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AAOS Appropriate Use Criteria Summary

Management of Pediatric
Supracondylar Humerus Fractures
With Vascular Injury

James O. Sanders, MD The American Academy of Orthopaedic Surgeons has developed the
Michael H. Heggeness, MD Appropriate Use Criteria (AUC) document Management of Pediatric
Supracondylar Humerus Fractures With Vascular Injury. Evidence-
Jayson N. Murray, MA
based information, in conjunction with the clinical expertise of
Ryan C. Pezold, MA physicians, was used to develop the criteria to improve patient care
Kaitlyn S. Sevarino, MBA and obtain the best outcomes while considering the subtleties and
distinctions necessary in making clinical decisions. The AUC clinical
patient scenarios were derived from patient indications that generally
accompany a pediatric supracondylar humerus fracture with vascular
From the University of Rochester,
Rochester, NY (Dr. Sanders), the
injury, as well as from current evidence-based clinical practice
University of Kansas School of guidelines and supporting literature. The 6 patient scenarios and 18
Medicine, Wichita, KS (Dr. treatments were developed by the Writing Panel, a group of clinicians
Heggeness), and the American
Academy of Orthopaedic Surgeons,
who are specialists in this AUC topic. Next, the Review Panel, a
Rosemont, IL (Mr. Murray, Mr. Pezold, separate group of volunteer physicians, independently reviewed
and Ms. Sevarino). these materials to ensure that they were representative of patient
Dr. Sanders or an immediate family scenarios that clinicians are likely to encounter in daily practice.
member has stock or stock options Finally, the multidisciplinary Voting Panel (made up of specialists and
held in Abbott, Abbvie, GE Healthcare,
and Hospira and serves as a board nonspecialists) rated the appropriateness of treatment of each
member, owner, officer, or committee patient scenario using a 9-point scale to designate a treatment as
member of the American Academy of Appropriate (median rating, 7 to 9), May Be Appropriate (median
Orthopaedic Surgeons, the Pediatric
Orthopaedic Society of North America, rating, 4 to 6), or Rarely Appropriate (median rating, 1 to 3).
and the Scoliosis Research Society.
Dr. Heggeness or an immediate family
member has received royalties from
K2M and Relievant Medsystems, patient types. AAOS staff con-
serves as a paid consultant to Intrinsic Overview and Rationale vened the three independent volun-
Orthopaedics and Relievant
Medsystems, and has stock or stock This Appropriate Use Criteria teer physician panels that developed
options held in Relievant Medsystems.
(AUC) document was approved by this AUC.
None of the following authors or any Musculoskeletal care is provided in
immediate family member has received the American Academy of Ortho-
anything of value from or has stock or paedic Surgeons (AAOS) Board of many settings by different providers.
stock options held in a commercial Directors on June 12, 2015. The The AAOS created this AUC docu-
company or institution related directly ment as an educational tool to guide
or indirectly to the subject of this article:
purpose of the AUC is to help
Mr. Murray, Mr. Pezold, and Ms. determine the appropriateness of qualified physicians through a series
Sevarino. treatments of the heterogeneous of treatment decisions in an effort to
patient population routinely seen in improve the quality and efficiency of
J Am Acad Orthop Surg 2016;24:
e21-e23 a practice. The best available scien- care. These criteria should not be
tific evidence is synthesized with construed as including all indications
JAAOS-D-15-00701 collective expert opinion on topics or excluding indications reasonably
for which randomized clinical trials directed to obtaining the same results.
Copyright 2016 by the American
Academy of Orthopaedic Surgeons. are not available or are inadequately The criteria are intended to address
detailed for identifying distinct the most common clinical scenarios

February 2016, Vol 24, No 2 e21

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Management of Pediatric Supracondylar Humerus Fractures With Vascular Injury

Table 1 patient indications, assumptions,

and treatments based on an
Indications and Classifications
evidence-based systematic review
Indication Classification of the literature conducted by
Vascular Patients with a suspected vascular injury after closed reduction AAOS staff research analysts; (2)
status and pinning constructing a review panel con-
Patient had vascularity restored. The patient will be admitted sisting of 10 to 30 clinicians to
and observed. review the writing panel’s materials
Perfusion Perfused hand (one that is warm, pink, and capillary refill is ,3 s) and provide any suggestions for
with dopplerable distal pulse
Perfused hand (one that is warm, pink, and capillary refill is improvement; and (3) constructing
,3 s) without dopplerable distal pulse a multidisciplinary voting panel
Nonperfused hand (one that is cold, white, and capillary refill is that uses a review of the most cur-
.3 s)
rent and relevant literature, along
with their expert clinical judgment,
to rate the appropriateness of
facing all appropriately trained sur- are associated with some known treatment of various patient
geons and all qualified physicians risks, especially invasive and surgi- scenarios.
managing patients under consider- cal procedures. In addition, con- General assumptions were devel-
ation for treatment of pediatric supra- traindications vary widely based on oped by the Management of Pediatric
condylar humerus fractures with the treatment administered. There- Supracondylar Humerus Fractures
vascular injury. The ultimate judgment fore, discussion of available treat- With Vascular Injury AUC panel
regarding any specific criteria should ments and procedures applicable members to clarify the interpretation
address all circumstances presented by to the individual patient relies on of the patient scenarios and provide
the patient and the needs and resources mutual communication between the standardization for the parameters
particular to the locality or institution. patient and physician, weighing the used to rate the appropriateness of
Appropriateness treatment ratings for potential risks and benefits for that treatment.
six patient scenarios were developed patient. This AUC was approved by the
for the AUC for Management of Appropriate Use Criteria Section, the
Pediatric Supracondylar Humerus Council on Research and Quality,
Fractures With Vascular Injury.
and the AAOS Board of Directors.
The AAOS uses the RAND/UCLA All tables, figures, and appendices,
Potential Harms and Appropriateness Method to develop as well as the details of the methods
Contraindications AUC.1 The process includes the used to prepare this AUC, are
following steps: (1) constructing a detailed in the full AUC, which is
The aim of treatment is pain relief writing panel, consisting of 6 to 10 available at
and maintenance of the patient’s clinicians who are experts in the research/Appropriate_Use/PSHF_
functional status. Most treatments topic under study, to create a list of Vascular_Injury_AUC.pdf.

These appropriate use criteria were approved by the American Academy of Orthopaedic Surgeons on June 12, 2015.
The complete Appropriate Use Criteria for Management of Pediatric Supracondylar Humerus Fractures With Vascular Injury includes all
tables, figures, and appendices, and is available at
Management of Pediatric Supracondylar Humerus Fractures With Vascular Injury AUC Writing Panel: Fizan Abdullah, MD, PhD, Matthew
Halsey, MD, Christine Ho, MD, Col. Kathleen McHale, MD, MSEd, FACS, Kevin McHorse, PT, SCS, Cert. MDT, James F. Mooney, MD,
Kishore Mulpuri, MD, David G. Nelson, MD, Matthew Oetgen, MD, Larry Pack, MD, Laurel H. Saliman, MD, John M. Stephenson, MD, and
Yi-Meng (Beng) Yen, MD, PhD, FAAP. Review Panel: Donald Bae, MD, Holly J. Benjamin, MD, Dale Blasier, MD, FRCS(C), MBA, Patrick
Bosch, MD, Gregory J. Della Rocca, MD, PhD, FACS, Eric Edmonds, MD, Hilton Gottschalk, MD, Daniel Green, MD, MS, Sumit Gupta, MD,
James Hanley III, MD, Daniel Hely, MD, Stephanie Holmes, MD, Pooya Hosseinzadeh, MD, Charles J. Hyman, MD, Mark Kraus, MD, Walter
Krengel, MD, Kevin Little, MD, John Loiselle, MD, FAAP, John Lovejoy, MD, Douglas Lundy, MD, Stephen A. Mendelson, MD, Joshua Murphy,
MD, Sara Rasmussen, MD, PhD, Jeff Schunk, MD, Richard M. Schwend, MD, Mauricio Silva, MD, and Vikas Trivedi, MD, DNB (Ortho),
MNAMS (Ortho), FASIF. Voting Panel: Jeffrey O. Anglen, MD, Teresa Cappello, MD, Robert B. Carrigan, MD, Prasad Gourineni, MD, MS,
William L. Hennrikus, MD, Danielle Katz, MD, Annalise N. Larson, MD, Kevin Latz, MD, William M. Mirenda, Jr., MD, Norman Y. Otsuka, BSc,
MSc, MD, Min Jung Park, MD, MMSc, Peter Darrell Pizzutillo, MD, Brian Snyder, MD, PhD, Dale P. Woolridge, MD, PhD. Moderators: Michael
H. Heggeness, MD, and James O. Sanders, MD. Staff of the American Academy of Orthopaedic Surgeons: Deborah S. Cummins, PhD, Jayson
Murray, MA, Ryan Pezold, MA, Peter Shores, MPH, Ann Woznica, MLS, Kaitlyn Sevarino, MBA, and Erica Linskey.

e22 Journal of the American Academy of Orthopaedic Surgeons

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
James O. Sanders MD, et al

Indications and Figure 1

Table 1 provides the list of patient
indications and classifications devel-
oped by the Management of Pediatric
Supracondylar Humerus Fractures
With Vascular Injury AUC Panels.

The following treatments are ad-
dressed within the Management of
Pediatric Supracondylar Humerus
Fractures With Vascular Injury
AUC document: (1) same-day dis-
charge (only an option before vas-
cular restoration); (2) continue
in-hospital observation without
intervention (only an option before Summary of appropriateness ratings of the Management of Pediatric
vascular restoration); (3) warm the Supracondylar Humerus Fractures With Vascular Injury Appropriate Use Criteria.
extremity; (4) remove fixation (only
an option before vascular restora- arterial reconstruction or arteriot-
tion); (5) explore the fracture site omy (only an option after vascu- AUC Mobile Application
for brachial artery entrapment larity is restored); and (18) return to
(only an option before vascular As part of the dissemination efforts for
the OR for topical application of
restoration); (6) angiogram; (7) the Management of Pediatric Supra-
nitroglycerin paste and/or papav-
pharmacologic anticoagulation; (8) condylar Humerus Fractures With
erine to artery (only an option after
topical application of nitroglycerin Vascular Injury AUC, this web-based
vascularity is restored).
paste and/or papaverine to artery mobile platform was developed to
(only an option before vascular provide physicians with immediate
restoration); (9) assessment by a Results of Appropriateness access to information to assist them in
vascular surgeon; (10) nitroglycer- Ratings providing evidence-based patient care.
ine paste to skin; (11) immediate The mobile platform includes the list of
transfer to a facility with vascular Of 72 total voting items, 19 voting patient indications and treatment rec-
or microsurgery services; (12) items (26%) were rated as Appro- ommendations. Once the clinician
compartment releases (only an priate, 22 voting items (31%) were enters a patient indication profile
option before vascular restoration); rated as May Be Appropriate, and specifying the vascular status and
(13) same-day discharge with 31 voting items (43%) were rated as perfusion, a list of treatment recom-
observation ,24 hours (only an Rarely Appropriate (Figure 1). mendations is provided. For the
option after vascularity is restored); Additionally, the voting panel selected patient profile, green circled
(14) continue in-hospital observa- members were in agreement on 27 checkmarks reflect appropriate treat-
tion for ,24 hours (only an option voting items (38%) and were in ments, yellow caution symbols reflect
after vascularity is restored); (15) disagreement on 2 voting items treatments that may be appropriate,
measure compartment pressures (3%). The final appropriateness and red circled X’s reflect treatments
(only an option after vascularity is ratings assigned by the 14-member that are rarely appropriate.
restored); (16) return to the oper- voting panel can be accessed online
ating room (OR) to perform com- via the AAOS Management of Reference
partment releases (only an option Pediatric Supracondylar Humerus
after vascularity is restored); (17) Fractures With Vascular Injury 1. Fitch K, Bernstein SJ, Aguilar MD, et al: The
RAND/UCLA Appropriateness Method
return to the OR for exploration of AUC web-based mobile application User’s Manual. Santa Monica, CA, RAND
the brachial artery for possible at Corporation, 2001.

February 2016, Vol 24, No 2 e23

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.