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Olecranon screw traction for displaced supracondylar fractures of the humerus in children
li~~ury Vol. 29, No. 6, pp. 457-460, 1998 0 1998 Elsevier Science Ltd. All rights reserved Printed in Great Britain 0020-1383/98 $19.00+0.00
ELSEVIER
PII: SOO20-1383(98)00087-4
Olecranon screw traction for displaced supracondylar fractures of the humerus Nitin
P. Badhe and Peter W. Howard
Department
of Orthopaedics,
Derbyshire
Royal Infirmary,
Tzocnty six children with severely displaced supracorzdylar frnctures zucrc tmnted witlz closed reduction and vertical osseous trnction ruith an olecrarzorz screw. Four children required n second upernfivn in fire form of open reductiun rind K-mire fixation for failure to achiezlc n sntisjzctory redzlction. After R nzenzz follow up $48 zueeks, 20 children (91 per cent) /zad nn excellent result zoith no significant loss v f moz~emezzf. Tzoo children (9 per cent) Iznd mininznl cubitus ZWIIS (nz~. 8”) zohich did not require a correctizle ostcotvmy. All jour children zvhv /znd il secozzd operntivzz izad nn excellent result. The aucrrrge hospitnlisntion tinze wets 19 days. TIze method v f vlecrnzzorz screw traction is technically easy to perform mzd carries fezu risks of complicntions. 0 2998 Elsezlicr Sciezzce Ltd. All r&hfs reserved.
Injury,
in children
Vol. 29, No. 6,457-460,
1998
Introduction Supracondylar fractures of the distal humerus often instil a sense of apprehension in the treating surgeon. Supracondylar fracture of the humerus accounts for 3 per cent of childhood fractures. It is the commonest fracture around the region of the elbow in children and accounts for 80 per cent of elbow injuries. The most common but neglected complication of supracondylar fracture of the humerus in children is cubitus varus. Because the early management concentrates on avoiding the more serious complications, viz Volkman’s ischaemic contracture and neurovascular lesions, control of the carrying angle may receive low priority. This is reflected in a reported change of carrying angle of up to 57”‘. Although extensive literature on this fracture describes many methods of treatment, both non-operative and operative, no one method is suitable for all fractures nor has any method gained universal acceptance. Smith in 1947 described skeletal traction with the help of K-wire through the proximal end of the ulna. Olecranon screw traction for the management of supracondylar fractures of the humerus was
Derby, UK
described as early as 1963 by Edman and Lohrg’. Bosanquet and Middleton” used a Thomas splint for the treatment of this injury. Closed reduction with K-wire fixation and open reduction are becoming increasingly popular’,‘. In view of the increasing tendency towards operative treatment, we report our results of olecranon screw traction in severely displaced supracondylar fractures.
Patients and methods From January 1992 to December 1996, 26 patients (18 male and eight female) with severely displaced supracondylar fractures of the humerus were treated with vertical olecranon screw traction. The left side was the commonly involved one (17 children). All 26 patients had a trial of manipulation. Failure to achieve or maintain a satisfactory reduction was an indication for olecranon screw traction. A selfcutting 6.5 mm A0 cancellous screw with a washered clip was inserted at the level of the coronoid process of the ulna under radiological control. Vertical traction was applied through this, with sufficient weight to lift the shoulder off the bed. The forearm was held pronated over the head with the child supine (Figure 1). Radiological assessment was done at the end of 48 hours. Determination of presence or absence of angulation was performed by measuring the Baumann’s angle on the anteroposterior view (the angle between the long axis of the humerus and the growth plate of the capitulum)h. The same angle was measured in the same position on the uninjured side. Inadequacy of reduction was indicated by more than a 4” difference in the Baumann’s angle7. When the Baumann’s angle is the same on both sides, a normal carrying angle can be expected. The average Baumann’s angle is 72”, SD. PR. The lateral view provides more information to determine the accuracy of reduction. Firstly it tells whether the shaft-condylar axis has been re-established. Secondly it is valuable in assessing horizontal rotation that may contribute to mediolat-
458
Injury:
International
Journal
of the Care of the Injured
Vol. 29, No. 6,1998
Figure 1. A child in olecranontraction.
era1 coronal angulation. When the reduction is anatomic without rotation the diameters of the fragments at the fracture site are equal. Some assessment of varus and valgus angulation can also be made on the lateral view. Normally in a true lateral view of the elbow the ossification centre of the lateral condyle does not overlap on the olecranon. There is usually a radiolucent space between the ossification
centres. If there is a significant tilt of the distal fragment then these areas of ossification may overlap creating a ‘crescent’ as described by Conn and Wade (Figure 3)‘. No attempt was made to correct the rotational malalignment provided Baumann’s angle was re-established on the anteroposterior view. After a satisfactory reduction was achieved, traction was maintained for two to three weeks (average 19 days) till early evidence of callus formation was visible radiologically. The screw was later removed under a general anaesthetic and the elbow supported in a collar and cuff sling. Elbow mobilisation was started after clinical and radiological evidence of union.
Figure 2. Pre-operative radiograph (Holmberg Group IV) of
Figure
a child with a displaced supracondylar fracture of the humerus.
3. Reduction achieved with olecranon traction showing a normal Baumann’s angle and absence of crescentsign ( > ).
Badhe and Howard:
Olecranon
screw traction
for displaced
Table I. Holmberg classificationof supracondylar fractures Holmberg group
I II III IV
Displacement Fractures Fractures Fractures Fractures without
Number children
without displacement with sideways displacement with displacement due to rotation with considerable displacement contact between the fragments.
Total
supracondylar
Table II. Final resultsaccording to Flynn’s criteria
of
0 0 3 23
Result ~-~-__
Function floss of flexionextension)
Excellent Good Fair Poor
26
Results The criteria of Flynn et al.” (T&L II) were used to evaluate the results. It is both a functional and cosmetic assessment of grading. Function is graded as the restriction of the flexion-extension arc and appearance as the change in the carrying angle. Only two patients (9 per cent) had radiological evidence of cubitus varus (7 and 9” respectively). Both these children had a full range of movement
Figure 4. Final remodeling of fracture at one year.
O-5” 6-10 1 I-15” > 15”
Change carrying angle
in
O-5” 6-10” 11-15” > 15”
who underwent reduction were
Number patients
of
20 (91%) 2 (9%) 0 0 22
Total Note: four patients achieve satisfactory
All fractures were classified according to the criteria of severity of ‘Holmberg’“’ (T&e I). Twenty three children had grade IV fractures, while the remaining three children had grade III fractures. Satisfactory reduction with olecranon screw traction could not be achieved in four patients who underwent an open reduction with K-wiring. All these patients had button-holing of the spike of the proximal fragment through the brachialis muscle preventing the reduction. These were later excluded from this series. Two children had median nerve palsy which recovered without treatment. None of the children had any vascular problem. The screw site was dressed regularly. None of the patients had superficial or deep infection. All patients had radiological signs of union four weeks after the injury (FjLqzrres 2-4).
459
fractures
open reduction excluded from
for failure the series.
to
and were unaware of their deformity and were graded as good according to Flynn’s criteria. Thus 20 children (91 per cent) had excellent cosmetic and functional results. Mention must be made of the fact that four patients who underwent open reduction with K-wire fixation at the end of one week for failure to achieve satisfactory reduction with olecranon screw have been excluded from the series. Each of these four patients had no radiological deformity with excellent functional results.
Discussion Grossly displaced supracondylar fractures are often associated with swelling and reduction in flexion compromises the radial pulse distally. Hence the elbow often cannot be flexed beyond 90”. In such a position the stabilisation action of triceps and posterior periosteum is lost and redisplacement of the fracture with cubitus varus may occur. This is the ‘supracondylar dilemma’: flexion stabilises the fracture but compromises the circulation”. The aim of treatment is to achieve accurate reduction and prevent cubitus varus deformity. A varus deformity develops as a result of tilting and medial rotation of the distal fragment. D’Ambrosia’” has shown that if the forearm is supinated, lateral ligamentous structures become lax, which allows medial tilt of the distal fragment. On the contrary, when the forearm is pronated, the ligamentous structures become tight and the distal fragment is brought into close contact preventing medial angulation. With vertical olecranon traction the hand lies in a slightly pronated position to aid reduction. Elevation of the elbow also helps to treat the oedema around the elbow. There is however a risk of failure to achieve a satisfactory reduction for which alternate methods of treatment should be adopted. In our series of 26 patients, four patients did not achieve satisfactory reduction and underwent an open reduction and K-wire fixation. The results in our series are similar to those of other series treated with olecranon screw traction. Warlock and Colton, Kramhoft et al. and RodriguezMerchan’-‘-‘” have all reported excellent results ranging from 83 to 58 per cent; with a cubitus varus
460
Injury:
International
deformity of 7 to 3.3 per cent. In our series of 22 patients, 20 patients (91 per cent) had excellent results and two patients (9 per cent) had a mild cubitus varus deformity. This series also compares favourably with the results obtained by other methods of treatment. Manipulation and strapping in flexion gave 95 per cent excellent results, but a cubitus varus deformity in 22.7 per cent of the patients17. Closed reduction and percutaneous K-wire fixation gave excellent results in 80 per cent of cases, while open reduction and K-wire fixation gave 93 per cent excellent, with three patients (10 per cent) having fair resultsIx. The incidence of cubitus varus has been reported by some authors to be as high as 22 per cent” with percutaneus pinning and 25 per cent” with open reduction and K-wire fixation. Thus it is clear that manipulation and percutaneous pinning or open reduction and pinning require expertise and poor results will follow an incomplete reduction. The technique of olecranon screw traction is simple, safe and relatively non-invasive with no significant complications. However periodic radiographs need to be taken to ensure that the fracture reduction is maintained. If deformity recurs, further manipulation or adjustment of traction must be made within the first week. After this, any further adjustment is unlikely to succeed in altering the position of the fracture and surgical intervention is required to correct it. The only disadvantage of this procedure is prolonged hospital stay which is justified by the reduction in serious complications.
6 7
8
9 10 11
12 13
14
15
16
17
References 1 Smith L. Deformity following supracondylar fractures of humerus. 1 Bone Joint Surg (Am) 1960; 42A: 235-252. 2 Edman P. and Lohrg G. Supracondylar fractures of humerus treated with olecranon traction. Acta Ckir Scan 1963; 126: 505-516. 3 Bosanquet J. S. and Middleton R. W. The reduction of supracondylar fractures of humerus in children treated by traction in extension. A review of 18 cases. Itzjuvy 1983; 14: 373-380. 4 Arino V. L., Lluch L. E., Ramirez A. M., Ferrer J., Rodriguez L. and Baixauli F. Percutaneous fixation of supracondylar fractures of humerus in children. I Bone Joint Surg (Am) 1977; 59A: 914-916. 5 Aronson D. C., Van vollenhoven E. and Meeuwis J. D. K wire fixation of supracondylar humeral fractures in children. Results of open reduction via ventral
18
19
Journal
of the Care of the Injured
Vol. 29, No. 6,1998
approach in comparison with closed treatment. ir:juuy 1993; 24(3): I79-181. Baumann E. Zur behandlung der knochenbruche am ellogengelenk. Langenbecks Arch Ckir 1960; 295: 300-304. Williamson D. M., Coates C. J., Miller R. K. and Cole W. G. Normal characteristics of Baumann’s (Humero Capitulum) angle: An aid in assessment of supracondylar fractures. J Paed Ortkop 1992; 12(5): 636-639. Boyd D. W. and Aronson D. D. Supracondylar fractures of the humerus: A prospective study of percutaneous pinning. J Orthop Trauma 1992; 6(4): 407-412. Conn J. Jr and Wade I’. A. Injuries of the elbow. A ten year review. 1 Trauma 1961; 1: 248-268. Holmberg L. Fractures in distal end of the humerus in children. Acta Chir Stand 1945; 92(suppl. 103:s): l-69. Flynn J. C., Mathew J. G. and Benoit R. L. Blind pinning of displaced supracondylar fractures of humerus in children. 16 years experience with long term follow up. 1 Bone Joint Surg (Am) 1974; 56: 263-272. Rang M. Children Fractures. J. B. Lippincott, Philadelphia, 1974. D’Ambrosia R. D. Supracondylar fractures of humerus. Prevention of cubitus varus. I Bone Joint Surg (Am) 1972; 54: 60-62. Warlock I’. H. and Colton C. Severely displaced supracondylar fractures of humerus in children: A simple method of treatment. ] Paed Ortkop 1987; 7(l): 49-53. Kramhoft M., Kellar I. L. and Solgaurd S. Displaced supracondylar fractures of the humerus in children. Clin Ortkop 1987; 221: 215-220. Rodriguez-Merchan E. C. Supracondylar fractures of the humerus in children treated by overhead skeletal traction. Ortlzop Rev 1992; 21(4): 475-482. Williamson D. M. and Dole W. G. Treatment of selected extension supracondylar fractures of the humerus by manipulation and strapping in flexion. Injury 1993; 24(4): 249-252. Crammer K. E., Dento D. P. and Green N. E. Comparison of closed reduction and percutaneous pinning versus open reduction and percutaneous pinning in displaced supracondylar fractures of the humerus in children. I Ortkoy Trauma 1992; 6(4): 407-412. Weiland A. J., Meyers S., To10 V. T., Berg H. L. and Muellar J. Surgical treatment of displaced supracondylar fractures of the humerus in children: Analysis of 52 cases followed for 5-15 years. J Bone Joinf Surg (Am) 1978; 60: 657-661.
Paper accepted 17 March 1998. Requests for reprints should be addressed to: Dr Nitin I’. Badhe, Derbyshire Royal Infirmary, London Road, Derby DE1 2QY, UK.
ELSEVIER
PII: SOO20-1383(98)00087-4
Olecranon screw traction for displaced supracondylar fractures of the humerus Nitin
P. Badhe and Peter W. Howard
Department
of Orthopaedics,
Derbyshire
Royal Infirmary,
Tzocnty six children with severely displaced supracorzdylar frnctures zucrc tmnted witlz closed reduction and vertical osseous trnction ruith an olecrarzorz screw. Four children required n second upernfivn in fire form of open reductiun rind K-mire fixation for failure to achiezlc n sntisjzctory redzlction. After R nzenzz follow up $48 zueeks, 20 children (91 per cent) /zad nn excellent result zoith no significant loss v f moz~emezzf. Tzoo children (9 per cent) Iznd mininznl cubitus ZWIIS (nz~. 8”) zohich did not require a correctizle ostcotvmy. All jour children zvhv /znd il secozzd operntivzz izad nn excellent result. The aucrrrge hospitnlisntion tinze wets 19 days. TIze method v f vlecrnzzorz screw traction is technically easy to perform mzd carries fezu risks of complicntions. 0 2998 Elsezlicr Sciezzce Ltd. All r&hfs reserved.
Injury,
in children
Vol. 29, No. 6,457-460,
1998
Introduction Supracondylar fractures of the distal humerus often instil a sense of apprehension in the treating surgeon. Supracondylar fracture of the humerus accounts for 3 per cent of childhood fractures. It is the commonest fracture around the region of the elbow in children and accounts for 80 per cent of elbow injuries. The most common but neglected complication of supracondylar fracture of the humerus in children is cubitus varus. Because the early management concentrates on avoiding the more serious complications, viz Volkman’s ischaemic contracture and neurovascular lesions, control of the carrying angle may receive low priority. This is reflected in a reported change of carrying angle of up to 57”‘. Although extensive literature on this fracture describes many methods of treatment, both non-operative and operative, no one method is suitable for all fractures nor has any method gained universal acceptance. Smith in 1947 described skeletal traction with the help of K-wire through the proximal end of the ulna. Olecranon screw traction for the management of supracondylar fractures of the humerus was
Derby, UK
described as early as 1963 by Edman and Lohrg’. Bosanquet and Middleton” used a Thomas splint for the treatment of this injury. Closed reduction with K-wire fixation and open reduction are becoming increasingly popular’,‘. In view of the increasing tendency towards operative treatment, we report our results of olecranon screw traction in severely displaced supracondylar fractures.
Patients and methods From January 1992 to December 1996, 26 patients (18 male and eight female) with severely displaced supracondylar fractures of the humerus were treated with vertical olecranon screw traction. The left side was the commonly involved one (17 children). All 26 patients had a trial of manipulation. Failure to achieve or maintain a satisfactory reduction was an indication for olecranon screw traction. A selfcutting 6.5 mm A0 cancellous screw with a washered clip was inserted at the level of the coronoid process of the ulna under radiological control. Vertical traction was applied through this, with sufficient weight to lift the shoulder off the bed. The forearm was held pronated over the head with the child supine (Figure 1). Radiological assessment was done at the end of 48 hours. Determination of presence or absence of angulation was performed by measuring the Baumann’s angle on the anteroposterior view (the angle between the long axis of the humerus and the growth plate of the capitulum)h. The same angle was measured in the same position on the uninjured side. Inadequacy of reduction was indicated by more than a 4” difference in the Baumann’s angle7. When the Baumann’s angle is the same on both sides, a normal carrying angle can be expected. The average Baumann’s angle is 72”, SD. PR. The lateral view provides more information to determine the accuracy of reduction. Firstly it tells whether the shaft-condylar axis has been re-established. Secondly it is valuable in assessing horizontal rotation that may contribute to mediolat-
458
Injury:
International
Journal
of the Care of the Injured
Vol. 29, No. 6,1998
Figure 1. A child in olecranontraction.
era1 coronal angulation. When the reduction is anatomic without rotation the diameters of the fragments at the fracture site are equal. Some assessment of varus and valgus angulation can also be made on the lateral view. Normally in a true lateral view of the elbow the ossification centre of the lateral condyle does not overlap on the olecranon. There is usually a radiolucent space between the ossification
centres. If there is a significant tilt of the distal fragment then these areas of ossification may overlap creating a ‘crescent’ as described by Conn and Wade (Figure 3)‘. No attempt was made to correct the rotational malalignment provided Baumann’s angle was re-established on the anteroposterior view. After a satisfactory reduction was achieved, traction was maintained for two to three weeks (average 19 days) till early evidence of callus formation was visible radiologically. The screw was later removed under a general anaesthetic and the elbow supported in a collar and cuff sling. Elbow mobilisation was started after clinical and radiological evidence of union.
Figure 2. Pre-operative radiograph (Holmberg Group IV) of
Figure
a child with a displaced supracondylar fracture of the humerus.
3. Reduction achieved with olecranon traction showing a normal Baumann’s angle and absence of crescentsign ( > ).
Badhe and Howard:
Olecranon
screw traction
for displaced
Table I. Holmberg classificationof supracondylar fractures Holmberg group
I II III IV
Displacement Fractures Fractures Fractures Fractures without
Number children
without displacement with sideways displacement with displacement due to rotation with considerable displacement contact between the fragments.
Total
supracondylar
Table II. Final resultsaccording to Flynn’s criteria
of
0 0 3 23
Result ~-~-__
Function floss of flexionextension)
Excellent Good Fair Poor
26
Results The criteria of Flynn et al.” (T&L II) were used to evaluate the results. It is both a functional and cosmetic assessment of grading. Function is graded as the restriction of the flexion-extension arc and appearance as the change in the carrying angle. Only two patients (9 per cent) had radiological evidence of cubitus varus (7 and 9” respectively). Both these children had a full range of movement
Figure 4. Final remodeling of fracture at one year.
O-5” 6-10 1 I-15” > 15”
Change carrying angle
in
O-5” 6-10” 11-15” > 15”
who underwent reduction were
Number patients
of
20 (91%) 2 (9%) 0 0 22
Total Note: four patients achieve satisfactory
All fractures were classified according to the criteria of severity of ‘Holmberg’“’ (T&e I). Twenty three children had grade IV fractures, while the remaining three children had grade III fractures. Satisfactory reduction with olecranon screw traction could not be achieved in four patients who underwent an open reduction with K-wiring. All these patients had button-holing of the spike of the proximal fragment through the brachialis muscle preventing the reduction. These were later excluded from this series. Two children had median nerve palsy which recovered without treatment. None of the children had any vascular problem. The screw site was dressed regularly. None of the patients had superficial or deep infection. All patients had radiological signs of union four weeks after the injury (FjLqzrres 2-4).
459
fractures
open reduction excluded from
for failure the series.
to
and were unaware of their deformity and were graded as good according to Flynn’s criteria. Thus 20 children (91 per cent) had excellent cosmetic and functional results. Mention must be made of the fact that four patients who underwent open reduction with K-wire fixation at the end of one week for failure to achieve satisfactory reduction with olecranon screw have been excluded from the series. Each of these four patients had no radiological deformity with excellent functional results.
Discussion Grossly displaced supracondylar fractures are often associated with swelling and reduction in flexion compromises the radial pulse distally. Hence the elbow often cannot be flexed beyond 90”. In such a position the stabilisation action of triceps and posterior periosteum is lost and redisplacement of the fracture with cubitus varus may occur. This is the ‘supracondylar dilemma’: flexion stabilises the fracture but compromises the circulation”. The aim of treatment is to achieve accurate reduction and prevent cubitus varus deformity. A varus deformity develops as a result of tilting and medial rotation of the distal fragment. D’Ambrosia’” has shown that if the forearm is supinated, lateral ligamentous structures become lax, which allows medial tilt of the distal fragment. On the contrary, when the forearm is pronated, the ligamentous structures become tight and the distal fragment is brought into close contact preventing medial angulation. With vertical olecranon traction the hand lies in a slightly pronated position to aid reduction. Elevation of the elbow also helps to treat the oedema around the elbow. There is however a risk of failure to achieve a satisfactory reduction for which alternate methods of treatment should be adopted. In our series of 26 patients, four patients did not achieve satisfactory reduction and underwent an open reduction and K-wire fixation. The results in our series are similar to those of other series treated with olecranon screw traction. Warlock and Colton, Kramhoft et al. and RodriguezMerchan’-‘-‘” have all reported excellent results ranging from 83 to 58 per cent; with a cubitus varus
460
Injury:
International
deformity of 7 to 3.3 per cent. In our series of 22 patients, 20 patients (91 per cent) had excellent results and two patients (9 per cent) had a mild cubitus varus deformity. This series also compares favourably with the results obtained by other methods of treatment. Manipulation and strapping in flexion gave 95 per cent excellent results, but a cubitus varus deformity in 22.7 per cent of the patients17. Closed reduction and percutaneous K-wire fixation gave excellent results in 80 per cent of cases, while open reduction and K-wire fixation gave 93 per cent excellent, with three patients (10 per cent) having fair resultsIx. The incidence of cubitus varus has been reported by some authors to be as high as 22 per cent” with percutaneus pinning and 25 per cent” with open reduction and K-wire fixation. Thus it is clear that manipulation and percutaneous pinning or open reduction and pinning require expertise and poor results will follow an incomplete reduction. The technique of olecranon screw traction is simple, safe and relatively non-invasive with no significant complications. However periodic radiographs need to be taken to ensure that the fracture reduction is maintained. If deformity recurs, further manipulation or adjustment of traction must be made within the first week. After this, any further adjustment is unlikely to succeed in altering the position of the fracture and surgical intervention is required to correct it. The only disadvantage of this procedure is prolonged hospital stay which is justified by the reduction in serious complications.
6 7
8
9 10 11
12 13
14
15
16
17
References 1 Smith L. Deformity following supracondylar fractures of humerus. 1 Bone Joint Surg (Am) 1960; 42A: 235-252. 2 Edman P. and Lohrg G. Supracondylar fractures of humerus treated with olecranon traction. Acta Ckir Scan 1963; 126: 505-516. 3 Bosanquet J. S. and Middleton R. W. The reduction of supracondylar fractures of humerus in children treated by traction in extension. A review of 18 cases. Itzjuvy 1983; 14: 373-380. 4 Arino V. L., Lluch L. E., Ramirez A. M., Ferrer J., Rodriguez L. and Baixauli F. Percutaneous fixation of supracondylar fractures of humerus in children. I Bone Joint Surg (Am) 1977; 59A: 914-916. 5 Aronson D. C., Van vollenhoven E. and Meeuwis J. D. K wire fixation of supracondylar humeral fractures in children. Results of open reduction via ventral
18
19
Journal
of the Care of the Injured
Vol. 29, No. 6,1998
approach in comparison with closed treatment. ir:juuy 1993; 24(3): I79-181. Baumann E. Zur behandlung der knochenbruche am ellogengelenk. Langenbecks Arch Ckir 1960; 295: 300-304. Williamson D. M., Coates C. J., Miller R. K. and Cole W. G. Normal characteristics of Baumann’s (Humero Capitulum) angle: An aid in assessment of supracondylar fractures. J Paed Ortkop 1992; 12(5): 636-639. Boyd D. W. and Aronson D. D. Supracondylar fractures of the humerus: A prospective study of percutaneous pinning. J Orthop Trauma 1992; 6(4): 407-412. Conn J. Jr and Wade I’. A. Injuries of the elbow. A ten year review. 1 Trauma 1961; 1: 248-268. Holmberg L. Fractures in distal end of the humerus in children. Acta Chir Stand 1945; 92(suppl. 103:s): l-69. Flynn J. C., Mathew J. G. and Benoit R. L. Blind pinning of displaced supracondylar fractures of humerus in children. 16 years experience with long term follow up. 1 Bone Joint Surg (Am) 1974; 56: 263-272. Rang M. Children Fractures. J. B. Lippincott, Philadelphia, 1974. D’Ambrosia R. D. Supracondylar fractures of humerus. Prevention of cubitus varus. I Bone Joint Surg (Am) 1972; 54: 60-62. Warlock I’. H. and Colton C. Severely displaced supracondylar fractures of humerus in children: A simple method of treatment. ] Paed Ortkop 1987; 7(l): 49-53. Kramhoft M., Kellar I. L. and Solgaurd S. Displaced supracondylar fractures of the humerus in children. Clin Ortkop 1987; 221: 215-220. Rodriguez-Merchan E. C. Supracondylar fractures of the humerus in children treated by overhead skeletal traction. Ortlzop Rev 1992; 21(4): 475-482. Williamson D. M. and Dole W. G. Treatment of selected extension supracondylar fractures of the humerus by manipulation and strapping in flexion. Injury 1993; 24(4): 249-252. Crammer K. E., Dento D. P. and Green N. E. Comparison of closed reduction and percutaneous pinning versus open reduction and percutaneous pinning in displaced supracondylar fractures of the humerus in children. I Ortkoy Trauma 1992; 6(4): 407-412. Weiland A. J., Meyers S., To10 V. T., Berg H. L. and Muellar J. Surgical treatment of displaced supracondylar fractures of the humerus in children: Analysis of 52 cases followed for 5-15 years. J Bone Joinf Surg (Am) 1978; 60: 657-661.
Paper accepted 17 March 1998. Requests for reprints should be addressed to: Dr Nitin I’. Badhe, Derbyshire Royal Infirmary, London Road, Derby DE1 2QY, UK.