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Pink Pulseless hand – Evaluation and Decision making: Is there a Consensus?

Vol 1 | Issue 1 | July-Sep 2015 | page:19-22 | Venkatadass K.


Authors : Venkatadass K[1].

[1] Consultant Paediatric Orthopaedic Surgeon, Ganga Medical Centre & Hospitals, Coimbatore, India.

Address of Correspondence
Dr. K. Venkatadass
Ganga Medical Centre & Hospitals, Coimbatore, India.
Email- venkatpedortho@gmail.com


Abstract

Background: The standard of care for the initial treatment of pulseless supracondylar fracture of the humerus is emergency closed reduction and percutaneous pin stabilization. Some of these patients remain pulseless even after closed reduction and pin fixation with a well perfused hand. The management of this so-called pink pulseless hand still remains controversial. The options described in the literature are either of the two extremes of just observation or exploration of the vessel and vascular repair if needed. There are no clear guidelines on when to explore a pink pulseless hand. This article reviews the current literature on this gray area with recommendations on the process of evaluation and decision-making in pink pulseless hand.
Keywords: Supracondylar humerus fracture, vascular injury, pink pulseless hand.


Introduction
The incidence of vascular injuries associated with displaced supracondylar fractures of humerus in children is about 10-20% [1,2,3]. It is reported to be more common in extension type fractures due to the close proximity of the proximal fragment to the neurovascular bundle [4,5]. In a child presenting with a pulseless supracondylar humerus fracture an urgent closed reduction with percutaneous pin stabilization is recommended. In majority of these patients the injured limb gets back the pulse and the hand appears well perfused after closed reduction and pin fixation. These patients are then treated as any other patient with supracondylar fracture humerus without any additional special precaution [3]. There is no confusion in the literature regarding the management of those patients in whom the limb remains pulseless, pale and unperfused after a closed reduction and stabilization [3]. Emergency exploration of the artery and arterial repair if needed to get back the circulation of the affected limb is the current recommendation. But there is still no consensus on the management of those limbs, which remain pulseless after closed reduction and pinning, but are pink and well perfused. The main reason for this confusion is lack of details of natural history of this entity [2]. The current literature on this enigmatous situation has been reviewed and a recommendation based on the available literature and our experience for the management of pink pulseless hand in supracondylar fracture humerus is presented.

Mechanism of vascular injury
The mechanism of injury to the neurovascular structures following supracondylar fracture of the humerus has been described in great detail by Meyerding as early as 1936 [6]. He was the first to study the configuration of the fracture in detail and propose that in extension type supracondylar fractures, the injuring force carries the distal fragment posteriorly stripping the posterior periosteum. The sharp anterior fragment pierces the anterior periosteum and brachialis and injures the neurovascular bundle, which lies in close proximity anteriorly. The vascular insult could either be due to compression from the fragment, spasm or thrombosis or rarely complete arterial transection. Most times the absence of pulse might just be due to the compression of grossly displaced fragments. A gentle closed reduction would relieve the compression and artery becomes pulsatile again. Louahem et al. [7 described 26 patients with a pink pulseless hand in a series of 210 patients with severely displaced supracondylar fractures. In 21 cases, the pulses returned immediately after closed reduction of the fracture.

Collateral circulation
The exuberant collateral circulation around the elbow has been credited with maintaining the vascularity of the limb in patients managed without vascular exploration [8]. The radial recurrent artery arises distal to the elbow and anastomoses with the radial collateral branch of the profunda brachii. The superior ulnar collateral artery is the other main descending collateral. It arises from the brachial artery, a little below the middle of the arm and anastomoses with the posterior ulnar recurrent and inferior ulnar collateral arteries [8].

What is pink pulseless hand?
There is variable use of this terminology in the literature. Some authors use this terminology to label those supracondylar fractures presenting without a pulse with a well perfused hand. While there is no controversy regarding the management of these fractures, more than 50% of these pink pulseless limbs would turn pulsatile just after closed reduction. The limb appearing pink and perfused on presentation mainly depends on the time duration since injury, as it needs some time for the collateral circulation to be established. None of the authors had looked into the time since injury and its correlation to perfusion status at presentation. Ideally, a pink pulseless limb is one that remains pink and well perfused without a palpable pulse following closed reduction and pinning of a pulseless supracondylar fracture [2]. These are the ones that pose management controversy as to whether it needs urgent exploration for the vessel or a closed monitoring for the vascular status and just observation. Though there is some evidence in the literature supporting immediate exploration, more recent evidence seems to be in favour of in-patient observation and close monitoring [3].

Role of Doppler
There has been increased interest in the role of colour Doppler in the process of evaluation and decision making for pink pulseless hands. White et al has recommended the use of colour Doppler to assess the severity of arterial injury following closed reduction and pinning to decide on further management. A colour Doppler evaluation of the brachial artery would help to differentiate between spasm, thrombosis and complete transection. It is important to remember the fact that there is no question of brachial artery injury in this scenario and the real issue is about the adequacy of the collateral circulation to maintain the viability and function of hand. Doppler evaluation of the brachial artery might infact increase the number of explorations of the artery. Valentini et al has reported the use of color-coded duplex scanning (CCDS) and ultrasound velocimetry (UV) of the hand as an additional tool for evaluation in all their patients with pink pulseless hands [9]. In their series, all seven patients with pink pulseless hand were found to have brachial artery injury by Doppler and all of them were treated by arterial repair. But, there are no clear guidelines on severity of arterial injuries on colour dopper and their management.  Using Doppler to assess the radial artery in a pink pulseless hand helps to assess the adequacy of the collateral circulation. Weller et al [10] in their series of 54 pulseless supracondylar humerus fractures have documented that 26 patients regained the pulse after closed reduction, 20 remained pulseless after closed reduction but radial artery Doppler signals were picking up and 4 others had absent pulse as well as Doppler signals. All four were taken up immediate surgical exploration and found to have arterial injury requiring repair. All 20 patients who had pulse detected by Doppler but had no palpable radial pulse were observed. One of the 20 developed late ischaemia after nine hours and was taken up for surgical exploration. Shah et al have included triphasic radial artery doppler signal in their algorithm for decision making in pink pulseless limbs and recommends immediate surgical exploration for patients who do not have triphasic radial artery doppler signals.

Figure

Proponents for Immediate Exploration
White et al [11] after a systematic analysis of pink pulseless supracondylar fractures have concluded that there is significant arterial injury in 70% of patients and thus vascular exploration may limit the chances of late complications in these patients. They have also stated that with reported patency rates of more than 90% it is worthwhile considering exploration and arterial repair in these patients.  Korompilias et al. [7] reported on five patients with a pink pulseless hand and recommended vascular exploration for the restoration of brachial artery patency, even in the presence of a viable well-perfused hand after an attempt at closed reduction. Copley et al [13] in their series of 17 patients with pulseless supracondylar fractures had a return of pulse in 14 of them following closed reduction. All the three patients were taken up for exploration and 2 of the fourteen patients who developed loss of pulse over the next 24 hours were also explored. They recommend immediate exploration if pulse is absent after closed reduction as a measure towards prevention of late complications.  Blakey et al. found that twenty three of twenty-six patients with a pink, pulseless hand following initial management had some evidence of ischemic contracture, and they advocated for urgent exploration when the pulse does not immediately return after closed reduction [14]. Mangat et al [15] reported on the predictive value of co-existing median or anterior interiosseous nerve injury after studying a series of patients with nerve injury who underwent exploration. A significant relationship was found between preoperative median and anterior interosseous nerve deficits and vascular entrapment and tethering of the nerve at the fracture site. The authors recommended early exploration for patients with a Gartland type-III supracondylar fracture when they have coexisting anterior interosseous or median nerve palsy as the benefits of exploration outweigh the disadvantages.  In a recent study by Scannell et al [17], the authors have tried to correlate the presence of median or anterior interosseous nerve with patency of brachial artery at long term follow-up in 20 twenty patients. In their series, median nerve palsy had good prediction of brachial artery occlusion while anterior interosseous nerve palsy did not predict brachial artery occlusion.

Proponents for Observation
Many authors are in favour of observation and close monitoring of the vascular status for pink pulseless hands. In contrast to the general belief that the literature in vascular surgery would be more in favour of arterial exploration, the recent papers in vascular surgery are recommending observation in case of pink pulseless hands [3].  Choi et al [18] presented the largest series of 33 patients with pink pulseless hands and concluded that in patients presenting with well perfused hand, fracture reduction and pinning alone would be sufficient treatment. Scannell et al [17] have reported the long term results of their series of 20 patients of pink pulseless hand that were treated by observation. All 20 had good functional outcome except one who had chondrolysis of the distal humerus. They also recommended long term follow-up of these patients for radiographic evidence of osteonecrosis as three of their 20 patients with pink pulseless hands developed avascular necrosis of the trochlea. Weller et al [10] in their analysis of 20 patients with pink pulseless hands have concluded that lack of palpable radial pulse is not an absolute indication for arterial exploration if Doppler signals and capillary refill is good suggesting a well perfused hand. Matuszewski [19] has published his follow-up results of pulseless supracondylar humerus fractures have concluded that children who, after satisfactory closed reduction, have a well-perfused hand but absent radial pulse do not necessarily require routine exploration of the brachial artery. Sabharwal et al [20], in their follow-up study patients with pulseless supracondylar fracture who were treated with arterial exploration and revascularisation found a high rate of asymptomatic reocclusion and residual stenosis and hence opined that collateral circulation would have been adequate to maintain a viable extremity. Garbuz et al [21] in 1996 presented the outcome of treatment of supracondylar fractures with absent radial pulse from the Hospital for Sick Children, Toronto. In their series of 22 patients, five had pink perfused pulseless hands who were managed by close observation and all had excellent functional outcomes. They concluded that absent pulse is not an absolute indication for exploration, provided the hand remains well perfused and compartment syndrome does not develop.

Is there a Consensus?
Though the literature is filled with publications on pink pulseless hand in supracondylar fractures, there still seems to be no consensus on the management of this condition. The AAOS guidelines [22] for the management of supracondylar fractures of humerus in children published in 2010 stated that ”We cannot recommend for or against open exploration of the antecubital fossa in patients with absent wrist pulses but with a perfused hand after reduction of displaced pediatric supracondylar humerus fractures” as there was no strong evidence supporting either observation or exploration. Five years down the line, the question still remains unanswered as far as evidence goes. But, what has changed over the years is that now we have more objective ways of assessing the perfusion rather than just relying on pink colour of the hand and capillary refill. The use of Doppler ultrasound and pulseoximeter signals to assess the perfusion of limb have come into vogue [23]. The presence of associated median nerve injury is more predictive of a significant arterial injury and hence these patients should be considered for exploration.
Hence in the present scenario, three factors needs to be considered in the decision making process of pink pulseless hand:
1.Presence of radial artery Doppler signals
2.Presence of good pulseoximeter waveforms and oxygen saturation >95%.
3.Intact Median Nerve function.

If all the three criteria are met, the recommendation is to observe the child closely for circulation and symptoms of compartment syndrome. If all three are absent, it is an indication of poor perfusion and it is an indication for arterial exploration. The combination of absence of radial artery Doppler signals and absence of pulse oximeter signals again indicates poor perfusion and favors exploration.  There is no evidence to comment on other scenarios of either isolated median nerve palsy or isolated absence of radial artery Doppler signals or pulse oximeter signals and their combinations. There are no studies, which have documented all these factors for all their patients, and we are not sure whether a limb can have absent radial artery Doppler signals with good pulse oximeter waveforms. These would rather be hypothetical situations and if someone comes across such a situation in clinical practice, the best would be to individually assess the case and decide for exploration versus observation. However, considering the complications and the reported incidence of significant arterial injuries up to 70% in patients without a positive radial artery Doppler signal, it may be a safer option to consider exploration in these patients. The use of Doppler of the brachial artery to know the severity of the arterial injury and taking it as a sole factor for considering exploration is not justifiable, as the limb can still have good collateral circulation.  Thus in conclusion both clinical and diagnostic methods have to be taken into account while making a balanced decision in terms on observation or surgical exploration of a pink pulseless hand [3,24].


References

1. Schoenecker PL, Delgado E, Rotman M, Sicard GA, Capelli AM. Pulseless arm in association with totally displaced supracondylar fracture. J Orthop Trauma 1996; 10:410–415.
2. Robb JE. The pink, pulseless hand after supracondylar fracture of the humerus in children. J Bone Joint Surg Br. 2009 Nov;91(11):1410-2.
3. Badkoobehi H, Choi PD, Bae DS, Skaggs DL. Management of the pulseless pediatric supracondylar humeral fracture. J Bone Joint Surg Am. 2015 Jun 3;97(11):937-43.
4. Korompilias AV, Lykissas MG, Mitsionis GI, Kontogeorgakos VA, Manoudis G, Beris AE (2009) Treatment of pink pulseless hand following supracondylar fractures of the humerus in children. Int Orthop 33(1):237–241.
5. Matuszewski Ł. Evaluation and management of pulseless pink/pale hand syndrome coexisting with supracondylar fractures of the humerus in children. Eur J Orthop Surg Traumatol. 2014 Dec;24(8):1401-6.
6. MEYERDING HW. Volkmann’s ischemic contracture associated with supracondylar fracture of humerus. Journal of the American Medical Association, 1936:106:1139-1144.
7. Louahem DM, Nebunescu A, Canavese F, Dimeglio A. Neurovascular complications and severe displacement in supracondylar humerus fractures in children: defensive or offensive
strategy? J Pediatr Orthop B 2006; 15(1):51–57
8. Ramesh P, Avadhani A, Shetty AP, Dheenadhayalan J, Rajasekaran S. Management of acute ‘pink pulseless’ hand in pediatric supracondylar fractures of the humerus. J Pediatr Orthop B. 2011 May;20(3):124-8.
9. Benedetti Valentini M, Farsetti P, Martinelli O, Laurito A, Ippolito E. The value of ultrasonic diagnosis in the management of vascular complications of supracondylar fractures of the humerus in children. Bone Joint J. 2013 May;95-B(5):694-8.
10. Weller A, Garg S, Larson AN, Fletcher ND, Schiller JR, Kwon M, Copley LA, Browne R, Ho CA. Management of the pediatric pulseless supracondylar humeral fracture: is vascular exploration necessary? J Bone Joint Surg Am. 2013 Nov 6;95(21):1906-12.
11. White L, Mehlman CT, Crawford AH. Perfused, pulseless, and puzzling: a systematic review of vascular injuries in pediatric supracondylar humerus fractures and results of a POSNA questionnaire. J Pediatr Orthop. 2010 Jun;30(4):328-35.
12. Korompilias AV, Lykissas MG, Mitsionis GI, Kontogeorgakos VA, Manoudis G, Beris AE. Treatment of pink pulseless hand following supracondylar fractures of the humerus in children. Int Orthop. 2009 Feb;33(1):237-41.
13. Copley LA, Dormans JP, Davidson RS. Vascular injuries and their sequelae in pediatric supracondylar humeral fractures: toward a goal of prevention. J Pediatr Orthop. 1996 Jan-Feb;16(1):99-103.
14. Blakey CM, Biant LC, Birch R. Ischaemia and the pink, pulseless hand complicating supracondylar fractures of the humerus in childhood: long-term follow-up. J Bone Joint Surg Br. 2009 Nov;91(11):1487-92.
15. Copley LA, Dormans JP, Davidson RS. Vascular injuries and their sequelae in pediatric supracondylar humeral fractures: toward a goal of prevention. J Pediatr Orthop. 1996 Jan-Feb;16(1):99-103.
16. Luria S, Sucar A, Eylon S, Pinchas-Mizrachi R, Berlatzky Y, Anner H, Liebergall M, Porat S. Vascular complications of supracondylar humeral fractures in children. J Pediatr Orthop B. 2007 Mar;16(2):133-43
17. Scannell BP, Jackson JB 3rd, Bray C, Roush TS, Brighton BK, Frick SL. The perfused, pulseless supracondylar humeral fracture: intermediate-term follow-up of vascular status and function. J Bone Joint Surg Am. 2013 Nov 6;95(21):1913-9.
18. Choi PD, Melikian R, Skaggs DL. Risk factors for vascular repair and compartment syndrome in the pulseless supracondylar humerus fracture in children. J Pediatr Orthop. 2010 Jan-Feb;30(1):50-6.
19. Matuszewski Ł. Evaluation and management of pulseless pink/pale hand syndrome coexisting with supracondylar fractures of the humerus in children. Eur J Orthop Surg Traumatol. 2014 Dec;24(8):1401-6.
20. Sabharwal S, Tredwell SJ, Beauchamp RD, Mackenzie WG, Jakubec DM, Cairns R, LeBlanc JG. Management of pulseless pink hand in pediatric supracondylar fractures of humerus. J Pediatr Orthop. 1997 May-Jun;17(3):303-10.
21. Garbuz DS, Leitch K, Wright JG. The treatment of supracondylar fractures in children with an absent radial pulse. J Pediatr Orthop. 1996 Sep-Oct;16(5):594-6.
22. The treatment of pediatric supracondylar humerus fractures. AAOS Clinical Practice Guidelines Unit v1.0_092311. Summary of Recommendations. available from
http://www.aaos.org/research/guidelines/SupracondylarFracture/SupConFullGuideline.pdf
23. Soh RC, Tawng DK, Mahadev A. Pulse oximetry for the diagnosis and prediction for surgical exploration in the pulseless perfused hand as a result of supracondylar fractures of the distal humerus. Clin Orthop Surg. 2013 Mar;5(1):74-81.
24. Shah AS, Waters PM, Bae DS. Treatment of the “pink pulseless hand” in pediatric supracondylar humerus fractures. J Hand Surg Am. 2013 Jul;38(7):1399-403
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How to Cite this Article: Venkatadass K. Pink Pulseless hand – evaluation and decision making: Is there a consensus?. International Journal of Paediatric Orthopaedics July-Sep 2015;1(1):19-22.         

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Supracondylar Humerus Fractures in Children: Epidemiology and Changing Trends of Presentation

Vol 1 | Issue 1 | July-Sep 2015 | page:3-5 | Sandeep V Vaidya.


Authors : Sandeep V Vaidya[1,2,3*].

[1] Children’s Orthopaedic Clinic, Thane.
[2] B J Wadia Children’s Hospital, Parel Mumbai
[3] Jupiter Hospital, Thane, Maharashtra, India

Address of Correspondence
Dr Sandeep V Vaidya
Director, Children’s Orthopaedic Clinic, Thane. India.
Email: drsvvaidya@gmail.com


Abstract

Diseases show a tendency to vary according to changing socio-economic trends and fractures too have shown this tendency. Paediatric supracondylar humerus fractures are one of the most common fractures seen by paediatric orthopaedic surgeons. There are few notable trends that have been reported and few other that I have personally noted in my practice and in practice of my colleagues. This article put together the changes reported in literature and tries to combine it with clinically relevant practical situations. Special focus is on fracture presentation and on decision making in management.
Keywords: Supracondylar Humerus fracture, classification, management.


Introduction:
Supracondylar humerus fractures in children are commonly seen in day to day practice. In this section, we study the epidemiology and changing trends of these fractures with respect to incidence, patient profile, types, modes of injury, treatment trends and complications.

Incidence:
Supracondylar humerus fractures (SHF) comprise 17% of all pediatric fractures and are second in frequency to forearm fractures. According to an epidemiological study, the incidence of fracture supracondylar humerus is 308/100000 per year in the general population. It is also the commonest pediatric fracture around the elbow. One epidemiological study identified supracondylar fractures in 206 out of 355 elbow fractures (58%) [1]. Barr reported a higher incidence of supracondylar humerus fractures during the vacations [2].

Age and sex:
If age distribution is considered, in the 0 to 7 year age group, SHF is easily the commonest fracture seen (28%) [3]. The mean age at which fracture supracondylar humerus occurs is 5 to 8 years [1,2]. Wilkins proposed that when a child falls on extended upper extremity, the patients who demonstrate hyperextension (cubitus recurvatum) of the elbow are more predisposed to have supracondylar fractures. The children who do not have hyperextension of the elbow tend to sustain fractures of the radius and the ulna, usually at the distal portion. Since ligamentous laxity with elbow recurvatum is seen in younger children, this explains the higher incidence of supracondylar humerus fractures in younger children and higher incidence of radius ulna fractures in older children.
Recently, there seems be increase in incidence of SHF in lower age group(less than 2 years). Fractures occurring in these very young children may pose a diagnostic dilemma because in many of these cases, the fracture line is extremely low and on plain radiographs may mimic a fracture lateral condyle humerus due to the largely cartilaginous component of the distal fragment. In such cases, additional imaging like MRI or arthrogram may be needed to differentiate these low supracondylar fractures from the lateral condyle fractures (Fig. 1). Another peculiarity of the low supracondylar humerus fractures is that such fractures can be complicated by Avascular necrosis of the trochlea with subsequent later sequelae.

Fig 1

Figure 1: (Case Courtesy Dr Sandeep Patwardhan)1a: Elbow radiograph`of a 2 year old child with fall on outstretched hand. The fracture line is extremely distal and only a flake of metaphysis is seen.1b,c: The fracture was treated by closed reduction and K wire pinning .

In most of the earlier studies, the fracture occurred much more commonly in boys than in girls. However in most of the recent series, the frequencies in girls and boys seems to be equalizing. Some series have actually reported a higher incidence in girls than boys[1,2]. This changing sex distribution may be attributed to more active participation of girls in sports activities.

Mode of injury:
The cause of fracture supracondylar humerus is accidental fall while playing in most of the cases (60 to 80 %). Road traffic accidents account for 10 to 20% of SHF [2]. High velocity trauma can lead to fractures with metaphyseal comminution or in rare cases fractures with intercondylar extension.
Child abuse is an uncommon etiology of SHF[4]. However Strait and colleagues reported supracondylar fractures from abuse in three of 10 abused children under the age of 3, and cautioned that SHF should not be assumed to have non-abusive causes without careful consideration [5].

Types:
Extension type is the commonest type, flexion type is seen in 1 to 3% cases [6]. The patients in the flexion-type group (mean age, 7.5 years) are significantly older than those in the extension-type group (mean age, 5.8 years). The fractures in flexion-type group are also more probable to require open reduction (31%) than those in the extension-type group (10%). The flexion-type group had a significantly increased incidence rate of ulnar nerve symptoms (19% vs 3% in the extension-type group) and need for ulnar nerve decompression [7].
Gartland classification is the commonest classification system used to grade supracondylar humerus fracture. Grade 1 fractures are the commonest, followed by Grade 2 and then Grade 3 [1,2].
In addition to these 3 types, Leitch et al described a type 4 fracture with multidirectional instability (unstable in both flexion and extension). This fracture type was noted in 9 out of 297 displaced fractures. These fractures are associated with high velocity trauma, the periosteal sleeve is completely torn and special manoeuvres are needed for closed reduction- pinning [8].
In extension type fractures the distal fragment may be displaced posteromedially or posterolaterally. Posteromedial displacement is commoner and seen in approximately 75% cases in most series. Posteromedial displacement of the distal fragment places the radial nerve at risk, whereas in fractures with posterolateral displacement the brachial artery and median nerve are at risk [9]. Bahk et al additionally classified extension type supracondylar fractures based on orientation of the fracture line in coronal as well as sagittal planes. In coronal plane, transverse fractures were the commonest (49%) followed by lateral oblique fractures (44%). Medial oblique (4%) and high transverse fractures (3%) were less common. Whereas transverse and lateral oblique fractures are amenable to lateral only pinning, the medial oblique and transverse fractures need to be fixed with medial-lateral cross pins [10].
High SHF are also being increasingly reported recently. Sen et al reported an incidence of high metaphyseal- diaphyseal supracondylar humerus fractures in 6 out of 182 fractures [11].

Treatment:
Blount in 1955 had cautioned against operative treatment in SHF citing the high incidence of complications following operative treatment [12]. However with significant advances in operative techniques and intraoperative imaging, operative treatment with Closed Reduction Percutaneous Pinning (CRPP) is easily the treatment of choice for displaced supracondylar humerus fractures [13]. Approximately 40% of SHF are treated operatively making it the commonest pediatric fracture to undergo operative treatment [2]. Cheng et al in an epidemiological study of 6493 fractures reported that the closed-reduction and percutaneous pinning rates for supracondylar humerus fractures increased 4.3 to 40% over a 10 year period from 1985 to 1995. The changes in treatment pattern were also accompanied by a corresponding decrease in the open-reduction rate and hospital stay periods from <10% to 38% of patients being discharged within 1 day of admission in the 10-year period [3].

The incidence of operative treatment is 0% in Grade 1 fractures, almost 50% for Grade 2 fractures, 100% for Grade 3 fractures and 100% for flexion type fractures. The incidence of open reduction is highest in flexion type fractures (50%) [2]. In an epidemiological study, out of 3235 children with displaced SHF treated operatively at a tertiary care children’s hospital at Toronto, 78.7% underwent operative treatment in the form of Closed Reduction Percutaneous Pinning (CRPP) whereas the remainder 21.8% underwent Open Reduction Internal Fixation (OR). There was a significant difference in the delay to surgery between the CRPP and OR groups [14]. In developed countries, there is a trend for more number of SHF are being treated by pediatric orthopaedic subspecialists. In New England, only 37% of SHF were treated by Pediatric Orthopaedic surgeons in 1991, this number rose to 68% in 1999. Kasser et al reported that in fractures treated by pediatric orthopaedic surgeons the length of hospitalization was lesser (1.4 ± 0.4 days) than for fractures treated by general orthopaedic surgeons (2.2 ± 0.6 days) [15]

Pin configurations, changing trends:
Pin configurations used by surgeons have shown a changing trend over the past decade. Several biomechanical studies published before 2005 revealed that crossed medial- lateral pin configurations are biomechanically stronger than lateral only pin configurations. Hence crossed medial- lateral pinning was preferred. However a major danger of the medial pin was iatrogenic ulnar nerve injury. Incidence of iatrogenic ulnar nerve injury with crossed medial- lateral pinning in various series has ranged from 0% to 6% [16,17]. Lyons et al reported iatrogenic ulnar nerve palsy in 19 out of 375 crossed medial- lateral pinning. 15 out of these 19 palsies recovered within 4 months after medial pin removal. However 4 palsies failed to recover, underwent ulnar nerve exploration and neurolysis [17]. A systematic pooled analysis of 32 trials comprising 2639 children suggests that there is an iatrogenic ulnar nerve injury for every 28 patients treated with the crossed pinning compared with the lateral pinning [16].
An inherent fallacy of the early biomechanical studies was that these studies were based on in-vitro findings wherein loads applied to create displacement were significantly higher than those which would be applied in-vivo wherein the fixation would be additionally supplemented with plaster slab application. Lee et al in their series of 61 consecutive lateral only pinning reported a zero incidence of loss of reduction as well as iatrogenic ulnar nerve palsy [18]. A randomized controlled study published in 2007 concluded that lateral entry only pinning did not result in increase incidence of loss of reduction as compared to crossed medial-lateral pinning [19]. A survey involving eight surgeons conducted in 2012 confirmed that this RCT had a significant influence on the surgeons’ practice. Five out of eight surgeons individually had a statistically significant change in their practice pattern for pin configuration. Except for certain selected fracture patterns, lateral only pinning is being increasingly used as the standard pin configuration for supracondylar humerus fractures [20].

Complications:
Complications of fracture supracondylar humerus include compartment syndrome, vascular injury, nerve injury (fracture related or iatrogenic) and malunion with cubitus varus deformity. The incidence of compartment syndrome is approximately 0.1% to 0.3% of all supracondylar humerus fractures [21]. Ipsilateral forearm fracture significantly increases risk of compartment syndrome [22]. In a study, the incidence of compartment syndrome was — % in fractures reduced and fixed within – hours of injury as compared to — % in fractures fixed after a delay of – hours.
The incidence of vascular injuries is approximately 20% and majority are associated with Grade 3 fractures [1, 23, 2]. Fractures with posterolateral displacement are more at risk for vascular injuries (approximately 65%) than fractures with posteromedial displacement (approximately 53%) [23]. If the hand is well perfused but pulseless, the great majority of the time fracture reduction is sufficient treatment. In contrast, patients presenting with a pulseless and poorly perfused hand have a nearly 50% chance of requiring vascular surgery and nearly 25% chance of developing a compartment syndrome [24, 25].
Nerve injuries are seen in approximately 4% fractures and majority are associated with Grade 3 fractures [1,2]. Overall, the most commonly injured nerve is median nerve (50%) followed by radial nerve (28%) followed by ulnar nerve (22%). The pattern of displacement is the most important risk factor in nerve injury. In fractures with median nerve palsy, posterolateral displacement is seen in 87% cases. In cases with radial nerve palsy, posteromdeial displacement Is seen in almost all cases [23] In flexion type, ulnar nerve is most commonly injured [7].


References

1. Houshian S, Mehdi B, Larsen MS. The epidemiology of elbow fracture in children: analysis of 355 fractures, with special reference to supracondylar humerus fractures. J Orthop Sci 2001;6(4):312-5
2. Barr LV. Pediatric supracondylar humeral fractures: epidemiology, mechanisms and incidence during school holidays. J Child Orthop. 2014; 8:167–170
3. Cheng, Jack CY, Ng, BKW, Ying, S. Y, Phil P. A 10-Year Study of the Changes in the Pattern and Treatment of 6,493 Fractures. 19(3), May/June 1999, pp 344-350
4. Kemp AM, Dunstan F, Harrison S, Morris S, Mann M, Rolfe K, Datta S, Thomas DP, Sibert JR, Maguire S. Patterns of skeletal fractures in child abuse: systematic review. BMJ 2008; 337:a1518
5. Strait RT, Siegel RM, Shapiro RA. Humeral fractures without obvious etiologies in children less than 3 years of age: when is it abuse? Pediatrics. 1995 Oct;96(4 Pt 1):667-71
6. Cheng JC, Lam TP, Maffulli N. Epidemiological features of supracondylar fractures of the humerus in Chinese children. J Pediatr Orthop B 2001;10(1):63-67
7. Mahan SD, May CD, Kocher MS. Operative Management of Displaced Flexion Supracondylar Humerus Fractures in Children. J Pediatr Orthop 2007;27:551-556
8. 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 Joint Surg Am. 2006 May;88(5):980-5.
9. Skaggs DL, Flynn JM. (2010) In Rockwood and Wilkins’ Fractures in Children. Philadelphia. Lippincott Williams and Wilkins. 514-515
10. Bahk MS, Srikumaran U, Ain MC, Erkula G, Leet AI, Sargent MC, Sponseller PD. Patterns of Pediatric Supracondylar Humerus Fractures. J Pediatr Orthop 2008;28:493-499.
11. Sen RK, Tripathy SK, Kumar A, Agarwal A, Aggarwal S, Dhatt S. Metaphyseo-diaphyseal junction fracture of distal humerus in children. 
J Pediatr Orthop B 2012, 21:109–114
12. Blount WP. Fractures in Children. Baltimore: Williams and Wilkins, 1955
13. France J, Strong M. Deformity and function in supracondylar fractures of the humerus in children variously treated by closed reduction and splinting, traction and percutaneous pinning. J Pediatr Orthop. 1992:12(4): 494-498
14. Khoshbin A, Leroux T, Wasserstein D, Wolfstadt J, Law PW, Mahomed N, Wright JG. The epidemiology of paediatric supracondylar fracture fixation: A population-based study. Injury. 2014; 45: 701–708Khoshbin A, Leroux T, Wasserstein D, Wolfstadt J, Law PW, Mahomed N, Wright JG. The epidemiology of paediatric supracondylar fracture fixation: A population-based study. Injury. 2014; 45: 701–708
15. Kasser JR. Location of treatment of supracondylar fractures of the humerus in children. Clin Orthop Relat Res. 2005 May;(434):110-3
16. Slobogean BL, Jackman H, Tennant S, Slobogean GP, Mulpuri K. Iatrogenic ulnar nerve injury after the surgical treatment of displaced supracondylar fractures of the humerus: number needed to harm, a systematic review. J Pediatr Orthop 2010;30(5):430-6
17. Lyons, James P. M.D.; Ashley, Edwin M.D.; Hoffer, M. Mark M.D. Ulnar Nerve Palsies After Percutaneous Cross-Pinning of Supracondylar Fractures in Children’s Elbows. J Pediatr Orthop. 1998:18, 43-45
18. Lee YH, Lee SK, Kim BS, Chung MS, Baek GH, Gong HS, Lee JK. Three Lateral Divergent or Parallel Pin Fixations for the Treatment of Displaced Supracondylar Humerus Fractures in Children. J Pediatr Orthop 2008;28:417-422
19. Kocher MS1, Kasser JR, Waters PM, Bae D, Snyder BD, Hresko MT, Hedequist D, Karlin L, Kim YJ, Murray MM, Millis MB, Emans JB, Dichtel L, Matheney T, Lee BM. Lateral entry compared with medial and lateral entry pin fixation for completely displaced supracondylar humeral fractures in children. A randomized clinical trial. J Bone Joint Surg 2007;89(4):706-12
20. Mahan ST, Osborn E, Bae DS, Waters PM, Kasser JR, Kocher MS, Snyder BD, Hresko MT. Changing Practice Patterns: The Impact of a Randomized Clinical Trial on Surgeons Preference for Treatment
of Type 3 Supracondylar Humerus Fractures. J Pediatr Orthop 2012;32:340–345
21. Battaglia TC, Armstrong DG, Schwend RM. Factors affecting forearm compartment pressures in children with supracondylar fracture of the humerus. J Pediatr Orthop. 2002; 22(4): 431-439
22. Blackmore LC, Cooperman DR, Thompson GH. Compartment syndrome in ipsilateral humerus and forearm fractures in children. Clin Orthop and Relat Res. 2000; 376: 32-38
23. Campbell CC, Waters PM, Emams JB, Kasser JR, Millis MB. Neurovascular injury and displacement in type 3 supracondylar humerus fractures. J Pediatr Orthop. 1995;15(1):47-52
24. Choi PD, Melikian R. Skaggs DL. Risk Factors for vascular repair and compartment syndrome in the pulseless supracondylar humerus fracture in children. J Pediatr Orthop 2010;30:50-56
.


How to Cite this Article: Vaidya SV. Supracondylar Humerus Fractures in Children:
Epidemiology and Changing Trends of Presentation. International Journal of Paediatric Orthopaedics July-Sep 2015;1(1):3-5.          

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Open reductions of Paediatric Supracondylar Humerus Fractures- When, How and, Risks

Vol 1 | Issue 1 | July-Sep 2015 | page:16-18 | Ashish Ranade, Gauri Oka.


Authors : Ashish Ranade[1], Gauri Oka[1].

[1] Dept. of Orthopaedics, Deenanath Mangeshkar Hospital, Pune 411004.

Address of Correspondence
Dr Ashish Ranade
Dept. of Orthopaedics, Deenanath Mangeshkar Hospital, Pune 411004.
Email address:ashishranade@yahoo.com


Abstract

Supracondylar humerus fracture is one of the commonest fractures in pediatric elbow. Usually closed reduction and percutaneous pinning is the preferred treatment for most of the displaced fractures. Nowadays closed reduction and percutaneous pinning has become standard of care for majority of displaced supracondylar humerus fractures. Rarely, an open reduction via appropriate approach becomes necessary. Various types of approaches that have been described are anterior, posterior, medial, lateral, and combined approaches. There is ambiguity of information as to selection of approach for doing open reduction in a supracondylar humerus fracture. There is debate about timing of treatment, approach selection and indications for doing open reduction.1 In this article we discuss indications, various types of approaches with their pros and cons and risks involved in open reduction of supracondylar humerus fractures in children.
Keywords: Supracondylar humerus fracture, open reduction, surgical approach.


Introduction
Supracondylar humerus fracture (SHF) is one of the commonest fractures in pediatric elbow. Nowadays closed reduction and percutaneous pinning has become standard of care for majority of displaced supracondylar humerus fractures. Rarely, an open reduction via appropriate approach becomes necessary. Various types of approaches that have been described are anterior, posterior, medial, lateral, and combined approaches. There is ambiguity of information as to selection of approach for doing open reduction in a supracondylar humerus fracture. There is debate about timing of treatment, approach selection and indications for doing open reduction [1]. In this article we discuss indications, various types of approaches with their pros and cons and risks involved in open reduction of supracondylar humerus fractures in children.

Case Example
A 9 year old boy was referred for the treatment of left supracondylar humerus fracture. He had sustained an injury following fall from a tree 10 days ago and was put in an above elbow splint in his village. On examination, radial pulse was present and he was neurologically intact.

Figure 1, 2

The elbow was grossly swollen and there was deep abrasion with blister formation along the elbow crease on the anterior aspect. (Figure 1) There was ecchymosis along anterior aspect of elbow. The radiographs showed posterolaterally displaced type III supracondylar humerus fracture (Figure 2). Under general anaesthesia, closed reduction was attempted. Satisfactory reduction could not be achieved by closed means. Hence, a decision was made to perform open reduction. Considering the anterior wound, combined medial and lateral approach was chosen. Initially, a medial incision was made and the bony spike of the proximal fragment was separated from the brachialis fibres and the median nerve. At this point, reduction was attempted again. In view of difficulty in getting a satisfactory alignment, a lateral incision was made and the interposing tissues were removed. Periosteum was found to be torn on both sides. (Figure 3)After achieving open reduction, the fracture was fixed with crossed k wires and maintained in an AE slab for 3 weeks(Figure 4).  Postoperatively, the patient made uneventful recovery and the fracture healed well in a satisfactory position. The elbow had 5 degrees loss of terminal flexion.

Figure 3, 4

Discussion

Open reduction has been indicated for fractures with vascular injuries, signs of compartment syndrome, failure of closed reduction to achieve satisfactory alignment, and for severe swelling interfering to achieve good reduction [2-7]. In present day scenario, the main indication is failure to achieve satisfactory reduction by closed methods. This could be because of several factors such as instability of the fracture or interposition of neurovascular bundle or brachialis muscle. The overall proportion of supracondylar humerus fractures needing open reduction varies between 3 to 46% based on various studies[2,8-10]. This rate varies between centres and some centres may prefer to do open reductions than using closed methods. Delayed presentation of the fracture is one of the most important factors while discussing open reduction for supracondylar humerus fractures[ 5].
There are several options available for approach selection. There is no clear superiority of one approach over another. Mazzini and co-authors have published a systematic review of literature pertaining to surgical approaches in the treatment of open reduction and pinning[11]. In this review, authors found high frequency of poor results in terms of functional outcomes with posterior approach. High frequency of excellent results was found with the lateral and medial approach and a high frequency of good results within the anterior approach group. A Canadian study sites buttonholing of the proximal fragment through the brachialis muscle and interposition of joint capsule or periosteum between fragments[12]. With the posterior approach , anterior structures such as brachialis, and the neurovascular bundle cannot be accessed and probably the posterior scar leads to limitation of movements of the elbow joint[13]. In the same article, authors have found the change in the carrying angle (cosmetic outcome) as the most common complication seen after an open reduction via the posterior or lateral approach. However, relatively newer studies utilizing posterior approach do not report these complications [7,14]. Medial column communition and internal rotation and/or varus tilt of the distal fragment may be addressed sufficiently through lateral/posterior approach. In review by Mazzini et al, the time to union remains the same irrespective of the approach used. There was higher tendency of ulnar nerve injury in the posterior and lateral approach group. This is attributed to lack of direct visalization of ulnar nerve. Based on the findings, authors recommend anteromedial approach for open reduction[11].
While choosing an approach, one must take into consideration surgeon’s experience and the anatomical structures involved. It is known from various studies that fracture union time and rate of approach related complications are similar with various approaches [7,11].
In a study by Aslan and co-authors, clinical and radiographic results of children with Gartland type 3 supracondylar humerus treated with primary open reduction using four different approaches were studied [7]. Fifty eight patients were treated with either anterior, medial, lateral and , posterior approach. Choice of approach was decided by fracture pattern and neurovascular injury. All fractures were fixed with two lateral entry k wires or crossed k wires as per surgeon’s preference. In this series, three quarters of patients were operated within 24 hours since injury. Flynn criteria were used to measure outcomes. The outcome was comparable in all groups.
Ozkoc and co-authors studied 99 patients with supracondylar humerus fracture. In this group, 44 patients were treated with primary open reduction and k wire fixation and 55 were treated with closed reduction and percutaneous pinning. They found that in the open group the average loss of extension was 6 degrees compared to 0.6 degrees in the closed group[2].
Koudstaal and colleagues have reported the use of anterior approach in 26 children [15]. In another study, Ay and co-authors report their experience of using the anterior approach in 61 children [16]. In both these studies, a transverse incision was used in the antecubital fossa. In both studies, excellent results were noted without any significant loss of elbow movement.
In summary, various options are available for performing an open reduction of a supracondylar humerus fracture. The anterior approach certainly offers advantages of direct visualisation and retraction of entrapped structures. The treating surgeon must choose the appropriate approach based on the indication for open reduction.

Author’s preferred treatment
Our indications for open reduction are as follows:
1) Vascular compromise or disappearance of pulse after doing closed reduction- In this scenario, we suspect the brachial artery likely to be caught between fracture fragments. Hence, we perform an exploration via the anterolateral or anteromedial approach. The vascular structures are explored and reduction of fragments is achieved under vision. We undertake this approach with a vascular/plastic surgeon available in the operation theatre in case the need for vascular repair arises.
2) Inability to achieve satisfactory reduction by closed method- Usually this is encountered in late presentation of fractures with severely swollen elbow. Usually, attempts of closed reduction are made and if satisfactory reduction cannot be achieved, then open reduction is performed. Our preferred approach for this type is usually the anterior approach. However when skin conditions do not permit anterior approach, then a medial and/or lateral approach depending upon the fracture configuration is used.
Open fractures: Usually there is an anterior wound. Anterior approach is used in these cases.


References

1. Mulpuri K, Wilkins K. The treatment of displaced supracondylar humerus fractures: evidence based guideline. J Pediatr Orthop 2012;32:S143-S152
2. Ozkoc G, Gone U, Kayaalp A, Teker K, Peker TT. Displaced supracondylar humeral fractures in children: open reduction vs. closed reduction and pinning. Arch Orthop Trauma Surg 2004; 124:547-551.
3. Cramer KE, Devito DP, Green NE. Comparison of closed reduction and percutaneous pinning versus open reduction and percutaneous pinning in displaced supracondylar fractures of the humerus in children. J Orthop Trauma 1992;6:407-412.
4. Oh CW, Park BC, Kim PT, Park IH, Kyung HS, Ihn JC. Completely displaced supracondylar humerus fractures in children: results of open reduction versus closed reduction. J Orthop Sci 2003;8:137-141
5. Walmsley PJ, Kelly MB, Robb JE, Annan IH, Porter DE. Delay increases the need for open reduction of type –III supracondylar fractures of the humerus. J Bone Joint Surg Br 2006;88:528-530.
6. Mulhall KJ, Abuzakuk T, Curtin W, O;Sullivan M. Displaced supracondylar fractures of the humerus in children. Int Orthop 2000;24:221-223.
7. Aslan A, Konya MN, Ozdemir A, Yougancigil H, Maralcan G, Uysal E. Open reduction and pinning for the treatment of Gartland extension type III supracondylar humeral fractures in children. Strat Trauma Limb Recon 2014;9:79-88.
8. Aktekin CN, Toprak A, Ozturk AM, Altay M, Ozkurt B, Tabak AY. Open reduction via posterior triceps sparing approach in comparison with closed treatment of posteromedial displaced Gartland type III supracondylar humerus fractures. J Pediatr Orthop B 2008;17:171-178.
9. Gupta N, Kay RM, Leitch K, Femino JD, Tolo VT, Skaggs DL. Effect of surgical delay in perioperative complications and need for open reduction in supracondylar humerus fractures in children. J Pediatr Orthop 2004;24:245-248.
10. Reitman RD, Waters P, Millis M. Open reduction and internal fixation for supracondylar humerus fractures in children. J Pediatr Orthop 2001;21:157-161.
11. Mazzini JP, Martin JR, Esteban EMA. Surgical approaches for open reduction and pinning in severely displaced supracondylar humerus fractures in children: a systematic review. J Child Orthop 2010;4:143-152.
12. Fleiriau-Chateau P, McIntyre W, Letts WM. An analysis of open reduction of irreducible supracondylar fractures of the humerus in children. Can J Surg 1998;41(2):112-118.
13. Gruber MA, Hudson OC. Supracondylar fracture of the humerus in childhood. End results study of open reduction. J Bone Joint Surg Am 1964;46:1245-1252.
14. Sibly TF, Briggs PJ, Gibson MJ. Supracondylar fractures of the humerus in childhood: Range of movements following the posterior approach to open reduction. Injury 1991;22(6):456-458.
15. Koudstaal MJ, De Ridder VA, De Lange S, et al. Pediatric supracondylar humerus fractures: The anterior approach. J Orthop Trauma 2002;16(6):409-412.
16. Ay S, Akinnci M, Kamiloglu S, Ercetin O. Open reduction of displaced pediatric supracondylar humeral fracture through the anterior cubital approach. J Pediatr Orthop 2005;25:149-153
.


How to Cite this Article: Ranade A, Oka G. Open reductions- When, How and, Risks. International Journal of Paediatric Orthopaedics July-Sep 2015;1(1):16-18.      

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Controversial Issues in Closed Reduction and percutaneous pinning of Supracondylar Fractures of Humerus in children

Vol 1 | Issue 1 | July-Sep 2015 | page:11-15 | Taral Nagda, Jaideep Dhamele, Chetan Pishin.


Authors : Taral Nagda[1], Jaideep Dhamele[1], Chetan Pishin[2].

[1] Consultant Institute of Pediatric Orthopedic Disorders Mumbai India.
[2] Fellow Institute of Pediatric Orthopedic Disorders Mumbai India.

Address of Correspondence
Dr . Taral Nagda
Consultant Institute of Pediatric Orthopedic Disorders Mumbai India.
Email address: taralnagda@gmail.com


Abstract

Introduction: Closed reduction and percutaneous pinning is the mainstay in treatment of supracondylar humerus fractures in children. Although most of the issues are quite straight forward, but in certain situations, there exists difference in opinion in literature. Individual/ group of researchers will always find data to favor one approach over other, but the metaanalysis of the entire literature on the topics fails to show any advantage of one over other. We have tried to touch upon few such questions like Pin Configurations, emergency vs delayed fixation, radiation exposure etc. The pattern of the article is quite unique in terms of referencing the references in details and one after the other. The results are then compiled and guidelines are suggested according to current literature.
Keywords: Closed reduction, supracondylar humerus fracture, percutaneous pinning.


Introduction
Percutaneous pinning of supracondylar fracture is one of the commonest procedures in paediatric orthopaedics, yet there remain certain areas of controversy or lack of consensus. This article is prepared in separate dialectic sections each dealing with a unique question. Relevant literature is then reviewed to reach a logical answer.

A] Pin configurations: Lateral v/s Cross
Closed reduction and pinning is a gold standard in the management of displaced supracondylar fractures of humerus in chidren [1]. It allows the elbow to be maintained in a position of relative extension thus minimizing chances of compartment syndrome and vascular compromise yet providing stability and avoiding malunion associated with the fracture. There is an ongoing debate on choice of the the pin configuration while fixing SCFH [2]. In laboratory settings, cross pinning appears to have better stability but in clinical setting both seem to do equally well with additional risk of iatrogenic ulnar nerve palsy with medial pinning. We examined some of recent papers which can guide an orthopedic surgeon solve the dilemma.

Literature 

1. Medial and Lateral Crossed Pinning Versus Lateral Pinning for Supracondylar Fractures of the Humerus in Children: Decision Analysis [1].

Salient Features
-A decision analysis model was designed containing the probability of iatrogenic ulnar nerve palsy and malunion caused by unstable fixation for each of lateral pinning and medial and lateral crossed pinning techniques. The final outcome was function adjusted life year and used as a utility in the decision tree, where function was evaluated using the McBride disability evaluation.
-Medial and lateral crossed pinning and lateral pinning have opposite aspects to each other in terms of mechanical stability and iatrogenic ulnar nerve injury.
-Iatrogenic ulnar nerve injury after percutaneous pinning of a supracondylar fracture of the humerus can be devastating and irreversible, whereas malunion is correctable. Therefore, the authors recommend the lateral pinning technique for supracondylar fracture of the humerus in children.
-If the minimal medial incision technique could reduce the iatrogenic ulnar nerve injury rate down to 0.7%or a surgeon used a crossed pinning technique with an iatrogenic ulnar nerve injury rate of <0.7%, then the medial and lateral crossed pinning technique could be a better choice than the lateral pinning technique.

2. Is lateral pin fixation for displaced supracondylar fractures of the humerus better than crossed pins in children? [2]

Salient features
-A meta-analysis of the data from pubmed, embase and cochrane library of RCTs.
-Using varoius stastical analytic tools, it was found out that iatrogenic ulnar nerve palsy rate was higher in patients who underwent cross pinning.
-There were no statistical differences in radiographic outcomes, function, and other surgical complications. No significant heterogeneity was found in these pooled results.
-Authors recommended 2 lateral k wires.

3. Meta-Analysis of Pinning in Supracondylar Fracture of the Humerus in Children [3]

Salient Features
-All randomized controlled trials and cohort studies comparing outcomes (ie, loss of fixation, iatrogenic ulnar nerve injury, and Flynn criteria) between crossed and lateral pinning were identified.
-The risk of iatrogenic ulnar nerve injury was 4.3times higher in cross pinning compared with lateral pinning.
-There was no significant difference for loss of fixation, late deformity, or Flynn criteria between the two types of pinning.
-The study concluded that lateral pinning is preferable to cross pinning for fixation of pediatric supracondylar humerus fractures as a result of decreased risk of ulnar nerve injury.

4. Treatment of displaced supracondylar humeral fractures among children: Crossed versus lateral pinning.[4]

Salient features
-108 children were treated by closed reduction and percutaneous pinning: 37 with crossed pins, 37 with two lateral pins and 34 with two lateral and one medial pin
-Fractures fixed by two lateral pins were found significantly prone to postoperative instability, late complications and need for medial pin fixation.
-Of the 48 type III fractures fixed primarily with two lateral pins, 31 showed intraoperative instability that warranted an additional medial pin. Of the 17 fractures fixed by lateral pins alone, 8 demonstrated significant postoperative instability and 4 of these developed
cubitus varus deformity.
-There was a significant relation between either delay to surgery or postoperative instability and occurrence of complications.
-Fixation by two lateral pins only is not recommended for treating type III supracondylar humeral fractures, but could be used initially to fix severely unstable fractures to allow extension of the elbow before inserting a medial pin. Every effort should be made to avoid iatrogenic ulnar nerve injury while inserting the medial pin.
-Measures taken to avoid iatrogenic ulnar nerve damage while inserting a medial pin include relative extension of the elbow with a maximum of 60 flexion, after inserting the lateral pin. This should reduce possible ulnar nerve subluxation before inserting the medial pin. In very unstable fractures, a second lateral pin may be needed to provide more stability before partially extending the elbow for safe medial pin placement. If the ulnar nerve and groove can not be identified with confidence, a small incision should be made over the pin insertion site and blunt dissection should be performed down to the bone, to place the pin under direct vision. Dorgan’s technique of inserting crossed pins from the lateral side of the arm, as described by Shannon et al. offers the biomechanical advantages of cross-pinning while avoiding the risk of iatrogenic ulnar nerve injury.

5. Crossed pinning in paediatric supracondylar humerus fractures: a retrospective cohort analysis. [5]

Salient features
-Clinical and radiological results of 78 paediatric patients treated with closed reduction and percutaneous pinning
-No iatrogenic ulnar nerve palsy but one iatrogenic radial palsy which recovered in 13 weeks
-All paients were operated within 6 hours of injury
-Authers concluded that In cases were the ulnar nerve is palpable in the ulnar groove, blind percutaneous crossed pin placement is safe. If closed reduction fails or ulnar nerve subluxation cannot be excluded, a medial mini-open approach to visualise the nerve is certainly safer and should be preferred.

6. Biomechanical Analysis of Pin Placement for Pediatric Supracondylar Humerus Fractures: Does Starting Point, Pin Size, and Number Matter? [6]

Salient features
-20 synthetic humeri were sectioned in mid-olecraon fossa, and were directly reduced and fixed with 2 lateral k wires. There were 2 groups, one where both wires had a lateral entry and one group where one wire was put through capitellum and other through more lateral entry. Capitellar group provided greater stiffness in internal and external rotation. Capitellar entry provides for better stiffness of the construct compared to direct lateral entry by engaging sufficient bone and providing enough separation between the wires.
-Authors concluded that a capitellar entry should be used for one of the k wires.

7. Radial nerve safety in Dorgan’s lateral cross-pinning of the supracondylar humeral fracture in children: a case report and cadaveric study [7].

Salient Features
-Authors encountered a radial nerve palsy while using a lateral proximal pin entry for the cross K wire fixation for supra-condylar fracture of humerus.
-They did a cadaveric study in a pediatric humeri and noted that radial nerve is farthest from the wire in the postero lateral plane.
-Authers concluded that direction of the pin should be posterolateral within 2 cm of the lateral epicondyle.

8. Safe Zone for Superolateral Entry Pin Into the Distal Humerus in Children: An MRI Analysis [8]

Salient features
To determine the course of the radial nerve at the lateral distal humerus, authors reviewed 23 elbow radiographs and MRIs of 22 children and mapped radial nerve course.
-They concluded that Percutaneous direct lateral entry Kirschner wires and half-pins can be safely inserted in the distal humerus in children along the transepicondylar axis, either at or slightly posterior to the lateral supracondylar ridge, when placed caudal to the point located where the lateral supracondylar ridge line diverges from the proximal extent of the supracondylar ridge on AP elbow radiograph.

9. A retrospective analysis of loss of reduction in operated supracondylar humerus fractures [9].

Salient features
-18% patients had loss of reduction. Technical errors were noted to be higher in those patients were reduction was lost.

10. Management of Pediatric Type III Supracondylar Humerus Fractures in the United States: Results of a National Survey of Pediatric Orthopaedic Surgeons [10].

Salient features
-A short survey was sent to Pediatric Orthopaedic Society of North America (POSNA) members using an online survey and questionnaire service. The purpose of the survey was to establish an overview of current practices in the United States concerning treatment of type III supracondylar humerus fractures and the influence of the recent literature on the management of these injuries. — A total of 309 members, representing a wide range of locations and years in practice, responded to the survey
They reported 3 lateral pins (37%), 2 lateral pins (33%), and cross pins (30%) as the preferred method of fixation among respondents. This does show that two thirds of survey participants were using lateral pins primarily.
-However, many of those responding noted that they will add a medial pin to a lateral pin construct if they feel like more stability is needed intraoperatively. Some said that medial cortex comminution is one instance where a medial pin may be needed.
-The respondents that do place a medial pin regularly, advise placement of the lateral pin first for stability, followed by extension of the elbow for placement of the medial pin. This plus opening the medial side and exposing the medial epicondyle has been shown as a reliable technique to assist in protecting the ulnar nerve during medial pin placement. Overall, the sense was that ulnar nerve injury is not a common occurrence if proper precautions are taken.

Authors Comments and recommendations
1. The battle between lateral pinning and cross pinning is a battle between safety and stability
2. The supracondylar fractures are of different configurations and hence pin configurations have to be customized to the specific fracture geometry
3. Most cases of transverse and lateral oblique variety can be well treated by two or three lateral parallel or divergent pins. The stability of lateral pins can be improved in these cases by following measures
a. Capitellar entry point for one of the pins
b. Divergent pin configuration
c. Using wires more than 2 mm diameters
d. Pass pins from anterior to posterior direction at 15-300 to shaft of humerus to have maximum purchase in the distal humerus which is inclined 45 to shaft of humerus
e. Avoid multiple attempts. Multiple attempts weaken the pin bone interphase and weakens the hold of the K wire
4.In some situations medial pin may be added in addition to lateral pins These indications are
a. Intraoperative instability after passing lateral pins
b. Medial comminution
c. Medial oblique fracture
d. Adolescent supracondylar fracture
e. Low supracondular fractures
f. Obliquity in coronal plane which signifies instability
5. Some medial oblique fractures may need only medial pinning
6. The safety of medial pinning can be improved in these cases by
a. Pinning in relative extension The elbow should not be flexed more than 60
b. Pinning from anterior to epicondyle to posterior
c. Feeling the medial epicondyle and pushing ulnar nerve manually with a thumb pressure
d. In doubt or whenever there is a swelling using a mini opening on medial side to make sure the pin is well away from the nerve and does not entangle it
e. Use of a K wire protecting sleeve to prevent entanglement of ulnar nerve sheath.

B] Timing of surgery Emergency v/s Elective
Traditionally supracondylar fractures have been treated as emergency cases. The delay in management of supracondylar fracture may be because of delay in presentation of patient to the hospital or delay after the patient pesents to the hospital. If the patient presents in the morning hours the emergency management is not an issue but when the patient presents to hospital the emergency management poses issues of availability of senor consultant, anaesthesia risk, support staff and cost. The main concerns associated with delayed treatment are as follows:
1. the failure of closed reduction due to swelling
2. the need to convert to open reduction
3. the complications of neurovascular compromise and compartment syndrome.
One study found that children who underwent later surgery after injury (more than 8 h) were more likely to require an open reduction as compared with those who underwent earlier surgery after injury (8 h or less)[3], whereas other studies found no such statistically significant association [4,5]. One of the issues in the management of displaced supracondylar fracture is to manage the patient as emergency or do the surgery the next morning on a routine list. We have again explored recent literature to show some guidelines for treating orthopedic surgeons on this issue.

1. A systematic review of early versus delayed treatment for type III supracondylar humeral fractures in children [11].

Salient features
-Using medline and Cochrane database 156 publications were scrutinized. Only 7 studies were identified were the effect of early versus delayed treatment were studied. Treatment given in all of them was closed reduction and percutaneous pinning. All the studies were non-randomized and retrospective.
-The authers concluded that chances of failure of closed reduction and conversion to open reduction were significantly high if surgery was delayed beyond 12 hours.

2. Delayed surgery in displaced paediatric supracondylar fractures: a safe approach? Results from a large UK tertiary paediatric trauma centre [12].

Salient features
-Authors reviewed charts of patients :115 children into those treated before 12 h (early surgery) and after 12 h (delayed surgery) .
-The results indicate that delayed surgery appears to offer a safe management approach in the treatment of displaced supracondylar fractures, but it is important that cases are carefully evaluated on an individual basis

3. Operative Treatment of Type II Supracondylar Humerus Fractures: Does Time to Surgery Affect Complications? [13]

Salient Features
-Retrospective review of a consecutive series of 399 modified Gartland type II supracondylar fractures treated operatively at a tertiary referral center over 4 years. A total of 48% were pinned within 24 hours, 52% pinned >24 hours after the injury.
-Delay in surgery did not result in an increased rate of major complications following closed reduction and percutaneous pinning of type II supracondylar humerus fractures in children.

4. Management of Pediatric Type III Supracondylar Humerus Fractures in the United States: Results of a National Survey of Pediatric Orthopaedic Surgeons [10].

Salient features
-An overwhelming majority of respondent to the survey (81%) noted that they do not treat type III supracondylar humerus fractures on an emergent basis if they present after normal work hours, assuming the patient has no obvious reason for emergent intervention, such as, impending compartment syndrome, open injury, vascular injury, or skin compromise
-NPO status and aspiration risk is a concern during emergency surgery. This is a complication that can potentially be avoided with delayed treatment.
– Some respondents treated these on an emergent basis if the fracture is severely displaced or that reduction has seemed more difficult as swelling increases. Other participants cite the lack of OR time the following morning as a reason to fix some of these fractures after normal work hours.
-However, the majority of respondents felt like delayed surgical fixation in this setting was appropriate.

Authors Comments and recommendations
1. We feel that every displaced supracondylar fracture is different and need to have different strategy
2. A displaced supracondylar fracture should be splinted in 60 flexion in an above elbow slab and note be made of neurovascular status, swelling, compartment syndrome, open injury, pucker sign, medial spike
3. Most who present in routine hours get fixed in routine list
4. Those who present in after routine hours are classified into two types
a. Those who can wait till next day
1. Those not fitting into emergency fixation check list
2. Those Presenting after 48 hours where delay of few hours will not make a difference
b. Those who need to be fixed immediately
1. Open injury
2. Compartment syndrome or impending compartment syndrome or even suspicion of compartment syndrome
3. Nerve palsy
4. Pulseles hand pink or pale
5. Difficult reductions due to swelling medial spike puckering etc as the difficulty will increase with increasing time
5. In borderline cases or when doubt exists the case is operated as emergency in presence of senior consultant
6. Even in emergency situation make sure that facilities for open reduction if required are available.

C] Radiation Exposure – What is the risk?

The use of fluoroscopy facilitates the accurate placement of K wires while fixing supracondylar fractures. One negative side effect of fluoroscopic imaging, however, is ionizing radiation. It is a practice to use image intensifier in inverted fashion while doing CRPP for SCFH in children. The issue is what are the factors affecting direct beam and scattered radiation exposure and how to minimize this.

1. The Effect of C-Arm Position on Radiation Exposure During Fixation of Pediatric Supracondylar Fractures of the Humerus [14].

Salient features
-There is a concern that using image intensifier as operating table during surgery may lead to increased radiation exposure to the patient and to the surgeon. This study was done to determine radiation exposure from c-arm configurations.
-It was noted that there was 16% less scatter at waist level but 54% more scatter at the neck level when using c arm as operating table as compared to using an arm board.
-Although the statiscal difference was significant between the 2, yet neither of the 2 was safe.

2. Direct Beam Radiation Exposure to Surgeons During Pinning of Supracondylar Humerus Fractures: Does C-Arm Position and the Attending Surgeon Matter?

3842 fluoroscopic still images from 78 closed reduction and percutaneous pinning surgeries for supracondylar humerus fractures performed or supervised by 6 attending surgeons. The percentage of images containing a surgeon’s body was calculated as an indicator of direct beam radiation exposure. Total fluoroscopy time, C-arm position (standard or inverted), and whether the primary surgeon was an attending, resident, or both were recorded.
-They noted that fluoroscopy was significantly longer and surgeon’s exposure to direct beam radiation higher when the C-arm position was inverted when compared with the standard position.

Authors Comments and recommendations
1. Direct exposure delivers approximately 100 times more ionizing radiation to the surgeon compared with scatter radiation.
2. Standard radiation dosimeter badges are worn on the neck and waist of surgeons, which measure only scatter radiation unless the fluoroscopy beam directly hits the badge.
3. The surgeons’ hands are the most exposed part of the body during surgery, with the fingertips and the dominant index finger being at greatest risk.
4. Suggestions for minimizing the radiation exposure to both the patient and the surgeon.
a. Use of protective lead aprons, thyroid seals, leadlined eyeglasses, and lead-lined gloves.
b. Lead-lined gloves, however, may produce a false sense of security by providing little additional protection.
c. Being close to the radiation source side of the platform and reducing the fluoroscopy time is shorter.
d. Using a laser light guidance beam with the conventional C-arm.

D] Other issues

1. Can CRPP for supracondylar fractures be considered as being a day care procedure?
Answer : Yes. Provided fracfture is not open or associated with a neuro-vascular injury [16].

2. Does the Pin Size influence the stability of supracondylar fixation
Answer – Large pin sizes improved radiographic sagittal alignment at final follow-up without an increased rate of infection or ulnar nerve palsy. The commonly used 1.6-mm K-wire may be considered a “large” pin if used in a young or small patient, but also could be considered a “small” pin if used in an older or larger individual. The pin diameter should be similar to the thickness of the midshaft cortex. At the time of fracture reduction, the ratio of the diameter of the pin to the patient’s humeral midshaft cortical thickness can quickly and easily be determined by placing the pin over the arm during fluoroscopy. For a “large” pin, the ratio should be atleast 1 [17,18]

3. How long does it take for children supracondylar fractures to regain full range of motion after closed pinning?
Answer: By 6 weeks children gain 72% of elbow ROM of contralateral elbow and by 52 weeks 98% of elbow ROM of contralateral elbow [19].


References

1. Lee KM, Chung CY, Gwon DK, Sung KH, Kim TW, Choi IH, Cho TJ, Yoo WJ, Park MS. Medial and lateral crossed pinning versus lateral pinning for supracondylar fractures of the humerus in children: decision analysis. J Pediatr Orthop. 2012 Mar;32(2):131-8.
2. Zhao JG, Wang J, Zhang P. Is lateral pin fixation for displaced supracondylar fractures of the humerus better than crossed pins in children? Clin Orthop Relat Res. 2013 Sep;471(9):2942-53.
3. Woratanarat P, Angsanuntsukh C, Rattanasiri S, Attia J, Woratanarat T, Thakkinstian A. Meta-analysis of pinning in supracondylar fracture of the humerus in children. J Orthop Trauma. 2012 Jan;26(1):48-53.
4. Zamzam MM, Bakarman KA. Treatment of displaced supracondylar humeral fractures among children: crossed versus lateral pinning. Injury. 2009 Jun;40(6):625-30.
5. Krusche-Mandl I, Aldrian S, Köttstorfer J, Seis A, Thalhammer G, Egkher A. Crossed pinning in paediatric supracondylar humerus fractures: a retrospective cohort analysis. Int Orthop. 2012 Sep;36(9):1893-8.
6. Gottschalk HP, Sagoo D, Glaser D, Doan J, Edmonds EW, Schlechter J. Biomechanical analysis of pin placement for pediatric supracondylar humerus fractures: does starting point, pin size, and number matter? J Pediatr Orthop. 2012 Jul-Aug;32(5):445-51.
7. Gangadharan S, Rathinam B, Madhuri V. Radial nerve safety in Dorgan’s lateral cross-pinning of the supracondylar humeral fracture in children: a case report and cadaveric study. J Pediatr Orthop B. 2014 Nov;23(6):579-83.
8. Bloom T, Zhao C, Mehta A, Thakur U, Koerner J, Sabharwal S. Safe zone for superolateral entry pin into the distal humerus in children: an MRI analysis. Clin Orthop Relat Res. 2014 Dec;472(12):3779-88.
9. Balakumar B, Madhuri V. A retrospective analysis of loss of reduction in operated supracondylar humerus fractures. Indian J Orthop. 2012 Nov;46(6):690-7.
10. Carter CT, Bertrand SL, Cearley DM. Management of pediatric type III supracondylar humerus fractures in the United States: results of a national survey of pediatric orthopaedic surgeons. J Pediatr Orthop. 2013 Oct-Nov;33(7):750-4.
11. Loizou CL, Simillis C, Hutchinson JR. A systematic review of early versus delayed treatment for type III supracondylar humeral fractures in children. Injury. 2009 Mar;40(3):245-8.
12. Mayne AI, Perry DC, Bruce CE. Delayed surgery in displaced paediatric supracondylar fractures: a safe approach? Results from a large UK tertiary paediatric trauma centre. Eur J Orthop Surg Traumatol. 2014 Oct;24(7):1107-10.
13. Larson AN, Garg S, Weller A, Fletcher ND, Schiller JR, Kwon M, Browne R, Copley LA, Ho CA. Operative treatment of type II supracondylar humerus fractures: does time to surgery affect complications? J Pediatr Orthop. 2014 Jun;34(4):382-7.
14. Hsu RY, Lareau CR, Kim JS, Koruprolu S, Born CT, Schiller JR. The Effect of C-Arm Position on Radiation Exposure During Fixation of Pediatric Supracondylar Fractures of the Humerus. J Bone Joint Surg Am. 2014 Aug 6;96(15):e129.
15. Eismann EA, Wall EJ, Thomas EC, Little MA. Direct beam radiation exposure to surgeons during pinning of supracondylar humerus fractures: does C-arm position and the attending surgeon matter? J Pediatr Orthop. 2014 Mar;34(2):166-71.
16. Nayak AR, Natesh K, Bami M, Vinayak S. Is closed manipulative reduction and percutaneous Kirschner wiring of supracondylar humeral fracture in children as day-care surgery a safe procedure ? Malays Orthop J. 2013 Jul;7(2):1-5.
17. Srikumaran U, Tan EW, Erkula G, Leet AI, Ain MC, Sponseller PD. Pin size influences sagittal alignment in percutaneously pinned pediatric supracondylar humerus fractures. J Pediatr Orthop. 2010 Dec;30(8):792-8.
18. Srikumaran U, Tan EW, Belkoff SM, Marsland D, Ain MC, Leet AI, Sponseller PD, Tis JE. Enhanced biomechanical stiffness with large pins in the operative treatment of pediatric supracondylar humerus fractures. J Pediatr Orthop. 2012 Mar;32(2):201-5.
19. Zionts 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 Aug;467(8):2007-10.


How to Cite this Article: Nagda T, Dhamele J, Pishin C. Controversial Issues in Closed Reduction and percutaneous pinning of Supracondylar Fractures of Humerus in children. International Journal of Paediatric Orthopaedics July-Sep 2015;1(1):11-15.          

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Classifications of Supracondylar Humerus Fractures: Are they Relevant? Are we Missing Something?

Vol 1 | Issue 1 | July-Sep 2015 | page:6-10 | Mandar Agashe.


Authors : Mandar Agashe[1*].

[1] Director, Centre for Paediatric Orthopaedic Care (CPOC) at Dr. Agashe’s Hospital, Kurla, Maharashtra, India.

Address of Correspondence
Dr Mandar Agashe
Centre for Paediatric Orthopaedic Care (CPOC) at Dr. Agashe’s Hospital, Kurla, Mumbai, India.
Email: mandarortho@gmail.com


Abstract

 Classification systems are developed with focus on easy communication in research and academic discussion and also to have prognostic importance. Paediatric supracondylar fractures have been classified on basis of variety of criterias in fracture geometry, pattern of fractures etc. However it seems no single classification offers complete diagnostic and prognostic picture. This article attempts to provide overview of all the existing classifications of supracondylar fractures and tries to provide a clinical guidelines towards classifying the fractures.
Keywords: Supracondylar Humerus fracture, classification, management.


Introduction
Fractures of the supracondylar humerus constitute one of the most commonly encountered fractures in paediatric age group and are the most common fractures around the elbow [1,2,3]. They have also been historically associated with a number of complications. In fact, Gartland [4], in his seminal article in 1959, noted “the trepidation with which men, otherwise versed in the management of trauma, approach a fresh supracondylar fracture”. These fractures have been a topic of great amount of debate and discussion not just for the treatment modalities involved and these potential complications but also on the way these fractures need to be classified [5].  The first radiological classification of fracture supracondylar humerus could be attributed to Felsenreich in 19316 but the first (and probably the most) widely used classification was described by Gartland in 1959 [4]. The basic classification of supracondylar humerus fracture into extension (commonest- seen in 95-98% of times) and flexion type (seen in 3-5%) is not disputed. It is the internal classification of extension type supracondylar humerus fractures which has generated huge amount of controversy. In this article, we will be dealing primarily with the various classification systems for extension type supracondylar humerus fractures unless specified otherwise.

Incidence
As in any major fracture, it is the endeavor of the treating clinician to be able to classify the fracture with help of a classification system which is simple, reliable, reproducible and which can determine the protocol for management [7-10]. Though fractures of the supracondylar humerus have been studied by many authors, search is still on for a classification which fulfills all the criteria for widespread clinical as well as research use. The Gartland classification along with its Modified version is the main classification used in English speaking countries while the Lagrange and Rigault classification [11-12] is widely used in France and most French-speaking countries. Shortcomings in both these classifications led clinicians to develop different modifications as well as new classifications. Till date, as many as six to seven major classification systems exists which are used in various parts of the world, all of whom have their own positive and negative points [1,3,13,14].

Figure 1

Gartland/ Wilkins Modified Gartland’s classification
Gartland4 described his classification of extension type supracondylar fractures in 1959 according to degree of displacement into three types- Undisplaced, minimally displaced and displaced. However this classification was described to be too simplistic and as such was modified by K. Wilkins in 1984 (Fig 1) [5,15] with much more elaboration and explanation. In this classification, Type I fracture was undisplaced or minimally displaced such that the anterior humeral line passes through the centre of the ossification centre of the capitellum. Type II fracture had an obvious fracture line with displacement of the distal fragment. The anterior humeral line passes anterior to the capitellum. The anterior cortex is disrupted but the posterior cortex is still intact. The direction of displacement may be directly posteriorly or angulated medially or laterally and there may be a rotatory component. Type III fractures are those which are significantly displaced with no cortical contact with either posteromedial or posterolateral displacement. For ease of understanding, Wilkins also subclassified type II and III fractures into A (without rotation) and B (with rotation). A general protocol for management was put forth by Gartland according to the types with Type I fractures being immobilized with a long arm cast in about 75-80o of flexion. Type II and stable type III fractures were treated with manipulative reduction under anaesthesia and long arm cast while unstable type III fractures were treated with skeletal traction through the olecrenon with the elbow in extension (k-wire fixation was not the standard or care at that time). Since the concept of “stability” as described by Gartland was very vague, Wilkins described the component of rotation in the decision making process. He said that Type II fractures without rotation (Type IIA) required only manipulative reduction and long arm cast, while those with rotation (type IIB) required closed reduction and k-wire fixation and as such need to be dealt with like type II injuries. A modification of the Wilkins classification was described by Leitch et al in 2006 where multi-directionally unstable fracture was described as type IV(Fig 2) [16,17]. This type of fracture is unstable in both flexion and extension and is a high energy injury which results in circumferential loss of the periosteal hinge which helps in maintaining reduction in type II and III injuries. The treatment of these type IV injuries is very challenging and various authors have recommended their own modifications of k-wiring techniques for the same. The Wilkins modification of the Gartland classification though very simple and elegant, was not universally accepted due to problems with its reliability and reproducibility especially in type II and type IIIA injuries. There have been many studies describing the inter- and intra-observer variability of the modified Gartland classification. Heal et al [18] in their article found poor interobserver reliability in type I and only fair to moderate reliability in type II injuries. As expected, type III and flexion type injuries had good to very good inter-observer reliability. Another study by Barton et al [19] showed moderate to good inter- as well as intra-observer reliability though they said that 10% of the time, the second reading by the same person is different and they concluded that “this makes treatment recommendations based on only fracture types imprecise.” These studies led to the search for newer and better classifications which do not have the disadvantages of the modified Gartland’s classification while still retaining its simplicity.

Figure 2

Lagrange and Rigault classification
Lagrange and Rigault [11] described this classification in 1962 and since then it has become the most widely used classification system in France and other French speaking countries (Fig 3). It has divided extension type supracondylar humerus fractures into 5 types- Type I- undisplaced fractures involving primarily the anterior cortex of the humerus. Type II are fractures which involve both the cortices but with little or no displacement. Type III fractures are displaced fractures but in which there is some contact between the proximal and distal fragments. Type IV fractures are severely displaced with no contact between the proximal and distal fragments. The last type, type V fractures are basically meta-diaphyseal fractures (high supracondylar fractures) which are quite unstable. Since the Lagrange and Rigault system is used in only a few countries, there have been very scanty literature about the reliability and reproducibility of this system. De Gheldere et al in 2010 [12], discussed about the reproducibility of the classification and found good inter- and intra-observer reliability, though in the similar range of the Gartland classification. So what is the need for these two classifications and what is the difference between the two? Most clinicians feel that type I Gartland is the same as Legrange I and type III Gartland is the same as type IV Legrange. The types II and III of Legrange classification are similar to type II of the Gartland in some cases and type I and type III in some cases and that has in fact added to the confusion in classifying and treating these injuries.

Figure 3

AO displacement based validated classification
Looking at the shortcomings of the two main classification systems, the AO group put forth a classification system in continuity with the AO paediatric long bone fracture classfication which was being developed (Fig 4). They planned to design a simple but clinically relevant system which is standardised , validated and reproducible. Lutz et al [13] with a group of six experienced paediatric orthopaedic surgeons at five different centres validated this method and put forth their findings in their article in 2011. According to Lutz et al, they got good to very good diagnostic accuracies as well as reliability with this classification. The feature of this classification was that there was some importance given to the AP view also as against the Gartland classification where most of the stress was on the lateral view. The classification is as follows:
Grade I: Incomplete fractures: Here the Rogers (anterior humeral line) Line was intersecting the capitellum and there is not more than 2 mm of varus valgus angulation on the AP view.
Grade II: Incomplete fracture but with angulation: This corresponds to the type II injury of the Gartland’s classification but with more elaboration. Here the Rogers line fall anterior to the capitellum. The size of the capitellum is defined by drawing a circle with the diameter equal to the shaft of the humerus and placing that circle over the capitellum. There is also more than 2 mm of varus-valgus angulation on the AP view.
Grade III: Complete fractures: There is no bony continuity but still some contact between the fracture fractures irrespective of the type of displacement.
Grade IV: Complete fractures: There is no bony continuity and absolutely no contact between the fractured fragments. There is significant bony shortening and overlapping of fragments.
This classification system was extensively evaluated by a group of experienced paediatric orthopaedic surgeons and found to have excellent inter- and intra-observer reliability. The addition of grade III also seems to have precluded one of the main concerns about the Wilkins-Gartland classification, which was that there are some fractures which are more displaced than grade II fractures but less displaced than grade III fractures.The AO classification definitely goes a long way in making a standardized reliable and relatively easy to use system for supracondylar humerus fractures. However it still has some shortcomings. The most important is probably those fractures which are grossly rotated, which appear less displaced than conventional type IV (according to AO classification) and as such are classified as type III in the AO classification. These fractures are sometimes even more difficult to reduce than severely displaced type IV fractures. Hence to classify them as lower than type IV fractures may be fallacious. The other issue is that there are some characteristics about each fracture pattern which are much more important than just simple types or grades of fractures in deciding the prognosis of that particular pattern. Characteristics like coronal and sagittal plane angulation, obliquity of the fracture and level of the fracture are very important and as such have been proved to have a definite impact on the eventual healing of the fracture. With such a view in mind, an excellent classification has been put forth by Bahk et al [3] which elucidates these points.

Figure 4 final

The “pattern-based” classification: (Bahk et al)[3]
Bahk et al in 2008[3], retrospectively evaluated more than 200 cases of various patterns of supracondylar humerus fractures and classified them according to their fracture patterns (Fig 5). Accordingly four coronal plane patterns (typical transverse, medial oblique, lateral oblique and high fractures) and 2 sagittal patterns (low sagittal and high sagittal) were described. With the help of these patterns, it becomes very easy for the practicing clinician to understand the severity of injury, the possibility of communition, the chance of complications like rotational mal-alignment and extension mal-union. Medial and lateral obliquity of the fracture also helps to decide on the pin configuration as a medial oblique fracture is amenable to medial pinning while lateral obliques and transverse fractures are very stable with lateral-only pinning. High supracondylar fractures require medial and lateral cross pinning. The authors also have quantified the obliquity of the fracture planes on coronal and sagittal views and have said that coronal obliquity of more than 10o and sagittal plane obliquity of more than 20o are associated with more complications. Hence any fracture which falls beyond 10o coronal and 10o sagittal obliquity needs additional stability in the form of a third pin or cross pins. This fracture was relatively easy to use, simple and was found to have excellent reliability in inter- and intra-observer studies.

Figure 5 final

Further imaging and future trends
The basic fallacy of most of the current classification systems for supracondylar humerus is the difficulty in getting a proper true AP and Lateral view in a child in tremendous amount of pain. There is always some component of rotation which precludes taking a proper Lateral view and hence any classification which is based only on plain radiographs is theoretically likely to be prone for errors. Hence, some authors have endeavored to evaluate these fractures by multi-slice CT scan. According to Douira- Khomsi et al, the 3-D spiral CT scan gives a much better understanding of the fracture patterns including the rotational component which may be missed on the plain radiograph. This method enabled them to describe 3 different types of partially displaced supracondylar humerus fractures- sub-type I- only the anterior cortices of the 2 columns are completely fractured, sub-type II- fracture of the anterior two and one posterior cortex of the medial cortex and type III- three cortices are fractured with the posterior cortex of the lateral column being involved. However, the authors of this article are quite clear that this classification is still not completely validated and needs to be confirmed on further studies with a larger set of patients as well as more number of investigators in order to test its inter-observer reliability. This method, with the easier availability of CT scans as well as the faster process of performing a CT, certainly has a promise for the future and may result in a simple, accurate and 3-dimensional classification which may find general acceptance.

Conclusion
Thus to conclude, in spite of being so common, fracture of the supracondylar humerus still remains one of the most difficult fractures to accurately and reliably classify, with the resultant difficulty in standardization of care. The Wilkins modification of the Gartland classification still remains the most commonly used classification worldwide though concerns have been raised about its reliability and accuracy. The AO classification and the Bahk’s pattern based classification have improved our understanding of the fracture patterns and are also helpful in deciding the management of these injuries. Other classifications like the Lagrange and Rigault classifications are used in some parts of the world with limited success. Inspite of these classification, the perfect, completely accurate, reliable and easy to use classification still remains elusive.


References

1. Lee BJ, Lee SR, Kim ST, Park WS, Kim TH, Park KH, Radiographic outcomes after treatment of pediatric supracondylar humerus fractures using a treatment-based classification system. J Orthop Trauma. 2011 Jan;25(1).
2. Minkowitz B, Busch MT. Supracondylar humerus fractures. Current trends and controversies. Orthop Clin North Am. 1994 Oct;25(4):581-94.
3. Bahk MS, Srikumaran U, Ain MC, Erkula G, Leet AI, Sargent MC, Sponseller PD. Patterns of pediatric supracondylar humerus fractures. J Pediatr Orthop. 2008 Jul-Aug;28(5):493-9.
4. Gartland JJ. Management of supracondylar fractures of the humerus in children. Surg Gynecol Obstet. 1959 Aug;109(2):145-54.
5. Wilkins KE. Supracondylar fractures of the distal humerus. In: Rockwood CA Jr, Wilkins KE, Beaty JH , eds. Fractures in Children. 4th Ed.
6. Felsenreich F. Kindliche supracondylaive fracturen und posttraumatisch deformotaten des ellenbogen gelenhes [in German]. Arch Orthop Unfall-Chir 1931;29:555–9.
7. Garbuz DS, Masri BA, Esdaile J, Duncan CP. Classification systems in orthopaedics. J Am Acad Orthop Surg. 2002 Jul-Aug;10(4):290-7. Review.
8. Audigé L, Bhandari M, Kellam J. How reliable are reliability studies of fracture classifications? A systematic review of their methodologies. Acta Orthop Scand. 2004 Apr;75(2):184-94. Review
9. Burstein AH. Fracture classification systems: do they work and are they useful? J Bone Joint Surg Am. 1993 Dec;75(12):1743-4.
10. Slongo T, Audigé L, Schlickewei W, Clavert JM, Hunter J; International Association for Pediatric Traumatology. Development and validation of the AO pediatric comprehensive classification of long bone fractures by the Pediatric Expert Group of the AO Foundation in collaboration with AO Clinical Investigation and Documentation and the International Association for Pediatric Traumatology. J Pediatr Orthop. 2006 Jan-Feb;26(1):43-9.
11. Martin JS, Marsh JL. Current classification of fractures. Rationale and utility. Radiol Clin North Am. 1997 May;35(3):491-506.
12. Lagrange J, Rigault P. [Treatment of supra-condylar fractures of the humerus in children]. Presse Med. 1970 Dec 12;78(53):2382. French.
13. de Gheldere A, Legname M, Leyder M, Mezzadri G, Docquier PL, Lascombes P. Reliability of the Lagrange and Rigault classification system of supracondylar humerus extension fractures in children. Orthop Traumatol Surg Res. 2010 Oct;96(6):652-5.
14. Lutz N, Audigé L, Schmittenbecher P, Clavert JM, Frick S, Slongo T. Diagnostic algorithm for a validated displacement grading of pediatric supracondylar fractures. J Pediatr Orthop. 2011 Mar;31(2):117-23.
15. Douira-Khomsi W, Smida M, Louati H, Jlalia Z, Ghachem MB, Bellagha I. Multi slice computed tomography approach in the assessment of supracondylar humeral fractures in children Acta Orthop Belg. 2012 Aug;78(4):458-64.
16. Wilkins KE. Fractures and dislocations of the elbow region. In: Rockwood CA Jr, Wilkins KE, King RE, eds. Fractures in Children. Vol 3, 4th ed. Philadelphia: Lippincott-Raven, 1996: 680-1.
17. 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 Joint Surg Am. 2006 May;88(5):980-5
18. Silva M, Cooper SD, Cha A. The Outcome of Surgical Treatment of Multidirectionally Unstable (Type IV) PediatricSupracondylar Humerus Fractures. J Pediatr Orthop. 2014 Nov 6. [Epub ahead of print.
19. Heal J, Bould M, Livingstone J, Blewitt N, Blom AW. Reproducibility of the Gartland classification for supracondylar humeral fractures in children. J Orthop Surg (Hong Kong). 2007 Apr;15(1):12-4.
20. Barton KL, Kaminsky CK, Green DW, Shean CJ, Kautz SM, Skaggs DL. Reliability of a modified Gartland classification of supracondylar humerus fractures. J Pediatr Orthop. 2001 Jan-Feb;21(1):27-30.


How to Cite this Article: Agashe M. Classifications of supracondylar humerus fractures: Are they relevant? Are we missing something?.  International Journal of Paediatric Orthopaedics July-Sep 2015;1(1):6-10.

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Delayed presentation of SC fractures – Open Reduce now or accept for Future Osteotomy

Vol 1 | Issue 1 | July-Sep 2015 | page:23-25 | Premal Naik, Hitesh Chauhan.


Authors : Premal Naik[1*], Hitesh Chauhan[1].

[1] Rainbow Superspeciality hospital & Children’s Orthopaedic Centre, Ahmedabad, Gujarat, India.

Address of Correspondence
Dr Premal Naik
Rainbow Superspeciality hospital & Children’s Orthopaedic Centre, Ahmedabad, Gujarat, India.
Email: premalnaik@gmail.com


Abstract

Background: Delayed presentations of paediatric supracondylar humerus fractures presents a unique situation. The decision between conservative management, closed reduction and fixation and open reduction are to be weighed against malunion and correction at later date. The existing literature talks about delay in terms of hours or days, however we in our country see patients presenting weeks later after injury. There are no clear existing guidelines for such delayed presentation and decision making is multifactorial depending on age, amount of displacement, degree of union and days of delay. In this review we have presented the various available treatment modality and a treatment algorithm for management of delayed presentation of paediatric supracondylar humerus fracture.
Keywords: Supracondylar Humerus fracture, delayed presentation, management.


Introduction
In our practice we still encounter patients with supracondylar fracture of distal Humerus presenting late, though recently the number is drastically reducing. Late presentation is considered when there is delay in presentation of more than 2 days after injury[1, 2]. The reasons of delay could be due to lack of awareness and initial treatment by bone-setters, injury in areas remote from health facilities. Sometimes primary centers (not well equipped) tend to shift patients with excessive swelling and associated neurovascular problems to higher centers leading to further delay in final treatment.  Treatment of late cases has higher chances of perioperative and postoperative complications like iatrogenic nerve injury, Volkmann’s ischemic contracture, cubitus varus, elbow stiffness and myositis ossificans [3-5]. There remains a dilemma while managing late cases, whether to treat it as fresh supracondylar fracture or to allow it to mal-unite and consider for corrective surgery at later stage. Unfortunately in literature there are no clear guide lines or consensus regarding management of delayed presentation of supracondylar fractures.

Literature review
In delayed presentation cases up to 2 weeks we can adopt one of the following treatment modalities
1. Gradual reduction of fracture with traction (skin traction or skeletal)
2. Skeletal traction followed by percutaneous fixation
3. Trial of gentle manipulation and percutaneous fixation
4. Open reduction and internal fixation
In cases presenting three weeks after injury gradual reduction with traction is mostly not helpful. In such cases open reduction becomes technically difficulty because of difficulty in delineating uniting fracture fragments and need for greater soft tissue dissection. Hence it is imperative to allow fracture to unite and perform secondary corrective osteotomy at later stage (if required) after remodeling stage. Devnani et. al [6] in their series of 28 children with average delay in presentation of 5.6 days (2 to 21 days) advocated gradual fracture reduction with traction. Average hospital stay for treatment was 14 days (12 – 18 days) and 71% patients had good results according to Flynn criteria [7]. No patient had treatment related neurological injuries or new bone formation. They observed that overall functional outcome was better in patients presenting within 7 days of injury.
Agus et al [8] reported 13 patients with delay of more than 1 day and extensive swelling. Patients were treated with skeletal traction till satisfactory healing of skin and soft tissue, followed by percutaneous pinning. In his series average hospitalization was 7 days, 85% patient had excellent functional outcome and 77% had excellent cosmetic outcome. Tiwari et al [9] in their series of 40 patients presenting within 7 days, could successfully reduce 25 fractures by gentle closed manipulation under image intensifier and stabilize percutaneously. They advocated open reduction using mediolateral (posterior triceps sparing) approach in patients presenting after 7 days.  Lal and Bhan [10] in their series of 20 patients with a delay of 11 – 17 days , performed open reduction by posterior approach after primary immobilization in Thomas splint and healing of skin and soft tissue oedema. They performed V-Y plasty of triceps in all cases for improvement of flexion. All patients had unsatisfactory functional recovery according Mitchell’s and Adam’s criteria [11]. In their series 35% patients had cubitus varus deformity and 85 % patient developed myositis ossificans. Abdullah Eren[12] in their series of 31 patient with an average delay of 6 days (2- 19 days) performed open reduction by medial approach and cross K-wire fixation. All patients had full functional recovery at 5 months. They reported 6.5% pin tract infection and 22.5 % of cubitus varus. Tahir et al [13] performed open reduction by Kocher’s incision in 40 patients with an average delay of 5 days. List of complication in this series included myositis ossificans and restricted elbow movements in 5% and pin tract infection in 6.5 %. Most of patients (95%) achieved full range of motion.
Yildirim et al [14] in their prospective study of 190 patients on timing of surgical treatment of type III supracondylar humerus fracture showed that open surgery was inevitable after a delay of 32 hours after injury.

Discussion
Surgeons tend to choose modalities of treatment depending on expertise level, type of set up and patient factors (time of presentation, amount of swelling, neurovascular injury, ipsilateral injury).
Conservative treatment:This modality would be considered when resources are not adequate or patient condition precludes more aggressive treatment. One can choose between skin traction and skeletal traction to maintain reduction. For skeletal traction pin is passed through the olecranon.
Advantages of gradual reduction by traction
1.Traction allows simultaneous healing of soft tissues along with reduction of fracture
2. Chances of iatrogenic neurovascular injury are remote
3. Many authors have reported Incidence of cubitus varus to be comparable to other method with traction [6, 15]
4.Technically easy and can be performed at small centers
Disadvantages of gradual reduction 1. Prolonged hospital stay with cumbersome nursing care
2. Patient presenting late (more than 7 days) tend to have inferior results [6]

Operative treatment: In fully equipped set up with good patient parameters and experienced surgical team, operative treatment is commonly chosen.
Advantages of open reduction and internal fixation are:-
1. Accurate reduction, appropriate fixation and early mobilization
2. Lesser hospital stay
Disadvantages are –
1. Technically demanding procedure and requires experienced surgeon
2. Higher chances of myositis ossificans due to soft tissue stripping and iatrogenic nerve injury.

Chart 1

Authors preferred treatment
In patients presenting within 2 weeks and if skin condition permits, we prefer trial of gentle manipulation and reduction under anesthesia. If satisfactory reduction is achieved then fracture is stabilized with percutaneous K wire fixation (Illustrative case 1).
At the same stage if satisfactorily reduction is not achieved, we proceed for open reduction. We use anteromedial or anterolateral approach depending on direction prominent spike of proximal fragment (if proximal fragment has medial spike we use anteromedial approach and with lateral spike anteriolateral) (Case 2).
We prefer shortening of proximal fragment to achieve easy and accurate reduction over performing extensive soft tissue dissection.
In patients presenting after 3 weeks we prefer to accept union in malposition and consider for corrective osteotomy at later date.
Illustrative cases
Case 1:- 1 year old female, sustained injury in right arm while playing. Primarily she was treated conservatively with above elbow slab (Fig. 1). She presented to us 15 days post injury, with progressive medial collapse Successful reduction was obtained after gentle manipulation under anaesthesia and fixation was done with lateral wires.

Figure 1
Case 2 – 7 year, Male with RTA, sustained injury in left upper limb which was primarily treated elsewhere with above elbow slab. He presented to us two weeks after injury. He had ipsilateral distal radial physeal injury and type 3 supracondylar fracture (Fig. 2). After failed gentle attempt of closed reduction, open reduction was planned by anterolateral approach (as proximal spike was protruding laterally). Due to severe soft tissue contracture reduction of fracture was not possible as length could not be achieved. Instead of aggressive soft tissue dissection, shortening of proximal fragment was performed, translation was accepted and fracture was fixed with K wires.

Figure 2


References

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How to Cite this Article: Naik P, Chauhan H. Delayed presentation of SC fractures – Open Reduce now or Accept for Future Osteotomy. International Journal of Paediatric Orthopaedics July-Sep 2015;1(1):23-25.         

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