Supracondylus Humeri in Child Fracture

8/17/2019 Supracondylus Humeri in Child Fracture

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CurrentConceptsReview

Supracondylar Humeral Fracturesin Children

By Reza Omid, MD, Paul D. Choi, MD, and David L. Skaggs, MD

Investigation performed at Childrens Hospital Los Angeles, Los Angeles, California

Operative fixation is indicated for most type-II and III supracondylar humeral fractures in order to prevent malunion.

Medial comminution is a subtle finding that, if treated nonoperatively, is likely to lead to unacceptable varus

malunion.

Angiography is not indicated for a pulseless limb, as it delays fracture reduction, which usually corrects the

vascular problem.

A high index of suspicion is necessary to avoid missing an impending compartment syndrome, especially when

there is a concomitant forearm fracture or when there is a median nerve injury, which may mask symptoms of

compartment syndrome.

Lateral entry pins have been shown, in biomechanical and clinical studies, to be as stable as cross pinning if they

are well spaced at the fracture line, and they are not associated with the risk of iatrogenic ulnar nerve injury.

Supracondylar humeral fractures are the most common elbow fractures seen in children1-3 . Modern techniques for theirtreatment have dramatically decreased the rates of malunionand compartment syndrome. There still remain several con-troversial topics with regard to the treatment of these injuries,including the urgency of operative treatment, pin placementconfiguration, whether type-II supracondylar fractures shouldbe treated operatively or nonoperatively, and management of dysvascular limbs.

Epidemiology

Two-thirds of children hospitalized because of an elbow injury have a supracondylar humeral fracture4. The age range inwhich most supracondylar fractures occur is between five andseven years old. Traditionally, boys have had a higher incidenceof this type of fracture, but the difference in rates between girlsand boys seems to be equalizing, and higher rates in girls haveactually been reported in some series5,6. The injuries have

predominantly involved the left, or nondominant side, in al-most all studies5-8.

Mechanism of Injury and Anatomy

Supracondylar fractures are divided into extension and flexiontypes. Extension-type fractures, which account for approxi-mately 97% to 99% of supracondylar humeral fractures5,9, areusually due to a fall onto the outstretched hand with the elbow in full extension, and they are the focus of this review. Themedial and lateral columns of the distal part of the humerusare connected by a thin segment of bone between the olecra-non fossa posteriorly and the coronoid fossa anteriorly, re-sulting in a high risk of fracture to this area. With elbow extension, the olecranon engages the olecranon fossa and actsas a fulcrum, while the anterior aspect of the capsule simul-taneously provides a tensile force on the distal part of thehumerus proximal to its insertion. The resulting injury is anextension-type supracondylar humeral fracture.

Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a

member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial

entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice,

or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

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J Bone Joint Surg Am. 2008;90:1121-32 d doi:10.2106/JBJS.G.01354


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With extension-type injuries, the anterior periosteum istorn. The intact posterior periosteal hinge provides stability tothe fracture and facilitates reduction. Abraham et al. describedthe different types of periosteal changes seen with extension-type supracondylar humeral fractures in immature monkeys10.They reported that the position of maximum stability for re-duction was full flexion and pronation as opposed to supina-tion. Subsequently, many authors have also described using pronation to assist in reduction, but this should not be auto-matic. The direction of fracture displacement often indicateswhether the medial or lateral periosteum remains intact. The

most common posteromedially displaced fracture is usually associated with an intact medial periosteum. Pronation placesthe medial periosteum on tension, thus closing the hinge andcorrecting varus malalignment (Fig. 1). However, the medialperiosteum is often torn in patients with a posterolaterally displaced fracture, in which case pronation may be counter-productive. Instead, supination may be better, especially whenthe lateral periosteum is intact, which it usually is with thisinjury. If the posterior periosteal hinge is also disrupted, thefracture becomes unstable in both flexion and extension; suchan injury has been recently described as a multidirectionally unstable, modified Gartland type-IV fracture11.

Classification

The modified Gartland classification of supracondylar humeralfractures is the most commonly accepted and used system12.The kappa values for the intraobserver and interobserver vari-ability of this classification were higher than those for previ-ously assessed fracture-classification systems, according to areport by Barton et al.13.

Type I A Gartland type-I supracondylar fracture is nondisplaced orminimally displaced (by 2

mm), and the posterior cortex is presumably intact, buthinged. On a true lateral radiograph of the elbow, the anteriorhumeral line does not go through the middle third of thecapitellum (Fig. 2). Generally, no rotational deformity is seenon an anteroposterior radiograph because of the intact pos-terior hinge. With common usage of the classification, any

Fig. 1

Laterally torn periosteum in association with a

posteromedially displaced supracondylar hu-

meral fracture. (Reprinted, with permission,

from: Skaggs DL. Closed reduction and pinning

of supracondylar humerus fractures. In: Tolo VT,

Skaggs DL, editors. Master techniques in or-

thopaedic surgery: pediatrics. Philadelphia:

Lippincott, Williams and Wilkins; 2008.)

Fig. 2

Lateral radiograph of an elbow with a supracondylar hu-

meral fracture (black arrows) and an elevated posterior fat-

pad (white arrows). The anterior humeral line (thin white

line) passes through the capitellum but not through its

middle third, so some posterior angulation is present. This

fracture may be considered type II, although it is on the

border of being type I. (Reproduced with permission of

Childrens Orthopaedic Center, Los Angeles.)

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S U P R A C O N D Y L A R HU M E R A L F R A C T U R E S I N C H I L D R E N


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rotational deformity noted on an anteroposterior radiographwould qualify the fracture as type III.

Type III A Gartland type-III fracture is a displaced supracondylarfracture with no meaningful cortical contact. There is usually extension in the sagittal plane and rotation in the frontal and/or transverse planes. The periosteum is extensively torn, andsoft-tissue and neurovascular injuries often accompany thisfracture. A potential pitfall is to underappreciate the extent of loss of normal alignment in fractures with comminution andcollapse of the medial column. Involvement of the medialcolumn in this way signifies malrotation in the frontal planeand thus defines the injury as type III.

Type IV Leitch et al. retrospectively reviewed the characteristics of 297displaced extension-type supracondylar fractures and de-

scribed nine (3%) w ith multidirectional instability 11. Thesefractures are characterized by an incompetent periosteal hingecircumferentially and are defined by instability in both flexionand extension. This multidirectional instability is usually de-termined with the patient under anesthesia at the time of theoperation. The instability pattern may be due to the initialinjury, or it may occur iatrogenically during attempted re-duction. Classifying this fracture as a separate type may bewarranted as multidirectional instability has treatment impli-cations; however, time will tell if others find this addition to theGartland classification system useful.

Clinical Evaluation

When a child with elbow pain is examined, it is essential thatthe entire extremity be evaluated, as forearm fractures canoccur in association with supracondylar fractures and cansubstantially increase the risk of compartment syndrome14.The examiner must take note of soft-tissue swelling, ecchy-mosis, and skin puckering. Skin puckering results from theproximal segment piercing the brachialis muscle and engaging the deep dermis. This is a sign of considerable soft-tissue dam-age. Any bleeding from a punctate wound should be consideredto indicate an open fracture. Assessment of the vascular statusis essential. The prevalence of displaced supracondylar hu-meral fractures presenting with vascular compromise has beenreported to be up to 20% (10% [twenty-three of 230] in the

study by Pirone et al.15, 12% [seventeen of 143] in that by Shaw et al.16, and 19% [eleven of fifty-nine] in that by Campbellet al.17). The vascular status may be classified into one of threecategories: class I, which indicates that the hand is well per-fused (warm and red) and a radial pulse is present; class II,which indicates that the hand is well perfused but the radialpulse is absent; and class III, which indicates that the hand ispoorly perfused (cool and blue or blanched) and the radialpulse is absent.

The neurologic examination must be performed care-fully because of the high prevalence of neurologic injury.Preoperative assessment of the ulnar nerve in particular may

be challenging, as young children in pain may not be able tocross their fingers. However, even young children will usually pinch an examiner’s finger and allow the examiner to palpatecontraction of the first dorsal interosseous muscle and confirmulnar motor function. As a last resort, the hand can be wrappedin a wet cloth. In this test, any area of skin not exhibiting thenormal wrinkling response is presumed to have an injury tothe nerve innervating that area. During the physical exami-nation, a very high index of suspicion is needed to avoidmissing a developing compartment syndrome; considerableswelling and/or ecchymosis, anterior skin puckering, and anabsent pulse are indications of this complication.

Radiographic Diagnosis

Radiographic examination begins with a true anteroposteriorview of the distal part of the humerus, rather than an antero-posterior radiograph of the elbow, and a true lateral radio-graph of the elbow. Initial radiographs may show no evidence

of a fracture except for a posterior fat-pad sign. In a series of thirty-four patients with traumatic elbow pain and a posteriorfat-pad sign but no visible fracture, one of us (D.L.S.) andMirzayan found that 53% (eighteen) had a supracondylarhumeral fracture, 26% (nine) had a fracture of the proximalpart of the ulna, 12% (four) had a fracture of the lateralcondyle, and 9% (three) had a fracture of the radial neck 18.When an osseous injury is present, two main radiographicparameters are used to evaluate these fractures. On a truelateral radiograph of a normal elbow, the anterior humeral lineshould cross the capitellum through its middle third (Fig. 3).In an extension-type supracondylar fracture, the capitellum isposterior to this line. The Baumann angle, or humeral cap-

itellar angle, is the angle between the long axis of the humeralshaft and the physeal line of the lateral condyle; the normalrange for this angle is about 9 to 26. A decrease in theBaumann angle is a sign that a fracture is in varus angulationand may be seen with subtle comminution of the medial col-umn (Fig. 4).

Treatment

Initial Management Displaced supracondylar fractures requiring a reduction shouldbe initially treated with a splint, with the elbow in a com-fortable position of approximately 20 to 40 of flexion andavoidance of tight bandaging or splinting. Excessive flexion or

extension may compromise the limb’s vascularity and increasecompartment pressure19,20. The arm should then be gently elevated.

Treatment with TractionTraction as definitive treatment for supracondylar fractures inchildren is largely of historic interest in modern centers. Ratesof cubitus varus ranging from 9% to 33% have been reportedin some series21,22, whereas excellent results have been reportedin others23-25. Nevertheless, fourteen to twenty-two days of in-hospital traction are difficult to justify given the excellent re-sults with closed reduction and pin fixation, which usually

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requires no more than one night of hospitalization and is as-sociated with a low rate of intraoperative complications.

Closed Reduction and Pin Fixation

This is the most common operative treatment of supracon-dylar fractures. An initial attempt at closed reduction is indi-cated for almost all displaced supracondylar fractures that arenot open. With the patient under general anesthesia, thefracture is first reduced in the frontal plane with fluoroscopicverification. The elbow is then flexed while the olecranon ispushed anteriorly to correct the sagittal deformity and reducethe fracture. Criteria for an acceptable reduction include res-toration of the Baumann angle (which is generally >10) onthe anteroposterior radiograph, intact medial and lateral col-umns as seen on the oblique radiographs, and the anteriorhumeral line passing through the middle third of the capitel-lum on the lateral radiograph. As there is considerable rotation

at the shoulder, a certain amount of rotational malalignment inthe axial plane can be tolerated at the fracture site. Any rota-tional malalignment is detrimental to fracture stability, so, if itis present, one must be especially careful in assessing the sta-bility of the reduction and probably use a third fixation pin.

The fracture reduction is held with two or threeKirschner wires, as will be discussed later in this review. Theelbow is immobilized in 40 to 60 of flexion, depending onthe amount of swelling and the vascular status. If there is aconsiderable gap in the fracture site or the fracture is irre-ducible with a so-called rubbery feeling on attempted reduc-tion, the median nerve and/or brachial artery may be trapped

in the fracture site and one should proceed to an open re-duction. A detailed description of this operative technique isavailable in the literature26.

Open Reduction

Open reduction is indicated in cases of failed closed reduction,a dysvascular limb, and open fractures. In the past, open re-duction led to concerns regarding elbow stiffness, myositisossificans, unsightly scarring, and iatrogenic neurovascularinjury. However, several studies have demonstrated a low rateof complications associated with open reduction. In a study of fifty-two displaced fractures treated with open reductionthrough a lateral approach, Weiland et al. reported a moderateloss of motion of 10% (five) of the elbows but no cases of infection, nonunion, or myositis ossificans27. Fleuriau-Chateauet al. reported that, of thirty-four patients treated with openreduction through an anterior approach, 6% (two) had anunsatisfactory loss of motion but none had infection, myositis

ossificans, malunion, or a Volkmann contracture28. Reitmanet al.29 reported that 78% (fifty-one) of sixty-five patientstreated with open reduction (through either a medial or alateral approach) had an excellent or good result according tothe criteria of Flynn et al.30. Loss of motion was reported infour cases. In a prospective, randomized controlled study of twenty-eight children, Kaewpornsawan31 compared closed re-duction and percutaneous pin fixation with open reduction(through a lateral approach); the patients treated with per-cutaneous pin fixation showed no differences with regard to

Fig. 4

The Baumann angle is formed by the line perpen-

dicular to the long axis of the humeral shaft and the

physeal line of the lateral condyle. A decrease in the

Baumann angle may indicate medial comminution.

(Reprinted, with permission, from: Skaggs DL, Flynn

JM. Staying out of trouble in pediatric orthopaedics.

Philadelphia: Lippincott, Williams and Wilkins;

2006.)

Fig. 3

The anterior humeral line should cross the capitel-

lum through the middle third on a true lateral radio-

graph of a normal elbow. (Reprinted, with permission,

from: Skaggs DL, Flynn JM. Staying out of trouble

in pediatric orthopaedics. Philadelphia: Lippincott,

Williams and Wilkins; 2006.)

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cubitus varus, neurovascular injury, the range of motion, theinfection rate, the union rate, or the criteria of Flynn et al.

Although the direct anterior approach to the elbow isnot commonly used by many orthopaedists, it is our preferredapproach, particularly in cases of neurovascular compromise.The anterior approach has the advantages of allowing directvisualization of the brachial artery and median nerve as well asthe fracture fragments. When the operation is performedthrough a relatively small (5-cm) transverse incision along thecubital fossa, the resulting scar is much more cosmetic than isthe scar resulting from the lateral approach, and scar con-traction limiting elbow extension is not an issue. In a seriesof twenty-six patients treated with the anterior approach,Koudstaal et al.32 found the results to be equivalent to those of the traditional lateral or combined lateral and medial approachin terms of malunion, the criteria of Flynn et al.30, and therange of motion.

The posterior approach is generally not recommended

because of the high rate of loss of motion and, more impor-tantly, the risk of osteonecrosis secondary to disruption of theposterior end arterial supply to the trochlea of the humerus33,34.

Treatment by Fracture Type

Type-I FracturesIt is generally agreed that these fractures should be managed ina long arm cast with the elbow in approximately 60 to 90 of flexion for approximately three weeks. It is recommended thatfollow-up radiographs be made at one and two weeks to iden-tify any fracture displacement.

Type-II Fractures

The optimal treatment of type-II fractures has evolved into thecurrent trend of operative intervention rather than cast im-mobilization. The distal part of the humerus provides 20% of the growth of the humerus and thus has little remodeling potential. The upper limb grows approximately 10 cm during the first year of life, 6 cm during the second year, 5 cm during the third year, 3.5 cm during the fourth year, and 3 cm during thefifth year2. Toddlers (less than three years old) have some re-modeling potential so the surgeon may accept nonoperativetreatment of a type-II fracture in which the capitellum abutsthe anterior humeral line but does not cross it. However, achild who is eight to ten years old has only 10% of growth of the distal part of the humerus remaining, so an adequate re-

duction is essential to prevent malunion.The results of two studies support the initial treatment of

type-II fractures with closed reduction and a cast. Hadlow et al.made the point that pin fixation of all type-II fractures in theirseries would have meant that 77% (thirty-seven) of the forty-eight patients would have undergone an unnecessary operativeprocedure35. However, 23% (eleven) of the forty-eight patientsin that series lost reduction following closed reduction andunderwent a delayed operation. Two of fourteen patients whowere followed had a poor outcome on the basis of the criteriaof Flynn et al.30. In a retrospective study of twenty-five elbowstreated with closed reduction and a cast, Parikh et al.36 reported

that 28% (seven) had a loss of reduction, 20% (five) had de-layed surgery, and 8% (two) had an unsatisfactory outcomeaccording to the criteria of Flynn et al.

In contrast, in a consecutive series of sixty-nine childrenwith a type-II fracture treated with closed reduction and pinfixation, there was no radiographic or clinical loss of reduction,no cubitus varus, no hyperextension, no loss of motion, noiatrogenic nerve palsies, and no need for additional surgery 37.In a study of 191 consecutive type-II fractures treated withclosed reduction and percutaneous pin fixation, there werefour pin track infections (2%), three of which were treatedsuccessfully with oral antibiotics and pin removal38. In thefourth case, operative irrigation and débridement was per-formed for a wound infection not involving the joint. Therewere no nerve or vascular injuries and no loss of reduction,delayed union, or malunion.

Another reason for advocating operative treatment of these injuries is that the amount of hyperflexion needed to

maintain reduction of type-II fractures without pin fixationwould predispose these patients to increased compartmentpressures19. In a study by Mapes and Hennrikus, who usedDoppler examination, positions of pronation and increasedflexion were found to decrease flow in the brachial artery 20. Theauthors recommended a position of flexion and supination for‘‘vascular safety.’’ Pin fixation of these fractures obviates theneed for immobilization with considerable elbow flexion. Thebasic concept is that, in any case requiring elbow flexion of >90 to hold reduction, the reduction should instead be heldby pins and the arm should be immobilized with the elbow inless flexion (usually about 45 to 70).

Type-III FracturesIf the child presents to the emergency department with theextremity in either extreme flexion or extreme extension, thearm should be carefully placed in 30 of flexion to minimizevascular insult and compartment pressure. The standard of care in most centers for the treatment of type-III fractures isoperative reduction and pin fixation.

The Special Case of Comminution of the Medial Column

Fractures with medial comminution may not have the dra-matic displacement of most type-III fractures, but they mustbe treated with operative reduction because collapse of themedial column will lead to varus deformity in an arm with an

otherwise minimally displaced supracondylar fracture (Fig. 5).De Boeck et al.39 recommended closed reduction with percu-taneous pin fixation when a fracture has medial comminution,even if it is otherwise minimally displaced, in order to preventcubitus varus. In their retrospective review, cubitus varus didnot develop in any of six patients with medial comminutionwho had undergone operative fixation whereas it developed infour of seven patients who had been treated nonoperatively.

Type-IV FracturesWhile this extremely unstable fracture could be treated withopen reduction, Leitch et al. described a treatment protocol

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utilizing closed reduction in nine patients11. Their recommendedtechnique is to first place two Kirschner wires into the distalfragment. Next, the fracture is reduced in the anteroposteriorplane, and the reduction is verified by imaging. At this point,rather than the arm being rotated for a lateral image, as iscommonly done for more stable fracture patterns, the fluo-roscopy unit is rotated into the lateral view. The fracture is thenreduced in the sagittal plane, and the Kirschner wires are drivenacross the fracture site. All nine fractures treated with this tech-nique united; there were no cases of cubitus varus, malunion,or loss of motion; and no additional operative treatment wasrequired. Because of the limited number of these uncommon

yet potentially problematic fractures, the need for open reductionas well as the true complication rate cannot be predicted.

Complications

Vascular Injury Approximately 10% to 20% of patients with a type-III su-pracondylar fracture present with an absent pulse15,16,40,41. Anabsent radial pulse is not in itself an emergency, as collateralcirculation may keep the limb well perfused. Urgent, butnonemergent, reduction with pin fixation in the operating room is indicated42. An arm that is pulseless with signs of poorperfusion is an emergency. When a patient with a severely

displaced supracondylar fracture and compromised vascularity to the limb presents to the emergency department, the armshould be splinted with the elbow in approximately 20 to 40of flexion4.

Fracture reduction should not be delayed by waiting foran angiographic study, as reduction of the fracture usually restores the pulse43. Several reports have shown angiography tobe an unnecessary test that has no bearing on treatment15,16,41,44.Shaw et al. reported on a series of 143 type-III supracondylarfractures, seventeen of which were associated with vascularcompromise16. All underwent reduction and percutaneous pinfixation without a preoperative angiogram. Blood flow to thehand was not restored after the reduction in three of the sev-enteen patients, and open exploration was required. In four-teen of the seventeen patients, blood flow to the hand wasrestored without complications. The authors concluded thatprereduction angiography adds nothing to the management of these injuries. In another study, angiography was utilized for

four of seventeen dysvascular limbs with a supracondylar hu-meral fracture; the angiogram did not alter the course of management in any of the cases44.

If anatomic reduction cannot be obtained by closed re-duction in the setting of an absent pulse, open reductionthrough an anterior approach is indicated in order to allow evaluation of all vital structures at risk for incarceration betweenthe fracture fragments28,45. Once the artery has been freed fromthe fracture site, arterial spasm may be relieved by application of lidocaine, warming, and ten to fifteen minutes of observation.If, following fracture reduction in a pulseless limb, the pulsedoes not return and the hand remains poorly perfused, vascularreconstruction (usually by a vascular surgeon) is indicated.

There is controversy about what constitutes the besttreatment if the pulse does not return but the hand is wellperfused. Our practice is to admit the child to the hospital,elevate the limb slightly, and observe him or her for at leastforty-eight hours. Loss of perfusion can occur during this timeand necessitate emergent treatment. Alternatively, vascularreconstruction may be performed. However, Sabharwal et al.found that early repair of the brachial artery is associated witha high rate of symptomatic reocclusion and residual stenosis,and they recommended a period of close observation withfrequent neurovascular checks before more invasive correctionof this problem is contemplated42. If a pulse was present pre-operatively but is absent following reduction and pin fixation,

immediate rereduction, which in most cases should be open, isindicated, as the artery or adjacent tissue is presumed to beentrapped in the fracture site.

Neurologic Injury The rate of associated neurologic injury has been reported tobe as high as 49%, but in most modern series it has rangedbetween 10% and 20%17. Previously, investigators reportedthat the radial nerve is injured most often21,46-49, but, as firstnoted by Spinner and Schreiber50, the anterior interosseousnerve actually appears to be the most commonly injured withextension-type supracondylar fractures of the humerus40,51-53.

Fig. 5

Medial comminution is a subtle radiographic finding

and indicates a more unstable fracture variant, which

may collapse into varus if it is not treated appropri-

ately. (Reprinted, with permission, from: Skaggs DL,

Flynn JM. Staying out of trouble in pediatric orthopae-

dics. Philadelphia: Lippincott, Williams and Wilkins;

2006.)

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This condition presents as paralysis of the long flexors of thethumb and index finger without sensory changes. Completemedian nerve injury, due to contusion or transection of thenerve at the level of the fracture, has also been described withthese fractures and presents with sensory loss in the mediannerve distribution as well as motor loss of all muscles inner-vated by the median nerve50,54.

Open reduction of the fracture and exploration of theinjured nerve is not necessarily indicated when a nerve injury is associated with a closed fracture. Neural recovery, regardlessof which nerve is injured, generally occurs after two to 2.5months of observation, but it may take up to six months 4,55.Nerve transections are rare and almost exclusively involve theradial nerve52,56-58.

There is a lack of information in the literature on whichto base treatment of an iatrogenic ulnar nerve injury that oc-curs following placement of a medial pin. Lyons et al. reportedon seventeen patients with an iatrogenic ulnar nerve injury

that was presumably due to a medial pin59. All seventeen pa-tients had a complete return of function, although many didnot have it until four months later. Only four of the seventeenpatients had removal of the medial pins. This study demon-strates that ulnar nerve function can eventually return withoutpin removal.

Rasool demonstrated, with operative exploration, thatthe pin rarely directly impales the ulnar nerve but morecommonly constricts the nerve within the cubital tunnel by tethering adjacent soft tissue60. These findings were later con-firmed by an ultrasonographic study by Karakurt et al.61.Common sense suggests that removal of the causative factor(the medial pin) earlier rather than later may lead to a quicker

recovery of the nerve. However, routine surgical exploration of the ulnar nerve is not recommended30,55,60,62.

Compartment Syndrome The rate of compartment syndrome in the setting of a supra-condylar fracture is estimated to be 0.1% to 0.3%19. Blakemoreet al. found the prevalence of forearm compartment syndrometo be three of thirty-three in association with the combinedinjury of a supracondylar fracture and a radial fracture14.Battaglia et al. showed that the threshold position for increasedforearm pressures is between 90 and 120 of elbow flexion19.This highlights the importance of immobilization of the elbow in a position well below 90 of flexion. In what we believe is the

largest reported retrospective study of compartment syndromefollowing supracondylar humeral fractures in children, Skaggset al. showed that ecchymosis and severe swelling even in thepresence of an intact radial pulse with good capillary refillshould alert the treating physician to the possibility of acompartment syndrome63. Special attention must be paid tosupracondylar fractures with median nerve injury, as the pa-tient will not feel pain in the volar compartment64.

Cubitus VarusSome authors have proposed that unequal growth in the distalpart of the humerus causes cubitus varus deformity 46,65.

However, this is unlikely as there is not enough residual growthleft in this area to cause cubitus varus within the time in whichit is recognized. The most common reason for cubitus varus inpatients with a supracondylar fracture is therefore malunionrather than growth arrest17,23,27,30,66. Cubitus varus can be pre-vented by making certain that the Baumann angle is intact atthe time of reduction and remains so during healing. Pironeet al. reported cubitus varus deformity in eight (8%) of 101patients treated with cast immobilization compared with two(2%) of 105 patients treated with pin fixation, with ages rang-ing from 1.5 to fourteen years (mean, 6.4 years)15.

Treatment for cubitus varus has in the past been con-sidered for cosmetic reasons only. However, there are severalconsequences of cubitus varus such as an increased risk of lateral condyle fractures, pain, and tardy posterolateral rota-tory instability, which may be indications for an operativereconstruction with a supracondylar humeral osteotomy 67-72.

Pin Track InfectionsThe rate of pin track infections in children treated with per-cutaneous Kirschner wire fixation of a fracture has rangedfrom


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Zaltz et al. reported that, when the elbow was flexed>90, the ulnar nerve migrated over, or even anterior to, themedical epicondyle in most (thirty-two) of fifty-two childrenless than five years of age62. Wind et al. showed that the locationof the ulnar nerve cannot be adequately determined by pal-pation to allow blind medial pin placement80. Unfortunately,even making an incision over the medial epicondyle in aneffort to ensure that the ulnar nerve is not directly injured by apin does not guarantee protection of this nerve77. In contrast,Weiland et al. reported that fifty-two patients treated withcrossed pins and use of a small medial incision had no iatro-genic ulnar nerve injuries27. Green et al. reported that, of sixty-five patients treated with two lateral and one medial pin by

means of a mini-open technique, one had an iatrogenic nerveinjury 82.

In a series in which six iatrogenic ulnar nerve injurieswere treated with early exploration, the nerve was directly penetrated by the pin in two cases, constriction of the cubitaltunnel occurred in three cases, and the nerve was fixed anteriorto the medial epicondyle in one case60. Thus, even if directpenetration of the ulnar nerve is avoided, simply placing amedial epicondyle entry pin adjacent to the nerve may causeinjury, presumably by constriction of the cubital tunnel.

One of us (D.L.S.) and colleagues reported on a series of 345 supracondylar humeral fractures treated with percutane-

ous pin fixation and showed that the use of a medial pin wasassociated with a 4% risk of ulnar nerve injury (six of 149)when the medial pin was placed without elbow hyperflexionand a 15% risk (eleven of seventy-one) when the medial pinwas placed with the elbow in hyperflexion77. None of the 125procedures in which the fracture was treated with lateral entry pins alone resulted in iatrogenic ulnar nerve injury. This ob-servation is consistent with the finding of anterior subluxationof the ulnar nerve with elbow flexion beyond 90 in the study by Zaltz et al.62. Thus, one apparently undeniable conclusion isthat, if a medial pin is used, the lateral pin(s) should be placedfirst, the elbow should then be extended, and the medial pinshould be placed without hyperflexion of the elbow. Of course,

the simplest way to avoid iatrogenic nerve injuries is to notplace a medial pin. No iatrogenic ulnar nerve injuries werereported in a series of 124 consecutive fractures stabilized withlateral entry pins only, regardless of the fracture displacementor stability 37.

The second issue with regard to pin configuration isfracture stability. Biomechanical studies of the stability pro-vided by various pin configurations have been somewhatmisleading. In two studies evaluating the torsional strength of pin configurations, crossed pins were found to be strongerthan two lateral pins83,84. Unfortunately, those studies are of little relevance, as the two lateral pins were placed immediately

Fig. 6

Properly placed divergent lateral entry pins. On the anteroposterior radiograph, there should be maximal pin separation at the

fracture site, and the pins should engage both the medial and the lateral column just proximal to the fracture site and should

engage an adequate amount of bone proximal and distal to the fragments. On the lateral radiograph, the pins should incline

slightly in the anterior-to-posterior direction in accordance with normal anatomy. (Reprinted from: Skaggs DL, Cluck MW, Mostofi

A, Flynn JM, Kay RM. Lateral-entry pin fixation in the management of supracondylar fractures in children. J Bone Joint Surg Am.

2004;86:702-7.)

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adjacent to each other and were not separated at the fracturesite as is recommended37,85. A more relevant biomechanicalstudy by Lee et al. showed that two divergent lateral pinsseparated at the fracture site were superior to crossed pins withloading in extension and varus but were equivalent withloading in valgus86. The greater strength seen with divergenceof the pins was attributed to the location of the intersection of the two pins and the fact that the greater amounts of diver-gence between the two pins allow for some purchase in themedial column as well as the lateral column (Figs. 6 and 7).

Bloom et al. reported that three lateral divergent pinswere equivalent to cross-pin fixation and both of these con-structs were stronger than two lateral divergent pins87. Anotherstudy, in which medial comminution was simulated, showedthat three lateral divergent pins had torsional stability equiv-alent to that of standard crossed medial and lateral pins88.Thus, contemporary biomechanical studies support the clini-cal recommendations for use of three lateral entry pins in thetreatment of type-III fractures37,85.

One of us (D.L.S.) and colleagues demonstrated nomalunions or loss of fixation in a series of 124 consecutivefractures treated with lateral entry pins. They recommended

maximal pin separation at the fracture site with engagement of the medial and lateral columns, a low threshold for placementof a third laterally based pin if additional stability is needed,and the use of three pins for type-III fractures37. Gordon et al.further validated this point by recommending use of two lat-eral pins initially for a type-III fracture and then stressing thefracture under fluoroscopy to determine the need for a thirdlateral pin89.

In a study of eight supracondylar humeral fractures thatlost reduction, Sankar et al. reported that the loss of fixation inall cases was due to technical errors that were identifiable onthe intraoperative fluoroscopic images and could have beenprevented with proper technique85. They identified three typesof pin-fixation errors: (1) failure to engage both fragmentswith two pins or more, (2) failure to achieve bicortical fixationwith two pins or more, and (3) failure to achieve adequate pinseparation (>2 mm) at the fracture site. A systematic review of thirty-five articles showed a loss of reduction of zero of 849

fractures treated with crossed pins and four (0.7%) of 606fractures treated with lateral entry pins81.

In a prospective, randomized clinical trial comparing lateral and cross-pin fixation techniques in the treatment of type-III supracondylar humeral fractures, Kocher et al. found

Fig. 7-A

Intraoperative anteroposterior fluoroscopic

view of two lateral entry pins placed for a type-II

fracture. (Reproduced with permission of Chil-drens Orthopaedic Center, Los Angeles.)

Fig. 7-B

Intraoperative anteroposterior fluoro-

scopic view of three lateral entry pins

placed for a type-III fracture. Ideally, the

lateralmost pin could be more lateral,

running directly up the lateral column.

However, the fracture remained stable

during stress under fluoroscopy, so these

pin locations were accepted. (Reproduced

with permission of Childrens Orthopaedic

Center, Los Angeles.)

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no significant difference between the two treatment groupswith regard to any radiographic or clinical outcome measure90.However, because of the lack of power in this study, which hada small sample size of twenty-four patients who had undergonecross-pin fixation, the absence of iatrogenic ulnar nerve injury may have been due to chance alone. Another prospectiverandomized study, by Blanco et al., showed no significantdifference in the radiographic outcomes between lateral entry and cross-pin fixation techniques for the management of type-III supracondylar humeral fractures in children91.

Delayed Treatment The authors of several studies have concluded that an eight totwenty-one-hour delay before surgery does not have any del-eterious effects on the outcomes for children with a supra-condylar fracture75,76,92-94. These studies were all retrospectiveand may have demonstrated good results in large part becauseof the selection bias resulting from experienced pediatric or-

thopaedic surgeons choosing which fractures required urgenttreatment. While we are not aware of any published studies tosupport our opinion, we believe that, if conditions such aspoor perfusion, an associated forearm fracture, firm com-partments, skin puckering, antecubital ecchymosis, or very

considerable swelling are present, operative treatment shouldnot be delayed.

Overview

The current recommended treatment for Gartland type-II andIII fractures is operative reduction and pin fixation. Whencorrect technique is used, lateral entry pins alone providesufficient fixation stability with avoidance of the possibility of iatrogenic ulnar nerve injury. A supracondylar fracture in apulseless limb should be treated with urgent reduction, whichshould not be delayed to await an angiogram as fracture re-duction usually restores perfusion. Associated nerve injuriesnormally resolve, and immediate nerve exploration in patientswith a closed fracture is generally not indicated. n

Reza Omid, MDPaul D. Choi, MDDavid L. Skaggs, MDChildrens Orthopaedic Center, Childrens Hospital Los Angeles,4650 Sunset Boulevard, MS 69, Los Angeles, CA 90027

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Supracondylus Humeri in Child Fracture