Skip to main content
NCBI home page
JBJS Open Access logoLink to JBJS Open Access
. 2024 Aug 6;9(3):e24.00011. doi: 10.2106/JBJS.OA.24.00011

Predictors Associated with the Need for Open Reduction of Pediatric Supracondylar Humerus Fractures

A Meta-analysis of the Recent Literature

M Bryant Transtrum 1,a, Diego Sanchez 2, Shauna Griffith 3, Brianna Godinez 4, Vishwajeet Singh 5, Kyle J Klahs 4, Amr Abdelgawad 6, Ahmed M Thabet 4
PMCID: PMC11299990  PMID: 39108336

Abstract

Background:

Supracondylar humerus (SCH) fractures are some of the most common fractures in pediatric patients with surgery typically consisting of either open or closed reduction with internal fixation. The aim of this meta-analysis was to identify patient, injury, and administrative factors that are associated with treating pediatric SCH fractures with open techniques.

Methods:

Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, PubMed and CINAHL database searches were conducted for studies from 2010 to 2023 that made direct comparisons between open reduction and internal fixation (ORIF) and closed reduction and percutaneous pinning (CRPP) for treating SCH fractures in the pediatric population. The search terms used were “pediatric” AND “SCH fracture” OR “distal humerus fracture.” Screening, quality assessment, and data extraction were performed by 4 reviewers. After testing for heterogeneity between studies, data were aggregated using random-effects model analysis.

Results:

Forty-nine clinical studies were included in the meta-analysis. Summated, there were 94,415 patients: 11,329 treated with ORIF and 83,086 treated with CRPP. Factors that were significantly associated with greater rates of ORIF included obesity (p = 0.001), Gartland type IV fractures (p < 0.001), general neurological deficits (p = 0.019), and ulnar nerve deficits (p = 0.003). Gartland type II (p = 0.033) and medially displaced fractures (p = 0.011) were significantly associated with lower rates of ORIF. Secondary analysis showed cross-pinning constructs (p = 0.033) and longer hospital stays (p = 0.005) are more likely to be observed in patients undergoing ORIF compared with CRPP.

Conclusion:

This meta-analysis demonstrates that factors such as obesity, fracture displacement, and concomitant nerve deficits are more likely to require ORIF as opposed to CRPP.

Level of Evidence:

Therapeutic Level III.

Introduction

Supracondylar humerus (SCH) fractures are some of the most common fractures in pediatric patients and can present within a wide spectrum of severity1. If displaced, distal humerus fractures typically require surgical intervention to reduce the fracture and provide internal stability while healing2-4. Traditionally, closed reduction and percutaneous pinning (CRPP) is the first-line treatment for SCH fractures, with the more invasive open reduction and internal fixation (ORIF) being considered only after closed methods prove unsuccessful3,5,6. Factors such as patient demographics, injury characterization, and treatment administration likely all influence the ultimate treatment modality.

Patient demographics, such as age, race, body mass index (BMI), and gender, regardless of fracture pattern, may predispose to either a successful CRPP or conversion to ORIF. Previous studies have shown that age may be directly proportional to the likelihood of converting to open techniques7. Obese patients (defined as BMI ≥ 30.0) have also been found to undergo ORIF at higher rates than their nonobese cohorts8-11. Historically, male gender was believed to be positively associated with high-energy SCH fracture frequency and ORIF12,13; however, recent studies have challenged these findings14,15.

Injury patterns, such as open vs. closed fractures, fracture pattern, and extremity neurovascular status have all been implicated in surgical decision-making. The access to and visualization of the fracture site in these cases may result in the reasonable use of ORIF techniques as is seen in most open fractures treated in one previous study16. The Gartland classification system has been widely used to characterize SCH fracture displacement and may be a tool to easily predict the need to open17-19. A concomitant injury to surrounding nerves or vessels has also been associated with open exploration and ORIF20,21. Furthermore, the timing of injury presentation to the operative surgeon may also affect the ability to achieve a successful closed reduction22.

Other administrative factors, such as time to treat, treatment location, and surgeon experience, may also influence the treatment of SCH fractures. Community hospitals, tertiary referral centers, and dedicated pediatric hospitals are all sites of service for the treatment of SCH fractures. The potential correlation between treatment site and SCH fracture treatment type has not been previously investigated in the literature. The years of experience an orthopaedic surgeon has in practice as well as pediatric fellowship training may result in a nuanced understanding of and increased comfort with SCH fractures and their treatment. Several previous studies report that non–fellowship-trained surgeons used ORIF at a higher rate than those who underwent a pediatric orthopaedic surgery fellowship23-28.

Pediatric SCH fractures are one of the most prevalent operative injuries in children and are, therefore, highly studied; however, findings of individual studies are often inconsistent and difficult to generalize. Consequently, there remains a paucity in the literature concerning predictive demographic, injury, and administrative factors that may influence the decision to convert from CRPP to ORIF.

Materials and Methods

Search Strategies

This systematic review and meta-analysis were structured and written in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We identified and retrieved relevant studies from electronic databases PubMed and CINAHL databases. Search terms included “pediatric” AND “SCH fracture” OR “distal humerus fracture.” Search filters included text availability: full text; article type: age: 0 to 18 years; language: English; and publication date: January 1, 2010, to March 15, 2023. Four reviewers independently screened titles, abstracts, and article types for eligibility. Studies were selected for further review if they were relevant to the operative treatment of SCH fractures using open or closed reduction techniques.

Study Selection

Randomized controlled trials, cohort studies, and case series were included if they met the following predefined inclusion criteria: available data for the treatment of SCH fractures using ORIF and CRPP patient groups and sufficient results for data extraction, i.e., the number of subjects for each patient group was provided. Studies were excluded if they did not contain a pediatric focus, were written as a systematic review, or were only available in languages other than English. The same 4 reviewers independently performed full-text screening, excluding articles that were not relevant to the primary treatment of SCH fractures in pediatric populations or that did not make direct comparisons between ORIF and CRPP groups; only studies containing homogenous open and closed treatment groups could be included in the meta-analysis. In addition, studies were excluded if they described treatment protocols that did not meet North American standards of care. Most studies were retrospective comparative studies with level III evidence. The methodological items for nonrandomized studies (MINORS) instruments were used for the quality assessment of the included studies (Table I). This tool consists of 12 questions aimed at appraising multiple factors. Items are scored as 0 (not reported), 1 (reported but inadequate), or 2 (reported and adequate). The maximum score for noncomparative studies is 16 and for comparative studies is 24.

TABLE I.

MINORS Instrument*

MINORS Instrument
1 A clearly stated aim: The question addressed should be precise and relevant in the light of available literature
2 Inclusion of consecutive patients: All patients satisfying the criteria for inclusion have been included in the study during the study period
3 Prospective collection of data: Data were collected according to a protocol established before the beginning of the study
4 Endpoints appropriate to the aim of the study: Unambiguous explanation of the criteria was used to evaluate the main outcome, which should be in accordance with the question addressed by the study. Also, the endpoints should be assessed on an intention-to-treat basis
5 Unbiased assessment of the study endpoint: Blind evaluation of objective endpoints and double-blind evaluation of subjective endpoints. Otherwise, the reasons for not blinding should be stated
6 Follow-up period appropriate to the aim of the study: The follow-up should be sufficiently long to allow the assessment of the main endpoint and possible adverse events
7 Loss to follow-up less than 5%: All patients should be included in the follow-up. Otherwise, the proportion lost to follow-up should not exceed the proportion experiencing the major endpoint
8 Prospective calculation of study size: Information of the size of detectable difference of interest with a calculation of 95% confidence interval, according to the expected incidence of the outcome event, and information about the level for statistical significance and estimates of power when comparing outcomes
Additional Criteria in the Case of Comparative Studies
9 An adequate control group: Having a gold standard diagnostic test or therapeutic intervention recognized as the optimal intervention according to the available published data
10 Contemporary groups: Control and studied group should be managed during the same period (no historical controls)
11 Baseline equivalence of groups: The groups should be similar regarding the criteria other than the studied endpoints. Absence of confounding factors that could bias the interpretation of results
12 Adequate statistical analyses: Whether the statistics were in accordance with the type of study with calculation of confidence intervals or relative risk
Open in a new tab
*

Items are scored as 0 (not reported), 1 (reported but inadequate), or 2 (reported and adequate). The maximum score for noncomparative studies is 16 and for comparative studies is 24. Scores can be assessed as 0 to 4 = very low quality; 5 to 8 = low quality; 9 to 12 = moderate quality; 13 to 16 = high quality; and 19 to 24 very high quality. MINORS = methodological items for nonrandomized studies.

Preoperative Predictive Factors

Preoperative factors of interest included all reported demographic, injury, and administrative factors that were compared between CRPP and ORIF. Demographic factors included age, gender, ethnicity, race, and BMI. Injury characteristics comprised the following: affected arm sidedness and dominance, Gartland classification, open vs. closed injury status, fracture patterns, and neurovascular status. Finally, administrative factors included the following: time to treat, treatment location, and treating surgeon's pediatric fellowship status and years of experience.

Secondary Outcomes

In addition to preoperative factors, data related to intraoperative and postoperative outcomes were also collected. Intraoperative outcomes included operative time, surgical approach, and fixation constructs. Postoperative outcomes comprised duration of hospital length of stay, radiographic and functional outcomes, complications, and time to latest follow-up.

Data Extraction

A standardized data extraction sheet was used to gather information including the aforementioned preoperative factors and secondary outcome measures. Four authors independently extracted data. Any disagreement was adjudicated by a fifth author.

Data Analysis

Statistical software STATA (version 17; StataCorp) was used for the analysis. Data from 3 or more studies were required for any factor to be included in our meta-analysis. The extent of heterogeneity was performed based on the I2 statistics, where I2 ≤ 50% suggests moderate heterogeneity and I2 ≥ 50% indicates high heterogeneity. A random-effects model was used to obtain the pooled effect size values as odds ratio (OR) or standardized mean difference (SMD) with a corresponding 95% confidence interval (CI). A p value < 0.05 was considered statistically significant.

Results

After conducting a preliminary search with our search terms, a total of 4,217 articles were identified. 3,326 articles were eliminated from search filters for the following reasons: language other than English, not available in full text, outside of the publication range, and outside the pediatric age range. Screening resulted in 222 additional exclusions because of the removal of articles that were not relevant to our study or article types that were reviews, systematic reviews, or meta-analyses. After in-depth review of the remaining 669 studies, 621 were excluded for either having the wrong intervention, no reported ORIF vs. CRPP data, or unacceptable treatment protocol. The final total was 48 studies eligible for analysis. One study, Bell et al., separated out 2 groups each containing an open and closed treatment group, and so, it was counted as 2 separate studies, bringing the total to 49 study groups7. A total of 94,415 patients, with 11,329 in the ORIF group and 83,086 in the CRPP group, across all 49 studies were eligible for meta-analysis. A PRISMA flow diagram of studies from search through screening to inclusion and exclusion outlines each step of the review process (Fig. 1). Also, a quality assessment of the included studies using the MINORS instrument was conducted (Table II).

Fig. 1.

Fig. 1

Open in a new tab

PRISMA flow diagram of studies from search through screening to inclusion and exclusion. PRISMA = Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

TABLE II.

Overview and Quality Appraisal of Included Studies Using the MINORS Instrument*

Author (yr) Country LoE Study type N 1 2 3 4 5 6 7 8 9 10 11 12 Total
Aksakal et al. (2013) Turkey III therapeutic Retrospective comparative 65 2 2 0 2 2 2 2 0 2 2 2 2 20
Aydoğmuş et al. (2017) Turkey III therapeutic Retrospective comparative 91 1 2 0 2 2 2 2 0 2 2 2 2 19
Beck et al. (2012) United States III therapeutic Retrospective comparative 174 2 2 0 2 2 2 2 0 2 2 2 2 20
Bell et al. (I) (2017) United States III therapeutic Retrospective comparative 44 2 2 0 2 2 2 2 0 2 2 2 2 20
Bell et al. (II) (2017) United States III therapeutic Retrospective comparative 37 2 2 0 2 2 2 2 0 2 2 2 2 20
Cambon-Binder et al. (2018) France III therapeutic Retrospective comparative 27 1 2 0 2 2 2 2 0 2 2 2 2 19
Dabash et al. (2019) United States III therapeutic Retrospective comparative 17 1 2 0 2 2 2 2 0 2 2 2 2 19
DeFrancesco et al. (2018) United States III therapeutic Retrospective comparative 2,594 2 2 0 2 2 2 2 0 2 2 2 2 20
Donnelly et al. (2012) United Kingdom III therapeutic Retrospective comparative 133 1 2 0 0 2 2 2 0 2 2 2 2 17
Ducić et al. (2016) Serbia II therapeutic Prospective comparative 71 2 2 2 2 2 2 2 0 2 2 2 2 22
Eguia et al. (2020) United States III therapeutic Retrospective comparative 284 1 2 0 2 2 2 2 0 2 2 2 2 19
Ekwedigwe et al. (2021) Nigeria III therapeutic Retrospective comparative 57 1 2 0 2 2 2 2 0 2 2 2 1 18
Flynn at al. (2017) United States III therapeutic Retrospective comparative 2,783 2 2 0 2 2 2 2 0 2 2 2 2 20
Harris et al. (2019) United States IV therapeutic Retrospective comparative 71 2 2 0 2 2 2 2 0 2 2 2 2 20
Hockensmith et al. (2021) United States III therapeutic Retrospective comparative 485 2 2 0 2 2 2 2 0 2 2 2 2 20
Hussein et al. (2019) Iraq III therapeutic Retrospective comparative 66 2 2 0 2 2 2 2 0 2 2 2 2 20
Jenkins et al. (2021) United States III therapeutic Retrospective comparative 201 1 2 0 2 2 2 2 0 2 2 2 2 19
Kim et al. (2020) United States III therapeutic Retrospective comparative 19 1 2 0 2 2 2 2 0 2 2 2 0 17
Kzlay et al. (2017) Turkey III therapeutic Retrospective comparative 70 2 2 0 2 2 2 2 0 2 2 2 2 20
Latario et al. (2022) United States III therapeutic Retrospective comparative 211 2 2 0 2 2 2 2 0 2 2 2 2 20
Lewine et al. (2018) United States III therapeutic Retrospective comparative 96 2 2 0 2 2 2 2 0 2 2 2 2 20
Li et al. (2018) United States IV therapeutic Case series 31,905 2 2 0 2 2 2 2 0 X X X X 14
Louahem et al. (2016) France III therapeutic Retrospective comparative 404 1 2 0 2 2 2 2 0 2 2 2 0 17
Mitchell et al. (2019) United States IV therapeutic Retrospective comparative 194 1 2 0 2 2 2 2 0 2 2 2 2 19
Mitchelson et al. (2013) United States IV therapeutic Retrospective comparative 382 1 2 0 2 2 2 2 0 2 2 2 2 19
Nazareth, A. et al. (2021) United States III prognostic Retrospective comparative 283 2 2 0 2 2 2 2 0 2 2 2 2 20
Novais et al. (2016) United States III therapeutic Retrospective comparative 384 2 2 0 2 2 2 2 0 2 2 2 2 20
Okkaoglu et al. (2021) Turkey III therapeutic Retrospective comparative 150 1 2 0 2 2 2 2 0 2 2 2 2 19
Paci et al. (2018) United States III therapeutic Retrospective comparative 263 1 2 0 2 2 2 2 0 2 2 2 2 19
Pesenti et al. (2018) France III therapeutic Retrospective comparative 236 1 2 0 2 2 2 2 0 2 2 2 2 19
Prabhakar et al. (2019) United States III therapeutic Retrospective comparative 309 1 2 0 2 2 2 2 0 2 2 2 2 19
Pullagura et al. (2013) United Kingdom III therapeutic Retrospective comparative 81 0 2 0 0 2 2 2 0 2 2 2 2 16
Ralles et al. (2020) United States III therapeutic Retrospective comparative 9,169 1 2 0 2 2 2 2 0 2 2 2 2 19
Schmid et al. (2015) Switzerland III therapeutic Retrospective comparative 343 2 2 0 2 2 2 2 0 2 2 2 2 20
Silva et al. (2018) United States III therapeutic Retrospective comparative 212 2 2 0 2 2 2 2 0 2 2 2 2 20
Silva et al. (2015) United States III therapeutic Prospective comparative 130 1 2 2 2 2 2 2 0 2 2 2 2 21
Sinikumpu et al. (2017) Finland III therapeutic Retrospective comparative 565 1 2 0 2 2 2 2 0 2 2 2 2 19
Striano et al. (2020) United States III therapeutic Retrospective comparative 472 2 2 0 2 2 2 2 0 2 2 2 2 20
Suganuma et al. (2020) Japan III therapeutic Retrospective comparative 120 1 2 0 2 2 2 2 0 2 2 2 2 19
Sullivan et al. (2022) United States III therapeutic Retrospective comparative 311 2 2 0 2 2 2 2 0 2 2 2 2 20
Sun et al. (2022) China IV therapeutic Retrospective comparative 171 2 2 0 2 2 2 2 0 2 2 2 2 20
Tarallo et al. (2022) Italy III therapeutic Retrospective comparative 55 2 2 0 2 2 2 2 0 2 2 2 1 19
Tokyay et al. (2022) Turkey III therapeutic Retrospective comparative 112 2 2 0 2 2 2 2 0 2 2 2 2 20
Tuomilehto et al. (2018) Finland III therapeutic Retrospective comparative 210 1 2 0 2 2 2 2 0 2 2 2 2 19
Turgut et al. (2015) Turkey III therapeutic Retrospective comparative 42 2 2 0 2 2 2 2 0 2 2 2 1 19
Vorhies et al. (2019) United States III prognostic Retrospective comparative 40,706 2 2 0 2 2 2 2 0 2 2 2 2 20
Wendling-Keim et al. (2019) Germany III therapeutic Retrospective comparative 97 1 2 0 2 2 2 2 0 2 2 2 2 19
Xie et al. (2020) China III therapeutic Retrospective comparative 46 2 2 0 2 2 2 2 0 2 2 2 1 19
Yaokreh et al. (2012) France III therapeutic Retrospective comparative 58 2 2 0 2 2 2 2 0 2 2 2 2 20
Open in a new tab
*

Items are scored as 0 (not reported), 1 (reported but inadequate), or 2 (reported and adequate). The maximum score for noncomparative studies is 16 and for comparative studies is 24. Scores can be assessed as 0 to 4 = very low quality; 5 to 8 = low quality; 9 to 12 = moderate quality; 13 to 16 = high quality; and 19 to 24 very high quality. MINORS = methodological items for nonrandomized studies.

The eligible 49 studies all reported the proportion of cases with open and closed reduction7,10,25-50,51-70. The pooled overall proportion obtained for ORIF was 0.16 (95% CI = 0.14, 0.18; Table III; Fig. 2). High heterogeneity was observed between studies reporting proportion of open reduction (I2 = 99.0%, p < 0.001). The factors that met our inclusion criteria for the meta-analysis are subsequently listed along with their study characteristics (Tables III–V).

Fig. 2.

Fig. 2

Open in a new tab

Proportion of ORIF and CRPP. CRPP = closed reduction and percutaneous pinning, and ORIF = open reduction and internal fixation.

TABLE III.

Overall Proportion of ORIF and CRPP*

Factors N I2 Overall Proportion (95% CI)
Proportion of open reduction 49 99.0% 0.160 (0.140-0.181)
Proportion of closed reduction 49 99.0% 0.840 (0.819-0.860)
Open in a new tab
*

Heterogeneity is expressed as I2 percentage; CI = confidence interval, CRPP = closed reduction and percutaneous pinning, and ORIF = open reduction and internal fixation.

TABLE IV.

Summary of Odds Ratios for Preoperative Factors Associated with ORIF

Factors N I2 OR (95% CI) p
Demographic
 Age 9 84.1% 0.166 (−0.164 to 0.496)* 0.324
 Female gender 14 8.8% 0.962 (0.904 to 1.032) 0.213
 Obesity 3 0.0% 1.869 (1.272 to 2.745) 0.001
Injury
 Left-sided injury 4 70.5% 0.725 (0.303 to 1.739) 0.472
 Gartland type II 13 70.6% 0.307 (0.104 to 0.909) 0.033
 Gartland type III 17 75.6% 1.600 (0.699 to 3.659) 0.266
 Gartland type IV 6 44.2% 5.970 (2.959 to 12.044) <0.001
 Flexion-type injury 7 84.4% 2.354 (0.546 to 10.140) 0.251
 Extension-type injury 7 80.2% 0.454 (0.131 to 1.571) 0.212
 Closed injury 5 63.8% 0.178 (0.029 to 1.078) 0.060
 Medial displacement 3 0.0% 0.347 (0.154 to 0.781) 0.011
 General neurological deficit 7 72.2% 3.434 (1.222 to 9.648) 0.019
 Median nerve deficit 3 0.0% 0.848 (0.362 to 1.989) 0.705
 Ulnar nerve deficit 3 74.3% 13.537 (2.385 to 76.837) 0.003
Administrative
 Surgeon with pediatric fellowship 6 73.3% 0.923 (0.377 to 2.256) 0.860
Open in a new tab
*

Values expressed as SMD (95% CI). Heterogeneity is expressed as I2 percentage; CI = confidence interval, OR = odds ratio, ORIF = open reduction and internal fixation, and SMD = standard mean difference.

Bold indicates statistical significant values.

TABLE V.

Summary of Odds Ratios for Intraoperative and Postoperative Factors Associated with ORIF

Factors N I2 OR (95% CI) p
Intraoperative
 Operation duration 3 98.2% 0.482 (−1.551 to 2.515)* 0.642
 Crossing k-wire construct 4 81.9% 15.867 (1.250 to 201.39) 0.033
 Hospital stay (days) 3 49.7% 0.407 (0.121 to 0.692)* 0.005
Postoperative
 Flynn functional 7 48.3% 0.905 (0.310 to 2.640) 0.854
 Flynn cosmetic 3 0.0% 0.731 (0.183 to 2.916) 0.657
 Anterior humeral line (normal) 3 0.0% 0.754 (0.239 to 2.378) 0.629
 Overall complications 7 65.1% 0.845 (0.226 to 3.160) 0.802
 Malunion 4 0.0% 1.155 (0.344 to 3.876) 0.816
 Infection 5 16.4% 3.111 (0.925 to 10.47) 0.067
 Impaired range of motion 6 0.0% 0.999 (0.512 to 1.952) 0.998
 Revision surgery 6 58.3% 1.727 (0.388 to 7.685) 0.473
Open in a new tab
*

Values expressed as SMD (95% CI). Heterogeneity is expressed as I2 percentage; CI = confidence interval, OR = odds ratio, ORIF = open reduction and internal fixation, and SMD = standard mean difference.

Bold indicates statistical significant values.

Preoperative Factors

Obesity

Three studies were included in the analysis evaluating patient BMI10,50,62. Obese patients demonstrated a significantly higher likelihood of requiring ORIF (OR = 1.87; 95% CI = 1.27, 2.75; p = 0.001) with no heterogeneity (I2 = 0.0%, p = 0.72) (Table IV).

Fracture Displacement

Thirteen studies were included in the analysis evaluating Gartland type II fractures31,34-36,41,43,45,49,56,58,60,66,68. Patients with Gartland type II fractures demonstrated a significantly lower likelihood of requiring ORIF (OR = 0.31; 95% CI = 0.10, 0.91; p = 0.033) with high heterogeneity (I2 > 50%, p < 0.001) (Table IV).

Six studies were included in the analysis evaluating Gartland type IV fractures28,34,40,48,57,68. Patients with Gartland type IV fractures demonstrated a significantly higher likelihood of requiring ORIF (OR = 5.97; 95% CI = 2.96, 12.04; p < 0.001) with moderate heterogeneity (I2 = 44.2%, p = 0.11) (Table IV).

Three studies were included in the analysis evaluating medial fracture displacement45,51,62. Patients with medially displaced fracture patterns demonstrated a significantly lower likelihood of requiring ORIF (OR = 0.35; 95% CI = 0.15, 0.78; p = 0.011) with no heterogeneity (I2 = 0.0%, p = 0.79) (Table IV).

Neurological Deficits

Seven studies were included in the analysis evaluating general preoperative neurological deficits32,35,45,46,62,63,70. Patients with general preoperative nerve deficits demonstrated a significantly higher likelihood of requiring ORIF (OR = 3.43; 95% CI = 1.22, 9.65; p = 0.019) with high heterogeneity (I2 > 50%, p = 0.001) (Table IV).

Specifically, 3 studies were included in the analysis evaluating preoperative ulnar nerve deficits39,62,70. Patients with preoperative ulnar nerve deficits demonstrated a significantly higher likelihood of requiring ORIF (OR = 13.54; 95% CI = 2.39, 76.84; p = 0.003) with high heterogeneity (I2 > 50%, p = 0.021) (Table IV).

No statistical significance was observed in the relationships between ORIF and the following preoperative factors:

  • • Demographic: patient age (SMD = 0.17) and gender (OR = 0.96).

  • • Injury: left-sided injury (OR = 0.73), Gartland type III fractures (OR = 1.60), flexion-type injury (OR = 2.35), extension-type injury (OR = 0.45), closed injury (OR = 0.18), and median nerve deficits (OR = 0.85).

  • • Administrative: pediatric fellowship status of operating surgeon (OR = 0.92).

Secondary Intraoperative/Postoperative Outcomes

Fixation Constructs

Four studies were included in the analysis evaluating crossing k-wire configurations28,35,37,70. A significant, positive association was observed between crossing k-wire constructs and ORIF (OR = 15.87; 95% CI = 1.25, 201.39; p = 0.033) with high heterogeneity (I2 > 50%, p = 0.001) (Table V).

Hospital Stay

Three studies were included in the analysis evaluating hospital length of stay29,67,70. A significant, positive association was observed between hospital length of stay and ORIF (SMD = 0.41; 95% CI = 0.12, 0.69; p = 0.005) with moderate heterogeneity (I2 = 49.7%, p = 0.14) (Table V). The average hospital stay for patients treated with ORIF was 1.9 days compared with 1.2 days for those treated with CRPP.

No statistical significance was observed in the relationships between ORIF and the following intraoperative/postoperative factors: operation duration (SMD = 0.48), Flynn functional criteria (OR = 91), Flynn cosmetic criteria (OR = 0.73), normal anterior humeral line (OR = 75), impaired range of motion (OR = 1.00), overall complications (OR = 0.85), malunion (OR = 1.16), infection (OR = 3.11), and revision surgery (OR = 1.73).

Discussion

The purpose of this study was to determine preoperative predictive factors associated with the utilization of ORIF techniques as opposed to CRPP in pediatric SCH fractures. We conducted a systematic review and meta-analysis of all studies published and available on PubMed from January 1, 2010, to March 15, 2023, to determine whether identified preoperative factors contributed to operative modality as well as commonly reported outcomes. We found that obese patients were significantly more likely to undergo an ORIF compared with nonobese patients. Higher Gartland class and preoperative neurovascular deficits were also associated with a higher probability of needing ORIF. In addition, cross-pinning constructs and longer duration of hospitalization were positively associated with the ORIF group.

Obesity was positively predictive for ORIF likely because of a higher mechanism of energy based on increased patient mass as compared to those nonobese71,72. Childhood obesity also contributes to bone mineral metabolism, which increases not only the risk of fracture but also the displacement risk73. Multiple studies have identified pediatric obesity to generate more complex and adult-like fracture patterns74-76. Li et al. found obesity to be a risk factor for ORIF because of the increased difficulty with closed manipulation beneath a large, traumatized soft-tissue envelope10. The obese patient presents many challenges to the orthopaedic surgeon that may influence the decision to expand direct fracture visualization and ensure construct stability.

Fracture characteristics were significantly related to the ultimate surgical method used to treat SCH fractures. Higher Gartland class, especially type IV, where the posterior osseous hinge and periosteal stability were eliminated, was more likely to require ORIF to stabilize the fracture while securing with internal fixation. Simple, routine, SCH fracture patterns such as Gartland type II and III, were not associated with an increased need to open and were likely more easily close-reduced before internal fixation.

Preoperative general neurological deficits and specifically ulnar nerve palsies were associated with using open operative techniques. Nerve palsies typically represent a larger, more diffuse soft-tissue injury surrounding the fracture that occurs in a predictable pattern77-79. Larger soft-tissue injuries facilitate more edema, swelling, and potentially a more difficult environment for closed fracture manipulation and maintenance of reduction, requiring other, more invasive techniques. A study by Sun et al. investigating only flexion-type fractures identified ulnar nerve palsies as a predictive factor for ORIF62. Although flexion-type SCH fractures were not found to be predictive of ORIF in our study, ulnar nerve palsies, which are typically accompanied by flexion-type fractures, were associated with ORIF.

When assessing intraoperative techniques there was heterogeneity in describing and labeling certain configurations. Reported surgical approaches were almost equally divided between posteromedial and posterolateral approaches to the distal humerus. This likely represents large rotational deformity in the fracture pattern, necessitating opening manually and obtaining a reduction before internal fixation80. More than half of open techniques that reported on pin configuration used cross pins. Cross-pin configuration, although inherently imposes a higher risk of iatrogenic nerve injury, has been shown to be biomechanically superior to alternative pin configuration81-83. Within these evaluated studies, the surgeons were likely faced with very unstable fracture pattern types in those cases requiring open techniques and, therefore, took on more risk with cross-pins to achieve greater fracture stability.

There is an increasing trend to treat pediatric SCH fractures in an ambulatory setting84-86. It has been shown to be not only cost-effective, but also safe, with very low rates of postoperative infections and complications84-86. Our study demonstrated longer hospital stay for those patients undergoing ORIF, likely because of continued postoperative prophylactic antibiotics and evaluation of neurovascular recovery.

There were many limitations to this meta-analysis, to include limitation of eligible studies during our data collection period (2010-2023), a high heterogeneity on both preoperative demographic information as well as reported outcomes, and scarcity of adverse events making direct comparisons difficult. Most studies included in this meta-analysis were level III evidence retrospective comparative studies. Ideally, prospective studies would be preferred for meta-analysis; however, available prospective studies are limited in the literature. In addition, although we included studies on pediatric patients from 0 to 18 years of age, generalizing our findings to skeletally mature adolescents may be inappropriate because many surgeons may opt to directly treat this population with open reduction and fixation with plate constructs as they would with an adult injury. Studies on these patients would likely fall outside the limits of those included in our analysis because pinning constructs are typically used in younger, skeletally immature children. These limitations contributed to some loss of power within our analysis and prohibited the direct comparisons of some factors.

Areas for future research include expanding our data collection period to capture a larger number of potentially eligible prospective studies that directly compare SCH fractures treated with CRPP vs. ORIF.

Conclusion

This meta-analysis demonstrates that factors such as obesity, fracture displacement, and concomitant nerve deficits are more likely to require ORIF as opposed to CRPP.

Acknowledgments

Note: The authors thank Alok Kumar Dwivedi, Ph.D., for his biostatistics consulting services.

Footnotes

Investigation performed at the Department of Orthopaedic Surgery and Rehabilitation, Texas Tech University Health Sciences Center El Paso, El Paso, TX

Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSOA/A654).

The authors have no conflicts of interest to declare.

Contributor Information

Diego Sanchez, Email: Diego.e.Sanchez@ttuhsc.edu.

Shauna Griffith, Email: shauna.griffith@ttuhsc.edu.

Brianna Godinez, Email: Brianna.Godinez@ttuhsc.edu.

Vishwajeet Singh, Email: vissingh@ttuhsc.edu.

Kyle J. Klahs, Email: kyle.j.klahs@gmail.com.

Amr Abdelgawad, Email: amratef@doctor.com.

Ahmed M. Thabet, Email: ahmed.thabet.md@gmail.com.

References

  • 1.Saeed W, Waseem M. Elbow fractures overview. In: StatPearls [Internet]. Treasure Island, FL: StatPearls Publishing; 2023. Available at: https://www.ncbi.nlm.nih.gov/books/NBK441976/. [PubMed] [Google Scholar]
  • 2.Brubacher JW, Dodds SD. Pediatric supracondylar fractures of the distal humerus. Curr Rev Musculoskelet Med. 2008;1(3-4):190-6. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 3.Mulpuri K, Hosalkar H, Howard A. AAOS clinical practice guideline: the treatment of pediatric supracondylar humerus fractures. J Am Acad Orthop Surg. 2012;20(5):328-30. [DOI] [PubMed] [Google Scholar]
  • 4.Shrader MW. Pediatric supracondylar fractures and pediatric physeal elbow fractures. Orthop Clin North Am. 2008;39(2):163-71. [DOI] [PubMed] [Google Scholar]
  • 5.Alam W, Rehman SU, Jan R, Hussain S. Outcome of open reduction and internal fixation of supracondylar fractures of humerus in children with lateral approach. Pak J Surg. 2014;30(2):146-9. [Google Scholar]
  • 6.Shenoy PM, Islam A, Puri R. Current management of paediatric supracondylar fractures of the humerus. Cureus. 2020;12(5):e8137. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 7.Bell P, Scannell BP, Loeffler BJ, Brighton BK, Gaston RG, Casey V, Peters ME, Frick S, Cannada L, Vanderhave KL. Adolescent distal humerus fractures: ORIF versus CRPP. J Pediatr Orthop. 2017;37(8):511-20. [DOI] [PubMed] [Google Scholar]
  • 8.Gettys FK, Jackson JB, Frick SL. Obesity in pediatric orthopaedics. Orthop Clin North Am. 2011;42(1):95-105. [DOI] [PubMed] [Google Scholar]
  • 9.Lazar-Antman MA, Leet AI. Effects of obesity on pediatric fracture care and management. J Bone Joint Surg Am. 2012;94(9):855-61. [DOI] [PubMed] [Google Scholar]
  • 10.Li NY, Bruce WJ, Joyce C, Decker NM, Cappello T. Obesity's influence on operative management of pediatric supracondylar humerus fractures. J Pediatr Orthop. 2018;38(3):e118-21. [DOI] [PubMed] [Google Scholar]
  • 11.Li NY, Kalagara S, Hersey A, Eltorai AEM, Daniels AH, Cruz AI, Jr. Impact of obesity on operative treatment and inpatient outcomes of paediatric limb fractures. Bone Joint J. 2019;101-B(4):491-6. [DOI] [PubMed] [Google Scholar]
  • 12.Landin LA. Fracture patterns in children. Analysis of 8,682 fractures with special reference to incidence, etiology and secular changes in a Swedish urban population 1950-1979. Acta Orthop Scand Suppl. 1983;202:1-109. [PubMed] [Google Scholar]
  • 13.Cheng JC, Lam TP, Maffulli N. Epidemiological features of supracondylar fractures of the humerus in Chinese children. J Pediatr Orthop B. 2001;10(1):63-7. [PubMed] [Google Scholar]
  • 14.LiBrizzi CL, Klyce W, Ibaseta A, Shannon C, Lee RJ. Sex-based differences in pediatric supracondylar humerus fractures. Medicine (Baltimore). 2020;99(20):e20267. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 15.Farnsworth CL, Silva PD, Mubarak SJ. Etiology of supracondylar humerus fractures. J Pediatr Orthop. 1998;18(1):38-42. [PubMed] [Google Scholar]
  • 16.Armstrong DG, Monahan K, Lehman EB, Hennrikus WL. The pediatric open supracondylar fracture: associated injuries and surgical management. J Pediatr Orthop. 2021;41(4):e342-6. [DOI] [PubMed] [Google Scholar]
  • 17.Cekanauskas E, Degliūte R, Kalesinskas RJ. Treatment of supracondylar humerus fractures in children, according to Gartland classification. Medicina (Kaunas). 2003;39(4):379-83. [PubMed] [Google Scholar]
  • 18.Li YA, Lee PC, Chia WT, Lin HJ, Chiu FY, Chen TH, Feng CK. Prospective analysis of a new minimally invasive technique for paediatric Gartland type III supracondylar fracture of the humerus. Injury. 2009;40(12):1302-7. [DOI] [PubMed] [Google Scholar]
  • 19.Mallo G, Stanat SJ, Gaffney J. Use of the Gartland classification system for treatment of pediatric supracondylar humerus fractures. Orthopedics. 2010;33(1):19. [DOI] [PubMed] [Google Scholar]
  • 20.Khoshbin A, Leroux T, Wasserstein D, Wolfstadt J, Law PW, Mahomed N, Wright JG. The epidemiology of paediatric supracondylar fracture fixation: a population-based study. Injury. 2014;45(4):701-8. [DOI] [PubMed] [Google Scholar]
  • 21.Vaquero-Picado A, González-Morán G, Moraleda L. Management of supracondylar fractures of the humerus in children. EFORT Open Rev. 2018;3(10):526-40. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 22.Shah RK, Rijal R, Kalawar RPS, Shrestha SR, Shah NK. Open reduction and internal fixation of displaced supracondylar fracture of late presentation in children: a preliminary report. Adv Orthop Surg. 2016;2016:1-6. [Google Scholar]
  • 23.Bagsby DT, Loder RT, Myung K. Operative intervention of supracondylar humerus fractures more complicated in July: analysis of the July effect. J Pediatr Orthop. 2017;37(4):254-7. [DOI] [PubMed] [Google Scholar]
  • 24.Fisher BT, Chong ACM, Flick T, Forness M, Sauer BR, Peterson JB. Does surgeon subspecialty training affect outcomes in the treatment of displaced supracondylar humerus fractures in children? J Am Acad Orthop Surg. 2021;29(9):e447-57. [DOI] [PubMed] [Google Scholar]
  • 25.Jenkins KA, South S, Bovid KM, Kenter K. Pediatric supracondylar humerus fractures can be safely treated by orthopaedic surgeons with and without pediatric fellowship training. Iowa Orthop J. 2021;41(1):69-75. [PMC free article] [PubMed] [Google Scholar]
  • 26.Pesenti S, Ecalle A, Peltier E, Choufani E, Blondel B, Jouve JL, Launay F. Experience and volume are determinantive factors for operative management of supracondylar humeral fractures in children. J Shoulder Elbow Surg. 2018;27(3):404-10. [DOI] [PubMed] [Google Scholar]
  • 27.Ralles S, Murphy M, Bednar MS, Fishman FG. Surgical trends in the treatment of supracondylar humerus fractures in early career practice: an American Board of Orthopaedic Surgery (ABOS) part-II database study. J Pediatr Orthop. 2020;40(5):223-7. [DOI] [PubMed] [Google Scholar]
  • 28.Silva M, Kazantsev M, Aceves Martin B, Delfosse EM. Pediatric supracondylar humerus fractures: is surgeon experience a surrogate for the need of open reduction? J Pediatr Orthop B. 2018;27(2):103-7. [DOI] [PubMed] [Google Scholar]
  • 29.Aksakal M, Ermutlu C, Sarısözen B, Akesen B. Approach to supracondylar humerus fractures with neurovascular compromise in children. Acta Orthop Traumatol Turc. 2013;47(4):244-9. [DOI] [PubMed] [Google Scholar]
  • 30.Aydoğmuş S, Duymuş TM, Keçeci T, Adiyeke L, Kafadar AB. Comparison of daytime and after-hours surgical treatment of supracondylar humeral fractures in children. J Pediatr Orthop B. 2017;26(5):400-4. [DOI] [PubMed] [Google Scholar]
  • 31.Beck JD, Riehl JT, Moore BE, Deegan JH, Sartorius J, Graham J, Mirenda WM. Risk factors for failed closed reduction of pediatric supracondylar humerus fractures. Orthopedics. 2012;35(10):e1492-6. [DOI] [PubMed] [Google Scholar]
  • 32.Cambon-Binder A, Jehanno P, Tribout L, Valenti P, Simon AL, Ilharreborde B, Mazda K. Pulseless supracondylar humeral fractures in children: vascular complications in a ten year series. Int Orthop. 2018;42(4):891-9. [DOI] [PubMed] [Google Scholar]
  • 33.Dabash S, Gerzina C, Prabhakar G, Thabet AM, Jeon S, Heinrich SD. Screw fixation for supracondylar humerus fractures in children: a report of seventeen cases. Eur J Orthop Surg Traumatol. 2019;29(3):575-81. [DOI] [PubMed] [Google Scholar]
  • 34.DeFrancesco CJ, Shah AS, Brusalis CM, Flynn K, Leddy K, Flynn JM. Rate of open reduction for supracondylar humerus fractures varies across pediatric orthopaedic surgeons: a single-institution analysis. J Orthop Trauma. 2018;32(10):e400-7. [DOI] [PubMed] [Google Scholar]
  • 35.Donnelly M, Green C, Kelly IP. An inconvenient truth: treatment of displaced paediatric supracondylar humeral fractures. Surgeon. 2012;10(3):143-7. [DOI] [PubMed] [Google Scholar]
  • 36.Ducić S, Bumbasirević M, Radlović V, Nikić P, Bukumirić Z, Brdar R, Radojicić Z, Bukva B, Abramović D, Ducić TJ. Displaced supracondylar humeral fractures in children: comparison of three treatment approaches. Srp Arh Celok Lek. 2016;144(1-2):46-51. [DOI] [PubMed] [Google Scholar]
  • 37.Eguia F, Gottlich C, Lobaton G, Vora M, Sponseller PD, Lee RJ. Mid-term patient-reported outcomes after lateral versus crossed pinning of pediatric supracondylar humerus fractures. J Pediatr Orthop. 2020;40(7):323-8. [DOI] [PubMed] [Google Scholar]
  • 38.Ekwedigwe HC, Anyaehie UE, Ede O, Anikwe IA, Eyichukwu GO, Anieze JK. Predictors of early elbow function following paediatric humeral supracondylar fractures: a retrospective analysis. Niger J Clin Pract. 2021;24(11):1590-5. [DOI] [PubMed] [Google Scholar]
  • 39.Flynn K, Shah AS, Brusalis CM, Leddy K, Flynn JM. Flexion-type supracondylar humeral fractures: ulnar nerve Injury Increases risk of open reduction. J Bone Joint Surg Am. 2017;99(17):1485-7. [DOI] [PubMed] [Google Scholar]
  • 40.Harris LR, Arkader A, Broom A, Flynn J, Yellin J, Whitlock P, Miller A, Sawyer J, Roaten J, Skaggs DL, Choi PD. Pulseless supracondylar humerus fracture with anterior interosseous nerve or median nerve injury—An absolute indication for open reduction? J Pediatr Orthop. 2019;39(1):e1-7. [DOI] [PubMed] [Google Scholar]
  • 41.Hockensmith LH, Muffly BT, Wattles MR, Snyder EN, McFarland BJ, Jacobs C, Iwinski HJ, Riley SA, Prusick VW. Evaluating perioperative complications surrounding supracondylar humerus fractures: expanding indications for outpatient surgery. J Pediatr Orthop. 2021;41(9):e745-9. [DOI] [PubMed] [Google Scholar]
  • 42.Hussein Al-Algawy AA, Aliakbar AH, Witwit IHN. Open versus closed reduction and K-wire fixation for displaced supracondylar fracture of the humerus in children. Eur J Orthop Surg Traumatol. 2019;29(2):397-403. [DOI] [PubMed] [Google Scholar]
  • 43.Kim KY, Conaway W, Schell R, Hennrikus WL. Prevalence of ulnar nerve palsy with flexion-type supracondylar fractures of the humerus. J Pediatr Orthop B. 2020;29(2):133-6. [DOI] [PubMed] [Google Scholar]
  • 44.Kzlay YO, Aktekin CN, Özsoy MH, Akşahin E, Sakaoğullar A, Pepe M, Kocadal O. Gartland type 3 supracondylar humeral fractures in children: which open reduction approach should be used after failed closed reduction? J Orthop Trauma. 2017;31(1):e18-23. [DOI] [PubMed] [Google Scholar]
  • 45.Latario LD, Lubitz MG, Narain AS, Swart EF, Mortimer ES. Which pediatric supracondylar humerus fractures are high risk for conversion to open reduction? J Pediatr Orthop B. 2023;32(6):569-74. [DOI] [PubMed] [Google Scholar]
  • 46.Lewine E, Kim JM, Miller PE, Waters PM, Mahan ST, Snyder B, Hedequist D, Bae DS. Closed versus open supracondylar fractures of the humerus in children: a comparison of clinical and radiographic presentation and results. J Pediatr Orthop. 2018;38(2):77-81. [DOI] [PubMed] [Google Scholar]
  • 47.Louahem D, Cottalorda J. Acute ischemia and pink pulseless hand in 68 of 404 gartland type III supracondylar humeral fractures in children: urgent management and therapeutic consensus. Injury. 2016;47(4):848-52. [DOI] [PubMed] [Google Scholar]
  • 48.Mitchell SL, Sullivan BT, Ho CA, Abzug JM, Raad M, Sponseller PD. Pediatric Gartland type-IV supracondylar humeral fractures have substantial overlap with flexion-type fractures. J Bone Joint Surg Am. 2019;101(15):1351-6. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 49.Mitchelson AJ, Illingworth KD, Robinson BS, Elnimeiry KA, Wilson CJ, Markwell SJ, Gabriel KR, McGinty J, Saleh KJ. Patient demographics and risk factors in pediatric distal humeral supracondylar fractures. Orthopedics. 2013;36(6):e700-6. [DOI] [PubMed] [Google Scholar]
  • 50.Nazareth A, Schur M, Schroeder AJ, Whitlock PW, Skaggs DL, Goldstein RY. Obesity as a predictor of outcomes in type III and type IV supracondylar humerus fractures. J Orthop Trauma. 2021;35(11):e418-22. [DOI] [PubMed] [Google Scholar]
  • 51.Novais EN, Carry PM, Mark BJ, De S, Miller NH. Posterolaterally displaced and flexion-type supracondylar fractures are associated with a higher risk of open reduction. J Pediatr Orthop B. 2016;25(5):406-11. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 52.Okkaoglu MC, Ozdemir FE, Ozdemir E, Karaduman M, Ates A, Altay M. Is there an optimal timing for surgical treatment of pediatric supracondylar humerus fractures in the first 24 hours? J Orthop Surg Res. 2021;16(1):484. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 53.Paci GM, Tileston KR, Vorhies JS, Bishop JA. Pediatric supracondylar humerus fractures: does after-hours treatment influence outcomes? J Orthop Trauma. 2018;32(6):e215-20. [DOI] [PubMed] [Google Scholar]
  • 54.Prabhakar P, Ho CA. Delaying surgery in type III supracondylar humerus fractures does not lead to longer surgical times or more difficult reduction. J Orthop Trauma. 2019;33(8):e285-90. [DOI] [PubMed] [Google Scholar]
  • 55.Pullagura M, Odak S, Pratt R. Managing supracondylar fractures of the distal humerus in children in a district general hospital. Ann R Coll Surg Engl. 2013;95(8):582-5. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 56.Schmid T, Joeris A, Slongo T, Ahmad SS, Ziebarth K. Displaced supracondylar humeral fractures: influence of delay of surgery on the incidence of open reduction, complications and outcome. Arch Orthop Trauma Surg. 2015;135(7):963-9. [DOI] [PubMed] [Google Scholar]
  • 57.Silva M, Cooper SD, Cha A. The outcome of surgical treatment of multidirectionally unstable (type IV) pediatric supracondylar humerus fractures. J Pediatr Orthop. 2015;35(6):600-5. [DOI] [PubMed] [Google Scholar]
  • 58.Sinikumpu JJ, Pokka T, Sirviö M, Serlo W. Gartland type II supracondylar humerus fractures, their operative treatment and lateral pinning are increasing: a population-based epidemiologic study of extension-type supracondylar humerus fractures in children. Eur J Pediatr Surg. 2017;27(5):455-61. [DOI] [PubMed] [Google Scholar]
  • 59.Striano BM, De Mattos C, Ramski DE, Flynn KR, Horn BD. Displaced supracondylar humerus fractures in toddlers. Orthopedics. 2020;43(5):e421-4. [DOI] [PubMed] [Google Scholar]
  • 60.Suganuma S, Tada K, Yasutake H, Horii T, Takata M, Shimanuki K, Tsuji D, Takagawa S, Asano Y, Tsuchiya H. Timing of surgery for pediatric supracondylar humerus fractures and early postoperative results. J Hand Surg Asian Pac. 2020;25(2):226-31. [DOI] [PubMed] [Google Scholar]
  • 61.Sullivan MH, Stillwagon MR, Nash AB, Jiang H, Lin FC, Chen AT, Louer CR. Complications with surgical treatment of pediatric supracondylar humerus fractures: does surgeon training matter? J Pediatr Orthop. 2022;42(1):e8-14. [DOI] [PubMed] [Google Scholar]
  • 62.Sun J, Shan J, Meng L, Liu T, Wang E, Jia G. Predictive factors for open reduction of flexion-type supracondylar fracture of humerus in children. BMC Musculoskelet Disord. 2022;23(1):859. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 63.Tarallo L, Novi M, Porcellini G, Schenetti C, Micheloni GM, Maniscalco P, Catani F. Gartland type III supracondylar fracture in children: is open reduction really a dangerous choice? Injury. 2022;53(suppl 1):S13-8. [DOI] [PubMed] [Google Scholar]
  • 64.Tokyay A, Okay E, Cansü E, Aydemir AN, Erol B. Effect of fracture location on rate of conversion to open reduction and clinical outcomes in pediatric Gartland type III supracondylar humerus fractures. Ulus Travma Acil Cerrahi Derg. 2022;28(2):202-8. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 65.Tuomilehto N, Sommarhem A, Nietosvaara AY. 9 years' follow-up of 168 pin-fixed supracondylar humerus fractures in children. Acta Orthop. 2018;89(3):351-6. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 66.Turgut A, Kalenderer Ö, Bozoğlan M, Bacaksız T, Ağuş H. Flexion type supracondylar humerus fractures: 12 year experience of a pediatric orthopedics clinic. Eklem Hastalik Cerrahisi. 2015;26(3):151-7. [DOI] [PubMed] [Google Scholar]
  • 67.Vorhies JS, Uzosike OB, Imrie MN, Rinsky L, Hoffinger S. Treatment in a nonpediatric hospital is a risk factor for open reduction of pediatric supracondylar humerus fractures: a population-based study. J Orthop Trauma. 2019;33(9):e331-8. [DOI] [PubMed] [Google Scholar]
  • 68.Wendling-Keim DS, Binder M, Dietz HG, Lehner M. Prognostic factors for the outcome of supracondylar humeral fractures in children. Orthop Surg. 2019;11(4):690-7. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 69.Xie LW, Wang J, Deng ZQ, Zhao RH, Chen W, Kang C, Ye JJ, Liu X, Zhou Y, Shen H. Treatment of pediatric lateral condylar humerus fractures with closed reduction and percutaneous pinning. BMC Musculoskelet Disord. 2020;21(1):707. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 70.Yaokreh JB, Gicquel P, Schneider L, Stanchina C, Karger C, Saliba E, Ossenou O, Clavert JM. Compared outcomes after percutaneous pinning versus open reduction in paediatric supracondylar elbow fractures. Orthop Traumatol Surg Res. 2012;98(6):645-51. [DOI] [PubMed] [Google Scholar]
  • 71.Davidson PL, Goulding A, Chalmers DJ. Biomechanical analysis of arm fracture in obese boys. J Paediatr Child Health. 2003;39(9):657-64. [DOI] [PubMed] [Google Scholar]
  • 72.Pollack KM, Xie D, Arbogast KB, Durbin DR. Body mass index and injury risk among US children 9-15 years old in motor vehicle crashes. Inj Prev. 2008;14(6):366-71. [DOI] [PubMed] [Google Scholar]
  • 73.Nowicki P, Kemppainen J, Maskill L, Cassidy J. The role of obesity in pediatric orthopedics. J Am Acad Orthop Surg Glob Res Rev. 2019;3(5):e036. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 74.Chang CH, Kao HK, Lee WC, Yang WE. Influence of obesity on surgical outcomes in type III paediatric supracondylar humeral fractures. Injury. 2015;46(11):2181-4. [DOI] [PubMed] [Google Scholar]
  • 75.Fornari ED, Suszter M, Roocroft J, Bastrom T, Edmonds EW, Schlechter J. Childhood obesity as a risk factor for lateral condyle fractures over supracondylar humerus fractures. Clin Orthop Relat Res. 2013;471(4):1193-8. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 76.Seeley MA, Gagnier JJ, Srinivasan RC, Hensinger RN, VanderHave KL, Farley FA, Caird MS. Obesity and its effects on pediatric supracondylar humeral fractures. J Bone Joint Surg Am. 2014;96(3):e18. [DOI] [PubMed] [Google Scholar]
  • 77.Campbell CC, Waters PM, Emans JB, Kasser JR, Millis MB. Neurovascular injury and displacement in type III supracondylar humerus fractures. J Pediatr Orthop. 1995;15(1):47-52. [DOI] [PubMed] [Google Scholar]
  • 78.Louahem DM, Nebunescu A, Canavese F, Dimeglio A. Neurovascular complications and severe displacement in supracondylar humerus fractures in children: defensive or offensive strategy? J Pediatr Orthop B. 2006;15(1):51-7. [DOI] [PubMed] [Google Scholar]
  • 79.Lyons ST, Quinn M, Stanitski CL. Neurovascular injuries in type III humeral supracondylar fractures in children. Clin Orthop Relat Res. 2000;376:62-7. [DOI] [PubMed] [Google Scholar]
  • 80.Wingfield JJ, Ho CA, Abzug JM, Ritzman TF, Brighton BK. Open reduction techniques for supracondylar humerus fractures in children. J Am Acad Orthop Surg. 2015;23(12):e72-80. [DOI] [PubMed] [Google Scholar]
  • 81.Skaggs DL, Hale JM, Bassett J, Kaminsky C, Kay RM, Tolo VT. Operative treatment of supracondylar fractures of the humerus in children. The consequences of pin placement. J Bone Joint Surg Am. 2001;83(5):735-40. [PubMed] [Google Scholar]
  • 82.Slobogean BL, Jackman H, Tennant S, Slobogean GP, Mulpuri K. Iatrogenic ulnar nerve injury after the surgical treatment of displaced supracondylar fractures of the humerus: number needed to harm, a systematic review. J Pediatr Orthop. 2010;30(5):430-6. [DOI] [PubMed] [Google Scholar]
  • 83.Zionts LE, McKellop HA, Hathaway R. Torsional strength of pin configurations used to fix supracondylar fractures of the humerus in children. J Bone Joint Surg Am. 1994;76(2):253-6. [DOI] [PubMed] [Google Scholar]
  • 84.Iobst CA, Spurdle C, King WF, Lopez M. Percutaneous pinning of pediatric supracondylar humerus fractures with the semisterile technique: the Miami experience. J Pediatr Orthop. 2007;27(1):17-22. [DOI] [PubMed] [Google Scholar]
  • 85.Modest JM, Brodeur PG, Lemme NJ, Testa EJ, Gil JA, Cruz AI, Jr. Outpatient operative management of pediatric supracondylar humerus fractures: an analysis of frequency, complications, and cost from 2009 to 2018. J Pediatr Orthop. 2022;42(1):4-9. [DOI] [PubMed] [Google Scholar]
  • 86.Rider CM, Hong VY, Westbrooks TJ, Wang J, Sheffer BW, Kelly DM, Spence DD, Flynn JM, Sawyer JR. Surgical treatment of supracondylar humeral fractures in a freestanding ambulatory surgery center is as safe as and faster and more cost-effective than in a children's hospital. J Pediatr Orthop. 2018;38(6):e343-8. [DOI] [PubMed] [Google Scholar]

Articles from JBJS Open Access are provided here courtesy of Wolters Kluwer Health

RESOURCES