Keywords
supracondylar humeral fracture - treatment - closed reduction
Introduction
Supracondylar humeral fractures are the second most common type of bone injury in
children. The incidence of these fractures' ranges from 55% to 75% of all fractures
in the elbow[1] and 3% of all pediatric fractures. The incidence by gender is similar due to the
increased sports performance by girls. The peak incidence occurs from 5 to 6 years
old. The annual incidence of these fractures is estimated at 177.3/100,000 children.
These injuries have a seasonal distribution, with a higher frequency during the summer
months. In addition, supracondylar humeral fractures are more common in the left elbow.[2]
Ninety-seven percent of humeral supracondylar fractures result from forces hyperextending
the upper limb. In rare occasions, these injuries occur due to a strong direct impact
on the posterior surface of the humerus with the elbow in flexion (3%).[3] In hyperextension-related injuries, the fracture line typically propagates through
the center of the olecranon fossa, potentially displacing the distal fragment in a
posterolateral or posteromedial direction.[4]
In extension fractures, the Gartland classification helps to describe injury severity
and guides therapeutic management[5]
[6] ([Table 1]).
Table 1
|
I
|
No displacement
|
|
II
|
Displacement > 2 mm with an intact posterior cortex
|
|
III
|
Displacement with no cortical contact
|
|
III A
|
Posteromedial displacement
|
|
III B
|
Posterolateral displacement
|
|
IV
|
Fractures with multidirectional instability, circumferential periosteal tear, and
instability in flexion and extension.
|
These injuries are potentially dangerous since the raw edge of the proximal fragment
can damage vascular and nervous structures. Early complications include brachial artery
injury (3.7% to 7%), nerve injuries (6% to 12%), and compartment syndrome. Late complications
include valgus or varus axis deviations (6% to 16%) and elbow stiffness. Therefore,
the ideal treatment for these lesions should occur within 12 hours, be exact, and
be as least invasive as possible.[3]
Useful measurable angular relationships for humeral supracondylar fractures include
the Baumann angle on the anteroposterior radiograph of the elbow and the anterior
humeral line and condylar-humeral angle, among others, in lateral radiographs[2]
[7] ([Fig. 1]).
Fig. 1 a) The Baumann angle lies between the mid-diaphyseal line and the epiphyseal line
of the lateral condyle. Normal values range from 9° to 26° for β. The α angle is complementary
and has the same value for both elbows. b) The normal humeral condyle angle ranges
from 30° to 45° (Zorrilla, 2015).
Some treatment modalities for Gartland type III fractures ([Fig. 2]) include cast immobilization, traction, open reduction, and closed reduction with
percutaneous pinning.[4] Different pin configurations have been described: two crossed pins, two lateral
and one crossed pins, and pins on a single side (usually two or three).[2]
Fig. 2 Gartland type IIIA fracture. Note the cortical rupture and the large posterior and
medial displacement (Clinical File).
Vuillermin et al.[8] described the steps of closed reduction and percutaneous nailing. Abraham et al.[9] described the correction of varus or valgus alignment in their experimental report,
and Ariño[10] reported fixation with two lateral pins. The reinforcement with a third wire described
by Larsson[11] has been used in a standardized way by our study group per the following methodology.
Surgical Technique ([Fig. 3])
Fig. 3
Surgical technique from the case shown in Figure 2. a) Assessment of the fracture posterior displacement and overriding in the lateral
view using an image intensifier. b) Traction performance with the elbow at 30° of
flexion for overriding and partial posterior displacement correction under fluoroscopic
control. c) “Ordering” maneuver performance for posterior displacement correction
and fracture reduction in the sagittal plane. d) With the elbow at 90° of flexion,
pronation performance to close the lateral column and distal humeral varus correction.
e) Elbow placement in hyperflexion for the pending correction of the condylar-humeral
angle (c). Anatomical fracture reduction in the lateral and the Jones views (Clinical
File).
-
Patient placement in a supine position with the affected limb close to the fluoroscopic
detector.
-
Reduction occurs as follows: a) Longitudinal traction with the elbow at 30° of flexion;
b) Medial or lateral displacement correction through forced valgus or varus; c) Maintaining
traction and with the elbow in flexion, pressure the olecranon (“ordering” maneuver)
to correct the posterior displacement at the fracture site; d) Varus or valgus malalignment
correction by forearm pronation or supination with the elbow at 90° of flexion according
to the experimental study by Abraham et al.[9]
-
Reduction assessment using anteroposterior and lateral fluoroscopic views.[7]
-
Using the technique conceived by Ariño for fracture fixation[10] (lateral crossed wires), placement of two parallel Kirschner wires introduced through
the lateral condyle, crossing the fracture, and anchored at the medial cortex. Occasionally,
a third wire may increase stability, as described by Larson et al.[11]
-
Fixation stability checking by elbow mobilizing.
-
Wire cut and bending outside the skin; next, placement of a long splint with the elbow
at 70° of flexion.[8]
-
Pin removal between the sixth and seventh postoperative week in our population (average
observed union time), depending on the radiographic signs of consolidation, followed
by elbow mobility.[8] ([Fig. 4])
Fig. 4
Fixation and consolidation (case shown in Figure 2). a) Use of two 1.6-mm lateral Kirschner wires and a long arm splint. b) Fracture consolidation
in anatomical position 5 weeks after surgery (Clinical File).
Material and Methods
This study is a retrospective longitudinal analysis of medical records from patients
with Gartland and Wilkins type III pediatric humeral supracondylar fractures from
March 1, 2018, to June 30, 2018. We collected the following data: age, gender, mechanism
of injury, diagnosis, classification, affected side, additional lesions, and pre-
and postoperative (3 months) radiological features in the coronal and sagittal planes
(fracture line, Baumann angle, condylar-humeral angle, displacement, rotation, and
overriding). The study did not include open or pathological fractures.
The sampling technique was the convenience of consecutive cases.
Descriptive statistics included central tendency (mean, median, and mode for ungrouped
quantitative variables), dispersion (standard deviation), and simple frequency measurements
(percentages for qualitative variables).
For radiological variables in the coronal and sagittal planes before and 3 months
after surgery (Baumann angle and condylar-humeral angle), the statistical analysis
used the student's t-test and Pearson's chi-square (for rotation evaluation).
This study complies with the ethical standards regarding scientific research on human
beings by the Nuremberg Declaration and its modifications. Similarly, it complies
with the Regulations of the General Health Law on Health Research and institutional
ethical standards. The study did not require an informed consent form since the information
came from secondary sources.
The research team received no contributions from third parties or sponsorships.
Results
Between March 1, 2018, and June 30, 2018, 86 patients presented with distal humerus
fractures, including 66 cases of humeral supracondylar fractures.
All injuries occurred after falls, including 50% (32 cases) from the patient's plane
of support, 20.3% (13 cases) from a height ranging from 0.1 to 0.5 meter, 23.4% (15
cases) from a height ranging from 0.6 to 1 meter, and only 6.3% (four cases) from
a height higher than 1 but lower than 2 meters ([Fig. 5]).
Fig. 5 Mechanisms of injury in humeral supracondylar fractures.
Supracondylar humeral fractures occurred in a male-to-female ratio of 2.8 to 1, with
73.4% males and 26.6% females. Fractures involved the right side in 26.6% of the cases
and the left side in 73.4% ([Fig. 6]).
Fig. 6 Gender distribution.
The mean age of the patients was 5.2 ± 2.8 years old, ranging from 1 to 14. Age distribution
was as follows: 0 to 4 years old, 32.8%; 5 to 8 years old, 48.4%; 9 to 12 years old,
15.6%; and 13 years old or more, 3.1%. On average, males presented these injuries
a year and a half later than females (5.7 years old for males versus 4 years old for
females).
Per the Gartland and Wilkins classification, 45.3% of the cases had a posterolateral
displacement (Group IIIB), 48.4% had a posteromedial displacement (Group IIIA), and
four cases (6.3%) presented a pure posterior displacement ([Fig. 7]).
Fig. 7 Subclassification of type III humeral supracondylar fractures by the Gartland and
Wilkins system.
Regarding the clinical outcomes per the aesthetic Flynn scale, 78.1% had excellent
results, and 2.9% presented good outcomes. In contrast, functionality was excellent
in 65.6% of cases, good in 32.8%, and limited in a single case (with a 15° extension
deficit).
As for radiographic characteristics according to the complementary Baumann angle,
type III fractures presented a range of 5° to 18° (mean, 8.6° ± 6.75°) before surgery
and a range of 5° to 15° (mean, 10° ± 5°) 3 months after surgery. The Student's t-test
for the Baumann complementary angle revealed t = 0.70 and p = 0.5, potentially due
to the limited number of cases. The preoperative humeral condylar angle ranged from
30° to 60° (mean, 48.2° ± 14.14°), and the postoperative humeral condylar angle ranged
from 42° to 45° (mean, 45° ± 0°). The Student's t-test for the humeral condylar angle
revealed t = 0.61 and p = 0.58. In contrast, there were no rotations before or 3 months
after surgery.
The radiographic complementary Baumann angle in type IIIA fractures ranged from -20°
to 60° (mean, 9.19° ± 17.52°) before surgery and 0° to 25° degrees (mean, 14.03° ± 4.3°)
3 months after surgery. The student's t-test for the Baumann complementary angle revealed
t = 8.75 and p <0.0001. The humeral condylar angle ranged from 30° to 110° (mean,
77.75° ± 20.82°) before surgery and 40° to 80° (mean, 48° ± 9.8°) after surgery. The
student's t-test for the humeral condylar angle revealed t = -1.47 and p = 0.15. On
the other hand, 23 of 31 fractures presented preoperative rotations, of which only
two persisted after the reduction (chi-square <0.0001, p <0.0001)
The radiographic complementary Baumann angle in type IIIB fractures ranged from 0°
to 35° (mean, 12.07° ± 12.6°) before surgery and from 0° to 20° degrees (mean, 15° ± 3.4°)
after surgery. The student's t-test for the Baumann complementary angle revealed t = 7.003
and p <0.0001. The humeral condylar angle ranged from 30° to 110° (mean, 74.5° ± 25°)
before surgery and from 30° to 80° (mean, 47.75° ± 11.2°) after surgery. The student's
t-test for the humeral condylar angle revealed t = -1.18 and p = 0.24. In contrast,
24 of 29 fractures presented preoperative rotations, of which four persisted after
the reduction (chi-square <0.0001, p <0.0001).
All cases consolidated 6 weeks postoperatively.
There were no cases of intraoperatively conversion to open treatment.
Two patients presented a neuropraxia-type nerve injury (3%). One of them had an injury
involving the median nerve, while the other one had a preoperative radial nerve injury
and no further complications from the traumatic event. No complications occurred after
surgical treatment.
Discussion
Closed reduction and percutaneous nailing, described by Swenson[12] and later popularized by Flynn et al., is a simple procedure with excellent outcomes[.13]
The Flynn criteria ([Tabla 2]) are probably the most frequently used tool to evaluate cosmetic and functional
outcomes in patients with supracondylar humeral fractures. These criteria allow a
clinical assessment to differentiate functional and cosmetic outcomes since some patients
may have a large deformity and good function, and vice-versa.[13] Following Ducic et al., our group opts for closed reduction and percutaneous nailing
as a treatment method due to the clinical outcomes obtained[.14] In addition, Kazimoglu et al. reported that closed reduction has similar clinical
outcomes to open reduction[15] with no need for conversion to open surgical. These authors also reported good or
excellent outcomes in more than 95% of the cases per the Flynn scale.
Table 2
|
Outcome
|
Cosmetic factor: Loss of carrying angle
|
Functional factor: Loss of movement
|
|
Excellent
|
0°-5°
|
0°-5°
|
|
Good
|
6°-10°
|
6°-10°
|
|
Regular
|
11°-15°
|
11°-15°
|
|
Poor
|
>15°
|
>15°
|
A meta-analysis from Guol et al. found that closed reduction and percutaneous fixation
provide similar clinical outcomes to open treatment according to the Flynn criteria,
with no statistically significant cosmetic and functional differences. Likewise, Guol
et al. suggest that fixation with two lateral wires is an effective and reliable method
to avoid iatrogenic ulnar nerve injury, warranting the selection of this fixation
form by our department. The incidence of infection was 6.4% for closed reduction and
percutaneous fixation and 7.1% for open reduction. However, there were no postoperative
infections.[1]
Scaglione et al. evaluated 76 type III supracondylar fractures in patients aged 6
to 15, including 66 type IIIA and 10 type IIIB. Using the Flynn criteria for overall
result evaluation, 101 patients (81%) did not have varus/valgus deformities. Valgus
deformity occurred in seven subjects, and 17 patients presented varus deformities.
Only two varus elbows presented a 15° deviation. No patients showed limitations in
range of motion. The average Baumann angle was 16°. Considering these results, 80%
were very good, 11% were good, 6% were borderline, and 3% were poor. There were no
complications or conversions to open surgeries.[3]
Our functional outcomes are consistent with Kumar, who, in 1974, treated 192 Gartland
grade II and 85 grade III fractures with closed reduction and percutaneous fixation
with crossed pins. Kumar obtained 97.4% of good to excellent outcomes and 2.52% of
poor or borderline outcomes. The poor and borderline outcomes were due to cosmetic
factors, but the function was excellent. Six patients required a conversion to open
surgery.[13] In our study, the only case with a borderline function was due to loss of extension
at 15° degrees, which did not limit the functional life of the patient.
Barr reviewed 159 patients and found 97% of extension fractures, of which only 28
were Gartland type III. This author treated all cases with closed/open reduction and
pin fixation. Six patients developed neurological injuries after the fracture compared
to only two subjects in our study.[16]
In the Woratanarat meta-analysis, Sinikumpu et al. treated 16 fractures with closed
reduction and percutaneous fixation with good or excellent outcomes according to the
Flynn criteria.[17]
Farnsworth and Barr reported that up to 38% of fractures were due to falls from sports
equipment such as handrails and trampolines and 16% from falls from furniture.[16]
[18] This contrasts with our study, in which the most frequent mechanism was a fall from
the patient's support plane, including 43.7% occurring from a height of up to one
meter, i.e., the height of any domestic furniture. However, we did not record this
data.
Conclusion
Closed reduction and percutaneous nailing provided satisfactory outcomes for treating
Gartland type III pediatric supracondylar humeral fractures from a clinical, radiological,
and aesthetic point of view within 3 months after surgery. The patients studied did
not present immediate additional complications beyond those upon admission. Longer
follow-up is required to evaluate long-term complications such as avascular necrosis,
physeal damage, and angular deformity, among other factors.
