Treatment of supracondylar fractures of the humerus in children through an anterior approach is a safe and effective method

In this prospective case series we evaluated the effectiveness and safety of using an anterior approach to paediatric supracondylar humerus fractures. We gathered data on 46 children that had a displaced supracondylar fracture of the humerus. All the patients had sustained a Gartland type III extension fracture that could not be reduced by closed means. Open reduction through an anterior approach was performed and two Kirschner wires were used to fix the fracture to the medial and lateral sides. Patients were recalled for follow-up and were evaluated using Flynn’s radiological and clinical criteria. Loss of extension and flexion was noted by clinical assessment and carrying angle measured on radiograms. A follow-up examination performed in the 24th postoperative week showed that all fractures had healed; the patients’ outcomes were rated as excellent or good according to Flynn’s criteria. As a result the anterior approach for open reduction of paediatric supracondylar humeral fractures is a safe and reliable method with very good results.     

Functional outcome of supracondylar humerus fracture in children with the use of pin configuration as per Bahk classification

IntroductionA variety of fracture patterns are seen in supracondylar humerus fractures in children and these are well described by Bahk et al. Currently followed treatment protocol doesn’t recognize these common fracture patterns and pin placement is done at the discretion of the treating surgeon. The aim of the study is to evaluate the usefulness of Bahk classification system in deciding the pin configuration for the specific fracture patterns and thereby assess the functional outcome in the management of supracondylar fractures in children.MethodThe study was done on 100 children of 2–12 years of age from February 2019 to January 2020. After closed reduction under general anesthesia, fractures were classified and pin configuration was decided according to Bahk classification. In the follow-up, patients were assessed for clinicoradiological outcomes based on Modified Flynn’s criteria, Baumann angle, and anterior humeral line.ResultsIn our study Typical transverse and low sagittal fracture were the most common fracture patterns. In the final follow up as per Flynn’s criteria, 93% of the patients showed excellent results. Mean Baumann’s angle was not significantly different from the uninjured side and anterior humeral line passed through anterior or middle third of the capitulum in 95% patients.ConclusionUsing pin configuration suitable to fracture pattern as per Bahk classification improves functional outcome in supracondylar humerus fractures in children and minimizes complications.     

Surgical management for late presentation of supracondylar humeral fracture in children

PURPOSE: To report the results of surgical management for late-presenting displaced supracondylar fractures of the humerus in children. METHODS: Between February 2002 and June 2003, 40 children (mean age, 7 years) with late presentation (range, 2-12 days) of displaced supracondylar humeral fractures were prospectively recruited. Gentle closed manipulation under image intensification was attempted in all patients, except one with a compound open fracture. Manipulation was successful in 25 patients and percutaneous skeletal stabilisation with Kirschner wires was performed. The remaining 15 patients were treated with open reduction and Kirschner wire fixation, using a mediolateral approach. RESULTS: The mean delay in presentation was approximately 4 days. No patients presenting more than 7 days after injury had the fracture reduced by closed manipulation. The mean hospital stay was 41 hours. At the final follow-up (mean, 18 months), 88% of the patients had a satisfactory result, according to Flynn's criteria. CONCLUSION: Operative treatment for late presentation of supracondylar humeral fractures in children is effective. It minimises the risk of complications and the need for continuous traction or corrective osteotomy.     

Completely displaced supracondylar humerus fractures in children: results of open reduction versus closed reduction

 This retrospective study was performed to understand the clinical results after closed reduction and open reduction in 35 children (mean age 6.4 years) with completely displaced supracondylar fractures of the distal humerus between 1996 and 2000. Closed reduction (21 cases) was attempted, with open reduction (14 cases) indicated in irreducible cases with or without severe swelling. After an average follow-up of 22 months, according to Flynn's criteria, the results were excellent in 18, good in 12, fair in 2, and poor in 3. The satisfactory results rates were similar for closed and open reduction. The unsatisfactory results were related to the poor initial reduction and redisplacement after operation. The mean Baumann's angle was 8.7° in the closed reduction group and 6.6° in the open reduction group. None of the patients showed restricted elbow motion of more than 10°, even in two cases of hypertrophic scar in the open reduction group. Selective open reduction for displaced supracondylar fractures of the distal humerus produced as good results as closed reduction. Received: January 7, 2002 / Accepted: November 20, 2002 Offprint requests to: C-W. Oh     

Complications and timing of follow-up after closed reduction and percutaneous pinning of supracondylar humerus fractures: follow-up after percutaneous pinning of supracondylar humerus fractures

The purpose of this study was to evaluate the need for clinical evaluation with radiographs within 10 days of closed reduction and percutaneous pinning for the treatment of displaced supracondylar humerus fractures. Between May 1 and December 31, 2001, the authors evaluated the complications with closed reduction and percutaneous pinning of 104 displaced supracondylar humerus fractures. Fifty-two of the patients had the initial follow-up examination with radiographs 10 days or less after pinning; the other 52 patients had the initial follow-up examination with radiographs either after 10 days or on the day of pin removal. The overall complication rate for the series was 7.7% (8/104). All eight complications were in type III fractures. The early follow-up group had six complications; the late follow-up group had two complications. Baumann's angle, lateral humerocapitellar angle, and lateral rotational percentage were not significantly different between the two groups. The only variable tested that was associated with a complication was pin configuration. No association between late follow-up and complications was identified. The authors conclude that clinical and radiographic evaluation of routine displaced supracondylar humerus fractures requiring closed reduction and percutaneous pinning may be safely delayed until pin removal.     

Supracondylar fractures of the humerus in childhood: range of movement following the posterior approach to open reduction

The posterior approach for open reduction of supracondylar fractures of the humerus has been condemned for causing decreased elbow movement. This study investigates this by comparing the range of movement in children treated by posterior open reduction and Kirschner wiring with those treated by closed reduction and immobilization. A total of 65 children with severely displaced supracondylar humeral fractures have been reviewed.

There was some loss of movement in 66 per cent of the open reduction group and 42 per cent of the closed reduction group. The proportion losing more than 10 ° of movement was the same in both groups. The difference between the two groups was due to the increased numbers in the open reduction group who lost less than 10 ° of motion. Posterior open reduction of childhood supracondylar fractures is not associated with an important loss of elbow movement and need not be avoided on this account.     

Comparison of closed reduction and percutaneous pinning versus open reduction and percutaneous pinning in displaced supracondylar fractures of the humerus in children.

A retrospective review of 29 children with displaced supracondylar humerus fractures was performed. Fifteen patients treated with closed reduction and percutaneous pinning and 14 patients treated with open reduction and percutaneous pinning were evaluated at a minimum of 18 months (range 18-80 months). Results were graded according to the criteria of Flynn et al. (Flynn JC, Matthews JG, Benoit RL: Blind pinning of displaced supracondylar fractures of the humerus in children. J Bone Joint Surg [Am] 56:263-272, 1974) using both cosmetic and functional evaluations. Excellent or good results were obtained in 14 of the 15 fractures treated with closed reduction and percutaneous pinning and in 12 of the 14 fractures treated with open reduction and percutaneous pinning. The three fair cosmetic results were associated with inadequate reduction and residual medial angulation. Ten to 15 degrees of motion loss occurred in three older patients. One patient in each group had a minor pintract infection. There were no cases of iatrogenic nerve injury or myositis ossificans. The treatment goal in displaced supracondylar humerus fractures in children is anatomic reduction. If an anatomic reduction cannot be achieved with closed reduction, open reduction is indicated. This can be done without an increased risk of complications.     

Open reduction via posterior triceps sparing approach in comparison with closed treatment of posteromedial displaced Gartland type III supracondylar humerus fractures

The results of closed and open reduction via posterior approach with percutaneous pinning of posteromedial displaced supracondylar humerus fractures in children were evaluated. Fifty-five consecutive patients with Gartland type III fractures were reviewed. The mean follow-up period was 22 months (12-48 months). The closed reduction group consisted of 32 patients and the open reduction group with the posterior approach using the triceps-sparing method consisted of 23 patients. Both groups were stabilized with cross Kirschner wire fixation and followed the same protocol. In comparison with closed reduction, despite the fact that better bone alignment was obtained with open reduction, longer union time (7 vs. 5.8 weeks), significantly reduced range of motion of the elbow (12.3 degrees vs. 3.8 degrees), poorer functional outcomes and bad cosmetics because of hypertrophic scar tissue of the skin were found. The patients were analyzed according to their Bauman angle and Flynn criteria: good or excellent functional and cosmetic results were 91% in the closed reduction group but 52% in the open reduction group. On the basis of results of this study, closed reduction and percutaneous fixation of the posteromedial totally displaced fractures are preferable to open reduction with posterior approach.     

多方向不稳定的儿童肱骨髁上骨折的治疗

目的探讨急诊手术内固定治疗多方向不稳定的儿童肱骨髁上骨折的疗效。方法对26例多方向不稳定肱骨髁上骨折患儿采用闭合或切开复位克氏针内固定,术后肘关节屈曲20°～40°位石膏托固定3周后逐步进行功能锻炼。结果26例均得到随访,时间12～50个月,26例均临床愈合,骨折愈合时间4～6周。肘关节功能评价：优23例,良2例,可1例。无畸形愈合、感染、活动受限等并发症发生。结论闭合复位克氏针内固定是治疗多方向不稳定的儿童肱骨髁上骨折的有效方法,尽早复位及稳定固定骨折端,可有效减少或避免并发症的发生,利于肢体功能的恢复。     

A systematic review of early versus delayed treatment for type III supracondylar humeral fractures in children

We performed a systematic review of early versus delayed treatment for type III Gartland supracondylar humeral fractures in children. We identified five non-randomised retrospective studies that fulfilled our criteria. We performed the analysis on 396 patients who sustained a type III supracondylar humeral fracture of which 243 (61.4%) belonged to the early treatment group and 153 (38.6%) belonged to the delayed treatment group. The planned treatment was closed reduction and percutaneous pin fixation. We found that failure of closed reduction and conversion to open reduction was significantly higher in the delayed treatment group (22.9%) as compared with the early treatment group (11.1%). Our study provides evidence that type III supracondylar humeral fractures in children should be treated early within 12 h of injury.     

Treatment of ipsilateral supracondylar and forearm fractures in children.

The treatment of ipsilateral supracondylar fractures of the humerus and fractures of the forearm bones was evaluated in 11 children. After an average of 6 years, 10 children had excellent or good results and one had a poor result from Volkmann's ischaemic contracture. Displaced supracondylar fractures of the humerus associated with distal fractures of the forearm bones are best treated by closed reduction and percutaneous pin fixation of the humeral fracture and a below-elbow plaster backslab.     

Deformity and function in supracondylar fractures of the humerus in children variously treated by closed reduction and splinting, traction, and percutaneous pinning.

The radiographs of 137 patients with supracondylar fractures of the humerus treated by closed reduction and splinting, traction, and closed reduction and percutaneous pinning (CRPP) were reviewed to determine the adequacy of the initial reduction and the maintenance of the reduction. Eighty-four patients were examined for function and deformity. Initially, Baumann's angle was adequate and similar in all patients, but the humerocapitellar angle was better with CRPP. Maintenance of reduction in both planes was superior with CRPP, and significantly better clinical results were achieved by CRPP. Nevertheless, there was no functional loss in any patient, and no parent wanted correction of deformity.     

不同类型儿童肱骨髁上骨折的治疗探讨

目的探讨不同类型儿童肱骨髁上骨折的治疗方法。方法对GartlandⅠ型骨折,单纯应用石膏外固定;GartlandⅡ型和Ⅲ型骨折,选择闭合复位、经皮穿针内固定;对于闭合复位、经皮穿针失败或伴有明显血管、神经损伤症状以及患肢肿胀特别严重的病例,采用切开复位克氏针内固定。结果未出现骨筋膜室综合征、血管或神经受损等并发症。术前合并神经损伤的病例,其神经功能得以完全恢复。56例随访16~28个月,平均20.6月,按F lynn功能评价标准,优38例,良16例,可1例,差1例。结论针对不同类型儿童肱骨髁上骨折采取相应的治疗方法,疗效满意。     

Metaphyseo-diaphyseal junction fracture of distal humerus in children

Six metaphyseo-diaphyseal junction fractures of distal humerus and 182 supracondylar fractures of humerus treated in our institute over a period of 5 years were retrospectively analyzed. Clinical data regarding child's age, neurovascular status, mechanism of injury, mode of treatment, and ultimate clinical outcome were collected for both these fractures and a comparison was made. Oblique (n=2), comminuted (n=3), and transverse types (n=1) of fracture patterns were identified at distal humeral metaphyseo-diaphyseal junction. The oblique and comminuted fractures were managed by closed reduction and plaster of Paris cast, whereas the only transverse fracture was treated by closed reduction and Kirschner wire fixation. In contrast, 125 patients of supracondylar fractures were treated by closed reduction and plaster of Paris cast and the remaining 57 fractures needed Kirschner wire fixation after closed reduction. Assessment by Flynn criteria after 1 year after of injury revealed better functional outcome in metaphyseo-diaphyseal junction fractures. Although transverse fractures are unstable and may require surgical fixation; oblique and comminuted fractures at the metaphyseo-diaphyseal junction of distal humerus can be managed conservatively.     

Treatment of flexion-type supracondylar humeral fracture in children

PURPOSE: To assess the results of treatment for flexion-type supracondylar humeral fracture in children. METHODS: The treatment of 14 children with flexion-type supracondylar humeral fracture was reviewed. Severity was classified according to the Gartland system for extension-type fractures. Type-I fractures were treated with immobilisation in an extension cast. For type-II and -III fractures, closed reduction was first attempted followed by percutaneous pinning. If closed reduction failed, open reduction and internal fixation was performed. RESULTS: Patients were followed up for at least one year (range, 14-36 months). Treatment results were excellent in 7 patients, good in 4, fair in 3, and poor in none. Patients were pain-free and satisfied and none suffered any activity restriction. CONCLUSION: Closed reduction and percutaneous pinning is a good treatment option for type-II and -III flexion-type supracondylar humeral fractures.     

Open medial placement of Kirschner wires for supracondylar humeral fractures in children

PURPOSE: To assess the efficacy of our protocol for treatment of displaced Gartland type-3 supracondylar fractures of the humerus in children. METHODS: Records of 43 children with displaced Gartland type-3 supracondylar fractures of the humerus admitted from October 1997 to October 2003 were reviewed. Patients were treated within 12 hours of admission by closed reduction (n=33) or open reduction (n=10). Crossed medial and lateral Kirschner wires through a medial approach were used in all patients. A 3-cm incision was made medially to identify the correct entry point of the medial wire, and thus prevent ulnar nerve injury. The incision was extendable for open reduction if closed reduction was unsuccessful. RESULTS: The mean age of the 43 patients was 7.2 years (range, 2-14 years). The mean follow-up period was 48 months (range, 12-84 months). 83% of the fractures occurred in boys. All fractures were closed, extension type, with 28 (65.1%) involved the right elbow. No patient had iatrogenic ulnar nerve injury. All patients showed satisfactory results according to Flynn criteria. CONCLUSION: If closed reduction is unsuccessful, open reduction and open medial placement of crossed Kirschner wires can provide reliable results. The small medial incision provides a viewing point for entry of the wire and prevents iatrogenic injury of the ulnar nerve. It is cosmetically more acceptable and can be extended to facilitate open reduction.     

Closed reduction and percutaneous pinning of displaced supracondylar fractures of humerus in children with delayed presentation

Objective: Supracondylar fractures of the humerus account for 60% of all the fractures around the pediatric elbow and even in developed countries 18% of patients undergo surgery 48 hours or longer following presentation in the hospital. Management guidelines are not clear yet for these patients who present late. The aim of this prospective study was to evaluate the clinical, radiological and functional outcome following closed reduction and percutaneous pinning of widely displaced supracondylar fractures of the humerus presenting 12 hours or more after injury.Methods: We reviewed the functional and radiological results of closed reduction and percutaneous pinning using crossed K-wires in 40 patients with displaced extension type supracondylar fracture of the humerus (Gartland type Ⅲ) with a delay of more than 12 hours in presentation. The average age of patients was 4.5 years and the mean delay in presentation was 17.55 hours.Results: Closed reduction and percutaneous pinning was successful in 90% of patients. The mean follow up period was 15 months. The Baumann's angle was restored within 4 degrees of the unaffected side in all patients. Use of a small medial incision in patients with severe swelling helped us avoid ulnar nerve injury. Using Flynn's criteria,38 patients (95%) had an excellent result. Two patients had mild myositis and both had a poor result. None of the patients developed cubitus varus.Conclusion: Closed reduction and crossed pinning of displaced supracondylar fractures of humerus in children is a safe and effective method even with delayed presentation.     

Displaced supracondylar humeral fractures in children: open reduction vs. closed reduction and pinning

Introduction In the literature the best results for pediatric supracondylar humerus fractures have been achieved by closed reduction and wire fixation. However, in these reports the patient group of open reduction and pinning contained the patients who had had previous ineffective closed reduction trials. This retrospective study compared open and closed reduction with pinning, in which the first group of patients was all consecutively treated with open reduction.Materials and methods The study included 99 children with displaced extension-type supracondylar fractures of humerus who had complete follow-up. Open reduction patients had not had a previous attempted closed reduction. Open reduction and pinning were performed through a posteromedial incision in the first 44 patients and closed reduction and pinning in the subsequent 55 patients. Mean duration surgery was 15 h with open reduction and 17 h with closed reduction. Mean follow up was 35 months with the open reduction and 21 months with closed reduction. Humeral-ulnar angle was compared to the contralateral elbow, clinical flexion deficiency and extension lag, and complications were evaluated.Results At the latest follow-up the open group had an average of 5.1° valgus change and the closed group 3.6° valgus change in humeral-ulnar angle compared to their uninvolved elbow. Average flexion deficiency was 8.61° in the open and 5.25° in the closed group. Average extension lag was 6.23° in the open and 0.6° in the closed group. Functional results were satisfactory in 71% of patients in the open and 93% of those in the closed reduction group. Cosmetic results were satisfactory in 95% of both groups.Conclusions Closed reduction and pinning is superior to open reduction and pinning for the treatment of pediatric supracondylar humerus fractures. In the case of technical insufficiencies open reduction and pinning through a posteromedial incision is an alternative treatment for decreasing the surgical time and complications. Complications was not caused in either group by the delayed surgical timing compared to reports in the literature.     

An analysis of open reduction of irreducible supracondylar fractures of the humerus in children

Objectives

To review experience with irreducible supracondylar fractures requiring open reduction in children, and to propose guidelines for an open approach to supracondylar fractures.

Design

A chart review.

Setting

The Children’s Hospital of Eastern Ontario (CHEO), a pediatric centre with a large referral base.

Patients

Forty-one children (18 boys 23 girls, average age 7 years), who had open reduction of irreducible supracondylar fractures at the CHEO over a 10-year period (1985 to 1995). Of these 41 children, 7 were lost to direct follow-up.

Interventions

After closed reduction of displaced supracondylar fractures of the humerus failed, all patients underwent open reduction and percutaneous fixation in the operating room. Before operation, 6 had no radial pulse, 5 lost their pulse with flexion after reduction and 4 had unstable fracture patterns.

Main outcome measures

Assessment of elbow range of motion and carrying angle, distal neurovascular status and radiographic measurement of the Baumann angle and the humerocapitellar angle.

Results

In 25 children, the humerus was found to have “buttonholed” through the brachialis muscle; 1 had entrapment of the common flexor muscle at its origin and 1 had entrapment of the triceps. In 15 children there was entrapment or tethering of the median nerve and radial nerve or brachial artery, or both, but this was not predictive of preoperative neurovascular deficit, which was recorded in 21 patients (fully recovered). At follow-up, the Baumann angle and the humerocapitellar angle differed by an average of 2° and 5.3° respectively compared with the unaffected arm. Range of motion was satisfactory in 94% of patients, and there was no significant cubitus varus.

Conclusion

Open reduction of supracondylar fractures is a safe and effective procedure, for which orthopedists should should lower their threshold, given certain appropriate indicators.     

Does the technique of lateral cross-wiring (Dorgan’s technique) reduce iatrogenic ulnar nerve injury?

In this study we compared the results of patients with displaced supracondylar humeral fractures who had been treated with all lateral cross-wire and medio-lateral cross-wire fixation techniques. Only the 139 patients who were able to attend the final examination were included in the assessment. The patients were allocated retrospectively into two groups according to the pin configuration used. Group 1 comprised 75 patients, 60 male and 15 female, with a mean age of 7.5 years (range, 1.5–14 years). After closed reduction, fixation was achieved with crossed K-wires placed from the lateral condyle and lateral humerus towards the medial epicondyle. Care was taken so that the end of the K-wire passing from the lateral humerus did not protrude excessively at the level of the medial epicondyle. Group 2 comprised 64 patients, 54 males and ten females, with a mean age of 7.8 years (range, 2–13 years). After closed reduction, two cross-wires passed—one from medial and one from lateral. In group 1 there was no postoperative iatrogenic nerve damage whereas in group 2 iatrogenic ulnar nerve damage developed in six (9%) patients. On statistical evaluation, a significant difference was seen between the two groups. According to Flynn’s criteria, there was no statistically significant difference between the two groups. In conclusion, the lateral cross-wire fixation technique may be a good choice in the treatment of paediatric supracondylar humerus fractures as it reduces the possibility of ulnar nerve damage and achieves the same level of stabilisation as medio-lateral fixation.