In a cross-sectional hospitals based study, related cases in the hospitals which had been collected through sentinel persons were 41 cases, 4 cases failed to fulfil components needed for criteria making the total number for the measuring outcome 37 cases.
A well control research done with internal validity statistical test for reliability (Cronbach's alpha) is 0.766. The mean age for patients is 6.1 years-old [SE, 0.4] range from 2 to 13 years-old, all of them underwent CRPP, males are dominant with 71%, most of trauma occurred at left arm with 71% and 70% that side is their dominant hand side, one case had associated injury which was head injury. Almost 95% of cases presented to the health system in the first 24 hours and only 5% had significant delay due to bone-setter.
The mean delay in hours before reaching the health facility was 4.6 hours [SE, 1.4] the maximum delay was 48.5 hours and the minimum delay was 15 minutes. 63% of patients had their first presentation to ER centre, 5% to Primary Health Care clinic, makes a total of 68% of cases sought immediate care to health system and only 32% sought help at bone-setters.
Dreadfully the mean delay from trauma to surgery was 99 hours [SE, 13], equivalent to 4.13 days, the minimum delay was 5 hours and the maximum was 386 hours, equivalent to 16 days. Most of these delays occurred after reaching the health system with mean delay within health system of 94 hours [SE, 13.1], equivalent to 3.9 days, with maximum delay of 384 hours, table {2}. 71% of these delays were due to waiting for schedule list, 20% of cases had no delay and 9% of cases was due to other causes.
According to Gartland classification 46% of patients had type II SHF, and as we set 32 hours as a cut – point for CRPP, any CRPP carried out after 32 hours was considered as delayed operation, only 7 cases had their operation in the first 32 hours (17% of cases) and the rest 83% of cases had delayed operation, table {3}. Those operations had been carried out by different levels of surgeons, 58% by orthopaedic trainees, Registrars, 15% by specialist so we can say that 63% of operations were done by Junior surgeons, 12% of operations were done by consultant orthopaedic surgeons other than paediatric speciality, and 15% of cases by paediatric orthopaedic surgeons making the percentage for operations done by senior surgeons 27%.
To measure the outcome in the reduction outcome criterion from full score of 7 and acceptable score of at least 4, the mean score was 4.5 [SE, 0.39] with minimum score of zero and maximum score of 7 and only 58% of patients (24 cases) had an acceptable reduction outcome, those with inacceptable reduction outcome were 32% and 4 cases were identified as missing which is only 10%. The picture is gloomy in the overall outcome criterion with mean score of 5.9 [SE, 0.46]. From a full score of 9 and an acceptable score of at least 6, the minimum score was also zero and the maximum was 9, making those who have an acceptable overall outcome 51% of cases, with 10% missing cases who failed to fulfil the criterion and 39% of cases had inacceptable overall outcome criteria. Table {3}
Regarding the fixation, the two fragments were perfectly fixed in 54% of cases (22 cases out of 41). Failed (either not catching the two fragments or K. wire was intramedullary) in 44% and only one case wasn’t assessable. Unfortunately, K. wires were crossing at fracture side in 73% of cases and only 27% had a satisfactory firm hold by K. wires at the fracture side.
The reduction outcome criteria had significant result when comparing it with the surgeon level (2 groups; seniors versus junior surgeons) with a Fisher’s Exact Test P value of 0.015, table {4}.With further analysis, we tested the original surgeon levels group (with 4 levels of surgeons) against the fixation outcome criteria, due to the relative small size it wasn’t significant with Chi-Square Test P value of 0.125, but the data suggested a problem with fixation in consultant orthopedic surgeons group as they have adequate fixation in one quarter of cases. That rose up the query that should we test the pediatric orthopedic surgeons group against other surgeons. Interestingly, it was significant with Fisher’s Exact Test P value of 0.027. Table {5}
The delay more than 32 hours and Gartland classification were both tested against reduction outcome criterion as possible confounders through Fisher’s Exact and Chi-square Tests respectively; both weren’t significant with P values of 0.383 and 0.501, table {6}. The same picture was for the overall criteria and both variables weren’t significant. Table {7}
Table (2) Descriptive analysis for different delays.
|
|
|
|
|
Variables
|
Minimum
|
Maximum
|
Mean
|
|
Mean
|
Std. Error
|
Delay before reaching health facility in hours
|
0.25
|
48.5
|
4.6
|
1.4
|
Delay from trauma to surgery in hours
|
5
|
386
|
99
|
13
|
Delay from trauma to surgery in days
|
0.21
|
16
|
4.13
|
0.5
|
Delay after reaching health facility in hours
|
4.5
|
384
|
94
|
13.1
|
Delay after reaching health facility in days
|
0.19
|
16
|
3.92
|
0.5
|
Table (3) Frequencies analysis for different categorical data
Variables
|
Frequency
|
Percent
|
Gartland Classification
|
Type II
|
19
|
46%
|
Type III
|
22
|
54%
|
Delay more than 32 hours
|
No delay
|
7
|
17%
|
Delayed
|
34
|
83%
|
Reduction criteria
|
Inacceptable reduction
|
13
|
32%
|
Acceptable reduction
|
24
|
58%
|
Total
|
37
|
90%
|
Missing
|
4
|
10%
|
Overall criteria
|
Inacceptable
|
16
|
39%
|
Acceptable
|
21
|
51%
|
Total
|
37
|
90%
|
Missing
|
4
|
10%
|
Table (4) Test between reduction outcome criteria and surgeon level.
|
Surgeon level
|
Total
|
Senior Surgeons
|
Junior surgeons
|
Reduction outcome criteria
|
Not acceptable reduction
|
0
|
13
|
13
|
Acceptable reduction
|
9
|
15
|
24
|
Total
|
9
|
28
|
37
|
Fisher's Exact Test, P value is 0.015 (significant)
Table (5) Tests between overall outcome criteria and surgeon level (Paediatric orthopaedic surgeon versus other surgeons).
|
Surgeon level
|
Total
|
Pediatric orthopedic Surgeons
|
Other surgeons
|
Overall outcome criteria
|
Not acceptable
|
0
|
16
|
16
|
Acceptable
|
6
|
15
|
21
|
Total
|
6
|
31
|
37
|
Fisher's Exact Test, P value is 0.027 (significant)
Table (6) Tests between reduction outcome criteria and different variables.
|
Reduction outcome criteria
|
Total
|
Not acceptable reduction
|
Acceptable reduction
|
Causes of delay before arriving health system
|
No delay
|
11
|
24
|
35
|
Bone-setter
|
2
|
0
|
2
|
Total
|
13
|
24
|
37
|
Delay more than 32 hours
|
No delay
|
1
|
6
|
7
|
Delayed
|
12
|
18
|
30
|
Total
|
13
|
24
|
37
|
Gartland classification
|
Type II
|
5
|
12
|
17
|
Type III
|
8
|
12
|
20
|
Total
|
13
|
24
|
37
|
Fisher's Exact Test for Causes of delay before arriving health system, P value is 0.117 (insignificant)
Fisher's Exact Test for Delay more than 32 hours, P value is 0.383 (insignificant)
Pearson Chi-Square for Gartland classification, P value is 0.501 (insignificant)
Table (7) Tests between overall outcome criteria and different variables.
|
Overall outcome criteria
|
Total
|
Not acceptable
|
Acceptable
|
Causes of delay before arriving health system
|
No delay
|
14
|
21
|
35
|
Bone-setter
|
2
|
0
|
2
|
Total
|
16
|
21
|
37
|
Delay more than 32 hours
|
No delay
|
2
|
5
|
7
|
Delayed
|
14
|
16
|
30
|
Total
|
16
|
21
|
37
|
Gartland classification
|
Type II
|
5
|
12
|
17
|
Type III
|
11
|
9
|
20
|
Total
|
16
|
21
|
37
|
Fisher's Exact Test for Causes of delay before arriving health system, P value is 0.180 (insignificant)
Fisher's Exact Test for Delay more than 32 hours, P value is 0.674 (insignificant)
Pearson Chi-Square for Gartland classification, P value is 0.117 (insignificant)