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