Intrainstitutional Changes of the Treatment of Supracondylar Humerus Fracture in Children over a Period of 9 Years

Abstract

To assess changes in treatment modalities for supracondylar humerus fractures (SCHFs) at a large pediatric university hospital, we analyzed patient data from 2014 to 2022. A total of 233 SCHFs treated surgically at our hospital were included. To evaluate postoperative outcome and quality of life, DASH and EuroQol-5D-Y questionnaires were sent to patients. In addition to a significant fluctuation in fracture severity, we found an increase in training interventions (more surgeries were performed by trainees) and a significant decrease in surgery times after 2016. From 2020, there was a significant shift in the type of surgical method away from closed reduction with elastic stable intramedullary nailing (ESIN) and towards closed reduction and crossed K-wire osteosynthesis (CRK). Surgeries performed in the morning and evening hours increased, while those performed in the afternoon and after midnight decreased. After a mean follow-up of 4 years, there was no difference in elbow function between ESIN and open reduction and K-wires (ORK). Treatment with ESIN was equivalent to ORK in terms of function, at least in the medium-term follow-up. In summary, the combination of shifting treatment from SCHF to daytime hours, increasing trainee participation and using cross K-wire fixation instead of ESIN had no negative impact on surgery times. In our setting, these measures have reduced resource utilization and increased efficiency without compromising patient care.

Keywords: elbow fractures; fracture fixation; hospitals; intramedullary; learning curve; operative time; quality of life; retrospective studies; university.

Figure 1

Two examples of surgical methods for SCHF. (A,B) Intraoperative images of a patient with a type II SCHF after closed reduction and ESIN. (C) The condition 4 months after surgery and before implant removal. (D,E) Images 1 week after open reduction and K-wire osteosynthesis plus plaster.

Figure 2

Time of the day on which the operations were performed. (A) The bars show the percentage of patients who underwent surgery at the highlighted time point. (B) The dotted lines show the corresponding linear regression of the percentages at each time point.

Figure 3

Percentage of surgeries in which the resident pediatric surgeon was assisted by a specialist (light blue: regardless of time of day; white: daytime (before 9 p.m.); dark blue: nighttime (after 9 p.m.); * p < 0.05 vs. 2014 daytime; ** p ≤ 0.01 vs. 2014 daytime); error bars show standard error of the mean (±SEM).

Figure 4

Development of operative time showing a decrease after 2018, especially for surgeries before 9 p.m. Depicted are the mean surgery durations ± standard error of the mean (±SEM); × indicate significant differences in operative time of surgeries before 9 p.m. compared with 2022; × p < 0.05; ×× p ≤ 0.01; ××× p ≤ 0.001.

Figure 5

Percentage of patients who underwent surgery using different methods is shown. The data reflect a transition from ESIN to CRK, starting in 2020 and peaking in 2022. The error bars indicate ± standard error of the mean (±SEM), and the dashed lines represent the moving averages over two periods. * indicates a significant difference in the percentage of patients undergoing CRK or ESIN compared with 2022 (p ≤ 0.001).

Figure 6

Results of questionnaires. (A) shows the results of EuroQoL and (B) the results of DASH scores of patients operated either via ESIN or ORK. Depicted are the mean scores ± standard deviation (StDev). (C) shows the mean operative time ± StDev for both procedures for the analyzed patients (n = 27 for ESIN and n = 21 for ORK). * p-values of t-tests < 0.05 were regarded as statistically significant.