» Setting Parents' Worries to Rest About Elbow Fractures in Children
Setting Parents' Worries to Rest About Elbow Fractures in Children

When a child fractures a bone and treatment is delayed, parents may worry excessively about the effects of that delayed treatment. Sometimes there just isn't an orthopedic surgeon available to evaluate and treat that child. The family may have to travel to another hospital or clinic where a physician is on-site. In other situations, the hospital's operating rooms are full. That means another delay in getting proper care for the fracture.

In this study from the UCLA Orthopaedic Hospital in California, surgeons compared two groups of children with supracondylar humeral fractures (SCHFs). One group had surgery soon after the fracture occurred. The other group was delayed in receiving surgical care. Everyone in both groups had a procedure called closed reduction and percutaneous pinning.

A supracondylar humeral fracture refers to a break just above the elbow at the bottom end of the humerus (upper arm bone). As many as 60 per cent of all elbow fractures in children occur at this location. In order to collect information on the effect of on-time versus delayed treatment, this study was done prospectively. That means the study was set up first, then each child coming into the urgent care center of this hospital with this type of fracture was evaluated.

One advantage of a prospective study over a retrospective study (looking back after the event) is the fact that information collected on each patient is the same. Consistency like this makes it possible to make direct comparisons between the two groups. In this study, data collected included time between injury/fracture and treatment, amount of time in the operating room, and length of hospitalization.

Of greater interest was how many patients developed problems after surgery. The question was raised: does a delay in treatment (pinning the fracture) result in more problems or more severe complications after surgery? The type of problems looked at included loss of blood supply to the bone, fracture healing (malunion, nonunion, delayed union), and infection. Other measurements reflective of the results included elbow range-of-motion, loss of fixation, and final carrying angle of the elbow.

The 144 children who came to the UCLA urgent care center with supracondylar humeral fractures could easily be divided into immediate care and delayed care based on the time between admission to the hospital and the start of surgery. Time between the injury and presentation at the clinic was not used because they didn't have this information for everyone in the study.

Patients who transferred to the urgent care center from some other hospital, clinic, or facility were in the delayed treatment group. The time delay was at least 21 hours. Patients who came directly to the urgent care center and received evaluation and treatment within eight hours were in the direct treatment group. Since it is not possible to intentionally delay surgery, this was the best way to compare early with delayed treatment for this type of pediatric elbow fracture.

In all cases in this study, the fractures were displaced (separated). Treatment was with closed reduction and fixation. Closed reduction means no incision was needed -- the surgeon could use traction to pull the bones apart and line them back up). Fixation refers to pins used to hold the bones together until the fracture healed.

So, what did they find out? Well, basically, that there was no difference in results eight weeks after treatment between the two groups. A delay in treatment for supracondylar humeral fractures is not cause for extreme alarm. The children should be monitored carefully, of course. Any sign of blood loss or nerve damage would be a red flag warning.

But delaying pinning of the fracture 21 hours or more after arriving at the urgent care center was safe and did not mean worse results. Patients (and their families) in the delayed group were just as satisfied with the final outcomes as those in the direct treatment group.

Of course, delays are always to be avoided whenever possible and each child should have treatment based on his or her individual needs. Any child with displaced supracondylar humeral fractures having extreme pain, loss of blood flow, and/or loss of sensation must be treated absolutely as soon as possible. Delayed treatment is not acceptable in this group.

Reference: Joshua G. Bales, MD, et al. The Effects of Surgical Delay on the Outcome of Pediatric Supracondylar Humeral Fractures. In Journal of Pediatric Orthopaedics. December 2010. Vol. 30. No. 8. Pp. 785-791.