Clinical Practice Guidelines for Common Elbow Fractures in Children

One of the most common elbow fractures in children occurs at the bottom of the humerus (upper arm bone). It is called a supracondylar humerus fracture. Efforts to find the best way to treat this type of fracture are underway. The best evidence from current studies was used to write 14 recommendations referred to as clinical practice guidelines (CPGs). This article is a summary of those guidelines.

The idea behind forming clinical practice guidelines for any condition is to improve treatment and give physicians a way to identify the best treatment for each patient. Sometimes that means taking into consideration the child/family’s needs and desires. In other cases, individual factors such as the child’s general health, type of fracture, and severity of injury must be taken into consideration when making a treatment decision.

The various treatment options include conservative (nonoperative) care or surgery. Conservative care consists of immobilization of the arm in a cast or splint. This is called a closed reduction. Surgery is more complex and may involve fixation hardware such as metal plates, pins, screws, or wires. These fixation devices are used to hold everything together until healing takes place. When surgery includes an open incision and fixation, the procedure is referred to as an open reduction and internal fixation (ORIF).

The first clinical decision becomes whether to recommend conservative care or surgery. The clinical practice guidelines provide criteria for selecting one treatment approach over another. When surgery is the necessary choice, research is being done to determine what type of surgery should be done, what type of fixation, and the direction of the fixation.

Then the decision must be made whether and when to remove the hardware after fracture healing. Should the child have physical therapy? When can the child return to full activities (especially sports activities)? Timing of each step in the rehab progress may be as important as the type of treatment provided. Here’s a brief summary of the main points of the 14 clinical practice guidelines:

  • Nondisplaced supracondylar fractures of the humerus in children can be immobilized. The strength of evidence for this recommendation is “moderate” (not weak or strong).
  • Closed reduction with pin fixation is recommended for displaced fractures (bone on each side of the fracture separates). The concern is to prevent ischemia (loss of blood) to the arm that could become a very serious complication of surgery. There is a risk of infection or nerve damage with hardware but the risk of losing the arm from ischemia is much greater.
  • There wasn’t enough evidence to create a guideline for the timing of surgery to avoid complications like ischemia. Most of the studies available were of low quality and considered flawed by the committee.
  • Pins may produce fewer problems if placed from the lateral side (side away the body). There is less risk of nerve damage and loss of reduction with this approach.
  • Surgery (open reduction) may be needed following conservative care (closed reduction) if there is elbow or arm deformity or malposition of the bones. Poor study design resulted in weak support for this recommendation.
  • Exploratory surgery is advised when blood supply to the hand does not improve after reduction. The risk of losing the limb outweighs the risks of surgery. This recommendation is based on expert opinion and consensus (agreement) rather than actual data from studies comparing one treatment to another.
  • The committee could not recommend the best timing for removal of hardware based on current studies available. Infection and elbow stiffness are two possible complications of pins left in a long time. On the other hand, removing the pins too soon can result in displacement and even refracture.
  • There are no current guidelines for optimal timing for returning to full activity. No studies have addressed this issue. Each case must be decided in a way that balances the concern for refracture (too much activity too soon) versus complications from not moving or not using the arm soon enough (stiffness).

    The authors point out that sometimes the physician must make an immediate decision based on obvious clinical factors and his or her own experience. For example, the child with absent pulses at the wrist and a completely pale hand may be best treated with a splint and sent to a surgical center as soon as possible. The delay in surgery may still yield a better result than trying to reduce the fracture without surgery.

    This attempt to provide helpful clinical practice guidelines for the treatment of supracondylar fractures in children gives us a clear idea that more high-quality research is needed in this area. Current recommendations are weak, inconclusive, or have only a moderate level of strength. Specific criteria based on good evidence is needed in making decisions such as closed versus open reduction, optimal timing for surgery, type of surgery, and direction of pin insertion when pins are used.

    The authors suggest specific studies to compare results from different treatment approaches. Finding optimal outcomes will help direct treatment in the future. Improvements that are important to the child and family should also be taken into consideration in any study.