Research Article
The Treatment of Pediatric Supracondylar Humerus Fractures: Experience in a Tertiary Medical Center in a Rural State
Karnes JM and Lubicky JP*
Department of Orthopaedics, West Virginia University, USA
*Corresponding author: John P. Lubicky, Department of Orthopaedics, West Virginia University, P.O. Box 9196, Morgantown, WV 26506-9196
Published: 15 Aug, 2016
Cite this article as: Karnes JM, Lubicky JP. The Treatment of Pediatric Supracondylar Humerus Fractures: Experience in a Tertiary Medical Center in a Rural State. Clin Surg. 2016; 1: 1082.
Abstract
Background: In our rural state, most children with supracondylar humerus fractures (SCFs) are referred to our tertiary care medical center. Over a 4+ year period, the one pediatric orthopaedic
surgeon in the state surgically treated more than 200 SCFs using a standard protocol. Closed
Reduction (CR) and percutaneous pinning was attempted in all cases. Open Reduction and
Percutaneous Pinning (OR/PP) was required in some. The purpose of this study was to review one
surgeon’s experience with the surgical treatment of SCF with a focus on fracture type and pattern
and the need for open reduction as well as the incidence of nerve injuries.
Methods: Institutional Review Board approval for a retrospective chart review was attained and
medical records of pediatric patients treated at our institution between 01/2010 and 09/2014 were
reviewed. Current Procedural Terminology codes 24538, 24545, and 24546 were used to identify
patients. Data were examined using summary statistics and Chi-square tests.
Results: Two hundred four patients were included in this study and 25 eventually required OR/
PP for definitive management. The following factors were not statistically associated with OR/PP:
fracture pattern, Gartland classification, laterality of extremity, or gender; however, age, presence
of neurological symptoms on initial evaluation, and energy of fracture etiology were significantly
associated. In 71 cases, a “U” shaped distal fragment was identified. The most common neurological
symptoms on initial presentation were anterior interosseous nerve palsy (n=10, 4.9%) and nondermatomal
paresthesias (n=5, 2.5%). Factors significantly associated with neurological symptoms
on initial presentation included: need for open reduction, medial-lateral pinning construct, Gartland
Type III injury, age, and “U-shaped” fracture pattern.
Conclusions: No identified fracture pattern was significantly associated with need for open
reduction; however, a previously undescribed “U-shaped” fracture pattern did have a significant
association with neurological symptoms. Patients most likely to require OR/PP for a SCF were
children over the age of five who presented with neurological symptoms on initial evaluation
and/or had a high-energy injury etiology. The main indication for OR/PP was failure to achieve
a satisfactory CR. Orthopaedic surgeons managing these fractures should have a low threshold to
transition to an open procedure in patients with these risk factors if closed fracture reduction cannot
be achieved expeditiously.
Level of Evidence: Level IV, case series
Keywords: Supracondylar fracture; Open reduction
Introduction
Supracondylar humerus fractures (SCFs) are common injuries in pediatric populations, especially in the 0-3 and 4-7 year old age groups [1]. Treatment for this injury is guided by the stability and displacement of the opposing fracture fragments. Nearly all patients with Gartland Type II and all Type III injuries require operative intervention to maintain a stable reduction. Closed Reduction with Percutaneous Pinning (CR/PP) is the preferred method of surgical management as it minimizes operative morbidity and enhances functional recovery. However, many authors have recommended a low threshold to use Open Reduction with Percutaneous Pinning (OR/PP) if closed reduction maneuvers fail or vascular compromise is encountered [2-9]. Repeated closed reduction attempts can cause soft tissue trauma, vascular, nervous, and physeal injuries, and compartment syndrome [8,10]. OR/PP of SCFs has been established as a safe and reliable procedure. Identifying fracture patterns and types that are likely to fail closed reduction may facilitate safer and more efficient operative strategies [2,11-13]. In our rural state, most children with displaced supracondylar fractures are referred to our tertiary care medical center. During the period of this study, there was only one fellowship trained pediatric orthopaedic surgeon in the state. The primary purpose of this retrospective study was to report on that one surgeon’s experience in the surgical treatment of SCF over a 4+ year time period with a focus on the need for open reduction and to determine if a specific fracture pattern was more likely to require that intervention. We hypothesized that a posterior to anterior, downward sloping fracture pattern would be more likely to require OR/PP due to unstable fracture anatomy and fragment displacement due to muscle forces (Figure 1). We also wanted to evaluate the incidence of nerve injuries related to this injury and risk factors for these injuries.
Figure 1
Figure 2
Materials and Methods
Patients were identified using Current Procedural Terminology
(CPT) codes 24538, 24545, and 24546; all pediatric patients identified
using this search were included in the study. Medical records and
radiographs of all patients treated between 01/2010 and 09/2014 at
our academic institution were retrospectively reviewed. Inclusion
criteria were Gartland Type II and III non-pathologic SCFs in a
previously uninjured elbow in skeletally immature children. Surgical
management was provided under the direction of one experienced
pediatric orthopaedic surgeon using the same protocol for all patients.
Closed reduction was first attempted and OR/PP was reserved for cases
with evidence of vascular compromise or failed closed reduction. An
all-lateral pin construct was the preferred arrangement, but a mediallateral
construct was used when additional stability was required.
Data collected included age, gender, injury etiology, open or
closed fracture upon initial evaluation, side of injury, extension
or flexion pattern, Gartland classification, time between injury
and surgery, and presence of a nerve or vascular injury on initial
evaluation. Anterior-posterior and lateral radiographs were reviewed
by the authors and notable findings were recorded and discussed.
Treatment-related data collected included open or closed reduction
of the fracture, pin orientation, postoperative neurovascular injury,
and failure to achieve union. Data analysis consisted of descriptive
statistics and Chi-squared studies. Significance was set at p<0.05.
The primary outcomes assessed were the incidence of open
reduction and its relationship to fracture pattern and perioperative
neurological symptoms. Secondary outcome variables were
indications for open reduction, incidence of pre/postoperative
neurovascular injury, types and risks of nerve injury, and pinning
technique.
Table 1
Table 1
Fracture etiology for patients included in analysis. All-terrain vehicle (ATV), motor vehicle collision (MVC).
Table 2
Table 2
Nerve symptoms encountered on the initial, preoperative physical
examination. Anterior interosseous nerve (AIN), posterior interosseous nerve (PIN).
Results
Two hundred twenty-four patients were identified and 204 met
inclusion criteria and were entered into the study. Their charts and
radiographs were reviewed. The majority of injuries occurred in
females (114, 55.9%) and the average age was 5.5years (range 1 to 12)
(Figure 2). One hundred twenty-eight children (62.7%) injured their
left upper extremities with a fall being the most common etiology
(91.2%) (Table 1). One hundred eighty-five (90.7%) of the patients
were treated within 24 hours of injury, 13 (6.4%) had a delayed
presentation to our facility and subsequently underwent treatment
more than 24 hours after injury [the medical records of six (2.9%)
did not document the time of injury]. Two patients (0.9%) presented
with an open fracture, no patients had a documented vascular injury,
and 29 (14.2%) presented with paresthesia, anesthesia, or palsy on
initial examination of the affected extremity (Table 2). Of 29 patients
presenting with neurological symptoms, eight (27.6%) had a general
decrease in sensation to light touch or reported paresthesias that
resolved by discharge from the hospital. The remaining 21 (72.4%)
had more specific symptoms with the most common being an
Anterior Interosseous Nerve (AIN) palsy (ten patients, 48%), followed
by a radial nerve palsy (three patients, 14%), ulnar nerve paresthesia
(two patients, 10%), and median nerve paresthesia (two patients,
10%) (Table 2).
Review of initial radiographs demonstrated 91 (44.5%) Gartland
extension Type II injuries and 103 (50.5%) Type III injuries. Five
(2.5%) were flexion type injuries and five (2.5%) injuries did not
clearly meet the Gartland criteria. Seventy-one patients (34.8%)
demonstrated a “U-shaped” fracture pattern where the most proximal
portion of the distal humeral fragment was smoothly concave when
viewed in the anterior-posterior view (Figure 3) and ten patients
(4.9%) presented with a posterior to anterior sloping fracture. Of the
71 “U-shaped” fractures, 32 (45.1%) were posterolaterally displaced,
30 (42.3%) were posteromedially displaced, and nine (12.6%) were
displaced in a direct posterior direction.
All 204 patients included in this study underwent operative
management for their SCFs and 25 patients (12.3%) required open
reduction (OR) (Table 3). Patients with suspected vascular injury (n=3)
initially underwent successful closed reduction with percutaneous
pinning, but subsequently lost radial and ulnar pulses and developed
a pale, cool hand. In all cases, the pins were removed, the fracture site
was exposed, and the vessels were inspected. No vascular injury was
found in any case and all patients recovered without incident. Both
open fractures underwent OR. Of the 71 patients with a “U-shaped”
fracture pattern, 13 (18.3% of the “U-shaped” fracture types) needed
open reduction accounting for 52% of all open reductions. Statistical
associations between independent factors and incidence of open
reduction are demonstrated in Table 4 and 5. No specific fracture
pattern was associated statistically with need for OR/PP.
One hundred forty-two (69.6%) fractures achieved stable fixation
with an all-lateral pin construct, which was the preferred technique.
Fifty-eight (28.4%) required a medial and lateral pin configuration
and four (2%) had pins with supplementary hardware placed as an
all-lateral construct failed to provide adequate stability. Patients
requiring medial-lateral pin constructs had a higher incidence of
perioperative neurological symptoms (p<0.0001), a higher incidence
of open reduction (p=0.007), and were more likely to have a Gartland
Type III fracture (p<0.0001); this construct was more commonly
required in patients older than five years (p=0.007). Twenty patients
(9.8%) initially presented without any neurological symptoms but
reported having symptoms at either the immediate postoperative
examination or in a subsequent outpatient visit. The most common
complaint reported was ulnar nerve paresthesia (seven patients, 3.4%)
and ulnar nerve palsy (seven patients, 3.4%) (Table 6). However, all
neurologic symptoms had resolved or were continuing to resolve at
the last office visit and no patient had a permanent functional deficit
at the last follow-up.
Considering all 204 patients, the overall incidence of perioperative
nerve symptoms was 49 (24.0%), which included complaints that
resolved prior to discharge perhaps indicating that the incidence of
true nerve injury might be over-represented. Two patients (0.9%)
required open exploration for ulnar nerve palsy that failed to improve
with typical conservative treatment; both patients had “U-shaped”
fractures. In both cases, the nerves were in continuity but surrounded
by scar. When the 71 patients with the “U-shaped” fracture pattern
were analyzed separately, 26 (36.6% of the “U-shaped” fracture
population and 53.1% of all patients exhibiting neurological
symptoms) were found to exhibit perioperative neurological
symptoms. Also, perioperative neurological symptoms were more
commonly reported in patients with a Gartland Type III injury
(p<0.0001), in patients requiring open reduction (p<0.005), and in
patients five years and older (p<0.0001).
Figure 3
Figure 3
Example of “U-shaped” fracture pattern of the distal humeral
epiphysis with the anterior view. Seventy-one patients (34.8% of sample)
presented with this injury
Table 3
Table 4
Table 4
Factors significantly associated with open reduction as determined by
Chi-squared analysis. All-Terrain Vehicle (ATV), Motor Vehicle Collision (MVC).
Table 5
Table 5
Factors not significantly associated with open reduction as determined
by Chi-squared analysis.
Table 6
Table 6
Patients that reported neurological symptoms following surgery, but
did not report any symptoms prior to the procedure. Anterior interosseous nerve
(AIN), posterior interosseous nerve (PIN).
Discussion
This retrospective review evaluated 204 Gartland Type II and III
supracondylar humerus fractures that were treated with either CR/
PP or OR/PP between 01/2010 and 09/2014 by one surgeon at a single
academic institution. The reported incidence of open reduction for
supracondylar fractures varies widely in the literature from 2.6%
to 50% [3-7,14-23] and seems to be influenced by study selection
criteria. Our 12.3% incidence of open reduction compares similarly
to a recent case series from another academic tertiary referral center
[18]. Other studies that reported a markedly lower incidence of open
reduction were published nearly 20 years ago, which may reflect
changes in practitioner attitudes toward surgical management [14].
The operative management of Gartland Type II and III supracondylar
humerus fractures is well established, with most literature advocating
for OR/PP for failed closed reduction. Achieving bony apposition
must be accomplished with minimal compromise of the soft tissue
which can be disrupted with repeated reduction attempts [8,10].
Several authors have suggested that factors commonly associated
with open reduction can most easily be classified as either patient
specific, injury pattern, or treatment specific variables.
Patient specific
A previous case series reported that age is significantly associated
with open reduction (7.7 y/o vs. 5.9 y/o) [3]. Our results were similar;
the average age of a patient undergoing OR/PP was 6.3 y/o (vs.5.4
y/o for CR/PP) and children five years and older were more likely to
require OR/PP (p=0.007). It is our suspicion that age is a proxy variable
for soft tissue density surrounding the fracture site, which can limit
the ability to manipulate fracture fragments. Similar difficulties have
been described in obese patients with the same injuries [5,24] and
have been attributed to a decreased ability to manipulate the osseous
structures through the increased subcutaneous tissue thickness.
Injury pattern
Although we found that open reductions more commonly
occurred in Gartland Type III injuries, a result that is consistent
with other case series [5,8], data analysis determined that it was not
statistically significant; this finding could be related to the relatively
small number of open reduction cases. Nevertheless, it makes intuitive
sense as the degree of displacement and damage to the surrounding
soft tissue is a consequence of the energy of the traumatic injury and
fractures with greater displacement result in a greater likelihood
of soft tissue interposition within the fracture site. Structures such
as periosteum [13], brachialis or flexor-pronator muscle [16], or
median/ulnar/radial nerve [8,22] have been proposed to be the main
contributing factor for supracondylar fracture irreducibility as they
serve as a mechanical block to reduction. Furthermore, vascular
structures trapped within the fracture gap also commonly lead to
open reduction, not only due to preventing re-approximation of the
fracture fragments but, more importantly, for preservation of the
distal blood supply. In addition to preventing proper apposition of
the fracture fragments, the humeral metaphysis can “buttonhole”
through the brachialis, which physically restrains the fragments and
has been commonly associated with the need for open reduction
[8,13,22,25,26].
Reported fracture characteristics associated with a higher
incidence of open reduction can be classified into two categories,
transverse and comminuted fragments. Transverse fracture patterns
with bayonet apposition increase the risk of brachialis interposition
and oblique supracondylar fractures that extend proximal-lateral
to distal-medial were found to have a higher incidence of flexorpronator
entrapment [16]. The second group is comprised of patterns
that are mechanically unstable due to comminution, orientation of
the fracture lines along areas of the bone that resist loading [8,13,16],
and the thin bone of the distal humerus, which destabilizes the
reduction due to concentration of deforming forces across a small
surface area [7]. There is a discrepancy that emerges over the direction
of displacement and the incidence of open reduction as some results
suggest that posteromedial displacement has a higher association
with open reduction [8] and others suggest that posterolateral
displacement has a higher association with open reduction [16].
Treatment specific
Because our patient population is predominantly rural, patients
often present several days after injury. Of the 13 patients that were
evaluated more than 24 hours following injury, only one patient (7.7%)
required open reduction, compared to the 12.4% of 185 children that
were treated within 24 hours of injury representing 92% (23/25) of the
open reductions in this series. This finding is consistent with several
other series that found that the incidence of open reduction was not
higher in patients that were not immediately treated [6,17,18,27-30],
but conflicts with other series suggesting that delayed treatment leads
to a higher incidence of open reduction [5]. As the increased difficulty
in achieving reduction in the delayed setting is thought to be caused
by peri-fracture swelling of the surrounding tissue [31], patients that
were treated more than 24 hours following injury in our series may
very well have been beyond the period of peak swelling.
Complications
There were no compartment syndromes, pin tract infections,
wound healing complications, or loss of fixation without a traumatic
etiology (n=2). There were only three suspected vascular injuries that
were encountered after closed reduction of a fracture. Immediately
after discovering this clinical finding, the pins were removed and
the injury site was explored with no vessel injury found. Therefore,
no true vascular injury was encountered in this series. The most
commonly encountered complication was transient neurological
symptoms [n=49(24.0%) with symptoms present only on preoperative
examination and n=41(20.1%) with symptoms that were present
on both preoperative and postoperative examinations]. Patients
undergoing open reduction had a higher incidence of transient
neurological symptoms than patients receiving closed reduction
(52% vs. 20%).
The main limitation of this study is its retrospective design.
However, it documents the outcome of treatment by one pediatric
orthopaedic surgeon working in a single hospital with a consistent
treatment protocol for every patient. Therefore, there was no
variation in how these patients were managed. Another limitation
which has not been actively raised in other studies is the reliability
of the neurovascular examination in these young patients. Trying to
determine specific motor function, sensation, or even obtaining pulses
can be challenging in these scared children who are in pain. What
was found to be a postoperative deficit may have, infact, been present
preoperatively and was not detectable. Also, length of follow-up was
not standardized in terms of an absolute time period. Because of the
rural nature of the practice, many patients came from long distances
to the medical center. The parents often found it a hardship to return
for repeated follow-ups and therefore follow-up was terminated as
soon as issues were resolved or resolving. Obviously, more data may
have been available if standard follow-up periods had been followed.
Data from this retrospective review did not support our
hypothesis that a posterior to anterior sloping fracture would be
associated with a higher incidence of OR/PP. In fact, no patients that
demonstrated this pattern required it. To our knowledge, this report
is the first to describe a “U-shaped” supracondylar humerus fracture
that demonstrated a higher, although not statistically significant,
incidence of OR/PP as well as a statistically significant association
of OR/PP with neurological symptoms on initial presentation. If the
sample size were larger, we anticipate that a statistical association
between the “U-shaped” fracture pattern and open reduction would
be made.
In conclusion, no identified fracture pattern was significantly
associated with need for open reduction; however, a previously
undescribed “U-shaped” fracture pattern did have a significant
association with neurological symptoms. Patients most likely to
require OR/PP for a supracondylar humerus fracture were children
over the age of five who presented with neurological symptoms on
initial evaluation and/or had a high-energy injury etiology. The main
indication for open reduction/percutaneous pinning was failure
to achieve a satisfactory closed reduction. Orthopaedic surgeons
managing these fractures should have a low threshold to transition to
an open procedure in patients with these risk factors if closed fracture
reduction cannot be achieved expeditiously.
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