%)), temperature (16 studies (64%)), and capillary refill time (13 studies (52%)). Other investigations included peripheral oxygen saturation (SaO2) (six studies (24%)), ultrasound (US) (14 (56%)), and CT angiogram (two studies (8.0%)). The parameters of 'normal perfusion' were often not objectively defined. The time to surgery ranged from 1.5 to 12 hours. A total of 412 patients (82%) were definitively treated with closed or open reduction and fixation, and 92 (18%) required vascular intervention, ranging from simple release of entrapped vessels to vascular grafts. The description of the vascular assessment of the patient with a supracondylar humeral fracture and a pulseless limb in the literature is variable, with few objective criteria being used to define perfusion. The evidence base for decision-making is limited, and further research is required. We were able, however, to make some recommendations about objective criteria for the assessment of these patients, and we suggest that these are performed frequently to allow the detection of any deterioration of perfusion.

Interventions for treating supracondylar elbow fractures in children

BACKGROUND

Elbow supracondylar fractures are common, with treatment decisions based on fracture displacement. However, there remains controversy regarding the best treatments for this injury.

OBJECTIVES

To assess the effects (benefits and harms) of interventions for treating supracondylar elbow fractures in children.

SEARCH METHODS

We searched CENTRAL, MEDLINE, and Embase in March 2021. We also searched trial registers and reference lists. We applied no language or publication restrictions.

SELECTION CRITERIA

We included randomised and quasi-randomised controlled trials comparing different interventions for the treatment of supracondylar elbow fractures in children. We included studies investigating surgical interventions (different fixation techniques and different reduction techniques), surgical versus non-surgical treatment, traction types, methods of non-surgical intervention, and timing and location of treatment.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. We collected data and conducted GRADE assessment for five critical outcomes: functional outcomes, treatment failure (requiring re-intervention), nerve injury, major complications (pin site infection in most studies), and cosmetic deformity (cubitus varus).  MAIN RESULTS: We included 52 trials with 3594 children who had supracondylar elbow fractures; most were Gartland 2 and 3 fractures. The mean ages of children ranged from 4.9 to 8.4 years and the majority of participants were boys. Most studies (33) were conducted in countries in South-East Asia. We identified 12 different comparisons of interventions: retrograde lateral wires versus retrograde crossed wires; lateral crossed (Dorgan) wires versus retrograde crossed wires; retrograde lateral wires versus lateral crossed (Dorgan) wires; retrograde crossed wires versus posterior intrafocal wires; retrograde lateral wires in a parallel versus divergent configuration; retrograde crossed wires using a mini-open technique or inserted percutaneously; buried versus non-buried wires; external versus internal fixation; open versus closed reduction; surgical fixation versus non-surgical immobilisation; skeletal versus skin traction; and collar and cuff versus backslab. We report here the findings of four comparisons that represent the most substantial body of evidence for the most clinically relevant comparisons.  All studies in these four comparisons had unclear risks of bias in at least one domain. We downgraded the certainty of all outcomes for serious risks of bias, for imprecision when evidence was derived from a small sample size or had a wide confidence interval (CI) that included the possibility of benefits or harms for both treatments, and when we detected the possibility of publication bias.  Retrograde lateral wires versus retrograde crossed wires (29 studies, 2068 children) There was low-certainty evidence of less nerve injury with retrograde lateral wires (RR 0.65, 95% CI 0.46 to 0.90; 28 studies, 1653 children). In a post hoc subgroup analysis, we noted a greater difference in the number of children with nerve injuries when lateral wires were compared to crossed wires inserted with a  percutaneous medial wire technique (RR 0.41, 95% CI 0.20 to 0.81, favours lateral wires; 10 studies, 552 children), but little difference when an open technique was used (RR 0.91, 95% CI 0.59 to 1.40, favours lateral wires; 11 studies, 656 children). Although we noted a statistically significant difference between these subgroups from the interaction test (P = 0.05), we could not rule out the possibility that other factors could account for this difference. We found little or no difference between the interventions in major complications, which were described as pin site infections in all studies (RR 1.08, 95% CI 0.65 to 1.79; 19 studies, 1126 children; low-certainty evidence). For functional status (1 study, 35 children), treatment failure requiring re-intervention (1 study, 60 children), and cosmetic deformity (2 studies, 95 children), there was very low-certainty evidence showing no evidence of a difference between interventions. Open reduction versus closed reduction (4 studies, 295 children) Type of reduction method may make little or no difference to nerve injuries (RR 0.30, 95% CI 0.09 to 1.01, favours open reduction; 3 studies, 163 children). However, there may be fewer major complications (pin site infections) when closed reduction is used (RR 4.15, 95% CI 1.07 to 16.20; 4 studies, 253 children). The certainty of the evidence for these outcomes is low. No studies reported functional outcome, treatment failure requiring re-intervention, or cosmetic deformity. The four studies in this comparison used direct visualisation during surgery. One additional study used a joystick technique for reduction, and we did not combine data from this study in analyses. Surgical fixation using wires versus non-surgical immobilisation using a cast (3 studies, 140 children) There was very low-certainty evidence showing little or no difference between interventions for treatment failure requiring re-intervention (1 study, 60 children), nerve injury (3 studies, 140 children), major complications (3 studies, 126 children), and cosmetic deformity (2 studies, 80 children). No studies reported functional outcome. Backslab versus sling (1 study, 50 children) No nerve injuries or major complications were experienced by children in either group; this evidence is of very low certainty. Functional outcome, treatment failure, and cosmetic deformity were not reported.  AUTHORS' CONCLUSIONS: We found insufficient evidence for many treatments of supracondylar fractures. Fixation of displaced supracondylar fractures with retrograde lateral wires compared with crossed wires provided the most substantial body of evidence in this review, and our findings indicate that there may be a lower risk of nerve injury with retrograde lateral wires. In future trials of treatments, we would encourage the adoption of a core outcome set, which includes patient-reported measures. Evaluation of the effectiveness of traction compared with surgical fixation would provide a valuable addition to this clinical field.

Current trends in the treatment of supracondylar fractures of the humerus in children: Results of a survey of the members of European Paediatric Orthopaedic Society

PURPOSE

The purpose of this study was to evaluate the current trends in the treatment of supracondylar humerus fractures as well as the preferred post-operative follow-up protocol among members of the European Paediatric Orthopaedic Society.

METHODS

The survey was composed by four main domains and 26 items: (1) surgeon information (3 items); (2) treatment (8 items); (3) post-operative treatment (3 items); and (4) factors influencing the outcome (12 items). All active members of European Paediatric Orthopaedic Society were invited by email to answer an electronic questionnaire.

RESULTS

The survey was submitted to 397 European Paediatric Orthopaedic Society active members; 184 members answered (46.3%) the questionnaire. Among respondents, 64.1% declared >10 years of experience and 55.4% declared to treat >20 supracondylar humerus fractures per year. Closed reduction, percutaneous pinning, and supine position were the preferred treatment option for Gartland type II and III supracondylar humerus fractures by 79.9%, 95.5%, and 84.8% of respondents, respectively. Supracondylar humerus fractures are treated within 24 h from trauma by 33.2% of respondents. Pins are removed 4 weeks from index procedure by 58.2% of respondents. Fracture type (72.3%), surgeon experience, and (71.2%) are of "crucial importance" for expected outcome of supracondylar humerus fractures treatment.

CONCLUSION

Surgeon experience, type of fracture, treatment modality, and pins configuration were considered the main factors potentially influencing the outcome of supracondylar humerus fractures. European Paediatric Orthopaedic Society members agreed on the treatment modality of Gartland type II and III supracondylar humerus fractures, patient positioning, and timing of hardware removal. Other important issues such as timing of surgery, pins configuration, surgical approach, and post-operative protocol are still debated.

LEVEL OF EVIDENCE

level II.