Extension-type Supracondylar Humerus Fractures Research Articles

Pulseless pink hand syndrome

Supracondylar humerus fracture is one of the most common elbow injuries in children, comprising 60% of all the elbow injuries in children. An elbow or forearm fracture should be suspected in a child with elbow pain or failure to use the upper extremity after a fall. The fracture typically occurs through the weak metaphyseal bone proximal to the fossae. A careful examination of the entire arm should be performed, and any area with tenderness or swelling should have radiograph as multiple fracture (such as supracondylar fracture and a radius/ulna fracture) are not uncommon. A thorough motor, sensory and vascular examinations should be performed, difficult in pediatric group but should be attempted and recorded accurately. Assessment of vascular status in supracondylar fracture of humerus is important as up to 20% of displaced fractures present with vascular compromise. Here we present a case report of 7-year-old girl who sustained extension type supracondylar humerus fracture with pulseless pink hand. Urgent manipulation was undertaken but it was unsuccessful, a posterior stab incision was taken to reduce the fracture fragments using bone spike. To our knowledge, there are various methods and flow charts regarding the treatment of the vascular compromise which accompany various associated risks and complications with no specific protocol.

Is the modified Gartland classification system important in deciding the need for operative management of supracondylar humerus fractures?

PurposeThis study examined levels of agreement between paediatric orthopaedic surgeons in the need for operative management of extension-type supracondylar humerus fractures.MethodsThis was the second phase of a two-part study. De-identified baseline anteroposterior and lateral elbow radiographs from 60 paediatric patients with extension-type supracondylar humerus fractures were compiled. After classifying each fracture according to Gartland classification guidelines, radiographs were randomized, and surgeons indicated whether they would use operative or non-operative management to treat each fracture. Kappa statistics using pairwise comparisons were calculated to determine agreement levels.ResultsIn total, 11 international surgeons participated, and 10/11 completed both survey rounds. The overall weighted interobserver agreement was moderate (0.530, 95%CI [0.215,0.854]) while overall weighted intraobserver agreement was substantial (0.740, 95%CI [0.513,0.963]). The largest variability in preferred treatment methods between surgeons was observed for type IIA fractures, with 6/11 preferring non-operative and 5/11 preferring operative management. The largest individual surgeon variability was observed for type IIA fractures, with 8/11 showing variability (defined by not having made the same decision for at least 90% of the cases) in choosing whether to operate.ConclusionsOur findings suggest moderate interobserver, and substantial intraobserver agreement in treatment decision making. The largest disagreements between surgeons were observed for type IIA and IIB fractures and treatment decisions did not follow expected trends based on surgeons’ preferred treatment methods for each fracture type. This suggests differences in treatment approaches between surgeons in the management of type IIA fractures and highlights the role of other variables that underlie differences between surgeons’ treatment preferences.Level of evidenceIII

The Reduction Maneuver for Pediatric Extension Type 3 Supracondylar Humerus Fractures.

Extension type supracondylar humerus fractures in children commonly displace in two directions: posteromedial and posterolateral. The traditional maneuver to reduce posteromedial displaced fractures utilizes pronation of the forearm, while the maneuver for posterolateral displaced fractures utilizes supination. Traditional teaching suggests that the periosteum is an aid to reduction. The purpose of this study is to take a second look at this periosteal hinge theory and reexamine the maneuver performed when reducing an extension type 3 supracondylar fracture. Sixty-nine consecutive displaced extension type 3 supracondylar fractures were studied. Intraoperative fluoroscopic radiographs were graded as posteromedial, posterolateral, or direct posterior displacement. All fractures were treated with closed reduction and percutaneous pinning. The best maneuver used to align the fracture during surgery was recorded in the operative note. The direction of displacement on radiographs was 32 (46.3%) posteromedial, 31 (45%) posterolateral, and six (8.7%) direct posterior. All of the 32 posteromedial displaced fractures were best aligned when pronation was utilized. All of the 31 posterolaterally displaced fractures were best aligned when supination was utilized. The six direct posteriorly displaced fractures obtained the best alignment in pronation. The current study reaffirms the classic teaching that the direction of displacement of the fracture indicates the site of the intact periosteum. The intact periosteal hinge can be used to obtain fracture reduction.

A two-stage retrospective analysis to determine the effect of entry point on higher exit of proximal pins in lateral pinning of supracondylar humerus fracture in children

BackgroundKirschner wire fixation remains to be the mainstream treatment modality in unstable or displaced supracondylar humerus fracture in children, with divergent lateral pins being the most preferred due to their sufficient stability and decreased risk of ulnar nerve injury. However, the entry point at which the proximal lateral pin can be inserted to achieve a more proximal exit and maximum divergence has not been reported. This study retrospectively analyzed the characteristics and factors influencing the entry and exit points of the proximal lateral pins.MethodsThe study was divided into two stages. In stage one, the entry and exit points of the proximal pins of lateral pinning configuration were analyzed from intra-operative radiographs of children treated for extension-type supracondylar humerus fractures. The coronal and sagittal pin angles formed by the proximal pins were also measured. Using the findings of stage one, we intentionally tried to achieve a more proximal exit with the proximal pins in stage two. Comparisons between groups of patients treated by random and intentional pinnings were done statistically.ResultsIn the first stage, 47 (29.2%) of the 161 proximal pins exited above the metaphyseal-diaphyseal junction (MDJ) region. Of these, 85.1% entered from lateral and posterior to the ossific nucleus of the capitellum (ONC). The pin angles averaged 58.4° and 90.5° in the coronal and sagittal planes respectively. In the second stage, 47 (65.3%) proximal pins in the intended group exited above the MDJ region, while only 32 (36%) in the random group exited above the MDJ region.ConclusionWhile aiming at the upper border of the distal MDJ during pinning, lateral pins can easily achieve a higher, proximal exit above the MDJ if inserted from lateral and posterior to the ONC and parallel to the humeral shaft in the sagittal plane. Higher exit can also be easily achieved in younger patients and patients fixated with smaller diameter pins.

Operative Time and Cost Vary by Surgeon: An Analysis of Supracondylar Humerus Fractures in Children.

Operative time is a critical driver of cost in orthopedics and an important target for improving value in health care. This study used an archetypal pediatric orthopedic procedure to identify surgeon-dependent variability in operative time. The authors reviewed patients 12 years or younger treated with closed reduction and percutaneous pinning for extension-type supracondylar humerus fractures. Variability in operative time across surgeons was assessed. Surgeon experience at the time of the procedure and case volume (quarterly) were evaluated to explain variations in operative time. A total of 1472 patients were reviewed (57% Gartland type II and 43% type III fractures). Procedures were performed by 12 fellowship-trained pediatric orthopedists with 2 weeks to 32.8 years of experience. For individual surgeons, the mean operative time ranged from 20.4 to 33.7 minutes for type II fractures and from 31.0 to 46.8 minutes for type III fractures. There was significant variation across surgeons in mean operative time and cost (P<.001). Analysis showed no significant effect of surgeon experience or quarterly case volume. Surgeons' mean operative time for type II fractures was strongly positively correlated with their mean operative time for type III fractures (r2=0.74). Mean operative time and cost for supracondylar humerus fracture closed reduction and percutaneous pinning vary significantly between surgeons, but this variation is not explained by experience or volume. Surgeons who required more time for type II fractures were also slower for type III fractures. Because of the high per minute cost of the operating room, surgeon variability significantly impacts cost. Identification and modification of sources of variation in surgeon behavior will allow for reduction in the cost of surgical care. [Orthopedics. 2019; 42(3):e317-e321.].

Percutaneous cross-pinning versus two lateral entry pinning in Gartland type III pediatric supracondylar humerus fractures

Background Supracondylar humerus fracture is the most common elbow fracture in children aged 5–7 years, affecting boys more than girls and the majority of fractures are of the extension type. These fractures are usually associated with a number of complications including neurovascular injuries, malunion, and elbow stiffness. Gartland type III fractures are usually treated by closed reduction and percutaneous pinning. Patients and methods A prospective study was carried out on children with Gartland type III extension-type supracondylar humerus fractures. The patients were randomized to undergo fixation either with crossed pinning (group A) or two lateral pinning (group B). We compared both groups with regard to their passive elbow range of motion, Flynn’s criteria, Baumann’s angle, change in Baumann’s angle, and Skaggs method of grading of loss of reduction and complications. Results Group A included 33 patients with a mean age of 5.4 years and group B included 34 patients with a mean age of 4.9 years. Group B had a statistically significant shorter operative time and radiation time. At final follow-up, there were no statistically significant differences between group A and group B with respect to the average Baumann’s angle, change in the Baumann angle, range of elbow motion, Flynn’s grade, or Skaggs criteria. There were no cases of iatrogenic ulnar nerve injury in both groups. Conclusion If a standardized operative technique is followed in each method, then the result of both methods will be same in terms of safety and efficacy. Orthopedic surgeons treating unstable pediatric supracondylar humerus fractures should be familiar with both pinning techniqus.

Perioperative Ketorolac for Supracondylar Humerus Fracture in Children Decreases Postoperative Pain, Opioid Usage, and Length of Stay

Royalty: Zimmer Biomet, Wolters Kluwer (Flynn) Perioperative administration of ketorolac in children undergoing closed reduction and percutaneous pinning for displaced supracondylar humerus fracture will lower pain scores, decrease opioid requirements, and permit earlier discharge from the hospital. This is a retrospective case-control investigation of children (aged 0–18 years) treated with closed reduction percutaneous pinning (CRPP) for closed, Gartland type III extension-type supracondylar humerus fractures at a single children's hospital between 2011 and 2017. Patients who received ketorolac perioperatively were randomly matched 1:2 by sex and age (±1 year) with patients who did not receive ketorolac. Elbow radiographs were reviewed to determine eligibility. Data abstraction included demographic and surgical details, length of stay, inpatient postoperative analgesic administration, pain ratings using the Wong-Baker FACES scale, and complications within 90 days. Differences between groups were compared with 2-tailed Mann-Whitney U and chi-square tests. 342 patients were included in the investigation including 114 patients who received ketorolac and 228 controls. Age (mean 6.2 ± 2.4 years) and sex ratio (M:F, 1.28:1) were equivalent between groups. There was also no difference in the operative time or total number of pins between groups. Mean pain rating at 0 to 29 minutes postoperatively was lower in the ketorolac group (0.7 ± 1.9) than in the control group (1.4 ± 2.6, P = .017). Mean pain rating at 30 to 120 minutes postoperatively was also lower in ketorolac group (1.1 ± 2.3) than the control group (1.7 ± 2.8, P = .036). Other pain ratings were not statistically different between groups (Figure 21-1). Patients in the ketorolac group received a lower number of inpatient oxycodone doses (1.0 ± 0.6) than did patients in the control group (1.2 ± 0.5, P = 0.003). Average postoperative morphine doses were not significantly different (0.5 ± 0.6 vs 0.6 ± 0.7, P = .137). Mean postoperative length of stay (LOS) was significantly longer for the control group (20.2 ± 11.2 hours) than the ketorolac group (13.5 ± 8.8 hours, P < .001). There was no difference in the 90-day complication rate between patients in the ketorolac group and the control group (P = .905). •There is a need for improved narcotic stewardship in orthopedic surgery.•The complementary administration of ketorolac reduces postoperative pain and opioid use in children with displaced supracondylar humerus fractures.•Ketorolac use reduces length of stay following CRPP for supracondylar humerus fractures and offers an opportunity for cost savings.

P127. Nerve ultrasound in children with ulnar neuropathy associated with supracondylar humerus fracture

Background Assessing nerve traumas in children is challenging. Electrodiagnostic studies are often not tolerated. We tested if ultrasound examination in children with recent supracondylar humerus fracture and ulnar nerve pathology was well tolerated and whether it was helpful in assessing the nerve trauma. Methods This is a retrospective analysis of all pediatric cases with recent supracondylar humerus fracture and persistent ulnar deficits presenting to our neurology outpatients clinic from October 2016 to September 2017. All patients underwent clinical neurological examination. Additional examinations in the form of EMG and nerve ultrasound using a 18 MHz hockey stick probe were proposed as additional investigations. Results Patients were aged 3–10 years (mean age 6.3 years), 4 male and 2 female. All experienced severe extension type supracondylar humerus fractures (Type III and Type IV), treated with closed (3 patients) or open reduction (3 patients) and fixed with crossed pinning (2–4 pins). Ulnar nerve deficits in intrinsic hand muscles ranged from M0 to M3. 3 patients showed complete loss of ulnar sensory motor function. 3 were able to tolerate EMG. All 6 patients tolerated and were able to complete ultrasound examination. In 1 patient with complete loss of function, discontinuity of the nerve with formation of stump neuromas was detected in ultrasound. In the other 5 cases, nerve continuity could be demonstrated, but significant nerve swelling (sulcus to upper arm ratios 1.4–2.7; mean 1.97) was apparent in all. In the 2 most severe cases of nerve swelling, additional nerve compromise with scar tissue was detected. Ultrasound findings led to surgical intervention in 2 cases (in one additional EMG data was available): 1) nerve repair by a sural nerve graft for the case of neuronotmesis and 2) neurolysis followed by anterior displacement in one case with severe nerve swelling and compromising scar tissue. Conclusions Nerve ultrasound is well tolerated in children and proved to be useful and informative for management and counselling. Useful ultrasound indicators of neuronal damage included loss of nerve continuity, neuroma formation, compromising scar tissue and nerve swelling.

Gartland Type II Supracondylar Humerus Fractures, Their Operative Treatment and Lateral Pinning Are Increasing: A Population-Based Epidemiologic Study of Extension-Type Supracondylar Humerus Fractures in Children.

Background Supracondylar humerus fractures are usual in children but their recent trends are unclear. Material and Methods A population-based study was performed to determine the epidemiology of childhood supracondylar humerus fractures during the decade, 2000 to 2009, in a geographic area of Oulu, Finland. Altogether, 565 extension-type supracondylar humerus fractures were included. The fractures and their treatment were analyzed according to the Gartland classification. Results Fracture incidence increased by 28%, from 50.9 to 65.2 per 100,000 during 2000 to 2009 (β = 1.03, p < 0.001). The increase was from 41.3 to 57.6 per 100,000 in girls (β = 1.9, p < 0.001). Trampoline-related fractures in particular increased in girls. Type II fractures increased twofold from 7.1 to 16.3 per 100,000 (β = 1.1, p < 0.001), whereas type I fractures decreased from 22.4 to 20.9 per 100,000 (β = -0.3, p = 0.026).Surgical treatment increased during the 10 years study period from 32.6 to 51.8% (p = 0.022); it was in particular due to increase of operative care of type II fractures (from 5.9% in 2000-2001 to 37.1% in 2008-2009; p = 0.011). Lateral pin fixation increased from nil to six (10.7%) (p < 0.001). Conclusion The incidence and surgical stabilization of type II fractures in particular are increasing. There is a trend toward lateral pin fixation.

Is Prone Position Ideal for Manipulation and Pinning of Displaced Pediatric Extension-type Supracondylar Fractures of Humerus? A Randomized Control Trial.

Closed reduction and percutaneous pin fixation is the standard of care for displaced supracondylar fractures of humerus in children. Although it is routinely performed in supine position, some authors recommend prone position to be advantageous as it aids in gravity reduction and avoids elbow hyperflexion. This study was conducted to compare the ease of manipulation and pinning, clinical, and radiologic outcomes in supine versus prone position. Fifty-two children with acute, grade III supracondylar humerus fractures without vascular injury were included in the study. They were grouped into prone (n=26) and supine (n=26) based on computer-generated block randomization. The duration of procedure, number of radiation exposures, attempts at closed reduction, and attempts at placing the pins were analyzed. Functional and radiologic outcomes were assessed for a minimum follow-up of 1 year. There was no significant difference between the 2 groups in the duration of procedure (P=0.422), number of radiation exposure (P=0.470), attempts at closed reduction (P=0.904), and attempts for pinning (P=0.745) and the final clinical and radiologic outcomes. One patient in prone group had cubitus varus of 8 degrees. Functionally, 2 in the supine group and 3 in prone group had poor outcomes. There is no significant difference in the ease of reduction and pinning between supine and prone positions. Grossly displaced fractures with skin puckering are difficult to manipulate in prone position. Supine position is ideal for closed reduction and pinning of all patterns of type III supracondylar fractures.

Supine Position Is Ideal for Manipulation and Pinning of All Types of Supracondylar Fractures Compared with the Prone Position

Venkatadass K, Balachandar G, Rajasekaran S. Is Prone Position Ideal for Manipulation and Pinning of Displaced Pediatric Extension-type Supracondylar Fractures of Humerus?: A Randomized Control Trial. J Pediatr Orthop. 2014 Nov 12. ### Question: In children with displaced supracondylar humeral fractures, is there an advantage to prone versus supine positioning while performing a closed reduction and pinning of the fracture? ### Design: Randomized (allocation concealed), unblinded, controlled trial with 1 year of follow-up. ### Setting: The Ganga Hospital in Coimbatore, Tamilnadu, India. ### Patients: 52 children between 3 and 14 years of age (mean age, 7 years; 79% boys) with acute Gartland type-III fractures. Exclusion criteria were Gartland type-I and II fractures, closed physis, associated vascular injury, or open fracture. 50 patients (96%) completed the study. ### Intervention: Patients were allocated to undergo surgery in the prone (n = 26) or supine position (n = 26). One surgeon experienced in both techniques performed the surgeries. Patients in the prone group were positioned with the arm over a board and a cushion supporting the elbow. The reduction in both …

Recovery of Motor Nerve Injuries Associated With Displaced, Extension-Type Pediatric Supracondylar Humerus Fractures: Level 4 Evidence

Nerve injuries occur in approximately 13% of pediatric extension-type supracondylar humerus fractures, but no large-scale studies have analyzed recovery of these nerve injuries (Ref 1). We hypothesized that the time to recovery for a motor nerve palsy associated with a supracondylar humerus fracture would vary by which nerve is injured, if more than one nerve is injured, and if immediate decompression of the affected nerve(s) occurred at the time of fracture fixation.

Iatrogenic Nerve Injuries in the Treatment of Supracondylar Humerus Fractures

Recent studies report the rate of iatrogenic nerve injury in operatively treated supracondylar humerus (SCH) fractures is 3% to 4%. A reliable neurological examination can be difficult to obtain in a young child in pain. We hypothesized that nerve injuries may be missed preoperatively, later noted postoperatively in a more compliant patient, and then falsely considered an iatrogenic injury. A prospective study was conducted on patients who presented between April 2011 and April 2013 with an extension-type SCH fracture that was managed surgically. A neurological examination was performed preoperatively, postoperatively, and at follow-up visits by a fellowship-trained attending pediatric orthopaedic surgeon. Only patients in whom the attending surgeon felt a reliable neurovascular examination was obtained were included in this study. Of the 100 patients, 16% had a nerve injury recognized on preoperative examination and 3% had a new nerve injury on postoperative examination (1 anterior interosseous, 1 median sensory, and 1 radial motor). The Gartland type (P=0.421), type of reduction (open vs. closed; P=0.720), and number of lateral-entry (P=0.898) or medial-entry (P=0.938) pins used were not associated with patients who had a new nerve injury found postoperatively. A trend was seen between fracture severity and rate of a preoperative nerve injury: type II 7% (2/28), type III 19% (9/58), and type IV 36% (5/14) (P=0.058). Preoperatively, nerve injuries were noted at the following rates: median 12% (12/100) (including 8 anterior interosseous nerve injuries), radial 8% (8/100), ulnar 3% (3/100). In this prospective study, in patients who were able to comply with a preoperative neurological examination done by an attending pediatric orthopaedic surgeon, the rate of iatrogenic nerve injury after operative treatment of SCH fractures is 3%. We conclude that this finding is true, and not a result of inadequate preoperative neurological examinations. Level I prognostic study.

Radiographic Outcomes After Treatment of Pediatric Supracondylar Humerus Fractures Using a Treatment-Based Classification System

To develop a radiographic method to categorize supracondylar fractures into four types that have logical treatment correlations. The new classification is described, illustrated, and then tested to see if it is reproducible, safe, and effective. Clinical follow-up study. Level I trauma center. One hundred forty-one extension-type supracondylar fractures. According to our system, a long arm cast without reduction was indicated for no or little displacement (Type I), closed reduction and long arm casting was indicated for minimal displacement (Type II), closed reduction and lateral pinning was indicated for moderate displacement (Type III), and closed or open reduction and medial-lateral crossed pinning was indicated for complete displacement (Type IV). Baumann's angle (anteroposterior) and the shaft-condylar angle (lateral). : No significant differences were observed among the four types with respect to changes in Baumann's angle or the shaft-condylar angle. No patient experienced a major loss of reduction and no iatrogenic ulnar nerve injury was encountered. The described treatment-based classification of extension-type supracondylar humerus fractures demonstrates promising results.

"Floating arm" injury in a child with fractures of the proximal and distal parts of the humerus: a case report

IntroductionSimultaneous supracondylar humerus fracture and ipsilateral fracture of the proximal humerus in children is rare.Case presentationA 10-year-old Turkish boy with an extension type supracondylar humerus fracture and ipsilateral fracture at the proximal metaphyseal-diaphyseal junction of the humerus was treated by closed reduction and percutaneous Kirschner wire fixation. Closed reduction was performed using a Kirschner wire as a "joystick" to manipulate the humeral shaft after some swelling occurred around the elbow and shoulder.ConclusionThe combination of fractures at the proximal and distal parts of the humerus can be termed as "floating arm" injury. Initial treatment of this unusual injury should be focused on the supracondylar humerus fracture. However, closed reduction can be difficult to perform with the swelling around the elbow and shoulder. A temporary Kirschner wire can be used as a "joystick" to fix and reduce the fracture.

Patterns of Pediatric Supracondylar Humerus Fractures

The Wilkins-modified Gartland classification of pediatric supracondylar humerus fractures does not consider coronal or sagittal obliquity. The purposes of our study were (1) to identify and describe fracture characteristics with unique properties and (2) to propose a fracture classification system that can be reproduced reliably. We retrospectively studied 203 consecutive displaced pediatric extension-type supracondylar humerus fractures treated operatively from January 1998 to January 2003. Fracture characteristics (eg, coronal and sagittal obliquity, postoperative alignment), type of surgical treatment, outcome, and complications were assessed and analyzed statistically with Student t test and a receiver operating characteristic curve. Significance was defined as P < 0.05. We incorporated significant cutoff values for fracture obliquity into our classification scheme and tested the classification's interobserver and intraobserver reliability. We identified 4 coronal (typical transverse, medial oblique, lateral oblique, and high fractures) and 2 sagittal (low sagittal and high sagittal) subtypes with significantly different characteristics and outcome. Compared with fractures with coronal obliquity of less than 10 degrees, fractures with coronal obliquity of 10 degrees or greater were associated with significantly more comminution and rotational malunion. Compared with fractures with sagittal obliquity of less than 20 degrees, fractures with sagittal obliquity of 20 degrees or greater were associated with a significantly higher incidence of additional injuries and were more likely to result in extension malunion. Analysis of the interobserver and intraobserver reliability for our system identified correlation coefficients ranging from 0.772 to 0.907 and 0.860 to 0.899, respectively. Because pediatric extension-type supracondylar humerus fractures vary significantly in terms of characteristics, identification of sagittal oblique and coronal oblique angles may have an important role in surgical decision making and may impact outcomes.

Treatment of Pediatric Supracondylar Humerus Fractures in the Community Hospital

Supracondylar fractures of the humerus are among the most common elbow injuries in the pediatric population. Because of the significant morbidity associated with treating displaced pediatric supracondylar humerus fractures, most community-based orthopedic surgeons prefer to transfer these injuries to specialty children's hospitals. Our intention in writing this article was to document and evaluate the results we obtained using the lateral diverging pin technique to treat patients at our community hospital. In doing so, we set out to determine if our results were comparable to those of specialty hospitals, allowing us in the future to eliminate the inconvenience placed on patients and their families when being transferred to a specialty facility. We retrospectively reviewed the patients treated surgically at our institution for a closed Gartland type II or type III supracondylar distal humerus fracture during the months of September and October of 2005. The medical records and radiographs of all children who had been treated for a displaced extension-type supracondylar humerus fractures were evaluated. The data recorded from the chart review included the age and sex of the patients, preoperative and postoperative neurovascular status, operative techniques (2 vs 3 lateral entry point Kirschner wires), and the operative time (start to close). The radiographs were reviewed to determine the Gartland type of fracture and the Baumann angle on the anteroposterior film immediately postoperative and at the time of fracture union. Four Gartland type II and 3 Gartland type III fractures were identified during the study period. There were 3 boys and 4 girls with a mean age of 6.29 years (range, 3.92-8.58 years). The mean immediate postoperative Baumann angle was 18.29 degrees (range, 10-25 degrees). At the time of fracture union, the mean Baumann angle was 19.0 degrees (range, 14-22 degrees). The mean range-of-motion loss as compared with the extension loss (range, 10-2 degrees) and 4.57 degrees of flexion loss (range, 10-2 degrees). The mean operative time was 20.43 minutes (range, 7-37 minutes). Our results show the change in Baumann angle and loss of range of motion compare favorably with results of studies done at specialty hospitals. We believe that the divergent lateral pinning technique, in combination with postoperative splinting and a sling can provide excellent results while eliminating the risk of injury to the ulnar nerve. With this knowledge, we feel that the advantage to treating these fractures at a community hospital is the elimination of the anxiety, stress, and time spent waiting in the emergency department of multiple hospitals.

Low Incidence of Ulnar Nerve Injury With Crossed Pin Placement for Pediatric Supracondylar Humerus Fractures Using a Mini-Open Technique

Several recent studies have suggested that medial pinning in pediatric supracondylar humerus fractures leads to increased rates of ulnar nerve injury. The purpose of this study was to determine the risk of iatrogenic ulnar nerve injury in a consecutive series of supracondylar fractures treated using a standardized technique of crossed pin placement. Single cohort retrospective. Metropolitan university tertiary care center. Seventy-one consecutive children with Gartland type II or type III supracondylar humerus were treated surgically by 2 pediatric orthopaedic surgeons at 1 institution between 1995 and 2000 using a medial mini-open and cross-pinning technique. Sixty-five patients were available for follow-up (92%). Patients were treated with a combination of medial and lateral pins using a mini-incision technique. Outcomes analyzed included ulnar nerve injury and clinical and radiographic evidence of healing. The study group consisted of 65 patients, of whom 29 (45%) presented with Gartland type III fractures, and the remaining 36 (55%) presented with a type II fracture. There were no ulnar nerve motor injuries. One patient was noted to have transient sensory changes in the ulnar nerve distribution postoperatively, which resolved by the 1-week follow-up visit. All patients were noted to have normal ulnar motor and sensory nerve function at final follow-up (average 4.5 months). No cases of nonunion, malunion, or infection were identified during the follow-up period. The rate of iatrogenic ulnar nerve injury with this specific technique of crossed pin placement for extension-type supracondylar humerus fractures was extremely low in this series. A single case of transient ulnar sensory neuropraxia occurred. Our series demonstrates that crossed pin fixation can be performed safely and reliably and is an appropriate treatment option for unstable supracondylar humerus fractures.

Pediatric supracondylar humerus fractures: the anterior approach.

To evaluate the efficiency of the anterior approach for displaced supracondylar pediatric humeral fractures. A retrospective analysis. Clinical and outpatient clinic care. The anterior approach group consisted of twenty-six patients. The historical group consisted of thirty-two patients. All had a completely displaced extension-type supracondylar humerus fracture (Gartland Type III). All were operated within six hours of admission. All patients were contacted; twenty-five of the twenty-six and twenty-nine of the thirty-two patients were re-examined at the outpatient clinic. The other patients were contacted by telephone. All fractures in the anterior approach group were operated through a ventral approach: An incision was made in the cubital fossa of only the skin and subcutaneous tissue, and reduction was performed with the thumb and index finger. The fractures in the historical group were approached through a lateral or a combined lateral and medial approach. For each case in both groups fixation was done with crossed percutaneous K-wires followed by plaster of Paris splinting for two weeks. Radiographic and clinical results were evaluated in follow-up examinations. Functional and anatomic measurements were obtained at follow-up. In both groups no compartment syndrome or Volkmann's ischemic contracture was seen. Two in the anterior approach group and one in the historical group had an associated brachial artery injury. Early postoperative fracture displacement occurred in one of the twenty-six anteriorly approached and in four of the thirty-two historical group patients. One of the four patients in the historical group with early displacement had no cosmetic or functional loss during follow-up examinations. One patient in the anterior approach group and two patients in the historical group had a rotational deformity, one of whom also suffered a functional loss. The only other functional losses were found in two patients in the anteriorly approached group and in three patients in the historical group. The results of this study show that the anterior approach is safe, simple, and easy to perform. The anterior approach has good and excellent results by Flynn's criteria in 84 percent versus 75 percent in the control group (p = 0.56).

Brachialis muscle entrapment in displaced supracondylar humerus fractures: a technique of closed reduction and report of initial results.

A retrospective review was conducted of 152 extension-type supracondylar humerus fractures in 151 children. Ninety-two (61%) of 152 of these fractures were displaced (Gartland type III). Initial irreducibility was present in 20 of the 92 displaced fractures. Brachialis muscle interposition was diagnosed by physical examination or intraoperative findings in 18 (90%) of the 20 initially irreducible fractures. Sixteen of the fractures with brachialis muscle interposition underwent an attempt at freeing the impaled proximal fragment by the described "milking maneuver." The maneuver was successful in 15 of the 16 patients and was followed by closed reduction and percutaneous pinning. Three of the remaining four cases required open reduction and pinning. We identify the incidence of initial irreducibility in displaced supracondylar humerus fractures, describe clinical findings suggestive of brachialis entrapment, and demonstrate the milking maneuver to be a valuable technique in the treatment of displaced supracondylar fractures with brachialis interposition.