Is the "Appropriate Use Criteria" for Type II Supracondylar Humerus Fractures Really Appropriate?

The Appropriate Use Criteria for the treatment of supracondylar humerus fractures (SCHFs), developed by American Academy of Orthopaedic Surgeons, recommends pinning for all type II SCHFs. However, previous studies have suggested that, with close follow-up some of the less severe type II SCHF's can be successfully treated without surgery. Our purpose was to analyze data collected prospectively on a large cohort of type II SCHF's.

We reviewed clinical and radiographic information on all type II pediatric SCHF (n=1120) that were enrolled in a prospective registry and were followed for a minimum of 8 weeks. The characteristics of the patients who were treated without surgery were compared with those of patients who were ultimately treated surgically. Treatment outcomes, as assessed by the final clinical and radiographic alignment, range of motion of the elbow, and complications were compared between the groups to define clinical and radiographic features that related to success or failure of nonoperative management.

Ultimately, 812 fractures (72%) were treated nonoperatively, and 309 fractures (28%) were treated surgically. At final follow-up, outcome measures of change in carrying angle, range of motion, and complications did not show clinically significant differences between treatment groups. Binary logistic regression analysis indicated that initial radiographic features, specifically rotational deformity, varus malalignment, valgus malalignment, and a shaft-condylar angle of <30 degrees were strongly related to selection for surgery. Patients with isolated extension deformity, but none of the other features, were more likely to complete successful nonoperative management.

Pinning all type II SCHF, as recommended by the Appropriate Use Criteria, would have resulted in unnecessary surgery in 72% of patients in this series. Given the wide range of injury severity within the type II category of SCHF, better discrimination of factors commonly associated with successful nonoperative treatment is required. In this particular series, fractures with an isolated extension deformity (without rotational or coronal malalignment) were more likely to complete successful nonoperative management.