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CC BY-NC-ND 4.0 · Rev Bras Ortop (Sao Paulo) 2022; 57(01): 023-032
DOI: 10.1055/s-0040-1709734
Artigo de Atualização
Ortopedia Pediátrica

Management of Supracondylar Humeral Fracture in Children

Artikel in mehreren Sprachen: português | English
Pedro Poggiali 
1   Pediatric Orthopedic Surgery, Rede Mater Dei de Saúde, Belo Horizonte, Minas Gerais, Brazil
,
Francisco Carlos Salles Nogueira 
1   Pediatric Orthopedic Surgery, Rede Mater Dei de Saúde, Belo Horizonte, Minas Gerais, Brazil
,
Maria Paula de Mello Nogueira 
1   Pediatric Orthopedic Surgery, Rede Mater Dei de Saúde, Belo Horizonte, Minas Gerais, Brazil
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Abstract

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.

Keywords

humeral fractures - elbow - child - fracture fixation


Publikationsverlauf

Eingereicht: 17. August 2019

Angenommen: 27. Januar 2020

Artikel online veröffentlicht:
23. Juli 2020

© 2020. Sociedade Brasileira de Ortopedia e Traumatologia. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commecial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)

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  • Referências

  • 1 Omid R, Choi PD, Skaggs DL. Supracondylar humeral fractures in children. J Bone Joint Surg Am 2008; 90 (05) 1121-1132
    CrossrefPubMedGoogle Scholar
  • 2 Robertson AK, Snow E, Browne TS, Brownell S, Inneh I, Hill JF. Who Gets Compartment Syndrome?: A Retrospective Analysis of the National and Local Incidence of Compartment Syndrome in Patients With Supracondylar Humerus Fractures. J Pediatr Orthop 2018; 38 (05) e252-e256
    CrossrefPubMedGoogle Scholar
  • 3 Alton TB, Werner SE, Gee AO. Classifications in brief: the Gartland classification of supracondylar humerus fractures. Clin Orthop Relat Res 2015; 473 (02) 738-741
    CrossrefPubMedGoogle Scholar
  • 4 Skaggs DL, Flynn JM. Supracondylar Fractures of the Distal Humerus. In: Waters PM, Skaggs DL, Flynn JM, Court-Brown CM. editors. Rockwood & Wilkins' fractures in children. Philadelphia: Wolters Kluwer; 2010: 754-844
    Google Scholar
  • 5 Holt JB, Glass NA, Shah AS. Understanding the Epidemiology of Pediatric Supracondylar Humeral Fractures in the United States: Identifying Opportunities for Intervention. J Pediatr Orthop 2018; 38 (05) e245-e251
    CrossrefPubMedGoogle Scholar
  • 6 Sankar WN, Hebela NM, Skaggs DL, Flynn JM. Loss of pin fixation in displaced supracondylar humeral fractures in children: causes and prevention. J Bone Joint Surg Am 2007; 89 (04) 713-717
    PubMedGoogle Scholar
  • 7 Abzug JM, Herman MJ. Management of supracondylar humerus fractures in children: current concepts. J Am Acad Orthop Surg 2012; 20 (02) 69-77
    CrossrefPubMedGoogle Scholar
  • 8 Badkoobehi H, Choi PD, Bae DS, Skaggs DL. Management of the pulseless pediatric supracondylar humeral fracture. J Bone Joint Surg Am 2015; 97 (11) 937-943
    CrossrefPubMedGoogle Scholar
  • 9 American Academy of Orthopaedic Surgeons. The Treatment of Pediatric Supracondylar Humerus Fractures. Rosemont, IL: AAOS; 2011
    Google Scholar
  • 10 American Academy of Orthopaedic Surgeons. Appropriate Use Criteria for the Management of Pediatric Supracondylar Humerus Fractures. Rosemont, IL: AAOS; 2014
    Google Scholar
  • 11 Ho CA, Podeszwa DA, Riccio AI, Wimberly RL, Ramo BA. Soft Tissue Injury Severity is Associated With Neurovascular Injury in Pediatric Supracondylar Humerus Fractures. J Pediatr Orthop 2018; 38 (09) 443-449
    CrossrefPubMedGoogle Scholar
  • 12 Flynn K, Shah AS, Brusalis CM, Leddy K, Flynn JM. Flexion-Type Supracondylar Humeral Fractures: Ulnar Nerve Injury Increases Risk of Open Reduction. J Bone Joint Surg Am 2017; 99 (17) 1485-1487
    CrossrefPubMedGoogle Scholar
  • 13 Gartland JJ. Management of supracondylar fractures of the humerus in children. Surg Gynecol Obstet 1959; 109 (02) 145-154
    PubMedGoogle Scholar
  • 14 Wilkins KE. Supracondylar fractures: what's new?. J Pediatr Orthop B 1997; 6 (02) 110-116
    CrossrefPubMedGoogle Scholar
  • 15 Spencer HT, Dorey FJ, Zionts LE. et al. Type II supracondylar humerus fractures: can some be treated nonoperatively?. J Pediatr Orthop 2012; 32 (07) 675-681
    CrossrefPubMedGoogle Scholar
  • 16 Ariyawatkul T, Eamsobhana P, Kaewpornsawan K. The necessity of fixation in Gartland type 2 supracondylar fracture of the distal humerus in children (modified Gartland type 2A and 2B). J Pediatr Orthop B 2016; 25 (02) 159-164
    CrossrefPubMedGoogle Scholar
  • 17 Silva M, Delfosse EM, Park H, Panchal H, Ebramzadeh E. Is the “Appropriate Use Criteria” for Type II Supracondylar Humerus Fractures Really Appropriate?. J Pediatr Orthop 2019; 39 (01) 1-7
    CrossrefPubMedGoogle Scholar
  • 18 Leitch KK, Kay RM, Femino JD, Tolo VT, Storer SK, Skaggs DL. Treatment of multidirectionally unstable supracondylar humeral fractures in children. A modified Gartland type-IV fracture. J Bone Joint Surg Am 2006; 88 (05) 980-985
    CrossrefPubMedGoogle Scholar
  • 19 Novais EN, Andrade MAP, Gomes DC. The use of a joystick technique facilitates closed reduction and percutaneous fixation of multidirectionally unstable supracondylar humeral fractures in children. J Pediatr Orthop 2013; 33 (01) 14-19
    CrossrefPubMedGoogle Scholar
  • 20 Mulpuri K, Wilkins K. The treatment of displaced supracondylar humerus fractures: evidence-based guideline. J Pediatr Orthop 2012; 32 (02, Suppl 2): S143-S152
    CrossrefPubMedGoogle Scholar
  • 21 Garg S, Weller A, Larson AN. et al. Clinical characteristics of severe supracondylar humerus fractures in children. J Pediatr Orthop 2014; 34 (01) 34-39
    CrossrefPubMedGoogle Scholar
  • 22 Choi PD, Melikian R, Skaggs DL. Risk factors for vascular repair and compartment syndrome in the pulseless supracondylar humerus fracture in children. J Pediatr Orthop 2010; 30 (01) 50-56
    CrossrefPubMedGoogle Scholar
  • 23 Mehlman CT, Strub WM, Roy DR, Wall EJ, Crawford AH. The effect of surgical timing on the perioperative complications of treatment of supracondylar humeral fractures in children. J Bone Joint Surg Am 2001; 83 (03) 323-327
    CrossrefPubMedGoogle Scholar
  • 24 Gupta N, Kay RM, Leitch K, Femino JD, Tolo VT, Skaggs DL. Effect of surgical delay on perioperative complications and need for open reduction in supracondylar humerus fractures in children. J Pediatr Orthop 2004; 24 (03) 245-248
    CrossrefPubMedGoogle Scholar
  • 25 Abbott MD, Buchler L, Loder RT, Caltoum CB. Gartland type III supracondylar humerus fractures: outcome and complications as related to operative timing and pin configuration. J Child Orthop 2014; 8 (06) 473-477
    CrossrefPubMedGoogle Scholar
  • 26 Bales JG, Spencer HT, Wong MA, Fong YJ, Zionts LE, Silva M. The effects of surgical delay on the outcome of pediatric supracondylar humeral fractures. J Pediatr Orthop 2010; 30 (08) 785-791
    CrossrefPubMedGoogle Scholar
  • 27 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 (04) 702-707
    CrossrefPubMedGoogle Scholar
  • 28 Pennock AT, Charles M, Moor M, Bastrom TP, Newton PO. Potential causes of loss of reduction in supracondylar humerus fractures. J Pediatr Orthop 2014; 34 (07) 691-697
    CrossrefPubMedGoogle Scholar
  • 29 Bloom T, Robertson C, Mahar AT, Newton P. Biomechanical analysis of supracondylar humerus fracture pinning for slightly malreduced fractures. J Pediatr Orthop 2008; 28 (07) 766-772
    CrossrefPubMedGoogle Scholar
  • 30 Wallace M, Johnson Jr DB, Pierce W, Iobst C, Riccio A, Wimberly RL. Biomechanical Assessment of Torsional Stiffness in a Supracondylar Humerus Fracture Model. J Pediatr Orthop 2019; 39 (03) e210-e215
    CrossrefPubMedGoogle Scholar
  • 31 Bauer JM, Stutz CM, Schoenecker JG, Lovejoy SA, Mencio GA, Martus JE. Internal Rotation Stress Testing Improves Radiographic Outcomes of Type 3 Supracondylar Humerus Fractures. J Pediatr Orthop 2019; 39 (01) 8-13
    CrossrefPubMedGoogle Scholar
  • 32 Zenios M, Ramachandran M, Milne B, Little D, Smith N. Intraoperative stability testing of lateral-entry pin fixation of pediatric supracondylar humeral fractures. J Pediatr Orthop 2007; 27 (06) 695-702
    CrossrefPubMedGoogle Scholar
  • 33 Gottschalk HP, Sagoo D, Glaser D, Doan J, Edmonds EW, Schlechter J. Biomechanical analysis of pin placement for pediatric supracondylar humerus fractures: does starting point, pin size, and number matter?. J Pediatr Orthop 2012; 32 (05) 445-451
    CrossrefPubMedGoogle Scholar
  • 34 Kocher MS, Kasser JR, Waters PM. et al. Lateral entry compared with medial and lateral entry pin fixation for completely displaced supracondylar humeral fractures in children. A randomized clinical trial. J Bone Joint Surg Am 2007; 89 (04) 706-712
    CrossrefPubMedGoogle Scholar
  • 35 Lee KM, Chung CY, Gwon DK. et al. Medial and lateral crossed pinning versus lateral pinning for supracondylar fractures of the humerus in children: decision analysis. J Pediatr Orthop 2012; 32 (02) 131-138
    CrossrefPubMedGoogle Scholar
  • 36 Gaston RG, Cates TB, Devito D. et al. Medial and lateral pin versus lateral-entry pin fixation for Type 3 supracondylar fractures in children: a prospective, surgeon-randomized study. J Pediatr Orthop 2010; 30 (08) 799-806
    CrossrefPubMedGoogle Scholar
  • 37 Lee YH, Lee SK, Kim BS. et al. Three lateral divergent or parallel pin fixations for the treatment of displaced supracondylar humerus fractures in children. J Pediatr Orthop 2008; 28 (04) 417-422
    CrossrefPubMedGoogle Scholar
  • 38 Skaggs DL, Hale JM, Bassett J, Kaminsky C, Kay RM, Tolo VT. Operative treatment of supracondylar fractures of the humerus in children. The consequences of pin placement. J Bone Joint Surg Am 2001; 83 (05) 735-740
    CrossrefPubMedGoogle Scholar
  • 39 Silva M, Knutsen AR, Kalma JJ. et al. Biomechanical testing of pin configurations in supracondylar humeral fractures: the effect of medial column comminution. J Orthop Trauma 2013; 27 (05) 275-280
    CrossrefPubMedGoogle Scholar
  • 40 Woratanarat P, Angsanuntsukh C, Rattanasiri S, Attia J, Woratanarat T, Thakkinstian A. Meta-analysis of pinning in supracondylar fracture of the humerus in children. J Orthop Trauma 2012; 26 (01) 48-53
    CrossrefPubMedGoogle Scholar
  • 41 Babal JC, Mehlman CT, Klein G. Nerve injuries associated with pediatric supracondylar humeral fractures: a meta-analysis. J Pediatr Orthop 2010; 30 (03) 253-263
    CrossrefPubMedGoogle Scholar
  • 42 Slobogean BL, Jackman H, Tennant S, Slobogean GP, Mulpuri K. Iatrogenic ulnar nerve injury after the surgical treatment of displaced supracondylar fractures of the humerus: number needed to harm, a systematic review. J Pediatr Orthop 2010; 30 (05) 430-436
    CrossrefPubMedGoogle Scholar
  • 43 Silva M, Cooper SD, Cha A. The Outcome of Surgical Treatment of Multidirectionally Unstable (Type IV) Pediatric Supracondylar Humerus Fractures. J Pediatr Orthop 2015; 35 (06) 600-605
    CrossrefPubMedGoogle Scholar
  • 44 Kwak-Lee J, Kim R, Ebramzadeh E, Silva M. Is medial pin use safe for treating pediatric supracondylar humerus fractures?. J Orthop Trauma 2014; 28 (04) 216-221
    CrossrefPubMedGoogle Scholar
  • 45 Ay S, Akinci M, Kamiloglu S, Ercetin O. Open reduction of displaced pediatric supracondylar humeral fractures through the anterior cubital approach. J Pediatr Orthop 2005; 25 (02) 149-153
    CrossrefPubMedGoogle Scholar
  • 46 Mahan ST, May CD, Kocher MS. Operative management of displaced flexion supracondylar humerus fractures in children. J Pediatr Orthop 2007; 27 (05) 551-556
    CrossrefPubMedGoogle Scholar
  • 47 Novais EN, Carry PM, Mark BJ, De S, Miller NH. Posterolaterally displaced and flexion-type supracondylar fractures are associated with a higher risk of open reduction. J Pediatr Orthop B 2016; 25 (05) 406-411
    CrossrefPubMedGoogle Scholar
  • 48 Karalius VP, Stanfield J, Ashley P. et al. The Utility of Routine Postoperative Radiographs After Pinning of Pediatric Supracondylar Humerus Fractures. J Pediatr Orthop 2017; 37 (05) e309-e312
    CrossrefPubMedGoogle Scholar
  • 49 Shore BJ, Gillespie BT, Miller PE, Bae DS, Waters PM. Recovery of Motor Nerve Injuries Associated With Displaced, Extension-type Pediatric Supracondylar Humerus Fractures. J Pediatr Orthop 2019; 39 (09) e652-e656
    CrossrefPubMedGoogle Scholar
  • 50 Harris LR, Arkader A, Broom A. et al. Pulseless Supracondylar Humerus Fracture With Anterior Interosseous Nerve or Median Nerve Injury-An Absolute Indication for Open Reduction?. J Pediatr Orthop 2019; 39 (01) e1-e7
    CrossrefPubMedGoogle Scholar
  • 51 Valencia M, Moraleda L, Díez-Sebastián J. Long-term Functional Results of Neurological Complications of Pediatric Humeral Supracondylar Fractures. J Pediatr Orthop 2015; 35 (06) 606-610
    CrossrefPubMedGoogle Scholar
  • 52 Patriota GS, Assunção Filho CA, Assunção CA. Qual a Melhor Técnica para Fixação no Tratamento de Fratura Supracondilar do Úmero em Crianças?. Rev Bras Ortop 2017; 52 (04) 428-434
    CrossrefPubMedGoogle Scholar
  • 53 Schmale GA, Mazor S, Mercer LD, Bompadre V. Lack of Benefit of Physical Therapy on Function Following Supracondylar Humeral Fracture: A Randomized Controlled Trial. J Bone Joint Surg Am 2014; 96 (11) 944-950
    CrossrefPubMedGoogle Scholar
  • 54 Spencer HT, Wong M, Fong YJ, Penman A, Silva M. Prospective longitudinal evaluation of elbow motion following pediatric supracondylar humeral fractures. J Bone Joint Surg Am 2010; 92 (04) 904-910
    CrossrefPubMedGoogle Scholar
  • 55 Fletcher ND, Schiller JR, Garg S. et al. Increased severity of type III supracondylar humerus fractures in the preteen population. J Pediatr Orthop 2012; 32 (06) 567-572
    CrossrefPubMedGoogle Scholar
  • 56 Moraleda L, Valencia M, Barco R, González-Moran G. Natural history of unreduced Gartland type-II supracondylar fractures of the humerus in children: a two to thirteen-year follow-up study. J Bone Joint Surg Am 2013; 95 (01) 28-34
    CrossrefPubMedGoogle Scholar
  • 57 Worlock P. Supracondylar fractures of the humerus. Assessment of cubitus varus by the Baumann angle. J Bone Joint Surg Br 1986; 68 (05) 755-757
    CrossrefPubMedGoogle Scholar
  • 58 Flynn JC, Matthews JG, Benoit RL. Blind pinning of displaced supracondylar fractures of the humerus in children. Sixteen years' experience with long-term follow-up. J Bone Joint Surg Am 1974; 56 (02) 263-272
    CrossrefPubMedGoogle Scholar
  • 59 O'Driscoll SW, Spinner RJ, McKee MD. et al. Tardy posterolateral rotatory instability of the elbow due to cubitus varus. J Bone Joint Surg Am 2001; 83 (09) 1358-1369
    CrossrefPubMedGoogle Scholar
  • 60 Spinner RJ, O'Driscoll SW, Davids JR, Goldner RD. Cubitus varus associated with dislocation of both the medial portion of the triceps and the ulnar nerve. J Hand Surg Am 1999; 24 (04) 718-726
    CrossrefPubMedGoogle Scholar