Safety and Clinical Impact of Emergency Department Closed Reduction for Gartland Type III Supracondylar Humerus Fractures

Background: Pediatric type 3 supracondylar humerus fractures (SCHFs) are typically immobilized in situ before definitive operative fixation because of concern for neurovascular injury during closed reduction. This study assesses the safety and clinical outcomes of emergency department (ED) closed reduction versus in situ splinting for type 3 SCHFs before definitive fixation. Methods: A retrospective review was conducted of all pediatric extension-type 3 SCHFs that underwent closed reduction versus no reduction by orthopaedic surgery residents in the ED at a single Level 1 trauma center over a 5-year period. Data included pre- and postreduction neurovascular examinations, multiple radiographic parameters, durations of time between injury, consult, and reduction to the operating room (OR), total operative time, and OR fluoroscopy duration. Results: Of 112 patients, 54 underwent closed reduction (CR) while 58 were not reduced (NR). Nine (20%) patients in the CR group and 9 (18%) patients in the NR group had abnormal neurological exams on presentation. Four (8%) patients in the CR group and 2 (4%) patients in the NR group had abnormal vascular exams. All 4 patients who underwent closed reduction had improved vascular exams from Doppler-able to palpable radial pulses ( P =0.12). No vascular injuries occurred with closed reduction. Importantly, 6 patients in the NR group with initial normal exams developed abnormal neurological deficits while awaiting surgical fixation ( P =0.03). The CR group demonstrated significantly improved radiographic parameters postreduction, including AP and lateral displacement, anterior humeral line displacement, lateral Baumann angle, and hourglass angle. The time from consult or reduction to OR was significantly less for the NR group compared with the CR group (9.83 vs. 13.45 h; P <0.01). The time from injury to the OR was also significantly less in the NR group (21.0 vs. 17.0 h; P =0.02). The CR group trended towards shorter operative times (33 vs. 40 min; P =0.15). Conclusion: Closed reduction of pediatric type 3 SCHFs in the ED by orthopaedic surgery residents is safe and can improve both neurovascular deficits and radiographic fracture alignment. As most pediatric extremity fractures undergo closed reduction in the ED, type 3 SCHFs should not be considered an exception. Level of Evidence: Level III—retrospective comparative study.