Supracondylar fractures of the humerus in children: is departmental documentation hitting national standards?

Background/aims The British Orthopaedic Association's Standards for Trauma for the management of supracondylar humerus fractures in children specify that: ‘A documented assessment of the limb, performed on presentation, must include the status of radial pulse, digital capillary refill time and the individual function of the radial, median (including anterior interosseous) and ulnar nerves.’ Methods The documentation of cases of supracondylar humerus fractures over 1 year was retrospectively analysed. An electronic pro forma for supracondylar humerus fractures was introduced, with prompts for the pieces of documentation required to meet national standards. The use of this pro forma was audited after 6 months and 12 months use. Results Documentation ranged from 10% for anterior interosseous nerve to 53% for radial pulse. In the second reaudit, documentation ranged from 86% for anterior interosseous nerve to 95% for median nerve function. There were 17 patients for whom all documentation was present, and for these patients the pro forma had been used. Use of an electronic clerking pro forma improves adherence. Conclusions Full documentation of neurovascular status in paediatric supracondylar fractures is vital to allow for effective preoperative and postoperative further assessment. With the move into paperless documentation, online pro formas can help clinicians with effective assessment and documentation.

Variables affecting complication rates in type III paediatric supracondylar humerus fractures

Purpose Unstable supracondylar humerus (SCH) fractures may have different outcomes as a result of direction of displacement and pin configuration. This study evaluates the impact of fracture displacement, pin configuration and fellowship training on clinical and radiographic outcomes in unstable fractures. Methods A total of 99 patients with completely displaced type III fractures were identified at an academic centre and a local community hospital. Patient characteristics and the fellowship training of the treating surgeon were recorded, and injury films documented the direction of displacement. Pin configuration, coronal and sagittal alignment were recorded from postoperative radiographs and at healing. Radiographic outcomes including coronal, sagittal and rotational malunion as well as clinical complications were analyzed. Results Fractures with direct posterior displacement had a lower composite malunion rate compared with those with posterolateral (PL) or posteromedial (PM) displacement (6.9%, 36.4%, 29.2% respectively; p = 0.019). PM displacement had a higher rate of coronal malunion compared with PL (18.2% versus 0%; post hoc p = 0.024). All-lateral constructs resulted in more rotational malunions (20.9% versus 1.8%; p = 0.002) compared with crossed pinning. PL fractures treated with all-lateral fixation showed a trend toward increased rotational instability or malunion (23.8% versus 1.3%; p = 0.073). Higher composite complication rates were noted in patients treated by surgeons with non-paediatric, non-trauma fellowship training. Conclusion For displaced SCH fractures, all-lateral fixation is associated with higher rates of rotational instability and malunion. Posteromedially and posterolaterally displaced fractures have higher rates of malunion compared with fractures with straight posterior displacement. Fellowship training other than paediatric or trauma was associated with increased complications. Level of Evidence Level III