Fig. 1 In a flexion-type supracondylar fracture, the distal fragment is displaced anteriorly. Reproduced from Otsuka NY and Kasser JR. Supracondylar Fractures of the Humerus in Children. J Am Acad Orthop Surg 1997;5:19-26

AAOS Now

Published 12/1/2015
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Jennie McKee

Fracture Pattern May Help Predict Surgical Outcomes of SCHFX

Data link flexion injuries to worse outcomes

Most children who undergo surgical treatment of supracondylar humerus fractures (SCHFX) return to high levels of physical function. But according to research presented at the Orthopaedic Trauma Association's 2015 annual meeting, patients whose SCHFX are classified as flexion injuries may have worse functional outcomes after surgery than those with extension injuries.

"Despite the fact the supracondylar humerus fracture are the most common operative fracture of the pediatric elbow, few studies have assessed functional outcomes following operative treatment of these injuries," noted Anthony Riccio, MD, the study's senior author. "The goal of this study was to correlate fracture pattern, severity, and direction of displacement to ultimate patient function," he added.

A prospective study
The researchers prospectively enrolled 752 pediatric patients (average age, 6.7 years; range, 2 years to 12 years) who underwent surgical treatment for SCHFX from January 2010 to December 2013 at a level 1 pediatric trauma hospital. Patients with adult-type extra-articular or intercondylar distal humerus injuries requiring open reduction and internal fixation (ORIF) with plates and screws, and skeletally mature patients were excluded. Captured information included the mechanism of injury, fracture characteristics, physical examination findings and Gartland classification.

According to Dr. Riccio, the vast majority of patients underwent closed reduction and percutaneous pin fixation, but open reduction and percutaneous pinning was performed when an acceptable closed reduction could not be achieved.

Follow-up continued until radiographic and clinical healing. Functional outcomes were obtained at the final appointment via Pediatric Outcomes Data Collection Instrument (PODCI) global functioning scores and Quick Disability of the Arm, Hand and Shoulder Questionnaire (QuickDASH) scores.

"We compared outcome scores of differing fracture patterns as well as of differing directions of displacement," noted Dr. Riccio. In addition, the investigators performed multiple regression analysis and controlled for other injury parameters, including presence of an open fracture, neurologic deficit, vascular abnormality, and patient age.

Analyzing results
Of the 752 enrolled patients, 26 percent (199 patients) completed functional outcomes measures at final follow-up (average, 79 days; range, 29–268 days). Of these, 5 percent (10 patients) had flexion-type fractures. The remaining 189 patients (95 percent) sustained extension injuries. One third of the extension injuries (62) were Type II fractures, and the rest were Type III fractures.

Analysis of direction of displacement for the extension injuries showed a fairly even distribution (Table 1). Average QuickDASH and PODCI global functioning scale scores for the entire patient cohort were 10.5 and 93.5, respectively, demonstrating that, in general, these patients had excellent functional outcomes and low levels of disability at final follow-up.

"After controlling for variables such as neurologic injury and vascular injuries, our data indicate that children with flexion-type fractures seem to have lower functional outcome scores in the areas of 'Transfer and Mobility' and 'Pain and Comfort' at final follow-up compared to those with extension-type fractures," concluded Dr. Riccio.

"Interestingly," he continued, "we found no difference in functional outcome scores between children with Gartland Type II and Gartland Type III extension fractures. Lastly, functional outcomes did not appear to vary with the direction of displacement for extension-type fractures."

Drawing conclusions
The study's primary strength was its prospective design, which enabled researchers to correlate functional outcomes to fracture pattern and direction of displacement.

"In addition, our overall numbers are quite good for a prospective study, though it would have been ideal to have more patients with flexion-type injuries," he said. "Although lack of follow-up is somewhat inherent to the patient population we treat at our trauma facility, it would have been ideal to have outcome scores on a higher percentage of our enrolled patients."

Dr. Riccio also noted that a minimal clinically important difference had yet to be defined for the PODCI.

"That makes it difficult to say whether the statistical differences we found in outcome scores of children with flexion-type injuries, —who had lower outcomes scores for 'Pain and Comfort' and 'Transfer and Mobility'—imply a significant clinical difference.

"The main take-home point from this study is that—in general—all children had very good function after surgical treatment of these injuries," continued Dr. Riccio. "The findings should enable surgeons to counsel parents that even children whose injuries resulted in significant amounts of displacement should achieve ultimate function equivalent to those with less severe displacement."

Dr. Riccio's coauthors of "Fracture Classification Predicts Functional Outcomes in Supracondylar Humerus Fractures" were Justin Ernat, MD; Robert L. Wimberly, MD; David A. Podeszwa, MD; and Christine A. Ho, MD. The authors' disclosure information can be accessed at www.aaos.org/disclosure

Jennie McKee is a senior science writer for AAOS Now. She can be reached at mckee@aaos.org

Bottom Line
Children who undergo surgical treatment of SCHFX generally have good functional outcomes.
Patients with flexion-type fractures seemed to have lower functional outcome at final follow-up compared to those with extension-type fractures.
However, it is unclear whether these differences imply a significant clinical difference.
Based on these findings, the authors state that surgeons can counsel parents that even children with significant displacement are likely to ultimately achieve function equivalent to SCHFX patients with less severe displacement.