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.     

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.     

Baumann角的放射学测量及其临床意义

测定了48例2～13岁正常小儿及71例肱骨髁上骨折小儿的Baumann角.结果提示Baumann角与提携角之间存在非常显著的相关性(P<0.01),骨折复位后Baumann角可用来准确地预测提携角,并有效地防止肘内翻畸形的发生.     

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.     

Fracture separation of the distal humeral epiphysis in children younger than three years old

This study evaluated the change of carrying angle and the causes of cubitus varus after the fracture separation of the distal humeral epiphysis in young children. Twelve cases of fracture separation of distal humeral epiphysis were treated from January 1995 to July 1997. The age of all patients was younger than 3 years old. A metaphyseal fragment was seen in all cases (Salter-Harris type II), but the size of the metaphyseal fragment was either a very small flake or a large Thurston-Holland fragment. Posteromedial displacement was seen in all cases. There were three treatment groups: closed reduction with percutaneous pinning, closed reduction with cast, and cast without reduction. Follow-up period averaged 23.5 months (range, 12-40). Cubitus varus deformity was seen in seven cases, and six of them had a partial defect of the medial condyle that was avascular necrosis. The methods of treatment, age of injury, and the type of epiphyseal injury had no influence on the development of cubitus varus, but avascular necrosis of the medial condyle was related to the cubitus varus deformity (p<0.05). The results of this study suggest that fracture separation of distal humeral epiphysis in young children is likely to produce cubitus varus deformity with the development of avascular necrosis of the medial humeral condyle.     

Supracondylar Fractures of the Humerus in Children

The treatment of type II and type III supracondylar fractures of the humerus in children with closed reduction and percutaneous pinning has dramatically lowered the rate of complications from this injury. The incidence rates of malunion (cubitus varus) and compartment syndrome have both decreased. Nerve injury accompanying this type of fracture (prevalence, 5% to 19%) is usually a neurapraxia, which should be managed conservatively. Vascular insufficiency at presentation (prevalence, 5% to 17%) should be managed initially by rapid closed reduction and pinning without arteriography. Persistent vascular insufficiency necessitates exploration and vascular reconstruction.     

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.     

Evaluation of the role of pin fixation versus collar and cuff immobilisation in supracondylar fractures of the humerus in children

Long term results of children with supracondylar humeral fractures treated with manipulation and strapping and manipulation followed by pin fixation were evaluated. Forty patients were regarded as Gartland type II injuries. 33 of these were treated with closed reduction and collar and cuff immobilisation and 7 with closed reduction and percutaneous pinning. Two cases of cubitus varus were reported one from each treatment modality. Forty-four patients were included as Gartland type III injuries. Of these 14 were treated with closed reduction and collar and cuff immobilisation, 25 with closed reduction and percutaneous pinning and five with open reduction and pinning. There were two cases of cubitus varus and one case of cubitus valgus following pin fixation. In addition one case of extension lag and one significant ulnar nerve neurapraxia was recorded following pin fixation. One case of cubitus varus was seen following manipulation and collar and cuff treatment. There was no statistical difference between either treatment modality in terms of predicting a better outcome (p0.05).We conclude that pin fixation has no advantages over simple immobilisation in certain Gartland II and III type injuries. Although pin fixation is beneficial in unstable injuries collar and cuff immobilisation continues to have an important role in the treatment of stable supracondylar fractures.     

Correlation between posteromedial or posterolateral displacement and cubitus varus deformity in supracondylar humerus fractures in children

Purpose Cubitus varus deformity is one of the most common complications after displaced supracondylar humeral fractures in children. The purpose of this study was to evaluate the relationship between the fracture displacement and cubitus varus deformity in displaced supracondylar humerus fractures. Methods Seventeen patients (11 males/6 females; mean age 7 years) with cubitus varus deformities occurring after Gartland type III posteromedial or posterolateral displaced supracondylar humerus fractures were evaluated with clinical and serial radiographic examinations. All patients had been treated surgically by open reduction through a medial approach and percutaneous cross-pinning. All fractures were reduced anatomically. Ten of the patients were operated within the first 24 h. The time interval between the initial injury and the surgical procedure for the remaining seven patients was 5.3 days on average (range 2–10 days). The carrying angle and range of motion of the elbow were measured throughout the follow-up period. The mean follow-up time was 3.7 years (range 2–12 years). Results Five patients with type III-B fractures had a mean carrying angle loss of 8.8° (range 6–10°), whereas for the remaining 12 type III-A patients the mean loss was 15° (range 6–29°) (P = 0.019). None of the patients in this study demonstrated limited elbow motion. According to the Flynn criteria, the results were good in five type III-B patients. There was no statistically significant relationship between the loss of carrying angle and the delay before the surgical procedure (P = 0.615 in type III-A, P = 0.096 in type III-B). Conclusions The carrying angle loss was more significant in type III-A fractures compared with type III-B in this series. These results suggest that although anatomic reduction has been achieved by surgical treatment without loss of reduction, there is still a risk for cubitus varus deformity for type III-A fractures due to the initial compression of the medial column or, in other words, physeal injury.     

闭合复位经皮克氏针交叉固定治疗儿童GartlandⅡ型肱骨髁上骨折

目的探讨闭合复位经皮克氏针交叉固定治疗儿童GartlandⅡ型肱骨髁上骨折的临床疗效。方法回顾性分析我科自2015年7月至2018年5月收治的36例儿童肱骨髁上骨折的病例资料,按照Gartland分型均为Ⅱ型骨折,其中ⅡA型16例,ⅡB型20例,均为闭合性骨折;男19例,女17例;平均年龄5.8(3~12)岁。所有病例均行闭合复位经皮内外侧交叉克氏针固定,术后长臂管型石膏固定3周,拆除石膏后进行肘关节屈伸功能锻炼。术后采用Flynn肘关节评分标准评定临床疗效。结果手术时间平均32(20~45)min。本组36例患儿无一例出现医源性尺神经损伤、Volkmann挛缩或肘内翻畸形,其中1例出现针道轻度感染,拔出克氏针后口服头孢类抗生素后痊愈。平均随访13.2(12~24)个月,末次随访按照Flynn临床功能评定标准评定临床疗效:优29例,良6例,可1例,优良率97.2%。结论闭合复位经皮内外侧交叉克氏针固定是治疗GartlandⅡ型儿童肱骨髁上骨折的有效方法,早期复位固定可有效减少单纯石膏固定引起的骨折移位、肘内翻畸形等并发症的发生,有利于肘关节的功能恢复。     

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.     

Supracondylar humeral osteotomy in children with severe posttraumatic cubitus varus deformity

The authors report the results of corrective osteotomy of the humerus in 11 children with severe posttraumatic cubitus varus deformity. The average carrying angle on the affected side was -24.4 degrees, and there was an average internal rotation deformity of the distal humerus of 22 degrees. Flexion and extension of the injured elbow were severely limited. A supracondylar lateral wedge osteotomy of the humerus was performed keeping the medial cortex intact. Two K-wires served as levers to correct the angular and rotational deformity of the elbow and then as fixation material to hold the osteotomy fragments. Postoperatively we immobilized the elbows in 90 degrees flexion for 3 to 4 weeks. There was no loss of the postoperative osteotomy alignment in most cases. Recurrence of mild varus deformity (-5 degrees and -7 degrees) occurred in only two patients. At the end of the follow-up we observed excellent results in 9 patients with an average carrying angle of 7.2 degrees (range 5-10 degrees).     

闭合复位克氏针内固定治疗GartlandⅢ型儿童肱骨髁上骨折

目的探讨闭合复位内外侧3针交叉固定治疗GartlandⅢ型儿童肱骨髁上骨折的疗效。方法对195例GartlandⅢ型儿童肱骨髁上骨折患者行闭合复位后,C臂机监视下先在肱骨髁外侧用2枚克氏针平行或交叉固定,再伸直肘关节到50°,保护尺神经下用1枚克氏针在内侧交叉固定,术后长臂石膏托固定于肘关节伸直70°制动3周。结果 195例均获随访,时间5~35个月。出现医源性尺神经损伤2例,肘内翻畸形需截骨矫形1例,肘部前侧局限性骨化4例。按Flynn标准评定疗效:优180例,良8例,一般6例,差1例,优良率为96.4%。结论闭合复位内外侧3针交叉固定治疗GartlandⅢ型儿童肱骨髁上骨折可有效减少医源性尺神经损伤,降低肘内翻畸形发生率,疗效满意。     

儿童移位肱骨髁上骨折的三级筛选式治疗

目的:制定儿童移位肱骨髁上骨折的规范化治疗方案,避免和减少并发症的发生。方法:对136例骨折中轻度肿胀的89例采用手法复位,失败的38例连同重度肿胀的42例采用骨牵引复位,牵引复位失败中的23例(10例拒绝手术治疗)连同陈旧性骨折的5例采用手术切开复位的三级筛选式治疗,并对其疗效进行分析评价。结果:手法复位成功51例,骨牵引后复位成功47例,手术切开复位成功28例。10例手法复位失败后拒绝手术治疗,后期发生肘内翻。随访136例,时间3~48个月,骨折均在3个月内愈合,肘内翻畸形26例,占19%。无筋膜间室综合征、伤口及针孔感染的发生。结论:三级筛选式治疗方案可明显提高肱骨髁上骨折的闭合复位成功率,降低手术率,避免和减少了并发症的发生,是一种理想的治疗手段。     

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.     

Correction of cubitus varus by French or dome osteotomy: a comparative study

BACKGROUND: The purpose of this study was to compare the outcomes of two different techniques of supracondylar osteotomy, French osteotomy and dome osteotomy, for the correction of posttraumatic cubitus varus. METHODS: A comparative randomized study was undertaken of 25 patients (average age 10 years) with an established posttraumatic cubitus varus deformity (mean time from injury to corrective osteotomy, 1.7 years). Patients were followed-up with for 1 year, and carrying angle, Baumann's angle, and internal rotation deformity were measured. Postoperative complications were assessed. RESULTS: A significant (p < 0.01) correction of carrying angle and Baumann's angle was achieved with both techniques, with no statistically significant differences between them. Although internal rotation deformity was corrected by both techniques, the correction was significantly greater with the dome osteotomy (p < 0.01). However, the persistence of internal rotation did not seem to affect the final outcome. There was a higher incidence of postoperative complications in the dome osteotomy group, including infection (1), inadequate correction (1), nerve palsy (1), loss of motion (5), and circulatory compromise (1). CONCLUSION: The dome osteotomy is technically more difficult than the French osteotomy and has a higher incidence of complications. We suggest that the French osteotomy be used for the correction of cubitus varus after supracondylar fractures of the elbow in children.     

Treatment of multidirectionally unstable supracondylar humeral fractures in children. A modified Gartland type-IV fracture

BACKGROUND: There is an uncommon subset of supracondylar humeral fractures in children that are so unstable they can displace into both flexion and extension. The purposes of this study were to describe this subset of supracondylar fractures and to report a new technique of closed reduction and percutaneous pinning for their treatment. METHODS: In a retrospective review of 297 consecutive displaced supracondylar humeral fractures in children treated operatively at our institution, we identified nine that were completely unstable with documented displacement into both flexion and extension as seen on fluoroscopic examination with the patient under anesthesia. We used a new technique for closed reduction and fixation of these fractures, and then we assessed fracture-healing and complications from the injury and treatment. RESULTS: All nine fractures were treated satisfactorily with closed reduction and percutaneous pinning. The complication rate associated with these unstable fractures was no higher than that associated with the 288 more stable fractures. Seven of the nine fractures were stabilized with lateral entry pin placement, and two fractures were stabilized with crossed medial and lateral pins. None of the patients had a nonunion, cubitus varus, malunion, additional surgery, or loss of motion. CONCLUSIONS: In rare supracondylar fractures in children, multidirectional instability results in displacement into flexion and/or extension. This fracture can be classified as type IV according to the Gartland system, as it is less stable than a Gartland type-III extension supracondylar fracture. These fractures can be treated successfully with a new technique of closed reduction and percutaneous pinning, thus avoiding open reduction.     

Die dislozierte suprakondyläre Humerusfraktur des Kindes Operationstechnik und Ergebnisse mit dem dorsolateralen Zugang

Anatomical reduction and stabilization of displaced supracondylar humeral fractures in children is necessary to obtain good results. For most cases percutaneous crossed pinning is recommended. Sometimes open reduction is necessary but even in these cases neurological complications and varus deformities have been reported. So the technique of open pinning was modified. From 1995 to 1998 22 children were treated by a dorsolateral approach. The fracture was stabilized by crossed pinning: The proximal K-wire is drilled 10 degrees ascending to the dorsal humerus through the medial pillar into the ventral part of the medial epicondyle, after shortening it is not bent. The distal K-wire stabilizes the lateral pillar, after shortening its end is bent down. Immobilization for 3-4 weeks, mobilization is done by the patient. The implants are removed 2 weeks later. The follow up in 21 out of 22 patients (8-57 months, mean 35 months) according to Flynn's criteria showed 16 excellent, 4 good and 1 fair result. The fair result was due to valgus deformity. One patient has been reoperated due to displacement of K-wire. Neither iatrogenic nerve lesions nor varus deformities nor infections did occur. The dorsolateral approach combined with the above mentioned technique of pinning shows excellent and good results.     

Post-traumatic cubitus varus in children (apropos of 8 cases in African children)]

The author describes his experience after treatment of 8 cases of cubitus varus secondary to displaced supracondylar fractures of the humerus in African children. Measurement of the Baumann angle is necessary for the assessment of cubitus varus. The median angle is 24 degrees with a range of 10 degrees to 45 degrees. Indications were dictated by functional problems, discomfort, and esthetic considerations. The surgical treatment consisted in a supracondylar osteotomy of the humerus for correction of cubitus varus.