Displaced supracondylar humeral fractures in children: open reduction vs.
closed reduction and pinning
Ravi Teja1 , Chaitanya.M*., Srinivasulu , Ramprasad Rallapalli4, , Siva Prasad Y5
1
Senior Resident(teja_bhimana@yahoo.com)2Senior Resident(chaitanyamogili@gmail.com)*3Senior Resident
(srinupuli549@gmail.com);3Assistant professor,(ramprasadrallapalli@gmail.com);4senior resident); 5Professor & HOD;
Narayana Medical College and Hospital, Nellore, A.P.
*Correspondence
Dr. Chaitanya
Department of Orthopaedics
Narayana Medical College and Hospital,
Chinthareddypalem, Nellore, A.P. India
Email: chaitanyamogili@gmail.com
Introduction:
Supracondylar humerus fracture (SCHF) is the most common fracture in children under 8years of age reported to
occur in 55% to 75% of patients with elbow fractures [1]. Lateral condylar fractures are the second most common,
followed by medial epicondylar fractures. The main objectives of treatment for displaced SCHFs in children are
prevention of Volkmann’s contracture, avoidance of deformities, and restoration of normal function [2]. In the
orthopedic literature it is reported that the best results are achieved by closed reduction and wire fixation [3, 4, 5, 6,
7, 8, 9]. However, in this study the patient group of open reduction and pinning included patients who had previous
ineffective closed reduction trials Old fractures (> 1 week duration) and Fractures with neurovascular injury that
demand repair. Aim of this study is to compare the elbow status functionally after both closed reduction and
percutaneous pinning and open reduction with k wire fixation and to restore the anatomy of distal end of humerus
with closed or open reduction with k-wires
MATERIALS AND METHODS
This is a prospective study including the patients operated for displaced supracondylar fractures of humerus from
Aug 2012 to Mar 2014 in Narayana Medical College hospital, Nellore.. Antero-posterior and Lateral radiographs
were taken for all cases. The patients were recorded for the presence of neurovascular injury, compartment
syndrome, ipsilateral upper-extremity fracture and type of surgical method. These patients were also recorded for
presence of postoperative infection, surgery-related nerve injury, and postoperative compartment syndrome. We
compared these rates with those reported in the literature. The patients were divided into two groups. Group 1
closed reduction and percutaneous k wire fixation and group 2 open reduction and k wire fixation. Based on the
indication, either a closed reduction technique or an open reduction technique was used. All the surgeries were
done by two surgeon. Consent was taken from all the patients before surgery.
INCLUSION CRITERIA:
Children with displaced supracondylar fracture of humerus with an open physis, (Grade III Gartland’s Type)
coming to Narayana Medical College during study period willing to participate in study after giving informed
consent.
EXCLUSION CRITERIA:
1. Patients with displaced fracture but with closed physis.
2. Un displaced & minimally displaced fractures (Gartland type I and II).
3.Compound fractures
INDICATIONS:
FOR CLOSED REDUCTION:
1. Fresh closed displaced fractures of less than 1 week duration & with no neurovascular injury that demand
repair.
FOR OPEN REDUCTION:
1. Failed closed reduction
2. Old fractures (> 1 week duration)
3. Fractures with neurovascular injury that demand repair
In group 1 closed reduction was done by Milking maneuver and either lateral pinning or crossed pinning was used
according to surgeon preference. In group 2 The intubated patient was placed prone with a sandbag under- neath
the abducted arm. The surgery was performed through a posteromedial incision posterior to the medial epicondyle.
After isolating the ulnar nerve the distal humerus was exposed between the brachialis and triceps muscles as in the
medial approach. The average period between injury and operation was 15 h (range 11–48) in the open group and
17 h (10–72) in the closed group. In both groups two smooth Kirschner wires were used. After the operation three
to 4 weeks of dorsal long arm splint at 90° was used for each group. By the end of fourth week the fracture was
examined by radiology, and wires were removed. In the case of improper radio- logical callus formation follow-up
radiography was performed in the 6th week. Active elbow range of motion rehabilitation program was encouraged
in the 4th week under the supervision of a physical therapist. The patients were followed radiologically and
clinically and were called for a final assessment at 18 months in both groups after the initial surgery. Patients were
evaluated for the radiological humeral-ulnar angle as the carrying angle and clinically for flexion and extension
degrees, and the findings were compared with those in the contralateral normal elbow. Final results were graded by
the criteria of Flynn et al. [4] Statistical analysis used Student’ s t
Yates’ correction for qualitative vari- ables.
RESULTS:
This is a prospective study including the patients operated for displaced supracondylar fractures of humerus from
Aug 2010 to Mar 2014. This study includes 20 patients with 10 patients in closed reduction and percutaneous k
wire fixation(group 1) and open reduction and k wire fixation(group 2). All cases selected had open physis and
between 0-12yrs of age with mean age of 7.5 years in group 1 and 8.9 years in group 2. In group 1 50% were males
and 50 % were female whereas in group 2 all the patients are males. In the present series all cases of both groups
had a history of trauma either direct or indirect and their distribution by various mechanisms is shown in (table 1)
Most of the fractures were sustained when the patient had fallen down on out stretched hand while playing or slip
and fall. In both groups left side is more involve then right. Associated injuries in group 1 are 1 case (Green stick
#both bones forearm)(1%) ,1 case(closed # distal radius) and in those group 2, 3 cases(30%) of those operated by
open reduction are associated with vascular injury, 2 cases: Brachial artery impingement, 1 case: Brachial artery
injury and Overall 4 cases(20%) had associated neurological injury . Type of construct used in both groups is show
in table 2 and 3 Indication of open reduction in our series in table 4. Complications occurred are 1case of ulnar
nerve palsy in case treated by closed reduction and cross construct. 1 case of cubitus varus and 2 cases of pin tract
infection. Grading of results(as per flynns) for both groups is shown in table 5 and 6
DISCUSSION
Supracondylar fractures of humerus are common fractures occurring in childhood. Prompt and effective treatment
should be given to these injuries to achieve best possible results. Adequate history and clinical evaluation including
neurovascular status of the limb, radiological diagnosis and classifying the fracture are imperative before giving
any mode of treatment. Anatomical reduction and stable fixation followed by proper physiotherapy are mandatory
to get good results Our series consists of 20 cases of displaced (Gartland’s Type III) supracondylar fractures of
humerus in children treated by either closed reduction and percutaneous K wire fixation or open reduction and K
wire fixation under general anesthesia and C-arm control. Of all the supracondylar fractures, only those patients
with open physis & who belonged to Gartland's Type Ill are included in our study. Out of 20 cases, all the cases
were of extension type with either postero-medial or postero-lateral displacement of distal fragment. KAYE
E.WILKINS; JAMES H.BEATY et al[10] compiled data from 7212 fractures occurring in 6l major series. They
observed male dominance with 62.8%; non-dominant limb involved in 60.5% of cases. Average age was 6.7
years.1%of cases were flexion type. In 1% of the cases, ipsilateral fractures of forearm were found; 1% were open
fractures. Neurological injury found in 7.7% of cases, out of these radial nerve was involved in 41.2%; median
nerve was involved in 36% of cases, ulnar nerve in 22.8%of cases. According to CHENG AND LAM et al.[11]
median age at presentation was 6yrs (6.6 years in boys, and 5 years in girls, with the non-dominant humerus
1.5times more commonly injured and they found flexion type of fractures in l% of cases. In our series, average
age was found to be 7.5 in cases operated by closed reduction &8.9 yrs in cases operated by open reduction.
Overall the average age was found to be 8.2yrs ,with 8.46yrs in boys and 7.4 yrs in girls. When compared to
KAYE E.WILKINS study average age of incidence in our study is 1.5 yrs more towards elder side. There is male
preponderance with 75%(overall),which is comparable to WILKINS study(62.8%).In our series supracondylar
fractures are common in non dominant side with an incidence of 65% which is comparable to WILKINS study and
observation of CHENG AND LAM et al [11]It was found that the injury was caused by low energy trauma. Most
of them were sustained due to fall on outstretched hand due to slip and fall or while playing at home or school,
which accounts for 70% of cases.15% of cases were injured in R.T.A and 15%of cases sustained injury due to fall
from height. Out of the 20 cases,3 cases had an association with vascular injury . 1% of cases , one each in those
treated by closed reduction and open reduction were associated with fractures of ipsilateral forearm .Green stick #
of distal end of both bones associated with closed supracondylar # was managed conservatively and the distal
radius # associated with supra condylar fracture was managed with percutaneous K wire fixation. CULP RW;
OSTERMAN et al [12]observed 12.8% neural injuries in their retrospective review of displace extension type of
supracondylar fractures in 101 children.70%of them spontaneously resolved at a mean of 2.5 months .They
concluded that observation and supportive therapy is the preferred initial approach; if there is no clinical or
electromyographic evidence of return of neural function at 5 months after injury ,exploration and neurolysis is
indicated LYONS ST ;QUINN et al [13]found 13.3%of neural compromise ,combined nerve and vascular
compromise in 2.9%of patients. Median nerve injury accounted for 58.9% of nerve injuries, followed by radial
(26.4%) and ulnar (14.7%) lesions,80%of them are anterior interosseous nerve compromise. In our series the
overall incidence of neural involvement was 20%. Out of these median nerve was involved in 2 cases(10%) and
radial nerve was involved in 2 cases(10%).Spontaneous recovery occurred in all within a mean time of 4 months
without any surgical intervention. Vascular compromise was found in 3 case. The overall incidence was
15%.Exploration was done in all cases .Compression of the artery was released in two cases. Intimal injury and
thrombus was found in one case which was treated by thrombectomy and end to end anastomosis. Majority of the
cases were admitted on the day of injury. All cases were taken up under general anesthesia as early as possible. Out
of 10 cases operated by open reduction ,40% had irreducible # by closed method,20% had # with delayed
presentation(>1 week),20% had closed vascular injury,10% had vascular injury and 10% had nerve palsy.
REITMAN RD, WATERs P et al [14] managed 65 type III fractures with open reduction and pinning. Of the 65
patients who were managed with open reduction, 46(71%)were due to irreducibility of fracture , 16(24%) had
associated vascular compromise, 8(12%)were open ,and one was associated with post reduction nerve palsy
.According to the criteria of Flynn et al 18(55%)elbows were rated excellent,8(24%) were rated good
three(9%)were rated fair and 4(12%) were rated poor after an average of 5.8 months post injury. SKAGGS DL
HALE J1. et al [15] concluded that there was no difference with regard to maintenance or fracture reduction
between the crossed pins configuration and the two lateral pin configuration .They found that use of a medial pin
was associated with ulnar nerve injury in 4% of the cases. REYNOLDS RA.MIRZAYAN R.et al [16] have shown
that there is a biomechanical advantage of crossed pin construct as opposed to two lateral pin construct .However
they have found 4.5% incidence of ulnar nerve injury with medial pin placement. We have fixed the reduced
fracture with a crossed pin technique in 25% of cases and a lateral two pin construct in 75% of cases. Our criteria
for a medial pin was to place it if the fixation is found to be unstable with two lateral pins alone. No neuro vascular
deficit occurred in cases of open reduction and
K wire fixation. Ulnar neuropraxia was identified in 1 case of
closed reduction and crossed pin construct and it recovered within 4 weeks. Immediately after identifying the palsy
the K wire was removed. In order to protect the ulnar nerve during medial pin placement, push the nerve anteriorly
during pinning or use a small incision over the medial epicondyle in the presence of gross swelling. The results of
the treatment were assessed using the criteria of FLYNN et al [17] to compare the motion and carrying angle of the
injured and the un injured elbow. The function is graded in 5 degree intervals of loss of flexion or extension, and
the cosmetic appearance of elbow is graded in 5 degree intervals of change in the carrying angle, with any varus
angulation resulting in a poor grade. YAOKREH J.B.,GICQUEL .P et al [18]observed that In paediatric extensiontype supracondylar fractures of elbow,Out of 58 children, Outcomes were satisfactory in 30 (90.9%) patients
treated with percutaneous pinning and in 23 (92%) patients treated with open reduction and cross-wiring.
Iatrogenic nerve injury in two (3.4%) patients. Cubitus varus occurred in two (6.06%)patients after closed
treatment and in one (4%) patient after open treatment. In our study out of 10 cases managed by closed reduction
excellent to good results are seen in 90% of cases and only 1 case had a poor result, which had a varus deformity
due to loss of reduction. Out of 10 cases that were managed by open reduction, excellent result is seen in 4 cases
(40%), good result is seen in 3 cases(30%),and poor result in 3(30%)cases. Poor result is seen in one case of
fracture with vascular injury and in two cases that presented late with resolved compartment syndrome. The most
probable causes of poor results are Vascular injury,Extensile incisions given for the vessel repair and grafting,
Delayed mobilization,Delayed presentation with compartment syndrome, Decreases the pliability of the soft tissue
preventing closed reduction aIatrogenic damage to soft tissue adds up to the stiffness. In summary excellent to
good results were obtained in about 90% of cases of closed reduction and K wire fixation and excellent to good
results in 70% of cases operated by open reduction and K wire fixation. The indication of open reduction remains
limited because of risk of stiffness of injury due to iatrogenic soft tissue injury. It is recommended to limit lateral
approach for prevention of stiffness which may be more common in posterior approach. Open reduction and
internal fixation is an effective and safe method of treatment if indicated and is associated with good outcome. The
concept of anatomical reduction and percutaneous pinning, followed by early and proper physiotherapy is the
choice of obtaining excellent results functionally and cosmetically in Gartland’s type III supracondylar fracture
humerus management in children. Shortcome of this study was cases size was small and and crossed and lateral pin
construct are not equally used in both groups but this study clearly tells the indications for open reduction and k
wire fixation and outcome in these cases.
Conclusion:
Fall on outstretched hand is the commonest cause and higher incidence in males and in non-dominant humerus. A
minimum distance of 10mm at the fracture site should separate the K wires. The C-arm should be rotated, and not
the arm to get an intra operative lateral view. The concept of gentle closed reduction and percutaneous K wire
fixation followed by early physiotherapy is the treatment of choice for obtaining excellent results functionally and
cosmetically in Gartland’s Type III supracondylar fractures of humerus in children. Open reduction through lateral
approach and internal fixation wire K wires is safe and effective method of treatment, if indicated, in supracondylar
fractures of humerus in children and is associated with a good outcome. A small incision medially in cases where
medial epicondyle cannot be defined to visualize the epicondyle and the ulnar nerve ,by which iatrogenic ulnar
nerve palsy in percutaneous fixation can be prevented. Observation and supportive therapy is the preferred initial
approach in nerve injuries associated with this fracture. K wires can be removed safely at 3-4 weeks after injury
and mobilization of the elbow should be started after the third week.
CONFLICT OF INTEREST
None of the authors has any conflict of interest.
ACKNOWLEDGEMENTS
The authors did not receive any funds for the preparation of this manuscript.
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Cases illustrations
Case 1
Closed reduction and K wiring pinning.
Post op
Pre op
At 4 month
Case 2 open reduction and cross pinning
8 wks
Post op
Pre op
A 4 months
Tables
8 wks
Table 1
Sl.No
Mode Of Injury
1
Fall on outstretched hand
No of Cases
Percentage
8
40%
6
30%
while playing
2
Slip and fall on outstretched
hand
3
Fall from height
3
15%
4
R.T.A
3
15%
Table 2
Sl.no construct
No. of cases percentage
1.
Lateral pinning
7
70%
2.
Crossed pinning
3
30%
Table 3
Sl.no construct
No. of cases percentage
1.
Lateral pinning
8
80%
2.
Crossed pinning
2
20%
Table 4
Sl.no Indication
No of cases percentage
1.
Failed closed reduction
4
40%
2.
Vascular injury
3
30%
3.
Delayed presentation(>1 wk)
3
30%
Table 5
Result
No of cases Percentage
EXCELLENT
7
70%
GOOD
2
20%
FAIR
0
---
POOR
1
10%
Table 6
Result
No of cases Percentage
EXCELLENT
4
40%
GOOD
3
30%
FAIR
0
---
POOR
3
30%