ELIMINATING ROUTINE POSTOPERATIVE RADIOGRAPHS FOR SURGICALLY MANAGED PAEDIATRIC SUPRACONDYLAR HUMERUS FRACTURES

The purpose of this study was to prospectively evaluate the rate at which follow-up radiographs altered management plans in surgically-managed paediatric supracondylar humerus (SCH) fractures that were intra-operatively stable following closed reduction and percutaneous pinning (CRPP). From June 2020 until May 2022, all SCH fractures managed with CRPP a single paediatric academic tertiary care hospital were identified. Our routine post-operative care pathway included an initial post-operative visit at 3 weeks for splint and wire removal followed by radiographs, and a clinical assessment. At the 3-week follow-up visit, clinicians were asked to document their management decision before evaluating the post-operative radiograph. A further clinical review, without radiographs, occurred at 12 weeks. Patients were excluded from the pathway and received individualized treatment plans if the treating surgeon was concerned with stability after CRPP based on intra-operative fluoroscopic examination; if the patient had an open fracture; or if the patient required an open reduction. Patients were excluded if their charts failed to document whether the patient was safe for the routine pathway, or if they incurred complications that were identified at unscheduled post-operative visits (e.g. for infection). Patients whose radiographs were evaluated before a treatment decision was documented were also excluded from analysis. Intervention after pin removal due to radiographic findings was the primary outcome variable of interest (e.g. additional immobilization, radiographs ordered at 12 week visit, etc.). 623 patients underwent surgical management for SCHF during the study period. 140 patients were excluded; 27 patients were deemed unsafe for the routine post-operative pathway based on intra-operative stability assessment after fixation, 3 patients with open fractures, 15 patients requiring open reduction, 31 with incomplete documentation of suitability for the pathway, 62 whose radiographs were evaluated before a treatment decision was document, and 2 patients were developed a post-operative infection at an unscheduled visit. 483 patients were Included in the final analysis. Radiographs altered management in 3 patients (0.6%). 2 patients had slow callous formation (1 placed in a splint for a further week, 1 had an additional visit with radiographs ordered at 6 weeks). 1 patient was identified as having cubitus varus on radiographs and additional radiographs were ordered for the scheduled 12-week visit. Subgroup analysis demonstrated that radiographs altered management in 0/188 (0%) type 2 SCH fractures, in 2/239 (0.8%) type 3 SCH fractures, and in 1/47 (2%) of type 4 SCH fractures. There is minimal utility to routine post-operative follow-up radiographs following uncomplicated CRPP of SCH fractures. Any post-operative imaging should be reserved for patients who have questionable intra-operative stability following fracture fixation or those with concerns identified on clinical examination. We have removed all post-operative radiographs from our routine post-operative care pathway for Type 2 and 3 SCH fractures. By eliminating routine post-operative radiographs for the vast majority of SCH fractures, we will decrease the time and financial burden on families and the healthcare system without negatively impacting patient outcomes.