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.     

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.     

Ipsilateral supracondylar fracture of humerus and forearm bones in children

A total of 34 children with ipsilateral supracondylar fractures of the humerus and forearm were studied over an 8-year period. Of these, 19 patients had fractures of the distal quarter of the forearm bones while eight patients had a distal radial epiphyseal injury. Five of the patients had undisplaced supracondylar fractures. One patient had an anterior supracondylar fracture. All forearm fractures were treated by closed reduction. Nine displaced supracondylar fractures which could not be reduced by closed manipulation were treated by olecranon pin traction in two cases and by percutaneous pinning in seven cases. Excellent or good results were found in 29 children after an average follow-up of 3.8 years.     

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.     

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.     

Multicentre collaborative cohort study of the use of Kirschner wires for the management of supracondylar fractures in children

Purpose: Supracondylar fractures of the humerus cause significant morbidity in children. Nerve damage and loss of fracture reduction are common recognised complications in patients with this injury. Un certainty surrounds the optimal Kirschner wire configuration and diameter for closed reduction and pinning of these fractures. This study describes current practice and examined the association between wire configuration or diameter and outcomes (clinical and radiological) in the operative management of paediatric supracondylar fractures. Methods: Children presenting with Gartland II or III supracondylar fractures at five hospitals in south west England were eligible for inclusion. Collaborators scrutinised paper and electronic case notes. Outcome measures were maintenance of reduction and iatrogenic nerve injury. Results: Altogether 209 patients were eligible for inclusion: 15.7% had a documented neurological deficit at presentation; 3.9% who were neurologically intact at presentation sustained a new deficit caused by treatment and 13.4% experienced a clinically significant loss of reduction following fixation. Maintenance of reduction was significantly better in patients treated specifically with crossed 3 Kirschner wire configuration compared to all other configurations. The incidence of iatrogenic nerve injury was not significantly different between groups treated with different wire configurations. Conclusion: We present a large multicentre cohort study showing that crossed 3 Kirschner wires are associated with better maintenance of reduction than crossed 2 or lateral entry wires. Greater numbers would be required to properly investigate nerve injury relating to operative management of supra condylar fractures. We found significant variations in practice and compliance with the British Ortho paedic Association Standard for Trauma (BOAST) 11 guidelines.     

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.     

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.     

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.     

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]).     

Displaced Supracondylar Fractures of the Humerus in Children

In a 3-year period, 101 children were admitted to hospital with supracondylar fractures of the humerus. Eighty-six were examined an average of 3.7 years after the injury.

Forty-seven cases were treated with closed reduction and plaster bandage. After an unsuccessful attempt at closed reduction, 39 cases were treated with percutaneous K-wire pinning and plaster.

The cases treated with percutaneous pinning thus include the most severe fractures. Nevertheless, the results at follow-up in these cases easily equalled those obtained by closed reduction of the less displaced fractures. They were also comparable with reported results of extension treatment and, in contrast, required only a few days of hospitalisation.     

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.     

Percutaneous pinning of pediatric supracondylar humerus fractures with the semisterile technique: the Miami experience

Pediatric supracondylar humerus fractures are common injuries. The standard of care for management of displaced supracondylar fractures has become closed reduction and percutaneous pinning of the fracture in the operating room. We have been using a "semisterile" surgical technique, similar to what is used when placing a traction pin at the bedside. The purpose of this study was to evaluate our cases from 2000-2004 requiring closed reduction and percutaneous pinning to determine if this method had an infection rate comparable to what is reported in the literature. A total of 304 cases were identified. There were no superficial pin track infections or deep infections requiring treatment in any patient. A review of the literature regarding percutaneous pinning of supracondylar humerus fractures reveals an overall infection rate of 2.34% (45/1922) with a deep infection rate of 0.47% (9/1922). Consequently, the use of the semisterile technique is safe and an efficient way to handle these cases in saving time, cost, and materials.We also found that the administration of perioperative antibiotics may not be necessary as 68% of our patients did not receive any antibiotics during the perioperative or postoperative period. Finally, we found that 37% of our patients were discharged home the same day the surgery was performed, and there were no cases of compartment syndrome or Volkmann ischemic contracture. This indicates that observation overnight in the hospital may not be necessary for every patient.     

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.     

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.     

Neurological complications in children with supracondylar fractures of the humerus.

OBJECTIVE: To study the incidence of primary and secondary nerve injury in supracondylar fractures of the humerus, and to find out which factors may be responsible for iatrogenic nerve injuries. DESIGN: Retrospective study. SETTING: University Hospital, The Netherlands. SUBJECTS: 32 children admitted with type II or type III supracondylar fracture of the humerus. MAIN OUTCOME MEASURES: Incidence of primary and secondary nerve injury and their relation to type of fracture and treatment. RESULTS: 3 patients developed primary nerve injuries (9%). 4 further children developed nerve injury during treatment. All these children had several closed reductions attempted before definitive treatment was given (either pinning with a Kirschner wire or overhead traction). CONCLUSION: Several attempts at closed reduction may cause iatrogenic nerve injury in unstable supracondylar fractures of the humerus.     

Sagittal plane analysis of the open and closed methods in children with displaced supracondylar fractures of the humerus (a radiological study)

OBJECTIVES: The aim of this study was to compare the radiological outcome of open and close reduction and osteosynthesis methods in the treatment of type II and III supracondylar humerus fractures in childhood with respect to the immediate post-operative reduction quality in sagittal plane. METHOD: One hundred and forty four-pediatric patients with type IIb and III supracondylar humerus fractures treated at two centers between 1995 and 2005 were evaluated radiologically within a retrospective study. Seventy-six patients (54 boys, 22 girls, mean age 7.6, range 2-12) were treated by closed reduction and cross percutaneous pinning while 68 (49 boys, 19 girls, mean age 7.3, range 2-13) were treated by open reduction. The reduction quality of the open and closed groups was compared on immediate post-operative lateral radiographs by measuring of lateral humerocapitellar angle, anterior humeral line and anterior coronoid line criteria. The reduction quality was classified excellent, good, fair and poor according to the achievement of three, two, one or none of the criteria, respectively. Reductions classified as excellent and good were introduced as acceptable results. RESULTS: At least one criterion was achieved in all the patients of both the groups. The mean humerocapitellar angle was 30.1 degrees in closed reduction group while the mean of it was 29.8 degrees in open reduced group. Radiograph of 48 (63.1%) patients with closed reduction were found to display the anterior humeral line intersecting the middle one-third of capitellum while this criteria was 45 (66%) in open reduction group. The anterior coronoid line was disturbed in three patients in each of both the groups. The reduction quality was evaluated to be excellent in 32 patients, good in 31, fair in 13 at the closed reduction group while these evaluations were 31, 20 and 17 in open reduction group, respectively. Successful reduction was achieved in 74.9% of the patients in closed reduction group and 75% of the patients in open reduction group. CONCLUSION: It is concluded that there was no significant difference between closed and open reductions of pediatric displaced supracondylar fractures with regard to the radiological criteria of reduction quality in sagittal plane.     

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.     

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。