Vascular injuries accompanying pediatric supracondylar humerus fractures are relatively uncommon but potentially devastating. A newly issued Appropriate Use Criteria (AUC) application from the Academy (www.aaos.org/auc) provides surgeons with guidance in diagnosing and managing these injuries.

“Orthopaedists are generally comfortable in handling humerus fractures,” said James O. Sanders, MD, chair of AAOS AUC within the Committee on Evidence-Based Quality and Value. “However, in the case of a suspected vascular injury, little literature is available to guide the surgeon as to what to do. It may be a once-in-a-blue-moon occurrence, and the surgeon might be not quite comfortable with identifying the best steps for treatment. Our goal was to use the AUC methodology, which is quite good at identifying what is effective and discerning best steps to make excellent clinical decisions. This AUC helps the physician make decisions in an acute situation to ensure that the child will be properly treated.”

This assistance can be critical, because if not treated appropriately, vascular injury can lead to permanent loss of function in the limb.

Initial assumptions
The AUC on pediatric supracondylar humerus fractures with vascular injury begins with the following set of assumptions:

1. A child who presents with a dysvascular limb is triaged in a timely and appropriate manner to a facility capable of handling these issues after an attempt to reposition or reduce the fracture into a more acceptable position to improve vascular status. A formal vascular consult or vascular study should not delay the child’s undergoing attempted repositioning or reduction of the fracture.
2. In the clinical setting of a fracture presenting with nonpalpable radial pulse in the emergency department, a qualified clinician may give consideration to reposition the elbow in slight flexion and reassess whether the pulse returns.
3. Regardless of return of pulse (or lack thereof) after repositioning of elbow, the patient should be admitted to the hospital for timely reduction/fixation and observation.
4. In the scenario of a pulseless extremity, transfer of the patient to another facility should be considered if no qualified vascular or microvascular surgeon is available at that institution.
5. When a patient undergoes vascular consultation, consultation should be performed by a clinician with specialized microvascular or vascular training.

After the user accepts these assumptions, the application provides algorithmic guidance. As Dr. Sanders explains, for a suspected vascular injury, the app “guides the surgeon through identifying how well the hand is perfused. If the hand is well perfused, the app provides the surgeon with a set of options. If the hand is not well perfused, the app provides the surgeon with a different set of options. Then as the surgeon goes through the steps, he or she can go back through the AUC, and say, ‘OK, that worked, or didn’t work; what do I do next?’ The app takes the surgeon through the process of finding the best options.”

Example recommendations
Procedure recommendations are indicated with one of the following symbols:

(White checkmark in green circle)—appropriate
(Black exclamation point in yellow triangle)—may be appropriate
(White x in red circle)—rarely appropriate

For example, if the child has a suspected vascular injury after the fracture has been pinned and set, but the hand is warm and red with a pulse, the app recommends in-hospital observation without intervention. “If the hand is white without a pulse, the AUC recommends that the surgeon consider removing the fixation and possibly obtaining an angiogram,” Dr. Sanders said. It does not advise warming the extremity in that situation.

The criteria stress the importance of proper referral depending on what is observed. “These children might be initially treated at a small hospital that may not have the needed resources,” Dr. Sanders noted. “In all situations where the hand is without a pulse, the criteria recommend that the child be assessed by a vascular surgeon, or immediately transferred to a facility with such expertise.”

He explained that although the guidelines are intended for use by orthopaedists rather than family care physicians, “this AUC could be very helpful for an emergency department physician initially seeing the child.”

The criteria serve an important checklist function, Dr. Sanders said. “In emergency situations, having guidelines or checklists is really helpful to provide additional patient safety. If the provider is faced with a situation not normally encountered and has to make a decision quickly, the AUC can help ensure that he or she takes the most appropriate action. AUC can be helpful even to experienced clinicians.”

For parents and the public, the issuance of the AUC signals “that the AAOS takes patient safety very seriously,” said Dr. Sanders. “We have created a tool to take care of an uncommon but potentially devastating injury in children.”

The value of AUC
AUCs are developed by three clinician panels—a writing panel, a review panel, and a voting panel, using the RAND/UCLA Appropriateness Method. AUC specify when it is “appropriate” to use a procedure, based on the following explanation:

“An ‘appropriate’ procedure is one for which the expected health benefits exceed the expected health risks by a wide margin. Often, sound data is not available or does not provide evidence that is detailed enough to apply to the full range of patients seen in everyday clinical practice. Nevertheless, physicians must make daily decisions about when to use or not use a particular procedure. AUCs facilitate these decisions by combining the best available scientific evidence with the collective judgment of physicians in order to determine the appropriateness of performing a procedure.”

A user-friendly version of the AUC can be accessed with the AAOS OrthoGuidelines web-based app at www.orthoguidelines.org/auc

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

AUC from AAOS
To date, the AAOS has released the following 5 appropriate use criteria (AUC):

• Pediatric Supracondylar Humerus Fractures with Vascular Injury
• Pediatric Supracondylar Humerus Fractures
• Non-Arthroplasty Treatment of Osteoarthritis of the Knee
• Optimizing the Management of Full-Thickness Rotator Cuff Tears
• Treatment of Distal Radius Fractures

The following AUC are currently in development:

• Treatment of Anterior Cruciate Ligament Injuries
• Treatment of Hip Fractures in the Elderly

For more information, visit www.aaos.org/auc

Additional Information:

• Appropriate Use Criteria
• AAOS Press Release: New AAOS guidelines, mobile app outline steps for treating rare, yet potentially devastating, child elbow fractures with vascular injury