The VAS is a quick and easy method of rating a subjective experience such as pain and anxiety and has been used in similar studies both with children and adults [20
]. The use of a single VAS score to rate patients' and caregivers' experience with a treatment may not give a complete picture of this experience, but in our opinion gives an idea of how positive or negative that experience was.
The main findings in our previous article describing the clinical and epidemiological findings in these patients [18
] were that the introduction of crossed wire fixation reduced the median length of stay (LOS) from 11 to 2 days and that there was no statistically significant difference in complication rates between these two treatment groups. The large reduction in LOS was intuitively an obvious improvement for the children and their parents. There were also more reoperations in the skeletal traction group (4/46) compared to crossed wire fixation (0/45, P
= 0.04) because of unsatisfactory reduction of the fracture. Given the nature of skeletal traction treatment, the fact that the children needed to be hospitalized more than ten days, and the need to undergo general anesthesia twice, we had expected to find that crossed wire fixation was less of a traumatic experience than skeletal traction. However, this was not the case in this study. No statistically significant differences could be found in any of the children's VAS scores. In light of this one must ask one's self if a child's rating of such an experience several years after it happened can be trusted. There was a slight tendency for the children's VAS scores (mean 4.05) to be lower than their caregivers' scores (mean 4.5). This would support the general feeling that the children “forgive and forget” faster than their parents. However, the difference was not statistically significant (P
= 0.22) with the current study size and design. One could, along the same lines, argue that the relatively long followup was too long and that it would be expected that the mean VAS score would decrease proportionately to the number of years gone by since the fracture, but, as can be seen from , this does not appear to be the case either. Time to followup in the wire fixation and traction groups was different, and this difference in the children's maturity, or time gone by since the fracture, might be a source of bias.
The fact that the boys in this series rated their experience less severe than the girls could, of course, be due to the boys' not wanting to admit it was a bad experience as well as an actual difference in their perception of the experience. Either way it did display a gender difference we did not expect to find. It was also interesting to see that their parents did not differentiate between the girls and the boys.
The present study has the usual limitations of being a retrospective study when it comes to collection of data about the fractures and early complications. However, the information on the children's and their caregivers' experience of the treatment was prospectively collected as part of a dedicated study out patient visit. In our opinion, the fact that the patients were included consecutively before and after the introduction of a new method, with as little separation in time as possible, makes the groups comparable. One could argue that there was a selection bias as only 111 children and 104 parents rated their experience of treatment for SCHF. However, of the 181 patients identified from the hospital files as having been treated for SCHF and invited to participate in the study, 78% consented and returned for followup. The relatively lower number of parents that responded can be explained by the fact that not all the children came for followup with their parents. Some of them came alone, with older siblings, their grandparents, or another guardian. Also, not all the children could or wanted to rate their experience. All this considered, we do not think there is reason to believe there has been a large selection bias. Power analysis showed the sample size to be sufficiently large to detect clinically significant differences, though smaller differences could be overlooked. The statistically significant difference in VAS between parents with children who experienced a neurovascular complication at some time during the treatment and those that did not is hardly surprising. However, in our opinion, the study has shown that the parents' VAS ratings were not completely random, even after five to ten years. In effect, it is likely that the findings that there are no differences in their experience of the different treatment methods at long-term followup can be trusted.
There was no difference in the children's or the caregivers' negative experience at long-term followup after treatment for supracondylar humerus fractures as rated on a visual analogue scale when comparing POP, skeletal traction, or crossed wire fixation. Caregivers to children that experienced a neurovascular complication, however, had a more negative experience independent of treatment or fracture type. In the long term, then, whether or not complications could have been avoided seems to be more important to the caregivers than the choice of treatment for supracondylar humerus fractures in the children. Though this might be of mostly historical interest in high-income countries, in a limited resource setting—where traction and casting often still is the only treatment option for these injuries—surgeons may use this information to inform parents and to prioritize the use of resources in an orthopaedic department.