“A Clinical Study of Functional Outcome After Management of Supracondylar Fracture Humerus in A Child”


Vol 5 | Issue 1 | Jan - Apr 2017 | page: 27-31 | Vibhute Nilesh Deepakrao, Roney Thomas, Tony Kavalakkatt


Author: Vibhute Nilesh Deepakrao [1], Roney Thomas [1], Tony Kavalakkatt [1]

[1] Baby Memorial Hospital, Calicut, Kerala.
Institute Where Research Was Conducted: Baby Memorial Hospital, Calicut, Kerala.
University Affiliation: National Board of Examinations, New Delhi.
Year Of Acceptance Of Thesis: 2013.

Address of Correspondence
Dr. Vibhute Nilesh Deepakrao
Baby Memorial Hospital, Calicut. Kerala.
Email: dr.nileshvibhute03@gmail.com


Abstract

Objectives: Functional outcome following management of supracondylar Humerus fracture in a child was evaluated with different methods of management.
Method: 37 cases of supracondylar fractures treated by various methods [including conservative & operative methods] were studied between April 2011 to May 2013 at our institution and followed for an average of 6 months. Patients were treated with Closed reduction K wire fixation (open reduction if required) or closed reduction and strapping, or conservatively.
Results: Total 37 patients were evaluated. Out of 20 patients with TYPE III fracture treated by K wire fixation 13 (65%) patients had excellent results, 6 (30%) patients had good results & 1(5%) patient had fair result. The remaining 10 (33.33%) patients with type III fracture was treated with closed manipulation & reduction & above elbow pop slab and strapping of elbow around chest. , out of which 6 (60%) patient had excellent results, 2 (20%) patients had good results, 1 (10%) patient had fair result & 1(10%) patient had poor results. Out of 5 patients with type II fracture, 4 (80%) patients were treated conservatively with closed reduction and above elbow pop slab & all had excellent results, 1(20%) patient was treated with open reduction & internal fixation with k wires had good result. Out of 2 patients with TYPE I fracture all were treated conservatively in an above elbow pop slab & all had excellent results according to Flynn's criteria.
Conclusion: The results of Conservative treatment with closed manipulation & reduction with above elbow pop slab (elbow in 1100-1200 flexion) application and strapping of elbow around chest in type III fracture supracondylar fractures of humerus in children are almost similar to the operative group but there is high chance of increased rate of complications like loss of reduction, malunion & restriction of movement especially if it's done in older age group children.
Keywords: Supracondylar fracture Humerus, Distal humeral fractures.


THESIS SUMMARY

Introduction

Supracondylar fracture of humerus is the commonest injury around elbow in children. It constitutes about 65.4% of all the fractures about the elbow in children. Although the bony architecture of the distal humerus is responsible for the frequency of supracondylar humeral fractures, it is the soft tissue anatomy that has the potential to produce devastating long-term complications.
The management of displaced Supracondylar fracture of the humerus is one of the most challenging one to prevent complications. No single method of management is suitable for all Supracondylar fractures in children.
There is no controversy regarding treatment of undisplaced supracondylar fractures. But various modalities of treatment have been proposed for the treatment of displaced supracondylar fractures of the humerus in children.

Aim of Study

To study the Age, Sex and Side incidence of supracondylar fractures of humerus in children below 14ys of age.
To know the most common mechanism of injury.
To study complications associated with it.
To study outcome of conservative management with POP application & elbow strapping.
To study outcome of surgical management.
Percutaneous K wire fixation (Closed method)
Open reduction and k wire fixation

Methodology

37 cases of supracondylar fractures treated by various methods [including conservative & operative methods] were studied between April 2011 to May 2013 at our institution and followed for an average of 6 months.
All children upto 14 years of age with supracondylar fractures of humerus Closed fractures were included. Children more than 14yrs of age were excluded. The patients with open fractures and other fractures of the same extremity or polytrauma were also excluded from study.
The ethical clearance for this study has been taken from our institution. All patients selected for this study were admitted in Baby Memorial Hospital, Calicut Kerala and were examined according to protocol.
Preoperative informed consent was taken from the parents of the patient for anaesthesia and procedure.
We studied total of 37 patients out of which 30 were type III fractures, 5 type II fractures and 2 type I fractures.
Out of 30 patients with type III fracture, 20 patients were treated with surgical fixation which included 16 percutaneous pinning and 4 open reduction and k wire fixation.
Closed reduction was done under general anesthesia with use of image intensifier. Firstly, traction is applied with the elbow in 45o flexion and forearm in supination. While the traction is maintained the medial or lateral displacement is corrected by applying a valgus or varus force at the fracture site. The posterior displacement of the distal fragment is then corrected by applying a force to the posterior aspect over olecranon process and distal part of humerus while the elbow is gently hyperflexed and the elbow is secured in hyperflexion by strapping arm with forearm. The elbow is placed in the lateral position directly on the image intensification. The fracture is fixed with 1.2mm to 2.0 mm K-wires depending upon the age of the patients. In the coronal plane the pins are placed with an angle of 30° with the long axis of the humerus. Elbow was immobilized in 900 flexion.
10 patients were treated with closed reduction and strapping of elbow around chest. The closed reduction was obtained in similar manner described above.
Following achieving the reduction an above elbow POP slab is applied with the elbow at 110° flexion. This is then followed by strapping the elbow around the chest with dynaplast. The idea of strapping is to prevent the rotation at the fracture site by preventing movements at shoulder and elbow.
The patients were called for follow up after 3 weeks and the POP slab was removed. Active range of motion exercises was encouraged. A special mention and warning was given after the removal of splint about avoiding massage and passive stretching of elbow joint. Further follow up were done at 12 weeks and 24 weeks. The patients were examined clinically and radiologically, assessed for range of motion and carrying angle.

Results

The final results of present study of 37 patients, 30 (81.08%) patients had TYPE III fracture, 5 (13.51%) had TYPE II fracture & 2(5.4%) had TYPE I fracture. Out of 30 patients with TYPE III fracture , 20
( 66.66%) undergone surgical fixation with k wires with 16 patients treated with percutaneous k wire fixation & 4 patients with open reduction & internal fixation with k wires, 13 (65%) patients had excellent results, 6 (30%) patients had good results & 1(5%) patient had fair result. The remaining 10 (33.33%) patients with type III fracture was treated conservatively with closed manipulation & reduction & above elbow pop slab (with elbow in 1100-1200 of flexion) and strapping of elbow around chest. , out of which 6 (60%) patient had excellent results, 2 (20%) patients had good results, 1 (10%) patient had fair result & 1(10%) patient had poor results. Out of 5 patients with type II fracture, 4 (80%) patients were treated conservatively with closed reduction and above elbow pop slab & all had excellent results, 1(20%) patient was treated with open reduction & internal fixation with k wires had good result. Out of 2 patients with TYPE I fracture all were treated conservatively in an above elbow pop slab & all had excellent results according to Flynn’s criteria.
In our study of 37 patients majority of the patients were treated within 24 hours. We have started flexion and extension elbow exercises at the end of 4 weeks and K-wire were removed at 4 weeks and all patients showed radiological union at 4 weeks of follow up.

Discussion

Surgical fixation with closed reduction & percutaneous pinning gives more stable fixation, better anatomical reduction with minimal complication. So it is safe and effective method of fixation. It gives excellent functional and cosmetic results when done at appropriate time for displaced supracondylar fracture of humerus in children.
Moreover the results of closed reduction with POP slab followed by strapping of the elbow around chest in young kids are good when done early after injury. In this method the elbow is flexed at around 110 to 120 degrees which will be a problem if there is gross swelling at the fracture site. Hence one of the requisite for this method of treatment is absence of gross swelling. All the cases operated by this method in this series were operated within 6 hrs of hospital admission before the gross swelling appeared. The cases were observed for signs of compartment syndrome and vascular compromise. In our study no patient had any complications of compartment syndrome or vascular compromise due to this method of treatment. The idea behind strapping of the elbow around the chest is to prevent movements of the humerus preventing the fracture from getting displaced.
Conclusion: The results of surgical fixation with either closed reduction & percutaneous pinning or closed reduction and strapping of elbow around chest were comparable with one another.
Cubitus varus deformity is less with k wire fixation and with closed reduction and strapping of elbow around chest due to better anatomical reduction and prevention of movement at fracture.
Elbow stiffness is less with k wire fixation and with closed reduction and strapping of elbow around chest due to early mobilization of elbow.
The results of Conservative treatment with closed manipulation & reduction with above elbow pop slab (elbow in 1100-1200 flexion) application and strapping of elbow around chest in type III fracture supracondylar fractures of humerus in children are almost similar to the operative group but there is high chance of increased rate of complications like loss of reduction, malunion & restriction of movement especially if it’s done in older age group children.

References

1. Weiland AJ, Meyer S, Tolo VT, Berg HL, Mueller J. Surgical treatment of displaced supracondylar fractures of the humerus in children. Analysis of fifty-two cases followed for five to fifteen years. The Journal of bone and joint surgery American volume 1978; 60(5): 657-61.
2. Canale ST, Beaty JH, Campbell WC. Campbell's operative orthopaedics. 12th ed. St. Louis, Mo. ; London: Mosby; 2012.
3. Fleuriau-Chateau P, McIntyre W, Letts M. An analysis of open reduction of irreducible supracondylar fractures of the humerus in children. Canadian journal of surgery Journal canadien de chirurgie 1998; 41(2): 112-8.
4. Attenborough CG. Remodeling of the humerus after supracondylar fractures in childhood. The Journal of bone and joint surgery British volume 1953; 35-B(3): 386-95.
5. Flynn JC, Matthews JG, Benoit RL. Blind pinning of displaced supracondylar fractures of the humerus in children. Sixteen years' experience with long-term follow-up. The Journal of bone and joint surgery American volume 1974; 56(2): 263-72.
6. Aronson DD, Prager BI. Supracondylar fractures of the humerus in children. A modified technique for closed pinning. Clinical orthopaedics and related research 1987; (219): 174-84.
7. Kurer MH, Regan MW. Completely displaced supracondylar fracture of the humerus in children. A review of 1708 comparable cases. Clinical orthopaedics and related research 1990; (256): 205-14.
8. French PR. Varus deformity of the elbow following supracondylar fractures of the humerus in children. Lancet 1959; 2(7100): 439-41.
9. Ramsey RH, Griz J. Immediate open reduction and internal fixation of severely displaced supracondylar fractures of the humerus in children. Clinical orthopaedics and related research 1973; (90): 131-2.
10. Gruber MA, Hudson OC. Supracondylar Fracture of the Humerus in Childhood. End-Result Study of Open Reduction. The Journal of bone and joint surgery American volume 1964; 46: 1245-52.
11. D'Ambrosia RD. Supracondylar fractures of humerus--prevention of cubitus varus. The Journal of bone and joint surgery American volume 1972; 54(1): 60-6.
12. Sutton WR, Greene WB, Georgopoulos G, Dameron TB, Jr. Displaced supracondylar humeral fractures in children. A comparison of results and costs in patients treated by skeletal traction versus percutaneous pinning. Clinical orthopaedics and related research 1992; (278): 81-7.
13. Zionts LE, McKellop HA, Hathaway R. Torsional strength of pin configurations used to fix supracondylar fractures of the humerus in children. The Journal of bone and joint surgery American volume 1994; 76(2): 253-6.
14. Arino VL, Lluch EE, Ramirez AM, Ferrer J, Rodriguez L, Baixauli F. Percutaneous fixation of supracondylar fractures of the humerus in children. The Journal of bone and joint surgery American volume 1977; 59(7): 914-6.
15. Gjerloff C, Sojbjerg JO. Percutaneous pinning of supracondylar fractures of the humerus. Acta orthopaedica Scandinavica 1978; 49(6): 597-9.
16. Mohammed S, Rymaszewski LA. Supracondylar fractures of the distal humerus in children. Injury 1995; 26(7): 487-9.
17. Brown IC, Zinar DM. Traumatic and iatrogenic neurological complications after supracondylar humerus fractures in children. Journal of pediatric orthopedics 1995; 15(4): 440-3.
18. Campbell CC, Waters PM, Emans JB, Kasser JR, Millis MB. Neurovascular injury and displacement in type III supracondylar humerus fractures. Journal of pediatric orthopedics 1995; 15(1): 47-52.
19. Schoenecker PL, Delgado E, Rotman M, Sicard GA, Capelli AM. Pulseless arm in association with totally displaced supracondylar fracture. Journal of orthopaedic trauma 1996; 10(6): 410-5.
20. Garbuz DS, Leitch K, Wright JG. The treatment of supracondylar fractures in children with an absent radial pulse. Journal of pediatric orthopedics 1996; 16(5): 594-6.
21. Mulhall KJ, Abuzakuk T, Curtin W, O'Sullivan M. Displaced supracondylar fractures of the humerus in children. International orthopaedics 2000; 24(4): 221-3.
22. Sibinski M, Sharma H, Bennet GC. Early versus delayed treatment of extension type-3 supracondylar fractures of the humerus in children. The Journal of bone and joint surgery British volume 2006; 88(3): 380-1.
23. Lins RE, Simovitch RW, Waters PM. Pediatric elbow trauma. The Orthopedic clinics of North America 1999; 30(1): 119-32.
24. Davis RT, Gorczyca JT, Pugh K. Supracondylar humerus fractures in children. Comparison of operative treatment methods. Clinical orthopaedics and related research 2000; (376): 49-55.
25. Cekanauskas E, Degliute R, Kalesinskas RJ. [Treatment of supracondylar humerus fractures in children, according to Gartland classification]. Medicina 2003; 39(4): 379-83.
26. Cheng JC, Lam TP, Shen WY. [Closed reduction and percutaneous pinning for acute type III extension- Supracondylar fracture of distal humerus in children.]. Operative Orthopadie und Traumatologie 1997; 9(1): 59-68.
27. Skaggs DL, Hale JM, Bassett J, Kaminsky C, Kay RM, Tolo VT. Operative treatment of supracondylar fractures of the humerus in children. The consequences of pin placement. The Journal of bone and joint surgery American volume 2001; 83-A(5): 735-40.
28. Shim JS, Lee YS. Treatment of completely displaced supracondylar fracture of the humerus in children by cross-fixation with three Kirschner wires. Journal of pediatric orthopedics 2002; 22(1): 12-6.
29. Brauer CA, Lee BM, Bae DS, Waters PM, Kocher MS. A systematic review of medial and lateral entry pinning versus lateral entry pinning for supracondylar fractures of the humerus. Journal of pediatric orthopedics 2007; 27(2): 181-6.
30. Parikh SN, Wall EJ, Foad S, Wiersema B, Nolte B. Displaced type II extension supracondylar humerus fractures: do they all need pinning? Journal of pediatric orthopedics 2004; 24(4): 380-4.
31. Ay S, Akinci M, Kamiloglu S, Ercetin O. Open reduction of displaced pediatric supracondylar humeral fractures through the anterior cubital approach. Journal of pediatric orthopedics 2005; 25(2): 149-53.
32. Pandey S, Shrestha D, Gorg M, Singh GK, Singh MP. Treatment of supracondylar fracture of the humerus (type IIB and III) in children: A prospective randomized controlled trial comparing two methods. Kathmandu University medical journal 2008; 6(23): 310-8.
33. Havlas V, Trc T, Gaheer R, Schejbalova A. Manipulation of pediatric supracondylar fractures of humerus in prone position under general anesthesia. Journal of pediatric orthopedics 2008; 28(6): 660-4.
34. Hamdi A, Poitras P, Louati H, Dagenais S, Masquijo JJ, Kontio K. Biomechanical analysis of lateral pin placements for pediatric supracondylar humerus fractures. Journal of pediatric orthopedics 2010; 30(2): 135-9.
35. Lutz N, Audige L, Schmittenbecher P, Clavert JM, Frick S, Slongo T. Diagnostic algorithm for a validated displacement grading of pediatric supracondylar fractures. Journal of pediatric orthopedics 2011; 31(2): 117-23.
36. Novais EN, Andrade MA, Gomes DC. The use of a joystick technique facilitates closed reduction and percutaneous fixation of multidirectionally unstable supracondylar humeral fractures in children. Journal of pediatric orthopedics 2013; 33(1): 14-9.
37. Gray H, Standring S, Ellis H, Berkovitz BKB. Gray's anatomy : the anatomical basis of clinical practice. 39th ed. Edinburgh ; New York: Elsevier Churchill Livingstone; 2005.
38. Rockwood CA, Wilkins KE, Beaty JH, Kasser JR. Rockwood and Wilkins' fractures in children. 6th ed. Philadelphia: Lippincott Williams & Wilkins; 2006.
39. The RM, Severijnen RS. Neurological complications in children with supracondylar fractures of the humerus. The European journal of surgery = Acta chirurgica 1999; 165(3): 180-2.
40. Watson-Jones R, Wilson JN. Watson-Jones Fractures and joint injuries. 6th ed. Edinburgh ; New York: Churchill Livingstone; 1982.
41. Mulpuri K, Wilkins K. The treatment of displaced supracondylar humerus fractures: evidence-based guideline. Journal of pediatric orthopedics 2012; 32 Suppl 2: S143-52.
42. Wilkins KE. Supracondylar fractures: what's new? Journal of pediatric orthopedics Part B 1997; 6(2): 110-6.
43. Wilkins KE. The operative management of supracondylar fractures. The Orthopedic clinics of North America 1990; 21(2): 269-89.
44. Omid R, Choi PD, Skaggs DL. Supracondylar humeral fractures in children. The Journal of bone and joint surgery American volume 2008; 90(5): 1121-32.
45. Chen W, Li X, Zheng Z, et al. [Retrospective analysis of complications of supracondylar fracture of humerus in children]. Zhongguo xiu fu chong jian wai ke za zhi = Zhongguo xiufu chongjian waike zazhi = Chinese journal of reparative and reconstructive surgery 2010; 24(3): 315-8.
46. Masar J. [Vascular and neurological complications of supracondylar humeral fractures in children]. Acta chirurgiae orthopaedicae et traumatologiae Cechoslovaca 2007; 74(5): 349-53.
47. Sykora L, Jager R, Beder I, Trnka J. [Complications resulting from osteosynthesis in children after supracondylar fractures of the humerus]. Rozhledy v chirurgii : mesicnik Ceskoslovenske chirurgicke spolecnosti 2013; 92(1): 16-20.
48. Tschopp O, Rombouts JJ. [Complications of supracondylar fractures of the humerus in children]. Acta orthopaedica Belgica 1996; 62 Suppl 1: 51-7.
49. Kumar R, Kiran EK, Malhotra R, Bhan S. Surgical management of the severely displaced supracondylar fracture of the humerus in children. Injury 2002; 33(6): 517-22.
50. Mazda K, Boggione C, Fitoussi F, Pennecot GF. Systematic pinning of displaced extension-type supracondylar fractures of the humerus in children. A prospective study of 116 consecutive patients. The Journal of bone and joint surgery British volume 2001; 83(6): 888-93.
51. Pirone AM, Graham HK, Krajbich JI. Management of displaced extension-type supracondylar fractures of the humerus in children. The Journal of bone and joint surgery American volume 1988; 70(5): 641-50.
52. Fowles JV, Kassab MT. Displaced supracondylar fractures of the elbow in children. A report on the fixation of extension and flexion fractures by two lateral percutaneous pins. The Journal of bone and joint surgery British volume 1974; 56B(3): 490-500.
53. Palmer EE, Niemann KM, Vesely D, Armstrong JH. Supracondylar fracture of the humerus in children. The Journal of bone and joint surgery American volume 1978; 60(5): 653-6.
54. Farnsworth CL, Silva PD, Mubarak SJ. Etiology of supracondylar humerus fractures. Journal of pediatric orthopedics 1998; 18(1): 38-42.


How to Cite this Article: Vibhute N D, Thomas R, Kavalakkatt T. “A Clinical Study of Functional Outcome After Management of Supracondylar Fracture Humerus in A Child”. Journal Medical Thesis 2017 Jan-Apr ; 5(1):27-31.

Download Full Text PDF | Download Full Thesis