Missing the Deadline: Predictors of Surgical Delay Beyond 18 Hours in Pediatric Supracondylar Humerus Fractures

INTRODUCTION: A common national pediatric hospital ranking program utilizes treatment of supracondylar humerus fractures (SCHFx) within 18 hours of presentation as a quality metric when evaluating institutions. However, prior investigations have demonstrated that an arbitrary cutoff of <18 hours has no impact on patient outcomes. The present study aimed to identify clinical and systemic predictors of surgical delay beyond 18 hours following presentation to the emergency department (ED). We hypothesized that evening presentation to the ED and increased injury severity would delay patient care. METHODS: We identified 450 patients who underwent surgical treatment for SCHFx between 2013 and 2024. The primary outcome of this study was defined as time to the operating room (OR) following presentation to the ED. Descriptive statistics were obtained for demographic variables and injury specifics. Variables that were normally distributed were compared utilizing Student t tests, while non-normally distributed variables were compared using the Mann-Whitney U test. All categorical variables were compared using χ2 or Fisher exact test. A multivariate logistic regression model was utilized to identify predictors of treatment delays. RESULTS: The average age of patients was 6.0±2.4 years, and 51.8% (n=233) were male. Most patients were injured following a fall (n=319, 70.9%), had no vascular injury (n=437, 97.1%), no neurological injury (n=390, 86.7%), and no open injury (n=444, 98.7%). Most patients were referred to our institution (n=311, 69.1%) and arrived at the ED via private transportation (n=324, 72.0%), most commonly in the evening (n=256, 56.9%). Only 72 patients (16.0%) experienced surgical delay beyond 18 hours, while the average time to the OR was 12.2±5 hours. On multivariate analysis, evening ED arrival (OR=3.44, 95% CI: 1.87-6.34, P<0.001) and high Gartland severity (OR=2.39, 95% CI: 1.21-4.74, P=0.013) were independent predictors of surgical delay. DISCUSSION: The present study showed that surgical delays for SCHFx repair are driven by predictable system issues and clinical findings. High Gartland severity and evening ED arrival were predictors of delay. Higher-severity cases were more likely to exceed the proposed time to treatment threshold, likely secondary to interfacility transfers and the need for postoperative admission. National quality metrics for pediatric supracondylar humerus fractures should be grounded in clinical outcomes, which are more reflective of the quality of care delivered. LEVEL OF EVIDENCE: Level III.