Pediatric Supracondylar Humerus Fractures Research Articles

Beyond Tradition: "Figure of 8" Casting for Gartland Type 1 and Type 2A Pediatric Supracondylar Fractures of Humerus: Video Technique.

In the treatment of paediatric supracondylar humerus fractures (SCHFs), Gartland Type 1 fractures are traditionally managed with in situ above elbow casting, while Type 2A fractures are treated with closed reduction and above elbow casting. This technical note introduces a novel "figure of 8" cast technique for Type I and 2A fractures. The technique aims to maintain fracture reduction while reducing the risk of compartment syndrome by avoiding placement of cast material in the anterior elbow crease. This innovative casting method has the potential to enhance the management of these fractures in children, providing a alternative to conventional approaches. "Figure of 8" cast technique presents a unique, easy-to-implement, and effective approach for treating Type 1 and 2A SCHFs in children, maintaining fracture reduction in 100-110° elbow flexion and minimizing the risk of compartment syndrome.

Reliability of Gordon Lateral Rotation Percentage and Prabhakar Percentage of Metaphyseal Overhang for Pediatric Supracondylar Humerus Fracture; Is it Clinically Reliable for John Hopkins Classification Coronal Fracture Subtypes?

Reliability of Gordon Lateral Rotation Percentage and Prabhakar Percentage of Metaphyseal Overhang for Pediatric Supracondylar Humerus Fracture; Is it Clinically Reliable for John Hopkins Classification Coronal Fracture Subtypes?

Comparison of complications and results of early vs. delayed surgery for pediatric supracondylar humeral fractures.

Pediatric supracondylar humerus fracture (SCHF) is one of the most common elbow fractures in children aged 5-7 years. There is a continuous discussion regarding the optimal timing for conducting surgery for fractures of this nature. Therefore, we aimed to determine whether the timing of surgery in pediatric SCHFs has an impact on the frequency of early postoperative complications. Between January 2018 and March 2020, pediatric SCHF patients who underwent surgery at our hospital were retrospectively reviewed. Patients operated on within 12 hours after the fracture and those operated on later were respectively included in the early and late groups. Early postoperative complications, including neurological deficits, iatrogenic ulnar nerve injury, vascular injury, compartment syndrome, K-wire migration, and unexpected returns to the operating room, were compared between the two groups. We investigated surgical duration, reduction, and perioperative radiographic data. For modified Gartland type II or type III fractures, there was no significant difference in the incidence of early complications between the early and delayed groups. Additionally, there were no noticeable differences between the two groups in terms of perioperative radiographic data, reduction procedure, or surgical duration. Delayed surgery in type II or type III supracondylar humerus fractures was not associated with an increased incidence of early postoperative complications. The difficulty or effectiveness of reduction is not influenced by the timing of surgery.

Management of Traumatic Nerve Palsies in Paediatric Supracondylar Humerus Fractures: A Systematic Review.

Purpose: Up to 12% of paediatric supracondylar humerus fractures (SCHFs) have an associated traumatic nerve injury. This review aims to summarize the evidence and guide clinicians regarding the timing of investigations and/or surgical interventions for traumatic nerve palsies after this injury. Methods: A formal systematic review was undertaken in accordance with the Joanna Briggs Institute (JBI) methodology for systematic reviews and PRISMA guidelines. Manuscripts were reviewed by independent reviewers against the inclusion and exclusion criteria, and data extraction, synthesis, and assessment for methodological quality were undertaken. Results: A total of 51 manuscripts were included in the final evaluation, reporting on a total of 510 traumatic nerve palsies in paediatric SCHFs. In this study, 376 nerve palsies recovered without any investigation or intervention over an average time of 19.5 weeks. Comparatively, 37 went back to theatre for exploration beyond the initial treatment due to persistent deficits, at an average time of 4 months. The most common finding at the time of exploration was entrapment of the nerve requiring neurolysis. A total of 27 cases did not achieve full recovery regardless of management. Of the 15 reports of nerve laceration secondary to paediatric SCHFs, 13 were the radial nerve. Conclusions: Most paediatric patients who sustain a SCHF with associated traumatic nerve injury will have full recovery. Delayed or no recovery of the nerve palsy should be considered for exploration within four months of the injury; earlier exploration should be considered for radial nerve palsies.

Radiological and Clinical Outcomes of Pediatric Patients With a Supracondylar Humerus Fracture Surgically Treated With Closed Reduction and Percutaneous Pinning.

It was aimed to evaluate the clinical and radiological results of patients operated on with closed reduction and pinning due to pediatric supracondylar humerus fractures. The radiological and clinical results of 100 patients operated on with closed reduction and percutaneous pinning for pediatric supracondylar humerus fractures in the Department of Orthopedics and Traumatology were examined between January 2015 and February 2022. Clinical results were evaluated by performing cosmetic and functional scores defined by Flynn. Closed reduction and percutaneous pinning techniques were used in surgical treatment. In our study, 59 patients were male (59%), and 41 were female (41%). The average age of all patients is 6.21 ± 2.85 years. According to the Gartland classification, 21 patients' fractures were type IIA (21%), 12 patients' fractures were type IIB (12%), 51 patients' fractures were type III (51%), and 16 patients' fractures were type IV (16%). The average number of pins used in the treatment is 2.55 ± 0.50. The elbow bearing angle of the operated side of the patients was an average of 6.53 ± 3.29 degrees, the humerocapitellar angle was an average of 41.97 ± 3.08 degrees, and the lateral humerocapitellar angle was an average of 50.17 ± 3.58 degrees. Fifty-one patients had stage 0 (51%), 23 patients had stage 1 (23%), 23 patients had stage 2 (23%), and three patients had stage 3 (3%) residual sagittal plane deformity. According to the Flynn criteria, 92 patients had excellent functional results (92%), seven patients had good results (7%), and one patient had fair results (1%). Regarding cosmetic results, 91 patients had excellent results (91%), six patients had good results (6%), and three patients had fair results (3%). Supracondylar humerus fractures are common in children and can cause serious complications. Closed reduction and percutaneous pinning techniques are effective treatment methods in the treatment of displaced supracondylar humerus fractures.

Does Shorter Time to Treatment of Pediatric Supracondylar Humerus Fractures Impact Clinical Outcomes?

Does Shorter Time to Treatment of Pediatric Supracondylar Humerus Fractures Impact Clinical Outcomes?

Preliminary fracture reduction in children with type III supracondylar humerus fractures during the COVID-19 pandemic.

During the COVID-19 pandemic, the time elapsed from injury to definitive surgery necessitated delay in type III pediatric supracondylar humerus fractures. Preliminary fracture reduction was recommended in these fractures while waiting for operative treatment. The purpose of this study was to evaluate whether preliminary reduction afforded a better treatment experience and improved outcomes. A retrospective cohort analysis of 161 type III supracondylar humerus fractures compared treatment with preliminary closed fracture reduction and delayed percutaneous pin placement (110 children) to delayed combined closed reduction and pin placement (51 children) in a children's medical center. Of the preliminary reduction group, 22 (20%) required analgesic pain relief, compared to 18 (35%) in the non-preliminary reduction group ( P = 0.037), and the preliminary reduction group had statistically less pain (assessed using the Faces Pain Scale-Revised rating) the first night after injury and the first-night post-CRPP ( P = 0.019, P = 0.008). Cast splitting was more frequent in the non-preliminary reduction group, 11 patients (22%) than in the preliminary reduction group, 10 patients (9%; P = 0.029). The operative times in the preliminary reduction group were shorter ( P < 0.001). If delay is necessary for complete repair of type III supracondylar humerus fractures, a preliminary fracture reduction with a temporary cast can be recommended, as these children will experience a more comfortable interval, with less swelling and pain, and potentially a shorter operation. Level of Evidence: Level III-therapeutic study.

Comment on 'Which pediatric supracondylar humerus fractures are high risk for conversion to open reduction?'

Comment on 'Which pediatric supracondylar humerus fractures are high risk for conversion to open reduction?'

Using the Perfusion Index for Block Success in Pediatric Patients: A Retrospective Study.

To investigate the efficacy of the perfusion index in assessing block success in pediatric patients undergoing elective supracondylar fracture repair surgery. It was a retrospective study in a tertiary-care center. Twenty-eight pediatric supracondylar humerus fracture patients who underwent elective surgery for fracture repair were evaluated. Perfusion index, pulse rate, pleth variability index (PVi), and oxygen saturation were measured at different time intervals before and after the coracoid infraclavicular block procedure. The changes in perfusion index (PI) values were found to be statistically significant (p˂0.05). The Bonferroni analysis revealed that the results obtained at three separate measurement times differed significantly (p˂0.05). On the other hand, changes in other variables were not statistically significant (p˃0.05). The perfusion index can be used as an indicator of block success in elective surgeries of the upper extremities in pediatric patients.

Reliability of Gordon Lateral Rotation Percentage and Prabhakar Percentage of Metaphyseal Overhang for Pediatric Supracondylar Humerus Fracture; Is it Clinically Reliable for John Hopkins Classification Coronal Fracture Subtypes?

Rotational malalignment is a common problem in pediatric supracondylar humerus fractures (SCHF). Several techniques have been described to evaluate the true rotation value. Although the Prabhakar and Gordon techniques are used frequently, their superiority to each other in terms of measurement quality is unknown. The aim of this study was to investigate the clinical compatibility of the 2 techniques and to evaluate whether they are suitable for all subtypes. This cross-sectional study included 40 patients with SCHF (including subtypes; Typical, Medial Oblique, Lateral Oblique, and High fracture pattern). The Gordon lateral rotation percentage and Prabhakar percentage of metaphyseal overhang were measured twice by 4 experienced Orthopedics and Traumatology surgeons at 8-week intervals. The interobserver and intraobserver reliability were examined using the intraclass correlation coefficient. The interobserver reliability for Gordon and Prabhakar technique was 0.816 and 0.762 for the first measurement and 0.811 and 0.811 for the second measurement, respectively.The medial oblique fracture pattern was determined to have the best interobserver agreement among the subtypes. The result was excellent for the medial and lateral oblique subtypes, good for the typical fracture pattern, and fair for the high fracture pattern. The intraobserver reliability for Gordon and Prabhakar technique was excellent, 0.924 and 0.922, respectively. The main finding of this study was that the Gordon and Prabhakar techniques have similar interobserver and intraobserver reliability. Although the Gordon technique tends to have higher interobserver reliability, the difference was clinically insignificant. These measurements should not be relied upon in cases of SCHF with a high fracture pattern because of the different anatomic features of that region. Level III.

91 Introduction of a Simple Proforma Improves Documentation of Neuro-Vascular Status in Paediatric Supracondylar Humerus Fractures (Closing Loop Audit)

Abstract Introduction Supracondylar fractures of the humerus are the most common fracture around the elbow in children. There is a risk of significant complications including nerve injury, vascular compromise, compartment syndrome and clinical deformity. BOAST (British Orthopaedic Association Standards for Trauma) published guideline 11 in 2014 (updated in Oct 2020) which lists criteria that should be assessed and documented for each child with this injury. Aim Assess whether an introduction of a simple proforma will Improve documentation of the neuro-vascular status in paediatric supracondylar humerus fractures. Method a closing loop Audit to review the accuracy of documentation of the neuro-vascular status in the admission clerking against the standards published in the updated BOAST guidelines both before and after introduction of a simple documentation proforma. Results In the first audit cycle 30 patients were included and detailed documentation of the Neuro-vascular status as per the BOAST guideline was less than 40 %. After the proforma was introduced, the second closing loop cycle included 31 patients and detailed documentation of the Neuro-vascular status as per the BOAST guideline was 70 %. Conclusions The introduction of a simple proforma has improved significantly the documentation of the neurovascular status in children presenting to the ED with a supracondylar humerus fracture.

Assessment and Validation of Anterior Humeral Line for Diagnosing Supracondylar Humerus Fractures in the Pediatric Population.

Pediatric supracondylar humerus fractures are commonly evaluated using the anterior humeral line (AHL) on a lateral radiograph. Rotational variations in radiographic projection are common due to child discomfort and could lead to changes in management based on where the AHL intersects the capitellum. The purpose of this study was to establish whether rotational variations in elbow rotation leads to significant changes in AHL position and whether drawing the AHL based on the distal humerus versus shaft is more tolerant to rotation. Fifty children with nonoperative supracondylar humerus fractures were identified with sub optimally positioned injury and well positioned follow-up lateral radiographs. The proportion of the bone anterior to the intersection of the AHL and the capitellum was measured using the humeral shaft versus distal humerus to guide position of the AHL. This process was repeated on ten pediatric humerus dry cadaveric specimens which were imaged in 5-degree rotational increments along the axis of the humeral shaft from -20 to +20 degrees. AHL position correlated poorly when measured on rotated lateral radiographs of clinical patients versus non-rotated lateral radiographs when using the distal humerus as a guide (intraclass correlation coefficient 0.14), compared with when using the humeral shaft as a guide (intraclass correlation coefficient 0.81). When assessing the pediatric humerus dry cadavers between the 2 techniques, there was greater statistically significant variation in rotated positions compared with the neutral position in the distal humerus AHL measurement approach compared with the humeral shaft AHL measurement approach, with the mean AHL within the central third of the capitellum for more rotational positions when using the shaft compared with the distal humerus. With rotated lateral elbow radiographs in supracondylar humerus fractures, utilizing the humeral shaft provides more consistent AHL measurements than utilizing the distal humerus, and thus drawing the line starting at the shaft of the humerus is recommended for surgical decision making.

Effectiveness of an early operating room start time in managing pediatric trauma.

The timing of operative treatment for pediatric supracondylar humerus fractures (SCHF) and femoral shaft fractures (FSF) remains controversial. Many fractures previously considered to be surgical emergencies, such as SCHF and open fractures, are now commonly being treated the following day. When presented with an urgent fracture overnight needing operative treatment, the on-call surgeon must choose whether to mobilize resources for a late-night case or to add the case to an elective schedule of the following day. To describe the effect of a program allowing an early operating room (OR) start for uncomplicated trauma prior to an elective day of surgery to decrease wait times for surgery for urgent fractures admitted overnight. Starting in October 2017, patients were eligible for the early slot in the OR at the discretion of the surgeon if they were admitted after 21:00 the previous night and before 05:00. We compared demographics and timing of treatment of SCHF and FSF treated one year before and after implementation as well as the survey responses from the surgical team. Of the 44 SCHF meeting inclusion criteria, 16 received treatment before implementation while 28 were treated after. After implementation, the mean wait time for surgery decreased by 4.8 h or 35.4% (13.4 h vs 8.7 h; P = 0.001). There were no significant differences in the operative duration, time in the post anesthesia care unit, and wait time for discharge. Survey results demonstrated decreased popularity of the program among nurses and anesthesiologists relative to surgeons. Whereas 57% of the surgeons believed that the program was effective, only 9% of anesthesiologists and 16% of nurses agreed. The program was ultimately discontinued given the dissatisfaction. Our findings demonstrate significantly reduced wait times for surgery for uncomplicated SCHF presenting overnight while discussing the importance of shared decision-making with the stakeholders. Although the program produced promising results, it also created new conflicts within the OR staff that led to its discontinuation at our institution. Future implementations of such programs should involve stakeholders early in the planning process to better address the needs of the OR staff.

The John Hopkins classification system used in pediatric supracondylar humerus fractures requires more experience than the Gartland system.

The Gartland classification is used to decide on surgery. In contrast, the John Hopkins classification system predicts clinical outcomes for patients undergoing surgery and determines the risk of reduction loss. This study aims to investigate the usability of the Gartland and the John Hopkins classification systems by pediatric and general orthopedic surgeons. The preoperative images of 200 patients who presented at a tertiary-level trauma center with a supracondylar humerus fracture were examined by 4 observers, twice at an interval of 6 weeks. The observers comprised 2 pediatric orthopedic surgeons and 2 orthopedics and traumatology surgeons. Inter- and intra-observer reliability were excellent for the first and second measurements of the Gartland classification. The inter-observer agreement of the pediatric orthopedic surgeons and the general orthopedic surgeons was found to be similar (ICC >90). Inter-observer reliability was excellent (ICC: 0.808) and good (ICC: 0.732) for the measurements of the John Hopkins classification, respectively. The inter-observer agreement of the pediatric orthopedic surgeons and the general orthopedic surgeons was not similar. The inter-observer agreement between the two pediatric orthopedic surgeons was excellent for the measurements (ICC: 0.868; ICC: 0.756, respectively). The inter-observer agreement between the two general orthopedic surgeons was good for the measurements (ICC: 0.605; ICC: 0.663, respectively). The John Hopkins classification system has good intra- and inter-observer reliability, and a high experience level increases the agreement. The Gartland classification system was not affected by experience. This should be considered when taking measurements in studies and patient management.

Telehealth follow-up in the postoperative care of surgically treated pediatric supracondylar humerus fractures.

Supracondylar humerus fractures are a common pediatric orthopedic injury requiring surgery. These patients are typically seen 4 weeks post-op for cast and pin removal followed by an 8-12-week post-op motion check. Our study aimed to limit the number of in-office visits by conducting this last motion check by telehealth. This was a single-surgeon series of consecutive surgically treated supracondylar humerus fractures. The primary outcome was the number of patients who completed their range of motion check remotely. Loss to follow-up at the telehealth visit was compared to a prior cohort for whom the range of motion visit was performed in person. Secondary outcomes included number of patients missing work/school for the in-person vs. telehealth visits and satisfaction with the in-person and telehealth visits. Twenty-two patients were enrolled during the study period. Sixteen (73%) successfully completed their telehealth follow-up, which was similar to the prior in-person cohort. Significantly more parents/children had to take a day off from work/school to attend the in-person visit. No patient required a subsequent in-person visit or referral to physical therapy. A total of 100% of patients reported excellent satisfaction with their telehealth visit. Overall satisfaction was similar comparing the in-person vs. telehealth visits (84% vs. 100% reporting excellent satisfaction, P = 0.12). Telehealth is a viable option for the postoperative care of surgically treated supracondylar humerus fractures. This approach limits in-office visits and decreases the need for parents/children to miss work/school while maintaining excellent satisfaction scores.

Minimizing Surgeon Radiation Exposure During Operative Treatment of Pediatric Supracondylar Humerus Fractures.

Orthopaedic surgeons are exposed to high levels of radiation, which may lead to higher rates of cancer among orthopaedic surgeons. There are a series of techniques currently practiced to pin supracondylar humerus fractures including pinning the arm on the C-arm itself, using a plexiglass rectangle or a graphite floating arm board; however, the variation in radiation exposure to the surgeon is unknown. We aimed to determine how the position of the C-arm affects radiation exposure to the surgeon during the treatment of a pediatric supracondylar humerus fracture. A simulated operating room was created to simulate a closed reduction and percutaneous pinning of a supracondylar humerus fracture. A phantom model was used to simulate the patient's arm. We assessed performing the procedure with the arm on plexiglass, graphite, or on top of the C-arm image receptor. The C-arm was positioned either with the source down and image receptor up (standard position) or with the source up and image receptor down (inverted position). Radiation exposure was recorded from levels corresponding to the surgeon's head, midline, and groin. The estimated effective dose equivalent was calculated to account for the varying radiation sensitivity of different organs. We found the effective dose equivalent, or the overall body damage from radiation, was 5.4 to 7.8% higher than the surgeon when the C-arm was in the inverted position (source up, image receptor down). We did not find any differences in radiation exposure to the surgeon when the arm was supported on plexiglass versus graphite. The C-arm positioned in the standard fashion exposes the surgeon to less damaging radiation. Therefore, when the surgeon is standing, we recommend using the C-arm in the standard position. Orthopaedic surgeons who stand should use the C-arm in the standard position to pin supracondylar humerus fractures to lower the risk of ionizing radiation exposure.

FUNCTIONAL OUTCOME OF DISPLACED SUPRACONDYLAR HUMERUS FRACTURE IN CHILDREN MANAGED WITH PERCUTANEOUS PINNING - A PROSPECTIVE STUDY

Background: The majority of elbow injuries in children are supracondylar fractures of the humerus, accounting for around 60% of all elbow injuries in the rst ten years of life. Associated with complications like compartment syndrome, neurovascular damage, Volksman'sischaemic contracture and malunion. Two lateral pins or a cross pin construction are the most popular options for pinning. As compared to alternative treatment options, closed reduction and percutaneous K-wire xation are the most effective and least invasive. Complications like malunion, loss of reduction and compartment syndrome may arise from treating it conservatively. This research evaluates the functional and radiological results of closed reduction percutaneous K wire treatment for displaced supracondylar humerus fractures in children. Based on Materials and Methods: the inclusion and exclusion criteria from the consecutive sampling, 32 patients were chosen for the research. All patients had percutaneous K wirexation using the usual procedure. 20 children (63%) of them were affected in their rs Results: t decade of life, with a clear male predilection than females. Mayo elbow scoring was 2.5, 6.0 and 3.75 at 6 weeks, 3 months and 6 months. PTI and Cubitus Rectus was noted in 8 and 2 respectively in our study population. Clinical outcomes measured by Flynn criteria was poor in 2 cases, satisfactorily excellent in 28 and satisfactorily good in 2 case. Closed reduction and percutaneous pinning either by crossed conguration or by latera Conclusion: l pinning is the treatment of choice for paediatric supracondylar humerus fractures. Regardless of the conguration, the proper pinning method guarantees a successful result. Closed reduction and percutaneous pinning is a safe, cost-effective, less morbid procedure.

Does Shorter Time to Treatment of Pediatric Supracondylar Humerus Fractures Impact Clinical Outcomes?

Treatment of supracondylar humerus (SCH) fractures within 18 hours of presentation is a tracked quality metric for ranking of pediatric hospitals. This is in contrast with literature that shows time to treatment does not impact outcomes in SCH fractures. We aim to determine whether an 18-hour cutoff for pediatric supracondylar humerus fracture treatment is clinically significant by comparing the complication risks ofpatients on either side of this timepoint. Our hypothesis is that there will be no statistically significant differences based on time to treatment. A retrospective review of clinical outcomes was performed for 472 pediatric patients who underwent surgical management of isolated supracondylar humerus fractures between 1997 and 2022 at a single level I pediatric trauma hospital. The cohort was split based on time to surgery (within or ≥18h from Emergency Department admission). Surgical treatment occurred within 18 hours of arrival in 435 (92.2%) patients and after 18 hours in 37 (7.8%) patients. Mean age was 5.6±2.2 years and 51.5% of patients were female. Gartland fracture classification was type II [n=152 (32.3%)], type III [n=284 (60.3%)], type IV [n=13 (2.8%)], or flexion-type [n=18 (3.8%)]. There were no differences in demographic characteristics or fracture classification between cohorts. Fractures in the ≥18-hour cohort were treated more commonly with 2 pins (62.2% vs. 38.5%, P =0.04). There were no statistically significant differences in open versus closed reduction, utilization of medial pins, or postoperative immobilization between cohorts. We were unable to detect any differences in postoperative complications, including non-union, delayed union, stiffness, malunion, loss of reduction, iatrogenic nerve injury, or infection. This remained true when type II fractures were excluded. Using an arbitrary time cutoff of <18 hours does not influence clinical outcomes in the surgical treatment of SCH fractures. This held true when type II fractures were excluded. For this reason, we recommend modification to the USNWR guidelines to decrease emphasis on time-to-treatment of SCH fractures. Level III.

High-Volume Hospitals Have Lower Open Reduction Rates and Lower Cost of Care for Pediatric Supracondylar Humerus Fractures

Background: Open reduction and percutaneous pinning (ORPP) of pediatric supracondylar humerus (SCH) fractures is associated with increased morbidity compared to closed reduction. This investigation sought to assess variation in ORPP rates among U.S. children's hospitals by hospital treatment volume and ranking. Secondarily, we investigated costs associated with ORPP and closed reduction and percutaneous pinning (CRPP).Methods: The Pediatric Health Information System (PHIS), a database of U.S. children's hospitals, was queried for patients 3-10 years treated with ORPP or CRPP for closed SCH fractures from 2010-2014. Pediatric orthopaedic hospital rankings were collected from U.S. News and World Report. To account for differences in patient population, hospital ORPP rates were adjusted for patient characteristics. Analysis then assayed the effect of hospital treatment and ranking on cost of care and likelihood to treat with ORPP.Results: 28,100 patients were treated at 42 pediatric hospitals. 26,465 (94.2%) SCH fractures underwent CRPP and 1,635 (5.8%) underwent ORPP. Unadjusted ORPP rates varied from 1.9%-12.8%. Adjusted for patient characteristics, ORPP rates ranged from 4.2%–15.0%. Analysis demonstrated significant variation in cost and ORPP rates between hospitals (p<0.001). Patients treated at high-volume centers were less likely to undergo ORPP than patients at lower-volume centers (5.1% vs. 6.7%; Odds Ratio 0.70, 95% CI: 0.54-0.90). There was no difference in ORPP rates based on the USNWR ranking. Cost of care was also significantly lower at high-volume centers (p<0.001).Conclusions: At hospitals with low surgical volumes, children with SCH fractures are more likely to undergo ORPP and have a significantly higher cost of care.Level of Evidence: Therapeutic Level IIIKey Concepts•There is variability in operative pediatric supracondylar humerus (SCH) fracture care with some patients receiving less invasive closed reduction and percutaneous pinning (CRPP) and some receiving more morbid open reduction and percutaneous pinning (ORPP).•Patients treated at high-volume hospitals are 30% less likely to receive ORPP compared to patients treated at low-volume centers.•Cost of care was significantly less expensive at high-volume hospitals.

New Injury Patterns in Pediatric Supracondylar Fractures During COVID-19: Beds Are the New Monkey Bars.

The coronavirus disease 2019 (COVID-19) pandemic drastically altered children's activity patterns. Our goal was to investigate how COVID-19 affected demographics, injury characteristics, treatment patterns, follow-up, and outcomes in pediatric supracondylar humerus (SCH) fractures. This was an Institutional Review Board-approved retrospective analysis of patients undergoing surgery for a SCH fracture from May to November 2019 (pre-COVID-19) and from May to November 2020 (during COVID-19) at 2 tertiary children's hospitals. Demographic information, injury characteristics, hospital course, and follow-up data were collected and compared. SCH fractures decreased by >50% from 2019 (149) to 2020 (72). Children in the 2020 cohort were younger (mean 5.2y old) compared with 2019 (6.0y old) ( P =0.019). Mechanism of injury was significantly different in 2020 ( P <0.001), as the proportion of trampoline and furniture fractures increased from 8% and 17% to 15% and 33%, respectively. The proportion of playground and monkey bar fractures decreased from 20% and 17% to 3% and 4%, respectively. Distribution of Gartland type and neurovascular injury rates were similar in 2019 and 2020 ( P =0.411 and 0.538). Time from emergency department admission to the operating room and duration of hospital admission were both unchanged from 2019 to 2020 ( P =0.864 and 0.363). The duration of postoperative follow-up in 2019 was 94.5 days compared with 72.8 days in 2020 ( P =0.122), as more pandemic patients were lost to follow up (22.5% vs. 35.2%, P =0.049). The demographics, mechanism of injury, and follow-up practices of pediatric SCH fractures changed significantly during the pandemic, likely because of school closures and lock-downs changing activity patterns. Different mechanisms of injury affected younger patients and reflected the new ways children played. Trampoline-related and furniture-related injuries overtook the classic playground falls as primary mechanism of injury. Despite the need for COVID-19 testing, there was no delay in time to the operating room. Hospitalization duration did not change, yet postoperative follow-up was shorter, and more patients were lost to follow up. Despite these stressors, outcomes remained excellent in most children. Level III-Retrospective comparative study.