During the Pediatric Orthopaedic Society of North America Specialty Day, two surgeons took opposite positions on the question of whether or not to treat all supracondylar humerus (SCF) fractures with closed reduction and percutaneous pinning (CRPP). David L. Skaggs, MD, of Children’s Hospital Los Angeles, argued that all such fractures should be pinned, while Mauricio Silva, MD, of UCLA/Orthopaedic Institute for Children, said pinning should be used selectively, and that in many cases positive outcomes can be achieved with casting.

A Gartland type II fracture involves displacement with an intact posterior cortex (ie, intact hinge). Although the AAOS clinical practice guideline on the treatment of pediatric supracondylar humerus fractures suggests using CRPP for type II fractures, the recommendation is of only moderate strength.

Pin them all
With few exceptions, “my position is to pin all type II supracondylar fractures,” said Dr. Skaggs. “Without pins, you are relying on flexion to hold the reduction. But flexing the elbow too much results in a loss of the pulse and the risk of compartment syndrome. To stay out of trouble, you don’t want to flex a broken elbow more than 90 degrees. Elbow flexion beyond 90 degrees produces significant compartment pressure elevation.”

Dr. Skaggs noted that just 10 percent of humeral growth is in the distal humerus by the age of 10 years; 100 percent of the growth is proximal after age 14 years. Because some remodeling does occur in younger children, Dr. Skaggs will consider casting for patients younger than age 4 in whom “the anterior humeral line (AHL) almost touches the capitellum.” Otherwise, he said, the risks involved in casting are unacceptable.

“Clinically, among kids whose fractures healed in a malreduced position, 50 percent had limited elbow flexion,” he said. “One study demonstrated that a reasonable protocol might consist of urgent pinning for fractures in which the capitellum extends beyond the AHL. If the AHL doesn’t touch the capitellum, we should pin it.”

Although casting can lead to a good result, acknowledged Dr. Skaggs, the problem lies in identifying which patients will benefit from casting and which have fractures that will not resolve. “No factors have been identified that predict success of fracture healing with casting,” he noted. “Reduction is lost in one third of fractures that are casted.”

Delaying pinning until casting fails can have a deleterious effect. “If the patient doesn’t get to the operating room in time, there’s a good chance the results will be poor,” he said. “The patient can lose flexion permanently. In one study of 189 type II fractures, pinning had predictably good outcome.”

Give casting a chance
Taking the counterpoint position, Dr. Silva noted the difficulty in treating all patients alike. “The problem is the wide variety in these fractures, from minimally displaced fractures to open hinge fractures. Hypothetically, you might pin them all, but you must consider the surgical and anesthetic complications, which in a paper by Dr. Skaggs have been described as occurring in up to 2 percent of cases.”

“Plenty of studies have shown that these patients would do fine with closed reduction and casting,” he continued. “We need to work hard to identify those patients who will require surgery.”

Citing a large study of 259 patients that compared nonsurgical treatment with pinning, Dr. Silva noted that patients who had rotational deformity, varus angulation, or severely displaced fractures required surgery. But fractures without those features did fine without surgery. “In our experience,” he said, “60 percent of patients did not require a surgical procedure and had a good outcome.”

He also disputed the assertion that delaying the pinning would lead to poorer results. “We were initially taught that the result might not be as good as it would be if pinning were done on an acute basis. However, in one of our studies, we have demonstrated good outcomes even if the pinning is performed up to 7 days after the injury.”

According to Dr. Silva, the concern about compartment syndrome is misplaced. “One of the indications for early surgical fixation is significant swelling, which precludes the use of a cast, along with any neurovascular compromise,” he noted. “If these conditions are not present, using the cast is safe.” He cited his results from a prospective study in which he treated close to a thousand patients who met his criteria for closed reduction and casting of type II supracondylar fractures; not a single case of compartment syndrome developed.

“Management of these fractures is a dynamic process,” Dr. Silva said. “It requires close follow-up and willingness to change treatment modality.” He cited one study of 48 fractures treated initially with closed reduction and casting; 37 were managed successfully, and 11 required a second procedure with CRPP.

A second study of 259 patients, with a mean age of 5 years, found that, of 189 fractures initially treated nonsurgically, at a mean follow-up of 22 weeks, 150 had healed successfully and 39 had converted to surgery. “All had adequate outcomes,” he said.

If all fractures were pinned, he noted, 77 percent would be needless surgeries.

In summary, he said, “You can follow Dr. Skaggs’ recommendation and treat all patients with surgery, and they will do fine. Or, you can do more selective treatment, and 60 percent of your patients will do fine with closed reduction and casting.”

An audience member raised the issue of cost. “There should be an economic incentive for the surgeon who uses nonsurgical treatment in the right circumstances,” he said. “Surgeons should be rewarded for lowering costs.”

Disclosure information: Dr. Skaggs—Medtronic, Stryker, Biomet, Wolters Kluwer Health–Lippincott Williams & Wilkins, Growing Spine Foundation, Growing Spine Study Group, Medtronic Strategic Advisory Board, Scoliosis Research Society, Journal of Children’s Orthopaedics, Spine Deformity. Dr. Silva—World Federation of Hemophilia.

Terry Stanton is a senior science writer for AAOS Now. He can be reached at tstanton@aaos.org

Additional Information:
AAOS clinical practice guideline on the treatment of pediatric supracondylar fractures

References:

1. Simanovsky N, Lamdon R, Mosheiff R: Underreduced supracondylar fracture of the humerus in children. J Pediatr Orthop 2007; 27 (7): 733-738.
2. Fitzgibbons PG, Ben B, Got C, et al: Predictors of failure of nonoperative treatment for type-2 supracondylar humerus fractures. J Pediatr Orthop 2011; 31 (4):372-376.
3. Skaggs, DL, Sankar WN, Albrektson J, et al: How safe is the operative treatment of Gartland type 2 supracondylar humerus fractures in children? J Pediatr Orthop 2008; 28 (2): 139-141.
4. Spencer HT, Dorey FJ, Zionts LE, Dichter DH, Wong MA, Moazzaz, P, Silva M: Type II supracondylar humerus fractures: Can some be treated nonoperatively? J Pediatri Orthop 2012; 32 (7): 675-681.
5. Silva, M, Wong TC, Bernthal NM: Outcomes of reduction more than 7 days after injury in supracondylar humeral fractures in children. J Pediatri Orthop 2011; 31 (7): 751-756.