O0800 Oct.3: 1:20pm - Anxiety Surrounding Supracondylar Humerus Pin Removal in Children

Background/Purpose: Supracondylar humerus (SCH) fractures are the second most common pediatric fracture. Displaced SCH fractures are typically treated with closed reduction and percutaneous pinning (CRPP) and pins are removed in clinic at three to four weeks post-surgery. No studies to our knowledge quantify the physiological and behavioral response to pin removal. Therefore, the purpose of this study was to quantify the anxiety experienced undergoing pin removal following CRPP for SCH fractures.

Methods: We prospectively enrolled 53 patients (3-8 years) treated for SCH fracture with CRPP between July 24, 2018 and February 29, 2020. Demographic and injury data was recorded. Heart rate (HR) and the Face, Legs, Activity, Cry and Consolability (FLACC) Scale was measured immediately before first pin removal, after all pins were removed, and at follow-up clinic visit for a baseline measurement. An elevated HR was defined as a HR in excess of the upper 95% normal limit for a patient’s sex and age. The FLACC scale is measured on a 0-10 scale (0=no pain/distress, 10=maximum pain/distress).

Results: All patients experienced an anxiety response immediately prior to pin removal (95% CI, 94–100%) with a median FLACC score of 7 (IQR, 6-8). Additionally, 98% of subjects experienced an elevated HR. Patients experienced a median 73% reduction in FLACC score from prior to pin removal to after pin removal (p<0.001). All 45 patients who completed their follow-up visit had a FLACC score of 0. Forty-four subjects also had a subsequent clinic visit HR measurement recorded, with a mean of 89.7 bpm. Twenty-five of these (57%) had an elevated HR at the subsequent clinic visit for their age and sex. Mean HR prior to pin removal was 36% higher than at follow up. Overall, subjects experienced a mean 21% reduction in HR from prior to pin removal to after. There were no sex differences detected in FLACC scores or HR.

Conclusions: Pediatric patients experience considerable anxiety when undergoing pin removal following CRPP for SCH fractures. The fact that 57% of children had an elevated HR at baseline suggests that being at the orthopaedic clinic can be challenging for children. However, the median score of 7 on the FLACC scale immediately prior to pin removal was much higher in this study than in prior literature examining anxiety around cast removal in children.1 Our results compare with the published scores for intravenous line insertion, nasogastric tube insertion, and metered dose inhaler application, suggesting a highly anxiety-provoking experience.2 This study highlights an area of clinical practice where intervention should be targeted to decrease patient anxiety.

Significance: We have established that patients experience considerable anxiety when undergoing pin removal. This provides a baseline for future studies to assess interventions aimed at decreasing the associated anxiety responses.