Fixation Of Supracondylar Fractures Research Articles

Standard setting for orthopaedic trauma competencies in postgraduate specialty training- catching those falling behind the curve

BackgroundThe Curriculum for Trauma and Orthopaedics focuses on producing competent Day-One Consultants. However, the expected development trajectory is not clear. It is important, yet difficult to objectively identify trainees who are “falling behind”. This project proposes practical, consensus-based thresholds of Operative Trauma Competence at each Waypoint stage of training. Methods32 trainers and 73 trainees in one Deanery were identified. The trainers and trainees were asked their PBA level expectation of a trainee at ST4, ST6 and ST8 for nine trauma competencies. Lower quartile values were calculated providing thresholds. Results53 (72%) trainees and 22 (69%) trainers responded. At ST8, the lower quartile threshold was level 4 for all procedures. At ST6, three operation groups became apparent: Group 1 (hip hemiarthroplasty, Dynamic hip screw; k-wire distal radius fracture and Weber C Ankle open reduction, internal fixation (ORIF)) Group 2 (Tibial Nail; Olecranon Tension band wire, ORIF radial shaft; distal radius plate fixation)- Group 3 (supracondylar fracture fixation)Threshold levels for procedures were: Group 1- 4a; Group 2–3b and Group 3- 3a.At ST4, there was more variation and spread in responses, however, expectations could still be similarly grouped: Group 1- 3a; Group 2- 2b and Group 3- 2a. ConclusionIn an increasingly competency-based training environment we provide tangible thresholds for expectations of orthopaedic trainees’ progression and development. We identified two groups: basic trauma (Group 1 where level 4 competencies should be attained by ST6) and intermediate trauma (Groups 2 and 3 where level 4 competencies should be attained by ST8.)

Short Term Results of Intramedullary Fixation of Supracondylar Fracture of Femur by Retrograde Intramedullary Nail

Short Term Results of Intramedullary Fixation of Supracondylar Fracture of Femur by Retrograde Intramedullary Nail

Comparison of cross pinning versus lateral three pins in type three supracondylar fracture of distal humerus in children.

Background:
 Supracondylar fracture of distal humerus is the most common paediatric fracture. Type III supracondylar fractures should be treated with anatomical reduction and stable Kirschner wire (K- wire, pin) fixation to prevent the cosmetic deformity. The configuration of wires is debatable. Although two crossed K-wires are bio-mechanically stable, there is a risk of iatrogenic ulnar nerve injury. Lateral 3 K-wires is a good alternative. This study was done to compare the outcome of cross K- wire and lateral 3 K-wires in terms of stability.
 Materials and Methods:
 This is a prospective study done in Manipal Teaching Hospital. All the Gartland type 3 supracondylar fractures of the distal humerus were treated with closed reduction and stabilized with K wires. In Group I, fractures were stabilized with cross K wire fixation and in group II they were stabilized with 3 lateral K-wires. The patients were followed up at 4-5 weeks for wire removal and at 3 months and 6 months after surgery. Baumann's angle, a functional outcome as per Flynn's criteria, and range of motion were recorded in each visit. Outcomes were compared in term of displacement of fracture.
 Result:
 Seventeen children in each group were taken up for the study. There were no significant differences in term of patients and fracture character. No patients had significant loss of reduction at final follow up. There is no statistically significant difference seen in mean changes of Bauman's angle. According to Flynn's criteria good result was seen in more than 95% of cases in both groups.
 Conclusion:
 Both cross K-wires and Lateral 3 K-wires provide good stability. Fixation of supracondylar fracture from lateral side had an advantage of no risk of iatrogenic Ulnar nerve injury. Addition of third K-wire from lateral side provides good stability as that of cross K- wire fixation.

Comparative functional outcome of supracondylar femoral fracture stabilized with cross and end threaded intramedullary pinning in dogs

The study was conducted on 24 clinical cases of dogs (with 26 fractures) suffering from supracondylar fractures of femur which were stabilized using cancellous negative intramedullary (IM) end-threaded pin with 5 screws (Group I, n=8), cross-pinning (Group II, n=8, 9 fractures) and cancellous negative end threaded IM pin having 10– 18 threads (Group III, n=8, 9 fractures). Data collected included signalment, fracture characteristics (etiology, duration, Salter-Harris classification, pre-operative and post-operative displacement), surgical information (implant size, surgical duration) and outcome assessment (functional outcome and complications). Cross pinning technique used to stabilize supracondylar fracture of femur adversely affects flexion angles of stifle joint leading to joint stiffness compared to either of the end threaded pinning techniques; however, extension angles remain unaffected. Early weight bearing in group II suggested that crossing pinning is a rigid fixation technique compared to either end threaded pinning techniques. Minor implant related complications were recorded in group II (3) followed by group 3 (2) and group 1(1) which were managed successfully. Though fixation of supracondylar fractures using double armed end threaded pin with 5 cancellous negative threads was associated with shorter duration of surgery, and fewer postoperative complications; however, based on formation of minimal and smooth callus and better functional outcome, conventional end threaded pin with 10–18 cancellous negative threads was assessed to be a better fixation technique and was recommended for the repair of supracondylar fractures of femur in dogs.

The use of locked plate as a definitive fixation for open supracondylar fracture of the femur with partial bone loss in polytraumatized patients

Background Open supracondylar fractures of the femur are complex injuries usually presenting in a polytraumatized patient. Partial circumferential bone loss may result at the time of injury or during debridement. The way in which the fracture is treated has a substantial influence on the local mechanical and biological environment, which in turn will influence the quantity and quality of the osteogenic response. Although early skeletal stabilization can stop the cycle of injury, remove nidus for infection, and halt ongoing hemorrhage, it may be prudent to delay definitive surgery until the patient’s general condition is optimized. Meanwhile, debridement and a preliminary spanning external fixator is used to stabilize the fracture. The use of a locked plate for the fixation of supracondylar fracture of the femur with partial bone loss creates a rigid biomechanical environment needed for healing and maintenance of alignment until fracture healing. Patients and methods Eighteen patients with open supracondylar fracture of the femur were treated between January 2009 and June 2011. All patients were treated surgically within the first 24 h. Radical soft tissue and bone debridement was performed. Thirteen patients underwent definitive fracture fixation using a laterally placed locked distal femur plate. Five patients had their fractures primarily stabilized by an external fixator until improvement of their general condition. Results Bone healing was obvious on follow-up radiographs in 10 patients without the need for supplementary surgical procedures at a mean of 16 (12–20) weeks. Seven patients with no progressive radiologic healing by 20 weeks’ follow-up underwent an iliac crest cancellous bone graft; healing was then realized radiologically after a mean of 12 (8–18) weeks. Using the IOWA knee functional score for final patient assessment, we found excellent results in 14 patients, good results in three patients, and fair results in one patient. Conclusion Generally stable polytraumatized patients should be treated with thorough initial debridement, local antibiotics, and early definitive fracture fixation using a locked distal femur plate. Critically unstable patients with hemorrhagic shock are to be treated with damage control until improvement in their general condition. Bone graft is to be delayed for 20 weeks as many fractures would successfully heal by that time, even with partial bone loss.

A COMPARATIVE STUDY OF INCIDENCE OF IATROGENIC ULNAR NERVE INJURIES IN TWO DIFFERENT TECHNIQUES OF CROSS KIRSCHNER WIRE CONFIGURATION FOR FIXATION OF PAEDIATIC SUPRACONDYLAR FRACTURES OF HUMERUS

Abstract Objective: The objective of this study was to com-pare the incidence of iatrogenic ulnar nerve injuries in two different techniques of cross Kirschner wire configuration for the fixation of paediatric supracon-dylar fractures of humerus. Methodology: Forty patients attending Accident and Emergency Department of The Children's Hospital and Institute of Child Health, Lahore, with supracon-dylar fracture of humerus were studied from September 2014 to March 2015 to compare the incidence of iatrogenic ulnar nerve injuries in two techniques of cross Kirschner wire configuration for the fixation of supracondylar fractures of humerus. These patients were divided in group A and group B. Each group consisted of 20 patients. The fracture of patients in group A was fixed with two lateral cross Kirschner wires configuration and fracture of patients in group B was fixed with mediolateral cross Kirschner wires con-figuration. All the operations were performed by same team of Paediatric orthopaedic surgeons. Technique of Kirschner wire fixation of the fracture was allocated to the patients randomly. Informed consent was taken from parents of the patient. Detailed history of the patient was taken and thorough clinical examination including evaluation of neuromuscular status of the injured limb was done and recorded. Complete blood counts and urine analysis were done. Preoperative antibiotics were administered intravenously. In general anaesthesia, closed reduction of the fracture was done under C arm x-ray image intensifier control, fracture was held reduced manually and fixed with percuta-neous Kirschner wires according to the fixation techni-que allocated to the patient. The Kirschner wires were bent, cut, buried under the skin, aseptic dressing and plaster back slab was applied. After recovery from general anaesthesia neurovascular status of the limb was re-evaluated and check x-rays of the elbow were done. Next day, the patient was discharged from the hospital and examined clinically and radiologically at 3 weeks, 6 weeks and 12 weeks. Results: In this comparative study of incidence of iatrogenic ulnar nerve injuries in two different techni-ques of cross Kirschner wire configuration for fixation of paediatric supracondylar fractures of humerus, the peak incidence of the fractures was between the age of 5 - 7 years. There were 28 (70%) males and 12 (30%) were females with male to female ratio of 2.3:1. Nine (23%) patients sustained injury at home, 7 (17%) pat-ients during cycling, 22 (55%) patients during playing and 2 (5%) fell from height. Right side was fractured in 14 (35%) patients and left side was fractured in 26 (65%) patients. One patient (5%) had flexion type of fracture and 39 patients (95%) had extension type of fracture. According to Gartland classification 5 (13%) had type II and 34 (87%) had type III fractures. In gro-up A, in which the fracture was fixed with two lateral cross Kirschner wire configuration none of the patients had iatrogenic ulnar nerve injury. In group B, 1 (5%) patient in which fracture was fixed with mediolateral cross Kirschner wire configuration, an iatrogenic ulnar nerve injury was observed which completely recove-red in 6 weeks with physiotherapy. Conclusion: Techniques of two lateral cross Kirs-chner wire configuration and mediolateral cross Kirs-chner wire configuration are equally effective for fix-ation of paediatric supracondylar fracture of humerus. But mediolateral cross configuration technique can cause iatrogenic ulnar nerve injury. Therefore, it is concluded that two lateral cross Kirschner wire techni-que is a safe method for fixation of paediatric supra-condylar fractures of humerus in terms of iatrogenic ulnar nerve injury. Keywords: Supracondylar fracture, closed percutane-ous K wires, lateral cross and mediolateral cross.

Lateral three pin fixation for supracondylar fractures in children

Introduction: Paediatric Supracondylar fractures are the commonest elbow injuries encountered in the emergency departments. Most commonly they are the result of a fall on an outstretched hand that causes hyperextension of the elbow. The extension-type supracondylar humeral fractures account for 95% to 98% of all supracondylar fractures. Displaced fractures are treated with closed reduction and percutaneous pinning. However the method of pinning has been a matter of debate (lateral entry vs cross pinning). The issue with the lateral entry pinning like loss of reduction and ulnar nerve injury with the cross pinning method has always kept a doubt in the surgeons mind regarding the method of pinning. The present study was aimed to see functional results of using three lateral pins in type II and III supracondylar fractures and to look for any complications occurring thereafter. Methods: Forty consecutive patients of type II and III SC fractures were taken up for the study. Three lateral pins were used for all fractures. Using the Flynn criteria, the results were graded as excellent, good, fair or poor by comparing the carrying angle and range of motion with the opposite side. Results: Among the cohort of forty patients we had 25 males and 15 females. The mean age group was 6.5 + 3.2. Sixteen patients had type II fracture while as 24 had type III Gartlands fracture. The union occurred in all cases. At the final follow up, 87.5% patients showed excellent results 10% showed good and 2.5% fair results. There was no case of poor results. There were no iatrogenic nerve palsies, and no patient required additional surgery. Conclusion: Lateral three pin fixation is a good method for displaced supracondylar fractures and has little or no chances for ulnar nerve injury. This method has an easy learning curve among orthopaedic residents. A randomised control trail comparing it with other methods involving a larger series is needed to look for the effectiveness of this technique.

Transosseous fixation of intercondylar fracture of lower end humerus by tension band wiring technique

Background: Intercondylar fractures of lower end of humerus is a challenge for orthopedic surgeon to fix rigidly for early mobilization. We hereby have devised a novel technique of fixing an intercondylar fracture of lower end of humerus by transosseous route utilizing the Tension band wiring. We successfully obtained a rigid, stable reconstruct without affecting the anatomy of the region. Aims & Objective: To study the effect of transosseous fixation of intercondylar fracture of lower end humerus by tension band wiring technique. Materials and Methods: We have followed a novel technique for treating intercondylar fracture of lower end of humerus. Till date we have treated 10 patients of supracondylar fracture of humerus with intercondylar extension. All patients were selected randomly the only criteria was a supracondylar fracture of lower end of humerus with intercondylar extension. This method gave us four cortices fixation in the lower intercondylar region which was not possible till date by other methods of fixation. So now T-Y elbow type of fracture is converted into a supracondylar fracture. Rest fixation of supracondylar fracture was done with perpendicular plating and k wire TBW in case of osteoporotic bones. Results: Out of 10 treated cases with this method all get rigid fixation and radiological union at average of 8 weeks. Average ROM was 5-100. One case had postoperative stitch infection, one had k wire impinging on skin and two patients lost follow up after 3 months. Conclusion: Complicated fractures of intercondylar region of distal humerus can be successfully managed by interosseous TBW technique. We recommend such technique and further research regarding it.

The epidemiology of paediatric supracondylar fracture fixation: A population-based study

IntroductionThe epidemiology of paediatric supracondylar fracture (SCF) fixation has not been evaluated at a population level. The purpose of this study was to: (1) determine the incidence density rate (IDR) of SCF fixation and (2) determine the rate of and risk factors for re-operation. MethodsUsing administrative databases, all patients who underwent SCF fixation (closed reduction percutaneous pinning (CRPP) or open reduction (OR)) in Ontario between April 2002 and March 2010 were identified. Exclusion criteria included age (>12 years), a prior or concurrent non-SCF elbow fracture or previous humeral osteotomy. The overall IDR of SCF fixation and for subgroups of age, sex and season were calculated. A multivariate regression (immediate and short-term re-operation) and a Cox proportional hazards model (long-term re-operation) were used to identify patient, injury and provider factors that influenced re-operation risk and were reported as odds ratios or hazard ratios (HRs) with 95% confidence intervals (CIs), respectively. ResultsA total of 3235 patients with a median age of 6.0 years (interquartile range (IQR): 3.0) underwent SCF fixation. The median follow-up was 6.0 years (IQR: 3.7). The majority underwent a CRPP (78.7%) which were performed after hours (75.6%). The overall IDR was 20.7/100,000person-years (py), but it varied significantly by season and age. Re-operation was uncommon in the immediate (1.0%), short-term (1.4%) and long-term (0.3%) follow-up period. As compared to CRPP, patients who underwent OR were more likely to undergo early nerve exploration (odds ratio: 7.8 (CI: 3.0–20.6)) and re-operation in the long term (HR: 3.0 (CI: 1.0–8.7)). Increased surgeon volume of SCF fixation was protective against repeat fixation (odds ratio: 0.9 (CI: 0.9–1.0)) and re-operation in the long term (HR: 0.9 (CI: 0.8–1.0)). ConclusionsWhile SCF fixation is common, the rate of re-operation is low. No differences existed between the sexes and a higher volume of fixations occurred during the summer months.

Children’s orthopaedics

The April 2013 Children’s orthopaedics Roundup360 looks at: improving stress distribution in dysplastic hips; the dangers of fashion; the natural history of supracondylar fractures; ankles that perform well as knees; intra-articular hip pathology at osteotomy; the safe removal of flexible nails; supracondylar fracture fixation; and talipes.

Children’s orthopaedics

The December 2012 Children’s orthopaedics Roundup360looks at: whether arthrodistraction is the answer to Perthes’ disease; deformity correction in tarsal coalitions; ultrasound used to predict pain in Osgood-Schlatter’s disease; acetabular tilt; hip replacement for juvenile arthritis sufferers; whether post-operative radiographs are needed for supracondylar fractures; intra-articular local anaesthetic following supracondylar fracture fixation; and limb deformity.

Percutaneous crossed k-wiring for fixation of supracondylar fractures of the humerus: A common sense protocol to protect the ulnar nerve and minimise unnecessary incisions

Aim To investigate the effectiveness of a decision-based protocol designed to minimise the use of medial incisions when performing crossed-wire fixation of supracondylar fractures of the distal humerus whilst minimising ulnar nerve injury. Method We have employed a protocol for placing the medial wire during crossed k-wire fixation of supracondylar fractures dependent upon the medial epicondyle. When this is palpable, the wire is introduced percutaneously; when it is not, a mini-incision is made. All cases of closed reduction and crossed K-wiring of supracondylar fracture over a three year period (2008–2011) were identified from our department database. Cases with a neurological injury identified pre-operatively, and those in which the protocol had not been followed were excluded. Casenotes were reviewed to determine the incidence and outcomes of post-operative ulnar nerve deficit. Results A total of 106 cases were identified, from which 36 cases were excluded, leaving 70 cases in the study. The mean age was 5 (range 1–11). 68 were extension-type injuries, of which 29 (41%) were type 2 and 39 (56%) type 3 according to the classification of Gartland. 2 were flexion-type. A mini-incision for placement of the medial K-wire was required in only 3 cases (4.3%), with percutaneous placement in all other cases. There was clinical evidence of partial ulnar nerve injury in 1 case (1.4%) which recovered spontaneously within 11 months. Conclusion The results of this study demonstrate our protocol to be effective. Careful percutaneous placement of the medial wire can be performed in the majority of cases with little risk of significant or permanent injury to the ulnar nerve. Open placement of the medial wire is indicated in only a small proportion of cases. We suggest that the routine use of a medial mini-incision should be re-considered.

Open Reduction and Internal Fixation of Supracondylar Fractures of the Humerus: Revival of the Anterior Approach

Supracondylar fractures of the humerus occur commonly in the paediatric age group. Gartland type III fractures are treated by closed manipulation and percutaneous pinning with K-wires. Open reduction is indicated in open fractures, failed closed reductions and in a dysvascular limb. There are various approaches that can be utilized to perform an open reduction. The approach of choice must be safe, surgeon and patient friendly and should provide a good access to the fracture and the important surrounding structures. The anterior approach has been described as the most versatile approach. The aim of the study was to review the advantages and drawbacks of the anterior approach and to assess the functional outcome of fractures treated via this approach. Twenty five (15 male and 10 female) patients out of a hundred and twenty eight children with Gartland type III extension variety of supracondylar fractures of the humerus from underwent open reduction and internal fixation with K-wires via an anterior approach January 2007 to January 2011. The results were assessed at six months using Flynn's radiological and clinical criteria. Twenty five patients (19.53%) out of hundred and twenty eight patients underwent open reduction and internal fixation. According to Flynn's clinical and radiological criteria, 20 (80%) were found to have excellent and 5 (20%) good results. The anterior approach is safe, easy and provides direct exposure of the surrounding neurovascular structures with good to excellent results.

Comment on Memisoglu et al.: Does the technique of lateral cross-wiring (Dorgan’s technique) reduce iatrogenic ulnar nerve injury?

Dear Editor, We congratulate Kaya Memisoglu et al. for their excellent paper entiteled “Does the technique of lateral cross-wiring (Dorgan’s technique) reduce iatrogenic ulnar nerve injury?” [1]. The preferred method of fixation of supracondylar fractures in humerus is still controversial. In this article we noticed that in the X-rays in figures 1 and 2, only anteroposterior views are shown, with no lateral views. Also in figure 1 the lateral pin is protruding significantly into the soft tissues medially. There may be risk of ulnar nerve injury by the pin inserted from the lateral epicondyle protruding medially. There is also risk of late migration of K-wires passed from the lateral humerus beyond the medial epicondyle with risk of injuring the ulnar nerve in these cases. In this study the operations are done by different surgeons, so that the incidence of ulnar nerve injury in the crossed K-wire fixation group may be attributed to the surgery performed by a less experienced surgeon. The study also did not mention the position of the elbow while passing the medial pins. Various methods of avoiding ulnar nerve injury have been mentioned in literature, such as locating the ulnar nerve with a nerve stimulator suggested by Micheal and Stanislas [2]. Making a small 1.5-cm incision over the medial epicondyle for placement of the medial pin has also been proposed as a way to locate and protect the ulnar nerve. This technique works well and may avert the problem of iatrogenic ulnar nerve injury when crossed pinning is required for very unstable fractures. Furthermore, placing the lateral pin first with the elbow hyperflexed and then placing the medial pin with the elbow in only 90 degrees of flexion lessens this risk. In a biomechanical analysis of lateral pinning versus crossed pinning, Lee et al. [3] found that divergence of two lateral pins was superior to a parallel configuration. They found crossed pins provided significantly more strength in axial rotation. Onwuanyi and Nwobi [4], in a clinical series, also concluded that there was greater stability or ability to maintain reduction with the crossed pinning technique. Solak and Aydin, however, found no difference in complication rates with two lateral pins versus crossed pins [5]. In addition there is a theoretical possibility of injuring the radial nerve during the insertion of the pin from the lateral humerus. Thus, we maintain that if properly done the medio-lateral cross K-wire fixation method provides good stability with less chance of nerve injury.

Pediatric supracondylar fractures of the humerus Medial-lateral crossed pinning versus lateral pinning alone (UPDATE to December 2007 report)

Evidence from three small randomized controlled trials indicates that medial-lateral crossed pinning and lateral pinning for fixation of supracondylar fractures in children may be comparable. Overall, no differences were found between the treatment groups regarding mean Baumann-angle loss, carrying angle loss, range of motion,risk of poor outcome, iatrogenic nerve injury, and infection. Infection (two studies) and ulnar nerve injury (one study) were more common in the medial-lateral treatment group, but the difference was not significant.Additional randomized trials with larger sample sizes and longer follow-up are necessary to establish the long-term safety and efficacy of these two operative treatments. 3项小样本随机对照研究显示内外侧交叉克氏针固定与外侧克氏针固定治疗儿童肱骨髁上骨折疗效相当.根据总体研究结果分析,两治疗组间Baumann角和提携角的丢失、关节活动度、功能障碍、医源性神经损伤及感染的发生率等监测指标差异均无统计学意义.虽然感染(其中2项研究)和尺神经损伤(其中1项研究)在内外侧克氏针固定组更为常见,但是差异并无统计学意义.因此,为明确两种治疗方法的远期有效性和安全性,还需开展大样本随机对照研究,并进一步增加病例的随访时间.……

Prevention of ulnar nerve injury during fixation of supracondylar fractures in children by ‘flexion–extension cross-pinning’ technique

No consensus exists concerning the best pin configuration for displaced supracondylar fractures of the humerus in children. Although cross-pinning is the most stable biomechanically, this configuration may cause iatrogenic ulnar nerve palsy. For the last 7 years, we have been using a three-pin fixation technique with insertion of two K wires from the lateral side (elbow in full flexion) and the third wire through the medial side (elbow in full extension). We used this technique in 67 displaced supracondylar fractures without any complications related to the ulnar nerve. The technique provides excellent stability and eliminates the risk of iatrogenic ulnar nerve palsy.

Analysis of Reinterventions in Children?s Fractures?an Aspect of Quality Control

For a long time, orthopedic treatment was the first choice in pediatric fracture care. This often required more than one intervention. Meanwhile, new surgical modalities and differentiated techniques allow primary definitive (operative) fracture care in unstable fractures. The number of reinterventions show how often the initial decision failed. During a 3-year period, 1,497 children with limb fractures were treated. 65% received a plaster, 10.9% needed reduction before getting a cast, and 24.1% were stabilized with any kind of osteosynthesis. In 62 cases (4.1%), a second intervention became necessary. The main causes were misjudged stability of orthopedically treated forearm fractures (secondary osteosynthesis), insufficient Kirschner wire (K-wire) fixation of supracondylar fractures (reosteosynthesis), or other technical faults in osteosynthesis requiring revision. The number of reinterventions decreased over the 3-year study period. Initial definitive fracture care was seen in 95.9% of cases, but the 4.1% that failed requires further attention. Watchful and critical assessment of the stability of each orthopedic or surgical procedure is indispensable to further reduce the number of children who receive delayed treatment or repeated anesthesia.

Management of supracondylar fractures of the femur with Zickel supracondylar nails.

Twenty-one cases of supracondylar fracture of the femur treated at St Vincent's Hospital, Melbourne, during 1983-86, by intramedullary Zickel supracondylar nails were reviewed. The causes were high energy trauma in young patients (six), minor trauma in elderly patients (13), and metastatic malignant fracture (two). The functional results were considered excellent in 10, good in six and poor in five. There were two cases of superficial wound infection. All cases united after 3-6 months. The best functional results were in those patients below 60 years or with pathological fractures. It is concluded that internal fixation of supracondylar fractures of the femur with Zickel supracondylar nails is a successful technique and can be performed by open and closed methods. It is most useful in osteoporotic or pathological bone which is unsuitable for bone plating.

The use of bone cement as an adjunct to internal fixation of supracondylar fractures of osteoporotic femurs.

Bone cement was used as an adjunct to internal fixation of 14 supracondylar femoral fractures. The fractures were stabilized with ASIF plates. In all these fractures severe osteoporosis made a stable fixation impossible without the use of bone cement. The average age of the patients was 75 years. Eight of the patients had previously been operated on because of fractures of the same extremity and three suffered from disabling diseases. Twelve fractures healed without complications, despite early mobilization. One fracture needed additional external fixation before it healed and one lead to non-union. No infections were seen. It is concluded that use of bone cement as an adjunct to the internal fixation of supracondylar fractures secures a stable fixation of even the most severe osteoporotic femora, and this aids healing in most cases of such fractures. The method is recommended in selected cases of elderly patients.