A newly approved set of Appropriate Use Criteria (AUC) for the management of pediatric supracondylar humerus fractures will help guide orthopaedic surgeons and other physicians in treating patients with these common but potentially complex and serious injuries.

The AUC, accessible at www.aaos.org/aucapp, features a Web and mobile app that incorporates algorithms for following an optimal course of treatment, depending on the type and severity of the injury (Fig. 1).

“These are serious injuries requiring appropriate evaluation and treatment,” said James O. Sanders, MD, of the University of Rochester, section chair for AAOS AUC within the Committee on Evidence-Based Quality and Value.

From indications to recommendations
The app includes a checklist of assumptions to ensure that the surgeon embarking on treatment has the capability, necessary resources, and facilities for handling the case. Specifically, the assumptions in the list include the following:

• The patient is healthy enough to undergo surgery, if needed.
• A thorough history and physical examination of the patient have been conducted.
• Adequate radiographs (imaging) have been obtained and
  examined.
• The surgeon or surgeons who care for the child can perform the appropriate orthopaedic procedures.
• The surgery will be performed in a timely fashion, in an appropriate location.
• The facility has proper implants, ancillary equipment, and capable support personnel.

Once the surgeon reads and accepts these assumptions, he or she may proceed to the app and to treatment or elect to refer the patient to another facility or surgeon.

Procedure recommendations are based on an indication profile that must be completed. The profile includes the following indications:

• fracture type (1—nondisplaced; 2—displaced; 3—extension type with or without cortical continuity; transphyseal; and flexion)
• preoperative vascular status
• presence of nerve injuries
• soft-tissue envelope status
• presence or absence of ipsilateral radius and/or ulna fracture
• degree of swelling

From the information entered, the app provides treatment recommendations, with the option of viewing an interactive literature review. The algorithm can link users to more than 3,000 scenarios and related treatments ranked for their appropriateness, “helping to ensure optimal care and the best long-term outcome for resuming functional use of the elbow,” said Dr. Sanders.

The recommendations are given appropriateness ratings on a scale of 1 to 9. The following three main range categories determine how the median rating is defined:

1–3 = Rarely Appropriate
4–6 = May Be Appropriate
7–9 = Appropriate

Of the total voting items (220 patient scenarios × 14 treatments), 22 percent were rated as “Appropriate,” 14 percent were rated as “May Be Appropriate,” and 64 percent were rated as “Rarely Appropriate” (Fig. 2).

Use in practice
According to Dr. Sanders, surgeons familiar with management of these injuries will find that the AUC recommendations align with practice norms, covering issues such as perfusion, risk of compartment syndrome, and when and whether to cast or pin. He said, “The AUC will be particularly helpful for residents in training, emergency room physicians, and surgeons who only occasionally care for these injuries, giving them guidance on what to do when they see a patient with a supracondylar fracture, both immediately and in the long run, and whether the patient sustained a nerve or vascular injury in conjunction with the fracture.”

Dr. Sanders noted how management of pediatric supracondylar fractures has changed over the years. “A generation ago, the prevailing treatment was closed treatment or traction. Now it has evolved to try to protect the nerves and blood vessels from damage that can occur due to swelling from displaced fractures that are pinned so that the arm can be placed in a safe position. For nondisplaced fractures, the treatment generally remains splinting and casting,” he said.

The supracondylar humerus fracture work group is currently developing a branch for the AUC that will address how to treat the child with a vascular injury, “which can be controversial,” Dr. Sanders said.

AUCs are based on clinical practice guidelines, but also offer treatment recommendations in the face of imperfect evidence. The approach AAOS uses to develop AUCs was originated by the RAND Corporation and refined into a method well-suited to clinical medicine, in which physicians must make daily decisions about when to use a particular procedure even in the presence of unclear evidence from high-quality studies. The multiple scenarios developed during the development of the AUC provide sufficiently detailed criteria to apply to the full range of patients seen in everyday practice.

AUC are sequentially approved by the AAOS Appropriate Use Criteria Section, the AAOS Council on Research and Quality, and the AAOS Board of Directors. The Academy submits the AUC to the National Guidelines Clearinghouse and, in accordance with Clearinghouse criteria, will update or retire this AUC within 5 years of the publication date.

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

AUC Development
The AAOS Appropriate Use Criteria Section appointed members and specialty society representatives to the panels necessary to AUC development: the writing panel, review panel, and voting panel. In addition to the AAOS, members from the following organizations participated in the development of the AUC on pediatric supracondylar fractures: American Academy of Emergency Medicine; American Academy of Pediatrics; American Association for Hand Surgery; American College of Surgeons; American Pediatric Surgical Association; American Physical Therapy Association; American Society for Surgery of the Hand; Pediatric Orthopaedic Society of North America.

Data analyses and pertinent methodologic information are provided by the appropriate use criteria unit in the AAOS department of research and scientific affairs. The names and affiliations of panel members can be accessed by clicking the “Contributors” link on the Indications page. Users can also link to an explanation of the methods, a complete list of assumptions, and full documentation for the treatment indications.

Get involved in AUC development
Developing Appropriate Use Criteria (AUC) requires the participation of many volunteers. Each AUC involves two groups with both specialists and nonspecialists.

Writing panel members are specialists in the topic area who develop the list of clinical indications and clinical scenarios; voting panel members may be either specialists or nonspecialists who determine appropriateness by rating the scenarios.

Three AUC are currently being developed: The Treatment of Anterior Cruciate Ligament Injuries, Treatment of Osteochondritis Dissecans, and Treatment of Hip Fractures in the Elderly. Two AUC will be selected and developed during 2015.

Solicitations for members of writing and voting panels are regularly included in AAOS Headline News Now. Specialty societies also recommend representatives for relevant AUC panels. If you are interested in participating, contact Jayson Murray, AUC manager, at jmurray@aaos.org