Closed Reduction Fixation
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.

Rationale
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.

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