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Review Question - QID 214144

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QID 214144 (Type "214144" in App Search)
A 4-year-old healthy male sustained the closed injury shown in Figures A and B after falling from the monkey bars at 9:30 AM while at school. He underwent the procedure shown in Figure C the following day at 11 AM. No peri-operative antibiotics were given. Postoperatively, he was placed in a long arm splint and instructed to follow up in 3 weeks. When the splint was removed at follow up the patient was found to have a pin site infection. Which of the following aspects of his treatment is associated with the highest risk of developing this complication?
  • A
  • B
  • C

Age <4.5 years old

39%

643/1656

Delay in surgical treatment >24 hours

4%

58/1656

>14 days from the time of surgery to first follow up

10%

169/1656

Lack of preoperative antibiotics

34%

570/1656

Lack of pin site care postoperatively

12%

206/1656

  • A
  • B
  • C

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Of the options listed, only younger age has been statistically proven to be associated with a higher incidence of pin site infections.

Supracondylar humerus fractures are one of the most commonly encountered injuries in children, and typically occur between the ages of 5-7 years-old. Treatment for displaced injuries requires closed reduction and percutaneous pinning. Age <4.5 has been the only associated risk factor for pin site infections. Studies have shown no difference in infection rates with and without the use of perioperative antibiotics, delayed treatment or daily pin site care. Overall infection rate is between 1-2.5% and is typically treated with oral antibiotics when identified.

Larson et al reviewed the relationship between timing of treatment and complications in Type II supracondylar humerus fractures. They report on nearly 400 fractures in which 48% were pinned within 24 hours and 52% were pinned >24 hours after injury. They found no different in major complications rates between the two groups. They conclude that there is no increase in nerve injury, stiffness, pin site infection, refracture, or loss of fixation with delayed treatment.

Schroeder et al review the use of postoperative antibiotics after closed reduction and percutaneous pinning of supracondylar humerus fractures. They report 11 surgical site infections in the 618 fractures that were included in their study (1.8%). There was no association between rate of infection and whether postoperative antibiotics were given. They did find an association between patient age and the incidence of pin site infections; the patients diagnosed with pin site infections were statistically younger (4.4 years vs. 5.8 years, p=0.049).

Lu et al review differing pin site care regimens after supracondylar fracture pinning consisting of daily, every other day and once weekly. They report no difference in regards to incidence of severity of pin site infection between groups. They conclude that more frequent pin site care is associated with excessive child fear and parental anxiety.

Kao et al review infection rates in patients performing daily pin care vs no pin care following pinning of supracondylar fractures. They reported a higher infection rate in those patients performing more frequent pin care (57%), compared with only 26% in the non-care group. They conclude that daily pin site care should not be performed.

Figure A and B are the AP and lateral radiographs of an elbow demonstrating a Gartland Type II supracondylar humerus fracture. Figure C demonstrates a divergent pinning technique used for supracondylar humerus fractures.

Incorrect Answers:
Answer 2: There is no difference in pin site infection rates between those patients receiving delayed vs acute treatment.
Answer 3: Time to follow up after surgery has not been associated with increased risk of pin site infections.
Answer 4: Lack of perioperative antibiotics has not been associated with increased pin site infections after closed reduction and pinning of supracondylar fractures.
Answer 5: Daily pin site care is associated with an increase in pin site infections, not a decrease.

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