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Open reduction and pinning of displaced supracondylar fractures in children
Abstract
Purpose: The aim of this retrospective study was to evaluate the results of a primary open reduction and pinning of displaced supracondylar fractures in children. Methods: 25 children with displaced supracondylar humerus fractures were treated by primary open reduction and crossed K-wire fixation through a dorsal approach at the Kantonsspital Baden between 1992 and 1995. Twenty-four children with a mean age of 6.9 years (ranging from 3 to 13 years) were reviewed clinically at a mean follow-up of 2.4 years (ranging from 1 to 4 years). Results: At the time of review 3 children showed a flexion deficit of 10 to 15 degrees and 3 patients of 15 degrees or more. All children were able to extend the elbow 180 degrees. There were no varus or valgus deformities visible. No neurological complications occurred during surgery. Conclusions: Primary open reduction and crossed K-wire fixation through a dorsal approach for displaced supracondylar fractures in children allows an anatomical reposition of the fracture without neurological complications.
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Um der Ursache posttraumatischer Deformitten, vor allem des Cubitus varus auf den Grund zu gehen, wurden 183 dislozierte und 20 undislozierte supracondylre Extensionsfrakturen des Humerus nachuntersucht. Es waren verschiedene Therapieverfahren angewandt wurden: Nach meist geschlossener Reposition, Fixation im Spitzwinkelgips oder durch percutan eingebrachte, radiale oder radial und ulnar gekreuzte Drhte. Radiologisch fanden sich in etwa 75% der dislozierten Frakturen Achsenfehler in der Frontalebene gegenber der unverletzten Seite, klinisch in 55%. Als Ursache konnte eindeutig der Rotationsfehler ermittelt wurden, der bei Schrgfrakturen direkt, bei Querfrakturen indirekt ber den Weg der Instabilitt zur Varisierung, seltener auch zur Valgisierung der Ellenbogenachse fhrt. Ein spezieller Quotient zur Beurteilung des Rotationsfehlers (rfq) wird vorgestellt. Seitliche Einstauchungen allein haben keinen Einflu auf die Ellbogenachse. Seitliche Abkippungen sind stets Folge eines Rotationsfehlers. Wachstumsstrungen sind nach supracondylren Frakturen auch ohne Lsion der Epiphysenfuge mglich. Wegen der Seltenheit und des geringen Ausmaes sind sie aber ohne wesentliche klinische Bedeutung. Antekurvationsstellungen wurden bis zu ca. 80% spontan im weiteren Wachstum — unabhngig vom Alter bei Fraktur — vollstndig korrigiert. Es wird die klinische Bedeutung posttraumatischer Deformitten und die primre Therapie zur Vermeidung derselben besprochen. Als Mittel der Wahl — bei strenger Beachtung der technischen Fehlermglichkeiten — wird die rotationsstabile, gekreuzte, percutane Spickdrahtosteosynthese nach rotationsfehlerfreier Reposition empfohlen. An alle Therapieverfahren wird die Forderung gestellt, den ventralen Sporn, als Zeichen des Rotationsfehlers strikt bis zur sicheren Konsolidation der Fraktur zu vermeiden. Bei sonstiger korrekter Reposition der Fraktur erbrigen sich damit komplizierte Messungen und berlegungen, um nach Beendigung der Behandlung einer zufriedenstellenden Ellbogenachse sicher zu sein. (Alpha-Winkel?, Schrg-Querfraktur?, Ausma eines eventuellen Rotationsfehlers?, Ruhigstellung des Vorderarms in Pro-Supination? etc.)To find out the cause of posttraumatic varus and valgus deformity of the elbow a long-term follow-up examination of 183 dislocated and 20 undislocated supracondylar extension-fractures of the humerus was done. There were different methods of treatment: In most of the cases closed reduction was performed and fixation in acute angle-plaster or by percutaneous radial or radial and ulnar wires. 75% showed radiologically and 55% clinically an alteration of the carrying angle. The clear reason for this deformity was a rotation displacement, which leads in oblique fractures directly, in transverse fractures—caused by an instability—indirectly seldom to a valgus, in most of the cases to a varus deformity of the elbow. A special quotient to judge the rotation displacement is presented: the rotation failure quotient (rfq).There is no influence of lateral compression to the carrying angle. Lateral tilting is in any case a result of rotation displacement. Growth disturbance after supracondylar fractures is possible without lesion of the epiphysial plate: but as growth disturbances are seldom and their extent small, they are of no significant clinical importance.Extension displacement of the distal fragment will be spontaneously corrected in ca. 80% of all cases during the further growth. The clinical importance of posttraumatic deformities and the primary management to avoid them is discussed. The crossed percutaneous rotation-stable wire osteosynthesis is recommended as the best way of treatment. For all kinds of treatment the challenge is asked to avoid the ventral spur as a sign of rotation till consolidation of the fracture. By correct reposition in all other planes complicated measurements and reflections, as for instance the alpha-angle by Baumann, oblique or transverse fracture, pro- or supination of the forearm during fixation a. o. are unnecessary.
A series of supracondylar fractures of the humerus in children is presented. The majority was reduced by closed manipulation. The difficult fractures were defined as those in which adequate reduction either could not be achieved by manipulation or was not maintained, or those in which neurological or vascular complications occurred. Such cases were treated by open reduction and internal fixation. The results were assessed with regard to loss of elbow movement, deformity and symptoms. The results of the operative series were comparable with those achieved by closed manipulation in the easier cases. No secondary corrective procedures were necessary. It is concluded that closed manipulation should be used routinely as the method of treatment for supracondylar fractures of the humerus in children, except in the difficult case, for which operative treatment should be undertaken. Stiffness or deformity does not follow open reduction and internal fixation.
Report and analysis of the results of treatment of 56 children who exhibited a typical supracondylar fracture of the humerus necessitating reposition and treatment by clinical methods. The functional results were good on the whole and they were not clearly dependent on the nature of the treatment. The treatment consisting in manual reposition followed by application of a plaster cast was followed in about 50% of the cases by disfiguring cubitus varus. The causes of this phenomenon are discussed. The typical endorotation of the distal fracture fragment in regard to the proximal fragment plays an important part in causing cubitus varus. Cubitus varus may be prevented by wire traction through the olecranon, even if the rotation displacement persists. For this reason, this treatment is recommended. If the rotation displacement persists in the course of the traction treatment, it is advisable to use Baumann's method of demonstrating and correcting a possible varus tilting during the course of the traction treatment. If development of cubitus varus is still suspected, surgical reposition and fixation are possible, a safe method which gives good results. The surgical treatment should achieve an anatomically correct position of the fragments.
Six cases of supracondylar fracture of the humerus in children were treated by closed reduction and percutaneous pinning with two Kirschner wires inserted laterally through the capitellum of the humerus. This treatment has the same advantages as the commonly used percutaneous pinning with crossed Kirschner wires inserted through the epicondyles of the humerus, and it further eliminates the risk of damaging the ulnar nerve by the insertion of the medial Kirschner wire. © 1978 Informa UK Ltd All rights reserved: reproduction in whole or part not permitted.
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.
To get information about the importance of malrotation for posttraumatic varus or valgus deformity a clinical, radiological and CT follow-up examination of 20 children who were treated for supracondylar fracture from 1983 to 1985 was done. Rotational-displacement was measured on computed tomographical images taken from the region where fracture had happened. On the ap follow-up X-ray from both, the fractured and the other side, and the X-ray which was made after reduction, the medial and lateral colonne were measured from a "special point" in the middle of the shaft of the humerus. The length of the colonnes and their difference were compared. 15 of the 20 patients showed internal malrotation, 1 patient external malrotation and 4 showed no rotational-displacement. In 15 of the 16 patients with malrotation, the rotational-displacement caused a change in the length of the colonnes. Just in one case malrotation caused a minimal deformity of the carrying angle without alteration of the length of the colonnes. 93% of the cases with internal malrotation showed varus deformity. In 3 cases we saw growth disturbance of the epiphyseal plate, but the induced alteration of the length of the colonnes were minimal compared with the changes caused by malrotation.
Supracondylar fractures of the humerus are the most common fractures in children. They occur between the age of 2 and 15 yr, and most frequently between 3 and 8 yr. For purposes of comparison, Holmberg1 classified these fractures into four types, according to the degree of displacement. In France, LaGrange's2 classification, established at the 1962 French Orthopedic Society meeting concerning elbow fractures in children, is used. The two classifications are similar.Type 4 represents fracture with complete displacement without contact between the fragments, and the aim of this paper is to advocate surgery using an anterior and internal approach in the treatment of such supracondylar fractures. Therefore, types 1, 2, and 3 fractures, were no surgery is indicated, are not considered here, nor are complicated fractures where the indication for surgery is admitted by a great majority of authors, or medial and external condyle fractures of the humerus that represent a completely different problem.
To describe the anterior approach for open reduction of supracondylar fractures in children and to assess the morbidity and functional outcome.
Retrospective analysis.
University Hospital.
Eleven consecutive children (mean age 6 years, range 4-12) with supracondylar fractures who were treated by open reduction and fixation with a Kirschner wire through an anterior approach from 1984-1990 and followed up after a mean of 9 weeks (range 5-16 weeks).
There was no morbidity. Full functional recovery was achieved within four months of the accident. One patient had a mild (10 degrees) varus deformity with normal function of the elbow.
Open reduction of supracondylar fractures and fixation with a Kirschner wire through an anterior approach is a logical, safe and elegant technique, which we recommend for children in whom closed reduction has failed.
A study correlating the degree of medial rotational deformity of the distal humerus and the degree of cubitus varus deformity secondary to supracondylar fracture was performed in 23 patients who underwent corrective supracondylar osteotomy. The mean age of the patients at the time of operation was 10.9 years (range 5-14 years). The time interval from injury to operation averaged 3.2 years (range 1-6 years). A medial rotational deformity occurred in 20 cases. The degree of medial rotational deformity (MRD) averaged 16.2 degrees (range 0-34 degrees). Mean carrying angles (CA) of the deformed and normal sides were -19.6 degrees and 6.5 degrees, respectively. Mean humero-elbow-wrist (HEW) angles, measured from radiographs, of the deformed and normal sides, were -18.8 degrees and 7.7 degrees, respectively. There was no correlation between the degree of MRD and the degree of varus deformity, using as a comparison either the CA or the HEW angle of the deformed elbow or their differences from the normal side.