The practitioner might perform open reduction for displaced pediatric supracondylar fractures of the humerus with varus or other malposition after closed reduction.

Rationale
The work group recognizes that a percentage of pediatric supracondylar fractures of the humerus cannot be reduced using a closed technique.  Fracture pattern, soft-tissue interposition, patient characteristics, and surgeon experience may contribute individually or in combination.  In these more challenging cases the surgeon may need to perform an open reduction.  The studies included in the guideline only provide limited support this recommendation.           

Data on 28 outcomes from 8 studies were analyzed. Significant flaws in study design limited the strength of all the studies. The critical outcomes studied were cubitus varus, hyperextension, loss of reduction, malunion, pain, and elbow stiffness. Statistically significant data was found for only two of these outcomes. Aktekin, et al. report stiffness was greater in the patients treated with open reduction compared to patients treated with a closed reduction and pinning. Li, et al. reported that the fractures treated open had a lower incidence of loss of reduction compared to displaced fractures that could be managed successfully with closed reduction and pinning. Sibly, et al. found no statistically significant difference between groups for cubitus varus or elbow stiffness.

These non-randomized retrospective studies are prone to selection bias.  More severe injuries may have been selected for open reduction, potentially confounding the comparative data. We could not determine if adverse outcomes in the open reduction group were due to the severity of injury or to the intervention. Furthermore, the literature lacks clear definitions for an acceptable reduction.
  1. (56) Aktekin CN, Toprak A, Ozturk AM, Altay M, Ozkurt B, Tabak AY. Open reduction via posterior triceps sparing approach in comparison with closed treatment of posteromedial displaced Gartland type III supracondylar humerus fractures. J Pediatr Orthop B 2008;17(4):171-178.
  2. (57) Cramer KE, Devito DP, Green NE. Comparison of closed reduction and percutaneous pinning versus open reduction and percutaneous pinning in displaced supracondylar fractures of the humerus in children. J Orthop Trauma 1992;6(4):407-412.
  3. (58) Mazda K, Boggione C, Fitoussi F, Pennecot GF. Systematic pinning of displaced extension-type supracondylar fractures of the humerus in children. A prospective study of 116 consecutive patients. J Bone Joint Surg Br 2001;83(6):888-893.
  4. (59) Turhan E, Aksoy C, Ege A, Bayar A, Keser S, Alpaslan M. Sagittal plane analysis of the open and closed methods in children with displaced supracondylar fractures of the humerus (a radiological study). Arch Orthop Trauma Surg 2008;128(7):739-744.
  5. (60) Sibly TF, Briggs PJ, Gibson MJ. Supracondylar fractures of the humerus in childhood: range of movement following the posterior approach to open reduction. Injury 1991;22(6):456-458.
  6. (61) Lee HY, Kim SJ. Treatment of displaced supracondylar fractures of the humerus in children by a pin leverage technique. J Bone Joint Surg Br 2007;89(5):646-650.
  7. (62) Li YA, Lee PC, Chia WT et al. Prospective analysis of a new minimally invasive technique for paediatric Gartland type III supracondylar fracture of the humerus. Injury 2009.
  8. (63) Kekomaki M, Luoma R, Rikalainen H, Vilkki P. Operative reduction and fixation of a difficult supracondylar extension fracture of the humerus. J Pediatr Orthop 1984;4(1):13-15.