Supracondylar humerus fractures are common injuries in pediatric patients. Like other injuries, a growing number of supracondylar humerus fractures are being transferred to pediatric centers from the community. Handling this increase load has been challenging. Recent literature suggests that unless there is vascular compromise or an open fracture, the surgery can be safely performed on an urgent rather than an emergent basis. At Miami Children’s Hospital, the child is scheduled for surgery the following morning ahead of the regular elective surgeries. The patient is placed under general anesthesia and fluoroscopy is used to guide a closed reduction. With an assistant holding the arm in the reduced position, the surgeon puts on sterile gloves, places sterile towels around the surgical field, prepares the elbow locally in the anticipated area of the pin sites, and then pins the fracture. No gowns or additional sterile drapes are utilized. The elbow is then placed in sterile cast padding and immobilized in plaster. The purpose of this study is to determine if there is any risk of infection with limited sterile field method treatment compared with what has been reported in the literature. In addition, the authors evaluated if preoperative antibiotics are really necessary.
Between 2000 and 2004, a total of 328 patients were identified. Six patients were excluded because they were converted to an open procedure, which required full preparation and draping. Two other patients had associate injuries requiring full draping and preparation. Lastly, 16 patients did not have complete data. Consequently, a total of 304 patients were available for study.
There were 162 boys and 142 girls. The mechanism of injury was variable. One hundred twenty-five fractures were Type 2 and 179 were Type 3 according to the Gartland classification scheme. The average time of injury to surgery was nearly 20 hours. Cross pinning was used on 263 patients and lateral pin technique on 41 patients. Average time of surgery was 22 minutes. Antibiotics were given according to the surgeon’s discretion. Ninety-seven patients received a single intravenous dose and 204 patients did not receive any antibiotics.
There were 24 documented neurapraxias. The medial nerve was most common. All nerve deficits resolved within six months. There were six ulnar nerve palsies that occurred in patients with a cross pinned techniques. These also resolved. There were no pin track infections requiring treatment in the entire group of 304 patients. No patient developed a compartment syndrome.
This paper presents important information regarding pediatric supracondylar fractures. Scheduling this surgery prior to the elective schedule the day provides an attractive method to handle the increasing number of injuries seen at Pediatric centers. Using a limited sterile technique also decreases operative time and eases the burden on the surgical schedule. The reported pin track infection ranges from 0-7%. The authors in this report noted no pin track infections in this large series. No surgical gowns or drapes were utilized and the pins were removed approximately one month following the operation. Furthermore, the role of perioperative antibiotics is questioned since 207 patients or 68% did not receive any antibiotics. Lastly, this article strengthens the argument that displaced supracondylar fractures without considerable soft tissue or vascular injury may be safely managed on an urgent rather emergent basis.
Pediatric, Elbow, Supracondylar, Sterile, Fracture, Humerus