Every year, over 2,500 children in the UK undergo surgery for a broken elbow—a supracondylar fracture—yet surgeons disagree on the best way to treat them. This matters because current practice varies widely and is not backed by solid evidence. For minor fractures, doctors argue over whether to immobilise the arm or let it move early. For intermediate fractures, 79% of UK children receive surgery, even though non-operative care may work just as well. For severe fractures, surgeons debate whether to use crossed wires or lateral-only wires to fix the bone. A 2022 Cochrane review identified these exact questions as critical evidence gaps. If this research succeeds, it will directly change how the NHS treats these injuries. The study runs three parallel trials within one umbrella study, testing each severity separately. For minor fractures, it compares pain at three days. For intermediate and severe fractures, it compares arm function at three months. Results could reduce unnecessary surgeries, cut hospital stays, and get children back to school faster—without compromising recovery. The findings will feed straight into clinical guidelines, ending decades of guesswork in paediatric fracture care.
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Research Question: What is the most clinical and cost-effective treatments for children presenting with supracondylar elbow fractures? Background: Supracondylar fractures are the most common elbow injury requiring surgery in children, with over 2,500 operations performed annually in the UK. These fractures are classified by severity: Minor (Gartland I, 30%), Intermediate (Gartland IIA, 20%), and Severe (Gartland IIB/III, 50%). Current treatment varies substantially, with key uncertainties for each severity highlighted in a 2022 Cochrane review and recent international research prioritisation exercises. For minor fractures, there is debate between traditional immobilisation versus early mobilisation. For intermediate fractures, whilst operative treatment is standard in the UK (79% of cases), emerging evidence suggests non-operative care may be equally effective. For severe fractures, there are competing surgical techniques (crossed versus lateral-only wire configurations) with unclear relative benefits of one approach over the other. Aims and Objectives: This study aims to determine the most clinical and cost-effective treatments for children with supracondylar elbow fractures through three parallel randomised controlled trials in one overarching umbrella study: 1. Minor fracture trial: Compare pain at 3 days between rigid immobilisation versus early mobilisation. 2. Intermediate fracture trial: Compare function at 3 months between surgical correction versus outpatient realignment. 3. Severe fracture trial: Compare function at 3 months between the surgical technique of crossed-wire fixation versus lateral-only wire fixation. Methods: This is a multi-centre study comprising three pragmatic, parallel-group, randomised controlled superiority trials. We will recruit from approximately 40 UK hospitals over 12-18 months. Primary outcomes are pain; the Wong-Baker FACES Pain Scale (minor fracture trial) and function & PROMIS Upper Extremity Score for children (intermediate and severe fracture trials). Secondary outcomes include quality of life (CHU-9D), school absence, complications, and resource use. The study includes internal pilots to assess feasibility and recruitment. Sample sizes (90% power, 5% significance) are: minor fracture trial n=210 (to detect 1-point difference in pain); intermediate and severe fracture trials n=314 each (to detect 4-point difference in function). Patient and Public Involvement: Our PPI co-applicants bring lived experience of managing elbow fractures in children and have been instrumental in developing recruitment strategies and ensuring materials address real family concerns in emergency settings. Young people from the NIHR Generation R Advisory Group will guide development of age-appropriate trial materials and multimedia resources. Timelines: Total 60 months (starting January 2026); including 12 months setup, 6 months pilot, recruitment periods (12, 21 and 24 months) with follow-up to 12 months. Results will be reported March 2029 (minor), March 2030 (severe), and December 2030 (intermediate). Impact: This study will address critical evidence gaps in paediatric fracture care identified through Cochrane review and research prioritisation exercises. The results will directly inform clinical practice, potentially reducing unnecessary surgeries whilst ensuring optimal functional outcomes. The efficient umbrella design allows investigation of all fracture severities while minimising costs and administrative burden.
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