Supracondylar humeral fractures in children: American Academy of Orthopaedic Surgeons appropriate use criteria versus actual management in a teaching hospital

PURPOSE: The objective of this study was to explore whether there were any differences between the theoretical recommendations for children’s supracondylar humeral fractures (CSHF) according to the American Academy of Orthopaedic Surgeons (AAOS) guidelines and the treatments they actually received in our institution. METHODS: We retrospectively reviewed the medical charts and radiographs of all CSHFs at our hospital between January 2015 and December 2018. In all, 301 children meeting our inclusion criteria were identified and evaluated using the AAOS-Appropriate Use Criteria (AUC) application for supracondylar humerus fractures. Actual treatment was then compared with the treatment recommended by the AUC. RESULTS: Actual operative management was undertaken in 0/58 (0%) Gartland type I fractures, 61/108 (56.5%) type II fractures and 98/135 (72.6%) type III fractures. Actual nonoperative management was undertaken in 58/58 (100%) Gartland type I fractures, 47/108 (43.5%) type II fractures and 37/135 (27.4%) type III fractures. Surgeon decisions for nonoperative treatment were in agreement with the AUC recommendations 100% of the time, whereas surgeon decisions for surgery matched the AUC recommendations 65.4% of the time. Predictors of actual operative management were age (p =0.003), fracture classification (p =0.000), associated orthopaedic injury requiring surgery (p =0.025) and anterior humeral line (AHL) not intersecting the capitellum (p =0.008). CONCLUSION: We found low agreement between actual treatments and the AUC-recommended ‘appropriate’ treatments. The AUC favoured operative intervention more frequently largely on the basis of fracture classification while we emphasized age, fracture classification, associated orthopaedic injury requiring surgery and alignment of the AHL with the capitellum in our operative decision-making process. LEVEL OF EVIDENCE: Therapeutic Level II