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The treatment of displaced supracondylar humerus fractures: evidence-based guideline
Kishore Mulpuri1, Kaye Wilkins
1Department of Orthopaedic Surgery, British Columbia Children's Hospital, University of British Columbia, Vancouver, BC, Canada. kmulpuri@cw.bc.ca
Insights
For displaced pediatric humerus fractures, closed reduction with pin fixation is recommended. Lateral pinning is preferred over medial pinning to minimize harm, with open reduction reserved for malposition correction.
Area of Science:
- Orthopedic Surgery
- Pediatric Orthopedics
- Traumatology
Background:
- Supracondylar humerus fractures are the most common elbow fracture in children.
- Type III fractures, with no cortical contact, demand effective treatment to prevent adverse outcomes.
- A systematic review was conducted to inform clinical practice guidelines for type III fractures.
Purpose of the Study:
- To summarize findings from a systematic review on treating displaced pediatric supracondylar humerus fractures.
- To address key questions regarding reduction techniques, fixation methods, and open reduction complications.
- To provide evidence-based recommendations for managing these injuries.
Main Methods:
- A systematic literature search was performed across major databases (PubMed, EMBASE, CINAHL, Cochrane).
- 1726 relevant articles published between 1966 and 2010 were identified.
- 44 articles met the inclusion criteria for systematic review and analysis.
Main Results:
- Closed reduction with pin fixation is suggested for displaced pediatric supracondylar humerus fractures (Wilkins type II/III, flexion type).
- Using 2-3 laterally introduced pins is recommended for stabilization, while avoiding medial pins is advised.
- Open reduction may be considered post-closed reduction if malposition (e.g., varus) occurs.
Conclusions:
- Controversy persists regarding optimal treatments for pediatric supracondylar humerus fractures.
- High-quality randomized controlled trials are needed to definitively establish best practices.
- Current evidence suggests specific approaches for displaced fractures, emphasizing closed reduction and lateral pinning.
Background:
Supracondylar humerus fractures are widely considered the most common fracture of the elbow in children. Fractures can range from a less severe, nondisplaced type I fracture to a more severe, displaced type III fracture with no cortical contact. Type III fractures can lead to adverse physical, social, and emotional consequences if they are not treated effectively. The American Academy of Orthopaedic Surgeons recently carried out a systematic review of the literature to develop a clinical practice guideline. The guidelines provided answers for the following questions regarding the treatment for type III supracondylar fractures (1) which is the preferred treatment for displaced supracondylar fractures of the humerus: reduction and casting versus closed reduction and percutaneous pinning; (2) which is the preferred method for fixing displaced supracondylar fractures of the humerus: medial (crossed) versus lateral pinning; and lastly, (3) does open reduction cause increased stiffness or have a high rate of complication? The purpose of this paper is to summarize and highlight the major findings from this systematic review.
Methods:
PubMed, EMBASE, CINAHL, and The Cochrane Central Register of Controlled Trials were searched to locate 1726 relevant articles published from January 1966 to July 29, 2010. Of these, 44 met our criteria for inclusion and were reviewed systematically.
Results:
On the basis of the results from the systematic review: (1) we suggest closed reduction with pin fixation for patients with displaced (eg, Wilkins type II and III and displaced flexion) pediatric supracondylar fractures of the humerus. (2) The practitioner might use 2 or 3 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. (3) The practitioner might perform open reduction for displaced pediatric supracondylar fractures of the humerus after closed reduction if varus or other malposition of the bone occurs.
Conclusions:
Clearly, controversy exists regarding the best treatments for pediatric supracondylar humerus fractures. Properly designed randomized controlled trials comparing treatment options are necessary to determine optimal treatments.
Level Of Evidence:
Level II.
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