Background
Supracondylar fracture of the humerus is the second most frequent types of bone injury in children [
1,
2]. The occurrence of supracondylar fracture of the humerus account for 55 to 75% of patients with elbow fractures [
3,
4]. For treatment of this fracture, closed reduction and percutaneous pinning, and open reduction and internal fixation were two common managements for supracondylar fracture of the humerus [
5]. Ducic et al. [
6] revealed that closed reduction and percutaneous pinning was associated with an increase of the clinical outcomes. Kazimoglu et al. [
7] found that closed reduction has equally clinical outcomes than open reduction. Until now, there is no universal agreement among orthopedic surgeons on the most appropriate treatment for supracondylar fracture of the humerus. Currently, there was no relevant meta-analysis that compared closed reduction and open reduction.
Thus, it is necessary to evaluate the efficacy and safety of two different managements for supracondylar humeral fractures in children. This meta-analysis aimed to illustrate the clinical outcomes and safety of two different managements for supracondylar humeral fractures in children. We hypothesize that closed reduction and percutaneous pinning, and open reduction and internal fixation has similar clinical result for supracondylar humeral fractures in children.
Methods
This systematic review was reported according to the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines [
8].
Search strategies
The following databases were searched in September 2016 without restrictions on location or publication types: PubMed (1950–January 2018), EMBASE (1974–January 2018), the Cochrane Library (January 2018 Issue 3), and the Google database (1950–January 2018). The Mesh terms and their combinations used in the search were as follows: “supracondylar humeral fractures” OR “SCHF” AND “closed reduction” AND “open reduction”. The reference lists of related reviews and original articles were searched for any relevant studies, including RCTs involving adult humans. Only articles originally written in English or translated into English were considered. When multiple reports describing the same sample were published, the most recent or complete report was used. This meta-analysis collected data from published articles and thus no ethic approval was necessary for this article.
Inclusion criteria and study selection
Patients: patients was diagnose as supracondylar fracture of the humerus surgery; intervention: closed reduction and percutaneous pinning as an intervention group; comparison: open reduction and internal fixation as a comparison group; outcomes: cosmetic and clinical outcomes based on the criteria of Flynn, ulnar nerve injury, and the occurrence of infection; study design: randomized controlled trials (RCTs) and non-RCTs. Two independent reviewers screened the title and abstracts of the identified studies after removing the duplicates from the search results. Any disagreements about the inclusion or exclusion of a study were solved by discussion or consultation with an expert. The reliability of the study selection was determined by Cohen’s kappa test, and the acceptable threshold value was set at 0.61 [
6,
7].
Data abstraction and quality assessment
A specific extraction was conducted to collect data in a pre-generated standard Microsoft® Excel (Microsoft Corporation, Redmond, Washington, USA) file. The items extracted from relevant studies were as follows: first author and publication year, country, sample size of the intervention and control groups, mean age of the intervention and control groups, the protocol of intervention and comparison groups, and follow-ups. Outcomes such as cosmetic and clinical outcomes based on the criteria of Flynn [
9], ulnar nerve injury, and the occurrence of infection were abstracted and recorded in the spreadsheet. The criteria of Flynn were presented in Additional file
1. Data in other forms (i.e., median, interquartile range, and mean ± 95% confidence interval (CI)) were converted to the mean ± standard deviation (SD) according to the Cochrane Handbook [
10]. If the data were not reported numerically, we extracted these data using the “GetData Graph Digitizer” software from the published figures. All the data were extracted by two independent reviewers, and disagreements were resolved by discussion.
The quality of all included trials was independently assessed by two reviewers on the basis of the Cochrane Handbook for Systematic Reviews of Interventions, version 5.1.0 (
http://handbook.cochrane.org) [
10]. A total of seven domains were used to assess the overall quality: random sequence generation, allocation concealment, blinding of participant and personnel, blinding of outcome assessment, incomplete outcome data, selective reporting, and other bias. Each domain was measured as low bias, unclear bias, or high bias.
Outcome measures and statistical analysis
Dichotomous outcomes (cosmetic and clinical outcomes based on the criteria of Flynn [
9], ulnar nerve injury, and the occurrence of infection) were expressed as a risk ratio (RR) with 95% CI. Statistical significance was set at
P < 0.05 to summarize the findings across the trials. Variables in the meta-analysis were calculated using Stata software, version 12.0 (Stata Corp., College Station, TX, USA). Statistical heterogeneity was evaluated using the chi-square test and the I
2 statistic. When there was no statistical evidence of heterogeneity (
I2 < 50%,
P > 0.1), a fixed-effects model was adopted; otherwise, a random-effects model was chosen. Publication bias was tested using funnel plots. Publication bias was visually assessed using funnel plots and was quantitatively assessed using Begg’s test.
Discussion
This is the first systematic review and meta-analysis that comparing different managements for supracondylar humeral fractures in children. Results comprising four outcomes (cosmetic and functional outcomes based on the criteria of Flynn, ulnar nerve injury, and the occurrence of infection). Results shown that there was no significant difference between the above outcomes.
The ideal treatment for supracondylar humeral fractures is, according to many authors, closed reduction and percutaneous pinning. In current study, we found that closed reduction and percutaneous pinning has comparable clinical outcomes according to the criteria of Flynn. Results shown that there was no significant difference between the cosmetic and functional outcomes (
P > 0.05). Previously, a large number of studies initially tried closed reduction and pinning for supracondylar humeral fractures, and if closed reduction failed and other complications occurred, open reduction was tried. Therefore, open reduction groups generally included the more complicated patients and the clinical outcomes were always bad than closed reduction group. Mulpuri et al. [
15] conducted a systematic review and included 44 studies, and they suggested that closed reduction with pin fixation (2 or 3 laterally introduced pins) for patients with displaced supracondylar fractures of the humerus.
And, there was no significant difference between the occurrence of ulnar nerve injury (RR = 0.86, 95% CI 0.36, 2.02,
P = 0.725). Two lateral pins was an effective and relative stable method to avoid of iatrogenic ulnar nerve injury. Though, cross-pinning was associated with an increase of the occurrence of ulnar nerve injury, long-terms follow-up revealed that ulnar nerve injury will recover spontaneously without complication [
16,
17]. Thus, closed reduction was more preferable than open reduction for consideration of the ulnar nerve injury.
The occurrence of infection has been reported as 2.4–6.6% [
18‐
20]. In current meta-analysis, the occurrence of infection for the closed reduction and percutaneous pinning and open reduction was 6.41 and 7.14%, respectively. There was no significant difference between the two groups. These rates were also comparable with reports of previous literatures. Kazimoglu et al. [
7] revealed that there was no significant difference between the open group and closed group in terms of the pin tract infection. And all infectious patients were responded well to the oral antibiotic treatment.
There were several limitations in this meta-analysis: (1) only 6 potential studies were finally included, the effect size was relative small; (2) follow-up was relatively short and thus, the potential of these management complications may be underestimated; (3) the management of the K-wires was different and thus, may cause the heterogeneity for the outcomes; (4) subgroup analysis was not performed since the number of the included studies was limited and thus, more RCTs were need to further identify the clinical outcomes of these two managements.
Conclusion
In conclusion, closed reduction and percutaneous pinning, and open reduction and internal fixation of supracondylar humeral fractures in children result in similar construct stability and functional outcome. And there was no significant difference between the two managements as for the complications. Because the sample size and the number of included studies were limited, a multi-center RCT is needed to identify the effects of closed reduction and percutaneous pinning for supracondylar humeral fractures in children.
Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (
http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (
http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.