Time Threshold for Reduction
We are unable to recommend for or against a time threshold for reduction of displaced pediatric supracondylar fractures of the humerus without neurovascular injury.
Rationale
The timing of treatment of displaced pediatric supracondylar humerus fractures is an important practical concern. The advisability of urgent/emergent treatment is often weighed against the availability of a surgeon, access to an operating room, and the relative safety of anesthesia. Six low quality studies with moderate applicability were identified.
All studies took a continuous variable (time to treatment) and defined early versus late treatment. Early treatment was described as being within eight hours of injury in four studies and two used a twelve-hour cut-off (Table 44). While the time of an individual's presentation to the hospital is often well documented in the medical record, the time of injury is often estimated. Such uncertainties may affect the quality of conclusions in these studies.
Five of seven critical outcomes identified by the work group were reported in the studies. Four outcomes (compartment syndrome, cubitus varus, operative time, and need for reoperation) were not reported to be significantly different between early and late treatment groups in any of the studies.
One outcome, the need for open reduction, was reported in all six studies. Carmichael and Joyner, Iyengar, et al. and Sibinski, et al. reported no difference between early and late treatment groups. Gupta, et al. and Walmsley, et al. indicated an increased rate for open reduction in the delayed group, while Mehlman, et al. showed a decreased rate for open reduction with later treatment. The indication for open reduction is subjective and may therefore vary considerably. Without consistent, objective criteria for the requirement for open treatment, it is difficult to assess the results of the studies. Furthermore, these non-randomized retrospective studies are prone to selection bias. More severe injuries may have been selected for earlier treatment, potentially confounding the comparative data.
All studies took a continuous variable (time to treatment) and defined early versus late treatment. Early treatment was described as being within eight hours of injury in four studies and two used a twelve-hour cut-off (Table 44). While the time of an individual's presentation to the hospital is often well documented in the medical record, the time of injury is often estimated. Such uncertainties may affect the quality of conclusions in these studies.
Five of seven critical outcomes identified by the work group were reported in the studies. Four outcomes (compartment syndrome, cubitus varus, operative time, and need for reoperation) were not reported to be significantly different between early and late treatment groups in any of the studies.
One outcome, the need for open reduction, was reported in all six studies. Carmichael and Joyner, Iyengar, et al. and Sibinski, et al. reported no difference between early and late treatment groups. Gupta, et al. and Walmsley, et al. indicated an increased rate for open reduction in the delayed group, while Mehlman, et al. showed a decreased rate for open reduction with later treatment. The indication for open reduction is subjective and may therefore vary considerably. Without consistent, objective criteria for the requirement for open treatment, it is difficult to assess the results of the studies. Furthermore, these non-randomized retrospective studies are prone to selection bias. More severe injuries may have been selected for earlier treatment, potentially confounding the comparative data.
- (50) Carmichael KD, Joyner K. Quality of reduction versus timing of surgical intervention for pediatric supracondylar humerus fractures. Orthopedics 2006;29(7):628-632.
- (51) 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;24(3):245- 248.
- (52) 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;13(1):51-55.
- (53) 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;83-A(3):323-327.
- (54) Sibinski M, Sharma H, Bennet GC. Early versus delayed treatment of extension type-3 upracondylar fractures of the humerus in children. J Bone Joint Surg Br 2006;88(3):380-381.
- (55) 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;88(4):528-530.