We suggest closed reduction with pin fixation for patients with displaced (Gartland Type II and III, and displaced flexion) pediatric supracondylar fractures of the humerus.

Data on 48 outcomes from 11 studies formed the basis of this recommendation. For this analysis, Gartland Type II and III fractures were analyzed in aggregate since many of the studies combined the results from the two types. Similarly, the less common flexion type pediatric supracondylar fracture was included in this group. [Please refer to line 732 of this guideline for additional information.] The quality, applicability, and the strength of the evidence generated a preliminary strength of recommendation of “limited”. The work group upgraded the recommendation to “moderate” based on the potential for harm from non-operative treatment of displaced pediatric supracondylar fractures. For example, casting the arm in hyperflexion may cause limb threatening ischemia.

The initial recommendation of “limited” was based on the lack of evidence addressing the six critical outcomes that the work group had identified. Pin fixation was shown to be statistically superior to non-operative treatment for two critical outcomes, prevention of cubitus varus and loss of motion. 

Among the non-critical outcomes, pin fixation was statistically superior to non-operative treatment in a meta-analysis of Flynn’s Criteria. This outcome incorporates both range of motion and carrying angle. Two non-critical outcomes, infection and pin track infection, favored non-operative treatment because they can only occur in patients who receive operative treatment.

Although operative treatment introduces the risk of infection, the improved critical outcomes combined with the decreased risk of limb threatening ischemic injury outweigh these risks.
  1. (2) Sutton WR, Greene WB, Georgopoulos G, Dameron TB, Jr. Displaced supracondylar humeral fractures in children. A comparison of results and costs in patients treated by skeletal traction versus percutaneous pinning. Clin Orthop Relat Res 1992;(278):81-87.
  2. (24) Ababneh M, Shannak A, Agabi S, Hadidi S. The treatment of displaced supracondylar fractures of the humerus in children. A comparison of three methods. Int Orthop 1998;22(4):263-265.
  3. (25) Almohrij SA. Closed reduction with and without percutaneous pinning on supracondylar fractures of the humerus in children. Ann Saudi Med 2000;20(1):72-74.
  4. (26) France J, Strong M. Deformity and function in supracondylar fractures of the humerus in children variously treated by closed reduction and splinting, traction, and percutaneous pinning. J Pediatr Orthop 1992;12(4):494-498.
  5. (27) Kennedy JG, El AK, Soffe K et al. Evaluation of the role of pin fixation versus collar and cuff immobilisation in supracondylar fractures of the humerus in children. Injury 2000;31(3):163-167.
  6. (28) Khan MS, Sultan S, Ali MA, Khan A, Younis M. Comparison of percutaneous pinning with casting in supracondylar humeral fractures in children. J Ayub Med Coll Abbottabad 2005;17(2):33-36.
  7. (29) Padman M, Warwick AM, Fernandes JA, Flowers MJ, Davies AG, Bell MJ. Closed reduction and stabilization of supracondylar fractures of the humerus in children: the crucial factor of surgical experience. J Pediatr Orthop B 2010;19(4):298-303.
  8. (30) Pandey S, Shrestha D, Gorg M, Singh GK, Singh MP. Treatment of supracondylar fracture of the humerus (type IIB and III) in children: A prospective randomized controlled trial comparing two methods. Kathmandu University Medical Journal 2008;6(23):310-318.
  9. (31) Pirone AM, Graham HK, Krajbich JI. Management of displaced extension-type supracondylar fractures of the humerus in children. J Bone Joint Surg Am 1988;70(5):641-650.
  10. (32) Kaewpornsawan K. Comparison between closed reduction with percutaneous pinning and open reduction with pinning in children with closed totally displaced supracondylar humeral fractures: a randomized controlled trial. J Pediatr Orthop B 2001;10(2):131-137.
  11. (33) Ozkoc G, Gonc U, Kayaalp A, Teker K, Peker TT. Displaced supracondylar humeral fractures in children: open reduction vs. closed reduction and pinning. Arch Orthop Trauma Surg 2004;124(8):547-551.