P0253 - Clinical and Functional Outcomes of Nonoperatively Treated Pediatric Supracondylar Humerus Fractures at the Nkhotakota District Hospital, Malawi

Background: Displaced supracondylar humerus fractures are felt to benefit from closed reduction and percutaneous pinning. In Malawi, limited surgical capacity results in many of these injuries being treated nonoperatively with straight-arm traction and splinting. We sought to assess clinical and functional outcomes of nonoperatively treated supracondylar humerus fractures in a resource-limited setting.

Methods:
We retrospectively reviewed all patients with supracondylar humerus fractures treated at Nkhotakota District Hospital (NKKDH) in Malawi between January 2014 and December 2016. Patients identified from the retrospective cohort underwent subsequent clinical and functional follow-up assessment by Flynn’s criteria and radiographic review.

Results:
One hundred and eighty-two children (54% male, mean age 7.0 years) were identified with supracondylar humerus fractures. Most injuries (83%) were due to falls and were extension-type (98%). All were closed injuries. Gartland class distribution: type I (35%), type II (29%), and type III (35%). Treatments included straight-arm traction followed by manipulation under anesthesia without fluoroscopy and splinting (65%), traction and splinting without manipulation (32%), and sling alone (2%). Of this cohort, 137 patients underwent follow-up assessment at a mean of 3.9 years (range, 2.4-5.4 years) after injury. Radiographs demonstrated healing in all patients; 5% had malunions (varus or valgus). Flynn’s criteria for functional outcome was excellent in 95% of type I, 70% of type II, and 29% of type III fractures. Risk of a lower than excellent functional score was 6.2 times greater for type II (95% CI 1.5-25.8) and 14.6 times greater for type III (95% CI 3.7-57.2) than type I fractures. Flynn’s cosmetic difference in carrying angle was excellent in 98% of type I, 98% of type II, and 84% of type III fractures. Risk of lower than excellent cosmetic score was 6.7 times greater for type III (95% CI 0.9-51.3) than type I fractures. Children were able to return to school and chores without limitation or pain in 95% of type I, 67% of type II, and 41% of type III fractures.

Discussion:
Despite a low rate of radiographic complications, straight-arm traction for displaced (type III) supracondylar humerus fractures was associated with less than excellent functional and cosmetic results, and a significant rate of pain and functional limitations upon return to school and chores. The results of this study illustrate the urgent need for capacity-building in resource-limited areas to improve pediatric fracture care.