Cutting edge Orthopedics

14 • CUTTING EDGE - ORTHOPEDICS all Type II fractures may, arguably, be initially treated with CRPP as discussed above [5, 22, 34, 49, 57]. Closed reduction and percutaneous pinning is frequently recommended for Type II fractures with the following features: (1) displaced fracture with the anterior humeral line falling anterior to the capitellum [8, 9] or (2) coronal plane malalignment (decreased Baumann’s angle) or medial column comminution [5, 8, 19, 62]. Fractures that necessitate flexion greater than 90° to main- tain a reduction should undergo CRPP to allow for immobilization with less flexion [5, 19, 63]. Additionally, neurovascular compromise is an indication for CRPP [19, 25, 64]. Timing Displaced supracondylar humerus fractures were previously considered a surgical emergency [63, 65, 66]. Emergent management has been suggested to decrease the risk of neurovascular com- plications [63] and need for open reduction [66]. A multicenter study assessing compartment syndrome noted that ten of the eleven cases reviewed presented with “severe swelling” and were initially treated an average of 22 h after injury. This study suggested that time to management may have played a role in the development of compartment syndrome [67]. However, there are several reports indicating that surgical timing does not increase the rate of perioperative complications [68–75]. Mehlman and colleagues (2001) found no significant differences in conversion to open reduction and internal fixation, pin track infection, iatrogenic nerve injury, or compartment syn- drome between supracondylar humerus fractures treated within 8 h of injury and those treated more than 8 h after injury [68]. Similarly, Gupta and colleagues (2004) used a 12-h cutoff and found no significant differences in rates of open reduction, pin track infection, iatrogenic nerve injury, vascular injury, or compartment syndrome between groups [69]. Larson and colleagues (2014) found no significant difference in major complications following CRPP of Type II frac- tures in a retrospective review using a cutoff of 24 h from injury [75]. Bales and colleagues (2010) performed a prospective assessment of the effects of surgical timing on perioperative complica- tions in children with supracondylar humerus fractures [70]. The children were not randomized, but the outcomes were compared between children who were treated with CRPP within 21 h of presentation at their facility and children treated more than 21 h after presentation. They found no significant differences in rates of open reduction, iatrogenic nerve injuries, vascular compli- cations, compartment syndrome, surgical time, final carrying angle, range of motion, or overall outcome (satisfactory or unsatisfactory) as determined by the surgeon. However, they did note the possibility of bias as injuries that were felt to be more severe could have been treated more quickly since surgical timing was not randomized [70]. Finally, Barrett and colleagues (2014) found no significant difference in time to return of AIN function in patients with isolated AIN palsy in a large, multicenter retrospective study [76]. These findings suggest that AIN injury without sensory changes or concomitant vascular compromise may not be an indication for urgent management [76]. Although the evidence presented above suggests that children with uncomplicated supracon- dylar humerus fractures may be observed for a period of time prior to definitive management, cases involving additional ipsilateral fractures, neurovascular injury or skin or significant soft