Outcomes of nonoperatively treated pediatric supracondylar humeral fractures at the Nkhotakota District Hospital, Malawi

Background: Displaced supracondylar humeral fractures (SCHFs) benefit from closed reduction and percutaneous pinning. In Malawi, many SCHFs are treated nonoperatively because of limited surgical capacity. We sought to assess clinical and functional outcomes of nonoperatively treated SCHFs in a resource-limited setting. Methods: We retrospectively reviewed all patients with SCHFs treated at Nkhotakota District Hospital (NKKDH) in Malawi between January 2014 and December 2016. Patients subsequently underwent clinical and functional follow-up assessment. Results: We identified 182 children (54% male, mean age 7 yr) with an SCHF; 151 (83%) of the fractures were due to a fall, and 178 (98%) were extension-type (Gartland class distribution: 63 [35%] type I, 52 [29%] type II, and 63 [35%] type III). Four patients with type I fractures were treated with an arm sling alone, and 59 were treated with straight-arm traction to reduce swelling and then splint immobilization until union. All 119 of the patients with Gartland type II and III or flexion-type injuries were treated with straight-arm traction, manipulation under anesthesia without fluoroscopy and then splint immobilization until union. A total of 137 (75%) of the patients were available for follow-up, at a mean of 3.9 years after injury. Controlling for sex, delayed presentation, medical comorbidities, injury mechanism and skin blistering/ superinfection during traction, patients with type II fractures were 5.82 times more likely (95% confidence interval [CI] 1.71-19.85) and those with type III fractures were 9.81 times more likely (95% CI 3.00-32.04) to have a clinical complication or functional limitation than patients with type I fractures. Conclusion: Nonoperative treatment of type III SCHFs resulted in a high risk of clinical complications or functional impairment. These results illustrate the urgent need to increase surgical capacity in low-income countries like Malawi to improve pediatric fractures.