Complications of Pediatric Supracondylar Humeral Fractures

Carissa L. Meyer, MD Scott H. Kozin, MD Martin J. Herman, MD Shannon Saﬁ er, MD Joshua M. Abzug, MD

Abstract and occur equally in boys and girls. The Supracondylar humeral fractures are common in the pediatric population and can result usual mechanism of injury is a fall onto in complications caused by both the injury itself and surgical or nonsurgical treatment. an outstretched hand.4,5 Neurologic complications are frequent, with the anterior interosseous nerve being the most The Gartland classifi cation is the common nerve affected. Vascular injuries, although less common, can result in long-term most widely used classifi cation system sequelae and should be recognized and treated promptly. Loss of reduction can occur with for describing extension-type, supra- both surgical and nonsurgical treatment. Compartment syndrome and infection, although condylar humeral fractures, which rare, require rapid recognition and treatment. It is important to be familiar with the account for 97% to 99% of supracon- potential complications surrounding the treatment of pediatric supracondylar humeral dylar humeral fractures.3 In the original fractures to maximize outcomes and know when a referral may be warranted. classifi cation scheme, type I fractures Instr Course Lect 2015;64:483–491. were considered nondisplaced, type II fractures had an intact posterior hinge, and type III fractures were completely Supracondylar humeral fractures are commonly in children aged 5 to 7 years displaced.6 Wilkins7 modifi ed this clas- common in the pediatric population but have been reported to occur in chil- sifi cation, subdividing type II fractures and account for 3% of all pediatric dren aged 1 to 16 years.3 Fractures most into type IIA and type IIB to aid in fractures.1,2 These fractures occur most often occur on the nondominant side determining the presence of stability with closed reduction and casting alone Dr. Kozin or an immediate family member serves as a paid consultant to or is an employee of Checkpoint Surgical and serves versus closed reduction and percutane- as a board member, owner, offi cer, or committee member of the American Society for Surgery of the Hand. Dr. Herman ous pin fi xation (Table 1). or an immediate family member serves as a board member, owner, offi cer, or committee member of the American Academy of Orthopaedic Surgeons and the Pediatric Orthopaedic Society of North America. Dr. Safi er or an immediate family Most supracondylar humeral frac- member is a member of a speakers’ bureau or has made paid presentations on behalf of Orthopediatrics and serves as a tures can be treated with splinting and paid consultant to or is an employee of Orthopediatrics and Medicrea. Dr. Abzug or an immediate family member serves casting, closed reduction and casting, as a paid consultant to or is an employee of Axogen. Neither Dr. Meyer nor any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly or closed reduction and percutaneous to the subject of this chapter. pin fi xation. Open reduction is rarely

Table 1 Bloom et al14 performed biome- Modifi ed Gartland chanical testing on various pin con- Classifi cation fi gurations for both well-reduced and slightly malreduced fracture patterns. Type Description Several planes of motion were tested, I Nondisplaced but there was no difference between IIA Intact posterior hinge, no rotational deformity crossed pins or the lateral pin confi gu- IIB Intact posterior hinge, with rations. However, adding a third pin in rotational deformity or either confi guration improved stability, translation The authors believed that slight internal III Complete displacement, no posterior hinge rotation of the distal fragment is com- Figure 1 Lateral (A) and AP (B) monly accepted during pinning, which IV Unstable in both fl exion and illustrations of an ideal pin confi g- extension uration, with the pins maximally may lead to more internal rotation and separated at the fracture site and varus deformity during healing. Most both pins engaging cortices distal importantly, Bloom et al14 noted that and proximal to the fracture (bicor- necessary, but indications for open re- tical fi xation). (Courtesy of Dan A. distal fragment malrotation leads to a duction include a failure to achieve Zlotolow, MD, Philadelphia, PA.) less stable fracture after pinning in any reduction because of an unstable frac- confi guration. Obtaining anatomic re- ture pattern or soft-tissue interposition, duction in the axial plane maximized open fractures, or a vascular injury ne- II fractures surgically, whereas nonsur- stability in all pin confi gurations; there- cessitating open repair. gical management is reserved for very fore, the acceptance of any intraopera- Gartland type I fractures are almost young patients and those with minimal tive malalignment should be avoided. universally treated nonsurgically and extension and no rotational deformity. have excellent outcomes. Cast immo- The location of pin placement for Neurologic Complications bilization for 3 to 4 weeks in 90° of supracondylar humeral fractures also The incidence of nerve injury after a su- fl exion and neutral forearm rotation remains somewhat controversial. Op- pracondylar humeral fracture is reported is adequate. In contrast, Gartland tions include placing two or three lateral to range from 6% to 16%, including type III fractures are almost univer- pins alone or using a cross-pin confi gu- nerve injuries caused by the fracture it- sally treated surgically with closed re- ration. Although two crossed pins were self and iatrogenic injuries that primarily duction and percutaneous pinning. The initially advocated for more unstable result from pin placement.15-17 Typical- expectant outcomes are excellent, but fractures, several studies recently have ly, injuries that occur as a result of the several complications can occur. Sub- found no biomechanical advantage for fracture itself are caused by traction. stantial controversy exists regarding two crossed pins versus two lateral Patients usually recover between 2 and the treatment of type II fractures, with pins,9-11 whereas other authors have 2.5 months after the fracture; however, some authors recommending surgical found greater rotational stability with recovery can take up to 6 months.15,16,18,19 treatment of all type II fractures, others two crossed pins compared with lateral Although all nerves around the recommending nonsurgical treatment, pins.12,13 elbow have been documented to sus- and some determining treatment based If only two lateral pins are used, the tain an injury, the anterior interosse- on the presence or the absence of rota- pins should be placed in a bicortical ous nerve (AIN) is most commonly tion, based on the Wilkins subclassifi - fashion and diverge at the fracture site involved in extension-type fractures20 cation.1,3,7,8 Surgical intervention for all (Figure 1). The addition of a medial pin (Figure 2). In fl exion-type fractures, type II fractures limits the potential for is advocated in cases of medial cortex the ulnar nerve is most commonly loss of reduction and is less intensive comminution or if the fracture remains injured. In a review of 622 fractures, regarding the necessary follow-up than unstable, as noted with live fl uoroscopy, Bashyal et al21 reported neurologic defi - exists with nonsurgical care. This chap- after the placement of lateral pins. cits in 11.9% of cases, with the AIN ter’s authors prefer to treat most type most commonly affected, followed by

laxity exhibited ultrasound evidence of ulnar nerve subluxation. This ap- pears to be more common in children younger than 5 years, and the incidence decreases as children age. Skaggs et al10 reported that medial pinning at 90° or less led to a 4% risk of ulnar nerve injury, whereas hyper- fl exion during medial pinning increased that risk to 15%, which was caused by the nerve becoming more anterior with elbow fl exion. The authors rec- ommended lateral pin placement fi rst to Figure 2 Clinical photographs of the hand of a child with an anterior interos- allow for more elbow extension during seous nerve palsy after an extension type supracondylar fracture. Note the medial pinning. lack of thumb interphalangeal fl exion (A) and distal interphalangeal fl exion When it becomes necessary to place of the index fi nger (B). Asking the child to make an “OK” sign can aid in the diagnosis. (Courtesy of Joshua M. Abzug, MD, Baltimore, MD.) a medial pin, multiple authors have advocated making a small incision before pin placement.26-28 This incision permits the radial, median, and ulnar nerves. did not fi nd an increased rate of ulnar placement of the pin directly on the Only the ulnar nerve was affected in nerve palsy with medial pin placement. bone, thus ensuring that the pin does their series of fl exion-type injuries. It is unclear from their evaluations how not go through the bone. Alternatively, Dormans et al22 studied acute type many postoperative palsies were caused recent research has shown that the pre- III extension injuries and found a neu- by iatrogenic nerve injury versus sec- operative use of electrical stimulation rologic injury rate of 9.5%, including ondary differences in documentation twitch monitoring can help map the seven AIN injuries, four median nerve among providers. path of the ulnar nerve and avoid entry injuries, fi ve radial nerve injuries, and Rasool24 reported on six cases of into the cubital tunnel during pinning.29 three ulnar nerve injuries. Each injury ulnar nerve injury from medial pin was treated expectantly, except for one placement, which represented 5% of Vascular Injuries median nerve injury that accompanied all the supracondylar humeral frac- Vascular injury requiring intervention a brachial artery injury. Patients with tures pinned. In fi ve cases, the pin was is uncommon in pediatric supracondy- AIN palsies, which were most com- found in the cubital tunnel, and two lar humeral fractures. Approximately mon, recovered fully, on average, 12.5 cases resulted in penetrating injuries to 10% to 20% of patients with type III weeks after injury (range, 6 weeks to the nerve. In one case, a hypermobile fractures will present with pulseless 4 months). Of note, AIN palsies were nerve was fi xed anteriorly secondary to extremities,30-32 which may be further more common in fractures with pos- pin placement. At the study end point subdivided into perfused (pink) or not terolateral displacement. of 48 months, three patients had full perfused (white). In the case of the Garg et al23 reported a 12% nerve neurologic recovery, two experienced white, pulseless extremity, emergent palsy rate in type II and III fractures, partial recovery, and one showed no intervention is warranted, including with 75 being identifi ed preoperative- recovery after a penetrating injury. reduction of the fracture followed by ly and 30 postoperatively. Most palsies Children can have generalized liga- observation to see if the pulse returns involved the AIN or the median nerve mentous laxity, which may predispose or the hand becomes perfused (pink). (94 total patients, 24 identifi ed postop- them to ulnar nerve subluxation and If the hand remains white after reduc- eratively). Of the 16 ulnar nerve palsies, place the nerve in jeopardy during me- tion and pinning, vascular exploration 9 were identifi ed postoperatively. Con- dial pin placement. Zaltz et al25 found with decompression and/or repair is trary to previous studies, Garg et al23 that 71.9% of children with ligamentous warranted.

Shaw et al31 examined 143 type III only one instance of cold intolerance injuries in children, 17 of which pre- during ice hockey and no differences in sented with vascular compromise. Most average arm circumference, arm length, patients with vascular compromise have muscle endurance, or grip strength a pink, pulseless extremity. In such compared with the contralateral side. cases, emergent intervention still should be undertaken in an attempt to restore Compartment Syndrome normal vascular fl ow.28 Reduction of The rate of compartment syndrome the fracture usually restores the pulse, after isolated supracondylar humeral which is believed to be absent second- fractures has been reported between ary to kinking of the vessel. After the 0.1% to 0.3%.35 This rate increases in fracture is reduced, the vessel is no lon- combined injuries of the elbow and the ger kinked. However, hospital admis- forearm or wrist, the so-called fl oating sion and close observation of the limb elbow injuries (Figure 3). Ring et al36 is needed to identify any changes that reviewed 16 children with fl oating el- may occur in the vascular examination. bow injuries: compartment syndrome The use of ultrasound and/or Dop- developed in 2 patients, and symptoms pler has been advocated to assess bra- of compartment syndrome began in chial artery injuries or spasms in the 4 patients but responded to splitting of case of a pink, pulseless hand. One the cast. study identifi ed 11 children who had Battaglia et al35 found that fl exing vascular impairment after a type III the elbow past 90° of fl exion increases supracondylar humeral fracture, 8 of forearm compartment pressures. There- Figure 3 Lateral radiograph of a whom had a pulseless but clinically fore, children splinted in the emergency fl oating elbow. Note the distal both- well-perfused hand.33 Four of these department or postoperatively should bone fracture partially obstructed by the hand of the patient’s parent, as patients showed spasms and kinking be placed in 90° of fl exion or less. well as the supracondylar fracture. of the brachial artery but no occlusion The presence of compartment syn- (Courtesy of Joshua M. Abzug, MD, or thrombosis, and all had return of drome in children is more likely to be Baltimore, MD.) pulse after closed reduction maneuvers. manifested by an increase in analge- The other four patients showed severe sia requirement, anxiety, or agitation, thumb adduction, with the metacar- spasms and decreased fl ow in the bra- known as the three A’s, rather than the pophalangeal joints in extension and chial artery on color-coded Doppler fi ve P’s (pain, pallor, pulse, paresthe- the proximal interphalangeal joints in without return of fl ow after reduction. sia, and paralysis) commonly described fl exion. The median nerve is often af- All four of these children underwent for adults.37 Special attention should be fected more profoundly than the ulnar exploration and vascular repair with no paid to children with median nerve in- nerve because the median nerve lies in sequelae reported. juries because they will lack sensation the deep fl exor compartment. There has been concern for the in the volar forearm, thus masking the Blakey et al39 examined 26 children long-term effects of vascular injury, signs of compartment syndrome.38 at a mean of 3 months after they were including growth disturbance, arm If compartment syndrome is missed referred to the authors’ facility for weak circumference, endurance strength, or the diagnosis is delayed by more than or absent radial pulses after reduction and cold intolerance. A recent study by 6 hours, this can result in Volkmann and pinning. With the exception of 3 Scannell et al34 evaluated 29 patients ischemic contracture of the forearm, children who were treated with artery with pink, pulseless extremities at the which affects the deep volar compart- exploration and repair, the remaining time of injury. The authors collected ment most profoundly. The typical 23 children all had some amount of follow-up data for an average of 19.5 posture of the limb is elbow fl exion, ischemic contracture or fi brosis within months after the injury. They reported forearm pronation, wrist fl exion, and their forearm compartments.

Figure 4 Images from a 7-year-old girl with a left supracondylar humeral fracture. A, Clinical photograph showing cubitus varus. B, AP radiograph showing cubitus varus. C, Lateral radiograph with slight extension at the fracture site. (Courtesy of Martin J. Herman, MD, Philadelphia, PA.)

The goal of treatment after Volk- Typically, in childhood, this deformity lateral closing wedge osteotomy with mann ischemic contracture is to restore is painless and does not interfere with or without ligament reconstruction function; however, normal function elbow range of motion. Less commonly, (Figure 5). If a sagittal plane defor- should not be anticipated. Treatment children may have an increased risk of mity also is present, a biplanar closing consists of débriding necrotic tissue lateral condyle fractures or snapping wedge, dome, or step-cut osteotomy is and muscle and preserving neurovas- medial triceps.42,43 required for correction. These latter cular structures. Subsequently, a fl exor/ It is important to note that there procedures are more technically de- pronator slide or a free muscle transfer have been reports of elbow pain and manding and require accurate preop- may be used to improve hand position instability in adults in whom cubitus erative planning.46-48 and function.40,41 Individual fl exor ten- varus developed after a supracondy- don tenolysis or lengthening should not lar humeral fracture was sustained as Stiffness be performed because of the high rate a child. This is believed to be caused It is generally anticipated that full re- of recurrent contracture. However, ex- by tardy posterolateral elbow instabil- turn of elbow motion will occur after tensor to fl exor tendon transfers may be ity as a result of medialization of the supracondylar humeral fractures. Spen- performed to improve individual func- elbow mechanical axis and attenuation cer et al49 studied the range of motion tions of the hand and the wrist after of the lateral collateral ligaments across in children treated both surgically and release of the volar contracture. time.44 A three-dimensional CT analy- nonsurgically after supracondylar hu- sis of adult patients with cubitus varus meral fractures and found signifi cant Cubitus Varus found generally increased sizes of the differences in range of motion between Cubitus varus is a common complica- posterior trochlea, lateral capitellum, those treated surgically and nonsurgi- tion after supracondylar fractures, and and radial head, with medial shift of the cally until 24 weeks after injury. Al- it can be the result of either casting ulna, compared with the contralateral, though the average fl exion contracture or surgical treatment with pinning. unaffected side. at cast removal was 47°, by week 9, Cubitus varus is currently thought When considerable cubitus varus children had an average of 2° of hy- to be caused by inadequate fracture occurs after a pediatric supracondylar perextension of the affected arm, with reduction, which leads to malunion humeral fracture, the preferred treat- an arc of motion of 132° compared with rather than growth arrest3 (Figure 4). ment method of Kim et al45 is to use a 150° on the contralateral side. The need

Figure 6 Lateral (A) and AP (B) illustrations depicting failure to engage both the proximal and distal fragments with at least two pins. Note one pin exiting the fracture site (arrow). (Courtesy of Dan A. Zlotolow, MD, Philadelphia, PA.) Figure 5 Radiographs demonstrating a left lateral closing wedge osteotomy in a 7-year-old girl (patient in Figure 4). A, AP radiograph showing the correction of cubitus varus. B, Lateral radiograph showing improvement in coronal alignment. (Courtesy of Martin J. Herman, MD, Philadelphia, PA.) Common errors include a failure to engage both fragments with at least two pins (Figure 6), failure to achieve bicortical fi xation with at least two pins (Figure 7), and failure to achieve at least 2 mm of pin separation at the fracture site (Figure 8). Sankar et al50 reported loss of reduction in 8 of 279 fractures (2.9%) treated surgically. Seven of those eight fractures were treated with two lateral pins, and loss of reduction was attributed to tech- Figure 8 Lateral (A) and AP (B) nical errors. On further radiographic illustrations depicting less than Figure 7 Lateral (A) and AP 2 mm of pin separation (arrow) at review, four cases had only one pin in (B) illustrations depicting failure the fracture site. (Courtesy of Dan the distal fragment, and three cases had to achieve bicortical fi xation with A. Zlotolow, MD, Philadelphia, PA.) inadequate pin separation at the frac- at least two pins. Note the one pin stays intramedullary (arrow), thus ture site. One fracture did not have never achieving bicortical fi xation. of their types II and III supracondylar bicortical fi xation of the pins. There- (Courtesy of Dan A. Zlotolow, MD, humeral fracture patients were sent fore, the surgeon must ensure that pin Philadelphia, PA.) to physical therapy because of elbow placement is adequate. After fracture stiffness. reduction and pinning, live fl uoroscopy should be performed to ensure fracture for surgery, fracture severity, and age Pin-Related Complications stability. The elbow should be brought younger than 5 years all contributed to Loss of Reduction through a range of motion in fl exion longer times needed to return to full Loss of reduction after the surgical and extension, and varus and valgus motion. By 48 weeks after injury, 88% treatment of pediatric supracondylar stresses should be applied, all while of all the children had recovered 90% humeral fractures is most commonly evaluating for fracture motion.28 of motion compared with their contra- caused by technical errors in pin place- The experience of the treating lateral side. Garg et al23 noted that 8% ment or malreduction of the fracture. surgeon is related to the adequacy of

fracture reduction and stability. A study long-term sequelae of small changes in Operative treatment of supracondylar fractures of the humerus in children: of pediatric fellows found that nonideal fracture alignment. If surgical treat- The consequences of pin placement. J reductions occurred in the fi rst eight ment is required, anatomic reduction Bone Joint Surg Am 2001;83(5):735-740. 51 patients treated independently. The and accurate pin placement are critical 11. Gaston RG, Cates TB, Devito D, surgeons’ lack of experience, however, to optimal outcomes. et al: Medial and lateral pin ver- did not lead to any increase in compli- sus lateral-entry pin fi xation for References type 3 supracondylar fractures in cations in this study because the malre- children: A prospective, surgeon- ductions were not clinically relevant. 1. Minkowitz B, Busch MT: Supracondy- randomized study. J Pediatr Orthop lar humerus fractures: Current trends 2010;30(8):799-806. and controversies. Orthop Clin North Infection Am 1994;25(4):581-594. 12. Lee JK, Kim R, Ebramzadeh E, Pin site infection is common in pediat- Silva M: Is medial pin use safe for 2. Otsuka NY, Kasser JR: Supracondylar treating pediatric supracondylar ric fractures, ranging from 1% to 21%; fractures of the humerus in children. J humerus fractures? J Orthop Trauma however, the rate for supracondylar hu- Am Acad Orthop Surg 1997;5(1):19-26. 2014;28(4):216-221. meral fractures tends to be much low- 3. Omid R, Choi PD, Skaggs DL: 13. Brauer CA, Lee BM, Bae DS, Waters er, with reported incidences between Supracondylar humeral fractures PM, Kocher MS: A systematic review 52-54 in children. J Bone Joint Surg Am of medial and lateral entry pinning less than 1% and 6.6%. Most series 2008;90(5):1121-1132. versus lateral entry pinning for supra- report resolution of the superfi cial pin condylar fractures of the humerus. J 4. Cheng JC, Lam TP, Maffulli N: Pediatr Orthop 2007;27(2):181-186. tract infection with oral antibiotic use Epidemiological features of supra- and pin removal.54,55 This chapter’s condylar fractures of the humerus in 14. Bloom T, Robertson C, Mahar AT, authors prefer dose-appropriate ceph- Chinese children. J Pediatr Orthop B Newton P: Biomechanical analysis of 2001;10(1):63-67. supracondylar humerus fracture pin- alexin or clindamycin if the patient has ning for slightly malreduced fractures. 5. Farnsworth CL, Silva PD, Mubarak a penicillin allergy. J Pediatr Orthop 2008;28(7):766-772. SJ: Etiology of supracondylar Deep infections are rare but serious humerus fractures. J Pediatr Orthop 15. Culp RW, Osterman AL, David- complications that can result from the 1998;18(1):38-42. son RS, Skirven T, Bora FW Jr: Neural injuries associated with pin tracking through the elbow joint, 6. Gartland JJ: Management of supra- supracondylar fractures of the hu- condylar fractures of the humer- thus leading to septic elbow arthritis. merus in children. J Bone Joint Surg Am us in children. Surg Gynecol Obstet 1990;72(8):1211-1215. The reported incidence is less than 1% 1959;109(2):145-154. of supracondylar humeral fractures 16. McGraw JJ, Akbarnia BA, Hanel 7. Wilkins KE: Fractures and disloca- 21 DP, Keppler L, Burdge RE: Neu- treated surgically. A deep infection tions of the elbow region, in Rock- rological complications resulting requires surgical débridement, includ- wood CA, Wilkins KE, King RE, from supracondylar fractures of the eds: Fractures in Children. Philadelphia, ing irrigation and débridement of the humerus in children. J Pediatr Orthop PA, JB Lippincott, 1984, vol 3, pp 1986;6(6):647-650. elbow joint. 363-575. 17. Galbraith KA, McCullough CJ: Acute 8. Leitch KK, Kay RM, Femino JD, nerve injury as a complication of Summary Tolo VT, Storer SK, Skaggs DL: closed fractures or dislocations of the Treatment of multidirectionally unsta- Pediatric supracondylar humeral frac- elbow. Injury 1979;11(2):159-164. tures represent a wide spectrum of ble supracondylar humeral fractures in children: A modifi ed Gartland 18. Banskota A, Volz RG: Traumatic lac- injury severity and have several impor- type-IV fracture. J Bone Joint Surg Am eration of the radial nerve following tant nonsurgical and surgical complica- 2006;88(5):980-985. supracondylar fracture of the elbow: A case report. Clin Orthop Relat Res tions. Neurovascular complications are 9. Mahan ST, Osborn E, Bae DS, et 1984;184:150-152. common, and close attention should be al: Changing practice patterns: The impact of a randomized clinical paid to the initial presentation and any 19. Martin DF, Tolo VT, Sellers DS, Wei- trial on surgeons’ preference for land AJ: Radial nerve laceration and changes in the child’s physical exam- treatment of type 3 supracondylar retraction associated with a supracon- ination across time. Surgical treatment humerus fractures. J Pediatr Orthop dylar fracture of the humerus. J Hand 2012;32(4):340-345. of this fracture continues to evolve as Surg Am 1989;14(3):542-545. more work is done on the biomechani- 10. Skaggs DL, Hale JM, Bassett J, 20. Spinner M, Schreiber SN: Anteri- Kaminsky C, Kay RM, Tolo VT: or interosseous-nerve paralysis as cal stability of fracture fi xation and the

a complication of supracondylar 32. Campbell CC, Waters PM, Emans JB, varus malunion of a supracondylar fractures of the humerus in children. J Kasser JR, Millis MB: Neurovascular fracture in children. J Bone Joint Surg Br Bone Joint Surg Am 1969;13:502-505. injury and displacement in type III 1998;80(5):791-797. supracondylar humerus fractures. J 21. Bashyal RK, Chu JY, Schoeneck- 43. Spinner RJ, O’Driscoll SW, Davids Pediatr Orthop 1995;15(1):47-52. er PL, Dobbs MB, Luhmann SJ, JR, Goldner RD: Cubitus varus Gordon JE: Complications after 33. Benedetti Valentini M, Farsetti P, associated with dislocation of both pinning of supracondylar distal Martinelli O, Laurito A, Ippolito E: the medial portion of the triceps humerus fractures. J Pediatr Orthop The value of ultrasonic diagnosis in and the ulnar nerve. J Hand Surg Am 2009;29(7):704-708. the management of vascular compli- 1999;24(4):718-726. cations of supracondylar fractures of 22. Dormans JP, Squillante R, Sharf 44. O’Driscoll SW, Spinner RJ, Mc- the humerus in children. Bone Joint J H: Acute neurovascular complica- Kee MD, et al: Tardy posterolateral 2013;95-B(5):694-698. tions with supracondylar humerus rotatory instability of the elbow due fractures in children. J Hand Surg Am 34. Scannell BP, Jackson JB III, Bray C, to cubitus varus. J Bone Joint Surg Am 1995;20(1):1-4. Roush TS, Brighton BK, Frick SL: 2001;83(9):1358-1369. The perfused, pulseless supracon- 23. Garg S, Weller A, Larson AN, et al: 45. Kim HT, Lee JS, Yoo CI: Manage- dylar humeral fracture: Intermedi- Clinical characteristics of severe su- ment of cubitus varus and valgus. ate-term follow-up of vascular status pracondylar humerus fractures in chil- J Bone Joint Surg Am 2005;87(4): and function. J Bone Joint Surg Am dren. J Pediatr Orthop 2014;34(1):34-39. 771-780. 2013;95(21):1913-1919. 24. Rasool MN: Ulnar nerve injury after 46. DeRosa GP, Graziano GP: A new os- 35. Battaglia TC, Armstrong DG, K-wire fi xation of supracondylar hu- teotomy for cubitus varus. Clin Orthop Schwend RM: Factors affecting merus fractures in children. J Pediatr Relat Res 1988;236:160-165. forearm compartment pressures in Orthop 1998;18(5):686-690. children with supracondylar frac- 47. Skaggs DL, Glassman D, Weiss JM, 25. Zaltz I, Waters PM, Kasser JR: Ulnar tures of the humerus. J Pediatr Orthop Kay RM: A new surgical technique nerve instability in children. J Pediatr 2002;22(4):431-439. for the treatment of supracondylar hu- Orthop 1996;16(5):567-569. merus fracture malunions in children. 36. Ring D, Waters PM, Hotchkiss RN, J Child Orthop 2011;5(4):305-312. 26. Brown IC, Zinar DM: Traumatic Kasser JR: Pediatric fl oating elbow. J and iatrogenic neurological compli- Pediatr Orthop 2001;21(4):456-459. 48. Eamsobhana P, Kaewpornsawan cations after supracondylar humerus K: Double dome osteotomy for the 37. Bae DS, Kadiyala RK, Waters PM: fractures in children. J Pediatr Orthop treatment of cubitus varus in children. Acute compartment syndrome in 1995;15(4):440-443. Int Orthop 2013;37(4):641-646. children: Contemporary diagnosis, 27. Royce RO, Dutkowsky JP, Kasser JR, treatment, and outcome. J Pediatr 49. Spencer HT, Wong M, Fong YJ, Rand FR: Neurologic complications Orthop 2001;21(5):680-688. Penman A, Silva M: Prospective lon- after K-wire fi xation of supracondylar gitudinal evaluation of elbow motion 38. Mubarak SJ, Carroll NC: Volkmann’s humerus fractures in children. J Pediatr following pediatric supracondylar contracture in children: Aetiology Orthop 1991;11(2):191-194. humeral fractures. J Bone Joint Surg Am and prevention. J Bone Joint Surg Br 2010;92(4):904-910. 28. Abzug JM, Herman MJ: Management 1979;61(3):285-293. of supracondylar humerus fractures in 39. Blakey CM, Biant LC, Birch R: Is- 50. Sankar WN, Hebela NM, Skaggs children: Current concepts. J Am Acad chaemia and the pink, pulseless hand DL, Flynn JM: Loss of pin fi xation Orthop Surg 2012;20(2):69-77. complicating supracondylar fractures in displaced supracondylar humeral fractures in children: Causes and 29. Shtarker H, Elboim-Gabyzon M, of the humerus in childhood: Long- prevention. J Bone Joint Surg Am Bathish E, Laufer Y, Rahamimov N, term follow-up. J Bone Joint Surg Br 2007;89(4):713-717. Volpin G: Ulnar nerve monitoring 2009;91(11):1487-1492. during percutaneous pinning of supra- 40. Stevanovic M, Sharpe F: Management 51. Liu RW, Roocroft J, Bastrom T, condylar fractures in children. J Pediatr of established Volkmann’s contracture Yaszay B: Surgeon learning curve Orthop 2014;34(2):161-165. of the forearm in children. Hand Clin for pediatric supracondylar humerus fractures. J Pediatr Orthop 30. Pirone AM, Graham HK, Krajbich JI: 2006;22(1):99-111. 2011;31(8):818-824. Management of displaced extension- 41. Ultee J, Hovius SE: Functional type supracondylar fractures of the results after treatment of Volkmann’s 52. Battle J, Carmichael KD: Incidence humerus in children. J Bone Joint Surg ischemic contracture: A long-term of pin track infections in children’s Am 1988;70(5):641-650. followup study. Clin Orthop Relat Res fractures treated with Kirschner wire fi xation. J Pediatr Orthop 31. Shaw BA, Kasser JR, Emans JB, Rand 2005;431:42-49. 2007;27(2):154-157. FF: Management of vascular injuries 42. Takahara M, Sasaki I, Kimura T, in displaced supracondylar humerus Kato H, Minami A, Ogino T: Second 53. Boyd DW, Aronson DD: Su- fractures without arteriography. J fracture of the distal humerus after pracondylar fractures of the hu- Orthop Trauma 1990;4(1):25-29. merus: A prospective study of

percutaneous pinning. J Pediatr Orthop 55. Gupta N, Kay RM, Leitch K, Femino 1992;12(6):789-794. JD, Tolo VT, Skaggs DL: Effect of surgical delay on perioperative 54. Mehlman CT, Strub WM, Roy DR, complications and need for open Wall EJ, Crawford AH: The effect of reduction in supracondylar humerus surgical timing on the perioperative fractures in children. J Pediatr Orthop complications of treatment of 2004;24(3):245-248. supracondylar humeral fractures in children. J Bone Joint Surg Am 2001;83(3):323-327.