Timing and Outcome of Surgical Treatment in Supracondylar Humeral Fractures in Pediatric Patients, Khartoum, Sudan

A study aims to evaluate the timing of close surgical treatment in supracondylar humeral fractures in pediatric patients and to know the radiological outcome of its management, through measuring the mean delay per hour and assessing post-surgical radiological outcome for reduction. A cross- sectional hospitals based study carried out in Khartoum state, through randomized cluster sampling, both data sheets and pre/post-surgical images were filled and collected. A well-constructed criteria were developed to assess the radiological outcome. With sample size of 41 cases, we found that the mean delay from trauma to surgery was 99 hours [SE, 13], equivalent to 4.13 days. The reduction outcome criterion was significant when comparing it with the surgeon level P value of 0.015, but when comparing it with the delay more than 32 hours and Gartland classification both weren’t significant with P values of 0.383 and 0.501 respectively. These results are refuting the current concepts about the impossible reduction after a delay more than 32 hours and filled the current gap of knowledge about the outcome of supracondylar humeral fractures Gartland III with delayed presentation.

Background Supracondylar Humeral fractures are the most common elbow fractures in children, and surgical fixation to those fractures is the most common operation in pediatric orthopedic Trauma. Sudan and developing countries in general have a lot of struggles which delay the presentation of this common operation, neither the international research; due to lack of cases, nor the local one; due to lack in research activities, had address outcome in these special situation.
SHF is the most common fracture in children that will need surgical management, in spite of that, time for surgery still a contra versed issue (1). There is an agreement specially with SHF type III to be an emergency, if there is vascular insufficiency for the limb, open fracture or skin puckering, evolving compartment syndrome or floating elbow, median nerve palsy, young age and if a child has cognitive disability. (2) But if there was no indication to rush to the operation room, there is a big doubt for most surgeons to do it as emergency, as shown in a survey involving 309 pediatric orthopedic surgeons in US and Canada who had been asked about their practice,81% of them will do the operation next morning shift if there was no apparent cause for emergency. (3) Thus, contra version didn't end in spite the risk of shifting from close to open technique and a lot of researches were done to compare starting from less than, or equal to eight hours in comparison with more than eight hours (4,1), then in a comparison delay 12 hours and delay of 21 hours; all of them found no statistical difference with P value of "0.55", "0.37" and "1.7" respectively, which indicates the need for shifting to open technique (4,5,6,7).
In a hospital based long study with data from 1998 till 2006 with almost 190 cases after excluding all patients with emergency operation, it defined time of surgery (TS) as from injury to operation entrance, it divided the time into four quartiles to which open reduction versed close reduction operations were tested through logistic regression, it found that the probability to shift from close reduction to open reduction will increase by a factor of four after the first 15 hours post injury with statistical significant P value < 0.001, thus a close reduction becomes impossible after 32 hours. (8) This study is well controlled; the researchers did their best to control all possible factors even surgeon's interest or mood had been controlled through defined protocol to shift from close reduction to open one to which the two surgeons obligated.
Interestingly, unintended delay occurs when SHF type II is treated conservatively for a week with unsatisfactory result it will need operative reduction. A research in SHF type II did a comparison between a group which had surgery within the first seven days and another group had surgery after seven days, there was no statistical significance for the need to shift for open reduction but the mean difference was statistically significant for carrying angle degree and pin tract granuloma with -1.5 (CI -2.5 to -0.5) and -8.9 (CI-11.8 to -5.9) respectively Addressing those fractures correctly from the start will reduce most common serious complication of it cubitus varus, which is related to the adequate reduction and fixation more than the initial trauma for which it's better to make the concern about having a good reduction rather than jeopardizing it for doing a CRPP.
The great difference in the outcome between CRPP and ORPP reported traditionally in neurological injury, elbow stiffness, ugly scaring and myositis ossifficant, had been minimized (1,9). But still there is statistical significant difference between close and open reduction with lesser restriction in movement, better functional result and less time to unite with P value of 0.03, 0.03 and 0.01 respectively, towards the close reduction. (10) That makes CRPP a golden stander treatment of SHF which is the goal for all surgeons dealing with it.

Methods
We design a Cross-sectional hospitals based study, we collect 41 cases through a cluster sampling to ensure an appropriate way of probability sampling technique, because Khartoum state is a large geographical area a random selection of the three cluster geographical areas where one cluster was chosen, then stratified random sampling was used to cover the three categories of hospitals and to be more precise, the private hospitals were classified in two broad groups according to the level of luxury. All stratified groups have had random selections in all of them to make a group of hospitals, which will be representative to the cluster making the result generalizable for the whole state.
All cases which fulfilled the including criteria were identified through the sentinel persons there, then data sheet was filled from both; a child caregiver and the doctor who performed the surgery or participated on it, and pre/post images were collected.
Through Gartland classification, all preoperative images were classified because Gartland type 4 is an intraoperative diagnosis, therefor we classified the patients as type 3, so we have only two types to consider (2 and 3).
Up to the researcher's knowledge, no criteria to score the reduction in SHF, We created criteria to classify the postoperative images and to assess the radiological outcome for the surgeries, two important factors were used; the reduction and fixation, we called it The Blue Nile Criteria.
In the first criterion to assess the reduction outcome, four factors were used; Baumann angle, anterior humeral line, translation and the tear drop profile. Total score was 7, Baumann angle (measured through Protractor application) score is 2 when an angle between 9 and 26 degrees is obtained, if the angle was more than 26 degrees or less than 9 degrees the score is zero. The score was 2 when the anterior humeral line crosses the center of capitellum, if it passes through the anterior third the score is 1, and if it passes through posterior third or anterior to the anterior third, it scored zero. As for translation, if there is no translation (both medial and lateral columns maintain the continuity) scores of 2, if it has lateral displacement less than 5 mm the score is 1, and if it has medial displacement or excessive lateral the score is zero. For tear drop profile the full score is 1 if restored and zero if not. Any case which hadn't any assessable component was excluded from the criterion, all cases got a score of 4 or more were recognized as acceptable reductions.
Second criterion to assess fixation outcome through the well know method, K-wires should hold both sides of fracture (should have a firm hold from both fragments and no wire should be intramedullary), and they should not cross at fracture side to have a score of 1for each. It is either adequate fixation (scored 2) or inadequate fixation (scored 1 or zero).
When we joint the two above criterion, with overall score 9, we call it the Blue Nile criteria for assessing SHF, we assessed the case as acceptable radiological outcome when the score is 6 or more. Having a score of 6 was chosen based on the fact that any case to have acceptable overall outcome must have acceptable reduction, which needs a score of 4. Fixation has a minimum consideration because any fixation would be augmented by posterior plaster of Paris slab as routine in all cases 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  Fisher's Exact Test, P value is 0.015 (significant) Fisher's Exact Test, P value is 0.027 (significant) 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) and ORPP, and some authors put a delay more than 32 hours as cut point for CRPP (8). With a concept of dealing with SHF as an urgent operation if it was not an emergency but never as an elective operation. (1,7) Although no study gave an exact figure for delay with CRPP; our 4 days' delay is a long delay and it is close to study for CRPP after 7 days done for patients with acceptable Gartland type II SHF failed in conservative management which implies a minimum reduction defect unlike our research which had more patients with Gartland type III (11) Based on literatures, shift from close reduction to open reduction will increase by a factor of 4 after the first 15 hours post injury with statistical significant P value < 0.001, thus CRPP became impossible after 32 hours. (7) we grouped our sample in two groups those who had surgery before 32 hours (no delay group) consisting 17% of the cases, and those after 32 hours (delay group) consisting 83% (majority). We failed to find a statistical significance when comparing those groups with reduction or overall outcome criteria,

Conclusion
In a cross sectional hospitals based study aims to study the timing of close surgical treatment in SHF in pediatric patients and to know the radiological outcome of its management, through measuring the mean delay per hour and identifying the causes. And assessing post-surgical radiological outcome for reduction.
We found that the mean delay from trauma to surgery was 99 hours [SE, 13], equivalent to 4.13 days, 71% of these delay was due to wait for schedule list within the health system. The reduction outcome criterion was significant when comparing it with the surgeon level P value of 0.015, but when comparing it with the delay more than 32 hours and Gartland classification both weren't significant with P values of 0.383 and 0.501 respectively.