Quality of treatment of supracondylar humerus fractures in children

Two-thirds of children’s fractures occur in the upper extremity. The humerus is the second most common fracture location after the radius. Supracondylar humerus fractures (SCHFs) are the most common distal humerus fractures, followed by lateral condyle and medial epicondyle fractures. Medial condyle and lateral epicondyle fractures are rare. Displaced SCHF is commonly treated with internal fixation, and it is the most common operatively treated fracture type in children. Reduction and pin fixation of distal humerus fractures in children can be technically challenging, especially in inexperienced hands. Consultant assistance, for both diagnostic purposes and operative treatment, is usually more guaranteed during office hours. The quality of the reduction of SCHF has traditionally been assessed in radiographs by evaluating frontal alignment with respect to the Baumann angle (BA) and by evaluating sagittal alignment with respect to the anterior humeral line (AHL) crossing point with the capitellum or the lateral capitellohumeral angle (LCHA). Postoperative radiographic follow-up with radiographs 1–2 weeks after surgery and at pin removal is generally used without evidence of an effect on treatment. Vascular injuries are a rarity, even though up to one in seven children with dislocated SCHF has compromised blood circulation at admission to hospital. Displaced SCHF is associated with the highest risk of nerve injury among pediatric fractures. Most injuries are caused by the trauma itself, but an incidence of iatrogenic injuries related to pin fixation of up to 4% has been reported. Postoperative infections are mostly superficial and heal with pin removal and oral antibiotics. The most well-known complication of SCHF is varus (gun-stock) deformity, which is mostly considered a cosmetic problem, even though functional limitations and a risk of lateral condyle fractures have been reported. In Finland, treatment complications are compensated for by the Patient Insurance Centre (PIC). Long-term outcome of displaced SCHF has not been well documented. Objective long-term outcome is usually assessed using Flynn’s criteria and subjective outcome is assessed with validated outcome measures. Our objective is to improve the treatment of pin-fixed SCHF in children by formulating guidance for pin fixation of SCHF based on the conclusion of our study. The purpose of this study is to assess whether operative treatment of SCHF can safely be postponed to office hours with improved fracture reduction and pin fixation. The objective is also to assess the clinical significance of postoperative radiographic follow-up and to determine whether primary radiographic parameters have prognostic value for long-term outcome. Our goal is to identify the most common reasons for compensated treatment injuries in pediatric distal humerus fractures and to assess the quality of treatment of these fractures in Finland. We also want to determine the objective and subjective long-term outcomes in operatively treated SCHF in the Children’s Hospital, Helsinki.