AAOS Clinical Practice Guideline: The Treatment of Pediatric Supracondylar Humerus Fractures

Supracondylar fractures of the humerus in children are the result of trauma to the elbow, most often resulting from a fall from a height or related to sports or leisure activities.1 Supracondylar humerus fractures are widely considered the most common fracture of the elbow in children. The annual rate of children who present with supracondylar fractures has been estimated at 177.3 per 100,000.2 There are many components to consider when calculating the overall cost of treatment of pediatric supracondylar fractures of the humerus.3 The main considerations are the relative cost and effectiveness of each treatment option. However, hidden costs for pediatric patients must also be considered. These costs include the additional home care required for a patient, the costs of rehabilitation and of missed school, child care costs if both parents work, and time off work required by one or both parents to care for the pediatric patient. The potential deformity of the arm at the elbow, including varus deformity and prolonged loss of mobility, as well as absence from school, often associated with the management of pediatric supracondylar fractures of the humerus, can have adverse physical, social, and emotional consequences for the child as well as the child's family. Treatments that minimize these concerns are therefore desirable. Most management methods are associated with some known risks, especially invasive and surgical treatments. Contraindications vary widely based on the treatment administered. A particular concern when managing supracondylar humerus fractures is the potential for this fracture to cause vascular compromise of the limb, which can lead to long-term loss of nerve and/or muscle function. Additional factors may affect the choice of treatment, including but not limited to associated injuries the patient may present with as well as comorbidities, skeletal maturity, and/or specific patient characteristics, including obesity. Clinician input based on experience increases the probability of identifying patients who will benefit from specific management options. The individual patient's family dynamic will also influence treatment decisions; therefore, discussion of available treatments and procedures applicable to the individual patient rely on mutual communication between the patient's guardian and physician, weighing the potential risks and benefits for that patient. Once the patient's guardian has been informed of available therapies and has discussed these options with his or her child's physician, an informed decision can be made. History On September 20, 2011, at approximately 1:30 pm, the patient is playing on the monkey bars and falls approximately 6 feet onto his outstretched right hand. There is immediate pain and deformity to his right elbow, without any open injuries. There is no pain at the right shoulder, wrist, or neck; neither is there loss of consciousness. This is an isolated injury, and the patient has no previous injuries to his upper extremities. His last meal was before playing was at approximately 1:00 pm. He is assessed at Whistler Medical Clinic, approximately 3 hours north of Vancouver, where the supracondylar fracture is identified. He is put into a posterior slab and transported to BC Children's Hospital Emergency Department. Physical Examination and Imaging Studies On examination, the patient shows normal vital signs and is in minimal stress. The right posterior slab splint is removed to reveal a very swollen right elbow. The skin is intact. The ipsilateral shoulder and wrist are normal to screening examination. Good radial pulse is palpated. Neurologic assessment shows intact motor responses to median ulnar and radial nerve distributions. There is normal sensation of median, ulnar, and radial nerve distribution. Radial pulse is palpable in the hand, which is well perfused. Radiographs show a displaced type III extension supracondylar humerus fracture (Figure 1).Figure 1: AP (A) and lateral (B) radiographs demonstrating a displaced type III extension supracondylar fracture of the humerus in a pediatric patient.Assessment and Planning The patient is a 6-year-old boy presenting with a type III supracondylar humerus fracture. This is a severely displaced fracture and requires surgical fixation. Following the AAOS guideline and standard of care, the procedure will consist of closed reduction, possible open reduction, and Kirschner wire (K-wire) fixation. The risks and benefits are discussed with the parents, and consent is obtained. Two lateral divergent K-wires are used to stabilize the fracture (Figure 2).Figure 2: AP (A) and lateral (B) radiographs demonstrating two lateral divergent Kirschner wires transfixing the distal humerus.The AAOS guideline suggests closed reduction with pin fixation for patients with displaced (eg, Gartland types II and III, and displaced flexion) pediatric supracondylar fractures of the humerus (strength of evidence: Moderate). This was discussed with the parents, along with the possibility of open reduction. The AAOS guideline suggests the practitioner may use two or three laterally introduced pins to stabilize the reduction of displaced pediatric supracondylar fractures of the humerus. Considerations of potential harm indicate that the physician might avoid the use of a medial pin (strength of evidence: Weak). In this patient, we used two lateral divergent K-wires. The AAOS guideline is unable to recommend for or against a time threshold for reduction of displaced pediatric supracondylar fractures of the humerus without neurovascular injury (strength of evidence: Inconclusive). Because of transportation time, the patient receives reduction within 8 hours of injury. The AAOS guideline is unable to recommend an optimal time for removal of pins and mobilization in patients with displaced pediatric supracondylar fractures of the humerus (strength of evidence: Inconclusive). We typically remove pins at 3 to 4 weeks after fracture reduction. The AAOS guideline is unable to recommend for or against routine supervised physical or occupational therapy for patients with pediatric supracondylar fractures of the humerus (strength of evidence: Inconclusive). After release from the hospital, the child does not pursue therapy and is followed during clinic visits at 1 week, 3 weeks, and 6 months postinjury. At 6 months, the patient had full range of motion at the elbow. The AAOS guideline is unable to recommend an optimal time for allowing unrestricted activity after injury in patients with healed pediatric supracondylar fractures of the humerus (strength of evidence: Inconclusive). The child began unrestricted activity 3 to 4 weeks following removal of K-wires.