Scroll down to respond to the OrthopaedicsOne Poll: When a child presents with a supracondylar humeral fracture, what is your standard practice for the timing of treatment?
Supracondylar humeral fractures in children is a common injury with potentially serious complications. For this reason, many believe that same day care is mandatory. Given the limited access to the OR in Canada, the less-than-ideal conditions with surgery in the middle of the night or that some community surgeons do not feel comfortable with treating this injury (thus requiring transfer to a pediatric hospital in an urban centre), some believe that there are indications for next day treatment of these fractures.
Drs. Hamdy and Howard will discuss same day versus next day treatment, respectively, of supracondylar humeral fractures in children.
Viewpoint 1: Reggie C. Hamdy, MD, FRCSC
Supracondylar Fractures Require Treatment on the Same Day
Supracondylar fractures are the most common elbow fractures in children. The standard treatment for many years has been to treat Type 3 fractures as an emergency with closed reduction and percutaneous pinning the same day as presentation. The rationale behind treating Type 3 fractures the same day was to avoid an open reduction and to prevent complications – specifically compartment syndrome. As a result of this approach, most of these fractures have been treated during evening shift hours or after midnight, in the early hours of the morning.
In the early 2000s, this approach was challenged. The authors of at least four retrospective studies have compared the results of same day versus delayed surgical treatment and concluded that the treatment of most Type 3 fractures can be safely delayed until the next day where a controlled environment is available.
Read more…
In the last 2 years, at least three studies have shown that a delay in the management of Type 3 fractures is associated with an increased failure of closed reduction and an increased risk of compartment syndrome.
Have we gone too far from one extreme of treating all these fractures as an emergency to the other extreme of treating them the next day? The answer is probably yes!
Before deciding on whether a Type 3 fracture should be reduced the same day or the next day, two things need to be considered:
- The availability of operating room time the next day
- The severity of the fracture, specifically the condition of the soft tissues
First, in many hospitals, elective operating room time for trauma cases is simply not available. That has been and still is the case in our hospital. All emergency cases are performed at the end of the day after the elective list is completed (life-threatening conditions have priority). In such situations, deciding to delay the surgery until the next day may cause a delay of not only a few but of many hours. For example, if a child presents with a Type 3 fracture at midnight and the on-call surgeon decides to delay the treatment until the next day, an opening might not be available before midnight the next day.
The second point to consider is whether certain red flags are present or not. These include tenting of the skin, severe swelling, severe displacement of the fracture and any other evidence of pending vascular compromise or compartment syndrome. In such cases, closed reduction and percutaneous pinning should be performed on an emergency basis in the operating room.
In conclusion, we believe that, in the absence of available elective trauma time during the next day, all Type 3 supracondylar fractures should be treated in the operating room the day of presentation. This has been the policy in our institution. Furthermore, regardless of the presence or absence of elective trauma time, all fractures presenting with any of the red flags mentioned above should receive prompt operative treatment.
Reprinted with permission from the Spring 2009 issue of the COA Bulletin
Additional Reading
Green NE Overnight delay in the reduction of supracondylar fractures of the humerus in children. J Bone Joint Surg Am. 2001 Mar;83-A(3):321-2.
Gupta N, Kay RM, Leitch K, Femino JD, Tolo VT, Skaggs DL. Effect of surgical delay on perioperative complications and need for open reduction in supracondylar humerus fractures in children. J Pediatr Orthop. 2004 May-Jun;24(3):245-8.
Iyengar SR, Hoffinger SA, Townsend DR. Early versus delayed reduction and pinning of type III displaced supracondylar fractures of the humerus in children: a comparative study. J Orthop Trauma. 1999 Jan;13(1):51-5.
Leet AI, Frisancho J, Ebramzadeh E. Delayed treatment of type 3 supracondylar humerus fractures in children. J Pediatr Orthop. 2002 Mar-Apr;22(2):203-7.
Mehlman CT, Strub WM, Roy DR, Wall EJ, Crawford AH. The effect of surgical timing on the perioperative complications of treatment of supracondylar humeral fractures in children. J Bone Joint Surg Am. 2001 Mar;83-A(3):323-7.
Tiwari A, Kanojiu RK, Kapoor SK. Surgical management for late presentation of supracondylar humeral fracture in children. J Orthop Surg 2007 Aug;15(2):177-82.
Walmsley PJ, Kelly MB, Robb JE, Annan IH, Porter DE. Delay increases the need for open reduction of type-III supracondylar fractures of the humerus. J Bone Joint Surg Br. 2006 Apr;88(4):528-30.
Viewpoint 2: Andrew Howard, MD, MSc, FRCSC
Uncomplicated Supracondylar Fractures Can Safely Be Treated the Day After Injury
As a resident, I was trained to book all displaced supracondylar fractures as emergency cases, which invariably led to many such injuries being treated in the middle of the night. As with much of the training at the time, this was based on dogma rather than on evidence.
What does the evidence say? Beginning in 2001, a series of papers have compared early (<8 hours) versus late (8-hour or more delay) surgery for supracondylar humerus fractures. Mehlman in 2001 compared 52 patients treated at less than 8 hours with 146 patients treated at more than 8 hours and found no difference in complications, no compartment syndrome in either group, and equally low rates of conversion to open reduction.
Carmichael added to this the observation that the quality of reduction was equivalent among early and late treated cases. Sibinski reported a series of 77 fractures with Gartland 3 displacement and again showed an equally low complication rate whether the fractures were treated before or after 12 hours.
Read more…
A larger series of 171 Gartland 3 supracondylar fractures was reported by Walmsley, again with a low complication rate whether treated before or after 8 hours, but with a higher rate of open reduction (33% vs 11%) in the group treated after delay. The indications for open reduction were not stated, and the rate of open reduction in both groups in this series was substantially higher than that reported in most series.
There are no prospective studies or randomized trials on this topic, so the empirical clinical evidence is Level III evidence. Multiple series have come to the conclusion that 8 or 12 hours of surgical delay does not compromise the outcome in displaced supracondylar fractures without neurological or vascular compromise. Many centres, including our own, have adopted a policy of operating on such fractures the following day rather than beginning the case after 11 pm.
Is there any potential downside to operating at night? Doctors perform poorly during night hours, extended shifts, and traditional call schedules. Higher rates of cognitive and procedural errors in domains from ICU care to anaesthesia have been documented in relation to night work,5-7 and randomized trials of scheduling interns so as to restrict night work have shown a 36% reduction in overall errors and a 56% reduction in serious medical errors.
The cognitive and technical impairment related to night shift work has also been dramatically shown in a two- to three-fold greater odds of motor vehicle crashes among interns working 24-hour shifts. It is very clear that after-hours work creates additional risks and harms for patients and their doctors. Accordingly, a responsible policy is one that permits fractures to be cared for when patient outcomes are optimized, rather than being determined by system factors.
The current empirical evidence, although imperfect (Level III evidence), is consistent in showing no harm from 8 to 12 hours or more surgical delay when dealing with displaced supracondylar fractures without neurovascular compromise. In the face of mounting evidence about the reduced performance and worse outcomes of doctors in all domains from working in the middle of the night, a sensible policy seems to splint the fracture, sleep soundly, and operate fresh in the morning.
Reprinted with permission from the Spring 2009 issue of the COA Bulletin
References
- Mehlman CT, Strub WM, Roy DR, Wall EJ, Crawford AH, 2001. “The effect of surgical timing on the perioperative complications of treatment of supracondylar humeral fractures in children.” J Bone Joint Surg Am 83-A (3): 323-7
- Carmichael KD, Joyner K, 2006. “Quality of reduction versus timing of surgical intervention for pediatric supracondylar humerus fractures.” Orthopedics 29 (7): 628-32
- Sibinski M, Sharma H, Bennet GC, 2006. “Early versus delayed treatment of extension type-3 supracondylar fractures of the humerus in children.” J Bone Joint Surg Br 88 (3): 380-1
- Walmsley PJ, Kelly MB, Robb JE, Annan IH, Porter DE, 2006. “Delay increases the need for open reduction of type-III supracondylar fractures of the humerus.” J Bone Joint Surg Br 88 (4): 528-30
- Fisman DN, Harris AD, Rubin M, Sorock GS, Mittleman MA, 2007. “Fatigue increases the risk of injury from sharp devices in medical trainees: results from a case-crossover study.” Infect Control Hosp Epidemiol 28 (1): 10-7
- Gander P, Millar M, Webster C, Merry A, 2008. “Sleep loss and performance of anaesthesia trainees and specialists.” Chronobiol Int 25 (6): 1077-91
- Meretoja OA, 2009. “We should work less at night.” Acta Anaesthesiol Scand 53 (3): 277-9
- Landrigan CP, Rothschild JM, Cronin JW, Kaushal R, Burdick E, Katz JT, Lilly CM, Stone PH, Lockley SW, Bates DW, Czeisler CA, 2004. “Effect of reducing interns’ work hours on serious medical errors in intensive care units.” N Engl J Med 351 (18): 1838-48
- Barger LK, Cade BE, Ayas NT, Cronin JW, Rosner B, Speizer FE, Czeisler CA, , 2005. “Extended work shifts and the risk of motor vehicle crashes among interns.” N Engl J Med 352 (2): 125-34