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Uncomplicated Pediatric Supracondylar Fractures: Can Safely Be Treated the Day After Injury
Andrew Howard, M.D., MSc, FRCSC
Division of Orthopaedic Surgery,
The Hospital for Sick Children
Toronto, ON
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 (1. Carmichael added to this the observation that the quality of reduction was equivalent among early and late treated cases2. 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 hours3. A larger series of 171 Gartland 3 supracondylar fractures was reported by Walmsley, again with a low complication rate whether treated before or after eight 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 eight 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 11:00 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 work4-6, 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 errors7.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 shifts8. 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 eight 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.
References
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