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Paediatric humeral supracondylar fractures
CHILDREN'S TRAUMA
Paediatric humeral supracondylar fractures
Thinning of the bone, due to the presence of the fossae between the supracondylar pillars, can act as a stress riser and result in fracture in the supracondylar region under excessive mechanical load. Hyperextension of the child’s elbow also contributes to the concentration of stress at this point and results in the high incidence of extension type supracondylar fractures (approximately 97%). Flexion type supracondylar fractures of the humerus are rarely encountered. This article provides a review of the classification, assessment, treatment options and the controversies in the management of the paediatric supracondylar distal humeral fracture and associated long-term complications.
Christopher Talbot Sanjeev Madan
Abstract The supracondylar humeral fracture is the most common elbow fracture in children accounting for just under one-fifth of all paediatric fractures and 60% of paediatric elbow fractures. Modifications of the Gartland classification have been made over the years. The mainstay treatment option is that of closed reduction and percutaneous wiring. However, there remains no gold standard in the management of this injury. Outcomes from other treatment options, including traction and external fixator application have been described and report good results. There remains controversy in the wiring configuration used, and there is no consensus on the approach to be used when faced with an irreducible fracture. This article aims to provide an upto-date overview of the current practices in the management of this common injury, including the ‘pink pulseless’ hand, ‘poorly perfused white’ hand, surgical techniques, and the associated complications that can ensue.
Classification In 1959, Gartland1 described a simple classification scheme to emphasize the principles underlying treatment of patients with a supracondylar humerus fracture and discussed a method of management that has proven to be practical and effective with time. His classification described a rotatory and translational deformity, with posterior displacement (extension) of the distal fragment occurring most often. He described three types of extension injury based on degree of displacement: type I, nondisplaced; type II, moderately displaced; and type III, severely displaced injury. Flexion-type injuries were considered separately. Over the years, modifications of the Gartland classification have been proposed and are now commonly used. Wilkins2 modification of Gartland’s extension type classification consists of: Type I injuries are non-displaced Type II injuries are displaced anteriorly but have posterior humeral cortical contact: Type IIA: no rotational abnormality or fragment translation Type IIB: rotational deformity, resulting in more instability Type III fractures are displaced with no cortical contact: Type IIIA: the medial periosteal hinge is intact leading to the posteromedially distal fragment displacement Type IIIB: the lateral periosteal hinge is intact, leading to the posterolaterally distal fragment displacement. A subtype of the supracondylar fracture where the medial column of the humerus is comminuted and unstable, leading to loss of coronal alignment has been described. Following on from this there has been the addition of a type IV injury.3 This is a configuration with multiplanar instability due to no intact periosteal hinge. This pattern results from the initial injury or occurs iatrogenically during attempted reduction.
Keywords closed reduction; complications; cubitus varus; open reduction; percutaneous wiring; pink pulseless; supracondylar fracture
Introduction The supracondylar humeral fracture is the most common elbow fracture in children accounting for just under one-fifth of all paediatric fractures and 60% of paediatric elbow fractures. This is an extraarticular fracture of the distal humerus, in which there is a slight male preponderance. The complication profile of this injury is significant, including neurovascular injury and malunion. The annual incidence is approximately 180 per 100,000. Especially in patients above the age of 8 years, this type of fracture most often results from high-energy trauma. It has been shown that there is an association between obesity and more complex supracondylar humeral fractures, preoperative and postoperative nerve palsies, and postoperative complications. In most cases, the non-dominant arm is affected.
Initial assessment Clinical assessment The initial assessment of a child with a supracondylar fracture should be in keeping with Advanced Trauma Life Support principles. It is vital to ensure all life-threatening injuries are managed prior to limb-threatening ones, if significant trauma has taken place. The patient will present with a painful swollen elbow. The British Orthopaedic Association Standards for Trauma (BOAST) 11: Supracondylar Fractures of the Humerus in Children guidelines4 provide standards for practice, highlighting the importance of the initial assessment of the limb including the
Christopher Talbot MB ChB (Hons) FRCS (T&O) Consultant Paediatric Trauma and Orthopaedic Surgeon, Department of Orthopaedics, Alder Hey Children’s Hospital NHS Foundation Trust, Liverpool, UK. Conflicts of interest: none declared. Sanjeev Madan FRCS (Orth) MSc (Bioeng) MCh (Orth) MBA Consultant Trauma and Orthopaedic Surgeon, Department of Orthopaedics, Sheffield Children’s Hospital, Sheffield, UK. Department of Orthopaedics, Doncaster Royal Infirmary, Doncaster, UK. Conflicts of interest: none declared.
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CHILDREN'S TRAUMA
more than 5 indicates coronal plane deformity and should not be accepted. On the lateral view, the following radiological parameters should be assessed (Figure 2): A: Fat pad sign: a positive fat pad sign ‘sail sign’ is suggestive of occult fracture when no radiological fracture line is obvious. B: Anterior humeral line (AHL): a line drawn down from the anterior cortex of the humerus. This line should intersect with the middle third of the capitellum. C: Shaft condylar angle (SCA): the angle between long axis of humerus and lateral condyle. This is between 30 and 40 . D: Coronoid line: a curved line drawn on the lateral radiograph along the superior aspect of the ulna, through the coronoid and onto the anterior aspect of distal humeral shaft. This line should be in continuity and have no break in it.
status of the radial pulse, digital capillary refill time and the individual function of the radial, median (including anterior interosseous (AION)) and ulnar nerves. It is important to document the findings of both sensory and motor function of these nerves. In younger children, this can be difficult however in most if not all patients a full motor assessment can be made, using the thumb alone. The ‘OK’ sign is one well-described sign when assessing the AION. ‘Rock, paper, scissors’ is an effective way of assessing function in a young child. Assessment for any open fractures, deformity; including that of the ‘S deformity’, signs of critical skin compromise, skin puckering and antecubital fossa ecchymosis should be undertaken. A puckered, dimple and/or ecchymosis of the skin just anterior to the distal humerus may indicate a difficult reduction because the proximal, anteriorly directed fragment has penetrated the brachialis muscle and possibly the subcutaneous layer as well. A review of the whole limb is required as approximately 5% of supracondylar humerus fractures in children are associated with an ipsilateral forearm fracture. These patients have higher rates of acute neurologic injury compared to patients with isolated supracondylar humerus fractures (14.7% vs 7.8%), further increased when the forearm fracture requires manipulation. It is our practice that these patients remain in hospital for 48 hours after surgery, as there is a higher rate of compartment syndrome reported in the displaced supracondylar fracture with associated ipsilateral forearm fractures. It is also recommended that urgent senior orthopaedic review in the emergency department is required when there is absence of radial pulse, ischaemia of hand (pale and cool extremities), severe swelling in forearm and/or elbow or any clinical concerns regarding compartment syndrome, skin puckering, open injury and neurological injury.
Management Initial The initial management should include adequate analgesia including the application of a splint (above elbow back slab/ collar and cuff depending on surgeon/treating unit preference and severity of injury) in a comfortable position. Usually 20e40 of flexion is sufficient. Splinting in displaced or unstable fractures with the elbow in full extension or hyper-flexion is contraindicated because it stretches the neurovascular bundle over the fracture site or they may get impinged between fractured fragments. Excessive flexion should be avoided as this can reduce the arterial flow to the limb and increase the risk of compartment syndrome. Radiographs should be obtained only after appropriate analgesia and splintage of the extremity to avoid any neurovascular injury. If there is an open fracture, clinical photography, the administration of antibiotics, tetanus (if appropriate) and a saline soaked swab/gauze dressing placed over the wound are all vital aspects of treatment.
Radiological assessment The standard radiographic study of the injured limb should include an anteroposterior (AP) and a lateral view of the elbow and any other sites of deformity, pain, or tenderness. Due to the association of supracondylar fractures with forearm fractures, a low threshold should be had in obtaining AP and lateral radiographic views of the forearm. The carrying angle (the varus or valgus attitude of the distal humerus and elbow) is evaluated on AP view. The carrying angle is defined as the angle between the long axis of the ulna and the long axis of the humerus. The normal range can be between 5 and 15 of valgus. Carrying angle correlates positively with age, in addition the carrying angle in girls is on average greater than in boys. The use of Baumann angle (Figure 1), in clinical practice is an important standard in the assessment of reduction quality. This angle is formed by the intersection of a line drawn down the humeral shaft axis and a line drawn along the physeal line of the lateral condyle on the AP radiograph. This angle correlates closely with the carrying angle. The mean Baumann angle (humeral capitellar angle) is 72 , with 95% of the population lying between 64 and 81 . As Baumann angle increases the carrying angle decreases in valgus, such that 5 increase in Baumann angle leads to a 2 loss in carrying angle.5 Radiographs of the contralateral elbow can be obtained for comparison, if needed, as the Baumann angle varies among all individuals. A deviation of
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Definitive treatment options Traction: several traction techniques have been described (overhead, lateral, skin or skeletal). This treatment modality has declined in popularity. Excellent to good outcomes have been reported using traction in many patients (>90%), with poor results seen in older patients. There are, however concerns of cubitus varus, pin complications (if using an olecranon traction pin), compartment syndrome and prolonged admission. Despite several series describing successful results with straight-line traction, others report cubitus varus rates as high as 33%. Traction has been suggested for irreducible fractures to allow closed reduction in a very swollen arm and can be appropriate in children where there is a significant anaesthetic risk. Flexible nailing: antegrade intramedullary elastic nails can be used to stabilize supracondylar fractures, with good functional results reported from Germany.6 Two antegrade nails are used, with the aim of passing a nail down each column, across the fracture site and into the metaphysis. The advantages include the avoidance of iatrogenic ulnar nerve injury, low rates of cubitus varus, cast-free treatment, and the possibility to evaluate clinical motion postoperatively. There is however, a steep learning
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CHILDREN'S TRAUMA
removal of the nails. Additionally, complaints of scar size at the proximal upper arm have been reported. Closed reduction percutaneous pinning: for the extension type, and many surgeons’ preference for the flexion type supracondylar fracture, the patient is placed supine with the arm on an arm board. Under general anaesthetic, either over a radiolucent arm board, reduction is attempted. The first step is to apply traction and counter-traction in line with the humerus, correcting coronal plane abnormality. If there is suspicion that the proximal fragment has pierced through the brachialis muscle, following traction, a proximal to distal ‘milking’ manoeuvre over the brachialis can be undertaken to free the proximal fragment. The elbow is then flexed while the olecranon is pushed anteriorly to correct the sagittal deformity and reduce the fracture, while controlling pronation and supination depending on fracture displacement. If the distal fragment is internally rotated (most common), by pressing harder on the medial side and pronating the forearm may help improve chances of achieving a reduction, the opposite applies for an externally rotated distal fragment. Criteria for an acceptable reduction include restoration of the Baumann angle (within 5 ) compared to the contralateral side,4 achieving an intact medial and lateral column as seen on the oblique radiographs, and having the anterior humeral line passing through the middle third of the capitellum on the lateral radiograph. It is essential that the vascularity of the hand is then reassessed in all cases and abnormalities dealt with appropriately. External fixation: the use of a lateral external fixator with a lateral wire has been used in the treatment of supracondylar humeral fractures in children achieving satisfactory reduction, alignment and stability of the fracture. Furthermore, normal to good range of movement has been reported in approximately 97% of patients following removal of the external fixator. A concern is the risk of deep pin tract infection and osteomyelitis.
Figure 1 Radiograph illustrating Baumann angle.
curve. The treatment of these fractures with intramedullary nailing is a challenging procedure requiring active assistance, mainly during advancement of the nails while the surgeon performs the closed reduction. It requires a second anaesthetic for
Figure 2 (a) Fat pad sign, (b) anterior humeral line, (c) shaft condylar angle, (d) coronoid line.
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CHILDREN'S TRAUMA
The equipment required is that of two Schanz screws (one distal and one proximal to the fracture), an antirotation wire (1.6 mm or 2.0 mm depending on age), a 4.0 mm rod (preferable carbon fibre) with two standard pin-rod clamps. This fixation is sufficiently stable to allow early movement. Additional immobilisation with a plaster cast or splint is not required.7
Gartland II Within the UK, most Gartland II fractures are treated with either closed reduction and long arm casting in 90 flexion, or with closed reduction and percutaneous wiring. Angulation, displacement or loss of Baumann angle on the AP radiograph is a relative indication for closed reduction and percutaneous fixation. Debate surrounds the minimally posterior displaced fracture, minimally displaced fracture with medial column comminution or type IIb fracture that can result in cubitus varus. Furthermore, the distal part of the humerus provides 20% of the growth of the humerus and thus has little remodelling potential, especially in the older child. This is one of the reasons, some surgeons will choose to manage the younger child non-operatively with a type II fracture in which the anterior humeral line is not aligned with the middle one third of the capitellum. However, in an older patient the choice is that of closed reduction and percutaneous wiring. With these controversies, one view is that of performing closed reduction and percutaneous wiring as a treatment method for all displaced supracondylar humeral fractures including type II, owing to the increased risk of limb-threatening ischemic injury that can occur with casting in hyperflexion. Moreover, approximately 20% of these fractures treated without wiring may go on to lose reduction and require delayed surgery.8 However, recent research9 has identified if wiring all type II fractures was undertaken it would have resulted in unnecessary surgery in 72% of patients in this series of over 1000 patients. The authors concluded that given the wide range of injury severity within the type II category of supracondylar fractures, better discrimination of factors commonly associated with successful non-operative treatment is required and that fractures with an isolated extension deformity (without rotational or coronal malalignment) were more likely to complete successful non-operative management. If non-operative management of the minimally displaced fracture, especially the medially comminuted fractured is employed. Close observation with weekly radiographs is required to prevent missing a loss of position and allows for early intervention if required. Overall, an informed discussion with parents and patients about the advantages and disadvantages of techniques and procedures is required when deciding on the treatment of this category of fracture.
Open reduction: the most commonly reported indication for treatment with open reduction is failed treatment with closed methods. Additional indications include debridement of open fractures, compartment syndrome, and neurologic and/or vascular injury that requires open exploration and potential repair. If there is a considerable gap in the fracture site or the fracture is irreducible with a soft feel on attempted reduction, neurovascular structures may be trapped in the fracture site and conversion to an open reduction needs to be considered. Moreover, cases of significant swelling over the elbow pose certain limitations in reduction manoeuvres, and in such cases open reduction ought to be considered as attempting close reduction may further worsen the situation. No clear consensus exists regarding a preferred surgical approach when open reduction of a displaced supracondylar humerus fracture is indicated, the decision in which approach to utilize is predominantly one of surgeon preference and familiarity. These approaches include anterior, posterior, medial, lateral, and variations of these. The use of the anterior approach, lazy ‘S’ incision, allows access to potentially injured neurovascular structures with good cosmetic and functional outcomes and low complication rates. Some authors advocate the use of the medial or lateral approach based on the direction of displacement of the distal fragment and proximal metaphyseal spike. The lateral approach being used for the posteromedial distal fragment with its corresponding lateral metaphyseal spike, and medial approach for the posterolateral distal fragment with its corresponding medial metaphyseal spike. The exposure being chosen to avoid disruption of the intact periosteum, and to allow exposure to the potentially injured neurovascular structures. The posterior approach is associated with the least satisfactory outcomes, most notably limitations in sagittal plane motion, as well as reported concerns with trochlea osteonecrosis and cosmetic outcomes. However, when comparing open reduction approaches in terms of infection rates, compartment syndrome, time to union, and iatrogenic nerve injury, no significant differences have been found among the different surgical approaches. Irrespective of the approach utilized, the principles are that it should allow for reduction that results in anatomic alignment, access to involved neurovascular structures, and satisfactory cosmetic and functional outcomes while minimizing postoperative complications.
Gartland III/IV Techniques such as traction and application of external fixation, as described above, have been used with success for this type of fracture. However, most surgeons within UK practice would attempt closed reduction and percutaneous wiring, and if unsuccessful proceed to open reduction. The configuration of wires and debate surrounding this is discussed later within this review. Specifically, for the type IV fracture, Leitch et al3 offer a useful technique in which two Kirschner wires are first placed into the distal fragment. Following this, reduction of the fracture is performed in the AP plane with verification using fluoroscopy. At this point rather than the arm being rotated for a lateral image, as is commonly done for more stable fracture patterns, the fluoroscopy unit is rotated into the lateral view. The fracture is then reduced in the sagittal plane, and the Kirschner wires are driven
Treatment by Gartland type Gartland I These fractures are treated with a collar and cuff or an aboveelbow splint in 90 of flexion for 3e4 weeks. Correct plaster application is crucial, with pressure effects from the cast needing to be considered to reduce the incidence of iatrogenic compartment syndrome and vascular compromise.
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CHILDREN'S TRAUMA
across the fracture site. Rotation of the fluoroscopy unit is a simple manoeuvre and some surgeons advocate this practice routinely, because rotation of the arm can lead to redisplacement.
Flexion-type fracture Flexion-type fractures are uncommon; approximately 2e10%. The injury results from a fall directly onto the elbow. Treatment options for flexion-type fractures included skin/skeletal traction, manipulation and casting in an extension cast, closed reduction and percutaneous pinning, and open reduction. Closed reduction and percutaneous pinning are often required. Both supine and prone positions have been described when treating these injuries surgically, with no level 1 evidence supporting one position over the other. An alternative reduction method is with the patient positioned lateral, the elbow supported by a bolster and subsequently manipulated into extension. Green et al10 describe a simple technique with the use of a 2 mm transolecranon pin to help hold reduction of the flexion type injury. This technique corrects sagittal deformity first. The complication rate is higher than that of the extension type fracture, with conversion to open reduction also being higher. The ulnar nerve is the most commonly involved. Figure 4 Anteroposterior radiograph of a supracondylar fracture treated with a lateral only wiring technique with an adequate divergence of the wires and bicortical fixation.
Wire configuration At least two wires are required to prevent rotation. However, agreement on wiring technique, configuration and even diameter has not been reached and remains controversial. There are two common techniques of wire fixation; a crossed wire technique (at least one medial and one lateral) (Figure 3) and a lateral only wire technique using two (Figure 4) or three wires. The crossed wire configuration has been shown to offer greater mechanical stability in non-clinical studies, but has an increased risk of
iatrogenic ulnar nerve damage compared to an isolated lateral configuration. It is uncertain whether this increase in mechanical stability is of clinical importance. A recent meta-analysis11 of Gartland type II and type III fractures treated with percutaneous pin fixation comparing crossed and isolated lateral entry wiring was performed. It included 1163 patients with lateral only wires and 1059 patients with crossed wires. Of the 24 studies, 9 were randomized controlled trials, 5 prospective studies and 10 retrospective studies. Elbow functional outcomes, radiographic outcomes, and complications were measured. A significant difference was seen in Flynn criteria,12 with an excellent score occurring more commonly in patients treated with a crossed wire configuration compared to lateral only (RR ¼ 0.93; 95% CI 0.87e0.99; P ¼ 0.03). There was a significant difference regarding iatrogenic nerve injury, crossed wires being more common compared to isolated lateral wires (4.9% vs 0.5%). The risk of loss of reduction in radiograph or developing cubitus varus were similar in both groups. These findings add to the debate. Furthermore, fracture configuration is an important factor determining which technique to employ. The oblique fracture high on the medial side is anatomically unfavourable for wiring from the lateral side alone. Whereas, an all lateral wire construct may provide adequate stiffness to maintain reduction of low transverse, sagittal oblique, and high transverse patterns.13 In the authors’ experience, it is difficult to achieve adequate wire spread when using all lateral wires in the high transverse fracture. It is however agreed that irrespective of the method used, fixation must be bicortical and stable.4 If there is any doubt
Figure 3 Anteroposterior radiograph of a supracondylar fracture treated with a crossed wire technique. The wires cross proximal to the fracture and there is bicortical fixation.
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CHILDREN'S TRAUMA
stabilized, ensuring that regular observations of perfusion status are undertaken until surgery is performed. This is an urgent indication and should be performed as soon as possible. The second use of this term is the ‘pink pulseless’ limb following closed reduction and stabilisation. The options in this situation are observation and close monitoring versus urgent exploration. Proponents of observation argue that even early intervention by a vascular surgeon to repair the brachial artery is associated with a high rate of re-occlusion and residual brachial artery stenosis. In contrast, supporters of the latter believe reliance on collateral flow in the forearm may leave the hand viable but, however, risks sequelae such as cold intolerance, compartment syndrome, contractures and limb length discrepancy. It is the authors’ practice that observation and close monitoring is employed, with meticulous monitoring of perfusion status of the limb until the pulse returns, or the operating surgeon is confident and satisfied that there is no further risk of vascular compromise or compartment syndrome. If there is any suspicion of compartment syndrome or deterioration of perfusion, prompt immediate vascular reassessment, and intervention if required, should be undertaken.4
following fixation with live fluoroscopic screening in flexion/ extension and varus/valgus additional fixation, using a supplementary wire can be employed. This may be an additional lateral or medial wire. If an all lateral wire configuration is used, the wires must diverge to provide adequate spread at the fracture site on the AP view. An adequate spread is achieved if each column contains at least one wire or the divergence of the wires exceeds more than one third of the width of the fracture.7 In addition, in the authors’ experience, it is imperative to ensure wires are gripping cortex in both the distal and proximal fragments, engaging sufficient bone in the proximal and distal segments. Lateral wires should enter the humerus below the fracture line on the AP view and overlie the ossified capitellum on the lateral view. Oblique views are useful to ensure wires are traversing both fragments and both medial and lateral columns. If a crossed wire configuration is employed, the wire must not cross at the fracture site. If a medial wire is used, techniques such as, having the elbow in extension or 45 to avoid the ulna nerve subluxing anteriorly into the operative field when flexed; performing an open incision and placing a 2.0 mm drill guide directly onto the prominence of the medial epicondyle to establish an entry point, should be employed. Regarding diameter of the wire, a 2.0 mm wire is advised and the authors would advocate this, where possible. However, for smaller and younger children this may not be practical and with € r Osteosynreference to guidelines from Arbeitsgemeinschaft fu thesefragen (AO),7 1.6 mm wires may be used.
Management of a supracondylar fracture with associated nerve injury Neurological deficit reported after displaced supracondylar fractures in children is approximately 10e15% and can be as high as 50%. Of the nerve injury associated with extension type fractures, AION neurapraxia is the highest, most commonly involved in posterolateral displacement of the distal fracture fragment (more prevalent in irreducible fractures). Following a cadaveric study on 35 specimens,15 the AION was found to arise from the posterior portion of the median nerve distal to the humeral intercondylar line. When the median nerve was dissected, the AIN fascicles were always located posteriorly before emerging. Additionally, the AION had two portions; a transitional, proximal and free-moving part, and a distal interosseous part. It was suggested from this study that a combination of events may lead to the AION palsy including, direct contusion of the AION fascicles within the median nerve, and inability of the AION to withstand stretch due to the tethering effect of the interosseous portion of the nerve. This condition presents with paralysis of the long flexors of the thumb and index finger without sensory changes. Complete median nerve injury, due to contusion or transection of the nerve at the level of the fracture, has also been described and presents with sensory loss in the median nerve distribution as well as motor loss of all muscles innervated by the median nerve. The radial nerve is most commonly involved with posteromedial displacement of the distal fracture fragment. With flexion type fractures, ulnar nerve injury predominates. Moreover, in the pulseless limb with an associated median nerve deficit, the suspicion of an arterial injury should be raised. Managing a primary peripheral nerve palsy following a supracondylar humeral fracture is often challenging due to the difficulty in obtaining a reliable clinical examination during the acute presentation. In most cases it is a traction neuropraxia. Nerve transections are rare and almost exclusively involve the radial nerve. Recent research has highlighted the fact that most
Vascular injury and management of the ‘poorly perfused white’, and ‘pink pulseless’ hand The incidence of vascular injuries associated with displaced supracondylar fractures of the humerus in children is approximately 10e20%, more commonly seen in the extension type fractures. The mechanism of injury can be because of stretching or kinking of the vessel over the displaced fragments. Direct injury may lead to spasm, contusion, intimal tears, and less frequently partial laceration or complete transection. With an excellent collateral circulation, maintenance of vascularity of the limb can be achieved despite the distal part of the limb appearing pulseless. There is little debate surrounding the management of the pulseless and poorly perfused white hand following a supracondylar fracture. This requires discussion with the on call vascular team within the regional network prior to urgent operative reduction and stabilisation. Reduction of the supracondylar fracture often leads to restoration of perfusion and the pulse, up to 50e70%. However, if the limb remains ischaemic after open or closed fracture reduction, then exploration of the brachial artery is required with a surgeon competent to perform a small vessel vascular repair. An anterior transverse incision over the antecubital fossa is recommended (Figure 5), allowing for visualization of, and access to the neurovascular structures as well as to the fracture site.14 There remains controversy over the terminology and management of the pink pulseless viable hand. This terminology can be used in those presenting without a distal pulse and a well perfused hand. In this situation the limb should be reduced and
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CHILDREN'S TRAUMA
Figure 5 Anterior approach to the supracondylar fracture. Note the ease at which visualization of neurovascular structures (in particular the brachial artery and median nerve) and fracture site can be obtained through this approach.
associated ischemia may progress to infarction and subsequent development of the rare complication, Volkmann’s ischemic contracture: fixed flexion of the elbow, pronation of the forearm, flexion at the wrist, and joint extension of the metacarpalphalangeal joint. Recent research has identified a significantly increased risk of compartment syndrome if there is a neurovascular injury, floating elbow fracture, if the patient is male, and also in older patients.18 Angular deformities are seen, including cubitus varus or ‘gunstock’ deformity, cubitus valgus and recurvatum. Posttraumatic cubitus valgus deformity can lead to tardy (delayed) ulnar nerve palsy. Cubitus varus is usually a cosmetic issue rather than a functional one. However, although termed ‘cubitus varus’ the deformity is a combination of varus, extension and internal rotation which can lead to long-term complications, including chronic pain, ulnar nerve palsy, tardy posterolateral rotatory instability, snapping elbow, and an increased risk of lateral condyle and other secondary fractures.
nerve injuries (>90%) will recover within 6 months. However, the presence of either an isolated radial nerve injury or multiple nerve injuries is associated with prolonged motor recovery.16 It is important to provide explanation and reassurance to the parents and patients regarding these facts. However, one should consider nerve conduction studies if there is no improvement beyond 3 months. Following an iatrogenic nerve injury, most commonly the ulnar nerve, rarely does the medial wire directly impale the nerve. More commonly it constricts the nerve within the cubital tunnel by tethering adjacent soft tissue. The options include immediate nerve exploration, removal of the medial wire and treat expectantly. If the medial wire is removed, the stability of fracture fixation can be affected, and it is acceptable practice to reposition the wire to achieve stability, if possible aiming for an all lateral configuration.
Complications Pin migration (2%) can lead to injury to important structures and a loss of position (malunion), requiring further surgery. Pin site infection (1e2%) is usually superficial and can be managed with oral antibiotics. However, this can lead to deep infection/osteomyelitis with sinus formation requiring both surgical intervention and long courses of antibiotics (Figure 6). Although rare after casting alone and even wiring, postoperative stiffness can occur although this usually resolves within 6 months,17 with a loss of terminal extension or flexion. The current guidelines regarding the removal of wires is that of 3 e4 weeks with early gentle mobilization thereafter.4 Compartment syndrome, with an incidence 1e3 per 1000 fractures can occur and, if not treated in a timely fashion the
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Cubitus varus correction Cubitus varus is the most frequent complication following treatment for supracondylar humeral fractures in children. Correction of this deformity can be undertaken in the form of a humeral osteotomy to avoid such complications as previously mentioned. There have been several techniques described including the lateral closing wedge osteotomy, dome osteotomy, more complex multiplanar osteotomies, and distraction osteogenesis. In a recent systematic review,19 none of these techniques was found to be statistically safer or more effective than the other. The overall major complication rate for these osteotomies is around 15%, with nerve complication at 2.5% (78% of these
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CHILDREN'S TRAUMA
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Figure 6 Sequalae of osteomyelitis with sequestrum seen on CT scan (coronal plane distal humerus within the distal humerus) following closed reduction and K wiring of a supracondylar fracture.
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being temporary injury). In conclusion, it was recommended that patients/parents were counselled regarding the probability of nerve injury, residual varus or unsightly scarring.
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Conclusion
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This article provides an up-to-date overview of the key aspects and controversies in the assessment and management of the supracondylar humeral fracture in the paediatric population. There remains no current gold standard in management. There are various treatment options and techniques, all with their advantages and disadvantages, described in the literature. The importance of good clinical examination and recognition of neurovascular compromise and signs of compartment syndrome are crucial. It is important that families (parents and patient) are informed appropriately of the risks and benefits of proposed treatment options, as this will help both in the decision-making process, and postoperative phase. A
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REFERENCES 1 Gartland JJ. Management of supracondylar fractures of the humerus in children. Surg Gynecol Obstet 1959; 109: 145e54. 2 Wilkins KE. Fractures and dislocations of the elbow region. In: Rockwood CA, Wilkins KE, King R, eds. Fractures in children. PA: Lippincott, 1984; 363e575. 3 Leitch KK, Kay RM, Femino JD, Tolo VT, Storer SK, Skaggs DL. Treatment of multidirectionally unstable supracondylar humeral fractures in children. A modified Gartland type-IV fracture. J Bone Jt Surg Am 2006; 88: 980e5. 4 British Orthopaedic Association. British orthopaedic association standards for trauma (BOAST) BOAST 11: supracondylar fractures
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of the humerus in children. 2015. Available at: https://www.boa. ac.uk/wp-content/uploads/2015/01/BOAST-11.pdf (accessed 20 Feb 2018). Worlock P. Supracondylar Fractures of the humerus: assessment of cubitus varus by the Baumann angle. J Bone Jt Surg Br 1986; 68: 755e7. Lacher M, Schaeffer K, Boehm R, Dietz HG. The treatment of supracondylar humeral fractures with elastic stable intramedullary nailing (ESIN) in children. J Pediatr Orthop 2011; 31: 33e8. Howard A, Slongo T. Pediatric distal humerus. In: Monsel F, Colton C, ed. AO surgery reference pediatric trauma. Available at: https://www2.aofoundation.org/wps/portal/surgerymobile (accessed 3 Mar 2018). American Academy of Orthopaedic Surgeons. Appropriate use criteria for the management of pediatric supracondylar humerus fractures with vascular injury. 2014. Rosemont, IL: American Academy of Orthopaedic Surgeons. Available at: https://www. aaos.org/research/Appropriate_Use/PSHF_AUC.pdf (accessed 20 Feb 2018). Silva M, Delfosse EM, Park H, Panchal H, Ebramzadeh E. Is the “appropriate use criteria” for type II supracondylar humerus fractues really appropriate? J Pediatr Orthop, 2018; https://doi.org/10. 1097/BPO.0000000000001142. Green BM, Stone JD, Bruce Jr RW, Fletcher ND. The use of a transolecranon pin in the treatment of pediatric flexion-type supracondylar humerus fractures. J Pediatr Orthop 2017; 37: e347e52. https://doi.org/10.1097/BPO.0000000000000904. Na Y, Bai R, Zhao Z, et al. Comparison of lateral entry with crossed entry pinning for pediatric supracondylar humeral fractures: a meta-analysis. J Orthop Surg Res 2018; 13: 68. https:// doi.org/10.1186/s13018-018-0768-3. Flynn JC, Matthews JG, Benoit RL. Blind pinning of displaced supracondylar fractures of the humerus in children: sixteen years’ experience with long-term follow-up. J Bone Jt Surg Am 1974; 56: 263e72. Jaeblon T, Anthony S, Ogden A, Andary JJ. Pediatric supracondylar fractures: variation in fracture patterns and the biomechanical effects of pin configuration. J Pediatr Orthop 2016; 36: 787e92. Badkoobehi H, Choi P, Bae D, Skaggs D. Management of the pulseless pediatric supracondylar humeral fracture. J Bone Jt Surg Am 2015; 97: 937e43. Vincelet Y, Journeau P, Popkov D, Haumont T, Lascombes P. The anatomical basis for anterior interosseous nerve palsy secondary to supracondylar humerus fractures in children. Orthop Traumatol Surg Res 2013; 99: 543e7. https://doi.org/10.1016/j.otsr.2013.04. 002. Epub 2013 Aug 2. Shore BJ, Gillespie BT, Miller PE, Bae DS, Walter PM. Recovery of motor nerve injuries associated with displaced, extension-type pediatric supracondylar humerus fractures. J Pediatr Orthop, 2017; https://doi.org/10.1097/BPO.0000000000001056. Zoints LE, Woodson CJ, Manjra N, Zalavras C. Time of return of elbow motion after percutaneous pinning of pediatric supracondylar humerus fractures. Clin Orthop Relat Res 2009; 467: 2007e10. https://doi.org/10.1007/s11999-009-0724-y. Robertson AK, Snow E, Browne TS, Brownell S, Inneh I, Hill JF. Who gets compartment syndrome?: a retrospective analysis of the national and local incidence of compartment syndrome in
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patients with supracondylar humerus fractures. J Pediatr Orthop 2018; 38: e252e6. https://doi.org/10.1097/BPO. 0000000000001144. 19 Solfelt DA, Hill BW, Anderson CP, Cole PA. Supracondylar osteotomy for the treatment of cubitus varus in children: a systematic review. Bone Jt J 2014; 96-B: 691e700.
children: urgent management and therapeutic consensus. Injury 2016; 47: 848e52. https://doi.org/10.1016/j.injury.2016.01.010. Epub 2016 Jan 16. Omid R, Choi P, Skaggs D. Supracondylar humeral fractures in children. J Bone Jt Surg Am 2008; 90: 1121e32. Seeley MA, Gagnier JJ, Srinivasan RC, Hensinger RN, VanderHave KL, Farley FA. Obesity and its effects on pediatric supracondylar humeral fractures. J Bone Jt Surg Am 2014; 96: e18. https://doi.org/ 10.2106/JBJS.L.01643. Wingfield JJ, Ho CA, Abzug JM, Ritzman TF, Brighton BK. Instructional Course Lecture: open reduction techniques for supracondylar humeral fractures in children. J Am Acad Orthop Surg 2015; 23: e72e80.
FURTHER READING Kuoppala E, Parviainen R, Pokka T, Sirvio M, Serlo W, Sinikumpu JJ. Low incidence of flexion-type supracondylar humerus fracture but high rates of complications. A population-based study during 2000 e2009. Acta Orthop 2016; 87: 406e11. Louahem D, Cottalorda J. Acute ischemia and pink pulseless hand in 68 of 404 gartland type III supracondylar humeral fractures in
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Paediatric humeral supracondylar fractures
Thinning of the bone, due to the presence of the fossae between the supracondylar pillars, can act as a stress riser and result in fracture in the supracondylar region under excessive mechanical load. Hyperextension of the child’s elbow also contributes to the concentration of stress at this point and results in the high incidence of extension type supracondylar fractures (approximately 97%). Flexion type supracondylar fractures of the humerus are rarely encountered. This article provides a review of the classification, assessment, treatment options and the controversies in the management of the paediatric supracondylar distal humeral fracture and associated long-term complications.
Christopher Talbot Sanjeev Madan
Abstract The supracondylar humeral fracture is the most common elbow fracture in children accounting for just under one-fifth of all paediatric fractures and 60% of paediatric elbow fractures. Modifications of the Gartland classification have been made over the years. The mainstay treatment option is that of closed reduction and percutaneous wiring. However, there remains no gold standard in the management of this injury. Outcomes from other treatment options, including traction and external fixator application have been described and report good results. There remains controversy in the wiring configuration used, and there is no consensus on the approach to be used when faced with an irreducible fracture. This article aims to provide an upto-date overview of the current practices in the management of this common injury, including the ‘pink pulseless’ hand, ‘poorly perfused white’ hand, surgical techniques, and the associated complications that can ensue.
Classification In 1959, Gartland1 described a simple classification scheme to emphasize the principles underlying treatment of patients with a supracondylar humerus fracture and discussed a method of management that has proven to be practical and effective with time. His classification described a rotatory and translational deformity, with posterior displacement (extension) of the distal fragment occurring most often. He described three types of extension injury based on degree of displacement: type I, nondisplaced; type II, moderately displaced; and type III, severely displaced injury. Flexion-type injuries were considered separately. Over the years, modifications of the Gartland classification have been proposed and are now commonly used. Wilkins2 modification of Gartland’s extension type classification consists of: Type I injuries are non-displaced Type II injuries are displaced anteriorly but have posterior humeral cortical contact: Type IIA: no rotational abnormality or fragment translation Type IIB: rotational deformity, resulting in more instability Type III fractures are displaced with no cortical contact: Type IIIA: the medial periosteal hinge is intact leading to the posteromedially distal fragment displacement Type IIIB: the lateral periosteal hinge is intact, leading to the posterolaterally distal fragment displacement. A subtype of the supracondylar fracture where the medial column of the humerus is comminuted and unstable, leading to loss of coronal alignment has been described. Following on from this there has been the addition of a type IV injury.3 This is a configuration with multiplanar instability due to no intact periosteal hinge. This pattern results from the initial injury or occurs iatrogenically during attempted reduction.
Keywords closed reduction; complications; cubitus varus; open reduction; percutaneous wiring; pink pulseless; supracondylar fracture
Introduction The supracondylar humeral fracture is the most common elbow fracture in children accounting for just under one-fifth of all paediatric fractures and 60% of paediatric elbow fractures. This is an extraarticular fracture of the distal humerus, in which there is a slight male preponderance. The complication profile of this injury is significant, including neurovascular injury and malunion. The annual incidence is approximately 180 per 100,000. Especially in patients above the age of 8 years, this type of fracture most often results from high-energy trauma. It has been shown that there is an association between obesity and more complex supracondylar humeral fractures, preoperative and postoperative nerve palsies, and postoperative complications. In most cases, the non-dominant arm is affected.
Initial assessment Clinical assessment The initial assessment of a child with a supracondylar fracture should be in keeping with Advanced Trauma Life Support principles. It is vital to ensure all life-threatening injuries are managed prior to limb-threatening ones, if significant trauma has taken place. The patient will present with a painful swollen elbow. The British Orthopaedic Association Standards for Trauma (BOAST) 11: Supracondylar Fractures of the Humerus in Children guidelines4 provide standards for practice, highlighting the importance of the initial assessment of the limb including the
Christopher Talbot MB ChB (Hons) FRCS (T&O) Consultant Paediatric Trauma and Orthopaedic Surgeon, Department of Orthopaedics, Alder Hey Children’s Hospital NHS Foundation Trust, Liverpool, UK. Conflicts of interest: none declared. Sanjeev Madan FRCS (Orth) MSc (Bioeng) MCh (Orth) MBA Consultant Trauma and Orthopaedic Surgeon, Department of Orthopaedics, Sheffield Children’s Hospital, Sheffield, UK. Department of Orthopaedics, Doncaster Royal Infirmary, Doncaster, UK. Conflicts of interest: none declared.
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more than 5 indicates coronal plane deformity and should not be accepted. On the lateral view, the following radiological parameters should be assessed (Figure 2): A: Fat pad sign: a positive fat pad sign ‘sail sign’ is suggestive of occult fracture when no radiological fracture line is obvious. B: Anterior humeral line (AHL): a line drawn down from the anterior cortex of the humerus. This line should intersect with the middle third of the capitellum. C: Shaft condylar angle (SCA): the angle between long axis of humerus and lateral condyle. This is between 30 and 40 . D: Coronoid line: a curved line drawn on the lateral radiograph along the superior aspect of the ulna, through the coronoid and onto the anterior aspect of distal humeral shaft. This line should be in continuity and have no break in it.
status of the radial pulse, digital capillary refill time and the individual function of the radial, median (including anterior interosseous (AION)) and ulnar nerves. It is important to document the findings of both sensory and motor function of these nerves. In younger children, this can be difficult however in most if not all patients a full motor assessment can be made, using the thumb alone. The ‘OK’ sign is one well-described sign when assessing the AION. ‘Rock, paper, scissors’ is an effective way of assessing function in a young child. Assessment for any open fractures, deformity; including that of the ‘S deformity’, signs of critical skin compromise, skin puckering and antecubital fossa ecchymosis should be undertaken. A puckered, dimple and/or ecchymosis of the skin just anterior to the distal humerus may indicate a difficult reduction because the proximal, anteriorly directed fragment has penetrated the brachialis muscle and possibly the subcutaneous layer as well. A review of the whole limb is required as approximately 5% of supracondylar humerus fractures in children are associated with an ipsilateral forearm fracture. These patients have higher rates of acute neurologic injury compared to patients with isolated supracondylar humerus fractures (14.7% vs 7.8%), further increased when the forearm fracture requires manipulation. It is our practice that these patients remain in hospital for 48 hours after surgery, as there is a higher rate of compartment syndrome reported in the displaced supracondylar fracture with associated ipsilateral forearm fractures. It is also recommended that urgent senior orthopaedic review in the emergency department is required when there is absence of radial pulse, ischaemia of hand (pale and cool extremities), severe swelling in forearm and/or elbow or any clinical concerns regarding compartment syndrome, skin puckering, open injury and neurological injury.
Management Initial The initial management should include adequate analgesia including the application of a splint (above elbow back slab/ collar and cuff depending on surgeon/treating unit preference and severity of injury) in a comfortable position. Usually 20e40 of flexion is sufficient. Splinting in displaced or unstable fractures with the elbow in full extension or hyper-flexion is contraindicated because it stretches the neurovascular bundle over the fracture site or they may get impinged between fractured fragments. Excessive flexion should be avoided as this can reduce the arterial flow to the limb and increase the risk of compartment syndrome. Radiographs should be obtained only after appropriate analgesia and splintage of the extremity to avoid any neurovascular injury. If there is an open fracture, clinical photography, the administration of antibiotics, tetanus (if appropriate) and a saline soaked swab/gauze dressing placed over the wound are all vital aspects of treatment.
Radiological assessment The standard radiographic study of the injured limb should include an anteroposterior (AP) and a lateral view of the elbow and any other sites of deformity, pain, or tenderness. Due to the association of supracondylar fractures with forearm fractures, a low threshold should be had in obtaining AP and lateral radiographic views of the forearm. The carrying angle (the varus or valgus attitude of the distal humerus and elbow) is evaluated on AP view. The carrying angle is defined as the angle between the long axis of the ulna and the long axis of the humerus. The normal range can be between 5 and 15 of valgus. Carrying angle correlates positively with age, in addition the carrying angle in girls is on average greater than in boys. The use of Baumann angle (Figure 1), in clinical practice is an important standard in the assessment of reduction quality. This angle is formed by the intersection of a line drawn down the humeral shaft axis and a line drawn along the physeal line of the lateral condyle on the AP radiograph. This angle correlates closely with the carrying angle. The mean Baumann angle (humeral capitellar angle) is 72 , with 95% of the population lying between 64 and 81 . As Baumann angle increases the carrying angle decreases in valgus, such that 5 increase in Baumann angle leads to a 2 loss in carrying angle.5 Radiographs of the contralateral elbow can be obtained for comparison, if needed, as the Baumann angle varies among all individuals. A deviation of
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Definitive treatment options Traction: several traction techniques have been described (overhead, lateral, skin or skeletal). This treatment modality has declined in popularity. Excellent to good outcomes have been reported using traction in many patients (>90%), with poor results seen in older patients. There are, however concerns of cubitus varus, pin complications (if using an olecranon traction pin), compartment syndrome and prolonged admission. Despite several series describing successful results with straight-line traction, others report cubitus varus rates as high as 33%. Traction has been suggested for irreducible fractures to allow closed reduction in a very swollen arm and can be appropriate in children where there is a significant anaesthetic risk. Flexible nailing: antegrade intramedullary elastic nails can be used to stabilize supracondylar fractures, with good functional results reported from Germany.6 Two antegrade nails are used, with the aim of passing a nail down each column, across the fracture site and into the metaphysis. The advantages include the avoidance of iatrogenic ulnar nerve injury, low rates of cubitus varus, cast-free treatment, and the possibility to evaluate clinical motion postoperatively. There is however, a steep learning
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removal of the nails. Additionally, complaints of scar size at the proximal upper arm have been reported. Closed reduction percutaneous pinning: for the extension type, and many surgeons’ preference for the flexion type supracondylar fracture, the patient is placed supine with the arm on an arm board. Under general anaesthetic, either over a radiolucent arm board, reduction is attempted. The first step is to apply traction and counter-traction in line with the humerus, correcting coronal plane abnormality. If there is suspicion that the proximal fragment has pierced through the brachialis muscle, following traction, a proximal to distal ‘milking’ manoeuvre over the brachialis can be undertaken to free the proximal fragment. The elbow is then flexed while the olecranon is pushed anteriorly to correct the sagittal deformity and reduce the fracture, while controlling pronation and supination depending on fracture displacement. If the distal fragment is internally rotated (most common), by pressing harder on the medial side and pronating the forearm may help improve chances of achieving a reduction, the opposite applies for an externally rotated distal fragment. Criteria for an acceptable reduction include restoration of the Baumann angle (within 5 ) compared to the contralateral side,4 achieving an intact medial and lateral column as seen on the oblique radiographs, and having the anterior humeral line passing through the middle third of the capitellum on the lateral radiograph. It is essential that the vascularity of the hand is then reassessed in all cases and abnormalities dealt with appropriately. External fixation: the use of a lateral external fixator with a lateral wire has been used in the treatment of supracondylar humeral fractures in children achieving satisfactory reduction, alignment and stability of the fracture. Furthermore, normal to good range of movement has been reported in approximately 97% of patients following removal of the external fixator. A concern is the risk of deep pin tract infection and osteomyelitis.
Figure 1 Radiograph illustrating Baumann angle.
curve. The treatment of these fractures with intramedullary nailing is a challenging procedure requiring active assistance, mainly during advancement of the nails while the surgeon performs the closed reduction. It requires a second anaesthetic for
Figure 2 (a) Fat pad sign, (b) anterior humeral line, (c) shaft condylar angle, (d) coronoid line.
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The equipment required is that of two Schanz screws (one distal and one proximal to the fracture), an antirotation wire (1.6 mm or 2.0 mm depending on age), a 4.0 mm rod (preferable carbon fibre) with two standard pin-rod clamps. This fixation is sufficiently stable to allow early movement. Additional immobilisation with a plaster cast or splint is not required.7
Gartland II Within the UK, most Gartland II fractures are treated with either closed reduction and long arm casting in 90 flexion, or with closed reduction and percutaneous wiring. Angulation, displacement or loss of Baumann angle on the AP radiograph is a relative indication for closed reduction and percutaneous fixation. Debate surrounds the minimally posterior displaced fracture, minimally displaced fracture with medial column comminution or type IIb fracture that can result in cubitus varus. Furthermore, the distal part of the humerus provides 20% of the growth of the humerus and thus has little remodelling potential, especially in the older child. This is one of the reasons, some surgeons will choose to manage the younger child non-operatively with a type II fracture in which the anterior humeral line is not aligned with the middle one third of the capitellum. However, in an older patient the choice is that of closed reduction and percutaneous wiring. With these controversies, one view is that of performing closed reduction and percutaneous wiring as a treatment method for all displaced supracondylar humeral fractures including type II, owing to the increased risk of limb-threatening ischemic injury that can occur with casting in hyperflexion. Moreover, approximately 20% of these fractures treated without wiring may go on to lose reduction and require delayed surgery.8 However, recent research9 has identified if wiring all type II fractures was undertaken it would have resulted in unnecessary surgery in 72% of patients in this series of over 1000 patients. The authors concluded that given the wide range of injury severity within the type II category of supracondylar fractures, better discrimination of factors commonly associated with successful non-operative treatment is required and that fractures with an isolated extension deformity (without rotational or coronal malalignment) were more likely to complete successful non-operative management. If non-operative management of the minimally displaced fracture, especially the medially comminuted fractured is employed. Close observation with weekly radiographs is required to prevent missing a loss of position and allows for early intervention if required. Overall, an informed discussion with parents and patients about the advantages and disadvantages of techniques and procedures is required when deciding on the treatment of this category of fracture.
Open reduction: the most commonly reported indication for treatment with open reduction is failed treatment with closed methods. Additional indications include debridement of open fractures, compartment syndrome, and neurologic and/or vascular injury that requires open exploration and potential repair. If there is a considerable gap in the fracture site or the fracture is irreducible with a soft feel on attempted reduction, neurovascular structures may be trapped in the fracture site and conversion to an open reduction needs to be considered. Moreover, cases of significant swelling over the elbow pose certain limitations in reduction manoeuvres, and in such cases open reduction ought to be considered as attempting close reduction may further worsen the situation. No clear consensus exists regarding a preferred surgical approach when open reduction of a displaced supracondylar humerus fracture is indicated, the decision in which approach to utilize is predominantly one of surgeon preference and familiarity. These approaches include anterior, posterior, medial, lateral, and variations of these. The use of the anterior approach, lazy ‘S’ incision, allows access to potentially injured neurovascular structures with good cosmetic and functional outcomes and low complication rates. Some authors advocate the use of the medial or lateral approach based on the direction of displacement of the distal fragment and proximal metaphyseal spike. The lateral approach being used for the posteromedial distal fragment with its corresponding lateral metaphyseal spike, and medial approach for the posterolateral distal fragment with its corresponding medial metaphyseal spike. The exposure being chosen to avoid disruption of the intact periosteum, and to allow exposure to the potentially injured neurovascular structures. The posterior approach is associated with the least satisfactory outcomes, most notably limitations in sagittal plane motion, as well as reported concerns with trochlea osteonecrosis and cosmetic outcomes. However, when comparing open reduction approaches in terms of infection rates, compartment syndrome, time to union, and iatrogenic nerve injury, no significant differences have been found among the different surgical approaches. Irrespective of the approach utilized, the principles are that it should allow for reduction that results in anatomic alignment, access to involved neurovascular structures, and satisfactory cosmetic and functional outcomes while minimizing postoperative complications.
Gartland III/IV Techniques such as traction and application of external fixation, as described above, have been used with success for this type of fracture. However, most surgeons within UK practice would attempt closed reduction and percutaneous wiring, and if unsuccessful proceed to open reduction. The configuration of wires and debate surrounding this is discussed later within this review. Specifically, for the type IV fracture, Leitch et al3 offer a useful technique in which two Kirschner wires are first placed into the distal fragment. Following this, reduction of the fracture is performed in the AP plane with verification using fluoroscopy. At this point rather than the arm being rotated for a lateral image, as is commonly done for more stable fracture patterns, the fluoroscopy unit is rotated into the lateral view. The fracture is then reduced in the sagittal plane, and the Kirschner wires are driven
Treatment by Gartland type Gartland I These fractures are treated with a collar and cuff or an aboveelbow splint in 90 of flexion for 3e4 weeks. Correct plaster application is crucial, with pressure effects from the cast needing to be considered to reduce the incidence of iatrogenic compartment syndrome and vascular compromise.
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across the fracture site. Rotation of the fluoroscopy unit is a simple manoeuvre and some surgeons advocate this practice routinely, because rotation of the arm can lead to redisplacement.
Flexion-type fracture Flexion-type fractures are uncommon; approximately 2e10%. The injury results from a fall directly onto the elbow. Treatment options for flexion-type fractures included skin/skeletal traction, manipulation and casting in an extension cast, closed reduction and percutaneous pinning, and open reduction. Closed reduction and percutaneous pinning are often required. Both supine and prone positions have been described when treating these injuries surgically, with no level 1 evidence supporting one position over the other. An alternative reduction method is with the patient positioned lateral, the elbow supported by a bolster and subsequently manipulated into extension. Green et al10 describe a simple technique with the use of a 2 mm transolecranon pin to help hold reduction of the flexion type injury. This technique corrects sagittal deformity first. The complication rate is higher than that of the extension type fracture, with conversion to open reduction also being higher. The ulnar nerve is the most commonly involved. Figure 4 Anteroposterior radiograph of a supracondylar fracture treated with a lateral only wiring technique with an adequate divergence of the wires and bicortical fixation.
Wire configuration At least two wires are required to prevent rotation. However, agreement on wiring technique, configuration and even diameter has not been reached and remains controversial. There are two common techniques of wire fixation; a crossed wire technique (at least one medial and one lateral) (Figure 3) and a lateral only wire technique using two (Figure 4) or three wires. The crossed wire configuration has been shown to offer greater mechanical stability in non-clinical studies, but has an increased risk of
iatrogenic ulnar nerve damage compared to an isolated lateral configuration. It is uncertain whether this increase in mechanical stability is of clinical importance. A recent meta-analysis11 of Gartland type II and type III fractures treated with percutaneous pin fixation comparing crossed and isolated lateral entry wiring was performed. It included 1163 patients with lateral only wires and 1059 patients with crossed wires. Of the 24 studies, 9 were randomized controlled trials, 5 prospective studies and 10 retrospective studies. Elbow functional outcomes, radiographic outcomes, and complications were measured. A significant difference was seen in Flynn criteria,12 with an excellent score occurring more commonly in patients treated with a crossed wire configuration compared to lateral only (RR ¼ 0.93; 95% CI 0.87e0.99; P ¼ 0.03). There was a significant difference regarding iatrogenic nerve injury, crossed wires being more common compared to isolated lateral wires (4.9% vs 0.5%). The risk of loss of reduction in radiograph or developing cubitus varus were similar in both groups. These findings add to the debate. Furthermore, fracture configuration is an important factor determining which technique to employ. The oblique fracture high on the medial side is anatomically unfavourable for wiring from the lateral side alone. Whereas, an all lateral wire construct may provide adequate stiffness to maintain reduction of low transverse, sagittal oblique, and high transverse patterns.13 In the authors’ experience, it is difficult to achieve adequate wire spread when using all lateral wires in the high transverse fracture. It is however agreed that irrespective of the method used, fixation must be bicortical and stable.4 If there is any doubt
Figure 3 Anteroposterior radiograph of a supracondylar fracture treated with a crossed wire technique. The wires cross proximal to the fracture and there is bicortical fixation.
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stabilized, ensuring that regular observations of perfusion status are undertaken until surgery is performed. This is an urgent indication and should be performed as soon as possible. The second use of this term is the ‘pink pulseless’ limb following closed reduction and stabilisation. The options in this situation are observation and close monitoring versus urgent exploration. Proponents of observation argue that even early intervention by a vascular surgeon to repair the brachial artery is associated with a high rate of re-occlusion and residual brachial artery stenosis. In contrast, supporters of the latter believe reliance on collateral flow in the forearm may leave the hand viable but, however, risks sequelae such as cold intolerance, compartment syndrome, contractures and limb length discrepancy. It is the authors’ practice that observation and close monitoring is employed, with meticulous monitoring of perfusion status of the limb until the pulse returns, or the operating surgeon is confident and satisfied that there is no further risk of vascular compromise or compartment syndrome. If there is any suspicion of compartment syndrome or deterioration of perfusion, prompt immediate vascular reassessment, and intervention if required, should be undertaken.4
following fixation with live fluoroscopic screening in flexion/ extension and varus/valgus additional fixation, using a supplementary wire can be employed. This may be an additional lateral or medial wire. If an all lateral wire configuration is used, the wires must diverge to provide adequate spread at the fracture site on the AP view. An adequate spread is achieved if each column contains at least one wire or the divergence of the wires exceeds more than one third of the width of the fracture.7 In addition, in the authors’ experience, it is imperative to ensure wires are gripping cortex in both the distal and proximal fragments, engaging sufficient bone in the proximal and distal segments. Lateral wires should enter the humerus below the fracture line on the AP view and overlie the ossified capitellum on the lateral view. Oblique views are useful to ensure wires are traversing both fragments and both medial and lateral columns. If a crossed wire configuration is employed, the wire must not cross at the fracture site. If a medial wire is used, techniques such as, having the elbow in extension or 45 to avoid the ulna nerve subluxing anteriorly into the operative field when flexed; performing an open incision and placing a 2.0 mm drill guide directly onto the prominence of the medial epicondyle to establish an entry point, should be employed. Regarding diameter of the wire, a 2.0 mm wire is advised and the authors would advocate this, where possible. However, for smaller and younger children this may not be practical and with € r Osteosynreference to guidelines from Arbeitsgemeinschaft fu thesefragen (AO),7 1.6 mm wires may be used.
Management of a supracondylar fracture with associated nerve injury Neurological deficit reported after displaced supracondylar fractures in children is approximately 10e15% and can be as high as 50%. Of the nerve injury associated with extension type fractures, AION neurapraxia is the highest, most commonly involved in posterolateral displacement of the distal fracture fragment (more prevalent in irreducible fractures). Following a cadaveric study on 35 specimens,15 the AION was found to arise from the posterior portion of the median nerve distal to the humeral intercondylar line. When the median nerve was dissected, the AIN fascicles were always located posteriorly before emerging. Additionally, the AION had two portions; a transitional, proximal and free-moving part, and a distal interosseous part. It was suggested from this study that a combination of events may lead to the AION palsy including, direct contusion of the AION fascicles within the median nerve, and inability of the AION to withstand stretch due to the tethering effect of the interosseous portion of the nerve. This condition presents with paralysis of the long flexors of the thumb and index finger without sensory changes. Complete median nerve injury, due to contusion or transection of the nerve at the level of the fracture, has also been described and presents with sensory loss in the median nerve distribution as well as motor loss of all muscles innervated by the median nerve. The radial nerve is most commonly involved with posteromedial displacement of the distal fracture fragment. With flexion type fractures, ulnar nerve injury predominates. Moreover, in the pulseless limb with an associated median nerve deficit, the suspicion of an arterial injury should be raised. Managing a primary peripheral nerve palsy following a supracondylar humeral fracture is often challenging due to the difficulty in obtaining a reliable clinical examination during the acute presentation. In most cases it is a traction neuropraxia. Nerve transections are rare and almost exclusively involve the radial nerve. Recent research has highlighted the fact that most
Vascular injury and management of the ‘poorly perfused white’, and ‘pink pulseless’ hand The incidence of vascular injuries associated with displaced supracondylar fractures of the humerus in children is approximately 10e20%, more commonly seen in the extension type fractures. The mechanism of injury can be because of stretching or kinking of the vessel over the displaced fragments. Direct injury may lead to spasm, contusion, intimal tears, and less frequently partial laceration or complete transection. With an excellent collateral circulation, maintenance of vascularity of the limb can be achieved despite the distal part of the limb appearing pulseless. There is little debate surrounding the management of the pulseless and poorly perfused white hand following a supracondylar fracture. This requires discussion with the on call vascular team within the regional network prior to urgent operative reduction and stabilisation. Reduction of the supracondylar fracture often leads to restoration of perfusion and the pulse, up to 50e70%. However, if the limb remains ischaemic after open or closed fracture reduction, then exploration of the brachial artery is required with a surgeon competent to perform a small vessel vascular repair. An anterior transverse incision over the antecubital fossa is recommended (Figure 5), allowing for visualization of, and access to the neurovascular structures as well as to the fracture site.14 There remains controversy over the terminology and management of the pink pulseless viable hand. This terminology can be used in those presenting without a distal pulse and a well perfused hand. In this situation the limb should be reduced and
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CHILDREN'S TRAUMA
Figure 5 Anterior approach to the supracondylar fracture. Note the ease at which visualization of neurovascular structures (in particular the brachial artery and median nerve) and fracture site can be obtained through this approach.
associated ischemia may progress to infarction and subsequent development of the rare complication, Volkmann’s ischemic contracture: fixed flexion of the elbow, pronation of the forearm, flexion at the wrist, and joint extension of the metacarpalphalangeal joint. Recent research has identified a significantly increased risk of compartment syndrome if there is a neurovascular injury, floating elbow fracture, if the patient is male, and also in older patients.18 Angular deformities are seen, including cubitus varus or ‘gunstock’ deformity, cubitus valgus and recurvatum. Posttraumatic cubitus valgus deformity can lead to tardy (delayed) ulnar nerve palsy. Cubitus varus is usually a cosmetic issue rather than a functional one. However, although termed ‘cubitus varus’ the deformity is a combination of varus, extension and internal rotation which can lead to long-term complications, including chronic pain, ulnar nerve palsy, tardy posterolateral rotatory instability, snapping elbow, and an increased risk of lateral condyle and other secondary fractures.
nerve injuries (>90%) will recover within 6 months. However, the presence of either an isolated radial nerve injury or multiple nerve injuries is associated with prolonged motor recovery.16 It is important to provide explanation and reassurance to the parents and patients regarding these facts. However, one should consider nerve conduction studies if there is no improvement beyond 3 months. Following an iatrogenic nerve injury, most commonly the ulnar nerve, rarely does the medial wire directly impale the nerve. More commonly it constricts the nerve within the cubital tunnel by tethering adjacent soft tissue. The options include immediate nerve exploration, removal of the medial wire and treat expectantly. If the medial wire is removed, the stability of fracture fixation can be affected, and it is acceptable practice to reposition the wire to achieve stability, if possible aiming for an all lateral configuration.
Complications Pin migration (2%) can lead to injury to important structures and a loss of position (malunion), requiring further surgery. Pin site infection (1e2%) is usually superficial and can be managed with oral antibiotics. However, this can lead to deep infection/osteomyelitis with sinus formation requiring both surgical intervention and long courses of antibiotics (Figure 6). Although rare after casting alone and even wiring, postoperative stiffness can occur although this usually resolves within 6 months,17 with a loss of terminal extension or flexion. The current guidelines regarding the removal of wires is that of 3 e4 weeks with early gentle mobilization thereafter.4 Compartment syndrome, with an incidence 1e3 per 1000 fractures can occur and, if not treated in a timely fashion the
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Cubitus varus correction Cubitus varus is the most frequent complication following treatment for supracondylar humeral fractures in children. Correction of this deformity can be undertaken in the form of a humeral osteotomy to avoid such complications as previously mentioned. There have been several techniques described including the lateral closing wedge osteotomy, dome osteotomy, more complex multiplanar osteotomies, and distraction osteogenesis. In a recent systematic review,19 none of these techniques was found to be statistically safer or more effective than the other. The overall major complication rate for these osteotomies is around 15%, with nerve complication at 2.5% (78% of these
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CHILDREN'S TRAUMA
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Figure 6 Sequalae of osteomyelitis with sequestrum seen on CT scan (coronal plane distal humerus within the distal humerus) following closed reduction and K wiring of a supracondylar fracture.
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being temporary injury). In conclusion, it was recommended that patients/parents were counselled regarding the probability of nerve injury, residual varus or unsightly scarring.
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Conclusion
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This article provides an up-to-date overview of the key aspects and controversies in the assessment and management of the supracondylar humeral fracture in the paediatric population. There remains no current gold standard in management. There are various treatment options and techniques, all with their advantages and disadvantages, described in the literature. The importance of good clinical examination and recognition of neurovascular compromise and signs of compartment syndrome are crucial. It is important that families (parents and patient) are informed appropriately of the risks and benefits of proposed treatment options, as this will help both in the decision-making process, and postoperative phase. A
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of the humerus in children. 2015. Available at: https://www.boa. ac.uk/wp-content/uploads/2015/01/BOAST-11.pdf (accessed 20 Feb 2018). Worlock P. Supracondylar Fractures of the humerus: assessment of cubitus varus by the Baumann angle. J Bone Jt Surg Br 1986; 68: 755e7. Lacher M, Schaeffer K, Boehm R, Dietz HG. The treatment of supracondylar humeral fractures with elastic stable intramedullary nailing (ESIN) in children. J Pediatr Orthop 2011; 31: 33e8. Howard A, Slongo T. Pediatric distal humerus. In: Monsel F, Colton C, ed. AO surgery reference pediatric trauma. Available at: https://www2.aofoundation.org/wps/portal/surgerymobile (accessed 3 Mar 2018). American Academy of Orthopaedic Surgeons. Appropriate use criteria for the management of pediatric supracondylar humerus fractures with vascular injury. 2014. Rosemont, IL: American Academy of Orthopaedic Surgeons. Available at: https://www. aaos.org/research/Appropriate_Use/PSHF_AUC.pdf (accessed 20 Feb 2018). Silva M, Delfosse EM, Park H, Panchal H, Ebramzadeh E. Is the “appropriate use criteria” for type II supracondylar humerus fractues really appropriate? J Pediatr Orthop, 2018; https://doi.org/10. 1097/BPO.0000000000001142. Green BM, Stone JD, Bruce Jr RW, Fletcher ND. The use of a transolecranon pin in the treatment of pediatric flexion-type supracondylar humerus fractures. J Pediatr Orthop 2017; 37: e347e52. https://doi.org/10.1097/BPO.0000000000000904. Na Y, Bai R, Zhao Z, et al. Comparison of lateral entry with crossed entry pinning for pediatric supracondylar humeral fractures: a meta-analysis. J Orthop Surg Res 2018; 13: 68. https:// doi.org/10.1186/s13018-018-0768-3. Flynn JC, Matthews JG, Benoit RL. Blind pinning of displaced supracondylar fractures of the humerus in children: sixteen years’ experience with long-term follow-up. J Bone Jt Surg Am 1974; 56: 263e72. Jaeblon T, Anthony S, Ogden A, Andary JJ. Pediatric supracondylar fractures: variation in fracture patterns and the biomechanical effects of pin configuration. J Pediatr Orthop 2016; 36: 787e92. Badkoobehi H, Choi P, Bae D, Skaggs D. Management of the pulseless pediatric supracondylar humeral fracture. J Bone Jt Surg Am 2015; 97: 937e43. Vincelet Y, Journeau P, Popkov D, Haumont T, Lascombes P. The anatomical basis for anterior interosseous nerve palsy secondary to supracondylar humerus fractures in children. Orthop Traumatol Surg Res 2013; 99: 543e7. https://doi.org/10.1016/j.otsr.2013.04. 002. Epub 2013 Aug 2. Shore BJ, Gillespie BT, Miller PE, Bae DS, Walter PM. Recovery of motor nerve injuries associated with displaced, extension-type pediatric supracondylar humerus fractures. J Pediatr Orthop, 2017; https://doi.org/10.1097/BPO.0000000000001056. Zoints LE, Woodson CJ, Manjra N, Zalavras C. Time of return of elbow motion after percutaneous pinning of pediatric supracondylar humerus fractures. Clin Orthop Relat Res 2009; 467: 2007e10. https://doi.org/10.1007/s11999-009-0724-y. Robertson AK, Snow E, Browne TS, Brownell S, Inneh I, Hill JF. Who gets compartment syndrome?: a retrospective analysis of the national and local incidence of compartment syndrome in
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patients with supracondylar humerus fractures. J Pediatr Orthop 2018; 38: e252e6. https://doi.org/10.1097/BPO. 0000000000001144. 19 Solfelt DA, Hill BW, Anderson CP, Cole PA. Supracondylar osteotomy for the treatment of cubitus varus in children: a systematic review. Bone Jt J 2014; 96-B: 691e700.
children: urgent management and therapeutic consensus. Injury 2016; 47: 848e52. https://doi.org/10.1016/j.injury.2016.01.010. Epub 2016 Jan 16. Omid R, Choi P, Skaggs D. Supracondylar humeral fractures in children. J Bone Jt Surg Am 2008; 90: 1121e32. Seeley MA, Gagnier JJ, Srinivasan RC, Hensinger RN, VanderHave KL, Farley FA. Obesity and its effects on pediatric supracondylar humeral fractures. J Bone Jt Surg Am 2014; 96: e18. https://doi.org/ 10.2106/JBJS.L.01643. Wingfield JJ, Ho CA, Abzug JM, Ritzman TF, Brighton BK. Instructional Course Lecture: open reduction techniques for supracondylar humeral fractures in children. J Am Acad Orthop Surg 2015; 23: e72e80.
FURTHER READING Kuoppala E, Parviainen R, Pokka T, Sirvio M, Serlo W, Sinikumpu JJ. Low incidence of flexion-type supracondylar humerus fracture but high rates of complications. A population-based study during 2000 e2009. Acta Orthop 2016; 87: 406e11. Louahem D, Cottalorda J. Acute ischemia and pink pulseless hand in 68 of 404 gartland type III supracondylar humeral fractures in
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Ó 2018 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Talbot C, Madan S, Paediatric humeral supracondylar fractures, Orthopaedics and Trauma (2018), https:// doi.org/10.1016/j.mporth.2018.07.011