Accuracy of Closed Reduction of Pediatric Supracondylar Humerus Fractures Is Training in Pediatric Orthopedic Surgery Necessary?

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Background: Supracondylar humerus fractures account for two thirds of all hospitalizations for elbow injuries in children. A prevailing assumption exists regarding whether treatment quality varies by surgeon training background. This study compares radiographic outcomes of pediatric supracondylar humerus fractures treated by fellowship trained pediatric orthopedists (PO) and non-pediatric orthopedists (adult traumatologists, AT) with regard specifically to ability to obtain and maintain an operative closed reduction. Methods: We retrospectively reviewed all pediatric patients between 2007 and 2013 operatively treated for closed extension-type supracondylar humerus fractures. Inclusion criteria included skeletally immature patients with Gartland classification type II and III fractures. Eighty-five cases were included with 37 fractures treated by four fellowship trained adult traumatologists at a level I trauma center and 48 fractures treated by five fellowship trained pediatric orthopedists at a tertiary referral center. Radiographs were analyzed for Baumann's angle and shaft-condylar angle, then statistical comparisons were performed to compare preoperative and postoperative measurements. Results: There was no difference in age, gender, laterality, fracture classification, use of medial pins, or neurovascular injuries between PO and AT (p > 0.05). Change in Baumann's angle (p = 0.61) or shaft-condylar angle (p = 0.87) did not differ between PO and AT. There was no significant difference in operative and postoperative Baumann's angle (p = 0.18 and p = 0.59, respectively) and shaft-condylar angle measurements (p = 0.05 and p = 0.09, respectively) between PO and AT. There was no difference in loss of reduction between the two groups (p = 0.64). Conclusions: Radiographic analysis of supracondylar humerus fractures showed no significant difference in alignment or loss of reduction when treated by pediatric orthopedists compared to non-pediatric orthopedists. Though it seems that the trend is to send pediatric fracture care to tertiary referral centers it may not be necessary for simple fracture management.

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... Lower-volume and lower-ranked institutions may have more involvement of nonpediatric-trained orthopaedists caring for these injuries. While prior work has demonstrated acceptable care of these patients regardless of pediatric-specific training, [31][32][33] this data also suggests lower rates of ORPP 31 and superior radiographic alignment 31,32 among pediatric-trained individuals despite no significant difference in complications or outcomes. Thus, there could be an advantage to more complex SCH fractures (Gartland Type 3 and Type 4) being treated at high-volume centers with pediatrictrained specialists, where patients are more likely to avoid ORPP. ...
Background: Open reduction and percutaneous pinning (ORPP) of pediatric supracondylar humerus (SCH) fractures is associated with increased morbidity. This investigation sought to assess variation in ORPP rates among US children’s hospitals by hospital treatment volume and ranking. Secondarily, we investigated costs associated with ORPP and closed reduction and percutaneous pinning (CRPP). Methods: The Pediatric Health Information System (PHIS), a database of US children’s hospitals, was queried for patients 3-10 years treated with ORPP or CRPP for closed SCH fractures from 2010-2014. Pediatric orthopaedic hospital rankings were collected from US News and World Report. To account for differences in patient population, hospital ORPP rates were adjusted for patient characteristics. Analysis then assayed the effect of hospital treatment and ranking on cost of care and likelihood to treat with ORPP. Results: 28,100 patients were treated at 42 pediatric hospitals. 26,465 (94.2%) SCH fractures underwent CRPP and 1,635 (5.8%) underwent ORPP. Unadjusted ORPP rates varied from 1.9%-12.8%. Adjusted for patient characteristics, ORPP rates ranged from 4.2%–15.0%. Analysis demonstrated significant variation in cost and ORPP rates between hospitals (p<0.001). Patients treated at high-volume centers were less likely to undergo ORPP than patients at lower-volume centers (5.1% vs. 6.7%; Odds Ratio 0.70, 95%CI: 0.54-0.90). There was no difference in ORPP rates based on the USNWR ranking. Cost of care was also significantly lower at high-volume centers (p<0.001). Conclusions: At hospitals with low surgical volumes, children with SCH fractures are more likely to undergo ORPP and have significantly higher cost of care.
Background: Supracondylar humerus (SCH) fractures are common pediatric injuries, typically requiring closed reduction and percutaneous pinning or open reduction. These injuries are managed frequently by both pediatric-trained (PTOS) and nonpediatric-trained (NTOS) orthopaedic surgeons. However, some literature suggests that complications for pediatric injuries are lower when managed by PTOS. Therefore, this meta-analysis sought to compile existing literature comparing patients treated by PTOS and NTOS to better understand differences in management and clinical outcomes. Methods: Using preferred reporting items for systematic reviews and meta-analyses (PRISMA) methodology, a systematic review was conducted for all articles comparing SCH fractures managed by PTOS and NTOS in 4 online databases (PubMed, Embase, CINAHL, Cochrane). Study quality was assessed through the use of the Newcastle-Ottawa Scale. Meta-analyses were then performed for postoperative outcomes using pooled data from the included studies. Statistics were reported as odds ratios and 95% CI. Results: This search strategy yielded 242 unique titles, of which 12 underwent full-text review and 7 met final inclusion. All studies were retrospective and evaluated patients treated in the United States. There were a total of 692 and 769 patients treated by PTOS and NTOS, respectively. PTOS had shorter operative times [mean difference, 13.6 min (CI, -23.9 to -3.4), P=0.01] and less frequently utilized a medial-entry pin [odds ratios, 0.36 (CI, 0.2 to 0.9), P=0.03]. There were no differences in time to treatment, the necessity of open reduction, postoperative Baumann angle, or complications including surgical site infection or iatrogenic nerve injury. Conclusions: Despite shorter operative times and lower frequency of cross-pinning when treated by PTOS, pediatric SCH fracture outcomes are similar when treated by PTOS and NTOS. These findings demonstrate that these fractures may possibly be treated safely by both PTOS and experienced fellowship-trained academic NTOS who are comfortable managing these injuries in pediatric patients. Level of evidence: Level III; Meta-analysis.
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