displaced supracondylar fractures of elbow ... d’ambrosia 1972)butrequires aprolonged stay...

Antero-posterior and lateral radiographs of an elbow showing a Type 4 extension fracturewith complete posterior displacement of the distalfragment.

490 THE JOURNAL OF BONE AND JOINT SURGERY

DISPLACED SUPRACONDYLAR FRACTURES OF THE ELBOW

IN CHILDREN

A Report on the Fixation of Extension and Flexion Fractures

by Two Lateral Percutaneous Pins

J. V. FOWLES, MONTREAL, CANADA, and M. T. KASSAB, TuNis, TUNISIA

From the Centre for Orthopaedics, Kassar Said, Tunis

The orthopaedic service in Tunisia was opened in 1964 with 100 beds for a population

of some five million people. Referrals included patients with Volkmann’s ischaemic contracture

or with gangrene of the hand following supracondylar fracture of the humerus treated with

the elbow in acute fiexion. It was thus incumbent upon us to develop a reliable method of

treatment which would avoid these tragedies without blocking the limited bed space.

CLINICAL MATERIAL

Between 1966 and 1971, 175 children were admitted to the service with displaced

supracondylar fractures of the elbow across the olecranon fossa. Seventeen had fiexion

fractures and are the subject of the second part of this paper. One hundred and fifty-eight

children had extension fractures, the distal fragment being displaced posteriorly (Fig. 1).

Because of gross oedema, thirty-two patients were treated by skeletal traction using a Kirschner

wire through the olecranon, and were in hospital for an average of twenty days; two more

were treated in traction after failure of closed reduction, and fourteen had closed reduction

and fixation with one percutaneous Kirschner wire after the technique described by Jean Judet

in 1953. In order to improve the stability one of us (M. T. K.) modified this method by using

two pins, both inserted laterally so as to avoid the ulnar nerve. The remaining 110 children

DISPLACED SUPRACONDYLAR FRACTURES OF THE ELBOW IN CHILDREN 491

were treated by this method and are the subject of the first part of this paper. The technique

and its complications are described, and the results in eighty children, examined between six

months and five years later, are presented.

Clinical details-By the classification of Lagrange and Rigault (1962), all these I 10 fractures

were either Type 3, with rotation of the distal fragment and only one remaining point of

contact, or Type 4, with no contact whatsoever. The ages of the children varied from two to

fifteen years, the majority being between five and ten. There were eighty-nine boys and

twenty-one girls. The fracture was on the left side in sixty-three children and on the right in

forty-seven. Seventy-one patients were treated the same day; the remaining thirty-nine were

treated on average three days later, the longest delay being nine days.

TREATMENT

One hundred and four of the 1 10 patients were treated primarily by closed reduction.

Of the other six, four with grossly swollen elbows were treated first with skeletal traction for

several days to reduce the oedema and then had closed reduction, while two patients each

with a large open wound had open reduction. All the fractures were stabilised by two lateral

percutaneous pins (Fig. 2).

Technique-Under general anaesthesia, the patient’s arm was prepared and draped. Following

the technique described by Charnley (1961), with the elbow in extension and the forearm

supinated, the carrying angle was restored ; the elbow was then flexed and the reduction

confirmed radiographically. A fine Kirschner wire mounted in a chuck or electric drill was

driven into the distal humeral epiphysis immediately lateral to the olecranon, entering the

epiphysis at the junction of trochlea and capitellum. After crossing the fracture line the pin

was drilled 4 or 5 centimetres up the medullary canal of the diaphysis. A second wire was

introduced close to the first but at an angle of 30 degrees to it, and after crossing the fracture

line at a point well medial to the other pin, penetrated the medial cortex of the diaphysis.

Radiographs were taken (Fig. 2), and if the reduction and fixation were satisfactory, the pins

were bent outside the skin to prevent migration and then cut off, a sterile dressing was applied,

and a plaster back-slab made with the elbow at a right angle and the forearm in neutral

rotation. The following day the cast was completed, the reduction again confirmed by

radiographs, and the patient sent home. The average stay in hospital was four days. The

patient was seen at weekly intervals and three or four weeks later the cast and pins were

removed without anaesthetic.

COMPLICATIONS

Complications of the injury-On admission eight children had a faint or absent radial pulse;

seven had lateral displacement of the distal fragment. Another patient, aged four, had an

open supracondylar fracture with complete division of the brachial artery and displaced

fractures of both bones of the same forearm. At operation the artery was ligated, the fracture

reduced and pinned and the wound closed ; the forearm fractures were then reduced and held

with the cast. A stellate ganglion block was also done. The hand soon became warm and pink.

Six other patients had open fractures. One patient had open reduction through a large

wound; for the others the wounds were explored and closed and the fractures then reduced

and pinned in the usual manner.

Seven patients had nerve injuries. Three had a partial motor paralysis of the radial nerve

with normal sensibility, and another had sensory loss only. Three patients had a median

nerve injury-one complete paralysis, one motor weakness with complete anaesthesia, and

the third sensory loss only. The radial nerve injuries were associated with medial displacement

of the elbow, the median nerve lesions with lateral displacement. There were no ulnar nerve

lesions.

Six patients, including the girl with the ruptured brachial artery, had fractures of both

VOL. 56B, NO. 3, AUGUST 1974

FIG. 2Antero-posterior and lateral radiographs taken in the operating theatre immediately afterreduction and pinning of an extension fracture. The pins were later bent to avoid migration

and cut off outside the skin.

492 J. V. FOWLES AND M. T. KASSAB

THE JOURNAL OF BONE AND JOINT SURGERY

Antero-posterior and lateral radiographs of the same elbow as shown in Figure 2, takentwo years later. The distal humeral epiphysial plate appears normal, the olecranon andcoronoid fossae are well maintained, and the carrying angle and mobility of the elbow

are the same as on the other side.


bones of the same forearm. These were reduced and held in plaster after fixation of the

supracondylar fracture.

Complications of the freatment-Of the patients with no nerve lesions before reduction, two

had complete radial nerve paralysis after closed reduction, and another a complete median

nerve paralysis ; a fourth had motor paralysis only of the median nerve and a fifth had sensory

loss only. The radial nerve lesions were associated with medial displacement of the distal

fragment, and the median nerve lesions with lateral displacement. Another patient, a girl

of thirteen with greenstick fractures of both bones of the same forearm, had complete paralysis

and anaesthesia of the hand after operation, but no signs of ischaemia. These post-reduction

palsies were no doubt due to the additional trauma of the manipulative procedures.

Infection of the elbow joint occurred in three patients, two of whom were treated

immediately by drainage and closed irrigation (Compere, Metzger and Mitra 1967). The

third had a low grade infection which was not apparent for three months ; he was then treated

with systemic antibiotics. Five other patients had pin track infections withoutjoint involvement.

None of these eight patients had an open fracture. Three children required a general

anaesthetic to remove the wires, which had not been bent and had migrated.

RESULTS

Eighty children were examined on average two years after the fracture, the shortest

follow-up being six months and the longest five years. Based on the classification of Lagrange

and Rigault (1962), the results were divided into the following categories. Excellent-a normal

arm and hand ; good-either a deficit of less than 20 degrees in the range of movement of

the elbow or a change in the carrying angle of less than 10 degrees (if both abnormalities

were present the patient was placed in the next category); fair-a deficit in the range of

movement of less than 50 degrees, or a change in the carrying angle of less than 20 degrees;

and poor-the range of movement decreased by more than 50 degrees, or a change in the

carrying angle of more than 20 degrees.

TABLE I

THE RESULTS IN EIGHTY CHILDREN WITH EXTENSION FRACrURES

TREATED BY CLOSED REDUCTION AND Two LATERAL PINS

Result � Type 3 � Type 4 � Totals

Excellent . � 6 � 26 32

Good . . 5 33 38

Fair . . 0 � 8 8

Poor . . 0 � 2 � 2

The results are shown in Table I. Thirty-two patients (40 per cent) had an excellent result

(Figs. 3 and 4). Thirty-eight patients (47�5 per cent) had a good result; twelve lost less than

10 degrees of movement; and three less than 20 degrees; the other twenty-three had a change

of less than 10 degrees of the carrying angle; two of these had an increase of 6 degrees, while

the rest had a decrease. Eight patients (10 per cent) had a fair result; seven had varus

deformities with good mobility of the elbow; one lost 7 degrees of the carrying angle and

15 degrees of movement. Two children (2�5 per cent) had poor results, with only a few degrees

of movement from the right angle. One patient had a low grade infection recognised late;

the other, the girl of thirteen mentioned earlier, had a total paralysis of the median, radial

and ulnar nerves after operation, and the pins were left in place for eight weeks.

VOL. 56 B, NO. 3, AUGUST 1974

FIG. 4



A patient aged 7, sixteen months after an extension fracture of the right elbow was reduced and pinned bythe method described. Movement of the elbow and the carrying angle are normal.

In general, 90 per cent of the full range of movement of the elbow was regained by a year.

Improvement however continued into the fourth year, when eighteen of the nineteen patients

examined had full movement and one lacked only 10 degrees of flexion.

All the open wounds healed by primary intention and the patients regained a full range

of movement. There were no permanent vascular sequelae. All the children with a diminished

or absent radial pulse on admission had good vascularity of the hand after reduction and all

ultimately had a normal pulse. The patient with a divided brachial artery, when last seen

three years later, had a normal arm and hand. All the patients with nerve lesions, whether

before or after reduction, had full spontaneous recovery over the ensuing weeks. Of the five

patients with pin track infections, four returned for follow-up ; only one had loss of movement

-I 5 degrees of extension. Of the two patients whose joint infections were treated promptly,

one had full movement at eight months and the other was lost to review.

DISCUSSION OF EXTENSION FRACTURES

For a satisfactory result a displaced supracondylar fracture should be reduced accurately

and stabilised (Mouchet 1898, Sandegard 1943, Judet 1953, Watson-Jones 1955, Gruber and

Hudson 1964). Attenborough (1953) has shown that acceptance of a poor position leads to

imperfect results ; all four of his patients treated without reduction had limited movement of

the elbow, and three also had a varus deformity. Of the common methods of treatment, a

cast with the elbow in acute flexion is the most dangerous because of the risk of ischaemia

and its irrevocable sequelae (MacLennan 1937, Blount 1950, Judet 1953, B#{246}hler1956, F#{232}vre

and Judet 1957, Maylahn and Fahey 1958). If the elbow is not flexed sufficiently, however,

the fracture is likely to redisplace (Swenson 1948, Judet 1953, Charnley 1961). Treatment by

traction may give good results (H#{248}yer1952, Maylahn and Fahey 1958, Mitchell and Adams

1961, D’Ambrosia 1972) but requires a prolonged stay in hospital, constant surveillance and

frequent radiographs, all of which are drawbacks in a socio-economic environment such as

that of Tunisia.

These disadvantages are largely eliminated when reduction is maintained by crossed

percutaneous pins. The usual technique is to place one pin laterally and the other medially,

with some risk of damaging the ulnar nerve (Swenson 1948; Jones 1967; Haddad, Saer and

Riordan 1970; Anderson 1971). The use of two lateral pins avoids the risk of ischaemia

from acute flexion of the elbow, does not endanger any major nerve or vessel, ensures stability

of the reduction and greatly reduces the time in hospital. The technique is relatively simple

and easy to learn; our patients were in fact treated by no less than twenty-one doctors of

varying backgrounds and levels of training. The pins penetrate the distal humeral epiphysis

between trochlear and capitellum, without damaging articular cartilage. Although the fine


Kirschner wires cross the epiphysial growth plate, they do not interfere with its function

(Judet 1953 ; Campbell, Grisolia and Zanconato 1959). Thus of our eighty patients reviewed,

one developed a valgus deformity of 6 degrees over the first two years but none of the others

showed any growth disturbance (Fig. 3).

The radial and median nerves and the brachial artery are particularly vulnerable in

extension fractures, being at risk of stretch over the jagged edge of the shaft by the backward

and upward displacement ofthe distal fragment and elbow (Meyerding 1936, Hammond 1952,

Lipscomb and Burleson 1955, B#{246}hler 1956, Gartland 1959, Ottolenghi 1971). The brachial

artery and median nerve are injured mainly with radialdisplacement ofthe distal fragment; thus

Ottolenghi (1971) reported that thirty-five of thirty-nine arterial injuries occurred with radial

displacement. The radial nerve is injured mainly with medial displacement, because radial

displacement pulls the nerve away from the sharp edge of the diaphysial fracture. The ulnar

nerve is rarely injured by supracondylar fractures in extension (Hammond 1952, Lichtenberg

1954, Lagrange and Rigault 1962), being relaxed and carried backward away from the fracture

edge. The paper of Edman and L#{246}hr(1963) is unusual in reporting eleven ulnar nerve injuries

in a total of twenty-seven nerve lesions among 161 patients with supracondylar fractures, but

they did not differentiate between fractures in extension and in flexion. There was only one

ulnar nerve lesion in our series, the girl who had temporary paralysis of all three major nerves

at the elbow after the reduction.

With regard to infection, the elbow joint capsule is attached to the superior margins of

the olecranon and coronoid fossae (Ashhurst 1910, Smith 1954, Gray’s Anatomy 1958), and

a supracondylar fracture crossing these fossae is therefore intra-articular (Hammond 1952).

Hence the track of a pin crossing the fracture must communicate with the joint space. We

believe that the risk of a pin track infection extending into the joint is no greater with the

method we have described than with any other. The problem of infection lies in the

environment rather than in the technique.

The results compare favourably with those of other series (Sins 1939 ; Aitken, Smith and

Blackett 1943; Sandegard 1943; Holmberg 1945; Judet 1953; Lagrange and Rigault 1962;

Edman and L#{246}hr1963 ; El-Sharkawi and Fattah 1965). Seventy patients, or 875 per cent of

those followed for more than six months, had satisfactory results. Lagrange and Rigault found

that mobility of the elbow improved for two years after the fracture, but some of our patients

continued to regain movement into the fourth year. Those followed for a shorter period

should therefore continue to improve.

FRACTURES IN FLEXION

Clinical material-There were thirteen boys and four girls, aged from three to fourteen years.

The fracture was on the left side in eleven. Based on the classification of Lagrange and Rigault

(1962), three patients had Type 2 fractures with only a forward tilt of the distal fragment;

three had a Type 3 fracture, the distal fragment being rotated as well as tilted forward, with

only one point of contact; and eleven patients had a Type 4 fracture, with complete forward

displacement and no contact (Fig. 5).

Complications of the injury-Two patients had hypoaesthesia in the ulnar nerve territory;

another had weakness of the interossei as well. All three lesions were associated with radial

displacement of the distal fragment. There were no other nerve injuries, and no patient with

symptoms or signs of vascular insufficiency.

TREATMENT

Two patients early in the series were treated by closed reduction and immobilisation for

three weeks with the elbow flexed 30 degrees. Three others were treated by overhead skeletal

traction using a Kirschner wire through the olecranon, two after failure of closed reduction,


RESULTS

Fifteen patients were seen on average two

and a half years after the fracture, the shortest

follow-up being seven months and the longest

in Table II, were based on the classification of



the third because of gross oedema. Nine children had closed reduction and immobilisation

by two lateral percutaneous pins ; three were treated on the day of injury, the other six one to

three days later. Reduction was performed by traction with the elbow in 45 degrees of flexion,

the lateral and anterior displacement being corrected by direct digital pressure on the distal

fragment. The elbow was then flexed a further 20 degrees by the assistant and two Kirschner

wires were introduced lateral to the olecranon, following the technique already described. A

plaster backslab was applied with the elbow at

90 degrees and the forearm in neutral rotation.

Next day the cast was completed, and if the

radiographs showed a satisfactory position the

patient was discharged and seen at weekly

intervals until the cast and pins were removed

at three or four weeks.

Three patients in whom closed reduction

was unsuccessful had open reduction by the

Campbell posterior approach described by Boyd(1971). In two of the three the medial corner of

the shaft had buttonholed the triceps postero-

medially and had to be released before the

fracture could be reduced; in each instance the

ulnar nerve was sharply angled over the jagged

edge of the shaft and required careful retraction.

Complications-The only complication was one

pin track infection.

FIG. 5

A lateral radiograph of a Type 4 flexion fracturewith the distal fragment displaced forwards and

upwards.

four and a half years. The results, shown

Lagrange and Rigault (1962).

DISCUSSION OF FLEXION FRACTURES

Though two types of supracondylar fracture have been recognised for many years

(Malgaigne 1859, Hamilton 1880), fractures in flexion have received little attention in the past.

Their incidence is reported to be 4 per cent or less of all supracondylar fractures (Mouchet

1898, Sins 1939, Blount 1954, Watson-Jones 1955, Salter 1959, Mitchell and Adams 1961,

Lagrange and Rigault 1962). The high frequency in this paper, 10 per cent, is matched only

by the 1 1 per cent of Sorrel and Sorrel-Dejerine (1938) and the 10 per cent noted by Coventry

and Henderson (1956). The majority of boys over girls and of the left side over the right,

however, is similar to that reported in other series (Holmberg 1945, Lipscomb and Burleson

1955, Maylahn and Fahey 1958, Lagrange and Rigault 1962, Edman and L#{246}hr1963).

Among the 110 patients with extension fractures reported earlier, nineteen (18 per cent)

had complications involving the brachial artery, the radial nerve or the median nerve. In

marked contrast, no patient with a flexion fracture had any such complication. However, three

patients with flexion fractures (17 per cent) had some deficit of the ulnar nerve, compared

with only one patient with an extension fracture (1 per cent). When the distal fragment is

displaced anteriorly, the ulnar nerve is carried with it and may be sharply angled and stretched

over the fracture margin of the shaft as this juts posteriorly. This is even more likely if the

distal fragment is also displaced radially, as then the ulnar nerve is pulled laterally across

Closed reductionand pins

26 5-140 Lost 4 Fair(0-155)

0-145(0-145) No change Excellent



TABLE II

DETAILS OF SEVENTEEN CHILDREN WITH DISPLACED SUPRACONDYLAR FLExI0N FRACTURES OF THE ELBOW

Range of Change inLength of� movement

Sex Age Type of Complications Treatment follow-up J(normal side c�’j� Result‘(years) fracture� (months) in brackets) angle

(degrees)(degrees)

0-95Lost 12 PoorFemale 8 4 Cast in extension �

0-120Male 9 4 Cast in extension � Lost 2 Fair

Male 4 4 Failed manipulation,�traction

24 0-135(0-145)

10-110(0-145)

Lost 4

Varus 15

Fair

PoorMale 11 3 Ulnar nervehypoaesthesia

Failed manipulation,’traction ‘

Male 3 4 Traction�

Did notreturn

Female 8 4

‘

Closed reduction ,

and pins01400-14o

��

No change Excellent

Male 6 4 Closed reductionand pins

�

Did notreturn

Male 13 � 2

Closed reduction‘ 10 0-145 Nochange ExcellentFemale 7 , 3 � and pins � (0-145)

Closed reduction26 � 0-160 Lost 2 GoodMale 12 � 2‘ and pins � (0-160)

Closed reduction41 � 0-150 No change ExcellentFemale 6 4 and pins � (0-150)

Male 12 4 Pin track Closed reduction , 22 � 5-125 No change Fairinfection and pins � ‘ (0-145)

Closed reduction ‘ 0-15543Male 6 3 and pins , � (0-160) Lost 10 Fair

� , Ulnar nerve � Closed reduction � 0-145Lost 3 GoodMale 12 � hypoaesthesia ‘ and pins � (0-140)

Male � 14 � 4 � Openreduction 18 � 25135 Fair(0-145)

Ulnar nerve

Male 14 4 hypoaesthesia � Open reductionand weaknessof interossei

0-140Male 12 4 Open reduction 48 (0-140) Lost 4 Good� I

the shaft and cannot escape it. The vessels and nerves in front of the elbow, on the other hand,

are carried forward and upward away from the shaft and are therefore less vulnerable. This

reaffirms previous observations (Sorrel and Sorrel-Dejerine 1938, Hammond 1952, Smith 1954,

Lipscomb and Burleson 1955, B#{246}hler1956).

Sorrel and Sorrel-Dejerine recommended surgical exploration and release of an injured

ulnar nerve if there were no signs of recovery by ten or fifteen days. Hammond stated that

six weeks was the optimum period to wait before exploring the nerve. Seddon (1947) believed

498 i. V. FOWLES AND M. T. KASSAB

that nerve damage requiring exploration was rare. Corresponding with our experience of

nerve injuries associated with extension fractures, these three patients with ulnar nerve lesions

fully recovered spontaneously.

There was no correlation between the original displacement of the flexion fractures and

the functional or anatomical results. Both patients who were treated with the elbow in some

flexion finally lacked a significant degree of flexion, and one had a varus deformity. Of the

three patients treated by traction, two were seen at follow-up and both had unsatisfactory

results (Table II). When the method of treatment already used for extension fractures was

adopted, the increased difficulties of reduction, and of maintenance of reduction while

introducing the pins, soon became apparent. As in the experience of Sins (1939), closed

reduction failed in one-third of our patients, compared with only twice in 1 12 extension fractures.

The difficulty arises because, in reducing the anterior displacement, the distal fragment is often

flexed by the shaft rather than engaged with its fractured surface, and it is difficult to gain

a purchase on the small fragment and avoid this. Moreover, the fracture line is oblique in

an upward and forward direction, and reduction may easily be lost.

Of the fifteen patients reviewed, only seven had satisfactory results. Of four children

seen at follow-up who had been treated by traction, or by plaster with the elbow in moderate

extension, the outcome was satisfactory in none, two being fair and two poor. Five of eight

patients treated by closed reduction and percutaneous pins were excellent or good and three

were fair ; these results are disappointing compared with those obtained from extension

fractures. Open reduction of a supracondylar fracture may leave the patient with some

limitation of movement (Sandegard 1943, Blount 1954, Watson-Jones 1955, Gruber and

Hudson 1964), as was the case with one of the three patients in this series. Nevertheless,

these patients still had better results than those treated by traction or an extension cast alone,

and we therefore prefer open reduction if closed manipulation fails.

SUMMARY

Displaced extension supracondylar fractures of the elbow1 . One hundred and ten children were treated by reduction and stabilisation by two pins

inserted laterally at an angle of 30 degrees to one another.

2. The complications before and after treatment included fifteen nerve lesions in thirteen

patients. The ulnar nerve was involved on one occasion only. Solitary radial nerve injuries

occurred with postero-medial displacement of the distal fragment, while median nerve and

brachial artery injuries were associated with postero-lateral displacement. All the lesions

recovered spontaneously.

3. There were no ischaemic complications after treatment, despite the ligation of one ruptured

brachial artery.

4. The average stay in hospital was four days, compared with twenty days for thirty-two other

patients treated in traction because of gross oedema.

5. Of eighty patients seen six months to five years after the fracture, seventy (or 875 per cent)

had excellent or good results, seven patients with marked varus deformities had fair results,

and two patients had poor results with very stiff elbows.

Displaced flexion fractures1. The clinical features, complications and treatment of seventeen cases are described.

2. There were no complications involving the median or radial nerves or the brachial artery,

but three patients had a lesion of the ulnar nerve.

3. Nine children had closed reduction and fixation by two lateral percutaneous pins.

4. Reduction was difficult and the results poor compared with extension fractures. Closed

reduction failed in one-third of the children, and the functional and cosmetic results were

unsatisfactory in over half the patients reviewed.



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displaced supracondylar fractures of elbow ... d’ambrosia 1972)butrequires aprolonged stay...

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