Use of paralytic agents during the operative treatment of type III supracondylar humerus fractures in children: A single-center investigation and survey of Pediatric Orthopaedic Society of North America members

Abstract

ABSTRACT: Background: Paralytic agents are occasionally used during the surgical treatment of type III (OTA 13A2) supracondylar humerus fractures (SCHFx) in children depending on surgeon preference. Paralytic agents create a neuromuscular blockade and therefore may potentially help with ease of fracture reduction. Controversy regarding the use of a paralytic agent as an adjunct to anesthesia exists due to potential associated adverse drug reactions, including prolonged paralysis, cardiovascular effects, or electrolyte abnormalities.The purpose of this study was to investigate intraoperative paralytic use in pediatric type III SCHFx and to report survey responses of members of the Pediatric Orthopaedic Society of North America (POSNA) on paralytic use in SCHFx management. Methods: A retrospective chart review identified 319 type III SCHFx treated at our institution (January 2016–May 2019). Patients were assigned to 3 groups: group 1, surgical treatment without a paralytic agent (n = 240); group 2, treatment with rocuronium (n = 43); group 3, treatment with succinylcholine (n = 36). POSNA members were surveyed regarding paralytic use intraoperatively for type III SCHFx (November–December 2021) on paralytic use frequency, request for paralytics, reversal agent use, average time to surgery after injury and/or presentation, effect of time to surgery after injury and/or presentation on when to use a paralytic, annual number of SCHFx surgeries performed, awareness of paralytic complications, and years of surgeon experience. Statistical analysis was performed. Results: Average patient age was 5.2 ± 2.2 years. Group 2 had significant increases in anesthesia duration, surgical duration, fluoroscopic time, and radiation exposure compared to group 1. Group 2 had a higher conversion rate to open reduction than other groups. No statistically significant difference was found among groups in terms of sex, body mass index (BMI), laterality, radiographic measurements, or rates of open procedures or complications. Survey results indicated 32% (24/76) routinely use paralytics during closed reduction maneuvers; 71% (17/24) request administering paralytics at the beginning/before the case; and 33% (8/24) use paralytics in all type III SCHFx. Conclusions: Surgeons at our center reported paralytic use for closed reduction in 25% of patients; similarly, one-third of POSNA survey respondents reported paralytic use during operative management. Although paralytic agents are used during the treatment of supracondylar humerus fractures in children this study was unable to demonstrate an association of advantageous outcomes, such as shorter surgical times. Routine paralytic use to facilitate closed reduction of supracondylar humerus fractures in children warrants further study. Key Concepts: (1) Paralytic agents may be utilized in pediatric supracondylar humerus fracture (SCHFx) surgeries, but their efficacy remains controversial due to associated adverse reactions. (2) Administration of rocuronium during surgery was associated with prolonged anesthesia and surgical durations, as well as increased fluoroscopic time and radiation exposure, suggesting potential drawbacks to its use. (3) Despite common use, the study found no significant correlation between paralytic agent administration and beneficial outcomes such as shorter surgical times. (4) Survey responses revealed varying practices among orthopaedic surgeons regarding paralytic agent use during closed reduction maneuvers for SCHFx. (5) Understanding variations in paralytic agent use among orthopaedic surgeons underscores the importance of future research to guide clinical decision-making. (6) The study highlights the need for standardized protocols and evidence-based practices in the use of paralytic agents for pediatric SCHFx. (7) The findings underscore the need for further research to establish the efficacy and safety of routine paralytic use in pediatric SCHFx surgeries and inform standardized protocols. Level of Evidence: III, Retrospective chart review; Therapeutic study

Keywords

• Supracondylar fracture
• Neuromuscular blockade
• Reduction
• Paralytics
• Children