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Development and external validation of a decision-support model for predicting failed closed reduction in pediatric
Rong Guo1, Yi Zhou2, Xiaoxuan Dai1
1Department of Orthopedics, Xiangtan Central Hospital (Hunan University Affiliated Hospital), Xiangtan, Hunan, China.
Insights
A new model predicts when closed reduction for pediatric supracondylar humerus fractures (SCHF) may fail, requiring open reduction. This tool aids surgeons in preoperative planning for improved operative efficiency and patient safety.
Area of Science:
- Orthopedic Surgery
- Pediatric Orthopedics
- Surgical Outcomes Research
Background:
- Closed reduction and percutaneous pinning (CRPP) is standard for pediatric supracondylar humerus fractures (SCHF).
- Closed reduction can be challenging and may necessitate conversion to open reduction.
- A practical preoperative tool to predict failed closed reduction is currently lacking.
Purpose of the Study:
- To develop and externally validate a predictive model for failed closed reduction in pediatric SCHF.
- To identify key preoperative predictors of intraoperative conversion to open reduction.
- To enhance preoperative planning and surgical decision-making for SCHF treatment.
Main Methods:
- Multicenter retrospective cohort study of pediatric patients with SCHF undergoing intended CRPP.
- Predictors of failed closed reduction (conversion to open reduction) identified using LASSO and multivariable logistic regression.
- Model performance evaluated using discrimination (AUC), calibration, and decision curve analysis (DCA), with external validation.
Main Results:
- The final model included displacement direction, preoperative Baumann angle, and medial spike/entrapment sign as predictors.
- The model demonstrated good discrimination in the development cohort (AUC=0.842) and acceptable discrimination in the validation cohort (AUC=0.727).
- Calibration was good, and DCA suggested potential clinical utility for preoperative risk stratification.
Conclusions:
- An externally validated decision-support model for predicting failed closed reduction in pediatric SCHF was developed.
- This tool can aid in preoperative planning, allowing for timely preparation for open reduction when necessary.
- Further prospective validation is recommended before routine clinical implementation due to the retrospective design and limited cohort.
Background:
Closed reduction and percutaneous pinning (CRPP) is the standard treatment for pediatric supracondylar humerus fractures (SCHF). However, closed reduction can be challenging in a subset of patients and may fail, requiring conversion to open reduction. A practical preoperative tool to predict failed closed reduction remains lacking.
Methods:
This multicenter retrospective cohort study included pediatric patients with SCHF who underwent intended CRPP at Xiangtan Central Hospital and Zhuzhou Central Hospital between 2020 and 2025. The primary outcome was failed closed reduction, defined as intraoperative conversion to open reduction (including mini-open exposure) after attempted standard closed reduction maneuvers and before definitive K-wire fixation. Candidate predictors were selected using least absolute shrinkage and selection operator (LASSO) regression and incorporated into a multivariable logistic regression model. Model performance was assessed by discrimination, calibration, and decision curve analysis (DCA). External validation was performed using an independent cohort.
Results:
A total of 179 patients were included (development cohort, n = 86; validation cohort, n = 93). Conversion to open reduction occurred in 34.1% of patients. In the final multivariable model, displacement direction, preoperative Baumann angle, and the presence of a medial spike/entrapment sign were retained as predictors. The model demonstrated good discrimination in the development cohort (AUC = 0.842) and acceptable discrimination in the external validation cohort (AUC = 0.727). Calibration showed good agreement between predicted and observed risks, and decision curve analysis suggested potential clinical utility across relevant threshold probabilities.
Conclusions:
We developed and externally validated a practical decision-support model for predicting failed closed reduction (conversion to open reduction) in pediatric SCHF. This tool may facilitate preoperative planning and timely preparation for open reduction when needed, potentially improving operative efficiency and patient safety. However, given the retrospective design and the limited regional cohort, further prospective validation is required before routine clinical implementation.
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