At their meeting on Sept. 24, 2011, the AAOS Board of Directors approved a new clinical practice guideline (CPG) on the treatment of pediatric supracondylar humerus fractures. This is the third CPG to focus on a primarily pediatric condition.
Supracondylar fractures of the humerus are widely considered to be the most common fracture of the elbow in children (Fig. 1). Approximately 3 percent of all fractures in children are supracondylar fractures. They often result from trauma to the elbow, most often due to a fall from a height or related to sports or leisure activities.
Even though these fractures are so common, high-quality scientific data regarding their treatment are lacking. Of the 44 included studies in this clinical practice guideline, only 7 were randomized controlled trials (RCTs), none of which had strong scientific evidence.
The guideline addresses the treatment of isolated supracondylar fractures of the humerus in children who have not yet reached skeletal maturity. It is not intended for use in pediatric patients who have additional coexisting injuries that require formal surgical intervention or other life-threatening conditions that take precedence over the treatment of the supracondylar fracture of the humerus.
Of the 14 recommendations included in the guideline, two are supported by fair quality evidence (graded as moderate), two by poor quality evidence (graded as weak), eight are inconclusive (inconclusive or insufficient evidence), and two are based on the consensus of the workgroup (Table 1). The two consensus statements recognize that the conditions in question could result in loss of life or limb; thus, in the absence of reliable data, the recommendations are based on clinical opinion.
In the absence of strong evidence, it is particularly important that physicians thoroughly discuss available treatments and applicable procedures with the patient’s parents or guardians. The clinician’s experience with conservative management and his or her surgical experience and skills increase the probability of identifying patients who will benefit from specific treatment options.
The workgroup defined patients with “acute” fractures as those patients who were seen for treatment within 14 days of injury. Because no single fracture classification system has perfect inter- and intra-observer reliability or can take into account additional clinical factors such as mechanism of injury, time and duration since injury, soft-tissue damage and swelling, and/or presence of neurovascular compromise, the guideline uses the Gartland classification system simply as a point of reference. Although the Gartland classification system also applies only to extension fractures, all recommendations that address a displaced fracture refer to both extension and flexion fractures.
The first recommendation addresses Gartland Type I or nondisplaced pediatric supracondylar humerus fractures. Nonsurgical immobilization of these fractures is common practice.
The second recommendation covers Gartland Type II and Type III fractures, as well as the less common flexion-type pediatric supracondylar fracture. Although surgical treatment introduces the risk of infection, the improved critical outcomes—combined with the decreased risk of limb-threatening ischemic injury—outweigh the risk.
Because pin configuration and the potential complications related to instability and iatrogenic ulnar nerve injury are recognized concerns, the third and fourth recommendations cover pin stabilization. Critical outcomes investigated were iatrogenic ulnar nerve injury, loss of reduction, malunion, and reoperation rate. Although the group sought to see if there was a difference in ulnar nerve injury rates related to the technique of pin placement (percutaneous vs. open medial), no existing adequate data addressed the issue.
The timing of treatment for displaced pediatric supracondylar humerus fractures is an important practical concern addressed in the fifth recommendation. 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. In developing this recommendation, the workgroup identified the following critical outcomes: compartment syndrome, cubitus varus, need for open reduction, operative time, reoperation/loss of reduction, Baumann’s angle, and malunion.
The sixth recommendation recognizes that a percentage of these fractures cannot be reduced using a closed technique. In these more challenging cases, the surgeon may need to perform an open reduction. The studies included in the guideline, however, only weakly support this recommendation.
The seventh recommendation is based on expert opinion because the displaced pediatric supracondylar fracture with reduced perfusion jeopardizes the function and viability of the limb. 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. This recommendation is consistent with common medical practice.
Similarly, the eighth recommendation is based on consensus due to the risk of limb loss. In most 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 orthopaedic surgeon will need to use clinical judgment and may want a consult regarding vascular injury.
No data address the incidence and the impact of the clinical circumstance of a reduced pediatric supracondylar fracture with a perfused hand but absent wrist pulse discussed in the ninth recommendation.
Similarly, no studies were found that linked the duration of pinning or immobilization to any outcome of interest, a situation covered in the tenth recommendation. Prolonged pinning and immobilization might cause pin tract infection or elbow stiffness. Early removal of pins may increase the risk of redisplacement or refracture.
Concerns regarding range of motion after healing prompted the inclusion of recommendation 11. Workgroup members identified range of motion after 1 year, stiffness, function, pain, and return to activity as critical outcomes. The recommendation is inconclusive because a single study of limited applicability (restricted to open reductions) with flawed design (underpowered, not blinded) was the only evidence available.
The issue of unrestricted activity in recommendation 12 was addressed 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. Unfortunately, no studies addressed the question.
Nerve injuries can occur with pediatric supracondylar fractures and are addressed in recommendation 13. Although electrodiagnostic studies might supplement a repeated physical examination in the monitoring of nerve recovery, no data were found to determine if or when electrodiagnostic studies and/or nerve exploration are useful.
Finally, adolescent patients are addressed in recommendation 14. Adolescent patients have different fracture patterns, mechanisms of injury, and the potential for slower healing than juveniles. No data reporting on outcomes of interest in adolescent patients were available.
In summary, recommendations 4, 5, 9, 10, 11, 12, 13, and 14 all had inconclusive evidence. As a result, the guideline wording reflects that currently available data do not provide clear guidance on which course of action is best.
Kishore Mulpuri, MBBS, MS (Ortho), MHSc (Epi) served as vice-chair of the workgroup that developed the clinical practice guidelines on treatment of pediatric supracondylar fractures of the humerus.
How the guidelines came to be
This guideline and systematic review were prepared by the AAOS Treatment of Pediatric Supracondylar Fracture of the Humerus guideline workgroup with the assistance of the AAOS Clinical Practice Guidelines Unit in the Department of Research and Scientific Affairs.
To develop this guideline, the workgroup held an introductory meeting on Oct. 4, 2009, to establish the scope of the guideline and the systematic reviews. Upon completing the systematic reviews, the workgroup participated in a 2-day recommendation meeting (Oct. 2–3, 2010) to write, edit, and vote on the final recommendations and rationales. An initial draft was completed and submitted for peer review on Nov. 15, 2010.
Members of the workgroup included: Andrew Howard, MD, chair; Kishore Mulpuri, MBBS, MS (Ortho), MHSc (Epi), vice-chair; Mark F. Abel, MD; Stuart V. Braun, MD; Matthew J. Bueche, MD; Howard R. Epps, MD; Harish S. Hosalkar, MD; Charles Mehlman, DO, MPH; Susan Scherl, MD; Michael Goldberg, MD, Guidelines Oversight Committee chair; Charles Turkelson, PhD; Janet L. Wies, MPH; and Kevin Boyer.
Thereafter, the draft guideline was sequentially sent for approval to the AAOS Evidence Based Practice Committee, the AAOS Guidelines and Technology Oversight Committee, the AAOS Council on Research and Quality, and the AAOS Board of Directors, which approved it on Sept. 24, 2011.
Funding for this guideline was provided solely by the AAOS. The development of AAOS clinical practice guidelines is overseen by the Guidelines Oversight Committee and the Evidence-Based Practice Committee. The full guideline is available at www.aaos.org/guidelines