Supracondylar humerus fractures: should we avoid surgery during after-hours?
S.E.S. Terpstra P.T.P.W. Burgers H.J.L. van der Heide P.B. De Witte Leids Universitair Medisch Centrum, Leiden, The Netherlands
Background: Pediatric supracondylar humerus fractures occur frequently, composing 15% of all pediatric fractures. These fractures often require surgical reduction and fixation. Circumstances during after-hours can differ from those during office hours. Often, the decision has to be made whether to operate immediately, even during after-hours, or to wait until office hours.
Methods: Using the PICO strategy and Pubmed, we found three articles that compared the results of office hours and after-hours surgery for supracondylar humerus fractures. We assessed the outcomes of both groups in these studies, including successful reduction, function and complications.
Results: One of the three articles found a significant difference in poor fixation rate in favour of office hours, compared to after-hours. Another article found more malunions in the “night” subgroup versus the “all groups but night” group. The third article did not find any significant outcomes. And overall, no other differences were reported for complications, functional outcome and operation time in any of the articles.
Conclusion: No strong risks or benefits from either surgical reduction during office hours versus after-hours were found. Therefore, performing reduction after-hours appears to be generally safe. It can be advised to postpone surgery to office hours if circumstances are not optimal for acute surgery (e.g. no dedicated surgeon available), and if there is no medical contraindication.
Introduction Supracondylar humerus fractures account for 15% of all childhood fractures. The incidence decreases sharply after the age of 10 due to skeletal maturation, and after the age of sixteen, this fracture is very rare.1 The classic trauma mechanism is a fall on the outstretched arm, resulting in an extension type fracture, which accounts for 97% of supracondylar humerus fractures.2 A significant portion of these children need surgical reduction and fixation. However, there is increasing debate on whether or not to operate these injuries after-hours. The main indications for acute reduction are traumatic neurovascular injury, complicated fractures and significant fracture dislocation.3 Acute neurovascular injuries are reported in 17% of patients with a dislocated supracondylar humerus fracture.4 Dislocation is reported in 54% and is often characterized with the Gartland classification, Gartland I being a fracture without dislocation, which can be generally treated conservatively. Gartland type II indicates partial dislocation, which more often requires reduction with or without fixation. Type III and IV indicate complete dislocation, where type IV also has periosteal disruption.5 These types III and IV fractures are often associated with anterior interosseous nerve neuropraxia, brachial artery disruption, and other complications.1 Both usually require closed or open reduction and fixation. Fixation is generally performed with multiple K-wire fixation.6 Supracondylar humerus fractures are often managed on the day of admission, which can result in after-hours surgery.6 It is assumed that after-hours surgery provides additional risks for patients, mainly due to surgeon fatigue and the lack of a specialized team, which is also illustrated in some recent literature on orthopaedic trauma, as higher complication and mortality rates have been reported for orthopaedic trauma surgery performed during after-hours.7, 8 However, evidence for these alleged additional risks of after-hours procedures remains limited. For example, the hip fracture population has been investigated extensively on after-hours surgery. For these types of fractures, no significant differences have been reported between results of office hours and after-hours surgery.8 But these result cannot simply be extrapolated to the supracondylar humerus fracture patient group. Because of the lack of consensus on this subject of after-hours surgery on supracondylar humerus fractures, this article will investigate the following question: “Is it necessary and safe to perform surgery for paediatric supracondylar humerus fractures during after-hours?”
Methods Design A PICO-strategy was used,9 with the following research question: in children under 18 years old with a supracondylar humerus fracture (P) does after-hours surgery (I), compared to surgery during office hours (C) result in clinically different outcomes in follow-up, in terms of successful reduction, function and complications (O)? A search strategy was built in collaboration with a librarian (J.W. Schoones). This strategy was used for PubMed, Web of Science, Embase and Cochrane, to find all relevant articles, written in English and published in the past 10 years. (Addendum 1: Search strategy). All references of the articles identified were also evaluated for relevant articles. Results The search strategy yielded sixteen articles on August 28th 2018. After screening of the titles and abstracts by one person (ST), five relevant articles were identified. Three of these could be included, with the other two having primary outcomes other than outcomes in follow-up. The quality of the three articles included was assessed as sufficient for inclusion using the PRISMA criteria (Addendum 2). All three included articles retrospectively compared postoperative outcomes of patients who had surgery at different times of the day. Primary outcomes in the three studies were poor fixation rate (Aydogmus et al.)7, malunion (Paci et al.)10, and loss of reduction (Balakumar et al.)11. Furthermore, Aydogmus et al.7 and Paci et al.10 assessed functional outcome in follow-up. Other reported secondary outcomes were the length of hospital stay, duration of surgery, rate of open reductions, and complications.
Table 1. Outcomes and results of the articles included.
Aydoğmus et al.7 compared a group of 91 children (age 0-11) diagnosed with a Gartland III fracture without neurovascular injury in the period of January 2012 to October 2014. Of the 91 patients, 47 were operated during office hours (8:00-17:00), and 44 during after-hours (17:00-8:00). Surgical technique was chosen by the treating surgeon. Follow-up was weekly in the first month, followed by follow-up every three months for at least one year. “Poor fixation”, as the primary outcome, was defined as pins crossing the fracture line, pins not placed bicortically and/or pins for which the entry points were very close to each other. A significant difference in poor fixation was found between the groups: 4/47 patients (9%) in the office hours group had a poor fixation, compared to 17/44 (39%) in the after-hours group (p=0.005). The authors stated that a lack of sleep is often present when performing reduction at night, which might lead to a higher “poor fixation” rate. For the secondary outcomes, including surgical method, placement of any medial pins, operation time, neurovascular complications, successful reduction rate, successful fixation rate, range of motion, waiting time for reduction and any induced deformity, no differences were found. No reoperations were performed for any of the patients during follow-up. The authors concluded that reduction should be performed during office hours, instead of after-hours, by adequately rested surgical staff.
Paci et al.10 included 263 patients with a uncomplicated Gartland type II, III or IV fracture diagnosed in the period of August 1, 2002 to July 31, 2014. 263 patients with an average age of 5 years were included. 77 (29%) were reduced during office hours, which was defined as 6:00–16:00 from Monday to Friday. This group was compared with 186 (71%) reductions during after-hours, which was divided into evening (16:00-23:00), night (23:00-6:00) and weekend (Saturdays and Sundays, 6:00-16:00). The primary outcome was the rate of malunion, defined as a clinically significant deformity, resulting in a change in treatment or follow-up plan. Secondary outcomes included operative duration, range of motion, carrying angle, and functional flexion and extension. Functional flexion was defined as flexion ≥130 degrees, and functional extension as ≤30 degrees. A normal carrying angle was defined as 0–19 degrees of elbow valgus. On final follow-up X-rays , the Baumann angles were measured and considered normal when between 64 and 81 degrees. No significant differences were found in the primary and secondary outcomes after an average follow-up of 135 days. The authors reported no malunions among 77 cases in the office hours group, versus 4 malunions out of 186 (2.3%) in the after-hours group (p=0.3). However, when comparing all groups to the “night” subgroup, a borderline significant difference was found for malunion: 2/236 (0.9%) malunion in the “all groups but night” group, compared to 2/23 (9%) in the “night” group (p=0.05). This outcome might be at least partially associated with the fact that there were significantly more Gartland III/IV fractures in the after-hours group (selection bias): 129/186 (57%) in the office hours group, vs. 40/77 (73%) in the after-hours group (p=0.01). Furthermore, the authors found that it was more likely to have reduction performed by a fellow during after-hours compared to office hours 95/186 (49%) vs. 72/77 (93%, p<0.001). Therefore, the authors concluded that late night reduction performed between 23:00 and 05:59 may be associated with a higher rate of malunion, relating it to fatigue of the surgeon, variation in training and practice patterns of the operating surgeon, and experience of supporting staff. Regarding secondary outcomes, the authors reported 55/55 (100%) functional extension in the office hours group, versus 126/128 (98%) in the after-hours group (p=1.00), and 39/77 functional flexion in the office hours group (68%), versus 91/186 (72%) in the after-hours group (p=0.6). Based on these findings, the authors caution surgeons against operating during late night hours without urgent indication. If these late night hours are avoided, surgical treatment is assessed as generally safe.
Balakumar et al.11 analysed 77 supracondylar humerus fracture procedures from July 2004 to October 2009. These fractures were divided into 37 cases having reduction during office hours (8:00-20:00) and 40 cases having reduction during after-hours (20:00-8:00). 10 Gartland II fractures and 67 Gartland III fractures were included. The Gartland classifications were not reported separately for the office hours and after-hours group, neither were any other factors influencing the decision of timing of reduction. The primary outcome was loss of reduction during follow-up. Secondary outcomes were number of pins used, adequate initial reduction, number of cortical purchases and technical quality of pinning, lateral only pinning, technical errors, technical quality of pinning (which was sufficient when the anterior humeral line passed through the middle of the capitellum, the Baumann angle is restored and the medial and lateral column are intact). Outcome evaluation was done by reviewing the intraoperative X-rays , and comparing these to those acquired immediately after reduction, and after three weeks postoperatively. Four different pinning constructions were used, namely; a) two lateral pins b) three lateral pins c) crossed pins with one medial and one lateral entry pin and d) two lateral and one medial entry pin. A multivariate logistic regression analysis was done to analyse individual factors causing loss of reduction. No significant difference in terms of loss of reduction was found between the office hours and the after-hours group: seven cases were found with a loss of reduction after three weeks in both the office hours and the after-hours group, i.e. 7/37 (19%) vs. 7/40 (18%, p=1.00). The article did not report differences in secondary outcomes between both groups. Assessing the patient group with loss of reduction, lateral pinning (odds ratio: 7.73, p=0.029) and technical errors (odds ratio: 57.63, p=0.001) were associated with loss of reduction. No associations were found with the number of pins used, adequate initial reduction, number of cortical purchases and technical quality of pinning. The authors suggest that loss of reduction following fracture fixation is closely related to technical errors, which often results in inadequate reduction. However, as these technical errors were evenly distributed between office hours and after-hours, the authors concluded that timing of the procedure was not associated with loss of reduction.
Overall outcomes Primary outcomes Of the three articles, Aydogmus et al.7 found a significant difference in poor fixation between office hours and after-hours: 4 patients (9%) in the office hours group had a clinically relevant poor fixation, compared to 17 (39%) in the after-hours group. Paci et al.10 found that borderline significantly more malunion was present in the “night” subgroup (2/26, 8%) versus the “all groups but night” group (2/236, 1%) (p=0.05). Balakumar et al.11 did not find a significant difference in loss of reduction between their office hours and after-hours groups, as this was present in 7/37 (19%) in the office hours group and 7/40 (18%) in the after-hours group (p=1.00). Secondary outcomes No significant differences between groups were found for functional outcomes, length of hospital stay, numbers of open reductions needed, numbers of postoperative complications, and duration of surgery between office hours and after-hours, in any of the articles.
Discussion Obtaining immediate reduction and supposedly an optimal clinical outcome are often arguments to perform supracondylar humerus fracture reduction during after-hours. Still, more and more surgeons prefer to postpone surgery to office hours as it is generally assumed that after-hours surgery provides additional risks for patients.12 In this literature study using a PICO method, we found three relevant (retrospective) articles reporting outcomes of office hours and after-hours surgery in patients with supracondylar fractures. Primary outcomes Aydogmus et al.7 found a significantly higher rate of poor fixation in the after-hours group, compared to the office hours group. However, this higher rate of “poor fixation” apparently did not result in a loss of range of motion in the after-hours group. Paci et al.10 demonstrated a borderline significant difference in malunion rate when comparing their “all groups but night” subgroups to their “night” (23:00-6:00) subgroup, with a higher malunion rate in the latter. On the other hand, there was on average, a significantly higher Gartland classification in the night group of Paci et al.10, compared to the office hours group: i.e. more severe fractures appear to have been treated with minimal delay, i.e. during after-hours if deemed necessary (confounding by indication). In addition, there was a higher percentage of reductions being performed by a fellow at night (performance bias). Both are potential confounders for the identified inferior outcomes of the night hours group (selection bias). No other significant differences in outcomes were found for the primary outcomes in all three studies.
Secondary outcomes With regards to secondary outcomes, no clinically or statistically significant differences were found between office and after-hours groups, with regards to: operative duration, range of motion, carrying angle, surgical method, placement of any medial pins, operation time, neurovascular complications, successful reduction rate, successful fixation rate, range of motion, functional flexion and extension and any induced deformity. Early versus delayed reduction The aforementioned results suggest that the influence of surgery timing on radiological and functional outcomes in supracondylar humerus fractures is limited. Still, in order to draw more definite conclusions about this topic, it is also important to assess differences in outcomes between direct reduction and delayed reduction, regardless of day and night. Hence, postponing reduction to office hours implies a delay in reduction. In our literature evaluation, only the article of Aydogmus et al.7 assessed the waiting time between fracture and reduction between the groups. The article found no significant difference in this factor between their office hours and after-hours groups. Recently, an extensive review was published on this topic of delaying supracondylar humerus fracture reduction, regardless of day and night.13 This review assessed the outcomes of 1735 patients from 12 articles, and evaluated the functional outcomes of early reduction, compared to delayed reduction. The results of this review are in accordance with our CAT; the authors found no strong evidence that delaying reduction influences the outcomes of surgery negatively or positively.
Strengths and limitations of this study To our knowledge, this is the first report that summarizes results on after-hours surgery for supracondylar humerus fractures, thus it should contain the most up-to-date conclusions on this topic. There are some factors that should be taken into consideration when interpreting the outcomes of our study. First of all, only three relevant articles were found. All of these are retrospective and with methodological limitations, while, for example, an RCT setting would be preferable. This experimental setting would for example evade confounding by indication. In addition to this, literature on the topic of supracondylar humerus fractures at night is scarce. Furthermore, it is also important to note that in, our articles, the decision of performing surgery at night might be dependent on the trauma severity, and on the alleged risk of complications that postponing the reduction might cause for the individual patient. Therefore, a selection bias might be present due to the fact that reduction for fractures with a higher Gartland classification is less likely to be postponed. The quantity of possible bias differs between the articles included, as Aydogmus et al. included solely Gartland 3 fractures, Paci included Gartland 2, 3 and 4 fractures, and Balakumar included Gartland 2 and 3 fractures. Paci et al. reported this selection bias and made an effort to minimize this bias by using exclusion criteria and multivariable logistic regression in order to control for differences in baseline characteristics. The other articles in our study did not report on these potential causes of bias. Another limitation to the current study is that all three studies have relatively small research groups, and quite heterogeneous primary outcome measures. Comparison to the Dutch guideline for paediatric fractures This CAT was compared to the Dutch guideline for paediatric fractures of 201814. This guideline strongly recommends to always have a specialized team available, including a pediatric surgeon, for the treatment paediatric fractures in general, also after-hours. However, we cannot support this for supracondylar humerus fractures specifically, based on this PICO review.
Conclusion and recommendations In this literature study, we investigated the question “does after-hours surgery, compared to surgery during office hours result in clinically or statistically significant different outcomes in follow-up, in terms of successful reduction, function and complications?”. We found weak evidence for higher "poor fixation" and “malunion” rates for after-hours surgery. However, clinical implications seem limited: no significant differences were found in any of the articles for other outcomes in follow-up, including other complications and postoperative elbow function. Additionally, literature comparing early versus delayed surgery of supracondylar humerus fractures, shows no significant differences between groups. Concluding, it appears safe to postpone surgery for Gartland 2, 3 or 4 fractures to office hours if circumstances are not optimal for surgery (e.g. no dedicated surgeon available), and if there is no contraindication for the patient. The authors declare no conflict of interest. Acknowledgements We thank J.W. Schoones, librarian of the Leiden University Medical Center, for help with our PICO search strategy.
References 1. Saeed W, Waseem M. Elbow Fractures Overview. StatPearls. Treasure Island (FL)2019. 2. Barr L. Paediatric supracondylar humeral fractures: epidemiology, mechanisms and incidence during school holidays. Journal of Children's Orthopaedics, 8(2), 2014;pp.167-170. 3. Scherl SA, Schmidt AH. Pediatric trauma: getting through the night. Instr Course Lect. 2010;59:455-63. 4. Tomaszewski R, Wozowicz A, Wysocka-Wojakiewicz P. Analysis of Early Neurovascular Complications of Pediatric Supracondylar Humerus Fractures: A Long-Term Observation. BioMed Research International. 2017;2017:1-5. 5. Gartland JJ. Management of supracondylar fractures of the humerus in children. Surg Gynecol Obstet. 1959;109(2):145-54. 6. Sahu RL. Percutaneous K-wire fixation in paediatric Supracondylar fractures of humerus: A retrospective study. Niger Med J. 2013;54(5):329-34. 7. Aydogmus S, Duymus TM, Kececi T, Adiyeke L, Kafadar AB. Comparison of daytime and after-hours surgical treatment of supracondylar humeral fractures in children. J Pediatr Orthop B. 2017;26(5):400-4. 8. Halvachizadeh S, Teuber H, Cinelli P, Allemann F, Pape H, Neuhaus V. Does the time of day in orthopedic trauma surgery affect mortality and complication rates?. Patient Safety in Surgery. 2019;13(1). 9. da Costa Santos CM, de Mattos Pimenta CA, Nobre MR. The PICO strategy for the research question construction and evidence search. Rev Lat Am Enfermagem. 2007;15(3):508-11. 10. Paci GM, Tileston KR, Vorhies JS, Bishop JA. Pediatric Supracondylar Humerus Fractures: Does After-Hours Treatment Influence Outcomes? J Orthop Trauma. 2018;32(6):e215-e20. 11. Balakumar B, Madhuri V. A retrospective analysis of loss of reduction in operated supracondylar humerus fractures. Indian J Orthop. 2012;46(6):690-7. 12. Carter CT, Bertrand SL, Cearley DM. Management of pediatric type III supracondylar humerus fractures in the United States: results of a national survey of pediatric orthopaedic surgeons. J Pediatr Orthop. 2013;33(7):750-4. 13. Farrow L, Ablett AD, Mills L, Barker S. Early versus delayed surgery for paediatric supracondylar humeral fractures in the absence of vascular compromise: a systematic review and meta-analysis. Bone Joint J. 2018;100-B(12):1535-41. 14. Fracturen bij kinderen - Richtlijn - Richtlijnendatabase. Richtlijnendatabase.nl. 2018. https://richtlijnendatabase.nl/richtlijn/fracturen_bij_kinderen.html