The standard dictum for the treatment of supracondylar humeral fractures in the pediatric patients is that delayed treatment is appropriate as long as the neurovascular status is normal. Open fractures and those with a pulseless extremity require emergent treatment. There remains some debate, however, as to whether delaying treatment increases the chances of open reduction, and decreases the quality of outcome. The authors sought to answer this specific question.
At a single institution, 145 fractures in 144 patients were reviewed. One hundred and three were Type II supracondylar and 42 were Type III supracondylar fractures. Early treatment was defined as less than 21 hours and delayed greater than 21 hours. All fractures were treatment with closed reduction and pinning. Pinning was primarily performed via a lateral divergent technique using two to three 1.6mm Kirschner wires.
Immobilization was for one month. Multiple variables were compared including need for open reduction, length of surgery, length of hospitalization, presence and neurologic complications, vascular complications, compartment syndrome, pin tract infection, loss of fixation, final carrying angle, range of motion, and outcome.
The results were similar between the two groups without any statistical differences. Of note, any patient with an abnormal neurovascular status underwent urgent treatment with average time to surgery of 8 hours. At latest follow up, only 14 elbows were rated unsatisfactory. Five developed avascular necrosis of the trochlea, four had a pin track infection, and five did not achieve at least 85% of the range of the motion compared to the contralateral side.
The results of this study emphasize that surgical delay of supracondylar humeral fractures is appropriate as long as there is no neurovascular compromise. There are many shortcomings of this study including the selection of 21 hours to presentation at the institution. The time from injury would certainly be more appropriate information. The only take home point is that the outcome is similar (early vs. delayed) and that the necessity of open reduction is not related to delaying treatment greater than 21 hours.