From the Guidelines
Closed reduction with pin fixation is the recommended treatment for displaced pediatric supracondylar humerus fractures, including Gartland types II and III and displaced flexion fractures, due to its favorable outcomes in terms of cubitus varus and Flynn’s elbow criteria. This approach is supported by a moderate strength of recommendation based on evidence from nine level III studies and two level II studies 1. The treatment of pediatric supracondylar humerus fractures involves considering the potential for harm from nonsurgical treatment, such as limb-threatening ischemia, and weighing these risks against the benefits of closed reduction and pinning 1.
Key Considerations
- The quality, applicability, and strength of the evidence generated a preliminary strength of recommendation of Weak, which was upgraded to Moderate by the work group based on the potential for harm from nonsurgical treatment 1.
- Pin fixation was statistically superior to nonsurgical treatment in a meta-analysis of Flynn’s criteria, which incorporates both range of motion and carrying angle 1.
- The reduction method depends on fracture type and severity, with closed reduction under sedation being first-line for most displaced fractures, followed by immobilization with a cast or splint.
- Open reduction with internal fixation becomes necessary when closed reduction fails or with severely displaced fractures, especially those with neurovascular compromise.
Outcomes
- Cubitus varus: closed reduction and pinning has a more favorable outcome, with a number needed to treat (NNT) of 20 1.
- Flynn’s elbow criteria: closed reduction and pinning has a more favorable outcome, with a number needed to treat (NNT) of 7 1.
- Iatrogenic ulnar nerve injury: closed reduction and casting is favored, with a number needed to harm (NNH) of 108 1.
From the Research
Pediatric Humerous Fracture Displacement Guidelines for Reduction
- The management of proximal humerus fractures in the pediatric population is based on patient age, fracture displacement, and remodeling capacity 2.
- Nonoperative management is successful in younger patients or less displaced fractures, and operative management is usually considered in older patients with more displaced fractures 2.
- Closed reduction and percutaneous pinning is a common treatment option for displaced pediatric supracondylar humerus fractures, with a cross-pinning technique shown to be safe and reproducible with a significant decrease in the risk of iatrogenic ulnar nerve injury 3.
- The use of equimolar nitrous oxide as conscious sedation for closed reduction and casting appears to be a safe and appropriate conservative method of treatment for displaced Gartland type II supracondylar fractures in children 4.
- Treatment options for humeral midshaft fractures include open reduction and internal fixation with anterior or posterior plate fixation, with no significant difference in healing rate, primary nerve palsy recovery rate, or prevalence of secondary nerve palsy between the two approaches 5.
- Closed reduction and percutaneous fixation using the Humerusblock system is a reliable minimally invasive fixation method for selected displaced proximal humerus fractures, with good clinical outcomes and low rates of avascular necrosis 6.
Key Considerations
- Patient age and fracture displacement are important factors in determining the treatment approach for pediatric humerus fractures 2, 3.
- The choice of treatment approach should be based on the individual patient's needs and the specific fracture pattern 5, 6.
- Regular follow-up is mandatory to detect early secondary displacement and ensure optimal outcomes 4.