Type I Fracture

Type I fractures are typically treated closed with 3 to 4 weeks of immobilization in a long arm cast with the elbow flexed to 90°. A small degree of posterior angulation of the distal fragment may be accepted in anticipation of remodeling, although children may have more than normal elbow extension and less than normal elbow flexion until it does. Normally, the capitellum is angulated anteriorly about 30° and reduction is not required if the posterior angulation is 20° or less, that is, if the anterior humeral line intersects any part of the capitellum. In general, type I fractures simply require immobilization for comfort and protection, and this can be achieved with a posterior splint (if concerns about swelling are present) or a long arm cast. One pitfall in treating a type I fracture lies in not recognizing medial impaction of the fracture that, if left uncorrected, will result in a varus deformity, which will not correct with growth ( Fig. 10-14 ). De Boeck and associates identified 13 patients with medial compression of the distal end of the humerus in otherwise innocent-looking type I fractures that developed varus deformities. If medial compression is a concern, the best way to assess angular alignment of the extremity is by examination under anesthesia with full elbow extension so that the carrying angle of the injured elbow can be compared with the contralateral side. Because of nuances in positioning and the effect of rotation on accuracy, measurement of the Baumann angle or the medial epiphyseal angle may not accurately reflect the true carrying angle of the elbow.

Anteroposterior radiograph of the distal end of an elbow shows a nondisplaced supracondylar fracture with impaction of the metaphysis medially. The lateral column is intact. The deformity produced by this injury should be corrected to prevent persistent angular malalignment (cubitus varus) when the fracture heals.

A type I fracture with medial compression must be reduced so that development of cubitus varus is prevented. With the patient under general anesthesia, the fracture is reduced by application of longitudinal traction with the elbow in full extension. An assistant applies countertraction to the upper part of the arm. Valgus correction is obtained with the use of the forearm as a lever. Once reduced, the fracture may be treated in a long arm cast in extension or preferably, because the medial column may be inherently unstable, with crossed K-wires to prevent drift back into varus. Once the fracture is stabilized with crossed pins, the elbow may be flexed to 80° to 90° and immobilized for 3 weeks.

Type II Fracture

Management of type II fractures is controversial. Type IIA fractures, which are extended but have no rotation or translation, may be successfully treated with closed reduction and casting. Alignment of these fractures does need to be closely monitored for loss of reduction, primarily in the coronal plane because varus or valgus angulation will not remodel. Residual posterior angulation can be expected to remodel with growth because the deformity is close to and primarily in the plane of motion of the joint. Two pitfalls in managing type IIA fractures closed are accepting reduction when the distal fragment is angulated too far posteriorly such that the capitellum is posterior to the longitudinal axis of the anterior humerus and mistaking posterior translation of the distal fragment for angulation. In the former scenario, the patient may be left with a significant hyperextension deformity of the elbow that is more of a cosmetic than functional problem, and in the latter, the patient may have a significant flexion lag that can be a functional problem, particularly if it involves the dominant extremity. Type IIB fractures ( Fig. 10-15 ) should be treated operatively with closed reduction and percutaneous pinning.

Type II supracondylar humeral fracture. A, Lateral radiograph of the elbow shows posterior angulation of the distal humeral fragment. The anterior humeral line does not intersect any part of the capitellum. The distal fragment is rotated. B, Postreduction anteroposterior radiograph showing fixation with divergent lateral entry pins.

Type III Fracture

Type III fractures are best managed by closed reduction and percutaneous pin fixation. Type III fractures are more severe injuries that are associated with more significant swelling and soft tissue injury, are more difficult to reduce, and are more likely to have neurovascular injuries or complications. These fractures are completely displaced. In most instances, the proximal and distal bone fragments are not in contact, and only a small bridge of periosteum may be preserved posteriorly. These fractures are prone to developing residual deformity, particularly cubitus varus, when treated by closed reduction and casting. In separate retrospective studies by Kurer and Regan and Pirone and associates of completely displaced supracondylar fractures, closed reduction and splinting or casting resulted in significantly fewer good results and more complications than traction or percutaneous pinning, which provide the best results. Based on the best current evidence and a systematic review of published studies as reported by Howard and associates, closed reduction with percutaneous pinning is widely accepted as the best method of treatment for all type III fractures, as well as for any type II fractures that are not reducible or that are associated with neural or vascular status changes during fracture reduction.

Type IV Fracture

Type IV fractures are unstable in both flexion and extension, have complete disruption of the periosteum both anteriorly and posteriorly, and need to be managed operatively (see Fig. 10-13 ). This fracture is inherently unstable and requires internal fixation. Leitch and colleagues described a method of closed reduction and percutaneous fixation that involves placement of K-wires before reduction of the fracture and rotation of the fluoroscopy unit, rather than the extremity, to obtain orthogonal views. However, these fractures may need to be opened to obtain adequate reduction.

Traction

The use of traction, either skin or skeletal, is rarely used any longer as definitive treatment for supracondylar fractures, having been supplanted by closed reduction and percutaneous pinning. Traction may still have a role as a temporizing measure when the fracture cannot be treated otherwise because of swelling, local skin problems, or life-threatening conditions and in settings where access to specialized care may be delayed or is unavailable. Traction has been used in the management of supracondylar fractures since 1939 when Dunlop described a technique of skin traction with the elbow extended. Modifications involving skeletal traction with the use of a K-wire or screw anchor in the ulna have also been reported. Traction may be applied vertically, overhead, or horizontally, in a sidearm manner. Overhead traction ( Fig. 10-16 ) tends to be easier to manage and has the advantage of elevating the elbow, thereby helping to reduce swelling. In addition, with the arm overhead, the forearm rotates into pronation, which is the preferred position for fractures that are displaced posteromedially, because pronation is believed to close the lateral side of the fracture, which may decrease the risk of cubitus varus.

Overhead skeletal traction has been applied to this child’s arm with a supracondylar humeral fracture. A winged screw was inserted into the proximal end of the ulna at approximately the level of the coronoid process. Skeletal traction was then applied through the screw.

Several studies have shown that results for patients treated with skin and skeletal traction were equal to those treated with closed reduction and casting or pin fixation. ^∗

∗

Closed Reduction and Cast Treatment

Accurate closed reduction of supracondylar humeral fractures is critical for preventing cubitus varus deformity, regardless of whether the fracture is treated closed or pinned. Reduction of the fracture is accomplished with the patient under general anesthesia and with fluoroscopic guidance. With the elbow extended, gentle longitudinal traction is applied to the supinated forearm while countertraction is applied to the upper part of the arm by an assistant. The distal fragment is then translated medially or laterally, depending on the position of displacement, by application of digital pressure to the appropriate condyle. Most of these fractures are displaced posteromedially, and reduction of this component of the deformity is achieved by having the surgeon flex the patient’s elbow to 120° while simultaneously pronating the forearm and applying digital pressure with the thumb of the opposite hand to the olecranon to reduce the posterior displacement of the distal fragment. Pronating the forearm is thought to engage the intact posteromedial periosteum and allow the fracture to be reduced. Pronation also causes the wrist extensors and brachioradialis to tighten, which helps close down and stabilize the fracture laterally. If the fracture is displaced posterolaterally, the forearm is supinated so that the intact posterolateral periosteal bridge can be used in a reciprocal manner.

The elbow must be flexed maximally so that reduction of the fracture is maintained while imaging is performed to assess alignment. A lateral view is relatively easily obtained by external rotation of the shoulder. Alternatively, if the reduction is tenuous, this view can be obtained by rotation of the fluoroscopy tube to a cross-table position so that the arm does not have to be moved. Adequate sagittal alignment can be assessed by the relationship of the capitellum to the anterior humeral line and the presence or absence of overlap of the ossification center of the capitellum on the olecranon. Coronal alignment of the fracture is assessed with the so-called Jones view, which is, in essence, an AP image of the distal humerus taken through the flexed, overlying forearm. Although detail of the distal humerus is slightly obscured, the image is usually adequate for assessment of the alignment of the medial and lateral columns of the distal humerus and restoration of the olecranon fossa by slight internal and external rotation of the arm. The Baumann angle and the medial epicondylar epiphyseal angle can be measured on this view, and the adequacy of reduction is defined as a deviation of less than 5° compared with the contralateral side. Otsuka and Kasser believed that the Baumann angle, the relationship of the capitellum to the anterior humeral line, and restoration of the normal anatomy of the olecranon fossa represented the best indicators of a satisfactory reduction.

Once the fracture has been reduced, immediate flexion of the elbow with either pronation (for posteromedial displacement) or supination (for posterolateral displacement) of the forearm is required to maintain reduction in a cast. The problem with this position is that immediate flexion of the elbow increases the tension in an already swollen extremity, thus increasing the risk of vascular compromise by reduction of arterial flow into and venous flow out from the forearm. In a clinical study, Mapes and Hennrikus showed that the Doppler pulse became weaker and even disappeared in patients with supracondylar humeral fractures whose elbows were flexed. The more the elbow was flexed, the weaker the pulse became. Because of the dilemma of potential vascular compromise with cast immobilization in the position necessary to prevent loss of reduction, percutaneous pinning has emerged as the treatment of choice for maintaining alignment after closed (or open) reduction of displaced supracondylar humeral fractures.

Closed Reduction and Percutaneous Pinning (Author’s Preferred Treatment)

The modern era of treatment of this fracture began in 1948 with a description by Swenson of percutaneous pinning of distal humeral fractures in adults. In 1961, Casiano reported the use of this technique in children. Since this description, multiple reports of the use of percutaneous pinning for the maintenance of reduction of a displaced supracondylar fracture have appeared. Traditionally, a crossed pin configuration has been used to stabilize these fractures, but increasingly, the recent trend has been to stabilize only with lateral entry pins because of concerns of ulnar nerve injuries that have been reported in up to 10% of patients treated with a medial entry pin.

Technique

Closed reduction and pinning are typically done with the child positioned supine and the injured limb suspended over the side of the table. This position allows free access to the C-arm, which is placed directly under the arm parallel to the operating table ( Fig. 10-17 ). The procedure is usually done with sterile preparation and draping, with incorporation of the C-arm unit as the operating table. Alternatively the procedure can be done in a semisterile fashion. Iobst and associates have described their experience with a technique that does not require drapes or gowns, hence reducing operating room time and costs. In their series of more than 300 cases, there were no superficial or deep pin infections. Reduction of the fractures is performed by extension of the elbow with longitudinal traction applied to the forearm. An assistant places countertraction on the upper part of the arm. Medial or lateral displacement is corrected, and the arm is externally rotated so that the internal rotation deformity can be corrected. The surgeon then flexes the patient’s elbow maximally, maintaining traction while pronating (for posteromedial displacement) or supinating (for posterolateral displacement) the forearm. The surgeon’s thumb is used to push the olecranon forward, which assists in the reduction.

The C-arm machine is draped sterilely so that it can be used as the operating table for reduction and pinning of supracondylar humeral fractures.

Most fractures can be reduced with this technique; however, if the posterior periosteum is torn, the fracture will be completely unstable because the hinge that the intact posterior periosteum provides for reduction is lost, which would make reduction of the fracture difficult. Fracture reduction can also be hindered by soft tissue interposition in the fracture. If a spike of the proximal fragment penetrates the brachialis muscle, the muscle must be removed before the fracture is reduced. Peters and colleagues described a technique for dislodging the entrapped brachialis muscle by grasping the arm close to the axilla and gradually “milking” the anterior musculature in a proximal-to-distal direction toward the spike of the proximal fragment while an assistant applies countertraction through the axilla. Pressure is placed primarily on the lateral side to avoid injury to the medial neurovascular structures. Freeing of the entrapped muscle may be accompanied by a palpable sensation of the bone disengaging the soft tissues. Once the brachialis muscle has been cleared, the reduction can usually be completed ( Fig. 10-18 ). One must be cautious manipulating a supracondylar humeral fracture that is displaced in a posterolateral direction with buttonholing of the brachialis muscle, particularly when a neurologic deficit exists, because of the risk of further neurovascular injury. In 27 children with vascular deficits (22 of whom also had median nerve deficits) and posterolaterally displaced fractures, Rasool and Naidoo found that the neurovascular bundle was trapped just anterior to the metaphyseal spike in 18 patients, trapped behind the fracture in 5, and separated by the fracture spike in 4.

Markedly displaced extension type III supracondylar humeral fracture reduced with the “milking technique.” A and B, Anteroposterior (AP) and lateral radiographs show posteromedial displacement of the distal fragment. The anterior spike of the proximal fragment had penetrated through the brachialis muscle and was tenting the skin in the antecubital fossa. Neurovascular status of the extremity was intact. The fracture was reduced by closed means with a “milking technique” to massage the brachialis muscle off the end of the proximal fragment and then pinned percutaneously with the use of crossed, medial and lateral entry pins. C and D, Intraoperative AP and lateral radiographs show anatomic restoration of the distal humerus and the fracture stably fixed with pins crossing above the fracture site.

Once obtained, fracture reduction is confirmed fluoroscopically. Sagittal alignment may be checked by either external rotation of the shoulder on the C-arm or, if the reduction is tenuous, by rotation of the C-arm to prevent loss of reduction. The Jones (transcondylar) view is used to assess coronal alignment with the elbow flexed, and alignment of the medial and lateral columns of the distal humerus can be further assessed by slight internal and external rotation of the arm. If reduction is satisfactory, percutaneous pinning is performed. It is debatable whether a medial entry pin should be used or whether two lateral pins are sufficient. It has been shown that crossed pins are more stable biomechanically ; however, in comparative clinical studies, the stability afforded by two lateral pins has been shown to be adequate for maintenance of reduction in type II and most type III fractures. For type II fractures, the author uses two lateral pins, which afford ample stability ( Fig. 10-19 ), and for type III fractures, the author adds a third pin, either lateral- or medial-entry, depending on fracture characteristics and surgeon preference, as recommended by Bloom and colleagues ( Fig. 10-20 ). In children younger than 4 years, 0.062-inch K-wires are adequate. In older children, <SPAN role=presentation tabIndex=0 id=MathJax-Element-1-Frame class=MathJax style="POSITION: relative" data-mathml='564′>564564
5 64
-inch wires are more suitable.

A 4-year-old patient with a closed, extension type II supracondylar humeral fracture. A and B, Anteroposterior (AP) and lateral radiographs show posteromedial displacement with intact posterior cortex but with rotation of the distal fragment. C and D, AP and lateral intraoperative fluoroscopic images after closed reduction and pin fixation with two lateral entry pins. Note the slight divergence of the pins and bicortical fixation, both of which are desirable for stability. E, Internal rotation “stress” view shows a stable reduction with this pin configuration.

An 8-year-old patient with a widely displaced extension type III supracondylar humeral fracture that was treated by closed reduction and percutaneous fixation with three lateral entry pins. A and B , Anteroposterior (AP) and lateral radiographs of the elbow show the fracture and extent of bony displacement and soft tissue disruption. C and D , Intraoperative AP and lateral fluoroscopic views show a near-anatomic reduction. A third K-wire was placed based on the characteristics of this fracture. E, Internal rotation “stress” view shows the reduction to be stable. Another fixation option would have been to use a medial entry pin.

(Photos and radiographic images courtesy of Jonathan Schoenecker, MD, Vanderbilt University Medical Center, Nashville, TN.)

Pinning is performed with the elbow maximally flexed and resting on the C-arm tube. With the arm rotated to the neutral position, the hand pointing to the ceiling, and a small towel bump placed under the elbow to facilitate clearance from the C-arm, the first K-wire is inserted through the lateral condyle and across the distal humeral physis. The surgeon can check the pin fluoroscopically by rotating the shoulder externally to be sure that the pin is positioned and directed properly in the sagittal plane. The arm is rotated back to neutral, and the pin is then advanced just lateral to the olecranon fossa to engage the opposite cortex. The path of the pin in the coronal plane can be checked fluoroscopically with the use of the Jones (transcondylar) view. A second and, if necessary, a third lateral entry pin can be placed in similar fashion with the use of a parallel-to-slightly divergent path; the surgeon should attempt to achieve as much spread as possible, avoiding convergence or crossing at the fracture and engaging cortices of both the lateral and medial columns. A biomechanical study of pin configurations by Lee and colleagues comparing crossed pins, parallel lateral pins, and divergent lateral pins found that the stability provided by divergent lateral pins exceeded that of parallel lateral pins and was similar to crossed pins in all but torsional loading; the study prompted the recommendation for divergent placement for lateral entry pins so that stability could be maximized. If the fracture is comminuted or deemed to be very unstable, a medial entry pin may need to be placed. Zenios and colleagues performed prospective intraoperative evaluation of stability in 21 consecutive patients with type III fractures by taking lateral images of external and internal rotation after pinning with two lateral pins; the authors found only six (28%) to be stable, which necessitated placement of a third lateral or medial column pin.

There is no doubt that a crossed pin configuration is biomechanically the most stable construct and historically has been the technique of choice. Zionts and colleagues studied the torsional strength of different pin configurations in displaced supracondylar humeral fractures and found that the torque required to produce 10° of rotation was 37% less with the use of two lateral pins than with the use of medial and lateral pins, and it was 80% less if the lateral pins were crossed. However, reports of ulnar nerve injury with this technique in up to 10% of patients have prompted the current trend of lateral-entry pin fixation.

Injury to the ulnar nerve may occur by direct penetration, particularly when the nerve is unstable such that it subluxates in flexion, by tethering if adjacent soft tissues are wrapped up as the pin is inserted, or by stretching around the pin when the elbow is flexed. These potential problems can be mitigated when one performs medial-entry pin placement by extending the elbow to less than 80° flexion (permissible once fixation of the lateral column has been performed), allowing the ulnar nerve to move posteriorly away from the medial epicondyle, and then making a very small incision centered on the medial epicondyle to allow direct placement of the K-wire on the bone, which ensures that the nerve is avoided ( Fig. 10-21 ). The position of the medial pin is then checked with fluoroscopy and advanced toward the lateral cortex of the humerus; the lateral pin(s) crosses proximal to the fracture site and engages the far cortex for maximal stability. Once the medial pin is positioned, the elbow can be extended so that the carrying angle and coronal alignment of the fracture can be assessed on a true AP radiograph. The pins are padded and bent outside the skin, and the arm is splinted or placed in a bivalved cast with the elbow in 70° to 80° of flexion. Using this technique, Green and associates reported no ulnar nerve motor injuries and just one transient ulnar sensory neurapraxia in their single-cohort retrospective study of 71 consecutive children treated for Gartland type II or III supracondylar humeral fractures.

Technique for placement of medial entry pin. A, Patient is supine with arm draped free on the C-arm platform. B, The lateral entry pin is placed first, and the fracture is provisionally stabilized. C, The elbow can then be externally rotated and extended, which allows the ulnar nerve to move away from the medial epicondyle and permits access to the medial epicondyle. A 5-mm incision is made directly over the medial epicondyle, and soft tissue is swept away with a hemostat or elevator. D, The K-wire can then be positioned directly on the medial epicondyle and driven up the medial column. E, Anteroposterior and lateral radiographs showing pins crossing above the fracture site and bicortically engaged.

Children should be hospitalized until they are comfortable, their neurologic status can be confirmed, and the risk of circulatory compromise is past. The arm is placed in a sling. Alignment is checked 1 week postoperatively, and the splint is converted to a long arm cast. At 3 to 4 weeks after surgery, the pins are removed, and immobilization is discontinued if radiographs demonstrate sufficient healing. Unprotected motion, with activity restrictions, is allowed. Formal physical therapy is not typically necessary because most children regain normal motion by 3 to 4 weeks on their own.

Pin Configuration and Alternate Techniques

The relative safety of medial entry pins has been addressed in several recent studies of type III supracondylar humeral fractures. A systematic review by Brauer and associates of 2054 children from 35 studies found the probability of iatrogenic nerve injury to be 1.84 times higher with medial pins. Slobogean and associates performed a metaanalysis of 32 studies with 2639 patients and found a higher rate of ulnar nerve injury with crossed pinning and calculated the number needed to harm to be 28 (i.e., one ulnar nerve injury for every 28 patients treated with cross pinning). In their analysis of pooled data of 5154 fractures, Babal and associates found that medial entry pinning was associated with a 4% risk of injury to the ulnar nerve and that lateral entry was associated with a 3% risk to the median nerve. A prospective, randomized clinical study by Kocher and colleagues in 2007 comparing lateral entry pins to medial and lateral entry pins found no statistically significant difference in the rate of ulnar nerve injury. More recently, Garg and colleagues performed a retrospective, comparative study of 872 patients with type III supracondylar humeral fractures, representing the largest single center study of severe supracondylar humeral fractures (all type III), and found a slightly higher but statistically insignificant ( P > 0.5) increase in the rate of ulnar nerve palsy with medial entry pins. Specifically, five of 335 patients with medial pins and four of 537 patients without medial pins developed ulnar nerve palsy.

To avoid distal medial pin insertion, Shannon and colleagues, in their experience with 20 patients with type III supracondylar humeral fractures, used a novel lateral pin insertion technique to achieve bicolumnar fixation. They placed two Kirschner wires from the lateral side after fracture reduction. The first pin is introduced in standard fashion through the lateral condyle, across the fracture and through the medial cortex, proximal to the fracture. The second pin is started on the lateral cortex proximal to the fracture site and is passed in retrograde fashion across the fracture into the medial condyle but not through the medial cortex. They had no iatrogenic ulnar nerve injuries and good clinical results. The authors conclude that this technique offers the biomechanically superior benefits of a cross-pin configuration while concurrently avoiding the risks of iatrogenic ulnar nerve injury associated with distal medial-entry pinning. This may be a viable technique, but the biomechanical strength is likely not equal to the classic cross-pin configuration because the medial column pin only engages three cortices and not four. One concern is the risk of iatrogenic injury to the radial nerve during insertion of the proximal lateral pin, although no such injuries were reported in this series.

Fowler and Marsh provided a detailed description of closed reduction and percutaneous pin fixation of displaced supracondylar humeral fractures with the patient in the prone position. The advantage of this technique is that gravity can be used to facilitate fracture reduction without the need for hyperflexion of the elbow, theoretically minimizing the risks of vascular compression and iatrogenic ulnar nerve injury with pin placement that have been associated with the immediate hyperflexion of an injured, swollen elbow.

Sawaizumi and colleagues described a technique referred to as “leverage pinning” to facilitate percutaneous reduction of displaced supracondylar humeral fractures that avoids the need for hyperflexion of the elbow. In their original description, the authors positioned the patient laterally and placed the elbow in a reduction bracket attached to the operating room table with the forearm allowed to hang free. Under C-arm guidance, the medial and lateral alignment was corrected and confirmed on an AP view. Next, a 2-mm Kirschner wire was introduced percutaneously through the triceps, in a proximal-to-distal direction, into the fracture site, engaging the proximal fragment just past the posterior cortex. The Kirschner wire was then used as a “joystick” to lever the distal fragment in an anterior direction by movement of the pin distally. Once reduction was obtained, the Kirschner wire was advanced through the anterior cortex of the humerus, thus stabilizing the fracture. An additional lateral pin was added to complete fixation.

Yet another option is to place medial and lateral pins or two lateral pins and remove the reduction pin. Yu and colleagues reported their experience with a similar technique using a temporary 3-mm K-wire to facilitate reduction of type III supracondylar humeral fractures that could not be realigned with traditional closed maneuvers with the patient supine ( Fig. 10-22 ). They used this technique in 42 of 118 patients and did not have to resort to open reduction of the fractures. Their results with this technique were similar to conventional closed reduction and cross pinning.

Example of percutaneous leverage pinning to reduce a type III supracondylar humeral fracture. A and B , Anteroposterior and lateral radiographs show a type III supracondylar humeral fracture. C , Initial inability to obtain adequate closed reduction. D , A 2-mm Kirschner wire is placed percutaneously through the triceps tendon, into the fracture site. E , The surgeon moves hands distally, levering the fracture anteriorly, into more adequate alignment. F and G , Once adequate alignment is obtained, the wire is advanced through the anterior cortex to maintain reduction. The surgeon can then proceed with lateral or medial pin placement.

(Photos and radiographic images courtesy of Steven Lovejoy, MD, Vanderbilt University Medical Center, Nashville, TN.)

Open Reduction and Internal Fixation

The indications for open reduction of supracondylar fractures are for fractures that cannot be reduced by closed methods, for those that are not amenable to closed treatment because of intraarticular comminution, for open fractures that require irrigation and débridement, and for fractures with vascular compromise or neurologic loss after reduction that require exploration and possible repair of neurovascular structures. It is unusual for fractures to be irreducible by closed means; however, when it occurs, the most common cause is interposition of soft tissue or neurovascular structures. The brachialis is a common soft tissue impediment to reduction. Entrapment of the brachial artery may be heralded by vascular compromise on attempts at closed reduction. Fleuriau-Chateau and associates reported on 41 open reductions performed for irreducible supracondylar fractures. The most common finding intraoperatively was buttonholing of the brachialis muscle by the distal end of the proximal fragment. They also found tethering of the median or radial nerve (or both), with or without the brachial artery, that was not expected on the basis of a preoperative evaluation.

Failure to achieve adequate reduction is the most common cause of a poor outcome after supracondylar humeral fractures, and open reduction is preferable to repeated attempts at closed reduction or accepting suboptimal alignment. Results after open reduction compare favorably to closed reduction and pinning. Cramer and colleagues found comparable results for open reduction with pin fixation and closed reduction with percutaneous pin fixation, despite the fact that the fractures in the open reduction group were more severe and were unable to be reduced by closed means. Ozkoc and colleagues reported on 99 patients with displaced extension type supracondylar fractures of the humerus. The first 44 were treated with open reduction and internal fixation because of a lack of an image intensifier. The next 55 patients were treated with closed reduction and percutaneous pin fixation. These authors found that the open surgical group had slightly worse functional outcomes. They lost an average of 6° of extension and 8° of flexion compared with 0.6° and 8°, respectively, in the closed group. There were no cosmetic differences. This report confirms that closed reduction and percutaneous pinning is the preferred treatment but that open reduction also leads to very good results, if indicated.

Technique

Anterior, medial, lateral, and posterior surgical approaches to the distal humerus have all been described. A guiding principle in choosing an approach for supracondylar fractures is that it should be performed through the area of disrupted periosteum. The presence of a neurovascular deficit should also be considered when an approach is chosen. An anterior approach through a transverse incision in the antecubital fossa provides access to the common soft tissue impediments to reduction and the best exposure of the neurovascular structures ( Fig. 10-23 ). In addition, it can be converted to an extensile exposure by extension of the incision proximally in a longitudinal fashion along the medial side of the brachium or distally along the radial side of the forearm as needed. The medial approach is preferred for flexion type injuries in which the ulnar nerve is likely to be trapped in the fracture.

Anterior approach for open reduction of a type III supracondylar humeral fracture. A and B , Anteroposterior (AP) and lateral radiographs of a type III supracondylar humeral fracture in an 8-year-old patient with median nerve paresthesias and a decreased radial pulse. C , Anterior approach through a transverse incision in the antecubital flexion crease shows entrapment of the median nerve and tethering of the brachial artery by the fracture. D , Neurovascular structures were carefully decompressed and freed from the fracture site. The radial pulse improved almost immediately, which allowed the fracture to be reduced. E and F , AP and lateral radiographs showing anatomic reduction of the fracture and crossed pin fixation.

(Photos and radiographs courtesy of Gregory Mencio, MD, Vanderbilt University Medical Center, Nashville, TN.)

Koudstaal and colleagues reported their outcomes in 26 patients in whom the anterior approach was used and compared them with a historical group of their own patients whose fractures were treated through a lateral or combined medial and lateral approach. They used a transverse incision in the antecubital fossa. The scar runs parallel with the normal skin folds and, as such, is very cosmetic and avoids the contracture that can be associated with a longitudinal incision made across the flexor surface of the elbow. Results were evaluated with the use of Flynn’s criteria, and no statistically significant difference was noted between the three approaches. Advantages of the anterior approach were as follows: (1) a more thorough hematoma evacuation from the antecubital fossa, (2) excellent fracture visualization with concurrent visualization of entrapped muscle and vascular and neural structures, and (3) the ability to directly palpate the medial and lateral epicondyles, which allows the surgeon to correct any residual malposition. Ay and colleagues also performed a retrospective review of 61 children with displaced supracondylar humeral fractures who had open reduction and K-wire fixation via an anterior approach and found that all patients had either an excellent (73%) or good (27%) outcome by Flynn’s criteria. These two studies do lend support to the anterior approach for open reduction and internal fixation, but it is not clearly superior from a functional outcome standpoint compared with other approaches.

The medial approach is performed with the shoulder externally rotated. A 3- to 4-cm longitudinal incision is made on the medial side of the distal end of the humerus and elbow. Once the skin and subcutaneous fat have been incised, the fracture hematoma and the fracture are encountered. The ulnar nerve is protected but does not have to be visualized. The periosteum over the anterior aspect of the proximal fragment is usually stripped by the injury. The fracture hematoma can be evacuated and the fracture explored by visual and digital inspection; this ensures that no neural or vascular structure is trapped. Adequate visualization of the fracture is necessary to ensure anatomic reduction, but care must be taken not to disrupt the intact posteromedial periosteal hinge. The fracture is reduced and cross-pinned. If anatomic reduction is not possible, a lateral approach is made to ensure a perfect reduction. The lateral incision, which is also longitudinal, is made over the lateral condyle of the distal end of the humerus; such an incision allows exposure of the lateral side of the fracture. The pins are left protruding from the skin and are bent.

The posterior approach to the elbow is preferred when there is intraarticular extension or comminution of the distal humeral condyles in older patients. It is not generally indicated in young children with type III supracondylar fractures because it may compromise the only intact periosteum and blood supply to the distal humerus.

Postoperative discomfort is usually minimal, most likely attributable to decompression of the hematoma and neurovascular structures and stabilization of the fracture. Patients may typically be discharged from the hospital the day after surgery. Their follow-up is the same as that for closed pinning. The pins are generally removed and motion is begun 3 weeks after surgery. The risk of myositis ossificans, which discouraged surgery on these fractures in the past, has not been a problem in this author’s experience.

Vascular Compromise

Vascular conditions can be grouped into two types: acute, from occlusion of the brachial artery, and subacute, or Volkmann ischemia. Fortunately, acute vascular insufficiency is relatively uncommon, occurring in 5% to 12% of children with supracondylar humerus fractures. The vascular status of the extremity can be assessed by color of the hand (pink or white), temperature of the extremity (warm or cold), neurologic status, amount of pain, and status of the radial pulse (presence or absent). The elbow has excellent collateral circulation that usually provides sufficient blood flow to the arm, even if the brachial artery is damaged, hence the term pink, pulseless hand. The absence of the radial pulse on palpation is never normal, but it is not always an indication of a true arterial injury. In fact, the radial pulse may be absent because of spasm and may return after reduction of the fracture. Loss of the pulse during reduction may indicate obstruction from too much elbow flexion or entrapment of the artery in the fracture with reduction. Absence of the pulse on palpation and by Doppler ultrasound is significant and thought by some to be indicative of a true arterial injury.

Arterial exploration is always indicated in the event of a truly dysvascular extremity. However, simple absence of the radial pulse with good peripheral circulation may not always be an indication for arterial exploration. When the radial pulse is absent (regardless of the perfusion status of the hand), fracture reduction with pin fixation and reassessment of the vascular status are the recommended treatment steps. If the radial pulse is absent but concomitant median or AIN palsy is present, immediate exploration may be warranted. If the hand is perfused, but remains pulseless after reduction, opinion is divided about the need for immediate arterial exploration in all children.

The persistent absence of a radial pulse after fracture reduction is always worrisome. Campbell and colleagues studied 59 children with supracondylar humeral fractures in whom 11 (19%) had absent pulses; the pulses returned after reduction in five patients and required no further treatment. The other six patients underwent exploration of the brachial artery. The artery was interposed in the fracture in one patient and lacerated in one, and one had an intimal tear. The other three patients were found to have spasm that resolved without other treatment. They recommend vascular exploration if the radial pulse is absent after reduction of the fracture.

Copley and colleagues reviewed 128 children with grade III supracondylar fractures of the humerus. Seventeen of the children had absent or diminished (detected on Doppler but not on palpation) radial pulses on initial examination. Fourteen of the 17 recovered pulses after fracture reduction, but the remaining three had persistent absence of the radial pulse. These patients underwent arterial exploration of the brachial artery immediately, and a significant vascular injury requiring repair was found in each. In two of the 14 patients whose pulses returned after fracture reduction, progressive postoperative deterioration in their circulation developed during the first 24 to 36 hours after reduction, with loss of the radial pulse. In both, arteriography identified arterial injuries, and both underwent exploration and vascular repair. These investigators concluded that absence of the radial pulse after reduction of a supracondylar humeral fracture indicated the existence of a significant arterial injury requiring surgical exploration and vascular repair. Further, they recommended that in the event of deterioration of vascular status, arteriography may delay definitive treatment and is not necessarily indicated because the location of the arterial injury is always at the level of the fracture. Although acknowledging that there may be a role for close observation of a hand that is perfused (“pink”) but pulseless, their treatment algorithm for managing the pulseless hand advises arterial exploration if the pulse does not return after reduction of the fracture ( Fig. 10-24 ).

Flow chart to guide decision making in cases in which a possible vascular injury is associated with a displaced supracondylar humeral fracture. CRPP, Closed reduction and percutaneous pinning; OR, operating room.

(Redrawn from Copley LA, Dormans JP, Davidson RS: Vascular injuries and their sequelae in pediatric supracondylar humeral fractures: toward a goal of prevention. J Pediatr Orthop 16:99–103, 1996.)

Schoenecker and colleagues agreed with these authors in recommending arterial exploration in the absence of a Doppler-detectable radial pulse. They performed surgical exploration in seven limbs without a radial pulse after a supracondylar fracture and found the brachial artery to be either kinked or entrapped in the fracture in four. They repaired three of the arteries.

On the other hand, Garbuz and associates reviewed 326 patients with supracondylar fractures of the distal end of the humerus and found 22 whose radial pulses were absent on examination. Radial pulses returned in 15 patients after fracture reduction, and these extremities were monitored without exploration of the brachial artery. In seven patients, absence of the radial pulse persisted after reduction and the hand was dysvascular; all underwent arterial exploration with arterial repair. They recommend that patients with an absent radial pulse but good circulation to the hand be observed after fracture reduction because the collateral circulation around the elbow is excellent and will provide the arm and hand with excellent blood flow.

Sabharwal and colleagues reviewed patients with supracondylar fractures of the distal end of the humerus and found that 13 of 410 fractures did not have radial pulses. All patients without a radial pulse had adequate collateral circulation as demonstrated by magnetic resonance angiography, duplex scanning, or both. They performed arterial exploration in all these patients and found arterial injuries in all of them. Arterial repair was then performed in all patients; however, asymptomatic reocclusion and residual stenosis were observed in these patients at follow-up. They recommended observation of patients with supracondylar humeral fractures and an associated absence of a radial pulse. They reasoned that the collateral circulation is adequate for the normal survival and use of the upper extremity, and they further stated that if the brachial artery is repaired, it is likely to become occluded as a result of insufficient flow.

Choi and colleagues determined that 2.6% of supracondylar fractures (33/1255) are seen without a pulse. Of the 33 patients without radial pulses in this study, 24 were considered to be pulseless but well perfused at presentation, and all of these remained so immediately after reduction and internal fixation. Of the 24 patients, 14 (58%) were also noted to have a palpable pulse return. Four more patients subsequently had return of a palpable pulse at an average of 8 weeks. In all, 75% of the perfused and pulseless limbs (18/24 patients) normalized after reduction and fixation. The other six patients in this group never had a documented return of pulse but sustained no known ill effects. Of the nine pulseless and poorly perfused limbs, only two had return of both pulse and perfusion, and another two regained perfusion but remained pulseless. The other five patients with pulseless, dysvascular limbs underwent exploration and repair at an average of 7.3 hours after injury and had good results. Garg and colleagues observed restoration of a palpable pulse by the first postoperative visit in all of the children in their study of type III supracondylar fractures treated by closed reduction and pinning; their patients had initially been seen with absent palpable or Doppler-detected pulses but clinically perfused limbs.

More recent studies suggest that a “watchful, waiting” strategy of the pulseless, perfused limb after a supracondylar humeral fracture may underestimate the significance of the vascular injury. White and colleagues performed a metaanalysis in which they studied pooled data for 313 pulseless supracondylar fractures. They found a 77% rate of true vascular injury in the setting of a pulseless, perfused supracondylar fracture and a 91% patent artery rate after brachial artery repair at 2 years’ follow-up. Mangat and colleagues found that 80% of patients with a pulseless, perfused hand had tethering or entrapment of the vessel when a concomitant nerve palsy (median or AIN) was present and recommended immediate arterial exploration in these circumstances. They also documented that all vessels repaired remained patent at follow-up. Reigstad and colleagues performed exploration on five patients with type III supracondylar humeral fractures whose extremities remained pulseless with slow or absent capillary refilling after closed reduction and percutaneous pinning. All were found to have an entrapped brachial artery, of whom four required microvascular repairs and two had entrapment of the median nerve. Normal function was documented at more than 1 year after exploration.

Blakey and colleagues found that 23 of 26 patients with “pink pulseless hands” who did not immediately undergo surgical exploration had some degree of ischemic contracture when they were examined at an average follow-up of 25 years (range, 4 to 26 years). These authors concluded that a pink pulseless hand after fracture reduction is ischemic and that persistent and increasing pain with a deepening nerve lesion was indicative of critical ischemia. They recommended urgent surgical exploration when the pulse is absent to prevent the long-term sequelae observed in their study.

Consensus current practice for the management of displaced, type III supracondylar humeral fractures when the pulse is absent, regardless of the status of the vascularity of the hand, is to perform closed reduction and percutaneous pinning on an emergent basis. If the pulse returns, the extremity can be splinted, neurovascular status can be monitored to ensure that there is no deterioration, and the patient can be discharged when comfortable. Regardless of the status of the pulse, if the hand is well perfused, which indicates adequate distal circulation, observation is appropriate. Current evidence does not support exploring all limbs without a palpable radial pulse. Although findings by White and colleagues and a poll of members of the Pediatric Orthopaedic Society of North America suggest that the common opinion of watchful waiting for pulseless and perfused (i.e., pink) hands after supracondylar fractures should be questioned, there is consensus that exploration of the brachial artery is indicated if the pulse returns but the vascular examination is equivocal, if the extremity is dysvascular, if there are signs of forearm ischemia, or if there is a concomitant median or AIN palsy. Arteriography is rarely indicated preoperatively because the location of the lesion is at the level of the fracture, and an arteriogram is unlikely to reveal anything that is not already known and will only delay treatment that is otherwise necessary.

Compartment syndrome is a rare complication of supracondylar fractures of the humerus in children. Historically, Volkmann ischemia was more common after closed reduction and immobilization of the elbow in a hyperflexed position, which is a practice that has been largely abandoned in favor of current treatment with pin fixation that allows the elbow to be splinted in much less flexion. The rate of compartment syndrome in supracondylar humeral fractures is estimated to be 0.1% to 0.3%. The risk is highest in fractures with an absent radial pulse and dysvascular hand, even after successful vascular repair. Posterolaterally displaced supracondylar fractures have a higher risk of vascular injury and compartment syndrome, whereas ipsilateral supracondylar and forearm fractures are a marker of significant trauma and have a higher risk of neurovascular injury and compartment syndrome.

The traditional signs and symptoms of forearm ischemia in adults—pain, paresthesia, paralysis, pallor, and pulselessness—are less reliable in predicting the presence of impending compartment syndrome in children. Pain and paresthesia are early signs of ischemia and nerve compression. Paralysis, pallor, and an absent pulse are later findings of more prolonged ischemia and may reflect irreversible change. In children, an increasing analgesic requirement has been shown to be the most sensitive indicator of impending compartment syndrome, preceding changes in vascular status by more than 7 hours. In children the combination of increasing analgesic requirement plus anxiety and agitation, referred to as the three A s, may be more predictive of impending compartment syndrome. Progressively deteriorating neurologic status in the absence of pain or other “typical” clinical findings may also be a sign of an evolving compartment syndrome. This so-called silent compartment syndrome should be suspected if a median nerve injury is present. In a young child, if there is suspicion of compartment syndrome, tissue pressure measurements should be obtained. This is best done emergently in the operating room. If compartment pressures are found to be elevated, a fasciotomy should be performed through an extensile volar approach extending from the elbow through the carpal tunnel. A fasciotomy performed within a mean of 30 hours from diagnosis has been shown to be effective in reducing the risk of permanent damage in 90% of children.

Neurologic Injury

It has been shown that the risk of nerve injury after supracondylar humeral fractures increases with increasing fracture displacement. Based on the findings of two recent studies—a metaanalysis of 5154 fractures by Babal and colleagues and a single-institution, consecutive cohort study of 872 type III fractures by Garg and colleagues —the incidence of neurologic injury after extension type supracondylar humeral fractures is about 12%. The most common nerve injured is the anterior interosseous, observed in about one third of cases, followed by injury to the radial nerve. Ulnar nerve injury was the least frequent. Garg and colleagues found a 28% rate of iatrogenic nerve injury but observed no difference with pin configuration.

Most nerve injuries that occur at the time of fracture are neurapraxias, regardless of the nerve injured. Motor recovery typically takes about 2 to 3 months, whereas sensory function may take up to 6 months Routine (early) nerve exploration is not recommended unless no clinical or electromyographic evidence of recovery has been noted by 5 months. Amillo and Mora recommended that if nerve recovery is not seen within this time frame, nerve exploration should be undertaken as soon thereafter as possible because recovery is less predictable with further delay and results were not good in their series when exploration was performed beyond 1 year after injury. Results of neurolysis are predictably good for chronic nerve palsies in which the nerve is in continuity. Early nerve exploration is indicated if nerve function deteriorates after closed reduction and pinning of the fracture because of the likelihood of nerve entrapment in the fracture site or iatrogenic injury. Extraction of the nerve from the fracture or from constricting soft tissue structures and removal of any compromising hardware should be performed as soon as the deficit is identified. Provided the nerve is not lacerated, observation is recommended for these iatrogenic injuries.

Cubitus Varus

Cubitus varus, defined as loss of carrying angle of more 5° compared with the contralateral elbow, is the most common late complication of displaced supracondylar humeral fractures and the most common angular deformity. Historically, the incidence after closed treatment has been reported to be as high as 58%. Pirone and colleagues observed a 3% incidence of cubitus varus after pinning compared with 14% after closed treatment. It is estimated that 5% to 10% of children with supracondylar fractures of the humerus will develop this complication, irrespective of the method of treatment.

The prevailing thought is that cubitus varus is a malunion that occurs as a result of malreduction or loss of reduction of the fracture and is caused by internal rotation in the transverse plane, medial tilting coronally, and extension in the sagittal plane. ^∗

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Cubitus varus is usually not painful and has traditionally been regarded as a cosmetic problem. However, several studies have cast light on potential functional consequences of this deformity. Abe and colleagues reported on 15 patients with tardy ulnar nerve palsy caused by cubitus varus deformity, at a mean interval of 15 years from fracture to the onset of symptoms. At operation they found compression of the ulnar nerve by a fibrous band running between the two heads of the flexor carpi ulnaris. Surgical treatment included release of the fibrous band in 14 patients, with anterior subcutaneous transfer of the ulnar nerve in five, and corrective osteotomy in 11. Mitsunari and associates postulated that internal rotation was a contributing factor in five patients with tardy ulnar nerve palsy and posttraumatic cubitus varus deformity. Spinner and associates have observed ulnar neuropathy associated with cubitus varus caused by snapping of the medial portion of the triceps over the ulnar nerve. They recommended valgus osteotomy with or without lateral translation of the medial portion of the triceps and medial epicondylectomy.

Several biomechanical implications of residual cubitus varus have been identified. Davids and colleagues identified a preexisting, posttraumatic cubitus varus deformity as a contributing factor in six children with lateral condyle fractures. They postulated that the presence of varus malalignment increases both the torsional moment and the shear force generated across the capitellar physis by a routine fall. Takahara and colleagues have also found an increased incidence of fractures of the lateral condyle or distal humeral physis in patients with residual cubitus varus deformity. It therefore appears that a cubitus deformity may predispose a child to subsequent lateral condylar fracture.

More recently, O’Driscoll and colleagues reported on tardy posterolateral rotatory instability of the elbow in patients with known cubitus varus. They identified 22 patients who were seen primarily with lateral elbow pain and signs of elbow instability two to three decades after having sustained supracondylar fractures that had healed in varus. Intraoperatively, they observed that electric stimulation of the medial head of the triceps caused the proximal ulna to rotate externally and the elbow to displace posterolaterally. Based on observations, they postulated that the presence of cubitus varus shifts the mechanical axis of the elbow medially, altering forces generated across the elbow by the triceps that, over time, lead to increased stress and eventual attenuation of the lateral collateral ligament. The authors treated these patients with corrective osteotomy, reconstruction of the lateral collateral ligamentous complex, or a combination of the two.

The cosmetic issues and functional implications associated with significant cubitus varus underscore the importance of restoring anatomy and maintaining alignment when supracondylar fractures are initially treated and also support correction of residual deformity when it occurs. However, the timing of corrective osteotomy is best staged after the fracture has had a chance to heal and remodel and elbow motion has plateaued. Ippolito and associates found that the correction deteriorated with continued growth in young patients after osteotomy; thus the authors recommended waiting until children were closer to skeletal maturity. Voss and colleagues found that disruption of medial growth occurred in 11% of their patients with cubitus varus and was a potential cause of progressive deformity. They suggested waiting at least 1 year after injury before performing corrective osteotomy so that proper assessment of this potential problem could be undertaken. For all of the reasons just discussed, this author usually recommends waiting at least 1 year after injury before proceeding with surgery to correct residual cubitus varus.

The techniques for correction include simple or step-cut lateral closing-wedge osteotomies, which are uniplanar and address only coronal plane deformity, and three-dimensional or rotational dome osteotomies, which have the capacity to address multiplanar deformities. Different techniques of stabilization after osteotomy have also been described, although K-wire fixation is most common. All surgical techniques and methods of fixation have been associated with complication rates of up to 33%, including suboptimal cosmetic appearance, iatrogenic instability, delayed healing, recurrence of the deformity, nerve injuries, and elbow stiffness.

The traditional osteotomy originally described by French and still practiced by most surgeons worldwide is the lateral closing-wedge osteotomy. This procedure allows correction of the primary deformity and, although simple, has been fraught with a few technical pitfalls. Gaddy and colleagues reported good or excellent results in 12 children using a laterally based wedge proximal to the level of the olecranon fossa with cross-pin fixation. Voss and colleagues achieved permanent correction of varus deformity using a uniplanar lateral closing-wedge technique for correction of posttraumatic cubitus varus in which they preset their K-wires in the distal fragment. However, the clinical results after uniplanar osteotomy have been mixed because of loss of stability with pin fixation and the tendency of this osteotomy to produce a prominent lateral condyle after correction that may compromise the cosmetic outcome. ^∗ This lateral prominence after a simple lateral closing-wedge osteotomy may be decreased by medialization of the distal fragment, as described by Devnani.

∗

Hernandez and Roach identified 10 of 23 uniplanar supracondylar corrective osteotomies in their series that had poor results due to loss of initial correction and attributed the problem to instability of fixation with crossed pins. They recommended the use of a two-hole plate laterally plus a medial pin. Partly to address the issue of osteotomy instability, DeRosa and Graziano described a step-cut osteotomy that they attribute to Lloyd-Roberts, in which the inferior limb of the osteotomy stops 0.5-cm short of the lateral cortex and is connected to the proximal limb with a vertical cut. This approach leaves a lateral spike of bone attached to the distal fragment. Once the osteotomy is closed, it can be stabilized with a single screw placed from the lateral spike across the osteotomy ( Fig. 10-25 ). Although this osteotomy my be inherently more stable, it has the propensity to create a lateral condylar prominence if used for larger deformities (>30°) ( Fig. 10-26 , A ). Several modified step-cut and various geometric osteotomies including domed osteotomies ( Fig. 10-26 , B ) have since been described that allow fine tuning of the medial/lateral translation of the distal fragment to reduce lateral condylar prominence.

Closing-wedge osteotomy of the distal end of the humerus. A , The osteotomy is designed to correct the varus deformity of the distal part of the humerus; a small buttress of metaphysis is left to allow for screw fixation of the osteotomy. B , The appearance of the osteotomy after the wedge of bone has been removed and the osteotomy has been stabilized with a screw. Pin fixation may be sufficient in younger children.

A , Schematic diagram demonstrating lateral closing-wedge osteotomy for cubitus varus and resulting lateral prominence. B , Schematic diagram of corrective dome osteotomy and theoretical avoidance of lateral prominence.

(Reprinted with permission. Pankaj A, Dua A, Malhotra R, et al: Dome osteotomy for posttraumatic cubitus varus: a surgical technique to avoid lateral condylar prominence. J Pediatr Orthop 26:61–66, 2006.)

Others have described domed osteotomy to address the issue of prominence of the lateral condyle. Most recently, Pankaj and associates described their experience with a dome osteotomy that they attributed to Tien and colleagues in 12 patients with posttraumatic cubitus varus. They used a posterior triceps-splitting approach and created a dome osteotomy with a 2.5-mm drill bit and osteotome, centered at a point of rotation at the intersection of the midline axis of the humerus and the upper margin of the olecranon fossa. A preoperatively determined correction angle was used to determine the amount of rotation of the distal fragment, which was then fixed with two crossed Kirschner wires ( Fig. 10-27 ). Follow-up averaged 2.3 years, and they reported neither subjective complaints nor objective measurements of lateral condylar prominence.

Dome osteotomy for cubitus varus. A preoperative correction angle, a, is determined. A , Point O is the intersection between the superior border of the olecranon fossa and the midhumeral axis. This serves as the center of rotation for the dome. Point A is the intersection of the lateral junction of the periosteum and perichondrium. Point B is marked by measuring the predetermined correction angle, a. Segment OB then serves as the length of the dome radius. B , An osteotomy is performed, and the distal humerus is rotated such that point A is now at the previous site of point B. Crossed pins are used to maintain position.

(Reprinted with permission. Pankaj A, Dua A, Malhotra R, et al: Dome osteotomy for posttraumatic cubitus varus: a surgical technique to avoid lateral condylar prominence. J Pediatr Orthop 26:61–66, 2006.)

Most of the published techniques to correct cubitus varus have focused on the coronal plane angular deformity alone. However, cubitus varus results from an initial uncorrected internal rotational deformity of the distal fragment that allows the fracture to tilt into varus and extension. Three-dimensional osteotomies potentially allow correction of varus, internal rotation, and extension. Wong and Balasubramaniam measured humeral torsion in patients with cubitus varus deformity and found 30° of internal rotation of the distal end of the humerus compared with the normal side but also determined that it had no effect on the appearance of the carrying angle in their patients in whom they performed uniplanar osteotomies to correct coronal plane deformity. A more recent study by Takagi and colleagues also showed that internal rotation and extension deformities do not need to be corrected in addressing cubitus varus deformities and, further, that maintenance of coronal plane deformity correction is better with uniplanar osteotomies because they are more stable than three-dimensional osteotomies.

Regardless of the type of osteotomy performed and the type of fixation used, one may approach the distal end of the humerus either laterally or posteriorly. The lateral approach allows direct access to the lateral aspect of the distal part of the humerus. The humerus is then exposed subperiosteally. The advantage of this approach is that the elbow may be visualized anteriorly, which provides a more familiar anatomic perspective. Dome and step-cut osteotomies are best performed through a posterior triceps-splitting approach to the distal end of the humerus. The ulnar nerve is easily protected, and the deformity is visualized directly. The disadvantage of this approach is difficulty in visualizing the carrying angle of the elbow after correction.

Author’s Preferred Method of Treatment

The osteotomy is performed by creating a laterally based, closing wedge through the supracondylar region of the humerus. The distal portion of the humerus may be approached laterally through the interval between the brachioradialis and extensor carpi radialis longus muscles anteriorly and the triceps posteriorly. The radial nerve is protected anteriorly in this muscle wad; however, excessive retraction must be avoided so that the radial nerve is not stretched. The periosteum is split, and the humerus is exposed subperiosteally, both anteriorly and posteriorly. The size of the wedge to be removed can be determined preoperatively, as shown by Oppenheim and colleagues. AP radiographs of both upper extremities are taken with the elbows in full extension and the forearms supinated. A tracing is made of the AP radiograph of the normal arm. It can then be reversed and placed over the AP radiograph of the affected arm. The humerus–elbow–wrist angle is determined for both arms, and the difference between the two represents the magnitude of the osteotomy. A cutout simulating the laterally based closing wedge can then be arranged so that it is 2 cm above the olecranon fossa and oriented so that two limbs of the osteotomy are of roughly equal length. If the lower limb is longer than the upper limb, the prominence of the lateral epicondyle will be accentuated. The osteotomy is stabilized with crossed K-wires, which may be preset in the distal fragment before completion of the osteotomy, as described by Voss and colleagues.

If one leaves the medial cortex intact but very thin, it can be “cracked” as the osteotomy is closed. This technique creates a fairly stable osteotomy. Unfortunately, in patients with a moderately severe deformity, this type of osteotomy may leave a prominent lateral condyle, which can be eliminated by completion of the osteotomy and translation of the distal fragment medially ( Fig. 10-28 ).

Author’s preferred method for correction of cubitus varus using a closing-wedge osteotomy of the distal end of the humerus. A , The humerus–elbow–wrist (HEW) angle is measured by the intersection of a line drawn along the longitudinal axis of the humerus and a second line drawn from the middle of the distal end of the humerus to the ulnar aspect of the distal end of the radius. B , A lateral approach to the humerus is made through a longitudinal incision over the supracondylar ridge. C , The interval between the triceps and the brachioradialis is developed. The brachioradialis and wrist extensors are reflected anteriorly, and the triceps are reflected posteriorly. The radial nerve is protected anteriorly under the brachioradialis. D , The distal humerus is exposed subperiosteally, and the base of the osteotomy is outlined on the lateral cortex of the distal humerus, just above the olecranon fossa. E , The amount of correction is determined based on the difference between the HEW angles of the extremities. A tracing of the injured arm may be reversed and superimposed on the normal extremity, and the difference in angular alignment can be measured directly. F , Anteroposterior diagram of the distal end of the humerus demonstrating the wedge that is to be removed. The angle α determines the height of the base of the wedge of bone that has to be removed. G , Diagram demonstrating completion and fixation of the osteotomy with crossed K-wires.