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Mlinde, Elijah BSc(Ortho&Trauma)1; Amlani, Lahin M. BSc2,3; May, Collin J. MD, MPH2,4,5; Banza, Leonard N. MBBS, FCS(ECSA)6; Chokotho, Linda MBBS, FCS(ECSA), MPH7; Agarwal-Harding, Kiran J. MD, MPH2,a
1Department of Orthopedics, Nkhotakota District Hospital, Nkhotakota, Malawi
2Harvard Global Orthopaedics Collaborative, Boston, Massachusetts
3Johns Hopkins University School of Medicine, Baltimore, Maryland
4Department of Orthopaedics, Boston Children’s Hospital, Boston, Massachusetts
5Department of Orthopaedic Surgery, Harvard Medical School, Boston, Massachusetts
6Department of Orthopedics, Kamuzu Central Hospital, Lilongwe, Malawi
7Department of Surgery, Queen Elizabeth Central Hospital, Blantyre, Malawi
aEmail for corresponding author: [email protected]
Investigation performed at the Department of Orthopaedics, Nkhotakota District Hospital, Nkhotakota, Malawi, and the Harvard Global Orthopaedics Collaborative, Boston, Massachusetts
Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (https://links.lww.com/JBJSOA/A310 ).
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Displaced supracondylar humeral fractures (SCHFs) benefit from closed reduction and percutaneous pinning. In Malawi, many SCHFs are treated nonoperatively because of limited surgical capacity. We sought to assess clinical and functional outcomes of nonoperatively treated SCHFs in a resource-limited setting.
We retrospectively reviewed all patients with SCHFs treated at Nkhotakota District Hospital (NKKDH) in Malawi between January 2014 and December 2016. Patients subsequently underwent clinical and functional follow-up assessment.
We identified 182 children (54% male, mean age of 7 years) with an SCHF; 151 (83%) of the fractures were due to a fall, and 178 (98%) were extension-type (Gartland class distribution: 63 [35%] type I, 52 [29%] type II, and 63 [35%] type III). Four patients with type-I fractures were treated with an arm sling alone, and 59 were treated with straight-arm traction to reduce swelling and then splint immobilization until union. All 119 of the patients with Gartland type-II and III or flexion-type injuries were treated with straight-arm traction, manipulation under anesthesia without fluoroscopy, and then splint immobilization until union. A total of 137 (75%) of the patients were available for follow-up, at a mean of 3.9 years after injury. The Flynn functional outcome was excellent for 39 (95%) with a type-I fracture, 30 (70%) with type-II, and 14 (29%) with type-III. The Flynn cosmetic outcome was excellent for 40 (98%) with a type-I fracture, 42 (98%) with type-II, and 41 (84%) with type-III. Forty (98%) of the children with a type-I fracture, 41 (95%) with type-II, and 32 (65%) with type-III returned to school without limitation. Controlling for sex, delayed presentation, medical comorbidities, injury mechanism, and skin blistering/superinfection during traction, patients with type-II fractures were 5.82-times more likely (95% confidence interval [CI], 1.71 to 19.85) and those with type-III fractures were 9.81-times more likely (95% CI, 3.00 to 32.04), to have a clinical complication or functional limitation compared with patients with type-I fractures.
Nonoperative treatment of type-III SCHFs resulted in a high risk of clinical complications or functional impairment. These results illustrate the urgent need to increase surgical capacity in low-income countries like Malawi to improve pediatric fracture care.
Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.
Trauma-related mortality and disability are increasing in low- and middle-income countries1-3. Approximately 13% of trauma-related deaths worldwide occur among children <15 years of age4. Up to 30 million children and adolescents worldwide are affected by nonfatal injuries annually5. Long-term disability and health-care-associated costs over a lifetime make injuries in children especially devastating, often causing indignity, exclusion, pain, and poverty6-8.
Malawi is a low-income country in sub-Saharan Africa with 18 million people, 44% of whom are children <15 years of age9,10. Malawi has a high and rising incidence of musculoskeletal injury, and one-third of trauma patients are children11-13. Injury-related disability can disrupt children’s education and affect future employment, with substantial economic consequences for patients, their families, and communities12,14,15. Surgery can prevent short- and long-term disability, but access remains inadequate in Malawi because of limited hospital infrastructure, skilled staff, and essential resources15-17.
Supracondylar humeral fractures (SCHFs) are among the most common musculoskeletal injuries in children <16 years of age18,19. For Gartland type-II and III SCHFs, the literature supports surgical treatment with closed reduction and percutaneous pinning20-22. Few studies have examined the management and outcomes of SCHFs treated in low- and middle-income countries, where surgery is often unavailable19. In Malawi, most SCHFs are treated nonoperatively because of limited surgical capacity and expertise23, and patients’ clinical and functional outcomes remain unknown. To improve clinical care and guide surgical system development, we sought to assess outcomes of children with SCHFs treated nonoperatively in a rural Malawian district hospital where only nonoperative treatment was available.
Most health care in Malawi is delivered by public hospitals, organized into 3 levels: (1) health centers, providing basic medical and maternity care, and no surgical care; (2) district hospitals staffed by general doctors and clinical officers (nonphysician clinicians), providing nonspecialized surgical care; and (3) central hospitals, with specialist care23. Nkhotakota District Hospital (NKKDH), in Malawi’s Central region, serves a population of approximately 393,000, of whom about 180,000 are children <15 years of age9. Orthopaedic care is provided by 2 orthopaedic clinical officers trained in nonoperative treatment. NKKDH has 1 operating theater, mainly for obstetric and general surgical cases. There is no fluoroscope. Plaster for splinting/casting is occasionally unavailable16. The closest orthopaedic surgeon is in the capital city, Lilongwe, approximately 200 km away.
From NKKDH inpatient records, we retrospectively identified all children with SCHFs treated between January 1, 2014, and December 31, 2016. Patients with pathologic fractures, open fractures, and congenital musculoskeletal conditions were excluded. Children ≤3 years of age with transphyseal separations and those ≥15 years of age with adult-type distal humeral fractures were excluded. We recorded each patient’s sex, age at presentation, home traditional authority (a district subdivision), and medical comorbidities. We documented injury mechanism, injury characteristics, associated injuries, treatment provided, complications during hospitalization, and timeline from injury to hospital discharge.
All patients were admitted for at least overnight observation. Patients with minimal swelling and displacement were immobilized in a simple arm sling for 3 weeks. For all others, overhead straight-arm traction of the injured limb was used for fracture immobilization and to reduce swelling. To perform straight-arm traction, strips of medical-grade cloth tape were applied to the skin from the proximal forearm to the wrist. The distal ends of the tape strips were attached with an inelastic cord to an overhead beam, suspending the extremity (Fig. 1). Patients were hospitalized and on bed rest while in traction, which was discontinued once swelling subsided, usually in 3 to 7 days. Post-traction radiographs were made; traction effectively reduced swelling but did not substantially change fracture displacement.
Patients with nondisplaced, Gartland type-I injuries were immobilized in a posterior slab plaster splint in 90° to 100° of elbow flexion. Patients with displaced fractures (flexion-type, and Gartland type-II or III extension-type injuries) underwent closed manipulations under general anesthesia, without fluoroscopy. Formal post-procedure radiographs were made, and manipulations were repeated for patients with residual displacement. All patients who underwent manipulations were immobilized in a posterior slab splint: flexion-type injuries in 10° to 15° of elbow flexion, extension-type in 90° to 100° of elbow flexion. All patients were immobilized for at least 3 weeks, or until radiographic evidence of fracture union at the time of follow-up.
We invited patients identified from inpatient records to participate in the follow-up assessment. Patients were contacted by telephone when possible, we made radio announcements, and the first author (E.M.) performed assessments in patients’ homes. All patients or their parents/guardians gave informed consent/assent prior to participation.
Patients were evaluated for infection, neurovascular injury, myositis ossificans, amputation, and Volkmann ischemic contracture. Elbow flexion/extension and carrying angle were measured by goniometer and compared with those of the contralateral, uninjured limb using the Flynn criteria (loss of 0° to 5° = excellent, 6° to 10° = good, 11° to 15° = fair, and >15° = poor) to give functional and cosmetic scores24. Patients scored their functional impairment from 0 to 10, with 0 indicating no impairment and 10 indicating complete inability to perform regular activities in the 7 days prior to assessment. Pain was subjectively quantified from 0 to 10, with 0 indicating no pain and 10 indicating the worst pain possible in the 7 days prior to assessment. Patients were also asked whether they had returned to school and chores and whether return to either was limited by their injury.
All patients were referred to NKKDH for new elbow radiographs at the time of follow-up. We evaluated follow-up radiographs for fracture union and measured Baumann angles.
We used Redivis (Redivis, Inc.) to calculate estimated travel time for each patient from their home traditional authority to NKKDH. We grouped patients by an estimated travel time of <20 or ≥20 minutes; the latter has been associated with increased risk of delayed presentation17. We calculated the time from injury to presentation, treatment start to end, and discharge to follow-up assessment. Patient presentation ≥2 days after injury was considered delayed17.
We analyzed clinical and functional outcomes of patients who underwent follow-up assessment. We defined a “composite poor outcome” as any clinical complication, including neurovascular impairment, elbow stiffness or deformity (less-than-excellent Flynn functional or cosmetic score), abnormal Baumann angle, or any functional impairment or pain. For patients with isolated, extension-type injuries, we performed bivariate analyses using modified Poisson regression to examine associations between Gartland classification and the following outcomes: less-than-excellent Flynn functional score, less-than-excellent Flynn cosmetic score, return to school with limitations due to injury, return to chores with limitations due to injury, and composite poor outcome.
We then performed bivariate analyses using modified Poisson regression to examine associations between composite poor outcome and 10 covariates: age, sex, estimated travel time, delayed presentation, medical comorbidities, mechanism of injury, fracture laterality, Gartland type, complications during hospitalization, and inpatient treatment duration. Covariates with bivariate relative risks (RRs) of >1.25 or <0.8, or with p values of <0.05, were included in multivariate analysis17. The parsimonious model was constructed by sequentially excluding the covariate with an RR closest to 1.0 until all covariates were >1.25 or <0.8.
We performed statistical analysis using SAS 9.4 (SAS Institute). The Malawian National Health Sciences Research Committee gave ethical approval (Protocol #19/03/2265).
This project was supported by a research grant from the AO Alliance Foundation. The funder had no role in the study design or execution, analysis or interpretation of data, or decision to publish.
From January 2014 to December 2016, 182 patients with an SCHF (54% male, mean age of 7 years) were treated at NKKDH. All had closed, unilateral injuries. Most patients (114, 63%) had an estimated travel time of ≥20 minutes, and 17 patients (9%) had delayed presentation. A fall accounted for 151 (83%) of the fractures, 137 (75%) were left-sided, and 178 (98%) were extension-type. Extension-type injuries included 63 Gartland type-I fractures (35%), 52 type-II (29%), and 63 type-III (35%). Two patients had ipsilateral distal forearm fractures. Four patients with type-I fractures were treated with an arm sling alone, and 59 were treated with straight-arm traction and then splint immobilization. All 119 of the patients with Gartland types-II and III or flexion-type injuries were treated with straight-arm traction, manipulation under anesthesia, and then splint immobilization. Patients were hospitalized for a mean of 4.8 days (95% confidence interval [CI], 4.36 to 5.17 days). Eight (4.4%) of the patients had malaria, and 2 (1.1%) had respiratory infections. Skin blistering from tape used for traction and subsequent superinfection—the only reported complication during hospitalization—occurred in 23 (13%) of the patients (Table I).
A total of 137 (75%) of the patients were available for follow-up, at a mean (and standard deviation) of 3.9 ± 0.95 years after injury (median, 4.0 years; range, 2.4 to 5.4 years). Descriptive statistics are summarized in Table I. At the time of follow-up, 1 patient had an anterior interosseous nerve palsy, and 1 had numbness in the ulnar nerve distribution. On follow-up radiographs, 4 (3%) of the patients demonstrated a valgus deformity (Baumann angle of 60° to 62°), and 3 (2%) had a varus deformity (Baumann angle of 82° to 84°) (Table II). Five of the 7 patients with radiographic evidence of malunion had functional limitations/pain at the time of follow-up.
Eighty-seven (64%) of the patients had an excellent Flynn functional score, and 127 (93%) had an excellent Flynn cosmetic score. Flynn scores by Gartland type are reported in Table III. Return to school and chores was limited because of injury for 20 (15%) and 32 (23%) of the children, respectively. Most patients (105, 77%) reported no functional impairment, 27 (20%) reported functional scores of 1 to 2, and 5 (4%) reported scores of 3 to 5. Ninety-one (66%) of the patients reported no pain, 25 (18%) reported pain scores of 1 to 2, and 21 (15%) reported pain scores of 3 to 5. Sixty-one (44.5%) of the patients had a clinical complication or functional limitation at the time of follow-up (composite poor outcome) (Table II). Compared with those with type-I fractures, patients with types-II and III fractures were at greater risk for a less-than-excellent Flynn functional score, return to school/chores with limitations due to injury, and a composite poor outcome. Patients with type-III fractures were also at increased risk for a less-than-excellent Flynn cosmetic score (Table IV).
Girls had a 29% increased risk of a composite poor outcome (RR, 1.29; 95% CI, 0.77 to 2.19) compared with boys. Delayed presentation was associated with a 50% increased risk of a composite poor outcome (RR, 1.50; 95% CI, 0.58 to 3.84). Compared with patients without comorbidities, those with medical comorbidities had a 47% greater risk of a composite poor outcome (RR, 1.47; 95% CI, 0.50 to 4.26). Patients injured playing sports had a 50% greater risk of a composite poor outcome (RR, 1.50; 95% CI, 0.79 to 2.85) compared with those injured from a fall or road traffic collision. Patients with skin blisters with superinfection (early complication) had a 42% greater risk of a composite poor outcome (RR, 1.42; 95% CI, 0.71 to 2.82) compared with those who did not experience early complications. Controlling for sex, delayed presentation, medical comorbidities, mechanism of injury, and early complications, patients with Gartland type-II and III fractures had a significantly increased risk of a composite poor outcome compared with those with type-I fractures (type-II: 5.82 times more likely [RR, 5.82; 95% CI, 1.71 to 19.85]; type-III: 9.81 times more likely [RR, 9.81; 95% CI, 3.00 to 32.04]) (Table V).
SCHFs are common, but few studies have examined outcomes in low- and middle-income countries, where many patients are treated nonoperatively because of limited surgical capacity19,25. In our retrospective assessment of children with closed SCHFs treated nonoperatively at NKKDH in Malawi, we found that patients with Gartland type-II and III fractures had a significantly increased risk of clinical complications and functional impairment compared with patients with type-I fractures.
In our cohort, 54% of the patients were boys, 75% of the patients had left-sided injuries, and 83% were injured by falling, all of which are similar to rates reported in the literature19,25-30. Delayed presentation among pediatric fracture patients has previously been reported to be as high as 28% in Malawi17. However, only 9% of our cohort presented late, possibly because of the debilitating nature of SCHFs and the availability of care at NKKDH. Others have reported that 49% of type-III SCHFs can present with neurovascular compromise, and 3% to 15% can present with absent or diminished pulses31-33. No neurovascular injuries were documented in the inpatient records of our cohort. Two patients had nerve palsies at the time of follow-up, and no patient had dysvascular limbs/amputation or Volkmann ischemic contracture. Neurovascular injuries may have been inadequately documented in the inpatient record, and patients with severe complications may have been lost to follow-up34. In our cohort, 45% of the patients had a composite poor outcome. This was higher than the 25% of patients with unsatisfactory outcomes reported by Sinikumpu et al., although surgery was available to some patients in that cohort35.
Girls, older children, children who lived farther away from the hospital, those who presented late, and those who had medical comorbidities, early complications, sports injuries, and longer hospitalization all had increased risk of a poor outcome. Other studies in low- and middle-income countries have reported worse outcomes for girls, related to underreporting and inequitable access to care36,37. Older children have less potential for bone remodeling, resulting in persistent deformity38. Delayed presentation may result in early fracture consolidation, greater difficulty with fracture reduction, and worse soft-tissue trauma from delayed immobilization, which could potentially worsen outcomes17,39,40. Pediatric fracture patients in Malawi with sports-related injuries and who live farther from the hospital also have increased risk of delayed presentation17. Skin blisters with superinfection occurred in 13% of the patients, which is an unfortunate but expected complication of skin traction, and may be associated with longer time in traction. Longer hospitalization may be associated with severity of fracture displacement and/or soft-tissue injury, both of which predispose patients to worse outcomes41-43.
The literature supports nonsurgical treatment of Gartland type-I fractures and closed reduction and percutaneous pinning of types-II and III fractures21,22,44,45. Patients with type-III fractures in our cohort had significantly increased risk of elbow stiffness, deformity, functional limitation, and pain. Elbow stiffness and deformity are likely due to inadequate reduction and stabilization46-48. Distal humeral physeal injuries may cause abnormal growth and deformity49. In Pakistan, Khan et al. reported that 80% of patients with displaced SCHFs treated with manipulation without fluoroscopy and casting had less-than-excellent Flynn scores, compared with 35% of patients treated surgically in the same resource-limited setting50. We found similarly poor outcomes of nonsurgical care for displaced SCHFs, underscoring the urgent need to improve access to surgery for patients with type-III fractures.
This study had several limitations. First, initial injury radiographs were not available for review for most patients. We relied on patients/families keeping their hardcopy radiographs for review or clinicians’ documentation of fracture characteristics in the record, which was subject to error. Facilities for storing radiographs, whether in hardcopy or electronic form, would facilitate future retrospective studies. Second, lateral elbow radiographs, which are not obtained routinely by Malawian radiology departments, were not made at the time of follow-up, making assessment of sagittal-plane deformity impossible. With 95% of the patients in this study having a normal Baumann angle on follow-up anteroposterior radiographs, manipulation without fluoroscopy, traction, and splint immobilization may effectively correct and maintain coronal alignment. However, 71% of patients with Gartland type-III injuries had loss of elbow range of motion; this suggests a high rate of residual sagittal-plane extension malunion, and may explain some of the poor functional results43,51-53. Third, patient outcomes were not documented in the medical record, requiring us to seek out patients for follow-up assessments; 45 patients (25% of the cohort) were lost to follow-up. A prospective study might have improved follow-up rates. Fourth, data were collected from a single district hospital, limiting generalizability. Moreover, the first author (E.M.), who treated all patients initially, performed all assessments. This may have introduced bias toward underreporting complications or functional impairments. Future studies may benefit from independent assessments by research staff who do not participate in initial patient care. Lastly, all patients were treated nonoperatively, so the effectiveness of surgery in Malawi for SCHFs has not been demonstrated. Future studies should examine the feasibility and outcomes of surgical management of displaced SCHFs in Malawi.
In conclusion, despite its limitations, this study demonstrated unacceptable outcomes in Gartland type-II and III fractures treated nonoperatively in a low-resource setting. Without improving access to operative pinning with fluoroscopy, such poor results cannot be expected to change. There is a need to improve pediatric orthopaedic surgical capacity in Malawi and other similar settings. This will likely require standardization of treatment practices, advanced training of local providers, improved resource procurement, and investment in health-system infrastructure15,16,54-57. In Malawi, operative orthopaedic surgical capacity is present only in central hospitals. Surgical capacity at central hospitals should certainly be strengthened, but resources like Kirschner wires, wire-drivers, and fluoroscopy could also be pooled at select district hospitals, where local providers could be trained to manage SCHFs operatively and offload surgical volume from central hospitals. Future research assessing outcomes and the cost-effectiveness of surgery may further support the need for improvements in surgical capacity and increased access to surgery in countries like Malawi58,59.
Note : The authors thank the staff of Nkhotakota District Hospital, for their support and assistance with this project, and Louise Atadja, for her help with preparing the data collection guide. The authors also express special thanks to all of the patients and their families who participated in this study.
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