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Complications With Surgical Treatment of Pediatric Supracondylar Humerus Fractures: Does Surgeon Training Matter?
Mikaela H Sullivan1, Matthew R Stillwagon2, Alysa B Nash2
1University of North Carolina School of Medicine.
Insights
Pediatric orthopaedic surgeons (POs) and non-pediatric orthopaedic surgeons (NPOs) achieve similar outcomes for pediatric supracondylar humerus (SCH) fractures. While NPOs had a slightly higher rate of iatrogenic nerve injury, all resolved, indicating subspecialty training is not essential for successful treatment.
Area of Science:
- Orthopaedic Surgery
- Pediatric Orthopaedics
- Traumatology
Background:
- Increasing transfers for pediatric supracondylar humerus (SCH) fractures to referral centers.
- Belief that pediatric orthopaedic surgeons (POs) yield superior outcomes compared to non-pediatric orthopaedic surgeons (NPOs).
Purpose of the Study:
- To compare early surgical outcomes of pediatric SCH fractures treated by POs versus NPOs.
- To evaluate differences in major loss of reduction (MLOR) and iatrogenic nerve injury (INI) between surgeon groups.
Main Methods:
- Retrospective cohort study of 311 patients (ages 3-10) undergoing surgery for SCH fractures (2014-2020).
- Comparison of MLOR, INI, reoperation, infection, readmission, and open reduction rates.
- Analysis of operative times and pin construct quality.
Main Results:
- Similar rates of MLOR (1.5% PO vs. 2.2% NPO) and other complications between groups.
- Higher rate of iatrogenic nerve injury (INI) in the NPO group (3.4% vs. 0%), with all resolving.
- Shorter operative times for POs (38.1 min vs. 44.6 min) and superior pin construct grading in the PO group.
Conclusions:
- Pediatric subspecialty training is not a prerequisite for successful surgical management of SCH fractures.
- Similar early outcomes suggest reducing inter-facility transfers for these common pediatric fractures.
- Optimizing care delivery for pediatric SCH fractures may involve leveraging non-specialist expertise.
Introduction:
National trends reveal increased transfers to referral hospitals for surgical management of pediatric supracondylar humerus (SCH) fractures. This is partly because of the belief that pediatric orthopaedic surgeons (POs) deliver improved outcomes compared with nonpediatric orthopaedic surgeons (NPOs). We compared early outcomes of surgically treated SCH fractures between POs and NPOs at a single center where both groups manage these fractures.
Methods:
Patients ages 3 to 10 undergoing surgery for SCH fractures from 2014 to 2020 were included. Patient demographics and perioperative details were recorded. Radiographs at surgery and short-term follow-up assessed reduction. Primary outcomes were major loss of reduction (MLOR) and iatrogenic nerve injury (INI). Complications were compared between PO-treated and NPO-treated cohorts.
Results:
Three hundred and eleven fractures were reviewed. POs managed 132 cases, and NPOs managed 179 cases. Rate of MLOR was 1.5% among POs and 2.2% among NPOs (P=1). Rate of INI was 0% among POs and 3.4% among NPOs (P=0.041). All nerve palsies resolved postoperatively by mean 13.1 weeks. Rates of reoperation, infection, readmission, and open reduction were not significantly different. Operative times were decreased among POs (38.1 vs. 44.6 min; P=0.030). Pin constructs were graded as higher quality in the PO group, with a higher mean pin spread ratio (P=0.029), lower rate of "C" constructs (only 1 "column" engaged; P=0.010) and less frequent crossed-pin technique (P<0.001). Multivariate analysis revealed minimal positive associations only for operative time with MLOR (odds ratio=1.021; P=0.005) and INI (odds ratio=1.048; P=0.009).
Conclusions:
Postsurgical outcomes between POs and NPOs were similar. Rates of MLOR were not different between groups, despite differences in pin constructs. The NPO group experienced a marginally higher rate of INI, though all injuries resolved. Pediatric subspecialty training is not a prerequisite for successfully treating SCH fractures, and overall value of orthopaedic care may be improved by decreasing transfers for these common injuries.
Level Of Evidence:
Level III-retrospective cohort study.
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