Predictors of failed closed reduction in pediatric Gartland type III and flexion-type supracondylar humerus fractures

Pediatric supracondylar humerus fractures (SCHFs) are among the most common childhood injuries, often requiring surgical fixation. Closed reduction with percutaneous pinning was the preferred initial management due to its minimally invasive nature. This study aimed to evaluate demographic, clinical, and radiographic predictors of failed closed reduction in Gartland type III and flexion-type pediatric SCHFs, emphasizing the role of preliminary reduction performed in the emergency department. We hypothesized that preliminary reduction in the emergency setting would reduce the risk of failed closed reduction. This retrospective cohort study involved pediatric patients aged 2–13 years who underwent surgical treatment for Gartland type III or flexion-type SCHFs between January 2020 and March 2024 at two tertiary care centers. Demographic variables, clinical parameters, and radiographic characteristics were analyzed. For the Gartland type 3 fractures, gentle traction was performed while elbow is in 200 of flexion to achieve soft tissue realignment. Reduction was done in the coronal plane, and alignment was checked manually, and the elbow was flexed with forearm supination or pronation, depending on the direction of displacement. For the flexion type injuries, the reduction was achieved by applying gentle longitudinal traction with the elbow gradually extended, while posteriorly directed pressure was applied on the olecranon to restore the anterior cortical alignment. Intergroup comparisons between successful closed reductions and cases failed closed reduction were performed using independent-samples t-tests or chi-square tests, as appropriate. Variables with p < 0.10 in bivariate analyses were entered into a multivariable binary logistic regression model to identify independent predictors of failed closed reduction. Two hundred seventy-seven pediatric patients (mean age 6.3 ± 2.2 years; 65.0% male) were evaluated, with 28 (10.1%) requiring open reduction. Older age (OR = 1.40; 95% CI: 1.08–1.82; p = 0.01), male gender (OR = 3.556; 95% CI: 1.019–12.340; p = 0.047), low fracture height (OR = 2.88, 95% CI, 1.20–6.90, P = 0.018), flexion-type fracture configuration (OR = 2.644; 95% CI: 1.085–6.440; p = 0.032), and absence of a preliminary reduction attempt (OR = 57.37; 95% CI: 13.13–250.26; p < 0.001) were found as an independent predictors for failed closed reduction. Preliminary reduction attempts in the emergency setting significantly reduced the rate of failed closed reduction in Gartland type 3 and flexion type pediatric SCHFs. Older age, male gender, low fracture height, and flexion-type fractures were identified as additional risk factors for failed closed reduction. Implementing preliminary reduction protocols could enhance closed reduction and reduce the rates of failed closed reduction.