Supracondylar fractures are the most frequently occurring paediatric fractures about the elbow and may be associated with a neurovascular injury. The British Orthopaedic Association Standards for Trauma 11 (BOAST 11) guidelines describe best practice for supracondylar fracture management. This study aimed to assess whether emergency departments in the United Kingdom adhere to BOAST 11 standard 1: a documented assessment, performed on presentation, must include the status of the radial pulse, digital capillary refill time, and the individual function of the radial, median (including the anterior interosseous), and ulnar nerves.
Materials and Methods
Stage 1: We conducted a multicentre, retrospective audit of adherence to BOAST 11 standard 1. Data were collected from eight hospitals in the United Kingdom. A total of 433 children with Gartland type 2 or 3 supracondylar fractures were eligible for inclusion. A centrally created data collection sheet was used to guide objective analysis of whether BOAST 11 standard 1 was adhered to. Stage 2: We created a quality improvement proforma for use in emergency departments. This was piloted in one of the hospitals used in the primary audit and was re-audited using equivalent methodology. In all, 102 patients presenting between January 2016 and July 2017 were eligible for inclusion in the re-audit.
Stage 1: Of 433 patient notes audited, adherence to BOAST 11 standard 1 was between 201 (46%) and 232 (54%) for the motor and sensory function of the individual nerves specified, 318 (73%) for radial pulse, and 247 (57%) for digital capillary refill time. Stage 2: Of 102 patient notes audited, adherence to BOAST 11 standard 1 improved to between 72 (71%) and 80 (78%) for motor and sensory function of the nerves, to 84 (82%) for radial pulse, and to 82 (80%) for digital capillary refill time. Of the 102 case notes reviewed in stage 2, only 44 (43%) used the quality improvement proforma; when the proforma was used, adherence improved to between 40 (91%) and 43 (98%) throughout.
Adherence to BOAST 11 standard 1 is poor in hospitals across the country. This is concerning as neurovascular deficit may be an indication for emergent surgery, and missed neurovascular injury can cause long-term, or even permanent, functional impairment. We present a simple proforma that improves adherence to this standard, can easily be implemented into emergency departments, and may improve patient safety.
Cite this article: Bone Joint J 2018;100-B:346–51.
Supracondylar fractures of the humerus are the most common fracture around the elbow in children.1 The Gartland classification2 is still widely used to describe supracondylar fracture patterns, and Gartland commented that “It is interesting to see the trepidation with which men, otherwise versed in trauma, approach a fresh supracondylar fracture”.2 Such trepidation arises from complications that may accompany this fracture pattern. Between 10% and 20% of displaced supracondylar fractures (Gartland type 2 or 3) can be associated with neurovascular compromise.3,4 Traumatic neuropraxia occurs in 11% of patients, affecting the radial, median, ulnar, and, most frequently, the anterior interosseous nerve.4 An absent radial pulse on presentation causes complication in approximately 7% of patients.5 Neurovascular injury can be an indication for urgent surgery, and as such needs timely and accurate recognition.6 In addition, children with Gartland type 2 or 3 supracondylar fractures are at an increased risk of long-term functional impairment, including alteration of the carrying angle, reduced elbow range of movement, and ulnar nerve sensitivity.7
The British Orthopaedic Association (BOA) has published standards for the treatment of supracondylar fractures in children (BOAST 11).8 We have conducted a multicentre retrospective audit with the aim of assessing whether emergency departments (EDs) and orthopaedic teams in the United Kingdom are adhering to BOAST 11 standard 1: “A documented assessment of the limb, performed on presentation, must include the status of the radial pulse, digital capillary refill time and the individual function of the radial, median (including anterior interosseous) and ulnar nerves.”8
This paper presents results from 433 patients in eight hospitals audited nationwide. Re-audit results on a further 102 patients are presented following a pilot of a quality improvement implementation.
Materials and Methods
Stage 1: primary audit
Data collectors were recruited using the online networking platform British Orthopaedic Network Environment (BONE).9 The background, aims, and objectives of the audit are outlined on the BONE webpage such that potential data collectors have sufficient information to permit application for recruitment. Successful applicants for data collection received central training on the audit process. They required the supervision of a Consultant in Emergency Medicine or Orthopaedics local to the hospital they were auditing.
Inclusion criteria: Any children attending the ED with a supracondylar fracture (Gartland type 2 or 3) over the preceding three years were eligible for inclusion. Data were collected between January 2015 and May 2016 across eight hospitals in the United Kingdom. International Classification of Disease (ICD-10) codes for supracondylar fractures (S42.4) were used to develop a list of eligible patients.10 A total of 433 patients were identified for inclusion across the eight hospitals audited. Table I shows the number of patients assessed per hospital.
|Hospital||No. of patients|
|1: Bristol Royal Hospital for Children||71|
|2: Royal United Hospitals Bath||39|
|3: Royal Preston Hospitals||50|
|4: Gloucestershire Royal Hospital||64|
|5: Great Western Hospital||62|
|6: Musgrove Park Hospital||50|
|7: Sandwell General Hospital||36|
|8: Heartlands Hospital||61|
Following central training on how to scrutinize case notes, data collectors retrospectively reviewed the hospital records and information was collected on a standardized form. Any documented assessments made in the ED were accepted and this permitted multiple doctors’ assessments to be included.
Subjectivity in the interpretation of the patient notes was avoided by using an objective scoring system to record the emergency department documentation of aspects of neurovascular function (0 = not documented, 1 = documented and intact, 2 = documented and reduced, 3 = documented and absent).
After removing any patient identifiable data, all the patient records were collated into a single Microsoft Excel (Microsoft, Redmond, Washington) file for data analysis.
Stage 2: Quality improvement and re-audit
After completion of Stage 1, we created a standard proforma to be used in the ED as a quality-improvement measure (Fig. 1). This allowed all the relevant patient details to be collected as well as a pictorial guidance on assessing the neurovascular status, both preoperatively and postoperatively. The proforma was piloted in one of the hospitals audited in Stage 1
ED and orthopaedic medical staff were given a training session on the use of the proforma and copies of the proforma were made easily available for use by the admitting doctor.
The proforma was introduced on 15 January 2016. All children presenting between 15 January 2016 and 13 July 2017 with a Gartland type 2 or 3 supracondylar fracture were eligible for inclusion. In addition, the ED records were retrospectively reviewed and information collected on a standardized form with every effort made to collect the data in a consistent way as in the primary audit.
Data analysis: The extent of the adherence to guideline was calculated manually and tabulated for presentation. Data were then inputted into Microsoft Excel software to permit graphical representation of results, and comparison was made with Stage 1 primary audit results.
Stage 1: results of primary audit
Of the 433 eligible patients identified, a full data set was collected for all. Fewer than 233 patients (55%) had adequate documentation of the motor and sensory function of the relevant nerves (n = 433) (Fig. 2 and Table II). Documentation of radial pulse was only undertaken in 318 patients (73%) and capillary refill time in 247 (57%).
|ED documentation (n = 433)||AIN (motor)||Median (motor)||Radial (motor)||Ulnar (motor)||Median (sensory)||Radial (sensory)||Ulnar (sensory)||Radial pulse||CRT|
|Adherence to guideline (%)||48||52||46||52||54||53||54||73||57|
ED, emergency department; AIN, anterior interosseous nerve; CRT, capillary refill time
Stage 2: Re-audit results
A total of 102 eligible children were identified and a full data set was available for all. Following introduction of the proforma, in only 44 of the 102 (43%) reviewed notes was the proforma actually used. When the proforma was used, adherence to BOAST 11 Standard 1 was between 40 (91%) and 43 (98%) throughout (an improvement of between 39% and 47% for nerves, 22% for radial pulse, and 41% for digital capillary refill time (n = 44)). When the proforma was not used, adherence was between 39 (57%) and 50 (74%) throughout (n = 68) (Fig. 3 and Table III).Overall, adherence to BOAST 11 standard 1 improved to between 72 (71%) and 80 (78%) for motor and sensory function of the appropriate nerves (n = 102), documentation of the radial pulse improved to 84 (82%) and 82 (80%) for digital capillary refill time. (Fig. 3 and Table III).
|ED documentation||AIN (motor)||Median (motor)||Radial (motor)||Ulnar (motor)||Median (sensory)||Radial (sensory)||Ulnar (sensory)||Radial pulse||CRT|
|Adherence to guideline in original audit, % (n = 433)||48||52||46||52||54||53||54||73||57|
|Adherence to guideline, % (n = 102)||78||78||73||74||72||71||72||82||80|
|Improvement, change in %||+30||+26||+27||+22||+18||+18||+18||+9||+23|
|Adherence when proforma used, % (n = 44)||95||95||93||91||98||98||98||95||98|
|Adherence when proforma not used, % (n = 68)||69||71||60||68||59||57||69||74||69|
ED, emergency department; AIN, anterior interosseous nerve; CRT, capillary refill time
Careful documentation of the history and examination of patients is central to providing good medical care,11 and the failure to examine and document the neurovascular status in a timely manner may be detrimental to patient welfare. Neurovascular impairment can be an indication for urgent surgery.12 and a missed neurological injury risks long-term functional impairment. In addition, specific neurological injuries can provide an indication of the injury pattern and severity; for example, median nerve deficit is associated with posterolateral fracture displacement.13 Median nerve injury can also mask the pain of a developing compartment syndrome.14
A large meta-analysis of supracondylar fractures (n = 5154) identified that 12.7% of extension type fractures and 16.6% of flexion type fractures were associated with a traumatic neurapraxia.4 This high frequency of neurapraxia requires a reliable system to assess accurately and document the neurological status of the limb in the ED. Iatrogenic nerve injury has been reported in up to 15% of supracondylar fractures, in particular ulna nerve injury associated with medial placement of a Kirschner wire.15-17 Therefore, the accurate assessment and documentation of neurological status on presentation will help differentiate whether the nerve damage resulted from the fracture or from surgical intervention.
Few systems for assessing patients with suspected supracondylar fractures have been described in the literature. Marsh et al18 introduced a protocol to improve the ED assessment and documentation of neurological status in children presenting with an arm fracture. A simple and memorable phrase “rock, paper, scissors, OK” was used to guide ED doctors’ assessment of the motor function of the median, radial, ulnar, and anterior interosseous nerves respectively. The protocol did not, however, include a sensory or vascular assessment and did not document posterior interosseous nerve function (“thumbs-up” is a reliable sign).19
This study demonstrates that the introduction of a simple proforma can improve the documentation of the neurovascular status in children presenting to the ED with a supracondylar fracture, and is likely to improve patient safety by avoiding missed neurovascular injury. Our re-audit demonstrated that when the proforma was not used (68 of 102 assessments), adequate documentation was much lower than when it was used. We have also noted that adherence was consistently higher than in the primary audit even if the proforma was not used. We believe that education of the ED staff in use of the proforma had a positive effect on the documentation of the neurovascular status, even if the proforma was not actually used. If the proforma was used, then there was an additional positive effect.
Since this audit was undertaken, the proforma has been introduced into a number of EDs across the country. We would encourage all trusts to adopt this simple quality improvement measure.
The major limitation of this study was the low compliance in use of the proforma by ED doctors (44 of a possible 102 assessments; 43%). From qualitative data collected from ED doctors, it would appear that the reason given for the low uptake was the doctor having to leave the patient to find the proforma and so interrupting the consultation. One possible solution to this highlighted issue would be for the triage nurse in ED to place a copy of the proforma in the notes of any child presenting with an elbow injury, which would then be readily available for the ED doctor to use if necessary.
Take home message:
- The British Orthopaedic Association Standards for Trauma 11 (BOAST 11) state that all patients with supracondylar fractures need accurate and timely assessment and documentation of limb neurovascular status.
- We demonstrate consistent shortcomings in adherence to this standard in multiple centres across the UK.
- We present a simple proforma for use in emergency departments, with supporting data demonstrating improvements in adherence to the BOAST 11 standard following its implementation
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1 Cheng JC , Shen WY . Limb fracture pattern in different paediatric age groups: a study of 3,350 children. J Orthop Trauma1993;7:15–22. Google Scholar
2 Gartland JJ . Management of supracondylar fractures of the humerus in children. Surg Gynecol Obstet1959;109:145–154. Google Scholar
3 Louahem DM , Nebunescu A , Canavese F , Dimeglio A . Neurovascular complications and severe displacement in supracondylar humerus fractures in children: defensive or offensive strategy?J Pediatr Orthop B2006;15:51–57. Google Scholar
4 Babal JC , Mehlman CT , Klein G . Nerve injuries associated with pediatric supracondylar humeral fractures: a meta-analysis. J Pediatr Orthop2010;30:253–263. Google Scholar
5 Garbuz DS , Leitch K , Wright JG . The treatment of supracondylar fractures in children with an absent radial pulse. J Pediatr Orthop1996;16:594–596. Google Scholar
6 Omid R , Choi PD , Skaggs DL . Supracondylar humeral fractures in children. J Bone Joint Surg [Am]2008;90-A:1121–1132. Google Scholar
7 Sinikumpu JJ , Victorzon S , Pokka T , et al. . The long-term outcome of childhood supracondylar humeral fractures: A population-based follow up study with a minimum follow up of ten years and normal matched comparisons. Bone Joint J2016;98-B:1410–1417. Google Scholar
8 No authors listed. British Orthopaedic Association Standards for Trauma (BOAST) 11: Supracondylar fractures of the humerus in children. https://www.boa.ac.uk/wp-content/uploads/2014/12/BOAST-11.pdf (date last accessed 07 November 2017). Google Scholar
9 No authors listed. British Orthopaedic Network Environment. http://bone.ac.uk (date last accessed 07 November 2017). Google Scholar
10 No authors listed. World Health Organization. International Statistical Classification of Diseases and Related Health Problems 10th Revision. 2016. http://apps.who.int/classifications/icd10/browse/2016/en (date last accessed 29 November 2017). Google Scholar
11 No authors listed. General Medical Council. Good medical practice 2013. Record your work clearly, accurately and legibly, p9. http://www.gmc-uk.org/Good_medical_practice___English_1215.pdf_51527435.pdf (date last accessed 07 November 2017). Google Scholar
12 Kwok IH , Silk ZM , Quick TJ , et al. . Nerve injuries associated with supracondylar fractures of the humerus in children: our experience in a specialist peripheral nerve injury unit. Bone Joint J2016;98-B:851–856. Google Scholar
13 Lyons ST , Quinn M , Stanitski CL . Neurovascular injuries in type III humeral supracondylar fractures in children. Clin Orthop Relat Res2000;376:62–67. Google Scholar
14 Campbell CC , Waters PM , Emans JB , Kasser JR , Millis MB . Neurovascular injury and displacement in type III supracondylar humerus fractures. J Pediatr Orthop1995;15:47–52. Google Scholar
15 Brauer CA , Lee BM , Bae DS , Waters PM , Kocher MS . A systematic review of medial and lateral entry pinning versus lateral entry pinning for supracondylar fractures of the humerus. J Pediatr Orthop2007;27:181–186. Google Scholar
16 Slobogean BL , Jackman H , Tennant S , Slobogean GP , Mulpuri K . Iatrogenic ulnar nerve injury after the surgical treatment of displaced supracondylar fractures of the humerus: number needed to harm, a systematic review. J Pediatr Orthop2010;30:430–436. Google Scholar
17 Eberl R , Eder C , Smolle E , et al. . Iatrogenic ulnar nerve injury after pin fixation and after antegrade nailing of supracondylar humeral fractures in children. Acta Orthop2011;82:606–609. Google Scholar
18 Marsh AG , Robertson JS , Godman A , Boyle J , Huntley JS . Introduction of a simple guideline to improve neurological assessment in paediatric patients presenting with upper limb fractures. Emerg Med J2016;33:273–277. Google Scholar
19 Cravens G , Kline DG . Posterior interosseous nerve palsies. Neurosurgery1990;27:397–402. Google Scholar
R. Goodall: Designing the study, Project lead, Collecting and analyzing the data, Writing the paper, Quality improvement creation.
E. Wilson: Collecting the data and re-audit data.
H. Claireaux: Designing the study, Project lead, Collecting and analyzing the data, Writing the paper.
J. Hill: Quality improvement creation, Collecting the data.
F. Monsell: Quality improvement creation, implementation, and training, Supervision.
BOAST 11 Collaborative: Collecting the data.
P. Tarassoli: Designing the study, Project lead, Writing the paper, Analyzing the data, Supervision.
BOAST 11 Collaborative: Richard Goodall, Henry Claireaux, Josh Hill, Elizabeth Wilson, Fergal Monsell, Payam Tarassoli. Data collectors: Mark Woodward, Philippa Coull, Charles Baird, Sebastian Green, James Schuster Bruce, Diana Lim, Joanna Miles, Madeleine Bickley, Arjun Odedra, Mushfique Alam.
No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.
This article was primary edited by M. Barry and first proof edited by G. Scott.