Mini-CAT expanded from Rotation 5, Week 2 PICO
Clinical Question:
5 year old female with no significant past medical history who has met all appropriate milestones for her age is brought to the urgent care clinic by her mother complaining of right elbow pain x 4 hours. She reports that she was playing with her older brother when he picked her up and dropped her, causing her to fall on her elbow. Her mother reports that she was reluctant to move her arm at all and that she noticed right elbow swelling and bruising before putting it in a homemade sling made from a scarf.
Physical exam is remarkable for bruising and swelling 3 cm above to 3 cm below the right elbow and pain with palpation of the elbow joint. She has FROM in her right shoulder, wrist, and digits with intact sensation and 2+ radial pulse. A right elbow x-ray reveals a right supracondylar humerus fracture with posteriorly displaced fracture fragments.
She was referred to the emergency department for further evaluation and treatment.
PICO Question:
Do serial radiographs change the postoperative management of stable supracondylar humerus fractures in pediatric patients following closed reduction and percutaneous pinning?
Search Strategy:
| P | I | C | O |
| Pediatric patients with supracondylar humerus fracture | Serial post-operative radiographs | Management | |
| Supracondylar humerus fracture in children | Radiographs at 1 week and 3 weeks post-op | Change in management | |
| Pediatric SCH fracture | Radiographs after fracture repair | Revision surgery | |
| Serial radiographs after closed reduction and percutaneous pinning (CRPP) | Pin adjustment |
PubMed
- Serial radiographs pediatric supracondylar humerus fracture
- 2 results
- Utility of routine postoperative radiographs supracondylar humerus fracture
- 4 results
Google Scholar
- Utility of serial radiographs in pediatric supracondylar humeral fracture
- 3,900 results
- Filters: Exclude patents and citations, sort by relevance, published between 2015 and 2020
- 1,310 results
- Serial radiographs in postoperative management of supracondylar humerus fracture
- 6,510 results
- Filters: Exclude patents and citations, sort by relevance, published between 2015 and 2020
- 1,560 results
Cochrane Library
- Serial radiographs in postoperative supracondylar humerus fracture management
- 0 results
- Serial radiographs in postoperative supracondylar humerus fracture
- 0 results
- Radiographs in postoperative supracondylar humerus fracture
- 0 results
Trip Database
- P – Pediatric supracondylar humerus fracture
- I – Serial postoperative radiographs
- C –
- O – Management
- 13 results
Articles Chosen:
A Systematic Review of the Utility of Postoperative Imaging in the Management of Pediatric Supracondylar Humerus Fractures
Zusman, N. L., Barney, N. A., Woelber, E., & Yang, Scott. (2020). A systematic review of the utility of postoperative imaging in the management of pediatric supracondylar humerus fractures. Journal of Pediatric Orthopaedics; 40(6), 430 – 434.
Background:
Recently published studies call into question the clinical utility of postoperative radiographs in the management of pediatric supracondylar humerus (SCH) fractures. This topic has been addressed as part of the American Academy of Orthopaedic Surgeons Appropriate Use Criteria, although recommendations regarding serial radiographs were not included as part of the discussion. The purpose of this systematic review is to summarize the recent literature regarding the utility of postoperative radiographs as part of the management of SCH fractures.
Methods:
A systematic review of the literature published between January 1, 2000 and December 31, 2017 was conducted using PubMed/MEDLINE and SCOPUS databases to identify studies relevant to postoperative management of SCH. Eight studies met the inclusion criteria, from which data pooled estimates and an analysis of heterogeneity were calculated.
Results:
The pooled estimate of changes in fracture management on the basis of postoperative radiographs was 1% (0.98±0.33). Significant interstudy heterogeneity was observed with an I2 test statistic of 76%. Changes in fracture management included prolonged immobilization following pin removal and return to the operating room.
Conclusions:
There is a paucity of articles focusing on the utility or appropriate use of postoperative radiographs in changing management of SCH fractures, one of the most common upper extremity fractures in children. There is a very low rate of change in management on the basis of imaging, and frequently authors commented that the management change could have been prompted without routine serial radiographs. The cumulate findings of these studies suggest routine postoperative radiographs after SCH fractures are infrequently associated with changes in management. Practitioners should consider postoperative protocols with the intention of identifying early postoperative alignment loss or when the complication is suspected to prevent excessive routine radiography in the management of pediatric SCH fractures.
The Utility of the Early Postoperative Follow-Up and Radiographs After Treatment of Supracondylar Humerus Fractures in Children
Acosta, A. M., Li, Y. J., Bompadre, V., Mortimer, A., Trask, M., & Steinman, S. E. (2019). The utility of the early postoperative follow-up and radiographs after treatment of supracondylar humerus fractures in children. Journal of Pediatric Orthopedics; 40(5), 218 – 222.
https://pubmed.ncbi.nlm.nih.gov/31368922/
Background:
Supracondylar humerus (SCH) fractures are common elbow injuries in pediatric patients. The American Academy of Orthopedic Surgeons published guidelines for the standard of care in the treatment of displaced SCH fractures, however, no recommendations for follow-up care were made. With the recent push to eliminate unnecessary radiographs and decrease health care costs, many are questioning postoperative protocols. The purpose of our study was to evaluate the utility of the 1-week follow-up appointment after closed reduction and percutaneous pinning (CRPP) of displaced SCH fractures.
Methods:
A retrospective review performed at a single institution from 2014 to 2016 included patients under 14 years of age with a closed, displaced SCH fracture treated with CRPP. Exclusion criteria included patients without complete clinical or radiographic follow-up. Variables examined included time to initial follow-up, change in treatment plan after 1-week x-rays, complications, demographics, fracture type, pin number and configuration, reduction parameters, immobilization, time to pin removal, duration of casting, and clinical outcome.
Results:
A total of 412 patients were divided into 2 groups based on time to initial follow-up. Overall, 368 had an initial follow-up at 7 to 10 days (group 1) and 44 at 21 to 28 days (group 2). There was no difference in age, sex, fracture type, pin configuration, or a number of pins between groups. Statistically significant findings included time to initial follow-up and days to pin removal (group 1 at 26.2 d vs. group 2 at 23.8 d), type of immobilization (group 1 with 5% circumferential casts and group 2 with 70%), and time to surgery (26.2 vs. 62.9 h, respectively). There was no significant difference in complication rates and only a 0.5% rate of change in management in group 1.
Conclusions:
Early postoperative follow-up and radiographs did not change the patient outcome and might be eliminated in children with displaced SCH fractures treated with CRPP. Given the current focus of on efficiency and cost-effective care, eliminating the 1-week postoperative appointment would improve appointment availability and decrease medical cost.
Postoperative Radiographs After Pinning of Supracondylar Humerus Fractures: Are They Necessary?
Karamitopoulos, M. S., Dea, E., Littleton, A. G., & Kruse, R. (2012). Postoperative radiographs after pinning of supracondylar humerus fractures: Are they necessary? Journal of Pediatric Orthopaedics; 32(7), 672 – 674.
Background:
The purpose of this study was to evaluate the necessity of early postoperative radiographs after pinning of supracondylar humerus fractures by determining both the percentage of patients who displayed change in fracture fixation and whether these changes affected their outcome.
Methods:
A series of 643 consecutive patients who underwent operative management of Gartland type II and III fractures at our institution between January 2002 and December 2010 were reviewed. Demographic data were obtained through chart review, including age, sex, extremity, fracture type, and mechanism. Intraoperative fluoroscopic images were compared with postoperative radiographs to identify changes in fracture alignment and pin placement.
Results:
A total of 643 patients (320 females, 323 males) with a mean age of 6.1 years (range, 1.1 to 16.0) were reviewed. Fifty-seven percent of fractures were classified as type II and 43% were type III. The overall complication rate was 8.8% (57/643). Pin backout or fracture translation was seen in 32 patients (4.9%) at the first postoperative visit. All of these patients sustained type III fractures. One of these patients required further operative management. Patients with changes in pin or fracture alignment did not demonstrate a statistically significant difference in time to first postoperative visit (P=0.23), days to pin removal (P=0.07), or average follow-up time (P=0.10). Fracture severity did not correlate with change in alignment (P=0.952). No postoperative neurological complications were observed in patients with alignment changes.
Conclusions:
Mild alignment changes and pin migration observed in postoperative radiographs after pinning of supracondylar humerus fractures have little effect on clinical management parameters or long-term sequelae. Radiographs can therefore be deferred until the time of pin removal provided adequate intraoperative stability was obtained.
The Utility of Routine Postoperative Radiographs After Pinning of Pediatric Supracondular Humerus Fractures
Karalius, V. P., Stanfield, J., Ashley, P., Lewallen, L. W., DeDeugd, C. M., Walker, J., Larson, A. N., & Milbrandt, T. A. (2017). The utility of routine postoperative radiographs after pinning of pediatric supracondylar humerus fractures. Journal of Pediatric Orthopaedics; 37 (5), 309 – 312.
Background:
The purpose of this study was to determine the frequency with which postoperative radiographs resulted in a change in management following closed reduction and percutaneous pinning of displaced pediatric supracondylar humerus fractures. We hypothesize that only the initial postoperative radiograph will lead to changes in management of operative supracondylar humerus fractures.
Methods:
A retrospective review was performed at 2 level I pediatric trauma centers. Inclusion criteria were patients below 18 years of age who sustained supracondylar humerus fractures (Gartland type II, III, IV) who were operatively treated from 2008 to 2013 with adequate radiographic follow-up. Patients with flexion type, intra-articular, transphyseal, and open fractures were excluded from the study. Routine radiographs were taken at initial follow-up (1 wk postoperatively) and at pin removal (3 to 4 wk postoperatively).
Results:
The final analysis included 572 patients. Initial postoperative radiographs changed treatment in 9 patients (1.6%), including revision surgeries, 2 pin adjustments, and 2 early pin removals. At the time of pin removal, 20 (3.5%) patients required further immobilization. There were no changes to the initial plan for continued nonoperative treatment at final follow-up (6 to 8 wk postoperatively).
Conclusions:
In this large retrospective series of patients treated with closed reduction and percutaneous pinning of displaced supracondylar humerus fractures, radiographs at 3 weeks do not reveal a need to return to the operating room or other significant pathology. These findings suggest that radiographs should be obtained within 7 to 10 days postoperatively for type III fractures and may only need to be repeated if the clinical situation warrants it, such as severe fracture pattern, persistent pain, or clinical deformity.
Summary of the Evidence:
| Author (Date) | Level of Evidence | Sample/Setting
(# of subjects/ studies, cohort definition etc. ) |
Outcome(s) studied | Key Findings | Limitations and Biases |
| Zusman, N. L., Barney, N. A., Woelber, E., & Yang, Scott (2020) | Systematic Review | · 8 studies with a total of 2,815 participants with supracondylar humerus fractures
· All patients under age 18 |
· Primary:
o Postoperative complications o Change in management as a result of postoperative radiographs · Secondary: o Alternate methods of identifying poor healing outcome compared to serial radiography
|
· Loss of reduction was the most common post-op complication, followed by inadequate healing and pin migration, and, more rarely, deep infection.
· Postoperative SCH fracture management, including a greater length of time of immobilization and follow-up surgery, as a result of radiographic imaging occurred only about 1% of the time (CI 0.98 +/- 0.33). · Many of the article authors found that the complications and need for change in management could have been elucidated through physical exam and other means instead of radiographs |
· There was some heterogeneity found within the studies
· Small number of articles and relatively small number of participants |
| Acosta, A. M., Li, Y. J., Bompadre, V., Mortimer, A., Trask, M., & Steinman, S. E. (2019) | Retrospective cohort study | · 412 pediatric participants with supracondylar humerus fractures
o Group 1: 1st post-op visit and x-ray in week 1, 2nd visit, x-ray, and pin removal in 3-4 weeks post-op, n = 368 o Group 2: 1st post-op visit, x-ray, and pin removal in 3-4 weeks, n = 44 |
· Time to initial follow-up
· Change in treatment plan after 1-week post-op radiographs · Complications · Demographics · Fracture type · Pin number and configuration · Reduction parameters · Immobilization · Time to pin removal · Duration of casting · Clinical outcome |
· No significant difference in patient outcome or change in post-op management regardless of whether they had the 1-week follow-up visit
· Eliminating 1-week follow up could have improved outcomes in terms of appointment availability and medical costs |
· Small sample size |
| Karamitopoulos, M. S., Dea, E., Littleton, A. G., & Kruse, R. (2012) | Retrospective cohort study | · 643 pediatric patients with supracondylar humerus fractures
o 320 female, 323 male o Mean age 6.1 years o 57% type II fractures, 43% type III |
· Primary:
o First follow-up visit and radiograph o Changes in management o Patient outcome |
· No significant difference in complications or changes in management and patient outcome dependent on whether patents followed up within 10 days of surgery or if delayed imaging to 3-4 weeks
· Recommended that postoperative radiographs can be deferred without significant risk of complication until anticipated time of pin removal in patients with stable fractures |
· Included in the initial systematic review
· Small sample size · “Early” follow-up is quantified as within 10 days, but there is no standardization for when “late” follow-up is apart from stating that it is at the time of pin removal |
| Karalius, V. P., Stanfield, J., Ashley, P., Lewallen, L. W., DeDeugd, C. M., Walker, J., Larson, A. N., & Milbrandt, T. A. (2017) | Retrospective cohort study | · 572 pediatric patients with supracondylar humerus fractures from 2 different sites | · Baumann angle
· Mean time to initial follow up and pin removal · Frequency of revision and change in management |
· Mean initial follow-up in 7.58 days and pin removal in 26.1 days
· No significant change in management or additional intervention as a result of the 3-week follow up · No significant benefit in follow-up radiographs after the initial follow-up 7-10 days after closed reduction and percutaneous pinning |
· Multiple surgeons at two different sites creates a lack of standardization based on different techniques
· No long-term follow-up · Larger sample size than other similar studies, but still relatively small · Included in the systematic review |
Conclusion(s):
Article 1 – Serial radiographs following closed reduction and percutaneous pinning of stable supracondylar humerus fractures in pediatric patients rarely lead to a change in management or prolonged immobilization. Radiographs should be taken at either early (7-10 days) follow-up or at the time of pin removal. Physical exam and other procedures can be used to determine the necessity for an adjustment in treatment
Article 2 – Early post-operative follow-up and radiographs had no significant impact on patient outcome and change in management and may therefore be unnecessary, allowing for lower medical costs and better appointment availability.
Article 3 – Radiographs at the 1-week post-operative visit had little impact on fracture management and can therefore be deferred until the time of pin removal.
Article 4 – Radiographs at the 3-week follow up at the time of pin removal did not change the management in the clinically significant majority of cases. Physical exam maneuvers can be used to assess the need for a change in management.
Given the currently available literature addressing the necessity of multiple post-operative radiographs in the evaluation and management of supracondylar humerus fractures in the pediatric population, albeit a small number of articles, it appears that serial postoperative radiographs are not necessary and do not change the fracture management in stable fractures.
Therefore, in the interest of minimizing radiation exposure and medical costs cost as well as maximizing potential appointment availability with orthopedic specialists, radiographs and follow-up should be conducted 3-4 weeks post-op at the time of pin removal for stable supracondylar humerus fractures. Patients with unstable or questionably stable fractures after fracture repair surgery should follow-up within a week to minimize any complications inherently tied to this instability.
Clinical Bottom Line:
Weight of the Evidence
Being that the first article is a systematic review and the most recently published, I would weigh that the most in forming a clinical bottom line. As the highest level of evidence published so recently, the authors were able to review the most current research and look at the greatest number of data points to come to a conclusion. Next I would weigh the third article because of its greater sample size and the different number of variables it took into account. Third, I would weigh article 4 because of its sample size and the fact that they looked into physical exam findings as an alternative means of determining the need for a change in management. Finally, I would weigh article 2 because of its smaller sample size. Articles 2 and 4 also are lower in the weighing process because of the fact that they are included in the systematic review; this helps to ensure that the clinical bottom line is not biased in that these two articles would count disproportionately in the decision.
Magnitude of Any Effects
All the articles found that there is no significant benefit to having multiple radiographs at the 1 week and 3-4 week follow-up following closed reduction and percutaneous pinning for stable supracondular humerus fractures.
Clinical Significance
Since there was no clinical benefit in serial radiographs, stable fractures can be imaged at the 3-4 week follow up for pin removal. Otherwise, physical exam findings are sufficient in determining the need for a change in management. This will lower medical costs, improve appointment availability for cases that need more emergent or closer follow-up, and reduce the radiation exposure in the pediatric population. Unstable fractures should be followed-up at the early post-operative visit with radiographs or at the discretion of the practitioner.
Other Considerations
Currently there is not much evidence available for this topic, particularly in the pediatric population. More higher-level evidence should be conducted to get a clearer idea of the utility of serial radiography in the management of pediatric fractures.
Supracondylar humerus fractures are among the most common upper extremity fractures requiring operative management in the pediatric population. While closed reduction with percutaneous pinning as the method of operative management has been well-defined, there is little to no guideline concerning the postoperative management in terms of follow-up and radiography. Thus, it has become routine for pediatric patients to undergo serial radiography at 1- and 3-4-weeks post-op and following percutaneous pin removal. The necessity of this repeated radiation exposure therefore must be examined.
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