Editorial   |    
Overnight Delay in the Reduction of Supracondylar Fractures of the Humerus in Children
Neil E. Green, MD
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Department of Orthopaedics, Pediatric, Vanderbilt University Medical Center, Nashville, Tennessee

J Bone Joint Surg Am, 2001 Mar 01;83(3):321-321
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The article by Mehlman et al. in this issue of The Journal critically evaluates the need for emergent reduction and pin fixation of type-III supracondylar fractures of the distal part of the humerus in children. Those of us who treat a large number of these fractures have traditionally considered them to require immediate reduction and fixation to prevent or substantially reduce the risk of complications such as compartment ischemia and to increase the likelihood that closed reduction will be successful. Prior to the 1999 report by Iyengar et al.1, these fractures had been treated as an emergency.
Mehlman et al. performed a double-cohort study of 220 consecutive pediatric patients who had been treated operatively for a displaced supracondylar fracture of the distal part of the humerus. They excluded patients with open fracture, a dysvascular extremity, metabolic bone disease, and ipsilateral upper-extremity fracture. They then retrospectively compared the complication rates of two groups of patients, all less than fifteen years of age: fifty-two patients treated within eight hours after the injury and 146 patients treated more than eight hours after the injury. They did perform partial closed reduction in the emergency department for approximately 50% of the patients in the delayed-treatment group to relieve severe deformity and to move bone fragments that were tenting the skin.
We have seen a change in the attitude of trauma surgeons toward the need for immediate treatment of fractures in children and adults. Operating in the middle of the night does not always guarantee that all of the participants are at their best. In addition, the personnel who are available for assistance may not be familiar with the procedure. The necessary equipment is usually easily found in the day by the normal orthopaedic operating-room personnel; however, the evening and night teams may have difficulty locating all necessary instruments. Radiology technicians who work during the day will have no trouble with the c-arm; however, the night technician may find the procedure challenging.
The concern that has prevented us from delaying the treatment of these fractures has been the possibly higher rate of complications such as nerve injury and compartment ischemia. However, the results reported by Mehlman et al. were excellent. They found no significant difference between the early and delayed-treatment groups with regard to the need for open reduction. There were ten failures of closed reduction in the early-treatment group, and seven of them required open reduction. Only five open reductions were performed in the delayed-treatment group. On the surface, these results are outstanding; however, the authors do not tell us when they treated the patients in the early-treatment group. Were they seen early in their experience with the use of closed reduction and pin fixation? Was there a difference in the experience and ability of the surgeons participating in the study? If the two groups of patients were comparable—that is, treated at the same time and by surgeons with similar experience—the conclusions would have been even more compelling. The authors did not find any difference in the rate of infection or of iatrogenic nerve injury, and no patient in either group had compartment ischemia.
In spite of the concerns that I mentioned, I found this study to be excellent and convincing. The authors showed us that it is safe and prudent to treat displaced type-III supracondylar fractures of the humerus in children in a controlled environment rather than in the middle of the night. Mehlman et al. did perform partial closed reduction on a high percentage of their patients to correct unacceptable deformity. The patients should be admitted to the hospital, and thorough and continuous neurovascular evaluations are required. The elbow should be splinted in moderate extension to reduce the risk of vascular compression. With these cautions in mind, it appears that displaced supracondylar fractures of the humerus can be safely treated in a controlled environment.
Neil E. Green, MD
Department of Orthopaedics, Pediatric Vanderbilt University Medical Center Nashville, Tennessee
Iyengar SR; Hoffinger SA; and 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: 51-5, 1351  1999  [PubMed]

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Iyengar SR; Hoffinger SA; and 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: 51-5, 1351  1999  [PubMed]
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