|Treatment of Pediatric Supracondylar Humerus Fractures|
Gartland Type 1 Immobilization
We suggest nonsurgical immobilization of the injured limb for patients with acute (e.g. Gartland Type I) or non displaced pediatric supracondylar fractures of the humerus or posterior fat pad sign.
Gartland Type I or non-displaced pediatric supracondylar humeral fractures are fractures without significant distortion of anatomical bony landmarks of the supracondylar region and can be associated with posterior fat pad sign. Non-operative immobilization of these fractures is common practice.
This recommendation is based on two moderate quality studies that analyzed collar and cuff immobilization versus back-slab (posterior splint) immobilization for non-displaced pediatric supracondylar humeral fractures. Ballal, et al. was a prospective double-cohort study with a total of 40 patients and 20 in each group (collar and cuff versus back slab). Oakley, et al presented a randomized control trial with similar comparison groups and had a total of 50 patients (27 randomized to a posterior slab group and 23 to a collar and cuff). The randomized controlled trial was classified as moderate quality (see below for quality evaluation). Both of these prospective studies found better pain relief within the first two weeks of injury with the posterior splint/ back slab method of immobilization. The critical outcomes not reported include cubitus varus, hyperextension and loss of reduction.
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.
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.
Medial vs. Lateral Pinning
The practitioner might use two or three laterally introduced pins to stabilize the reduction of displaced pediatric supracondylar fractures of the humerus. Considerations of potential harm indicate that the physician might avoid the use of a medial pin.
Pin configuration and the potential complications related to instability and iatrogenic ulnar nerve injury are recognized concerns in this population. Therefore the work group deemed it important to examine the technique of pin stabilization.
Critical outcomes investigated were iatrogenic ulnar nerve injury, loss of reduction, malunion, and reoperation rate. This recommendation is based on data on 65 outcomes from 15 studies comparing pinning technique using lateral only pin entry to lateral and medial crossed pin technique.
Two of the six studies that were sufficiently powered for loss of reduction were statistically significant in favor of medial pins. The remaining four studies reported no statistically significant difference between lateral and medial pins.
One randomized, prospective study by Kocher, et al., examined loss of reduction and found a loss of reduction rate of 21% (6/28) in lateral only pins. Medial and lateral pins had a statistically significant lower loss of reduction rate of 4% (1/24). This loss of reduction was not clinically significant enough to warrant re-operation in either group. Meta-analysis of low and moderate quality studies found no statistically significant difference between lateral and medial pin configurations with respect to Baumann’s angle, Baumann’s angle change, Flynn’s Criteria and infection.
The ulnar nerve was injured in 3 of 557 (0.53%) cases with laterally introduced pins. Medially introduced pins resulted in 49 of 808 (6%) cases of ulnar nerve injury. Iatrogenic ulnar nerve injury was noted to be statistically significant in favor of lateral pinning in 6 of 11 studies. A meta-analysis of these studies and three additional underpowered studies (1 moderate quality and 13 low quality) also demonstrated a statistically significant effect in favor of lateral pinning (Number Needed to Harm = 22, Odds ratio = 0.27). This suggests a 1 in 22 chance of harm resulting from the medial pinning techniques used in these studies. Based on limited evidence, the practitioner might use two or three laterally introduced pins to stabilize the reduction of displaced pediatric supracondylar fractures of the humerus. The risk of potential harm from a medial pin must be weighed against the potential advantages.
Open Incision for Medial Pin
We cannot recommend for or against using an open incision to introduce a medial pin to stabilize the reduction of displaced pediatric supracondylar fractures of the humerus.
Pin configuration and the potential complications related to iatrogenic ulnar nerve injury are recognized concerns in this population. Therefore the group deemed it important to examine the technique of medial pin placement; specifically if there was a difference in ulnar nerve injury rates related to percutaneous vs. open medial pin placement. There was no existing adequate data to address the technique of medial pin placement.
Time Threshold for Reduction
We are unable to recommend for or against a time threshold for reduction of displaced pediatric supracondylar fractures of the humerus without neurovascular injury.
The timing of treatment of displaced pediatric supracondylar humerus fractures is an important practical concern. The advisability of urgent/emergent treatment is often weighed against the availability of a surgeon, access to an operating room, and the relative safety of anesthesia. Six low quality studies with moderate applicability were identified.
All studies took a continuous variable (time to treatment) and defined early versus late treatment. Early treatment was described as being within eight hours of injury in four studies and two used a twelve-hour cut-off (Table 44). While the time of an individual's presentation to the hospital is often well documented in the medical record, the time of injury is often estimated. Such uncertainties may affect the quality of conclusions in these studies.
Five of seven critical outcomes identified by the work group were reported in the studies. Four outcomes (compartment syndrome, cubitus varus, operative time, and need for reoperation) were not reported to be significantly different between early and late treatment groups in any of the studies.
One outcome, the need for open reduction, was reported in all six studies. Carmichael and Joyner, Iyengar, et al. and Sibinski, et al. reported no difference between early and late treatment groups. Gupta, et al. and Walmsley, et al. indicated an increased rate for open reduction in the delayed group, while Mehlman, et al. showed a decreased rate for open reduction with later treatment. The indication for open reduction is subjective and may therefore vary considerably. Without consistent, objective criteria for the requirement for open treatment, it is difficult to assess the results of the studies. Furthermore, these non-randomized retrospective studies are prone to selection bias. More severe injuries may have been selected for earlier treatment, potentially confounding the comparative data.
Open Reduction Criteria
The practitioner might perform open reduction for displaced pediatric supracondylar fractures of the humerus with varus or other malposition after closed reduction.
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.
Closed Reduction with Decreased Perfusion of Hand
In the absence of reliable evidence, the opinion of the work group is that emergent closed reduction of displaced pediatric supracondylar humerus fractures be performed in patients with decreased perfusion of the hand.
Ischemic injury with contracture and/or permanent muscle and nerve damage is a disastrous outcome of the displaced pediatric supracondylar fracture with vascular compromise. The precise incidence of these complications is not accurately reported but they do occur. Only 7 studies related to the recommendation were found and all were excluded based on their poor quality. This recommendation is based on expert opinion because the displaced pediatric supracondylar fracture with reduced perfusion jeopardizes the function and viability of the limb.
Several factors may impact decisions in this clinical scenario. The degree of vascular compromise can vary from absent pulses at the wrist with some perfusion to the hand, to a completely pale hand with concomitant nerve deficits. Additional factors include the skill level of the practitioners, the time from injury, and the availability of consultants such as vascular surgeons. In the absence of high level evidence related to these factors, the practitioner’s judgment will be important. In the case of a pale hand without wrist pulses, the potential benefit of manipulating the fracture may be greater than splinting and sending the patient to a center that is hours away. Conversely, if an unsuccessful reduction fails to improve blood flow, there may be trade-offs including worsening the condition by delaying access to specialized centers. This consensus recommendation allows for the discretion and judgment of the practitioner to determine who does the emergent reduction, where it is done, and what technique (open versus closed) is used. This recommendation is consistent with common medical practice.
Open Exploration for No Pulse and Underperfused Hand
In the absence of reliable evidence, the opinion of the work group is that open exploration of the antecubital fossa be performed in patients who have absent wrist pulses and are underperfused after reduction and pinning of displaced pediatric supracondylar humerus fractures.
In a majority of patients with displaced fractures and vascular compromise, limb perfusion improves after reduction. In the absence of improvement, surgical exploration of the antecubital fossa is indicated for patients with absent wrist pulses and a cold, pale hand. The work group issued this consensus recommendation, despite the paucity of evidence and the rarity of this occurrence, because of the risk of limb loss.
Benefits of immediate exploration outweigh the potential harms. The catastrophic risks of persistent inadequate perfusion include loss of limb, ischemic muscle contracture, nerve injury, and functional deficit. Risks of exploratory surgery include infection, neurovascular injury, and stiffness.
The orthopaedic surgeon will need to use clinical judgment. Consultation regarding vascular injury may be necessary. Treatment decisions should be made in light of all circumstances presented by the patient. This recommendation is consistent with common medical practice.
Open Exploration for No Pulse and Perfused Hand
We cannot recommend for or against open exploration of the antecubital fossa in patients with absent wrist pulses but with a perfused hand after reduction of displaced pediatric supracondylar humerus fractures.
There are no data to address the incidence and the impact of the clinical circumstance of a reduced pediatric supracondylar fracture with a perfused hand but absent wrist pulse, nor can the likelihood of avoiding adverse outcomes from this circumstance by open exploration of the antecubital fossa.
Timing of Pin Removal
We are unable to recommend an optimal time for removal of pins and mobilization in patients with displaced pediatric supracondylar fractures of the humerus.
Prolonged pinning and immobilization might cause pin track infection or elbow stiffness. Early removal of pins may increase the risk of redisplacement or refracture. There were no studies where the duration of pinning or of immobilization was explicitly linked to any outcome of interest.
Physical Therapy or Occupational Therapy
We are unable to recommend for or against routine supervised physical or occupational therapy for patients with pediatric supracondylar fractures of the humerus.
We addressed this topic because of concerns regarding range of motion after healing of the fracture. Critical outcomes sought included range of motion after one year, stiffness, function, pain, and return to activity. A single study was found. It prospectively compared patients who received physical therapy with patients who did not. The study was randomized but not blinded and included only patients who were treated by open reduction. The study was underpowered so we could not include the one year endpoint. However, statistically significant results were seen at earlier endpoints. Patients in the physical therapy group had better range of motion at both 12-13 weeks and 18-19 weeks.
The recommendation is inconclusive since a single study of limited applicability (restricted to open reductions) with flawed design (underpowered, not blinded) was the only evidence available.
Return to Activity
We are unable to recommend an optimal time for allowing unrestricted activity after injury in patients with healed pediatric supracondylar fractures of the humerus.
We addressed this topic because unnecessary restriction of activity contributes to the morbidity of a fracture from the patient and parent perspective, but this must be balanced against the risk of a refracture if activity is resumed too early. There were no studies addressing the question. Two critical outcomes were searched to answer this recommendation, incidence of refracture and timing of refracture.
We are unable to recommend optimal timing of or indications for electrodiagnostic studies or nerve exploration in patients with nerve injuries associated with pediatric supracondylar fractures of the humerus.
Nerve injuries can occur with pediatric supracondylar fractures. We addressed this topic because electrodiagnostic studies might supplement a repeated physical examination in the monitoring of nerve recovery. We were also interested in the role of nerve exploration. There were no data to determine if or when electrodiagnostic studies and/or nerve exploration are useful.
Open Reduction for Adolescents
We are unable to recommend for or against open reduction and stable fixation for adolescent patients with supracondylar fractures of the humerus.
We addressed this topic because adolescent patients have different fracture patterns and mechanisms of injury. We addressed the role of stable fixation because adolescents have the potential for slower healing than juveniles. There were no data available reporting on outcomes of interest in adolescent patients.
Guideline Work Group:
Andrew Howard, MD, Chair
Kishore Mulpuri, MD, Vice Chair
Mark F. Abel, MD
Stuart Braun, MD
Matthew Bueche, MD
Howard Epps, MD
Harish Hosalkar, MD
Charles T. Mehlman, DO, MPH
Susan Scherl, MD
AAOS Guidelines Oversight Committee:
Michael Goldberg, MD, Chair
Charles M. Turkelson, PhD, Director of Research and Scientific Affairs
Janet L. Wies, MPH, Manager, Clinical Practice Guidelines
Kevin Boyer, Manager, Appropriate Use Criteria