Keywords bone nails - bone wires - elbow joint - humeral fractures, distal - meta-analysis
Introduction
Supracondylar humerus fractures represent a common and clinically-significant pediatric
orthopedic injury; however, ita incidence has increased in the last decades, accounting
for 3% to 15% of all fractures in children. Moreover, it is the fracture that most
requires surgical treatment in the pediatric population.[1 ]
[2 ] These fractures typically occur in children aged between 5 and 7 years, and they
result from accidents such as falls on an outstretched hand.[3 ]
[4 ] Given the unique anatomical characteristics of pediatric bone and the potential
for complications, selecting the most appropriate treatment strategy is paramount
to achieve favorable outcomes.
The choice between two primary surgical techniques, closed reduction and percutaneous
pinning (CRPP) and open reduction and internal fixation (ORIF), has long been a subject
of debate and clinical interest. Several Brazilian authors prefer various methods
of CRPP, which involves the reduction of fractured bone fragments without the need
for a large incision as an advantage, followed by the insertion of percutaneous pins
to maintain alignment.[1 ]
[5 ]
[6 ] In contrast, ORIF requires open exposure of the fracture site (a disadvantage),
direct visualization, and fixation with screws or plates. Nevertheless, ORIF offers
the advantage of precise anatomical reduction and potentially stronger fixation, but
it comes with the drawbacks of increased surgical morbidity and extended hospitalization.[7 ]
The decision-making process regarding the optimal treatment approach for pediatric
supracondylar humerus fractures is multifaceted. It requires a comprehensive assessment
of patient-specific factors, fracture characteristics, and the available evidence.
Moreover, the selection of appropriate outcome measures to evaluate treatment success
plays a crucial role in guiding clinical decisions.[8 ] Among these outcome measures, two primary parameters stand out as central to the
assessment of treatment efficacy: Flynn's functional criteria and the Baumann angle.[8 ]
[9 ]
Flynn's functional criteria provide a comprehensive evaluation of functional recovery,
encompassing factors such as pain, range of motion, and strength. These criteria are
particularly relevant for pediatric patients, as they reflect the restoration of elbow
function, which is essential for activities of daily living and overall quality of
life.[10 ] And the Baumann angle is a radiological measure used to assess the anatomical alignment
of the elbow joint postfracture. Proper anatomical alignment is essential to minimize
long-term complications, such as cubitus varus or valgus deformities.[11 ]
While previous research has attempted to address the CRPP versus ORIF debate, inconsistencies
in study designs, patient populations, and outcome measures have contributed to a
lack of consensus in the field. Therefore, conducting a systematic review and meta-analysis
to synthesize the existing evidence, with a specific focus on Flynn's functional criteria
and the Baumann angle, is crucial. The present study aims to provide a comprehensive
overview of the comparative effectiveness of CRPP and ORIF in the management of pediatric
supracondylar humerus fractures. By consolidating the available data, we aim to inform
clinical decision-making and contribute to the optimization of care for this prevalent
and clinically-significant pediatric orthopedic condition.
Materials and Methods
Trial Registration
The current study was registered in the International Prospective Register of Systematic
Reviews (PROSPERO) on February 14, 2024 (registration number: CRD42024506147; available
from: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=506147 )
The present review employed a meta-analytic approach and adhered to the guidelines
of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)
statement, which encompass preparation, execution, and reporting stages.
Search Strategy
We conducted a comprehensive literature search in electronic databases (PubMed/MEDLINE,
ProQuest, and Cochrane Library) to identify qualified studies published between 2013
and 2013. Search terms were combined using the OR operator and linked with the AND
operator. The initial search included terms such as supracondylar humerus fractures , CRPP , and ORIF . The subsequent search included terms such as pediatric , operative , Flynn's criteria , and Baumann angle . We also expanded the research by reviewing references, reviews, and meta-analyses;
after that, we conducted a Google Scholar search to explore the citations. Then, two
of the authors (MAM and FF) also screened the reference lists of the eligible articles
for more potential papers. After removing duplicates, the titles and abstracts of
the studies were evaluated against predetermined inclusion/exclusion criteria. Discrepancies
were resolved through discussion with a third reviewer (NGGNU).
Selection Criteria
The study focused on children with radiographically-confirmed supracondyle fractures
who had undergone either ORIF or CRPP. The inclusion criteria were clinical trials
conducted between 2013 and 2023 that compared ORIF and CRPP in children under 18 years
of age with supracondylar humeral fractures. These trials were required to include
original data on various factors such as operative time, infection, avascular necrosis,
and non-union. The exclusion criteria were cases of supracondylar humeral fractures
combined with other fractures, pathological fractures, as well as case reports, cadaver
or model studies, and biomechanical studies. One of the authors (FF) also excluded
all review studies.
Risk of Bias Assessment
Two of the authors (MAM and FF) followed established methods using the Risk of Bias
in Non-Randomized Studies – of Interventions[12 ] (ROBINS-I) tool to assess the risk of bias due to confounding factors, selection
of participants or animals used in the study, classification of interventions, missing
data, measurement of outcomes, and selection of the reported results. The tool also
considers the management of incomplete outcome data, selective reporting of outcomes,
and it also spots other potential biases.
For each area examined, the authors classified the risk of bias as “low,” “high,”
or “unclear,” based on the available information. “Low” means there is a minimal chance
that bias could affect the study's results; “high” suggests a significant chance of
bias influencing the findings; and “unclear” indicates that there is not enough information
to decide the level of risk of bias.[13 ] The authors used this approach to comprehensively assess the quality of the reviewed
studies, enhancing the analyses and research conclusions by ensuring the consistent
and transparent application of the ROBINS-I tool.
Data Extraction
Two of the authors (MAM and FF) meticulously extracted pertinent data from the included
articles, referencing the full-text versions. Data extraction for the current study
involved a systematic approach. Pertinent data was meticulously collected from the
included articles. This encompassed key characteristics of the study population, including
age distribution, gender ratio (male:female), the total number of subjects, and the
duration of follow-up (in months). Additionally, the Gartland classification of the
patients submitted to CRPP and ORIF was extracted to assess injury severity and treatment
approaches.
Regarding the outcome measures of the studies included, the authors extracted data
related to Flynn's criteria, specifically evaluating the satisfactory outcomes for
CRPP and ORIF. The Baumann angle, a critical indicator in the assessment of fracture
reduction, was also recorded for both treatment groups. Furthermore, p -values were extracted to quantify the statistical significance of the differences
observed between CRPP and ORIF outcomes. This meticulous data extraction process facilitated
a comprehensive analysis of the study's findings and contributed to the study's overall
robustness. Subsequently, the articles selected were managed using the Review Manager
(RevMan, The Cochrane Collaboration, London, United Kingdom) software, version 5.4.
Results
The initial literature search yielded 52 studies that could be suitable for assessment.
Following a comprehensive review of titles and abstracts, 28 of these studies were
excluded. Subsequently, the full-text versions of the remaining 24 studies were obtained;
out of these, 18 were later disqualified. In the end, 6 studies,[14 ]
[15 ]
[16 ]
[17 ]
[18 ]
[19 ] involving a total of 405 subjects, satisfied the inclusion criteria for the present
systematic review ([Fig. 1 ]).
Fig. 1 Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) flow diagram.
The authors gathered data from the selected studies to compare the functional outcomes
of supracondylar humerus fractures in children after CRPP or ORIF. These studies were
categorized by their level of evidence ([Table 1 ]); most were cohort studies,[15 ]
[16 ]
[17 ]
[18 ]
[19 ] and only one was a case-control study.[14 ]
Table 1
No.
Study
Journal
Study design/ level of evidence
Mean age (years)
Sex (M:F)
Number of Subjects
Mean follow-up duration (months)
Gartland classification
Flynn's criteria (satisfactory)
Mean Baumann angle
CRPP
ORIF
CRPP
ORIF
CRPP
ORIF
CRPP
ORIF
CRPP
ORIF
p -value
CRPP
ORIF
1
Tomori et al., 2018[14 ]
Medicine (Baltimore)
Case-control/IV
5.4 ± 3.5
5.3 ± 2.1
10:11
6:7
CRPP: 21; ORIF: 13
7.9 ± 5.7
10.2 ± 5.3
II: 12 ; III: 9
II: 4 ; III: 9
20 (95.2%)
13 (100%)
0.83
74.9 ± 6.2
69.8 ± 3.7
2
Abousaleh et al., 2022[15 ]
Cureus
Retrospective cohort/III
5.21 ± 2.17
6.69 ± 4.08
14:14
1.9:1
CRPP: 28; ORIF: 32
3.64 ± 2.61
8.13 ± 11.16
−
−
26 (92.8%)
32 (100%)
0.214
68.02 ± 9.83
70.75 ± 7.17
3
Ayub et al., 2021[16 ]
Journal of Pakistan Orthopaedic Association
Retrospective cohort/III
6 ± 1.1
6.9 ± 3.83
21:9
18:12
CRPP: 30; ORIF: 30
12
12
III: 30
III: 30
30 (100%)
23 (76.6%)
<0.05
−
−
4
Dučić et al., 2016[17 ]
Serbian Archives of Medicine
Cohort/III
6.7 + 1.7
6.8 + 2
29:8
23:11
CRPP: 37; ORIF: 34
−
−
II: 13 ; IV: 24
II: 17 ; III: 17
37 (100%)
31 (91.1%)
0.02
−
−
5
Hossain et al., 2023[18 ]
Saudi Journal of Medical and Pharmaceutical Sciences
Cohort/III
6.5
5.9
29:14
26:11
CRPP: 43; ORIF:37
32.9 ± 12.5
29.5 ± 10.75
III: 43
III: 43
42 (97.6%)
36 (97.2%)
>0.05
−
−
6
Keskin and Sen, 2014[19 ]
Acta chirurgiae orthopaedicae et traumatologiae Cechoslovaca
Cohort/II
7.04
69: 31
CRPP: 50; ORIF:50
49.2 ± 20.5
14.12 ± 12.75
−
−
47 (94%)
45 (90%)
0.774
−
−
The authors assessed the bias in the selected studies using the ROBINS-I tool. The
method to generate random sequences was well described and presented minimal bias
risk, while allocation concealment was thoroughly explained and presented a low bias
risk. Blinding of the participants and personnel was not possible due to the nature
of the intervention, leading to a higher bias risk. However, the outcome assessors
remained unaware of the treatments, resulting in a low bias risk. Low dropout rates
and reporting prespecified outcomes without selective reporting signs maintained the
low bias risk. No additional bias sources were found, resulting in a low risk of bias
in other areas. Overall, the current study presented a low bias risk, except for the
blinding of the participants and personnel due to the intervention's nature ([Table 2 ]).
Table 2
Study
Random sequence generation
Allocation concealment
Binding of participants and personnel
Blinding of outcome assessment
Incomplete outcome data
Selective outcome reporting
Other source of bias
Tomori et al., 2018[14 ]
Low
Low
High
Low
Low
Low
Low
Abousaleh et al., 2022[15 ]
Low
Low
High
Low
Low
Low
Low
Ayub et al., 2021[16 ]
Low
Low
High
Low
Low
Low
Low
Dučić et al., 2016[17 ]
Low
Low
High
Low
Low
Low
Low
Hossain et al., 2023[18 ]
Low
Low
High
Low
Low
Low
Low
Keskin and Sen, 2014[19 ]
Low
Low
High
Low
Low
Low
Low
[Table 1 ] summarizes key characteristics from the selected studies involving a total of 405
patients. Tomori et al.[14 ] (2018) divided 34 patients into CRPP and ORIF groups, with follow-up durations of
around 5.4 and 5.3 months respectively. Gartland classifications revealed differences
between the groups. Abousaleh et al.[15 ] (2022) enrolled 60 patients in these groups, with CRPP having a shorter mean follow-up,
of 5.21 months, and a balanced gender distribution. Ayub et al.[16 ] (2021) studied 60 patients in each group for 6 months, observing differences in
Gartland classifications. Dučić et al.[17 ] (2016) included 71 patients in the same groups, with similar follow-up durations
and varied Gartland classifications. Hossain et al.[18 ] (2023) examined 80 patients with varying follow-up durations, focusing on type-III
fractures. Keskin and Sen.[19 ] (2014) studied 100 patients but did not report age and gender data, with the CRPP
group followed up for 7.04 months. These studies collectively provide insights into
treatment approaches and patient characteristics in this context.
[Table 1 ] summarizes the outcomes of the treatment of several pediatric supracondylar humerus
fractures in the studies[14 ]
[15 ]
[16 ]
[17 ]
[18 ]
[19 ] using Flynn's criteria and Baumann angle measurements. The CRPP and ORIF procedures
generally resulted in high rates of satisfactory outcomes based on Flynn's criteria.
Baumann angle measurements were comparable between the two methods across most studies,
without statistically significant differences. This suggests the effectiveness of
both approaches for pediatric supracondylar humerus fractures. However, variations
in factors such as age, sex distribution, sample size, and follow-up duration among
the studies should be considered when interpreting the results.
The forest plot analysis of Flynn's functional criteria in [Fig. 2 ] suggests that there was no statistically significant difference in functional outcome
between CRPP and ORIF for supracondylar humerus fractures in children. The pooled
effect estimates, represented by the diamond-shaped marker, are located to the left
of the line of no effect, indicating a slightly higher proportion of satisfactory
outcomes in the CRPP group. However, the confidence interval for the pooled effect
includes the line of no effect, indicating that the difference is not statistically
significant.
Fig. 2 Forest plot analysis Flynn's functional criteria.
Flynn's functional criteria were used as one of the primary outcome measures. [Fig. 3 ] shows that there was no statistically significant difference in terms of the Baumann
angle between CRPP and ORIF (p > 0.05). This suggests that both treatment approaches are viable options for supracondylar
humerus fractures in children, particularly in cases of Gartland type-III fractures.
The Baumann angle was also considered as a primary outcome measure. However, the limited
data availability (only two studies) on the Baumann angle precluded a conclusive comparison.
Therefore, no definitive conclusions regarding this measure can be drawn. Therefore,
both CRPP and ORIF can be considered viable treatment options for these fractures
in children.
Fig. 3 Forest plot analysis of the Baumann angle.
Discussion
Supracondylar humerus fractures pose a substantial challenge in pediatric orthopedics,
demanding a nuanced approach for optimal patient outcomes. The choice between CRPP
and ORIF has long been a subject of debate within the field. In this discussion, we
will delve deeper into our analysis, focusing on Flynn's functional criteria while
also considering Baumann angle measurements ([Figs. 2 ]
[3 ]) provided by individual studies to offer a more comprehensive understanding of the
comparative efficacy of these treatments.[20 ]
[21 ]
Our analysis revealed no statistically significant difference in the outcomes according
to Flynn's functional criteria between CRPP and ORIF for supracondylar humerus fractures
in children (p > 0.05). The findings suggest that both treatments offer comparable functional recovery,
rendering them viable options, particularly for Gartland type-III fractures. The forest
plot analysis visually reinforces this finding, with the pooled effect estimate slightly
favoring CRPP, but within a confidence interval encompassing the line of no effect.
The consistency of these results across multiple studies underscores the clinical
equipoise between CRPP and ORIF concerning functional outcomes. Zhu et al.[1 ] reported no statistical difference in clinical outcomes between CRPP and ORIF for
supracondylar fractures (p > 0.05). Furthermore, [Figs. 2 ]
[3 ] shed light on patient demographics and characteristics within each treatment group.
These data underscore the diversity of our dataset, with variations in patient age,
follow-up duration, and the distribution of the fractures according ot the Gartland
classification. Despite these variations, the individual studies consistently report
no significant disparities in functional outcomes between CRPP and ORIF, aligning
harmoniously with the overall meta-analysis results.
While the Baumann angle serves as a critical radiological parameter to assess the
anatomical alignment of the elbow, the limited data available on it (only two studies,[14 ]
[15 ]) in the present meta-analysis hinders us from drawing definitive conclusions regarding
the comparative effectiveness of CRPP and ORIF based on this parameter. Acknowledging
the constraints imposed by the limited data on the Baumann angle is essential, emphasizing
the need for future research with larger samples to comprehensively address this gap.
The lack of significant differences in functional outcomes between CRPP and ORIF can
be attributed to several key factors, such as careful patient selection, standardized
outcome assessment, surgical expertise, postoperative care, and advancements in surgical
techniques.[22 ]
[23 ] By focusing on a relatively-homogenous group of patients with type-III fractures
and employing Flynn's functional criteria as a standardized assessment tool, most
of the selected studies minimized potential confounding variables and measurement
bias. Additionally, the surgical teams' proficiency in both techniques likely contributed
to the consistent positive outcomes in the two treatment groups.[24 ]
[25 ] Advances in surgical instruments, imaging, and perioperative care further improved
the functional outcomes.
Besides Flynn's functional criteria and the Baumann angle, other factors warrant consideration
when making treatment decisions in pediatric supracondylar humerus fractures, as seen
in [Figs. 2 ]
[3 ]. Notably, the length of hospital stay and cosmetic outcomes are aspects that can
significantly influence the overall patient experience. A minimally invasive procedure,
CRPP often results in shorter hospital stays than the more extensive ORIF procedure.
Additionally, the limited surgical exposure and smaller incisions in CRPP may contribute
to potentially superior cosmetic outcomes, a crucial consideration in the pediatric
patient population.[25 ]
[26 ]
[27 ]
In the current clinical practice, these findings empower clinicians to make treatment
decisions based on individual patient characteristics and preferences. Younger children
with less severe fractures may benefit from CRPP's minimally-invasive nature and shorter
hospitalization, while ORIF may be preferred for cases requiring precise anatomical
reduction or stronger fixation. This patient-centered approach reflects the evolving
landscape of the pediatric orthopedic practice, ensuring tailored care optimizes patient
outcomes and overall well-being while considering unique circumstances.
The current study presents several limitations. Firstly, the low quality of the bias
of the study, which may have affected the reliability of the results. Moreover, the
small number of studies included in the meta-analysis limits the statistical power
to detect meaningful differences and increases the likelihood of publication bias.
This restricted sample size may have led to an overestimation or underestimation of
effect sizes, particularly in the presence of selective reporting or small-study effects.
Further high-quality, large-scale randomized controlled trials are needed to validate
these findings and provide more definitive evidence on the subject.
Conclusion
Both CRPP and ORIF are viable treatments for pediatric supracondylar humerus fractures,
particularly those classified as Gartland type-III, but further research is needed
to address Baumann angle data, standardize outcome assessments, and guide treatment
decisions based on functional, radiological, and cosmetic outcomes.
Bibliographical Record Febyan Febyan, Made Agus Maharjana, Nyoman Gede Grenata Nanda Ustriyana. Redução fechada
e fixação percutânea versus redução aberta e fixação interna em fraturas pediátricas supracondilares do úmero:
Uma revisão sistemática. Rev Bras Ortop (Sao Paulo) 2025; 60: s00451804496. DOI: 10.1055/s-0045-1804496