Carter, Craig T. MD*; Bertrand, Styles L. MD*,†; Cearley, David M. MD‡
Supracondylar humerus fractures are common injuries seen in the active pediatric population and are the most common elbow fractures in children. The most common mechanism of injury is a fall onto an outstretched arm.1,2 These fractures usually occur in the age range of 5 to 7.3 Although previous studies suggest that supracondylar humerus fractures tend to occur more often in boys,4 more recent studies show the distribution between boys and girls to be more equivalent.1,2
Supracondylar humerus fractures can be divided into flexion type and extension type, depending on the force applied and resultant displacement of the distal fragment. Extension type fractures make up approximately 97% to 98% of all supracondylar humerus fractures.3 Gartland5 further classified these fractures based on the severity of injury and degree of displacement; although modifications to this classification system have been proposed,6–8 it remains the basis for classification of these fractures.
The most severe of these, type III injuries, have seen the most debate on treatment regimens. Traditionally, these fractures were treated as surgical emergencies and were most often fixed with percutaneous pinning in a cross-pin configuration. Over the last 10 years, the literature has shown that delayed fixation is comparable to emergent fixation as long as there is no obvious need for emergent intervention (vascular compromise, open fractures, impending compartment syndrome, skin compromise, etc.). It has also been shown that although cross-pin configuration appears to be stronger than lateral pins in cadaver models, the 2 appear to have comparable results in a clinical setting.
The purpose of this survey was to establish an overview of current practice of pediatric orthopaedic surgeons in the United States concerning these issues in type III supracondylar humerus fractures. It will also address whether the recent literature has resulted in a change in approach to management of these injuries.
A short survey (Fig. 1) was sent to the members of the POSNA. The survey was conducted using an online survey and questionnaire service, and distribution of the survey was coordinated through POSNA.
Respondents were polled about their practices in surgical treatment of type III supracondylar humerus fractures concerning pin configuration and timing of surgery. Those responding were classified into groups concerning the geographic location using the regions and divisions of the United States, as designated by the US Census Bureau.9 For the purpose of this study, Hawaii and Alaska were included in the West region of the United States. This was done to ensure portrayal of an adequate picture of practicing pediatric orthopaedic surgeons across the United States and North America. The respondents were also classified by the number of years in practice to ensure adequate responses from physicians at all levels of experience.
Using the data obtained, trends were established. A “comment” section on the survey also allowed respondents to provide any additional insight on treatment of these fractures based on personal experience.
A discussion was had with the IRB at our institution and it was determined that no IRB approval was needed for this study as no patient information or clinical data was used.
Breakdown of Respondents
A total of 309 pediatric orthopaedic surgeons from across North America responded to our survey with a large sampling of practioners from across the United States and Canada. This represents 33% of the total number of POSNA members invited to participate in the survey. Twenty-two percent of respondents practice in the Midwest, 22% in the Northeast, 27% in the South, 23% in the West, 5% in Canada, and 3% in other locations across the world. Eight respondents declined to provide the location of their practices.
There was also a wide range noted in the length of time that respondents had been practicing. Seventeen percent are within the first 5 years of their practices, 19% had been practicing for 5 to 10 years, 14% for 10 to 15 years, 15% for 15 to 20 years, 14% for 20 to 25 years, 10% for 25 to 30 years, and 11% had been practicing for more than 30 years. Four of those surveyed declined to answer this question.
Number and Type of Fractures Seen
The majority of respondents answered that they saw >40 pediatric supracondylar humerus fractures per year, and 2/3 saw at least 25 per year. The breakdown shows 41% saw >40 fractures, 25% saw 26 to 40 fractures, 24% saw 11 to 25 fractures, and 10% saw 0 to 10 fractures. Three respondents declined to answer this question. Physicians responding to the survey answered the question concerning the number of type III fractures in different manners. Some used percentages and some used actual number of fractures. The average seemed that about 50% to 60% supracondylar humerus fractures seen were type III fractures. On some surveys, this number was as high as 75% to 80%, and 2 respondents noted that 95% of the supracondylar humerus fractures seen were type III fractures.
Timing of Surgery
About 81% of respondents preferred to splint type III supracondylar humerus fractures and plan for fixation the following morning, assuming there was no evidence of impending compartment syndrome, open fracture, vascular injury, skin compromise, or other issue necessitating obvious emergent fixation. Nineteen percent said that they prefer to treat type III supracondylar humerus fractures as emergent cases and definitively fix them within 8 hours from time of injury. Sixty percent of respondents noted that the recent literature showing comparable outcomes with delayed treatment had changed their approaches to management of these fractures concerning timing of fixation. Eleven and 8 of those surveyed declined to answer these questions respectively.
Preferred Method of Percutaneous Fixation
The preferred method of percutaneous fixation was fairly evenly distributed between cross-pin configuration, 2 lateral pins, and 3 lateral pins. Thirty-seven percent of respondents preferred 3 lateral pins, 33% preferred 2 lateral pins, and 30% preferred a cross-pin configuration. Fifty-six percent of those surveyed stated that the recent literature showing comparable outcomes with 2 lateral pins versus a cross-pin configuration had not changed their approaches to management of these fractures concerning the method of fixation. All 7 respondents declined to answer these questions, respectively.
Type III pediatric supracondylar humerus fractures are complex injuries and require thoughtful planning and precise technique for surgical management. However, the majority of these injuries have good clinical outcomes if treated appropriately. The method and timing of surgical management has been a subject of debate.
An overwhelming majority of respondent to our survey (81%) noted that they do not treat type III supracondylar humerus fractures on an emergent basis if they present after normal work hours, assuming the patient has no obvious reason for emergent intervention, such as, impending compartment syndrome, open injury, vascular injury, or skin compromise. Studies over the last 10 years have shown comparable clinical outcomes concerning healing and complications between emergent and delayed treatment. Mehlman et al10 reviewed 198 patients treated operatively for displaced supracondylar humerus fractures. Of the 198, 52 were treated within 8 hours from injury and 146 were treated after 8 hours. They showed no difference between the groups in conversion to open reduction, pin track infection, iatrogenic nerve injury, or rate of compartment syndrome. Leet et al11 reviewed 158 cases of type III supracondylar humerus fractures in which the average times from injury to presentation to the emergency department and from emergency room to operating room were 9.8 and 11.5 hours, respectively. They saw no difference in rate of conversion to open reduction, length of operative procedure, length of hospital stay, or the rate of unsatisfactory results between those fractures treated early versus those with delayed treatment. Iyengar et al12 evaluated 58 cases of type III supracondylar humerus fractures in children treated operatively. Of the 58, 23 were treated with early pinning and 35 were treated with delayed pinning. They showed no difference between the groups concerning rate of conversion to open reduction or clinical outcomes, including carrying angle, grip strength, and range of motion.
Sixty percent of respondents to our survey stated that this recent literature has changed their approaches to management of type III supracondylar humerus fractures concerning timing of fixation. One participant noted that NPO status and aspiration risk is a concern during surgery. This is a complication that can potentially be avoided with delayed treatment, with no difference in fracture outcome. Other respondents said that they will treat these on an emergent basis if the fracture is severely displaced or that reduction has seemed more difficult as swelling increases. Other participants cite the lack of OR time the following morning as a reason to fix some of these fractures after normal work hours. However, the majority of respondents felt like delayed surgical fixation in this setting was appropriate.
Preferred pin configuration can range from medial and lateral cross pins, 2 lateral pins, or 3 lateral pins. The mode of failure of surgical constructs for supracondylar humerus fractures is often rotational. Zionts et al13 evaluated the torsional strength of different pin configurations using cadaver models. They concluded that medial and lateral cross pins provides the most torsional strength to failure, followed by 3 lateral pins and 2 lateral pins. This was a biomechanical study, however, and did not account for clinical outcomes or complications of pin placement, including iatrogenic nerve injury. Skaggs et al14 retrospectively reviewed 204 type III supracondylar humerus fractures in children, 51 of which were treated with lateral pins only and 153 treated with cross pins. They demonstrated no difference between the groups concerning maintenance of reduction at follow-up. However, no fractures treated with lateral pins sustained an ulnar nerve injury, although ulnar nerve injuries were seen in almost 10% of those treated with cross pins. Cheng et al15 also reviewed type II supracondylar humerus fractures treated with percutaneous pin fixation and saw no difference in outcomes using the Flynn criteria between lateral pin fixation versus cross-pin stabilization.
Our survey showed a fairly even distribution between 3 lateral pins (37%), 2 lateral pins (33%), and cross pins (30%) as the preferred method of fixation among respondents. This does show that two thirds of survey participants are using lateral pins primarily. However, many of those responding note that they will add a medial pin to a lateral pin construct if they feel like more stability is needed intraoperatively. Some said that medial cortex comminution is one instance where a medial pin may be needed. The respondents that do place a medial pin regularly, advise placement of the lateral pin first for stability, followed by extension of the elbow for placement of the medial pin. This plus opening the medial side and exposing the medial epicondyle has been shown as a reliable technique to assist in protecting the ulnar nerve during medial pin placement.16 Overall, the sense was that ulnar nerve injury is not a common occurrence if proper precautions are taken. Even though two thirds of our respondents were using lateral pins primarily, only 44% of survey participants credit the recent literature for a change in their approaches to management of these fractures concerning pin configuration. Many noted that they have been using lateral pins for many years now.
A study similar to ours was carried out in the United Kingdom in the early 2000s.17 A survey was sent to surgeons with a special interest in pediatric orthopaedics regarding timing of fixation and preference of pin configuration for fixation of type III supracondylar humerus fractures in children. The results of that study show that 54.5% of those surveyed treat these injuries on a delayed basis, assuming no vascular compromise and that 83.9% of respondents preferred cross-pin configuration. This study was published around the same time as many of the studies showing comparable outcomes with timing and pin configuration.
Overall, we had a wide distribution of respondents when evaluating years in practice and geographic location of practice. We feel like the different geographic regions of the United States were adequately represented by our survey respondents. Moreover, Canada and other countries made up 8% of our survey population. Those responding to the survey saw a reasonable number of pediatric supracondylar humerus fractures per year. Two thirds of the participants saw >25, and the overall consensus was on average, 60%, and sometimes up to 90% of these were type III fractures.
The results of our study seem to reflect the most recent set of clinical practice guidelines on treatment of pediatric supracondylar humerus fractures from the American Academy of Orthopaedic Surgeons18 concerning the pin configuration. The clinical practice guidelines recommend the use of 2 or 3 laterally based pins for fixation and note the potential for ulnar nerve injury with a medially based pin. Two thirds of those responding to our survey noted that they are primarily using either 2 or 3 laterally based pins. As it applies to timing of fixation, the clinical practice guideline is less clear. It states that the committee cannot recommend a time threshold for reduction and fixation in which neurovascular complications would be reduced. There still appears to be some controversy in this area, although previous studies, and the majority of our respondents, feel that treatment on a nonemergent basis is acceptable. Again, this assumes that the patient has no obvious reason for emergent intervention, such as impending compartment syndrome, open injury, vascular injury, or skin compromise.
As this is an overview of general practice principles concerning management of type III supracondylar humerus fractures, there is no way to include every possible scenario that could present with these injuries into the survey.
Comparing our survey to a study carried out almost 10 years prior in the United Kingdom, it seems that the trend in management of type III supracondylar humerus fractures in children is progressing toward delayed treatment and lateral pin configuration. The results of our study provide an overview of the current practices of members of the POSNA concerning management of type III supracondylar humerus fractures. It also assesses the influence that the recent literature has had on decision making regarding these injuries. We feel like this information can be beneficial to both pediatric-trained and nonpediatric-trained orthopaedic surgeons as a consensus on the current management of type III supracondylar humerus fractures and help to guide their decisions when dealing with these injuries in their practices. However, it should be stated that all of these injuries should be treated individually. As many of the respondents to our survey noted, regardless of the method or timing of treatment, the primary goals of treatment for these injuries are stable fixation, minimization of complications, and reaching a satisfactory outcome.
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