Pediatric Supracondylar Fractures: Require Treatment on the Same Day 

Reggie C. Hamdy, M.D., FRCSC
Montreal, QC

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 2000's, 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.

In the last two 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: 1) the availability of operating room time the next day and 2) 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,

References

  1. Iyengar S.R., Hoffinger S.A., Townsend D.R. 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.
  2. Mehlman C.T., Strub W.M., Roy D.R., Wall E.J., Crawford A.H. 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.
  3. Leet A.I., Frisancho J., Ebramzadeh E. Delayed treatment of type III supracondylar humerus fractures in children. J Pediatr Orthop. 2002 Mar-Apr;22(2):203-7.
  4. Green N.E. 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.
  5. Gupta N., Kay R.M., Leitch K., Femino J.D., Tolo V.T., Skaggs D.L. 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.
  6. Walmsley P.J., Kelly M.B., Robb J.E., Annan I.H., Porter D.E. 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.
  7. Tiwari A., Kanojiu R.K., Kapoor S.K. Surgical management for late presentation of supracondylar humeral fracture in children. J Orthop Surg 2007 Aug;15(2):177-82.

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