Surgical Timing and Approach in Gartland Type III Supracondylar Humerus Fractures in Children: Does After-Hours Surgery Influence Clinical and Radiological Outcomes? A Retrospective Cohort Study

Background/Objectives: Gartland Type III supracondylar humerus fractures (SCHFs) represent the most surgically challenging pediatric elbow injuries, yet controversy persists regarding whether the timing of surgery, specifically after-hours versus working-hours operations, influences clinical and radiological outcomes. This study aimed to compare the functional, cosmetic, and radiological outcomes of Gartland Type III SCHFs managed during working hours versus after hours, with a secondary analysis incorporating the surgical approach (open vs. closed reduction). Methods: A retrospective cohort study was conducted, including 91 pediatric patients who underwent surgical treatment for Gartland Type III SCHFs between January 2020 and June 2025. Patients were stratified into working-hours (n = 48) and after-hours (n = 43) groups. Outcomes were assessed using Flynn’s criteria, radiological parameters, range-of-motion measurements, and complication rates. A secondary subgroup analysis was performed across four groups formed by combining surgical timing and approach. Results: The mean patient age was 70.36 ± 32.97 months with a mean follow-up of 28.07 ± 14.66 months. The time to surgery was significantly shorter in the working-hours group (median 16.0 h; IQR 13.5–20.0) compared with the after-hours group (median 20.0 h; IQR 17.0–27.0) (p = 0.009). No significant differences were observed between the two groups with respect to functional outcomes, cosmetic outcomes, radiological parameters, or overall complication rates (all p > 0.05). However, four-group subgroup analysis revealed a significant difference in Flynn’s functional outcomes (p = 0.019), with the after-hours open reduction subgroup demonstrating a lower rate of excellent results (76.92%) compared with the remaining subgroups (96.88–100%). Conclusions: Working-hours versus after-hours surgical timing alone does not significantly alter clinical or radiological outcomes in Gartland Type III SCHFs. However, the combination of after-hours surgery with open reduction appears to be associated with inferior functional outcomes and a trend toward higher complication rates, suggesting that open reduction for complex fractures should preferably be performed during working hours when optimal theatre conditions and experienced senior surgical teams are readily available.