Clinical and logistical determinants of operative timing, surgical approach, and admission in paediatric supracondylar humerus fractures

Clinical and logistical determinants of operative timing, surgical approach, and admission in paediatric supracondylar humerus fractures | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Clinical and logistical determinants of operative timing, surgical approach, and admission in paediatric supracondylar humerus fractures David Nelson, Alexander Kinstedt, Zachary Sheff, Brett Engbrecht, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9361150/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose: Among children undergoing operative treatment for supracondylar humerus fractures, it is unclear which clinical and presentation characteristics available at triage best predict operative timing, surgical approach, and inpatient disposition. We examined this question using a multivariable approach in a decade of operatively managed fractures at a non–trauma-designated tertiary paediatric referral centre. Methods: We performed a retrospective cohort study of children aged ≤14 years with operatively managed supracondylar humerus fractures at a non–trauma-designated tertiary paediatric referral centre (2010–2020). Candidate predictors included clinical severity (Gartland classification), demographic characteristics, injury mechanism, and logistical presentation factors.. Multivariable Firth logistic regression models were constructed for each primary outcome. Results: Of 242 patients, 160 (66.1%) had high-severity fractures (Gartland III+). These high-severity fractures had lower odds of deferred surgery (3.8% vs 26.8%; aOR 0.08; 95% CI 0.03–0.22), higher odds of open reduction (11.2% vs 2.4%; aOR 4.26; 95% CI 1.02–17.74), and higher odds of inpatient admission (81.2% vs 42.7%; aOR 5.29; 95% CI 2.80–9.99). The overall complication rate was 2.1%. Conclusions: Fracture severity was the dominant predictor of surgical approach, consistent with its established role in operative planning. Operative timing and inpatient admission reflected both clinical severity and logistical presentation factors, suggesting that their intersection — rather than severity alone — shapes the downstream care pathway. Gartland severity may serve as a practical triage signal to support operating room scheduling and bed planning at paediatric referral centres. Supracondylar humerus fracture Gartland classification Paediatric orthopaedics Triage Hospital admission Figures Figure 1 Figure 2 Figure 3 INTRODUCTION Background Paediatric supracondylar humerus fractures are the most common elbow fracture in children, with peak incidence between ages 5 and 7 years [1–3]. Displacement severity is classified using the Gartland system, guiding management from nonoperative treatment to closed reduction and percutaneous pinning, with open reduction reserved for irreducible injuries or neurovascular compromise [1,4–6]. Community hospitals routinely transfer children with displaced fractures to paediatric referral centres, where clinicians must simultaneously coordinate several resource-sensitive decisions: whether surgery proceeds during the index encounter or is deferred, whether open reduction may be required, and whether inpatient admission is likely [7–9]. These decisions compete for shared operating room access, staffing, and inpatient beds, and interfacility transfer carries substantial logistical and financial burden, particularly for fractures that do not require emergent intervention [8]. Clinical severity and operational demand are not independent. Population-level studies show that seasonal variation in fracture displacement severity is associated with fluctuations in operating room utilisation and inpatient admission independent of overall fracture volume [10], and pandemic-era increases in displacement severity coincided with shifts in resource utilisation and transport patterns [11]. Whether this clinical-operational relationship holds at the individual patient level — and which routinely available clinical and presentation characteristics can anticipate the linked decisions of operative timing, surgical approach, and postoperative disposition — has not been well characterised, particularly at non–trauma-designated paediatric referral centres. Objectives We examined which clinical and presentation characteristics available at triage were associated with operative timing, surgical approach, and postoperative disposition in a decade of operatively managed paediatric supracondylar humerus fractures at a non–trauma-designated tertiary referral centre. Primary outcomes were deferred surgery after emergency department discharge, need for open reduction, and inpatient admission. METHODS Ethics statement This study was approved by the institutional review board (No. R20210039) and conducted in accordance with the Declaration of Helsinki. The requirement for informed consent was waived by the institutional review board in view of the retrospective nature of the study, in which all data were collected from existing medical records. Study design and setting This retrospective cohort study examined paediatric patients with supracondylar humerus fractures treated surgically at a tertiary paediatric referral centre in the midwestern United States between January 2010 and December 2020. The study centre served as a regional non–trauma-designated facility throughout the study period. Participants Patients aged ≤14 years presenting within the hospital system were identified using diagnosis and procedure codes. Inclusion required operative management at the study centre and documented Gartland classification. Exclusions were nonoperative management (n=235), surgery at a satellite facility (n=16), scheduled surgery (n=44), and missing Gartland classification (n=87). Scheduled surgery was defined as elective procedures for patients presenting more than 7 days after injury or planned staged procedures following initial nonoperative management at an outside facility, distinct from deferred surgery as defined below. The final cohort included 242 patients (Fig. 1). Data collection Data were abstracted from the electronic medical record into a REDCap database [12,13] by a single reviewer using standardised definitions. Variables included age, sex, race, and primary language; mechanism of injury (fall vs other); presence of neurovascular compromise or multisystem injury on initial examination; Gartland classification abstracted from radiology reports and operative notes using the modified Gartland system [14] and dichotomised as low severity (types I–II) or high severity (types III+); transfer status and arrival time at the study centre; surgical approach (open vs closed reduction); operative time; deferred surgery (operative treatment following discharge from the index emergency department visit with subsequent return); inpatient admission; and intraoperative and postoperative complications identified through operative reports, discharge summaries, and follow-up documentation. Statistical analysis Descriptive statistics are reported as mean (SD) and median (IQR) for continuous variables and frequency (%) for categorical variables. Groups were compared using Wilcoxon rank-sum tests for continuous variables and chi-square or Fisher exact tests for categorical variables. Multivariable logistic regression models were constructed for each primary outcome using Firth's penalised likelihood method to address separation from low event counts [15]. Candidate predictors — including demographic, injury, and presentation variables — were screened using an AIC-based feature-selection approach [16] prior to final model estimation. Model discrimination was assessed using the area under the receiver operating characteristic curve (AUC) with leave-one-out cross-validated predicted probabilities. Complete-case analysis was used (n=239). Analyses were performed using Altair Analytics Workbench (Altair Engineering Inc., Troy, MI, USA) and Python. Figures were generated with the assistance of an artificial intelligence tool (Claude, Anthropic). All figure content was reviewed, revised, and approved by the authors, who take full responsibility for the accuracy and integrity of the work. Additional details regarding modelling decisions are provided in the Supplemental Statistical Note. RESULTS Participants Of 624 paediatric patients identified, 242 met inclusion criteria (Fig. 1); 239 were included in multivariable models. High-severity fractures (Gartland III+) comprised 66.1% of the cohort (160/242). Descriptive data Patient characteristics are presented in Table 1. Mean age was 5.3 years (SD 2.3). Approximately half were male (47.5%), most were White (80.1%) and English-speaking (79.3%), and fall-related injuries accounted for 95.0% of cases. Compared with low-severity fractures, high-severity fractures were more likely to occur in White patients (85.6% vs 69.1%, p=0.004), result from falls (97.5% vs 90.1%, p=0.02), and present with neurovascular compromise (7.5% vs 0%, p=0.01). Over half of patients were transferred from outside facilities (56.6%), with no difference by severity group. Outcome data Surgical and disposition outcomes are presented in Table 2. Open reduction was required in 20 cases (8.3%) and was more common among high-severity fractures (11.2% vs 2.4%, p=0.04). Mean operative time was longer for high-severity fractures (62.5 vs 42.4 minutes, p<0.001) and substantially longer for open versus closed cases (102.5 vs 51.5 minutes). Complications were infrequent overall (2.1%); one intraoperative complication involved pulse loss after pinning requiring vascular exploration, with successful re-fixation. Four postoperative complications occurred, all in high-severity fractures. Deferred surgery occurred in 28 cases (11.6%) and differed markedly by severity (26.8% low-severity vs 3.8% high-severity, p<0.001); among deferred cases, median time to surgery was 1.7 days (IQR 1.1–3.5). Inpatient admission occurred in 165 cases (68.2%) and was more frequent among high-severity fractures (81.2% vs 42.7%, p<0.001), with longer mean time from surgery to discharge (12.1 vs 6.7 hours, p<0.001). Table 1: Patient characteristics by Gartland severity group (n=242) Variable Overall (n=242) Gartland I-II (n=82) Gartland III+ (n=160) p-value Demographics Age, years 5.3 (2.3); 5.0 [4.0, 7.0] 5.3 (2.3); 5.0 [4.0, 6.0] 5.3 (2.3); 5.0 [4.0, 7.0] 0.83 Male, n (%) 115 (47.5%) 38 (46.3%) 77 (48.1%) 0.90 White, n (%) 193 (80.1%) 56 (69.1%) 137 (85.6%) 0.004 English-speaking, n (%) 192 (79.3%) 63 (76.8%) 129 (80.6%) 0.60 Injury Characteristics Gartland type, n (%) Type I Type II Type III Type IV N/A 1 (0.4%) 1 (1.2%) N/A 81 (33.5%) 81 (98.8%) N/A 153 (63.2%) N/A 153 (95.6%) 7 (2.9%) N/A 7 (4.4%) Mechanism, fall, n (%) 227 (95.0%) 73 (90.1%) 154 (97.5%) 0.02 a Neurovascular compromise, n (%) 12 (5.0%) 0 (0.0%) 12 (7.5%) 0.01 a Multisystem injury, n (%) 15 (6.2%) 5 (6.1%) 10 (6.2%) 1.00 Presentation Transfer from outside facility, n (%) 137 (56.6%) 41 (50.0%) 96 (60.0%) 0.18 Arrival hour (shifted, 7am=0) 12.4 (4.3); 12.5 [9.9, 15.3] 11.8 (4.3); 11.9 [9.3, 14.4] 12.7 (4.3); 12.9 [10.4, 15.6] 0.14 Daytime arrival (7am-7pm), n (%) 113 (46.7%) 42 (51.2%) 71 (44.4%) 0.38 Weekend arrival, n (%) 68 (28.1%) 27 (32.9%) 41 (25.6%) 0.30 a Fisher's exact test Table 2: Operative Timing, Surgical Approach, Postoperative Disposition, and Complications by Gartland Severity: N=242 Variable Overall (n=242) Gartland I-II (n=82) Gartland III+ (n=160) p-value Surgical Approach Open reduction, n (%) 20 (8.3%) 2 (2.4%) 18 (11.2%) 0.04 Operative Time OR time, min 55.8 (32.2); 51.0 [37.0, 65.0] 42.4 (15.0); 39.5 [33.0, 49.2] 62.5 (36.1); 56.0 [40.8, 72.2] <0.001 Closed cases (n=222) 51.5 (28.3); 47.5 [36.0, 60.2] 40.9 (11.8); 39.0 [33.0, 48.8] 57.4 (32.7); 53.0 [39.2, 66.8] <0.001 Open cases (n=20) 102.5 (35.4); 94.0 [79.0, 125.8] 100.0 (15.6); 100.0 [94.5, 105.5] 102.8 (37.3); 94.0 [77.0, 127.2] 0.95 Complications Intraoperative complications, n (%) 1 (0.4%) 0 (0.0%) 1 (0.6%) 1.00 a Postoperative complications, n (%) 4 (1.7%) 0 (0.0%) 4 (2.5%) 0.30 a Disposition Inpatient admission, n (%) 165 (68.2%) 35 (42.7%) 130 (81.2%) <0.001 Post-surgery to disposition, hrs 10.3 (9.8); 9.2 [2.5, 13.4] 6.7 (6.7); 3.8 [1.3, 10.3] 12.1 (10.7); 11.0 [5.1, 14.8] <0.001 Discharged same day (n=77) 4.7 (5.4); 1.9 [1.0, 7.9] 4.1 (5.4); 1.8 [1.1, 4.0] 5.5 (5.3); 2.4 [1.0, 9.6] 0.44 Admitted (n=165) 12.8 (10.4); 11.5 [6.2, 15.8] 10.1 (6.7); 9.4 [4.4, 14.3] 13.6 (11.0); 12.2 [7.0, 16.2] 0.09 Timing Delayed surgery, n (%) 28 (11.6%) 22 (26.8%) 6 (3.8%) <0.001 Days from initial discharge to surgery (n=28) 2.5 (2.0); 1.7 [1.1, 3.5] 2.4 (1.9); 1.7 [1.3, 2.8] 2.8 (2.4); 2.5 [1.0, 3.7] 0.81 Inpatient after delayed surgery (n=28) 7 (25.0%) 5 (22.7%) 2 (33.3%) 0.62 a a Fisher's exact test Main results Deferred surgery. High-severity fracture was strongly associated with lower odds of deferred surgery (aOR 0.08, 95% CI 0.03–0.22; p<0.001), consistent with prioritisation of more severe injuries for immediate intervention (Fig. 2, Panel A). Older age (aOR 0.71 per year, 95% CI 0.55–0.91; p=0.006), non-fall mechanism (aOR 0.04, 95% CI 0.001–0.99; p=0.049), and later arrival hour (aOR 0.87 per hour, 95% CI 0.77–0.98; p=0.02) were each associated with lower odds of deferral. Model discrimination was excellent (AUC 0.86, 95% CI 0.80–0.92). Open reduction. Neurovascular compromise (aOR 5.22, 95% CI 1.40–19.44; p=0.01), high-severity fracture (aOR 4.26, 95% CI 1.02–17.74; p=0.047), and non-fall mechanism (aOR 5.38, 95% CI 1.02–28.34; p=0.047) were each associated with open reduction (Fig. 2, Panel B). Model discrimination was acceptable (AUC 0.70, 95% CI 0.61–0.80). Notably, 13 of 20 open reductions (65%) occurred in high-severity fractures from fall mechanisms without neurovascular compromise, suggesting most conversions reflected intraoperative failure of closed manipulation rather than preoperatively identifiable risk. Inpatient admission. High-severity fracture was the strongest predictor of admission (aOR 5.29, 95% CI 2.80–9.99; p<0.001), persisting after adjustment for open reduction (Fig. 2, Panel C). Each additional year of age increased admission odds (aOR 1.18 per year, 95% CI 1.01–1.36; p=0.032); a 10-year-old had approximately twice the odds of admission compared with a 5-year-old (1.18⁵ = 2.29). Later arrival hour also contributed to the model (aOR 1.07 per hour, 95% CI 0.99–1.15; p=0.082). Model discrimination was moderate (AUC 0.78, 95% CI 0.72–0.85). Admission rates increased from approximately 35% for patients arriving mid-morning to over 90% for those arriving late evening (Fig. 3, Panel A). When stratified by severity, this timing effect persisted in the high-severity group while low-severity fractures showed relatively stable admission rates across arrival times (Fig. 3, Panel B). DISCUSSION Key findings In this retrospective cohort of 242 operatively managed paediatric supracondylar humerus fractures, clinical and presentation characteristics available at triage were associated with a linked set of management outcomes spanning operative timing, surgical approach, and postoperative disposition. Fracture severity was the dominant predictor across outcomes, but logistical factors — particularly arrival hour — contributed independently to operative timing and admission. Taken together, these findings suggest that the intersection of clinical severity and presentation logistics, rather than severity alone, shapes downstream resource use at paediatric referral centres. Severity as an operational signal That higher Gartland grade predicts greater operative complexity is well established [1,5,17]. What is less characterised is whether severity at triage also anticipates the broader operational cascade — deferred versus immediate surgery, likelihood of open reduction, and inpatient admission — as a related rather than separate set of decisions. Previous studies have generally examined these endpoints in isolation [6,18,19]. Our findings suggest they are linked, and that fracture severity may serve as an early signal across all three. This is consistent with population-level work showing that elbow fracture severity, independent of fracture volume, is associated with operating room utilisation and admission burden [10]; our data extend that observation to the individual patient encounter. Deferred surgery reflects both clinical severity and logistical timing More than one-quarter of low-severity fractures underwent deferred surgery, compared with fewer than 4% of high-severity fractures — a pattern more consistent with intentional triage than system failure. Deferred cases returned within a short interval (median 1.7 days) with infrequent complications, consistent with prior evidence supporting the safety of scheduled fixation for clinically stable injuries [6,9,20,21]. Importantly, arrival hour was an independent predictor of deferral: later-presenting patients were less likely to be deferred, likely reflecting reduced scheduling opportunity rather than clinical urgency. This suggests that operative timing decisions reflect both the clinical signal of fracture severity and the logistical reality of when patients arrive — a distinction relevant to after-hours resource planning. Open reduction is driven primarily by clinical factors Open reduction was required in 8.3% of cases, consistent with published referral-centre series [1,7]. Clinical factors — high-severity fracture, neurovascular compromise, and non-fall mechanism — were associated with higher odds of open reduction, and logistical variables did not contribute to this model. However, model discrimination was only moderate (AUC 0.70), and 65% of open reductions occurred in patients whose preoperative profile would typically prompt attempted closed reduction. This reflects a well-recognised reality: the decision to convert to open reduction is often made intraoperatively after unsuccessful closed manipulation and cannot be confidently anticipated from presentation characteristics alone. For clinical and administrative planning, severity and mechanism remain useful for raising the probability of greater operative complexity and longer room time, even when open reduction itself cannot be predicted with confidence. Admission reflects the clinical-logistical intersection Inpatient admission was strongly associated with fracture severity and this association persisted after adjustment for open reduction, suggesting severity influences admission through factors beyond operative complexity — postoperative monitoring requirements, pain management, and discharge readiness. Age independently predicted admission, possibly reflecting differences in perioperative recovery or institutional discharge thresholds. Arrival hour also contributed: patients presenting later had higher admission rates regardless of severity, consistent with the operational constraint that later surgery leaves insufficient time for same-day discharge. Low-severity fractures showed relatively stable admission rates across arrival times, while high-severity fractures arriving late evening approached admission rates of 90% (Fig. 3). These patterns may support bed planning and family counselling at the time of presentation. Limitations This study has several limitations. The retrospective design could not capture unmeasured drivers of clinical decisions, including surgeon preference, family factors, and real-time bed or operating room availability. Gartland classification was abstracted from clinical documentation rather than independently adjudicated, introducing potential misclassification. Eighty-seven patients with acute operative fractures lacked documented Gartland classification and were excluded; if these patients differed systematically, observed associations may be biased. The low-severity group consisted almost entirely of type II fractures, limiting inferences about nondisplaced injuries. Low event counts for open reduction and complications limited precision, as reflected in wide confidence intervals. Postoperative outcomes were assessed only through in-system documentation, potentially underestimating complication rates. Finally, as a single-centre study at a non–trauma-designated referral centre, findings may not generalise to lower-volume hospitals or centres with different transfer patterns, subspecialty support, or scheduling practices, as operative management of these injuries varies substantially across institution types [22]. Conclusions In operatively managed paediatric supracondylar humerus fractures, fracture severity at presentation was associated with operative timing, surgical approach, and postoperative disposition — outcomes that compete for shared operating room and inpatient resources. Logistical factors, particularly arrival hour, contributed independently to timing and admission decisions, suggesting that the clinical-logistical intersection at triage shapes the downstream care pathway. Among routinely available presentation variables, Gartland severity may serve as a practical early marker to support operative scheduling, staffing, and bed planning at paediatric referral centres. References Navarro Vergara AD, Navarro Fretes A, Arréllaga Alonso R et al (2023) Management of pediatric humeral supracondylar fractures in a referral center from a developing country: a comparison with American Academy of Orthopaedic Surgeons (AAOS) guidelines. Cureus 15:e44430. https://doi.org/10.7759/cureus.44430 Buryanov OA, Naumenko VO, Kvasha VP, Kovalchuk DY, Pylypchuk OR, Fedorenko DI (2023) Treatment outcomes analysis in supracondylar humerus fractures in children and adolescents. 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J Pediatr Orthop 43:e86–e92. https://doi.org/10.1097/BPO.0000000000002281 Pullagura MK, Odak S, Pratt R (2013) Managing supracondylar fractures of the distal humerus in children in a district general hospital. Ann R Coll Surg Engl 95:582–586. https://doi.org/10.1308/rcsann.2013.95.8.582 Bayisenga J, Ssebuufu R, Mugenzi D (2013) Early outcome of delayed management of supracondylar humeral fractures in children in Rwanda. East Cent Afr J Surg 18:94–102. Holt JB, Glass NA, Bedard NA, Weinstein SL, Shah AS (2017) Emerging U.S. national trends in the treatment of pediatric supracondylar humeral fractures. J Bone Joint Surg Am 99:681–687. https://doi.org/10.2106/JBJS.16.01209 Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9361150","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":627146226,"identity":"0e1a0d8c-f8b2-4683-84ea-7641a71b6cab","order_by":0,"name":"David Nelson","email":"data:image/png;base64,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","orcid":"","institution":"Peyton Manning Children's Hospital at Ascension St. Vincent","correspondingAuthor":true,"prefix":"","firstName":"David","middleName":"","lastName":"Nelson","suffix":""},{"id":627146228,"identity":"79022799-4cb3-472c-87d1-a3e5f17e1283","order_by":1,"name":"Alexander Kinstedt","email":"","orcid":"","institution":"Indiana University School of Medicine – Terre Haute","correspondingAuthor":false,"prefix":"","firstName":"Alexander","middleName":"","lastName":"Kinstedt","suffix":""},{"id":627146234,"identity":"18922635-877c-4be2-ad5b-032f20109a08","order_by":2,"name":"Zachary Sheff","email":"","orcid":"","institution":"Eli Lilly (United States)","correspondingAuthor":false,"prefix":"","firstName":"Zachary","middleName":"","lastName":"Sheff","suffix":""},{"id":627146236,"identity":"93bccca2-deb4-477a-b7be-90c72f545131","order_by":3,"name":"Brett Engbrecht","email":"","orcid":"","institution":"Peyton Manning Children's Hospital at Ascension St. Vincent","correspondingAuthor":false,"prefix":"","firstName":"Brett","middleName":"","lastName":"Engbrecht","suffix":""},{"id":627146238,"identity":"0d48440f-6634-4748-80a9-c3fd610b7c1e","order_by":4,"name":"Jonathan Wilhite","email":"","orcid":"","institution":"Peyton Manning Children's Hospital at Ascension St. Vincent","correspondingAuthor":false,"prefix":"","firstName":"Jonathan","middleName":"","lastName":"Wilhite","suffix":""}],"badges":[],"createdAt":"2026-04-08 21:38:11","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9361150/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9361150/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":107619993,"identity":"ec4a7399-fe22-487a-ae47-edad52d51dd7","added_by":"auto","created_at":"2026-04-23 09:34:29","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":128010,"visible":true,"origin":"","legend":"\u003cp\u003eFlowchart of patient selection for operatively managed paediatric supracondylar humerus fractures at the study institution from January 2010 to December 2020. SCH, supracondylar humerus\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-9361150/v1/28982c524df2f64eabedf5d9.png"},{"id":107707500,"identity":"4f6b8461-2ec4-4950-80c2-b00637ae5bda","added_by":"auto","created_at":"2026-04-24 09:20:27","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":114736,"visible":true,"origin":"","legend":"\u003cp\u003eMultivariable predictors of deferred surgery (A), open reduction (B), and inpatient admission (C). Adjusted odds ratios (aORs) with 95% confidence intervals from Firth logistic regression models are displayed on a log scale; marker size reflects the Wald χ² statistic; arrows indicate confidence intervals extending beyond the plotted range. NV, neurovascular\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-9361150/v1/ae74defcab998bda80e9259c.png"},{"id":107619995,"identity":"065babda-bc35-498a-b88c-386d641abf9b","added_by":"auto","created_at":"2026-04-23 09:34:29","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":272482,"visible":true,"origin":"","legend":"\u003cp\u003eInpatient admission rates by emergency department arrival time. (A) Observed admission rates (%) in two-hour blocks with 95% confidence intervals; shaded region indicates business hours. (B) Admission rates by arrival hour stratified by Gartland severity; point size is proportional to sample size\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-9361150/v1/1d9ca5072e6d1cd6992c8b32.png"},{"id":109502026,"identity":"44ac0b11-82a8-425e-afc7-d3e2c32881e9","added_by":"auto","created_at":"2026-05-18 23:24:07","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":639854,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9361150/v1/b70f3a25-68f2-487e-8662-297af2a6fd1c.pdf"},{"id":107619992,"identity":"345b1ab1-cfab-4140-ab3e-6c9321a90bd2","added_by":"auto","created_at":"2026-04-23 09:34:29","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":17099,"visible":true,"origin":"","legend":"","description":"","filename":"IOSupplementalStatisticalNote.docx","url":"https://assets-eu.researchsquare.com/files/rs-9361150/v1/406aa1805888a55743ee69ec.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Clinical and logistical determinants of operative timing, surgical approach, and admission in paediatric supracondylar humerus fractures","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePaediatric supracondylar humerus fractures are the most common elbow fracture in children, with peak incidence between ages 5 and 7 years [1\u0026ndash;3]. Displacement severity is classified using the Gartland system, guiding management from nonoperative treatment to closed reduction and percutaneous pinning, with open reduction reserved for irreducible injuries or neurovascular compromise [1,4\u0026ndash;6]. Community hospitals routinely transfer children with displaced fractures to paediatric referral centres, where clinicians must simultaneously coordinate several resource-sensitive decisions: whether surgery proceeds during the index encounter or is deferred, whether open reduction may be required, and whether inpatient admission is likely [7\u0026ndash;9]. These decisions compete for shared operating room access, staffing, and inpatient beds, and interfacility transfer carries substantial logistical and financial burden, particularly for fractures that do not require emergent intervention [8].\u003c/p\u003e\n\u003cp\u003eClinical severity and operational demand are not independent. Population-level studies show that seasonal variation in fracture displacement severity is associated with fluctuations in operating room utilisation and inpatient admission independent of overall fracture volume [10], and pandemic-era increases in displacement severity coincided with shifts in resource utilisation and transport patterns [11]. Whether this clinical-operational relationship holds at the individual patient level \u0026mdash; and which routinely available clinical and presentation characteristics can anticipate the linked decisions of operative timing, surgical approach, and postoperative disposition \u0026mdash; has not been well characterised, particularly at non\u0026ndash;trauma-designated paediatric referral centres.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObjectives\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe examined which clinical and presentation characteristics available at triage were associated with operative timing, surgical approach, and postoperative disposition in a decade of operatively managed paediatric supracondylar humerus fractures at a non\u0026ndash;trauma-designated tertiary referral centre. Primary outcomes were deferred surgery after emergency department discharge, need for open reduction, and inpatient admission.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003e\u003cstrong\u003eEthics statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the institutional review board (No. R20210039) and conducted in accordance with the Declaration of Helsinki. The requirement for informed consent was waived by the institutional review board in view of the retrospective nature of the study, in which all data were collected from existing medical records.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy design and setting\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis retrospective cohort study examined paediatric patients with supracondylar humerus fractures treated surgically at a tertiary paediatric referral centre in the midwestern United States between January 2010 and December 2020. The study centre served as a regional non\u0026ndash;trauma-designated facility throughout the study period.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eParticipants\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePatients aged \u0026le;14 years presenting within the hospital system were identified using diagnosis and procedure codes. Inclusion required operative management at the study centre and documented Gartland classification. Exclusions were nonoperative management (n=235), surgery at a satellite facility (n=16), scheduled surgery (n=44), and missing Gartland classification (n=87). Scheduled surgery was defined as elective procedures for patients presenting more than 7 days after injury or planned staged procedures following initial nonoperative management at an outside facility, distinct from deferred surgery as defined below. The final cohort included 242 patients (Fig. 1).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData collection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData were abstracted from the electronic medical record into a REDCap database [12,13] by a single reviewer using standardised definitions. Variables included age, sex, race, and primary language; mechanism of injury (fall vs other); presence of neurovascular compromise or multisystem injury on initial examination; Gartland classification abstracted from radiology reports and operative notes using the modified Gartland system [14] and dichotomised as low severity (types I\u0026ndash;II) or high severity (types III+); transfer status and arrival time at the study centre; surgical approach (open vs closed reduction); operative time; deferred surgery (operative treatment following discharge from the index emergency department visit with subsequent return); inpatient admission; and intraoperative and postoperative complications identified through operative reports, discharge summaries, and follow-up documentation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDescriptive statistics are reported as mean (SD) and median (IQR) for continuous variables and frequency (%) for categorical variables. Groups were compared using Wilcoxon rank-sum tests for continuous variables and chi-square or Fisher exact tests for categorical variables. Multivariable logistic regression models were constructed for each primary outcome using Firth\u0026apos;s penalised likelihood method to address separation from low event counts [15]. Candidate predictors \u0026mdash; including demographic, injury, and presentation variables \u0026mdash; were screened using an AIC-based feature-selection approach [16] prior to final model estimation. Model discrimination was assessed using the area under the receiver operating characteristic curve (AUC) with leave-one-out cross-validated predicted probabilities. Complete-case analysis was used (n=239). Analyses were performed using Altair Analytics Workbench (Altair Engineering Inc., Troy, MI, USA) and Python. Figures were generated with the assistance of an artificial intelligence tool (Claude, Anthropic). All figure content was reviewed, revised, and approved by the authors, who take full responsibility for the accuracy and integrity of the work. Additional details regarding modelling decisions are provided in the Supplemental Statistical Note.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003e\u003cstrong\u003eParticipants\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOf 624 paediatric patients identified, 242 met inclusion criteria (Fig. 1); 239 were included in multivariable models. High-severity fractures (Gartland III+) comprised 66.1% of the cohort (160/242).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDescriptive data\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePatient characteristics are presented in Table 1. Mean age was 5.3 years (SD 2.3). Approximately half were male (47.5%), most were White (80.1%) and English-speaking (79.3%), and fall-related injuries accounted for 95.0% of cases. Compared with low-severity fractures, high-severity fractures were more likely to occur in White patients (85.6% vs 69.1%, p=0.004), result from falls (97.5% vs 90.1%, p=0.02), and present with neurovascular compromise (7.5% vs 0%, p=0.01). Over half of patients were transferred from outside facilities (56.6%), with no difference by severity group.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOutcome data\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSurgical and disposition outcomes are presented in Table 2. Open reduction was required in 20 cases (8.3%) and was more common among high-severity fractures (11.2% vs 2.4%, p=0.04). Mean operative time was longer for high-severity fractures (62.5 vs 42.4 minutes, p\u0026lt;0.001) and substantially longer for open versus closed cases (102.5 vs 51.5 minutes). Complications were infrequent overall (2.1%); one intraoperative complication involved pulse loss after pinning requiring vascular exploration, with successful re-fixation. Four postoperative complications occurred, all in high-severity fractures.\u003c/p\u003e\n\u003cp\u003eDeferred surgery occurred in 28 cases (11.6%) and differed markedly by severity (26.8% low-severity vs 3.8% high-severity, p\u0026lt;0.001); among deferred cases, median time to surgery was 1.7 days (IQR 1.1\u0026ndash;3.5). Inpatient admission occurred in 165 cases (68.2%) and was more frequent among high-severity fractures (81.2% vs 42.7%, p\u0026lt;0.001), with longer mean time from surgery to discharge (12.1 vs 6.7 hours, p\u0026lt;0.001).\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"891\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" colspan=\"5\" valign=\"bottom\" style=\"width: 891px;\"\u003e\n \u003cp\u003eTable 1: Patient characteristics by Gartland severity group (n=242)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 254px;\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 190px;\"\u003e\n \u003cp\u003eOverall (n=242)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 190px;\"\u003e\n \u003cp\u003eGartland I-II (n=82)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 199px;\"\u003e\n \u003cp\u003eGartland III+ (n=160)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 56px;\"\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 254px;\"\u003e\n \u003cp\u003eDemographics\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 190px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 190px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 199px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 56px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 254px;\"\u003e\n \u003cp\u003eAge, years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 190px;\"\u003e\n \u003cp\u003e5.3 (2.3); 5.0 [4.0, 7.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 190px;\"\u003e\n \u003cp\u003e5.3 (2.3); 5.0 [4.0, 6.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 199px;\"\u003e\n \u003cp\u003e5.3 (2.3); 5.0 [4.0, 7.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0.83\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 254px;\"\u003e\n \u003cp\u003eMale, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 190px;\"\u003e\n \u003cp\u003e115 (47.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 190px;\"\u003e\n \u003cp\u003e38 (46.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 199px;\"\u003e\n \u003cp\u003e77 (48.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0.90\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 254px;\"\u003e\n \u003cp\u003eWhite, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 190px;\"\u003e\n \u003cp\u003e193 (80.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 190px;\"\u003e\n \u003cp\u003e56 (69.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 199px;\"\u003e\n \u003cp\u003e137 (85.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0.004\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 254px;\"\u003e\n \u003cp\u003eEnglish-speaking, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 190px;\"\u003e\n \u003cp\u003e192 (79.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 190px;\"\u003e\n \u003cp\u003e63 (76.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 199px;\"\u003e\n \u003cp\u003e129 (80.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0.60\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 254px;\"\u003e\n \u003cp\u003eInjury Characteristics\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 190px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 190px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 199px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 56px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" rowspan=\"5\" valign=\"bottom\" style=\"width: 254px;\"\u003e\n \u003cp\u003eGartland type, n (%)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; Type I\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; Type II\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; Type III\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; Type IV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 190px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 190px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 199px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 56px;\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 190px;\"\u003e\n \u003cp\u003e1 (0.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 190px;\"\u003e\n \u003cp\u003e1 (1.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 199px;\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 56px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 190px;\"\u003e\n \u003cp\u003e81 (33.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 190px;\"\u003e\n \u003cp\u003e81 (98.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 199px;\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 56px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 190px;\"\u003e\n \u003cp\u003e153 (63.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 190px;\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 199px;\"\u003e\n \u003cp\u003e153 (95.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 56px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 190px;\"\u003e\n \u003cp\u003e7 (2.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 190px;\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 199px;\"\u003e\n \u003cp\u003e7 (4.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 56px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 254px;\"\u003e\n \u003cp\u003eMechanism, fall, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 190px;\"\u003e\n \u003cp\u003e227 (95.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 190px;\"\u003e\n \u003cp\u003e73 (90.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 199px;\"\u003e\n \u003cp\u003e154 (97.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0.02\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 254px;\"\u003e\n \u003cp\u003eNeurovascular compromise, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 190px;\"\u003e\n \u003cp\u003e12 (5.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 190px;\"\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 199px;\"\u003e\n \u003cp\u003e12 (7.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0.01\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 254px;\"\u003e\n \u003cp\u003eMultisystem injury, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 190px;\"\u003e\n \u003cp\u003e15 (6.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 190px;\"\u003e\n \u003cp\u003e5 (6.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 199px;\"\u003e\n \u003cp\u003e10 (6.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 56px;\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 254px;\"\u003e\n \u003cp\u003ePresentation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 190px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 190px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 199px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 56px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 254px;\"\u003e\n \u003cp\u003eTransfer from outside facility, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 190px;\"\u003e\n \u003cp\u003e137 (56.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 190px;\"\u003e\n \u003cp\u003e41 (50.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 199px;\"\u003e\n \u003cp\u003e96 (60.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0.18\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 254px;\"\u003e\n \u003cp\u003eArrival hour (shifted, 7am=0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 190px;\"\u003e\n \u003cp\u003e12.4 (4.3); 12.5 [9.9, 15.3]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 190px;\"\u003e\n \u003cp\u003e11.8 (4.3); 11.9 [9.3, 14.4]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 199px;\"\u003e\n \u003cp\u003e12.7 (4.3); 12.9 [10.4, 15.6]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0.14\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 254px;\"\u003e\n \u003cp\u003eDaytime arrival (7am-7pm), n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 190px;\"\u003e\n \u003cp\u003e113 (46.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 190px;\"\u003e\n \u003cp\u003e42 (51.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 199px;\"\u003e\n \u003cp\u003e71 (44.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0.38\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 254px;\"\u003e\n \u003cp\u003eWeekend arrival, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 190px;\"\u003e\n \u003cp\u003e68 (28.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 190px;\"\u003e\n \u003cp\u003e27 (32.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 199px;\"\u003e\n \u003cp\u003e41 (25.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0.30\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 254px;\"\u003e\n \u003cp\u003e\u003csup\u003ea\u003c/sup\u003eFisher\u0026apos;s exact test\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 190px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 190px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 199px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 56px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"981\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" colspan=\"4\" valign=\"bottom\" style=\"width: 887px;\"\u003e\n \u003cp\u003eTable 2: Operative Timing, Surgical Approach, Postoperative Disposition, and Complications by Gartland Severity: N=242\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 95px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 285px;\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 198px;\"\u003e\n \u003cp\u003eOverall (n=242)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 206px;\"\u003e\n \u003cp\u003eGartland I-II (n=82)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 198px;\"\u003e\n \u003cp\u003eGartland III+ (n=160)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 95px;\"\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 285px;\"\u003e\n \u003cp\u003eSurgical Approach\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 198px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 206px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 198px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 95px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 285px;\"\u003e\n \u003cp\u003eOpen reduction, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 198px;\"\u003e\n \u003cp\u003e20 (8.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 206px;\"\u003e\n \u003cp\u003e2 (2.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 198px;\"\u003e\n \u003cp\u003e18 (11.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 95px;\"\u003e\n \u003cp\u003e0.04\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 285px;\"\u003e\n \u003cp\u003eOperative Time\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 198px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 206px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 198px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 95px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 285px;\"\u003e\n \u003cp\u003eOR time, min\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 198px;\"\u003e\n \u003cp\u003e55.8 (32.2); 51.0 [37.0, 65.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 206px;\"\u003e\n \u003cp\u003e42.4 (15.0); 39.5 [33.0, 49.2]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 198px;\"\u003e\n \u003cp\u003e62.5 (36.1); 56.0 [40.8, 72.2]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 285px;\"\u003e\n \u003cp\u003e\u0026nbsp; Closed cases (n=222)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 198px;\"\u003e\n \u003cp\u003e51.5 (28.3); 47.5 [36.0, 60.2]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 206px;\"\u003e\n \u003cp\u003e40.9 (11.8); 39.0 [33.0, 48.8]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 198px;\"\u003e\n \u003cp\u003e57.4 (32.7); 53.0 [39.2, 66.8]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 285px;\"\u003e\n \u003cp\u003e\u0026nbsp; Open cases (n=20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 198px;\"\u003e\n \u003cp\u003e102.5 (35.4); 94.0 [79.0, 125.8]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 206px;\"\u003e\n \u003cp\u003e100.0 (15.6); 100.0 [94.5, 105.5]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 198px;\"\u003e\n \u003cp\u003e102.8 (37.3); 94.0 [77.0, 127.2]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 95px;\"\u003e\n \u003cp\u003e0.95\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 285px;\"\u003e\n \u003cp\u003eComplications\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 198px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 206px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 198px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 95px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 285px;\"\u003e\n \u003cp\u003eIntraoperative complications, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 198px;\"\u003e\n \u003cp\u003e1 (0.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 206px;\"\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 198px;\"\u003e\n \u003cp\u003e1 (0.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 95px;\"\u003e\n \u003cp\u003e1.00\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 285px;\"\u003e\n \u003cp\u003ePostoperative complications, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 198px;\"\u003e\n \u003cp\u003e4 (1.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 206px;\"\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 198px;\"\u003e\n \u003cp\u003e4 (2.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 95px;\"\u003e\n \u003cp\u003e0.30\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 285px;\"\u003e\n \u003cp\u003eDisposition\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 198px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 206px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 198px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 95px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 285px;\"\u003e\n \u003cp\u003eInpatient admission, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 198px;\"\u003e\n \u003cp\u003e165 (68.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 206px;\"\u003e\n \u003cp\u003e35 (42.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 198px;\"\u003e\n \u003cp\u003e130 (81.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 285px;\"\u003e\n \u003cp\u003ePost-surgery to disposition, hrs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 198px;\"\u003e\n \u003cp\u003e10.3 (9.8); 9.2 [2.5, 13.4]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 206px;\"\u003e\n \u003cp\u003e6.7 (6.7); 3.8 [1.3, 10.3]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 198px;\"\u003e\n \u003cp\u003e12.1 (10.7); 11.0 [5.1, 14.8]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 285px;\"\u003e\n \u003cp\u003e\u0026nbsp; Discharged same day (n=77)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 198px;\"\u003e\n \u003cp\u003e4.7 (5.4); 1.9 [1.0, 7.9]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 206px;\"\u003e\n \u003cp\u003e4.1 (5.4); 1.8 [1.1, 4.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 198px;\"\u003e\n \u003cp\u003e5.5 (5.3); 2.4 [1.0, 9.6]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 95px;\"\u003e\n \u003cp\u003e0.44\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 285px;\"\u003e\n \u003cp\u003e\u0026nbsp; Admitted (n=165)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 198px;\"\u003e\n \u003cp\u003e12.8 (10.4); 11.5 [6.2, 15.8]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 206px;\"\u003e\n \u003cp\u003e10.1 (6.7); 9.4 [4.4, 14.3]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 198px;\"\u003e\n \u003cp\u003e13.6 (11.0); 12.2 [7.0, 16.2]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 95px;\"\u003e\n \u003cp\u003e0.09\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 285px;\"\u003e\n \u003cp\u003eTiming\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 198px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 206px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 198px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 95px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 285px;\"\u003e\n \u003cp\u003eDelayed surgery, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 198px;\"\u003e\n \u003cp\u003e28 (11.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 206px;\"\u003e\n \u003cp\u003e22 (26.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 198px;\"\u003e\n \u003cp\u003e6 (3.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 285px;\"\u003e\n \u003cp\u003e\u0026nbsp; Days from initial discharge to surgery (n=28)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 198px;\"\u003e\n \u003cp\u003e2.5 (2.0); 1.7 [1.1, 3.5]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 206px;\"\u003e\n \u003cp\u003e2.4 (1.9); 1.7 [1.3, 2.8]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 198px;\"\u003e\n \u003cp\u003e2.8 (2.4); 2.5 [1.0, 3.7]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 95px;\"\u003e\n \u003cp\u003e0.81\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 285px;\"\u003e\n \u003cp\u003e\u0026nbsp; Inpatient after delayed surgery (n=28)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 198px;\"\u003e\n \u003cp\u003e7 (25.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 206px;\"\u003e\n \u003cp\u003e5 (22.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 198px;\"\u003e\n \u003cp\u003e2 (33.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 95px;\"\u003e\n \u003cp\u003e0.62\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 285px;\"\u003e\n \u003cp\u003e\u003csup\u003ea\u003c/sup\u003eFisher\u0026apos;s exact test\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 198px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 206px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 198px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 95px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eMain results\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eDeferred surgery.\u003c/em\u003e High-severity fracture was strongly associated with lower odds of deferred surgery (aOR 0.08, 95% CI 0.03\u0026ndash;0.22; p\u0026lt;0.001), consistent with prioritisation of more severe injuries for immediate intervention (Fig. 2, Panel A). Older age (aOR 0.71 per year, 95% CI 0.55\u0026ndash;0.91; p=0.006), non-fall mechanism (aOR 0.04, 95% CI 0.001\u0026ndash;0.99; p=0.049), and later arrival hour (aOR 0.87 per hour, 95% CI 0.77\u0026ndash;0.98; p=0.02) were each associated with lower odds of deferral. Model discrimination was excellent (AUC 0.86, 95% CI 0.80\u0026ndash;0.92).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eOpen reduction.\u003c/em\u003e Neurovascular compromise (aOR 5.22, 95% CI 1.40\u0026ndash;19.44; p=0.01), high-severity fracture (aOR 4.26, 95% CI 1.02\u0026ndash;17.74; p=0.047), and non-fall mechanism (aOR 5.38, 95% CI 1.02\u0026ndash;28.34; p=0.047) were each associated with open reduction (Fig. 2, Panel B). Model discrimination was acceptable (AUC 0.70, 95% CI 0.61\u0026ndash;0.80). Notably, 13 of 20 open reductions (65%) occurred in high-severity fractures from fall mechanisms without neurovascular compromise, suggesting most conversions reflected intraoperative failure of closed manipulation rather than preoperatively identifiable risk.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eInpatient admission.\u003c/em\u003e High-severity fracture was the strongest predictor of admission (aOR 5.29, 95% CI 2.80\u0026ndash;9.99; p\u0026lt;0.001), persisting after adjustment for open reduction (Fig. 2, Panel C). Each additional year of age increased admission odds (aOR 1.18 per year, 95% CI 1.01\u0026ndash;1.36; p=0.032); a 10-year-old had approximately twice the odds of admission compared with a 5-year-old (1.18⁵ = 2.29). Later arrival hour also contributed to the model (aOR 1.07 per hour, 95% CI 0.99\u0026ndash;1.15; p=0.082). Model discrimination was moderate (AUC 0.78, 95% CI 0.72\u0026ndash;0.85).\u003c/p\u003e\n\u003cp\u003eAdmission rates increased from approximately 35% for patients arriving mid-morning to over 90% for those arriving late evening (Fig. 3, Panel A). When stratified by severity, this timing effect persisted in the high-severity group while low-severity fractures showed relatively stable admission rates across arrival times (Fig. 3, Panel B).\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003e\u003cstrong\u003eKey findings\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn this retrospective cohort of 242 operatively managed paediatric supracondylar humerus fractures, clinical and presentation characteristics available at triage were associated with a linked set of management outcomes spanning operative timing, surgical approach, and postoperative disposition. Fracture severity was the dominant predictor across outcomes, but logistical factors \u0026mdash; particularly arrival hour \u0026mdash; contributed independently to operative timing and admission. Taken together, these findings suggest that the intersection of clinical severity and presentation logistics, rather than severity alone, shapes downstream resource use at paediatric referral centres.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSeverity as an operational signal\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThat higher Gartland grade predicts greater operative complexity is well established [1,5,17]. What is less characterised is whether severity at triage also anticipates the broader operational cascade \u0026mdash; deferred versus immediate surgery, likelihood of open reduction, and inpatient admission \u0026mdash; as a related rather than separate set of decisions. Previous studies have generally examined these endpoints in isolation [6,18,19]. Our findings suggest they are linked, and that fracture severity may serve as an early signal across all three. This is consistent with population-level work showing that elbow fracture severity, independent of fracture volume, is associated with operating room utilisation and admission burden [10]; our data extend that observation to the individual patient encounter.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeferred surgery reflects both clinical severity and logistical timing\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMore than one-quarter of low-severity fractures underwent deferred surgery, compared with fewer than 4% of high-severity fractures \u0026mdash; a pattern more consistent with intentional triage than system failure. Deferred cases returned within a short interval (median 1.7 days) with infrequent complications, consistent with prior evidence supporting the safety of scheduled fixation for clinically stable injuries [6,9,20,21]. Importantly, arrival hour was an independent predictor of deferral: later-presenting patients were less likely to be deferred, likely reflecting reduced scheduling opportunity rather than clinical urgency. This suggests that operative timing decisions reflect both the clinical signal of fracture severity and the logistical reality of when patients arrive \u0026mdash; a distinction relevant to after-hours resource planning.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOpen reduction is driven primarily by clinical factors\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOpen reduction was required in 8.3% of cases, consistent with published referral-centre series [1,7]. Clinical factors \u0026mdash; high-severity fracture, neurovascular compromise, and non-fall mechanism \u0026mdash; were associated with higher odds of open reduction, and logistical variables did not contribute to this model. However, model discrimination was only moderate (AUC 0.70), and 65% of open reductions occurred in patients whose preoperative profile would typically prompt attempted closed reduction. This reflects a well-recognised reality: the decision to convert to open reduction is often made intraoperatively after unsuccessful closed manipulation and cannot be confidently anticipated from presentation characteristics alone. For clinical and administrative planning, severity and mechanism remain useful for raising the probability of greater operative complexity and longer room time, even when open reduction itself cannot be predicted with confidence.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAdmission reflects the clinical-logistical intersection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInpatient admission was strongly associated with fracture severity and this association persisted after adjustment for open reduction, suggesting severity influences admission through factors beyond operative complexity \u0026mdash; postoperative monitoring requirements, pain management, and discharge readiness. Age independently predicted admission, possibly reflecting differences in perioperative recovery or institutional discharge thresholds. Arrival hour also contributed: patients presenting later had higher admission rates regardless of severity, consistent with the operational constraint that later surgery leaves insufficient time for same-day discharge. Low-severity fractures showed relatively stable admission rates across arrival times, while high-severity fractures arriving late evening approached admission rates of 90% (Fig. 3). These patterns may support bed planning and family counselling at the time of presentation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLimitations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study has several limitations. The retrospective design could not capture unmeasured drivers of clinical decisions, including surgeon preference, family factors, and real-time bed or operating room availability. Gartland classification was abstracted from clinical documentation rather than independently adjudicated, introducing potential misclassification. Eighty-seven patients with acute operative fractures lacked documented Gartland classification and were excluded; if these patients differed systematically, observed associations may be biased. The low-severity group consisted almost entirely of type II fractures, limiting inferences about nondisplaced injuries. Low event counts for open reduction and complications limited precision, as reflected in wide confidence intervals. Postoperative outcomes were assessed only through in-system documentation, potentially underestimating complication rates. Finally, as a single-centre study at a non\u0026ndash;trauma-designated referral centre, findings may not generalise to lower-volume hospitals or centres with different transfer patterns, subspecialty support, or scheduling practices, as operative management of these injuries varies substantially across institution types [22].\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eIn operatively managed paediatric supracondylar humerus fractures, fracture severity at presentation was associated with operative timing, surgical approach, and postoperative disposition \u0026mdash; outcomes that compete for shared operating room and inpatient resources. Logistical factors, particularly arrival hour, contributed independently to timing and admission decisions, suggesting that the clinical-logistical intersection at triage shapes the downstream care pathway. Among routinely available presentation variables, Gartland severity may serve as a practical early marker to support operative scheduling, staffing, and bed planning at paediatric referral centres.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eNavarro Vergara AD, Navarro Fretes A, Arr\u0026eacute;llaga Alonso R et al (2023) Management of pediatric humeral supracondylar fractures in a referral center from a developing country: a comparison with American Academy of Orthopaedic Surgeons (AAOS) guidelines. Cureus 15:e44430. https://doi.org/10.7759/cureus.44430\u003c/li\u003e\n \u003cli\u003eBuryanov OA, Naumenko VO, Kvasha VP, Kovalchuk DY, Pylypchuk OR, Fedorenko DI (2023) Treatment outcomes analysis in supracondylar humerus fractures in children and adolescents. Travma 24:64\u0026ndash;69. https://doi.org/10.22141/1608-1706.3.24.2023.956\u003c/li\u003e\n \u003cli\u003eRokaya PK, Karki DB, Rawal M et al (2020) Pattern of pediatric supracondylar fracture operated at a rural teaching hospital of Nepal: a descriptive cross-sectional study. JNMA J Nepal Med Assoc 58:153\u0026ndash;157. https://doi.org/10.31729/jnma.4869\u003c/li\u003e\n \u003cli\u003eAlton TB, Werner SE, Gee AO (2015) Classifications in brief: the Gartland classification of supracondylar humerus fractures. Clin Orthop Relat Res 473:738\u0026ndash;741. https://doi.org/10.1007/s11999-014-4033-8\u003c/li\u003e\n \u003cli\u003eVaquero-Picado A, Gonz\u0026aacute;lez-Mor\u0026aacute;n G, Moraleda L (2018) Management of supracondylar fractures of the humerus in children. EFORT Open Rev 3:526\u0026ndash;540. https://doi.org/10.1302/2058-5241.3.170049\u003c/li\u003e\n \u003cli\u003eDucić S, Bumbasirević M, Radlović V et al (2016) Displaced supracondylar humeral fractures in children: comparison of three treatment approaches. Srp Arh Celok Lek 144:46\u0026ndash;51. https://doi.org/10.2298/SARH1602046D\u003c/li\u003e\n \u003cli\u003ePayvandi S, Fugle MJ (2007) Treatment of pediatric supracondylar humerus fractures in the community hospital. Tech Hand Up Extrem Surg 11:62\u0026ndash;66. https://doi.org/10.1097/bth.0b013e31804a8655\u003c/li\u003e\n \u003cli\u003eMechas K, Mayer SW, Iwinski HJ et al (2022) The costs of interfacility transfers for nonurgent pediatric supracondylar fractures. J Pediatr Orthop 42:e601\u0026ndash;e605. https://doi.org/10.1097/bpo.0000000000002177\u003c/li\u003e\n \u003cli\u003eChaudhry S (2024) Value-driven pediatric supracondylar humerus fracture care: implementing evidence-based practices. JAAOS Glob Res Rev 8:e24.00058. https://doi.org/10.5435/jaaosglobal-d-24-00058\u003c/li\u003e\n \u003cli\u003eSchultz J, Rees A, Wollenman L et al (2021) Factors that drive annual variation in pediatric elbow fracture occurrence, severity, and resource utilization. J Pediatr Orthop 41:e755\u0026ndash;e762. https://doi.org/10.1097/bpo.0000000000001915\u003c/li\u003e\n \u003cli\u003eSchultz J, Windmueller R, Rees A et al (2022) Impact of the COVID-19 pandemic on pediatric elbow fractures: marked change in management and resource utilization, without a change in incidence. J Pediatr Orthop 42:401\u0026ndash;407. https://doi.org/10.1097/bpo.0000000000002205\u003c/li\u003e\n \u003cli\u003eHarris PA, Taylor R, Thielke R et al (2009) Research electronic data capture (REDCap): a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform 42:377\u0026ndash;381. https://doi.org/10.1016/j.jbi.2008.08.010\u003c/li\u003e\n \u003cli\u003eHarris PA, Taylor R, Minor BL et al (2019) The REDCap consortium: building an international community of software platform partners. J Biomed Inform 95:103208. https://doi.org/10.1016/j.jbi.2019.103208\u003c/li\u003e\n \u003cli\u003eGartland JJ (1959) Management of supracondylar fractures of the humerus in children. Surg Gynecol Obstet 109:145\u0026ndash;154.\u003c/li\u003e\n \u003cli\u003eFirth D (1993) Bias reduction of maximum likelihood estimates. Biometrika 80:27\u0026ndash;38. https://doi.org/10.1093/biomet/80.1.27\u003c/li\u003e\n \u003cli\u003eZhao Z, Zhang R, Cox J et al (2013) Massively parallel feature selection: an approach based on variance preservation. Mach Learn 92:195\u0026ndash;220. https://doi.org/10.1007/s10994-013-5373-4\u003c/li\u003e\n \u003cli\u003eHahn SG, Schuller A, Pichler L et al (2024) Complications and outcomes of surgically treated pediatric supracondylar humerus fractures. Children (Basel) 11:791. https://doi.org/10.3390/children11070791\u003c/li\u003e\n \u003cli\u003eAbbott MD, Buchler LT, Loder RT et al (2014) Gartland type III supracondylar humerus fractures: outcome and complications as related to operative timing and pin configuration. J Child Orthop 8:473\u0026ndash;477. https://doi.org/10.1007/s11832-014-0624-x\u003c/li\u003e\n \u003cli\u003eBram JT, DeFrancesco CJ, Pascual-Leone N et al (2023) Impact of pediatric orthopaedic fellowship training on pediatric supracondylar humerus fracture treatment and outcomes: a meta-analysis. J Pediatr Orthop 43:e86\u0026ndash;e92. https://doi.org/10.1097/BPO.0000000000002281\u003c/li\u003e\n \u003cli\u003ePullagura MK, Odak S, Pratt R (2013) Managing supracondylar fractures of the distal humerus in children in a district general hospital. Ann R Coll Surg Engl 95:582\u0026ndash;586. https://doi.org/10.1308/rcsann.2013.95.8.582\u003c/li\u003e\n \u003cli\u003eBayisenga J, Ssebuufu R, Mugenzi D (2013) Early outcome of delayed management of supracondylar humeral fractures in children in Rwanda. East Cent Afr J Surg 18:94\u0026ndash;102.\u003c/li\u003e\n \u003cli\u003eHolt JB, Glass NA, Bedard NA, Weinstein SL, Shah AS (2017) Emerging U.S. national trends in the treatment of pediatric supracondylar humeral fractures. J Bone Joint Surg Am 99:681\u0026ndash;687. https://doi.org/10.2106/JBJS.16.01209\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Supracondylar humerus fracture, Gartland classification, Paediatric orthopaedics, Triage, Hospital admission","lastPublishedDoi":"10.21203/rs.3.rs-9361150/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9361150/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose:\u003c/strong\u003e Among children undergoing operative treatment for supracondylar humerus fractures, it is unclear which clinical and presentation characteristics available at triage best predict operative timing, surgical approach, and inpatient disposition. We examined this question using a multivariable approach in a decade of operatively managed fractures at a non–trauma-designated tertiary paediatric referral centre.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e We performed a retrospective cohort study of children aged ≤14 years with operatively managed supracondylar humerus fractures at a non–trauma-designated tertiary paediatric referral centre (2010–2020). Candidate predictors included clinical severity (Gartland classification), demographic characteristics, injury mechanism, and logistical presentation factors.. Multivariable Firth logistic regression models were constructed for each primary outcome.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e Of 242 patients, 160 (66.1%) had high-severity fractures (Gartland III+). These high-severity fractures had lower odds of deferred surgery (3.8% vs 26.8%; aOR 0.08; 95% CI 0.03–0.22), higher odds of open reduction (11.2% vs 2.4%; aOR 4.26; 95% CI 1.02–17.74), and higher odds of inpatient admission (81.2% vs 42.7%; aOR 5.29; 95% CI 2.80–9.99). The overall complication rate was 2.1%.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e Fracture severity was the dominant predictor of surgical approach, consistent with its established role in operative planning. Operative timing and inpatient admission reflected both clinical severity and logistical presentation factors, suggesting that their intersection — rather than severity alone — shapes the downstream care pathway. Gartland severity may serve as a practical triage signal to support operating room scheduling and bed planning at paediatric referral centres.\u003c/p\u003e","manuscriptTitle":"Clinical and logistical determinants of operative timing, surgical approach, and admission in paediatric supracondylar humerus fractures","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-23 09:34:19","doi":"10.21203/rs.3.rs-9361150/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"434605ac-08a6-40b6-9c8e-273a69e15da3","owner":[],"postedDate":"April 23rd, 2026","published":true,"recentEditorialEvents":[{"type":"decision","content":"Withdrawn","date":"2026-05-18T23:21:36+00:00","index":"","fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-05-18T23:23:59+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-23 09:34:19","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9361150","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9361150","identity":"rs-9361150","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}