Surgeon Learning Curve for Pediatric Supracondylar Humerus Fractures

Background: There has been an increasing trend toward referral of supracondylar humerus fractures in children to pediatric orthopaedic centers. The learning curve for treating this fracture is not well described. Methods: We retrospectively reviewed all supracondylar fractures treated by 21 pediatric orthopaedic fellows over the 2003 to 2009 academic years, with attending cases from 2005 to 2007 to serve as a control. Type IIa, IIb, and III fractures were used in the case count of for each fellows, whereas only type III fractures were used to record fluoroscopy time, operative time, and for radiographic review. Nonideal reduction was defined as a Baumann angle outside the range of 64 to 81 degrees, or an anterior humeral line that does not intersect the capitellum. Results: Of the 654 total operatively treated fractures, fellows treated 479 total and 213 type III fractures. Backup attendings were present in the operating room for 39% of type III fractures in the first academic quarter before falling to a baseline of 10% to 20% during the remaining quarters. Fluoroscopy time and operative time were consistent for fellows throughout the year. Nonideal reductions increased notably at case 7, correlating with increased fellow independence in the operating room, with reversal of the trend at case 15. There were no differences in complication rates and no malunions requiring osteotomy. Conclusions: In order to balance training and patient care, we recommend the availability of an attending backup surgeon for the first 15 cases of supracondylar humerus fractures treated by pediatric orthopaedic fellows.