Neurological complications resulting from supracondylar fractures of the humerus in children

One hundred thirty-eight children with supracondylar fractures of the humerus were reviewed. Seventeen (12%) exhibited neurological deficits. Nine median, four ulnar, and four radial neuropathies were encountered. The neurological deficit was treated expectantly. The osseous injury was treated by a variety of methods. All patients except two recovered spontaneously in an average of 9 weeks. One patient was still improving at 9 months' follow-up. Another patient with radial neuropathy underwent exploration 6 months after injury and was found to have a transected radial nerve. This study demonstrates that neurological deficits from supracondylar humeral fractures remain common, involve all three major nerves of forearm, and, with rare exception, recover with conservative therapy.     

Concomitant vascular complications in supracondylar humerus fractures in children

From January 1st 1990 to December 31st 1997, 614 children were treated for supracondylar humerus fracture at the Department of Orthopedic Surgery in the Olga Hospital, Stuttgart. Ten of these children had concomitant vascular complications. The concept of treatment we had chosen was analysed retrospectively. The median patient age of the seven girls and three boys with vascular complications was six years. The vascular injuries were diagnosed after admission to the hospital by palpation of the wrist pulse, clinical appraisal of the vascularity and by registration of the Doppler signal via the arteries of the wrist. The emergency operations carried out initially comprised fragment reposition and fixation with crossed K wires via an access route on the extensor side in all ten children. The subsequent appraisal of the blood flow revealed a pulse restoration (transient vascular occlusion due to dislocation) in two out of the ten children. In eight out of the ten children, the pulse did not return, which is why the vessel had to be explored under emergency conditions. Intraoperatively, we saw a vascular spasm with functional vascular occlusion in one of these eight children. Mechanical vascular occlusion were diagnosed in five of these eight children. In adventitial strangulation (two of these five children), the pulse transmission to the hand occurred immediately after severance of the strangulation connective tissue. In intimal damage (three of these five children), the vascular segment concerned was resected and reconstructed, mostly in the form of an end-to-end-anastomosis with venous patch grafting. We observed a combined vascular occlusion (mechanical-functional occlusion) in two out of these eight children. In the follow-up investigation, the wrist pulses could be palpated in nine children. Nine children had a physiological signal in color duplex sonography, and one child had a pathological monophasic signal over the brachial artery, radial artery as well as the ulnar artery. Late ischemic damage (cold intolerance, claudicatio, Volkmann's contracture) were not detected in any of the children. Appraisal of elbow joint mobility revealed a median extension deficit of 0 degrees (range 0-10 degrees ), a median flexion deficit of 0 degrees (range 0-15 degrees ) and a normal pronation and supination equal on each side. The load-carrying joint axis was normal in a comparison of the sides in all children.     

Neurologic complications after K-wire fixation of supracondylar humerus fractures in children

A retrospective review of 143 supracondylar humerus fractures in children treated with K-wire fixation disclosed four neurologic complications after treatment. There were two late ulnar neuropraxias. One ulnar nerve injury and one radial nerve injury resulted from direct trauma during insertion of a K-wire. All patients regained full neurologic function.     

Displaced supracondylar fractures of the humerus in children

We performed an outcome study of completely displaced supracondylar fractures in children in order to assess the outcome of primary open reduction and internal fixation for these injuries. A total of 16 patients (mean age of 5.9 years) were included in the study. The mean follow-up was 2.6 years and patients were assessed after fracture healing using the criteria of Flynn et al. and Mark et al. Thirteen patients had an excellent result, two had good results with less than 10° loss of carrying angle and one had a fair result based on degree of loss of elbow flexion. Open reduction and internal fixation of these fractures is an effective and safe method of primary treatment and is associated with good outcomes. We recommend a low threshold of proceeding to open treatment in these serious injuries.

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Résumé  Nous avons conduit un suivi de fractures supracondyliennes du coude chez l"enfant afin d"évaluer les effets d"une réduction ouverte primaire et d"une fixation interne sur ces lésions. Seize patients sont inclus dans cette étude, avec un age moyen de 5.9 ans. La durée moyenne du suivi fut de 2.6 ans et les patients furent examinés après consolidation, utilisant les critères de Flynn et al. et Mark et al. Treize patients présentèrent un résultat excellent, deux eurent de bons résultats avec une perte d"angle de charge inférieure de 10°, et un obtenait un résultat moyen à cause d"une perte de flexion du coude. La réduction ouverte avec la fixation interne des fractures complètement déplacé est une méthode efficace qui donne de bons résultats. Nous recommandons un passage plus fréquent aux traitements ouverts dans ces cas de lésions graves.

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Accepted: 25 March 2000     

Displaced supracondylar fractures of the humerus in children

From 1972 to 1981, 60 children with severely displaced supracondylar fractures were treated with closed reduction and vertical osseous traction with a screw in the olecranon. None of the patients had complications (infection or neurovascular damage) due to the treatment, but eight patients had loss of reduction and required second reduction. The average hospitalization time was 2.6 weeks, and all fractures had united within four weeks. A follow-up study of 56 patients was performed an average of 78 months after the injury. All patients had an excellent (75%) or good (25%) end result. Vertical osseous traction is easy to apply and carries few risks of complications. The method is recommended, provided longer hospitalization time is acceptable or permissible.     

Neurovascular complications and functional outcome in displaced supracondylar fractures of the humerus in children

We retrospectively studied the complications associated with a displaced supracondylar fracture of the humerus in children and its treatment. Between 1978 and 1997, 200 displaced fractures were treated by operative means. In 190 cases closed reduction and percutaneous pinning was performed. In 10 cases vascular impairment or unsatisfactory reduction necessitated open exploration. Functional and cosmetic success was achieved in 90% of all operated children. In 33 (16.5%) of all cases we found neurological impairment. All recovered without sequelae, except for one case with persistent radial nerve palsy which recovered after a sural nerve interposition graft. Transient neurological problems are common in this fracture. A mini-open procedure is recommended for the ulnar Kirschner wire (K-wire) to prevent iatrogenic ulnar nerve injury.     

Neural injuries associated with supracondylar fractures of the humerus in children

A retrospective review of displaced extension-type supracondylar fractures of the humerus in 101 children who were seen consecutively revealed eighteen associated neural injuries in thirteen children. Nine of the neural injuries in eight patients spontaneously resolved at a mean of 2.5 months (range, 1.5 to five months) after injury. The remaining nine lesions in five patients were explored at a mean of 7.5 months (range, five to fourteen months) after injury, because clinical and electromyographic studies showed no return of function. Neurolysis was performed on eight of the nerves that were explored (in five patients), and the remaining radial nerve was found to be completely lacerated and needed nerve-grafting. The length of follow-up after neurolysis averaged twenty-five months (range, thirteen to forty-four months). All five patients had functional recovery, as documented by range-of-motion, grip-strength and lateral pinch-strength, and von Frey and two-point-discrimination sensory testing. The patient who had had nerve-grafting never recovered neural function, and tendon transfers were needed. We concluded that observation and supportive therapy is the preferred initial approach for children who have a neural injury associated with a closed, displaced supracondylar fracture of the humerus. However, if there is no clinical or electromyographic evidence of return of neural function at five months after injury, exploration and neurolysis should be performed. If the nerve is in continuity, the prognosis after neurolysis is excellent.     

Varus deformity in supracondylar fractures of the humerus in children

Eighty cases of supracondylar fracture of the humerus at the elbow in children have been analysed. The post-reduction radiograph of the fracture was classified depending on the residual deformity present and related to the loss of carrying angle and cubitus varus deformity at the time of follow-up. Fifty-four per cent of the displaced fractures showed a loss of carrying angle greater than 5 °, and of these, 23 per cent developed cubitus varus deformity. Eighty-five per cent of those cases with a loss of carrying angle greater than 10 ° showed either residual tilt or medial rotation on the post-reduction radiograph. All cases in which there was residual medial tilt after manipulation and 40 per cent of those with medial rotation on the post-reduction radiograph developed cubitus varus.

In our series, there was no evidence of epiphyseal injury causing the deformity and in none of the cases was the deformity progressive. It is suggested that, in order to reduce the incidence of varus deformity in supracondylar fractures, open reduction and internal fixation is indicated in those fractures in which tilt or medial rotation cannot be reduced by conservative means.     

Displaced supracondylar fractures of the humerus in children. Audit changes practice

We performed an audit of 71 children with consecutive displaced, extension-type supracondylar fractures of the humerus over a period of 30 months. The fractures were classified according to the Wilkins modification of the Gartland system. There were 29 type IIA, 22 type IIB and 20 type III. We assessed the effectiveness of guidelines proposed after a previous four-year review of 83 supracondylar fractures. These recommended that: 1) an experienced surgeon should be responsible for the initial management; 2) closed or open reduction of type-IIB and type-III fractures must be supplemented by stabilisation with Kirschner (K-) wires; and 3) K-wires of adequate thickness (1.6 mm) must be used in a crossed configuration. The guidelines were followed in 52 of the 71 cases. When they were observed there were no reoperations and no malunion. In 19 children in whom they had not been observed more than one-third required further operation and six had a varus deformity. Failure to institute treatment according to the guidelines led to an unsatisfactory result in 11 patients. When they were followed the result of treatment was much better. We have devised a protocol for the management of these difficult injuries.     

Management of displaced supracondylar fractures of the humerus in children

A series of 33 children with displaced supracondylar fractures of the humerus (SFH) were all treated operatively by open reduction and internal fixation or by closed reduction and percutaneous pinning. A follow-up study was performed on average 29 months (range 3-63 months) after the injury. In 18 per cent of cases primary neurovascular injury was observed and confirmed at operation. Of these patients 32 had open reduction and internal fixation by K-wires; in only one case was closed reduction and percutaneous pinning attempted. If there was preoperative neurological deficit, the nerves were visualized; however nerve suture was not required in our series. In one case we had to reconstruct both the brachial and radial arteries because of intimal lesions totally occluding the vessels. The average hospital stay was 9 days, including pin removal, which was usually performed about 4-5 weeks later, at the time of plaster removal. By Innocenti's criteria, 27 of 30 patients reviewed had an excellent result; three had a good result and three patients were lost to follow-up. There were no complications due to the operation, such as wound healing problems, infections or nerve lesions. In the light of our experience and of the good results, we recommend that displaced SFH be managed by open reduction and internal K-wire fixation. Percutaneous pinning is a good alternative method when closed reduction is successful at the first attempt.     

Diagnosis of vascular injury in children with supracondylar fractures of the humerus

Four children with suspected vascular injury after supracondylar fractures of the humerus are presented. A noninvasive technique has been used in the diagnosis of vascular injury. A simple non-invasive method using the Doppler equipment connected to a spectrum analyser may exclude the need for arteriography and surgical exploration.     

Management of supracondylar fractures of humerus with condylar involvement in children

The intent of this study was to heighten awareness and to present the authors' experience of an uncommon supracondylar humerus fracture in children. Twenty-two children were studied over a period of 18 years. The average age was 7 years, and oldest child was 11 years at time of injury. The fracture subtypes with medial condyle, lateral condyle, and intercondylar extensions were classified based on radiographs. The patients were followed for an average of 6.5 years. Eighteen injuries (82%) were graded excellent or good, and there were two each with fair or poor outcomes. The most common complication was loss of carrying angle of more than 10 degrees, which occurred in three children. The best results were seen in cases where three or four cross-fixing wires were used across the fractures. The authors recommend closed reduction techniques and percutaneous multiple cross-pin fixation for the displaced fracture. The fracture is unique and distinctive enough to warrant a designation as supracondylar fracture type IV with subtypes in the younger child.