Closed and Open Reduction of Supracondylar Humerus Fractures

Kenneth D. Illingworth, MD

David L. Skaggs, MD, MMM

Dr. Illingworth or an immediate family member is a member of a speakers’ bureau or has made paid presentations on behalf of Nuvasive. Dr. Skaggs or an immediate family member has received royalties from ZimmerBiomet; is a member of a speakers’ bureau or has made paid presentations on behalf of ZimmerBiomet; serves as a paid consultant to or is an employee of Grand Rounds, Nuvasive, Orthobullets, and ZimmerBiomet; has stock or stock options held in Green Sun Medical, Orthobullets, and Zipline Medical, Inc.; has received research or institutional support from Nuvasive (Co-PI, Paid to Growing Spine Foundation); has received nonincome support (such as equipment or services), commercially derived honoraria, or other non-research-related funding (such as paid travel) from Medtronic and ZimmerBiomet; and serves as a board member, owner, officer, or committee member of the CHLA Foundation, the Growing Spine Foundation, and the Growing Spine Study Group.

This chapter is adapted from Skaggs DL, Choi PD, Carter C: Closed and open reduction of supracondylar humerus fractures, in Flatow E, Colvin AC, eds: Atlas of Essential Orthopaedic Procedures. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2013, pp 633-640.

INTRODUCTION

Supracondylar humerus fractures are among the most common orthopaedic injuries of childhood, comprising roughly two-thirds of all fractures involving the elbow. With an estimated emergency department visit incidence of 60.3 to 71.8 per 100,000 children annually, supracondylar humerus fractures represent a significant proportion of the injuries presenting for orthopaedic care.¹ It is therefore essential that the treating orthopaedic surgeon be armed with the proper tools for appropriate management. Most supracondylar humerus fractures occur in children aged 3 to 6 years, with an average age of 5.5 years for closed injuries.¹ The mechanism of injury typically involves a fall onto the outstretched upper extremity, with the vast majority of fractures resulting from a fall with the arm held in an extended or hyperextended position. Nearly 98% of all supracondylar humerus fractures are of this extension type, with the remaining 2% representing the much rarer flexion-type supracondylar fracture. Most fractures are treated with cast immobilization, whereas 24% of fractures require surgical intervention.²

The most widely used classification system for supracondylar humerus fractures is that of Gartland, first described in 1959.³ This system, as originally conceived, describes type I fractures as nondisplaced, with neither medial-lateral fracture displacement nor rotational malalignment. The anterior humeral line intersects the middle third of the capitellum on the lateral radiographic view, and Baumann’s angle is 10° to 26° on the AP view. In some cases, the only radiographic evidence of a type I fracture may be the presence of the posterior fat pad sign. Type II fractures are moderately displaced, with the extended distal fragment hinging on the intact posterior humeral cortex. Fractures that are completely displaced without any cortical contact are classified as type III. Type III fractures demonstrate varying degrees of rotational malalignment and may have significant comminution with associated soft-tissue injuries and disruption of the periosteal hinge. A modification to the Gartland classification system has been made by Leitch et al,⁴ who proposed the addition of a type IV fracture. Type IV fractures are multidirectionally unstable with complete incompetence of the periosteal hinge; as a result, the distal fracture fragment may be displaced into either a flexed or extended position.

At our institution, we consider any supracondylar humerus fracture with more than one plane of deformity to be considered at least a type 3. For instance, a supracondylar humerus fracture with extension in combination with medial or lateral column comminution/collapse would be considered a type 3 fracture regardless of the amount of cortical contact remaining. Type 2 fractures should only require sagittal plane correction during treatment.

PATIENT EVALUATION

Initial assessment of the child includes both clinical and radiographic evaluations. Physical examination involves inspection of the soft tissues of the arm, looking for evidence of surgical emergencies, including open fractures, vascular compromise, and compartment syndrome. Puckering of the skin anteriorly may be present and is associated with penetration of the brachialis by the proximal fracture fragment, which then engages the deeper layers of the dermis. Ecchymosis anteriorly in the antecubital fossa is indicative of significant underlying soft-tissue injury and should be considered a “red flag” for a possible evolving compartment syndrome (Figure 1). In addition,
the presence of significant soft-tissue injury (ecchymosis, puckering, excessive swelling, skin tenting) has been associated with neurovascular compromise.⁵ The adjacent bones and joints should be evaluated for the presence of concomitant injuries; importantly, combined forearm and elbow injuries place the patient at a higher risk for preoperative sensory nerve palsies and are at greater risk of developing compartment syndrome.⁶ Patients with a true floating elbow, ie, operative supracondylar humerus fracture and displaced/angulated ipsilateral forearm fracture requiring open or closed reduction, should be treated in an urgent or emergent fashion.

FIGURE 1 Photograph shows ecchymosis of the antecubital fossa with associated puckering of the skin. This is a red flag for significant underlying soft-tissue injury.

FIGURE 2 Illustration shows normal radiographic angles for the pediatric elbow. A, The anterior humeral line—a line drawn adjacent to the anterior humeral cortex on a true lateral view of the elbow—should intersect the capitellum in its central third. B, The Baumann angle is defined as the angle formed by the intersection of a line drawn perpendicular to the long axis of the humeral shaft with a line drawn parallel to the lateral humeral condylar physis. A Baumann angle greater than 10° is generally considered acceptable.

Following inspection of the skin and soft tissues, the presence and strength of a radial pulse should be noted along with an assessment of hand perfusion. A warm, pink hand may be considered well perfused, whereas a cool, white or blue-tinged hand is considered poorly perfused. Careful sensorimotor examination of the median, anterior interosseous (AIN), ulnar, radial, and posterior interosseous nerves is essential because traumatic neurapraxia is quite common. In a meta-analysis of 5,148 pediatric patients with displaced supracondylar humerus fractures, Babal et al⁷ identified traumatic nerve injuries at a rate of 11%. These authors confirmed the results of earlier studies, reporting that the AIN is the most frequently affected nerve in extension-type fractures. In their study, 34% of all traumatic neurapraxias associated with displaced extension-type supracondylar fractures involved the AIN. They additionally noted that flexion-type fractures were associated with an overall higher rate of traumatic neurapraxia than extension-type fractures as well as with a vastly higher rate of injury to the ulnar nerve; 91% of traumatic nerve injuries in patients with flexion-type fractures involved the ulnar nerve. Shore et al⁸ reported on their series of 244 traumatic nerve injuries with supracondylar humerus fractures and found that most nerve injuries recovered within 6 months without acute nerve decompression, and the presence of an isolated radial nerve injury or multiple nerve injuries was associated with prolonged motor recovery.

Radiographic evaluation is performed with AP and lateral views of the elbow. In type 2 fractures, the amount of extension can only be assessed on a true lateral. The normal radiographic appearance of the pediatric elbow includes an anterior humeral line that intersects the capitellum on the lateral view and a Baumann angle between 10° and 26° (Figure 2). A decrease in Baumann’s angle is associated with varus angulation of the fracture.
Comminution of the medial column should raise concern for varus angulation, and fractures with medial comminution require surgical treatment. Although radiographs of the contralateral elbow may be useful for purposes of comparison, they are not usually required. Standard orthogonal views of the adjacent bones and joints can be considered to evaluate for ipsilateral fractures and other associated injuries, especially if concomitant injury cannot be ruled out by physical examination, as in the setting of polytrauma or altered mental status.

NONSURGICAL MANAGEMENT

The treatment of type I supracondylar humerus fractures is immobilization in a long arm cast for 3 weeks. Although it is tempting to place the elbow in maximal flexion to optimize fracture reduction, increasing amounts of elbow flexion are associated with obliteration of the radial pulse and elevated compartment pressures, especially in fractures with associated soft-tissue injury. For type I injuries, we recommend placement of a long arm cast with the elbow positioned in less than 90° of flexion and the forearm in neutral rotation.

Although some centers continue to advocate for the closed management of type II fractures, there is good evidence that late complications of cast immobilization—including loss of reduction, delayed surgery, poor clinical outcomes, and increased forearm compartment pressures—do occur. By contrast, in a review of 189 type II consecutive supracondylar fractures treated surgically with closed reduction and percutaneous pin fixation, there were no reported instances of anesthesia-related complication or loss of fracture reduction.⁹ Clinical outcomes, as judged by the Flynn criteria, were uniformly good, with 187 of 189 patients having a good or excellent result and the remaining two patients having a fair outcome. We noted a 2% infection rate and a 0.5% rate of revision surgery (performed for a pin-tract infection). We believe that the benefits of closed reduction and percutaneous fixation for type II fractures outweigh the perceived risks of surgical intervention, and we routinely treat these surgically. With regard to type III and IV supracondylar humerus fractures, there is little debate that surgical treatment is warranted.

PROCEDURE

Room Setup/Patient Positioning

Once in the operating room, the patient is positioned supine on the operating table, general endotracheal anesthesia is administered, and a prophylactic dose of antibiotic is given. A short radiolucent arm board is applied to the operating table. In smaller patients, the head may be placed between the arm board and the operating table so that the elbow is far enough onto the arm board to facilitate fluoroscopic imaging and the head is not in danger of being pulled off the table during traction maneuvers. The patient is secured to the table with a safety strap. Some authors advocate using the image intensifier of the C-arm as the operating room table. Although this situation may work for a large portion of cases, it limits the ability to obtain lateral radiographs without moving the arm, which becomes critical in multidirectional unstable fractures.

The bed is then turned 45°, so that the affected arm is positioned away from the anesthesiologist; this creates a larger working space for the surgeon and his or her assistant. The C-arm is positioned parallel to the bed and enters the surgical field from the foot of the bed. The C-arm monitor is positioned directly across the table from the surgeon to allow direct viewing while placing pins. The arm is prepped to the shoulder in the usual sterile fashion, and the arm is draped free. Care is taken to leave room for a sterile tourniquet in the event that an open reduction is needed.

Surgical Technique

In most cases, surgery begins by attempted closed reduction of the fracture. The reduction maneuver is dependent on the fracture pattern, and each fracture should be approached individually. Type 2 fractures, as defined at our institution as only having sagittal plane deformity with extension and an intact posterior hinge, are treated with gentle elbow flexion. Majority of the time these fractures can be anatomically reduced with very little effort. At our institution, there have been cases of type 2 fractures being turned into type 4 fractures with overzealous manipulation and aggressive pressure applied to the tip of the olecranon to aid in reduction.

For type 3 fractures, we start with applying axial traction to the arm, with countertraction applied at the axilla by an assistant. The elbow is held in 20° to 30° of flexion during this maneuver to avoid tethering of the anterior neurovascular structures over the proximal spike of the fracture. The forearm may be alternately pronated and supinated to determine which position achieves the most fracture stability. In general, a posteromedially displaced fracture is associated with an intact medial periosteal hinge, which may be maximally tensioned with pronation of the forearm (Figure 3). Conversely, fractures that are displaced posterolaterally may be more stable with supination of the forearm, although this is variable.¹⁰ Dynamic fluoroscopy alternating between forearm pronation and supination may be especially useful in determining the optimal position of the forearm for addressing varus/valgus malalignment of the fracture and ultimately the stability of the reduction. Medial-lateral fracture translation may also be addressed at this time by direct manipulation of the distal fragment.

Once the coronal and axial plane deformities are corrected, the sagittal plane can be addressed. The reduction maneuver itself consists of pressure directed volarly on
the tip of the olecranon using the surgeon’s thumb(s) to lever the distal fragment anteriorly as the arm is slowly flexed to approximately 130° (Figure 4). A clunk may be heard and/or felt following attempted reduction, and an immediate increase in the passive flexion of the elbow is typically observed. For both type 2 and type 3 fractures, if the fingers cannot touch the shoulder following the reduction maneuver, this may be an indication that there is residual extension at the fracture site and the fracture is not reduced.

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