Posterolaterally displaced and flexion-type supracondylar fractures are associated with a higher risk of open reduction

Surgical outcomes for Gartland type III supracondylar distal humerus fracture in children: Comparison between flexion and extension types

BACKGROUND

Supracondylar distal humeral (SCH) fractures account for 50-70 % of pediatric elbow fractures, which are divided into extension and flexion type based on the injury mechanism. However, there has been no study comparing the surgical outcome between two types of SCH fractures in terms of radiographic and clinical outcomes. This study aimed to compare the surgical outcomes between the flexion and extension types of Gartland type III SCH fractures in children.

MATERIALS AND METHODS

This retrospective study included the children who underwent surgery for Gartland type III SCH fractures. Radiographic and clinical outcomes were compared between patients who had extension- and flexion-type fractures. Radiographic outcomes were evaluated by measuring the Baumann angle (BA), carrying angle (CA), and lateral capitellohumeral angle (LCHA). Clinical outcomes were assessed using the Flynn criteria. Univariable and multivariable logistic regression analysis was used to assess the risk factors for angular deformities after surgery.

RESULTS

This study included 257 patients (mean age, 6.1 years, 37 flexion-type and 220 extension-type). Pin configuration was significantly different between the two groups (p = 0.001). There were significant differences in radiographic outcomes in terms of BA (p = 0.040) and LCHA (p = 0.001) between the two groups. Flexion-type fractures were a significant risk factor for sagittal deformity, with an odds ratio of 3.225 (p = 0.002). According to the Flynn criteria, a satisfactory outcome (excellent or good) was observed in 158 patients (84.1 %) with the extension type and 25 (67.6 %) with the flexion type, but not statistically significant (p = 0.058).

CONCLUSIONS

In this study, we found that flexion-type supracondylar fractures had poor radiographic outcomes after surgery compared to extension-type fractures although, there was no significant difference between groups in clinical outcomes. Flexion-type fractures were significantly associated with poor sagittal alignment. Clinicians should focus on alignment during surgery, particularly in flexion-type SCH fractures.

Kirschner Wire Prying and Leverage Technique: a new closed reduction method in treatment of pediatric "Irreducible Supracondylar Humerus Fractures"

BACKGROUND

This study employs an innovative closed reduction approach to treat pediatric "Irreducible Supracondylar Humerus Fractures" with the goal of demonstrating its practical application compared to conventional methods.

METHODS

This study sampled 146 surgically treated cases of "Irreducible Supracondylar Humerus Fractures" in our department. After applying inclusion and exclusion criteria, 120 children were selected and divided into two groups based on treatment methods. Group 1 underwent Closed Reduction and Percutaneous Pinning (CRPP), while Group 2 received treatment using the Kirschner Wire Prying and Leverage Technique alongside CRPP. The relevant data to the study were collected and assessed during the follow-up period.

RESULTS

Results indicate that Group 2 demonstrated significantly shorter operative times and fewer instances of intraoperative fluoroscopy compared to Group 1. Furthermore, the percentage of cases requiring open reduction was notably higher in Group 1 than in Group 2. The analysis also identified age, BMI, time from injury to surgery, and the initial deviation of the distal fragment as independent risk factors associated with the failure of closed reduction. The integration of CRPP with the Kirschner Wire Prying and Leverage Technique emerges as a safe and effective strategy for managing "Irreducible Supracondylar Humerus Fractures." This innovative approach not only reduces operative time and intraoperative fluoroscopy needs but also diminishes the reliance on open reduction without compromising safety.

A new technique of intramedullary elastic reduction of the "de-sharpened" Kirschner wire for the treatment of Gartland type III posterolateral displaced supracondylar fracture of the humerus in children

OBJECTIVE

To compare the clinical effects of intramedullary elastic reduction of the "de-sharpened Kirschner wire and traditional three-dimensional manipulation in the treatment of Gartland type III posterolateral supracondylar fracture of the humerus in children.

METHODS

A retrospective cohort analysis was made on 106 cases of Gartland type III posterolateral supracondylar fracture of the humerus treated in the Department of Orthopaedics of a Children's Hospital from March 2020 to March 2022. According to different surgical technology, the patients were divided into two groups: intramedullary elastic reduction of the de-sharpened Kirschner wire group (experimental group, n = 50) and traditional three-dimensional manipulation group (control group, n = 56). The surgical operating time, intraoperative fluoroscopy times, postoperative Baumann angle changes, postoperative elbow function Flynn score, and complications were collected and compared between the two groups.

RESULTS

All the enrolled cases underwent surgery successfully and were followed-up at least 6 months. The surgical operating time of the experimental group was 32.88 ± 3.69 min and that of the control group was 45.56 ± 10.13 min, and the difference was statistically significant (P < 0.05). The intraoperative fluoroscopy times were 20.62 ± 5.41 times in the experimental group and 32.48 ± 8.20 times in the control group (P < 0.05). The change of Baumann angle in the experimental group after operation was 2.3 ± 1.3 and that in the control group was 6.0 ± 2.1 (P < 0.5). Elbow joint Flynn scoring standard to evaluate the curative effect: the excellent and good rate was 98.00% (49/50) in the experimental group and 92.86% (52/56) in the control group (P > 0.5). There were no complications such as osteomyelitis, compartment syndrome, iatrogenic vascular and nerve injury, and myositis ossificans in either group.

CONCLUSIONS

Good functional outcome can be obtained with both intramedullary elastic reduction of the de-sharpened Kirschner wire and traditional three-dimensional manipulation for Gartland type III posterolateral displaced supracondylar fracture of the humerus in children; however, the former does not need repeated manipulation, and the operation time is shorter, the number of intraoperative fluoroscopy is less, and the recovery of the Baumann angle is better.

Technique for facilitating closed reduction of difficult flexion type supracondylar humeral fracture in children

The displaced flexion type supracondylar humeral fractures (SCHF) are inherently unstable and there is great intraoperative difficulty in obtaining and maintaining the fracture reduction by closed means. We introduced a technique for closed reduction and K-wires pinning of displaced flexion type SCHF. Fourteen patients with flexion-type SCHF (9 boys and 5 girls) underwent a reduction technique using a construct of three K-wires. The proximal wire was used for rotational control of the proximal fragment and the two distal wires were used for correction of the flexion and rotational deformity of the distal fragment. The patient's mean age was 7 (6-11) years. Results were evaluated by the anterior humeral line, Baumann's angle, carrying angle radiographically and Flynn's criteria clinically. The mean time for the union was 4.8 (4-6)  weeks. The anterior humeral line passed through the middle one-third of the capitulum in 12 patients and the anterior third in two patients. The mean Baumann's angle was 19.60 ± 3.8 and the mean carrying angle was 14.21 ± 3.04. We reported no cases of failed closed reduction. The median operation time in this study was 30 (25-40)  min. The mean number of C-arm images was 33.5 ± 5.23. According to Flynn's criteria; 10 cases (71.4%) were excellent and 4 (28.6%) were good. This technique can achieve the accurate reduction of flexion type SCHF and avoid the complications of both repeated closed reduction trials and open reduction. Level of Evidence: Level IV, case series.

Predictive factors for open reduction of flexion-type supracondylar fracture of humerus in children

Objective

The incidence of open reduction and internal fixation (ORIF) in flexion-type supracondylar humerus fractures (SCHF) in children is significantly higher than that of extension-type fractures. This study aimed to identify risk factors for ORIF in flexion-type SCHF.

Methods

One hundred seventy-one patients with Wilkins type III flexion-type SCHF from January 2012 to December 2021 were retrospectively enrolled in a tertiary paediatric hospital. Patients were divided into ORIF group versus closed reduction and internal fixation (CRIF) group. Then, patients data of age, sex, injury side, obesity, deviation of displacement, fracture level, rotation, nerve injury, and delay from injury to surgery were reviewed. Univariate analysis and multivariate logistic regression were used to identify independent risk factors and odds ratios (OR) of ORIF.

Results

Overall, 171 children with type III flexion-type SCHF were analyzed (average aged 7.9 ± 2.8 years). Displacement was lateral in 151 cases, medial in 20. 20 cases had combined ulnar nerve injury. The failed closed reduction rate was 20%. Univariate analysis indicated age, distal fracture fragment rotation, and ulnar nerve injury were significantly associated with ORIF. (P = 0.047, P = 0.009, and P = 0.001, respectively). Multivariate logistic regression analysis showed that distal fracture fragment rotation (OR, 3.3; 95%CI:1.1–9.5; P = 0.028) and ulnar nerve injury (OR, 6.4; 95%CI:2.3–18.3; P = 0.001) were independent risk factors; however, the age was not an independent one (OR, 1.5; 95%CI:0.6–3.5; P = 0.397) for ORIF in the Wilkins type III flexion-type SCHF.

Conclusion

Distal fracture fragment malrotation on initial x-rays and ulnar nerve injury were significant risk factors for ORIF in Wilkins type III flexion-type SCHF. Surgeons should prepare tourniquets or other open reduction instruments when treating these types of fractures.

Level of evidence

Level IV

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05798-5.

Factors associated with conversion to open reduction of type 3 supracondylar humerus fractures in children

BACKGROUND

The US News and World report utilizes the number of supracondylar humerus fractures treated in an open procedure, excluding open fractures and vascular exploration, as a metric in assessing Pediatric Orthopedic trauma care. The purpose of this study was to identify factors that increase the likelihood of a patient needing open reduction for Gartland Type 3 SCH fractures.

METHODS

All pediatric patients who underwent surgical management of closed, Type 3 SCH fractures at our Pediatric Level 1 Trauma Center between 2011 and 2017 were considered for inclusion. Patient age greater than 16 years, patients with closed physes and open fractures were excluded. Electronic medical records and radiographic imaging were reviewed. Student's t- and chi-squared tests were used, and logistic regression was performed comparing closed v open reduction.

RESULTS

362 subjects were included in this study. 318/362 (87.8%) were treated with closed reduction. 44/362 (12.2%) required open reduction. There were no statistically significant differences in age, gender, BMI, concomitant ipsilateral extremity fractures, Type 4 unstable fracture or patients that underwent hospital transfer. The mechanisms of injury with the greatest percentage requiring open reduction were fall from furniture and trampoline. Of those patients that underwent open reduction, 65.9% had posterolateral displacement of the fracture. Those with displacement >4 mm had 3.14 higher odds of requiring an open reduction (p = 0.002). The anterior spike fracture pattern had the highest rate of failed closed reduction of 66.7%. Of those patients that had an open reduction, 13/44 (29.5%) had a neuropraxia and 5/44 (11.4%) had vascular compromise. Those with neuropraxia had 3.26 higher odds of requiring an open reduction (p = 0.005). Time to operating room was significantly shorter in patients that underwent open reduction (p < 0.001).

CONCLUSION

Our rate of open reduction for Type 3 SCH fractures, 12.2%, is consistent with previously described rates. Posterolateral displacement of fractures, displacement >4 mm, fractures with an anterior spike and fractures associated with neurovascular compromise are more likely to undergo open reduction. Transfer status, BMI and patient age were not associated with open reduction. Open reduction was associated with shorter time to the operating room, likely representing the urgent care of significantly displaced fractures associated with neurovascular compromise.

LEVEL OF EVIDENCE

Level III.

Supracondylar Humerus Fractures: Classification Based Treatment Algorithms

Supracondylar humerus fractures are the most common fractures around the elbow in children between 4 and 10 years of age. The treatment of supracondylar humerus fractures can vary from conservative treatment to operative treatment depending on the fracture type. All around the world, the most commonly used classification system is the Wilkins-modified Gartland classification of supracondylar humerus fractures. Currently, the decision to operate or conserve the fracture is taken on basis of this classification system. Non-operative treatment for type I fractures and operative treatment for type III fractures have been well-established in literature. The management of type II supracondylar humerus fracture creates confusion in the minds of numerous orthopaedic surgeons around the world. We have tried addressing this using a classification-based treatment algorithm. Other classification systems like the AO classification, Lagrange and Rigault classification and Bahk classification with special reference to special fracture patterns that require attention and pre-op planning have also been mentioned. It is important to understand that operative management of each supracondylar humerus fracture is unique as regards fixation method and it is important to consider the fracture pattern before internal fixation.

Manejo da fratura supracondiliana do úmero na criança

Supracondylar humeral fracture represents ∼ 3 to 15% of all fractures in children. It is the fracture that most requires surgical treatment in the pediatric population. Advances in treatment and care have contributed to a reduction in the most dramatic complication: Volkmann ischemic contracture. Nevertheless, the risks inherent to the fracture remain. Absence of palpable pulse in type-III fractures is reported in up to 20% of the cases. Careful sensory, motor, and vascular evaluation of the affected limb is crucial in determining the urgency of treatment. Older children, male patients, floating elbow, and neurovascular injury are risk factors for compartment syndrome. Medial comminution can lead to varus malunion, even in apparently innocent cases. The recommended treatment of displaced fractures is closed reduction and percutaneous pinning. Technical errors in pin placement are the main cause of loss of reduction. There is enough evidence for the addition of a third lateral or medial Kirschner wire in unstable fractures (types III and IV). Medial comminution may lead to cubitus varus even in mild displaced fractures. Based on current concepts, a flowchart for the treatment of supracondylar humeral fracture in children is suggested by the authors.

Flexion-Type Supracondylar Humeral Fracture with Ulnar Nerve Injury in Children: Two Case Reports and Review of the Literature

Case series

Patients: Female, 7-year-old • Male, 6-year-old

Final Diagnosis: Flexion-type supracondylar humeral fracture

Symptoms: Pain

Medication: —

Clinical Procedure: —

Specialty: Orthopedics and Traumatology

A comparison of fluoroscopic exposure and operative time during treatment of displaced supracondylar elbow fractures in children

Background

Intraoperative fluoroscopy can potentially expose the surgeon to levels of radiation beyond the recommended limits. This study aimed to assess the intraoperative differences between the fixation of types 2 and 3 supracondylar fractures for fluoroscopy time, operative time, direction of displacement, and potential cumulative risk of radiation to the surgeon.

Methods

Retrospective chart analysis was used to review 74 consecutive subjects with type 2 or 3 extension supracondylar fractures over a six-year period. Closed reduction and percutaneous pinning with fluoroscopy was used in all cases. Fluoroscopy time and operative time were analyzed based on the fracture type, direction of initial displacement, and the number of K-wires used.

Results

Type 2 supracondylar fractures require less fluoroscopy (mean: 16.8 s) and are shorter operations (mean: 19.2 min) when compared to type 3 (26.2 s and 25.1 min; p<0.05). The direction of displacement (posteromedial vs. posterolateral) did not influence operative (23.8 vs. 26.5 min) or fluoroscopy times (27.6 vs. 24.9 s; p>0.05).

Conclusions

Type 3 supracondylar fractures utilize more fluoroscopy time and operative time than type 2 fractures. The direction of displacement did not affect fluoroscopy time or operative time. Surgeons who perform large numbers of closed reduction and percutaneous pinning may be exposed to excess amounts of radiation.

Flexion-Type Supracondylar Humeral Fractures: Ulnar Nerve Injury Increases Risk of Open Reduction

BACKGROUND

The vast majority of displaced pediatric supracondylar humeral fractures can be treated successfully with closed reduction and percutaneous pinning. The need for open reduction is difficult to determine a priori and is typically due to the failure of closed reduction attempts or persistent limb ischemia. The aims of this study were to determine the prevalence of flexion-type supracondylar humeral fractures, the rate of open reduction for flexion-type fractures, and the predictive impact of ulnar nerve injury on the need for open reduction for flexion-type supracondylar humeral fractures.

METHODS

We developed a database of consecutive pediatric supracondylar humeral fractures treated operatively at a tertiary care pediatric trauma center from 2000 to 2015. Data recorded included age, mechanism of injury, fracture type (open or closed), fracture pattern (flexion-type or extension-type), concomitant skeletal injury, neurovascular injury, treatment, and surgeon. Radiographs of all flexion-type supracondylar humeral fractures were reviewed in order to confirm the classification of the injury pattern. The rate of open reduction for fractures with a flexion-type injury pattern and for such fractures with and without ulnar nerve injury at presentation was assessed.

RESULTS

Of 2,783 consecutive pediatric supracondylar humeral fractures treated by surgeons at our center, 95 (3.4%) were flexion-type fractures. Ulnar nerve injury was noted for 10 (10.5%) of the 95 flexion-type fractures. Open injuries were identified at presentation in 3 (3.2%) of the 95 cases. Among closed fractures, 21 (22.8%) of 92 flexion-type fractures required open reduction compared with 50 (1.9%) of 2,647 extension-type fractures (odds ratio [OR] = 15.4; 95% confidence interval [CI] = 8.8 to 27.0; p < 0.001). Among closed flexion-type fractures, open reduction was performed in 6 (60%) of 10 fractures with associated ulnar nerve injury and in 15 (18.3%) of 82 fractures without ulnar nerve injury (OR = 6.7; 95% CI = 1.7 to 26.7; p = 0.003).

CONCLUSIONS

Among closed supracondylar humeral fractures, the flexion-type injury pattern was associated with a 15.4-fold increase in the odds of open reduction. The presence of an ulnar nerve injury at presentation resulted in an additional 6.7-fold higher risk of open reduction among flexion-type supracondylar humeral fractures. Patients and families should be counseled regarding the high rate of open reduction for flexion-type supracondylar humeral fractures, particularly those with an associated ulnar nerve injury.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

The Use of a Transolecranon Pin in the Treatment of Pediatric Flexion-type Supracondylar Humerus Fractures

BACKGROUND

Flexion-type supracondylar humerus fractures are much more uncommon than their extension-type counterparts. Instability in elbow flexion renders traditional closed techniques inadequate and often results in the need for open reduction. We present a simple technique for closed reduction using a transolecranon pin for temporary stability.

METHODS

A retrospective review of 9 patients treated with a transolecranon pin technique for a flexion-type supracondylar humerus fracture was performed. Operative time, need for open reduction, postoperative range of motion, final radiographic alignment using Baumann angle, and the intersection of the anterior humeral line with the capitellum was evaluated.

RESULTS

All 9 patients were treated with closed reduction using a temporary transolecranon pin technique. Total surgical time averaged 38±15 minutes and was longer for type III than type II flexion-type fractures. All fractures healed by first follow-up at 1 month. There was 1 preoperative ulnar nerve deficit that resolved by the first postoperative visit. Average Baumann angle at radiographic healing was 71.2±3.3 degrees and all cases showed restoration of the normal anterior humeral line:capitellar relationship. Average postoperative flexion at final follow-up was 125 degrees and extension was 5 degrees. One patient had a flexion contracture of 10 degrees.

DISCUSSION

Use of a temporary transolecranon pin allowed for closed reduction of all flexion-type fractures with no radiographic malunion. This technique is technically simple and avoids the need for open reduction or multiple fluoroscopy views.

LEVEL OF EVIDENCE

Level IV-case series.