Treatment Approaches and Outcomes in Childhood Supracondylar Humerus Fractures

Home , Elbow fracture, Open fracture

European Review for Medical and Pharmacological Sciences 2012; 16: 936-941 Treatment approaches and outcomes in childhood supracondylar humerus fractures

B.Y. UÇAR, A. DEMIRTAŞ, D.E. UÇAR*

Department of Orthopaedics and Traumatology, Dicle University Medical Faculty, Diyarbakir (Turkey) *Department of Physical Medicine and Rehabilitation, Dicle University Medical Faculty, Diyarbakir (Turkey)

Abstract. – BACKGROUND, Being one of the Introduction most frequent elbow fractures during childhood, supracondylar humerus fractures require rapid Supracondylar humerus fractures are the most diagnosis and treatment, as they may be associ- common elbow fractures during childhood1,2. ated with significant neurovascular and functional problems. These fractures have been reported to constitute QUESTIONS AND PURPOSES, To evaluate de- nearly 60% of elbow fractures, and 13% of all mographic and clinical features, and treatment fractures in pediatric ages3. Most of these frac- outcomes of the patients with supracondylar tures occur between 5 and 7 years of age and are humerus fractures who underwent open reduc- more frequent in boys4,5. The frequency decreas- tion+minimal osteosynthesis or closed reduc- es after 12 years of age3, and most of the frac- tion+percutaneous wiring. 6,7 PATIENTS AND METHODS, Forty patients tures occur in the left or non-dominant side . (30 boys + 10 girls) between 2 and 13 years of Supracondylar humerus fractures are classified age who were operated on with the diagnosis as extension and flexion fractures, about 97%- of supracondylar humerus fracture, between 99% of which are extension-type fractures4,8 oc- August 2003 and December 2006, were includ- curring due to falling on the outstretched upper ed. Open reduction+minimal osteosynthesis extremity with the elbow in full extension. While (n=34) and closed reduction+percutaneous extension-type fractures are classified according wiring (n=6) were performed. The fractures were 9 classified according to the Gartland classifica- to the Gartland classification , flexion-type frac- tion and outcomes were assessed according to tures are classified according to the degree of dis- Flynn’s criteria. placement10,11. In extension-type injuries, the dis- RESULTS, All patients (mean age, 7.35 years; tal fragment of the fracture may cause compres- range, 2-13 years) had closed fractures (28 left sion of the radial nerve. Brachial artery and me- and 12 right). Seven (17.5%) and 33 (82.5%) pa- dian nerve may also be injured due to being com- tients had Gartland type II and III fractures respectively. Three patients had flexion-type and pressed between fracture fragments in the lateral 11 37 patients had extension-type fractures. Based displacement . In flexion-type fractures, the dis- on Flynn’s criteria, cosmetic results were excel- tal fragment of the fracture may cause compres- lent in 37 (92.5%) patients and good in 3 (7.5%) sion and injury of the ulnar nerve. patients, and functional results were excellent Forearm fractures accompanying supracondy- in 36 (90%) patients, good in 3 (7.5%) patients, lar fractures increase the risk of compartment and poor in 1 (2.5%) patient. A surgical success syndrome12. Prevalence of vascular involvement rate of 97.5% was noted. No significant difference was found between wire configurations (p in elbow injuries has been reported as 12%- 10,12,13 > 0.05). 20% . Following vascular examination, radi- CONCLUSIONS, Treatment of supracondylar al, ulnar, median and anterior interosseous nerves humerus fractures in children should be patient- are assessed on neurological examination. Pain, specific based on factors such as patient’s age, coldness, pallor, cyanosis, or absent pulse in the soft tissue conditions and deformity status. extremity due to injury induced neurovascular damage might be preliminary signs of compart- Key Words: ment syndrome. The next step of assessment in- volves true anteroposterior radiographic imaging Childhood, Supracondylar humerus fractures, Sur- of the distal humerus and true lateral radiograph- gical approach. ic imaging of the elbow. Fracture line may not al-

936 Corresponding Author: Bekir Yavuz Uçar, MD; e-mail: [email protected] Treatment approaches and outcomes in childhood supracondylar humerus fractures ways be visible on radiographic imaging, and Surgical incisions used during open surgery “fat-pad sign” may be the only sign of fracture14. included a posterior longitudinal incision extend- In the presence of a fracture disrupting bone in- ing from the distal humerus to the olecranon, a tegrity, two main radiography findings include lateral incision traversing the lateral condyle with posterior displacement of the middle third of the a slightly anterior tilt or a medial incision cen- capitellum with respect to the anterior humeral tered over the medial epicondyle. line and a decrease in the humeral-capitellar an- Posterior approach was performed by reaching gle (normal range, 9°-26°), known as “Bau- the fracture line from both of its sides without mann’s angle”. dissecting the triceps muscle. It was made sure The initial management of supracondylar that the ulnar nerve was exposed in this ap- humerus fractures in emergency conditions in- proach, and efforts were made to preserve the ra- cludes splint immobilization of the upper extrem- dial nerve during lateral incision. ity preserving the appropriate position. Neu- Fracture fragments were reduced through the rovascular control should be performed before posterior fracture line by a posterior incision or and after splint immobilization. Fracture frag- through the anterior fracture line by lateral or ments should be reduced if signs of ischemia are medial incisions. After stabilization by cross fix- noted in the distal part of extremity. Elbow flex- ation using Kirschner wires (K-wires), the tissues ion should be avoided to prevent potential neu- were closed as required. The K-wires were bent rovascular damage in extension-type fractures. and left outside the skin. The extremity was then The second and main part of management in placed in a long-arm splint with the elbow in 90 non-displaced fractures is three weeks of long- degrees of flexion. Prophylactic antibiotic treat- arm cast immobilization15. In displaced fractures, ment was initiated in these patients; the sutures however, open or closed reduction can be per- were removed on day 10, weekly radiographic formed. Cast immobilization, traction, and percu- controls were performed and the cast and K- taneous pin fixation can be performed following wires were removed depending on union forma- closed reduction16. Open reduction should be per- tion after 3-4 weeks of immobilization. formed in the presence of circulatory problems In closed approach, patients were placed in the due to fracture fragments, open fracture, failure prone position, and after closed repositioning un- in closed reduction, accompanying forearm frac- der scopic control, stabilization was established tures or irreducible fractures17-19. by cross fixation with K-wires inserted from lat- The present study aimed to evaluate demo- eral and medial sides. The K-wires were bent and graphic and clinical features, and treatment out- left outside the skin. The extremity was placed in comes of the patients with supracondylar a long-arm circular cast with the elbow in 90 de- humerus fractures who underwent open reduc- grees of flexion. Weekly radiographic controls of tion+minimal osteosynthesis or closed reduction these patients were performed, and the cast and + percutaneous wiring. K-wires were removed depending on union for- mation after 3-4 weeks of immobilization. Following the removal of the splint, both the Materials and Methods parents and children were instructed about elbow range of motion (ROM) exercises and asked to Forty patients (30 boys and 10 girls) between continue these exercises at home. Patients with 2 to 13 years of age who were operated on with limited elbow ROM at the end of 6-8 weeks de- the diagnosis of supracondylar humerus fracture spite this program were referred to the Physical between August 2003 and December 2006 were Medicine and Rehabilitation Clinic. included in the present study. The Gartland clas- Clinical and radiological assessments were sification9 was used for the classification of frac- performed at the final visit in all patients. Elbow tures. According to this classification, patients ROM were measured using a standard goniome- who had displaced type II and III supracondylar ter. Flexion/extension, pronation/supination mo- humeral fractures were treated surgically. Seven tions were evaluated, and limitations were patients had type II fractures, 33 had type III. recorded in degrees. Clinical assessment of angu- Three patients had flexion type, 37 had exten- lar deformity (varus or valgus deformity) was sion. All patients were followed up for at least 6 performed by measuring the carrying angles of months, and their final assessments were per- elbow bilaterally using a goniometer. Anteropos- formed. terior and lateral radiographs were obtained for

937 B.Y. Uçar, A. Demirtaş, D.E. Uçar

Table I. Flynn’s criteria.

Cosmetic assessment Functional assessment (change in the carrying angle) (loss of motion)

Excellent 0-5 degrees 0-5 degrees Good 6-10 degrees 6-10 degrees Fair 11-15 degrees 11-15 degrees Poor > 15 degrees > 16 degrees each elbow. The humeroulnar angle was mea- from a bike in 4 (10%) patients. Preoperative com- sured on the anteroposterior radiographs; the plications was noted in 7 (17.5%) patients (3 had humerocapitellar angle, anterior humeral line and anterior interosseous nerve injury, 2 had ulnar anterior coronoid line were evaluated on lateral nerve injury, 1 had radial nerve injury, and 1 had radiographs. radial and median nerve injuries). Distribution of Outcomes were assessed according to Flynn’s the patients according to gender and fracture side criteria20 (Table I). These criteria are the most is presented in Table III. commonly utilized criteria for the assessment of Thirty-four patients were treated with open re- treatment outcomes in supracondylar humerus duction+minimal osteosynthesis. Open reduction fractures. In Flynn’s criteria, patients are evaluat- was performed through a lateral approach in 25 ed according to the functional and cosmetic fac- (62.5%) patients, posterior approach in 6 (15%) tors. Functional assessment includes measure- patients, medial approach in 2 (5%) patients, and ment of limitation of ROM, while cosmetic as- lateral and medial approach in 1 (2.5%) patient. sessment includes measurement and comparison The remaining 6 patients underwent closed re- of bilateral elbow carrying angles. duction + percutaneous wiring. Surgical selection was an intraoperative decision. Statistical Analysis One patient developed tourniquet paralysis Statistical analysis were performed using the postoperatively. In all patients with preoperative Statistical Package for Social Sciences (SPSS, or postoperative neurological deficits, complete Inc., Chicago, IL, USA) version 15.0. Descrip- recovery was noted at the final visit. Vascular tive statistics were presented as frequency and pathology was not observed in any patient. One cross tables for categorical variables and as mean (2.5%) patient developed septic arthritis of the el- value for numerical variables. Chi-square test bow at the postoperative 7th week. Joint drainage was used to compare independent categorical was performed, and complete recovery was variables. A p value < 0.05 was considered statis- achieved following antibiotherapy+aggressive tically significant. physiotherapy and rehabilitation. Two (5%) patients had insufficient repositioning on postoperative radiographs; thus, revision was performed on Results the same day. One patient, who was operated on the day of admission, fell from his mother’s arms The mean age of the patients was 7.35 years 3 days after the surgery, and revision surgery was (range, 2-13 years). The mean age of girls and performed due to loss of reposition. boys were 5.4 and 8 years, respectively. The dis- According to Flynn’s criteria, cosmetic results tribution of patients according to age groups is were excellent in 37 (92.5%) patients and good presented in Table II. Seven (17.5%) and 33 (82.5%) patients had Table II. Distribution of the patients according to age Gartland type II and III fractures, respectively. groups. Three (7.5%) and 37 (92.5%) patients had flexion- Age groups type and extension-type fractures, respectively. All (years) n (%) fractures were closed fractures. The affected side was left in 28 patients and right in 12 patients. The 1-4 10 (25) causes of fractures were simple falls (while play- 5-9 17 (42.5) ing with a ball, running) in 31 (77.5%) patients, 10-13 13 (32.5) falling from high in 5 (12.5%) patients, and falling Total 40 (100)

938 Treatment approaches and outcomes in childhood supracondylar humerus fractures

Table III. Distribution of the patients according to gender and fracture side.

Fracture side Gender Right elbow n (%) Left elbow n (%) Total n (%)

Girls 6 (15) 4 (10) 10 (25) Boys 6 (15) 24 (60) 30 (75) Total 12 (30) 28 (70) 40 (100) in 3 (7.5%) patients, whereas functional results been reported in various series that these frac- were excellent in 36 (90%) patients, good in 3 tures are most common between 2 and 12 years (7.5%) patients, and poor in 1 (2.5%) patient. of age20 and are more frequent in boys11, and the Outcomes of different surgical approaches are left side is more commonly affected compared to presented in Table IV. Considering excellent and the right side6. Various physical force-response good results after surgery as general success mechanisms such as tendency toward hyperex- rates, a surgical success rate of 97.5% was tension due to ligamentous laxity in the juvenile achieved. age group, characteristics of bone structure in the Osteosynthesis was performed by medial and supracondylar region, and relationship of joint lateral insertion of two crossed K-wires in 21 pa- structures in hyperextension have been suggested tients, of them 20 had excellent and 1 had good to be responsible for the higher frequency of outcomes. Osteosynthesis was performed by 2 supracondylar humerus fractures in the first laterally and 1 medially inserted crossed K-wires decade of life22. Most frequent etiological factors in 11 patients; 10 had excellent and 1 had poor for supracondylar humeral fractures have been outcomes. Osteosynthesis was performed by 1 reported as simple falls, falling from high, and laterally and 1 medially inserted crossed K-wires accidents5. Extension-type fracture has been re- in 6 patients; outcome was excellent in 5 patients ported as the most common fracture type as 95% and good in 1 patient. In 1 patient, osteosynthesis of the supracondylar humeral fractures are exten- was performed by lateral insertion of 2 parallel sion-type fractures20. Demographic features of K-wires and outcome was good. Osteosynthesis the patients, etiological factors and morphologi- was performed by 2 laterally and 2 medially in- cal characteristics of the fractures in the present serted K-wires in 1 patient with a good outcome. study were noted to be similar to those reported No significant difference was found between in the above-mentioned studies. wire configurations used (p > 0.05). The main goal in the management of childhood supracondylar humerus fractures is to ob- tain the best functional and morphological out- Discussion come with the least number of complications. Al- though a consensus has been reached among Au- Supracondylar humerus fractures are com- thors on the treatment approach to non-displaced monly seen during childhood and constitute near- fractures, various treatment approaches that are ly 60% of elbow fractures in pediatric age currently being argued have been suggested for group21. These fractures are of special clinical displaced fractures. Closed reduction + casting, significance as they may lead to neurovascular which is one of these approaches, has been re- damage and morphological deformities. It has ported be associated with the worst outcomes as

Table IV. . Outcomes of different surgical approaches.

Surgical approach Excellent n (%) Good n (%) Fair n (%) Poor n (%)

Lateral 21 (84) 3 (12) – 1 (4) Posterior 5 (83.3) 1 (16.7) – – Medial 2 (100) – – – Lateral + medial 1 (100) – – – Closed 6 (100) – – – Total 35 (87.5) 4 (10) – 1 (2.5)

939 B.Y. Uçar, A. Demirtaş, D.E. Uçar compared to other modalities13,23,24. Closed re- deformity status. Closed reduction and fixation duction and osteosynthesis with percutaneous by percutaneous wiring provides an effective and wiring is another method which has been shown safe treatment for these fractures. However, in to be associated with favorable outcomes in the the presence of open fractures or neurological or management of supracondylar humeral frac- vascular pathologies accompanying the fracture tures13,25. Success rates ranging from 67% to and if treatment by closed repositioning fails, 91.8% have been reported with this technique in open reduction and osteosynthesis with internal different series25-28. Greater controversy exists re- fixation should be performed. garding open reduction and internal fixation, which is another surgical treatment alternative. While some Authors suggest that this method References should be the first choice of treatment, Others ar- gue that it should be performed in patients in 1) OTSUKA NY, KASSER JR. Supracondylar fractures of whom treatment with closed reduction fails29. In the humerus in children. J Am Acad Orthop Surg the present study, we achieved excellent results 1997; 5: 19-26. 2) CHENG JC, NG BK, YING SY, LAM PK. A 10-year study in all 6 patients treated with closed reduction and of the changes in the pattern and treatment of 6, percutaneous wiring, and in 85.3% of 34 patients 493 fractures. J Pediatr Orthop 1999; 19: 344- treated with open reduction and internal fixation; 350. these high success rates were in parallel with the 3) OMID R, CHOI PD, SKAGGS DL. Supracondylar results previously reported for these methods. humeral fractures in children. J Bone Joint Surg There is no consensus regarding the type of Am 2008; 90: 1121-1132. surgical incisions to be used during open reduc- 4) CHENG JC, LAM TP, MAFFULLI N. Epidemiological fea- tion procedures. Although successful outcomes tures of supracondylar fractures of the humerus in 30 31 Chinese children. J Pediatr Orthop B 2001; 10: have been reported using anterior , medial , and 63-67. posterior32 incisions, no statistically significant 5) FARNSWORTH CL, SILVA PD, MUBARAK SJ. Etiology of differences have been found between these ap- supracondylar humerus fractures. J Pediatr Or- proaches. Similar to these findings, we did not thop 1998; 18: 38-42. find any significant clinical and radiological dif- 6) TOPPING RE, BLANCO JS, DAVIS TJ. Clinical evaluation ferences between surgical incisions. of crossed-pin versus lateral-pin fixation in dis- In biomechanical studies comparing different placed supracondylar humerus fractures. J Pedi- wire configurations used for osteosynthesis in the atr Orthop 1995; 15: 435-439. management of supracondylar humeral fractures, 7) CHENG JC, LAM TP, SHEN WY. Closed reduction and it has been found that medial and laterally insert- percutaneous pinning for type III displaced supracondylar fractures of the humerus in children. J ed crossed Kirschner wire model is the most sta- Orthop Trauma 1995; 9: 511-515. 11,33,34 ble configuration . However, it should be 8) MAHAN ST, MAY CD, KOCHER MS. Operative man- noted that dissection should be performed before agement of displaced flexion supracondylar medial placement of these wires to avoid iatro- humerus fractures in children. J Pediatr Orthop genic ulnar nerve injury35. In the present study, 2007; 27: 551-556. we did not observe any complications associated 9) GARTLAND JJ. Management of supracondylar frac- with any wire configurations, and no statistically tures of the humerus in children. Surg Gynecol significant difference was noted between the suc- Obstet 1959; 109: 145-154. cess rates of different methods. 10) CAMPBELL CC, WATERS PM, EMANS JB, KASSER JR, MIL- LIS MB. Neurovascular injury and displacement in type III supracondylar humerus fractures. J Pedi- atr Orthop 1995; 15: 47-52. Conclusions 11) WILKINS KE. The operative management of supracondylar fractures. Orthop Clin North Am 1990; In conclusion, demographic and clinical fea- 21: 269-289. tures of our study population as well as treatment 12) SHAW BA, KASSER JR, EMANS JB, RAND FF. Manage- outcomes associated with surgical techniques ment of vascular injuries in displaced supra- that we used were noted to be similar to those re- condylar humerus fractures without arteriography. J Orthop Trauma 1990; 4:2 5-29. ported previously. Treatment of supracondylar 13) PIRONE AM, GRAHAM HK, KRAJBICH JI. Management humerus fractures should be patient-specific; of displaced extension-type supracondylar frac- treatment should be decided based on the factors tures of the humerus in children. J Bone Joint such as patient’s age, soft tissue conditions and Surg Am 1988; 70: 641-650.

940 Treatment approaches and outcomes in childhood supracondylar humerus fractures

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