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.     

Combination of ipsilateral supracondylar humeral- and forearm fractures in children

In an 11-year period, from 01. 08. 1987 to 31. 08. 1998, a total of 72 children (mean age 7.6 years, range 2-12 years) with dislocated supracondylar humeral fractures were treated surgically in the Department for Traumatology, University Hospital, Essen. The combination of supracondylar humeral fracture and ipsilateral forearm fracture occurred in 8 children (11.1 %). 4 revealed a complete forearm fracture in the distal third, 4 children a fracture of the distal physis (Salter-Harris type II). The supracondylar humeral fractures were reduced openly via a single lateral approach and stabilized by crossed K-wire fixation. The distal forearm fractures were treated by closed reduction and percutaneous pinning. Fractures of the distal physis were treated by closed reduction and application of an above elbow cast. Excellent results were achieved in all children with ipsilateral supracondylar and forearm fractures.     

闭合复位经皮克氏针固定治疗儿童肱骨髁上骨折

目的总结闭合复位经皮克氏针固定治疗儿童肱骨髁上骨折的疗效。方法18例儿童肱骨髁上骨折,均属GartlandⅢ型,均行闭合复位经皮克氏针固定。结果平均随访6(3~12)个月,所有骨折术后平均8.8(6~12)周愈合。参照F lynn临床功能评定标准:优13例,良2例,一般3例,优良率为83.3%。结论闭合复位经皮克氏针固定治疗儿童肱骨髁上骨折,是一种安全、简便、损伤小、固定可靠、有效的方法。     

Beware of ulnar nerve entrapment in flexion-type supracondylar humerus fractures

Purpose A recent study reported a higher incidence of pre-operative ulnar nerve symptoms in patients with flexion-type supracondylar fractures than in those with the more common extension supracondylar fractures and a greater need for open reduction (Kocher in POSNA paper #49 2006). We have encountered a specific pattern of flexion supracondylar fractures that often require open reduction with internal fixation (ORIF) due to entrapment of the ulnar nerve within the fracture. Methods Medical records and X-rays from 1997 to 2005 at our children’s hospital were examined to identify flexion supracondylar fractures that required open reduction. The operative reports were reviewed to identify cases that had the ulnar nerve blocking the reduction. Results During the 8 years examined, 1,650 supracondylar fractures had been treated by means of closed reduction and percutaneous pinning. Of these, only 1.8% or 30 cases could not be reduced closed and required open reduction internal fixation, excluding 11 open fractures. Of the 30 fractures requiring open reduction internal fixation, 24 were of the extension type needing ORIF because of interposed periosteum/muscle. The other 6 patients had flexion-type supracondylar fractures that failed closed reduction. All had a persistent medial gap at the fracture site. All 6 fractures had interposed periosteum or muscle, while in 3 cases the ulnar nerve was also entrapped within the fracture site (Figs. 1, 2) Conclusion Flexion-type supracondylar fractures remain a relatively uncommon variant (2–3%) of supracondylar fractures. Recent reports have noted that open treatment of these fractures is required more frequently than for extension fractures. In our series, 20% of the open cases were flexion-type fractures and in half of these the ulnar nerve was found to be entrapped in the fracture, preventing reduction. Study conducted at Rady Children’s Hospital and Health Center. No financial support was received for this project.     

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。     

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.     

Closed reduction with percutaneous Kirschner wire drill-and-pry for pediatric supracondylar humeral fractures with bony callus formation and delayed presentation

BackgroundSupracondylar humeral fractures are the most common type of pediatric elbow fractures, and are primarily treated using closed reduction and percutaneous pinning. For patients who are treated ≥14 days after the injury, after callus formation has occurred, closed reduction is usually not possible. The purpose of this study is to report the clinical outcomes of closed reduction with percutaneous Kirschner wire (K-wire) drill-and-pry for the delayed treatment of pediatric supracondylar humeral fractures with bony callus formation.MethodsWe retrospectively reviewed the data of 16 patients who underwent percutaneous K-wire drill-and-pry between November 2019 and August 2021 for the treatment of supracondylar humeral fractures with bony callus formation ≥14 days after the injury. Clinical outcomes were assessed using the Flynn criteria. The postoperative Baumann angle and pin configuration were evaluated using x-ray examinations.ResultsAll patients were followed up for 8–28 months (average, 16.63 months). The fractures healed in 4–6 weeks (average, 4.38 weeks). The operative time ranged from 10 to 124 min (average, 35.12 min). No iatrogenic vascular or nerve injury occurred. No patient developed cubitus varus. According to the Flynn criteria, 12 patients had excellent outcomes, 2 patients had good outcomes, 1 patient had a fair outcome and 1 patient had a poor outcome.ConclusionClosed reduction with percutaneous K-wire drill-and-pry is a mini invasive technique for supracondylar humeral fractures with bony callus formation in children. Most patients had a good clinical and cosmetic outcomes without scarring.     

闭合复位经皮克氏针内固定治疗儿童不稳定肱骨髁上骨折

目的探讨C臂X线机透视下闭合复位经皮克氏针内固定治疗不稳定儿童肱骨髁上骨折的疗效。方法C臂X线机透视下闭合复位经皮克氏针内固定术治疗儿童不稳定肱骨髁上骨折35例。结果35例均获随访,时间7～13个月。术后无缺血性挛缩,3例出现针孔渗出较多,经加强换药后痊愈。无一例出现肘内翻、尺神经损伤。按Flynn标准评价：优20例,良15例,无一般及差病例。结论C臂X线机透视下闭合复位经皮克氏针内固定治疗儿童不稳定肱骨髁上骨折手术创伤小,固定可靠,可以获得良好的肘关节功能和外形。     

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.     

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。     

Treatment of displaced supracondylar humeral fractures among children: Crossed versus lateral pinning

This retrospective study evaluated different pinning configurations used in the treatment of displaced supracondylar humeral fractures among children, mainly regarding maintenance of fracture reduction and avoidance of complications. The fractures (41 type II and 67 type III) of 108 children (mean age 6.48 years) were treated by closed reduction and percutaneous pinning: 37 with crossed pins, 37 with two lateral pins and 34 with two lateral and one medial pin. Mean follow-up period was 7.4 months. Type III fractures fixed by two lateral pins were found significantly prone to postoperative instability, late complications and need for medial pin fixation. There was a significant relation between either delay to surgery or postoperative instability and occurrence of complications. Final outcome was significantly poorer in type III than in type II fractures. Fixation by two lateral pins only is not recommended for treating type III supracondylar humeral fractures, but could be used initially to fix severely unstable fractures to allow extension of the elbow before inserting a medial pin. Every effort should be made to avoid iatrogenic ulnar nerve injury while inserting the medial pin.     

How safe is the operative treatment of Gartland type 2 supracondylar humerus fractures in children?

Whereas operative treatment of supracondylar fractures is now standard of care for Gartland type 3 supracondylar humerus fractures in children, the treatment of type 2 fractures remains somewhat controversial. The purpose of this article was to examine the safety and efficacy of closed reduction and pinning of type 2 supracondylar humerus fractures in children. METHODS: We performed a retrospective review of 189 type 2 supracondylar humerus fractures operatively treated at one tertiary care children's hospital from 2000 to 2006. Data were acquired from a review of radiographs and clinical notes. RESULTS: We found no intraoperative surgical or anesthetic complications in our series. None of our cases lost reduction after closed reduction and percutaneous pinning. There were 4 pin tract infections (2.1%) in our series: 3 were treated with antibiotics, and 1 needed irrigation and debridement in the operating room. This was the only patient who required reoperation for any reason. CONCLUSIONS: In this study, the largest reported series of type 2 supracondylar humerus fractures in children, we found an extremely low rate of complications after closed reduction and percutaneous pinning; secondary operations were also uncommon (0.5%). Our series demonstrates a high probability of satisfactory outcome after operative treatment of type 2 supracondylar fractures compared with previous studies of children treated by closed reduction without pinning. LEVEL OF EVIDENCE: Therapeutic study, level 4 (case series [no or historical control group]).     

Ultrasonography for non-displaced and mini-displaced humeral lateral condyle fractures in children

Objective： To evaluate the value of ultrasonography in non-isplaced and mini-displaced humeral lateral condyle fractures in children.
Methods： Nine children aged 2-9 years with non-displaced or mini-displaced humeral lateral condyle fractures were examined by high-resolution ultrasonography. The fracture line through the joint surface was visualized by ultrasonography in 6 case, in which closed reduction and percutaneous pinning was performed on 3 patients and other 3 patients did not receive the treatment because of patients＇ or their parents＇refusal. In the remaining 3 children, ultra- sonography did not reveal the cartilaginous trochle involvement at the joint surface and conservative treatment was adopted.
Results： The average follow-up period was 8 months. The sonographic findings were confirmed by magnetic resonance imaging in one child who received conservative treat-ment and another child who received percutaneous pinning. The elbow function and fracture healing were good in cases received closed reduction and percutaneous pinning. Among the three cases who refused to receive closed reduction and internal fixation, re-displacement occurred in 1 case and delayed union in 1 case. All three cases receiving conservative treatment had good results both in elbow function and fracture healing.
Conclusion： High-resolution ultrasonography enable to reveal non-displaced and mini-displaced humeral lateral condyle fractures as well as to ascertain whether the cartilaginous trochlea humeri was involved. For these cases, arthrography or magnetic resonance imaging is unnecessary.     

"Dorgan's" percutaneous lateral cross-wiring of supracondylar fractures of the humerus in children

The preferred treatment of displaced supracondylar humeral fractures in children is closed reduction and percutaneous pinning. Cross-wiring techniques are biomechanically superior to parallel lateral wiring techniques. The purpose of this study was to review the authors' experience with a novel cross-wiring technique performed entirely from the lateral side. Twenty children with supracondylar fractures who were manipulated and wired using a lateral cross-wiring technique were reviewed. Patient demographics, mechanism of injury, fracture classification, and associated neurovascular injuries were noted. All fractures were reduced, cross-wired from the lateral side, and rested in an above-elbow slab. Wires were removed at 4 weeks. Range of motion and carrying angle were measured at follow-up. Lateral cross-wiring of supracondylar fractures represents a real option in the treatment of these injuries, offering the biomechanical advantages of traditional cross-wiring without the risk of ulnar nerve injury.     

Flexion-type supracondylar elbow fractures in children.

SUMMARY: Flexion-type supracondylar elbow fractures are uncommon in children. Minimally displaced fractures were treated in plaster cast in 7 children, and 22 children with a displaced fracture were treated by closed reduction and percutaneous pinning. Results after an average follow-up of 6.3 years showed that the treatment of choice yielded excellent or good results in 86.2% of the patients. All patients were satisfied with the end result and had normal use of their elbow.     

Fracture-separation of the distal humeral epiphysis

We have reviewed 12 cases of fracture-separation of the distal humeral epiphysis, three of which were initially misdiagnosed as fractures of the lateral condyle and one as an elbow dislocation. Cubitus varus deformity is as common after this fracture-separation as it is following supracondylar fracture, and is most common in children under two years of age. Closed reduction and simple immobilisation is adequate for the older child, but we recommend for those under two years of age that closed reduction should be followed by percutaneous pinning, so that the carrying angle can be assessed immediately after reduction. If the elbow is then in varus the wires should be removed, reduction repeated and treatment by straight lateral traction used to maintain a valgus carrying angle.     

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.     

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.     

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.     

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.