Utility of the AAOS Appropriate Use Criteria (AUC) for Pediatric Supracondylar Humerus Fractures in Clinical Practice

Background: The American Academy of Orthopaedic Surgeons (AAOS) recently developed an Appropriate Use Criteria (AUC) for pediatric supracondylar humerus fractures (PSHF). The AUC is intended to improve quality of care by informing surgeon decision making. The aim of our study was to cross-reference the management of operatively treated PSHF with the AAOS-published AUC. Methods: The AUC for PSHF include 220 patient scenarios, based on different combinations of 6 factors. For each patient scenario, 8 treatment options are evaluated as appropriate, maybe appropriate, and rarely appropriate. We retrospectively reviewed the medical charts and radiographs of all operatively treated PSHF at our hospital from January 2013 to December 2014 and determined the appropriateness of the treatment. Results: Over the study period, 94 children (mean age: 5.2 y; 51 male, 43 female) were admitted with PSHF and underwent a surgical procedure (type IIA: 7, type IIB: 14, type III: 70, flexion type: 3). Only 8 of the 220 scenarios were observed in our patient cohort. The most frequent scenario was represented by a type III fracture, palpable distal pulse, no nerve injury, closed soft-tissue envelope, no radius/ulna fracture, and typical swelling. Of the 94 fractures, the AUC was appropriate for 84 cases and maybe appropriate for 9 cases. There was only 1 case of rarely appropriate management. Closed reduction with lateral pinning and immobilization was the most prevalent treatment option (58.5%). The rate of appropriateness was not affected by the operating surgeon. However, the definition of a case as emergent had a significant impact on the rate of appropriateness. Conclusions: Application of the AUC to actual clinical data was relatively simple. The majority of operatively treated PSHF (89.4%) were managed appropriately. With the introduction of electronic medical charts, an AUC application becomes attractive and easy for orthopaedic surgeons to utilize in clinical practice. However, validity studies of the AUC in different clinical settings are still required. Level of Evidence: Level IV.