Supracondylar humerus fractures in children treated with closed reduction and percutaneous pinning

Supracondylar fractures of the humerus in children are important for frequency and type of associated serious complications. The management of this kind of fractures is still controversial (Skaggs et al. in J Bone Joint Surg Am 86:702–707, 2004; Kalllio et al. in J Pediatr Orthop 12:11–15, 1992). We are going to present our experience in the treatment of supracondylar humeral fracture in children. In the Orthopedic Department of Pisa, we treated 150 cases from 1989 to 2006. We are used to perform, emergency or within 12 h, reduction and two lateral-entry percutaneous pins fixation. The mean age was 7.5 years. We checked 125 cases, because we excluded all the cases with follow up less then 5 years. The mean follow up was 8.2 years. We used Gartland classification modified by Wilkins. We evaluated 125 cases by using the Flynn classification: 100 % of patients did not have impairment of the elbow joint mobility. We had seven valgus deviation, one of which was more then 10°. We also had 17 varus deviations, 11 of which were not over 8° and only 2 of them were 15°. The average value of the joint Baumann angle was calculated as great as 16°. The obtained results were classified as very good 80 %, good 11 %, sufficiently good 6 %, and bad 3 %. In our experience, all the fractures type II and III by Gartland have to be treated within 12 h, with closed reduction and stabilization with lateral-entry K-wire technique. The conservative treatment by cast is indicated only in type I fracture. The trans olecranic treatment is not realizable, for the stiffness which can occur, for the risk of iatrogenic ulnar nerve lesion, and for long-time hospitalization. The open reduction remains the first choice treatment for exposed or nonreducible fractures, and in cases of vascular injury.     

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.     

Comparison between closed reduction with percutaneous pinning and open reduction with pinning in children with closed totally displaced supracondylar humeral fractures: a randomized controlled trial

This was a randomized controlled trial of 28 children 1 year to 12 years of age with closed totally displaced supracondylar humeral fracture. The purpose of the study was to compare closed reduction and pinning (group A) and open reduction and pinning (group B). Each group consisted of 14 children. The general characteristics of both groups (age, sex side, displacement, nerve injury preoperatively) were statistically the same (P > 0.05). All cases healed with good alignment without cubitus varus, without infection and with a good range of motion except for one. The mean +/- standard deviation of the Baumann's angle difference between the injured and uninjured side were 2.32 +/- 1.6 degrees in group A (range, 0-6.5 degrees) and 2.45 +/- 1.8 degrees in group B (range, 0-6.5 degrees). This difference was statistically not significant (P = 0.8). By Flynn criteria, group A had good to excellent results in 100%, and group B had good to excellent results in 93% and fair in 7%. This difference was not statistically significant (P = 1). The satisfaction score (0-10) was significantly higher in group A for both parents' and evaluator's (blinded to treatment) perspective (P = 0.017 and 0.019, respectively). The author concludes that both treatments gave good results. Closed reduction should be performed first and, if it fails, then open reduction can be performed. This will produce good results in the hands of an experienced surgeon.     

Early results of displaced supracondylar fractures of humerus in children treated by closed reduction and percutaneous pinning

Background:

Displaced supracondylar fractures are notorious for difficulty in reduction, maintenance of reduction and frequent involvement of neurovascular structures. No general agreement on the treatment is evident with controversy prevailing regarding the ideal timing of surgery, method of maintenance of reduction and configuration of the pin fixation. A crossed pin configuration, though believed by some to be mechanically more stable than the lateral pins alone, has the risk of ulnar nerve injury due to the medial pin. Lateral pins alone impart less rotational stability to the fracture although it has been attributed mainly to technical errors of pin placement. The aim of this study was to assess the efficacy of treatment of this fracture using one lateral and one trans-olecranon K-wires or lateral entry K-wires alone.

Materials and Methods:

Ninety cases of displaced supracondylar humerus fractures were included in the study. The mean age of the patients was 6.7 years (range 3–12 years). The male/female ratio was 5:1 and left side was involved in 70% whereas 30% had right sided injuries. The most common mode of trauma was fall from height with elbow in extension. All the 90 consecutively admitted patients had extension type injury with 73.3% fractures being Gartland type III and 26.7% were type II. Posteromedial displacement was noted in 70% whereas 30% fractures were posterolaterally displaced. In 60 cases, lateral entry wires alone were used whereas, in 30 cases, one lateral and another transolecranon transarticular K-wire was used. K-wires were removed at 3 weeks postoperatively and followup was done at 6 weeks and 12 weeks when they were evaluated according to the criteria described by Flynn. Chi-square test was used as a statistical test of significance to compare results among different variables.

Results:

Results were graded according to Flynn''s criteria. Excellent results were achieved in 12 (13.3%), good in 54 (60%), fair in 15 (16.7%) while in nine patients (10%) poor results were obtained.

Conclusions:

Both lateral entry K-wires and lateral-trans-olecranon wire techniques provide stable fixation when observing the guidelines for wire placement and consistently satisfactory results can be obtained, both cosmetically and functionally with both the techniques.     

Close reduction and percutaneous pinning in displaced supracondylar humerus fractures in children

BackgroundDisplaced supracondylar fractures of the humerus in children are common pediatric injuries treated by orthopedic surgeons. They also have a high rate of complications if not reduced and stabilized in optimal position which may lead to serious neurovascular injuries and residual deformity. Amongst the various methods used for treating these fractures, closed reduction and percutaneous pinning has shown improved results.MethodBetween March 2005 and April 2010, 277 cases of supracondylar humeral fractures (Gartland grade II and III) with less then 1 week old were included in this study. They were treated with closed reduction and percutaneous pinning with crossed Kirschner wires under image intensifier control. Clinical outcome were assessed according to Flynn's criteria.ResultsThe mean age at the time of operation was 6 years (range 2–10 years) and the average duration of follow-up was 4.6 years (range 2.1–7.2 years). The Flynn's criteria were excellent in 202, good in 68, fair in 5 and only 2 with poor results.ConclusionClosed reduction and percutaneous pinning is a sound and effective treatment for displaced supracondylar fractures.     

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.     

Supracondylar fractures of the humerus in children. A modified technique for closed pinning

Complications in the treatment of displaced supracondylar fractures of the humerus (DSFH), particularly cubitus varus, are a persistent problem. A prospective study was conducted on 20 children with DSFH, using a modified technique to reduce and pin the fracture. All fractures were treated with closed reduction and percutaneous pinning. After the fracture was internally fixed, intraoperative anteroposterior roentgenograms of each distal humerus were compared, using Baumann's angle. The reduction was accepted if Baumann's angle on the fractured extremity was within 4 degrees of that on the normal side. If the angles were not within 4 degrees, the closed reduction and percutaneous pinning was repeated. In this prospective series, all patients had a reduction to within 4 degrees of the normal side before they left the operating room. Three weeks after percutaneous pinning, the pins were removed and range of motion was begun. All patients returned for clinical and roentgenographic examination. With an average follow-up period of 17.2 months, all patients had excellent or good results. No patient developed cubitus varus deformity. Strict adherence to the guidelines of the protocol prevented cubitus varus deformity in this series of children with DSFH.     

Supracondylar fractures of the femur in children

Nonphyseal supracondylar fractures of the femur are considered to be uncommon in children and have received little attention in the literature. A retrospective review of femoral fractures in children at the authors' institution was undertaken to ascertain the incidence of supracondylar femoral fractures, the influence of associated musculoskeletal conditions, and pitfalls of management. In this study of 102 femoral fractures, there was an incidence of 12% of supracondylar fractures. Four of 12 patients had a significant predisposing musculoskeletal condition contributing to the genesis of the fracture. Five fractures were undisplaced and easily managed. Seven displaced fractures required intervention to achieve an adequate reduction. The literature is reviewed and a classification system for these fractures is presented. Treatment options are discussed and recommendations made based on this experience.     

Two-part and three-part fractures: open reduction and internal fixation versus closed reduction and percutaneous pinning

Surgical management of two-part and three-part proximal humerus fractures is difficult and requires familiarity with more than one method of fixation. Poor bone quality, comminution, and the deforming forces of the rotator cuff on the tuberosities influence the choice of operative approach and fixation techniques. Closed reductions and percutaneous pinning offer the potential advantage of minimal soft-tissue dissection; however, good bone quality and minimal comminution are prerequisites. Selected two-part surgical neck fractures and valgus-impacted fractures lend themselves well to this technique. Open reduction and internal fixation is indicated in two-part surgical neck fractures with poor bone quality or extensive comminution, two-part greater tuberosity or lesser tuberosity fractures, and most three-part fractures. The choice of surgical approach is dictated by the fracture pattern and includes an extended deltopectoral approach and a superior deltoid-splitting approach. Fixation techniques are myriad and are dependent on the fracture pattern. Potential fixation methods include intramedullary rods, interfragmentary sutures or wires, and extramedullary plates and screws or blade plates. Successful results are predicated on obtaining adequate enough fixation to allow early passive motion. Results also are influenced by the quality of the reduction and patient compliance.     

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.     

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.     

闭合复位经皮因定治疗肱骨髁上骨折的进展

肱骨髁上骨折是儿童肘部最常见的骨折,随着微创技术的进展,为了减少并发症和手术创伤,近年来闭合复位经皮克氏针内固定术在临床中得到了广泛的应用.本文查阅了儿童肱骨髁上骨折的相关文献,对肱骨髁上骨折的分类标准、闭合复位方法与参考标准、各种经皮克氏针内固定的进针技术及其疗效,以及闭合复位经皮内固定治疗的并发症与防治措施等研究进展做一综述.     

Supracondylar fractures of the humerus: a prospective study of percutaneous pinning.

In 1981, we designed a protocol to treat displaced supracondylar fractures using a modified technique of closed reduction and percutaneous pinning. After the fracture was internally fixed, intraoperative anteroposterior (AP) radiographs of each distal humerus were compared. The reduction and pinning was accepted only if the radiographs demonstrated that Baumann's angle was < or = 4 degrees of that on the normal side. Seventy-one patients had clinical and radiographic evaluations at an average of 2 years 6 months after the operation. According to Flynn's criteria, the results were satisfactory in 70 patients and unsatisfactory in one. No patient had a cubitus varus deformity at follow-up evaluation.     

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