SUPRACONDYLAR FRACTURES Part II COMPLICATIONS. I. INTRODUCTION 1. What is the most dreaded complication associated with

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1 1 SUPRACONDYLAR FRACTURES Part II COMPLICATIONS I. INTRODUCTION 1. What is the most dreaded complication associated with supracondylar fractures? The complication most often associated with supracondylar fractures is the development of Volkmann s ischemic contracture, which is the direct result of a compartment syndrome. Fortunately, this complication is extremely rare in the United Kingdom and the United States. 2. What is the most common lasting complication? Most of the acute complications associated with supracondylar fractures resolve with time. The most common complication that persists however, is that associated with mal-union, producing a cubitus varus deformity. 3. What is the order of frequency of the complications associated with supracondylar fractures? Nerve injuries are the most commonly associated injuries associated with supracondylar fractures. It is difficult to get an overall incidence of vascular injuries because many of them are transient and resolve with reduction of the fracture ( CO96,GA96 ). The frequency of the other complications in a sophisticated medical setting are rare. The frequency in descending order of the commonly associated complications with supracondylar fractures appears to be: 1. Nerve injuries. 2. Vascular injuries. 3. Mal-union. 4. Myositis Ossificans. 5. Avascular necrosis of the trochlea. 6. Non-union. II. NERVE INJURIES 4. What is the overall incidence of nerve injuries associated with supracondylar fractures? Originally, the incidence of injuries in the literature when many series were combined was said to be 7.7% ( WI96 ). In the past twenty years, there has been in increased recognition of the presence of injury to the anterior interosseous branch of the median nerve. As a result, when the data from seven recent series ( BR95, CR93, CU90, DO95, IP86, LY00, MC86 ) reporting neurovascular injuries associated with supracondylar fractures, the combined average incidence of nerve injuries had increased to 12%. 5. What is the most common nerve involved? The anterior interosseous branch of the median nerve ( AIN ) has now been recognised as the most common nerve injury associated with supracondylar fractures. It is interesting to note that it was only in the 1969 article by Spinner and Schreiber that the presence of this injury with supracondylar fractures was recognised ( SP69 ). The high incidence of this nerve injury has been confirmed in many recent series ( BA89, CR93, DO95, HO80, LY00 ). 6. Clinically, how is a deficit of the AIN manifest? There are no sensory deficits associated with injury to this nerve. The AIN supplies motor function to the flexor policis longus and the flexor digitorum profundus of the index finger. 7. What is the most common complication associated with this nerve?

2 Because there are no sensory deficits, there are very few complaints on the part of the patient. The motor function of the index and thumb flexion needs to be specifically examined, which may be difficult in a patient with an acute supracondylar fracture ( JO80 ). If the fracture pattern is posterolateral, then neurological examination needs to be performed to determine the presence or absence of the motor function of this nerve. If the fracture is adequately reduced, complete recovery usually occurs. 8. Why is this nerve especially vulnerable to injury? Spinner and Schreiber, in their original report ( SP69 ) proposed that this injury was due to traction on the nerve with posterior displacement of the distal fragment. In their dissection of cadavers, they found that the anterior interosseous branch after it leaves the radial side of the median nerve in the proximal forearm, passes under a fibrous arch of the origin of the pronator teres muscle. Posterior displacement of the distal fragment presses the nerve against this fibrous band. 9. By in large, what factor determines which nerve is most likely to be injured with Type III supracondylar fractures? Many series ( CA95, KI99, LY00 ) have demonstrated that the type of nerve injury that develops is determined by the direction of the displacement of the distal fragment. Each of the three major nerve injuries is associated with one of the specific three major displacement patterns such as: 1. Posteromedial extension. 2. Posterolateral extension. 3. Flexion. 10. What nerve injury is most commonly seen with the posteromedial extension fracture pattern? The radial nerve ( SE92 ). 11. What is the usual treatment following the reduction of a fracture with a radial nerve deficit? By in large, most radial deficits can simply be observed, if the deficit was present when the fracture first presented. 12. What is the usual time in which there should be full recovery? Five months ( CU90, SE92 ). 13. What are the criteria for surgically exploring the radial nerve? Various authors ( CU90, SE92 ) have proposed criteria for exploring the radial nerve associated with a supracondylar fracture. While other nerve injuries are traction injuries, complete laceration of the radial nerve is occasionally found. The criteria for acute exploration appear to be: 1. An open fracture. 2. An irreducible fracture with a nerve deficit. 3. The nerve function disappears after the reduction of the fracture fragments. 4. Both complete and sensory loss at the initial post injury presentation which may indicate that the radial nerve is either lacerated or interposed in the fracture site. Complete radial laceration has been reported with even minimally angulated fractures (SA97 ). 14. What nerve injury is most commonly seen with the posterolateral extension fracture pattern? The median nerve. 15. If there is a complete motor and sensory median nerve deficit what other complication may be masked? A compartment syndrome. The lack of sensation in the forearm 2

3 compartment may mask the pain of a developing compartment syndrome. ( WI92 ). 16. What nerve injury is most commonly seen with the flexion fracture pattern? The ulnar nerve. 17. What other conditions contribute to the development of an ulnar deficit associated with a supracondylar fracture? 1. Acutely. Ulnar nerve deficits have been associated with medially placed percutaneous pins ( LY98, RA98, RO02, RO91 ) 2. Chronically. A residual cubitus varus deformity may long term, produce ulnar nerve dysfunction (UC90 ). 18. If an ulnar nerve deficit occurs following the insertion of a medially placed percutaneous pin, what should be done? The recovery of an injured ulnar nerve following percutaneous pin fixation usually is complete (LY98, RO91 ). But this is not true in 100% of the cases. There may be no, or only partial recovery ( RA98, RO02 ). Therefore, there are three alternatives in the management of this problem. 1. Do nothing, simply leave the pins in place until the fracture has healed 2. Remove the offending pin and stabilise the fracture structure by inserting more pins laterally. 3. Remove the pin and immediately explore the nerve III. VASCULAR INJURIES: 19.What are the two major categories of vascular complications? 1. Direct injury to the brachial artery itself by the fracture fragments. 2. Indirect injury to the secondary structures of the forearm, especially the muscle in which also the skin and nerves can be involved. 20. What is the incidence of direct injuries? This exact figure is difficult to determine. When quoting series, it is difficult to determine the number of Type III fractures and the criteria for reporting vascular injuries. Some are present at the time of injury but resolve rapidly following a reduction of the fracture. Some injuries persist following reduction. In the most recent series of five reports dealing with vascular injuries associated with supracondylar humeral fractures the reported incidence varies from 2% to 10% ( CO96, KE99, PR00A, SA97, SH90 ). When all the cases in these five reports were combined, the overall incidence was around 5%. This agrees with the classic series of 830 cases of supracondylar fractures reported many years ago by Ottolengi in which the incidence of vascular complications was 4.7% ( OT71 ). 21. What is the incidence of indirect injuries? Fortunately, the reports of compartment syndrome and Volkmann s ischemic contractures are quite rare. In one review of over 7,000 cases of supracondylar fractures, the incidence of reported Volkmann s ischemic contracture was only 0.5% (WI96 ). In the most recent reported series, there are only two reported cases of Volkmann s contracture ( CO96, WI92 ). 22. What fracture pattern has the highest incidence of vascular injuries? The posterolateral fracture pattern has been shown to more frequently cause injury to the brachial artery. This is because along with the median nerve, the brachial artery can also tented across the medial edge of the distal fragment ( LY00, OT71 RA99 ). It must be remembered however, that brachial artery injuries can occur also with posteromedial fractures ( CA95 ). 23. What are the two major direct vascular injuries? 1. Vascular obstruction. In this instance, the vessel is still intact but is 3

4 temporarily obstructed by one of various structures. 2.Complete brachial artery rupture. This occurs only rarely. ( MA86 ). 24. What are the three most common causes of brachial artery obstruction? 1. Direct impingement at the fracture site. 2. Acute arterial muscular spasm. 3. Internal obstruction. 25. How is impingement at the fracture site remedied? By reducing the fracture with either non operative or operative means and stabilising it with the appropriate fixation ( GA96, PR00A, SH90 ). 26. How is the arterial spasm remedied? This usually involves open exploration of the vessel and then performing either a 1. Sympathetic block Or 2. Adventicial stripping with or without local papaverine injection ( KE99 ). If flow is not re-established with these measures, then many surgeons would proceed with surgical resection and repair of the spasmodic segment ( CO96, KE99 ). 27. What are the two causes of internal obstruction? 1. Thrombosis. 2. An intimal tear. 28. How is a thrombotic obstruction remedied? Very little is written on this specific complication and its management. Probably the most common treatment is by either an open arteriotomy or with a balloon catheter. One method reported rather recently ( CA 93 ) is dissolving the clot by intra arterial injection with a thrombolytic agent. There is only one report in the English literature on the use of this technique. 29. How is an intimal tear resolved? Most authors recommend resection and repair of the defect, either by direct anastomosis or with a vein graft ( CO96, KE99, SC96, SH90 ). 30. How is a complete brachial artery rupture usually managed? The usual recommendations are immediate surgical repair ( MA86, OT71 ). However, in one report, the ends of the artery were primarily ligated. This patient was reported as having only the development of a minor degree of cold intolerance later ( MA86 ). 31. What is the major indirect vascular complication? The development of a compartment syndrome in one or all of the muscular compartments of the forearm. This basically, is a swelling of the muscles within their compartments, sufficient to prevent the ingress of arterial blood to nourish the muscles. This is usually the result of ischemia to the muscles from vascular insufficiency or it can also be due to direct trauma to the muscles themselves. 32. What are the clinical manifestations of vascular insufficiency to the muscles? The absence of a radial pulse in of itself doesn t indicate that there is sufficient vascular insufficiency to the muscles to produce a compartment syndrome. There is an independence between the development of a compartment syndrome and a weakness or clinical absence of a radial pulse ( PR00A ). The signs of an impending compartment syndrome are those indicating muscle ischemia. Likewise, the presence of a radial pulse does not rule out the presence of a compartment syndrome. 4

5 33. Does the use of a pulse oximeter provide insurance that a compartment syndrome is not developing? Originally, it was believed that placing a pulse oximeter on the affected extremity could provide assurance of the adequacy of the circulation post fracture treatment ( RA91 ). However, later reports have mentioned that the pulse oximeter measures only the oxygenation of the skin and the amuscular digits ( SI92 ). It does not measure muscle blood flow. If the skin oxygenation is poor, then it stands to reason that the muscle blood flow is not adequate. By the same token, there can be adequate flow to the skin and amuscular soft tissues of the hand without adequate circulation to the higher metabolic muscles. 34. Which is a better measure of the adequacy of blood flow to the forearm muscles Technology or Functional Evaluation? There are many high technology pieces of equipment to measure the adequacy of circulation. However, they are not totally infallible. One of the premier signs of muscle ischemia is persistent pain in the muscles post reduction. This may often be manifest only by a change in the irritability of the patient ( KA98 ). 35. Which muscles are most likely to have early signs of motor dysfunction? The flexor digitorum profundus and the flexor pollicis longus are the most susceptible muscles because of their deep location in the forearm ( BO98 ). 36. If a patient has a definite compartment syndrome clinically, what should be done? Measurement of forearm pressures and compartment muscles may help if the pressures are elevated to confirm the diagnosis. Like the pulse, if the pressures are not elevated but there are clinically signs of a compartment syndrome, then it is probably prudent to go with one s clinical diagnosis and perform a fasciotomy. Hargens and Mubarak recommended the surgeon should weigh the clinical signs more heavily than compartment pressures in his or her s management of a suspected compartment syndrome ( HA 98 ). 37. What is the only treatment for a compartment syndrome? Initially, the surgeon can remove the constrictive dressings or immobilisation and then evaluate for return of flow to the hand, return of muscle function or decrease in forearm muscle pain. If the clinical findings don t resolve promptly and dramatically, then the only method to adequately decompress the muscles is by performing a fasciotomy. This involves releasing at a minimum, the deep and superficial flexor compartments ( HA98, KA98 ). 38. So what is the best method for a patient with symptoms or signs of vascular compromise after a reduction? If the patient exhibits signs of muscle ischemia, such as persistent forearm pain or absent muscle activity coupled with a pale cool hand, then an immediate fasciotomy should be performed. An arteriogram at this point is felt only to delay the treatment (KE99, SH90 SH98 ). The artery should be immediately explored surgically as well ( SH90, SH98 ). 39. What if the patient exhibits only an absence or very weak pulse? If the patient demonstrates no sign of muscle ischemia and a warm red hand, there are varying opinions as how to manage these patients. Some are very aggressive and evaluate for an injury to the brachial artery. If there is evidence of a vascular injury, even in the presence of adequate collateral circulation, a repair of the artery is immediately performed ( CO96, SC96, SH90 ). Others, feel if the hand is warm and there are signs of adequate collateral circulation, that careful observation is all that is necessary ( GI95, PR00, 5

6 SA97 ). In their experience, the radial pulse usually returns in a matter of days or weeks. 40. So, what is the bottom line in the treatment of vascular injuries associated with supracondylar fractures? Treat each case separately or as your experience or expertise dictates. The final decision may depend on the advice of your vascular consultant. 41. What are the most important points to remember. 1. The presence of a pulse alone does not rule out the absence of a compartment syndrome. 2. The presence of a normal compartment pressure alone does not rule out the presence of a compartment syndrome. 3. The absence of a pulse does not automatically mean that the patient has, or will develop a compartment syndrome. 4. Primary brachial artery repair may not ensure long-lasting arterial patency ( SA97 ). 5. An arteriogram does not need to be performed before exploring the suspected brachial artery ( SH90 ). There is a paucity of documented published reports that the absence of a brachial artery leads to any significant late claudication ( KE99, MA86 ). IV. MALUNION 42.Into what general patterns can malunion deformities be grouped? 1. Angulation. 2. Translocation. 3. Rotation. 43. Which ones have the tendency to remodel? Translocations in either the coronal or saggital plane will usually remodel. Angulation in either the saggital or coronal plane usually does not remodel. 44. How is angulation in the coronal plane manifest clinically? Cubitus varus. 45. How is loss of angulation in the saggital plane manifest clinically? It is manifest as hyperextension of the elbow, with often a loss of flexion. 46. What is the functional effect of hyperextension of the elbow? It may result in the loss of elbow flexion, which is usually of no clinical significance. 47 What is the cosmetic effect of the hyperextension deformity? It can accentuate the cubitus varus and make it look more cosmetically unappealing. 48. How does a rotational deformity alone affect the cosmetic appearance or function? As long as the shaft condylar angle is maintained, it usually has no effect upon the cosmesis or function of the elbow ( MA93, MA94, WO92 ). 49. How is the deformity of the distal humerus managed if the patient is first presents three weeks post injury? It is best to wait until the patient has fully healed and remodelled the fracture callous before correcting the deformity. As was mentioned in Part I late open reduction can produce myositis ossificans ( LA91 ). 50. How can the deformity be managed once the patient has fully recovered clinically and radiographically? At this time, there is no expectation of further remodelling of the angular mal alignment. The deformity can be corrected only with an osteotomy of the distal humerus. 51. When should the deformity be corrected? The patient should have regained full active motion within the limitations set by the deformity itself. For example, the hyper extension in the saggital plane 6

7 may limit elbow flexion. This is usually achieved within a year following the injury. 52. What are the components of the bony deformity? It is a true structural deformity and is not caused by growth arrest ( DO79 ). In a few cases it involves a pure coronal malalignment due to impaction of the weaker medial supracondylar column ( DE95 ). In the typical fully displaced Type III extension supracondylar fracture, the deformity is usually triplanar. 1.There is medial rotation in the horizontal plane. 2. There is hyperextension in the saggital plane. 3. There is a varus tilt in the coronal plane. These usually occur as a combined deformity with one plane often more severely deformed. 53. Which of these three plane deformities need to be corrected to improve the cosmesis of the upper extremity and possibly its function? This deformity has been extensively studied. The varus component appears to be the one which contributes the most to the cosmetic deformity ( CH94 ). Medial rotation in of itself does not appear to have any effect on the severity of the varus angulation ( MA93, MA94 ). Correction of the torsional alignment in the horizontal plane does not appear to have any appreciable effect on correcting the varus alignment ( WO92 ). 54. What is the complication rate associated with surgically correcting this deformity of the distal humerus? The success of having good results following a corrective osteotomy of the distal humerus was dismal in the past. In two early series the incidence of poor or unsatisfactory results was close from 50% ( IP90 ) to 33% ( HE94, LA82 ). In the most recent reports the incidence of poor results has dropped down to 15% or less ( BE99, VO94 ). 55. What types of osteotomies have been proposed? Probably the most commonly used of the various osteotomies is the simple lateral closing wedge osteotomy, in which only the coronal varus angulation is corrected ( BA98, BE84, DA91, DE97, GA94, GR90, HE94, MA96 ). 56. What is a common problem following the performance of a lateral closing wedge osteotomy? Often in performing this type of osteotomy, the distal fragment is shifted laterally, producing a large lateral prominence ( WO90 ). In the younger patients, much of this prominence remodels. It remains however, if the osteotomy is performed at a later age. One other problem with performing the simple lateral closing wedge osteotomy is getting the osteotomy cut distally enough so that the pins that stabilise the osteotomy are sufficiently separated to provide good stability and don t cross at the osteotomy site. 57. What modifications have been utilised in an effort to decrease the residua of this lateral prominence? 1. Some ( KA88, KU00, TI00 ) have advocated making the osteotomy cut in the shape of a dome. This allows both correction of the varus by rotating the distal fragment in the saggital plane thus decreasing the tendency of the fragment to translocate laterally. One investigator felt that this osteotomy was more stable than the simple closing wedge osteotomy (TI00 ). In another series, which compared a simple lateral closing wedge to the dome osteotomy, the lateral was found to have a higher incidence of post-operative complications ( KU00 ). 7

8 2. Another technique is to use a step cut in performing the osteotomy ( DE88, KI98 ). In addition to decreasing the tendency to translocate distally, this step-cut provides some intrinsic stability. 3. Voss and Kasser ( VO94 ) have found that by shifting the apex distally, the translocation could be lessened. 58. What needs to be done to try to correct more than one of the planes of deformity? Some authors feel that all aspects of the deformity need to be corrected. As a result a number of complex osteotomies have been proposed ( LA89, MI98, UC91, US95 ). These osteotomies involve taking wedges in more than one plane. It must be remembered that the more complex the osteotomy, the greater the chance for a complication. 59. What are the usual surgical approaches? 1. For the simple lateral closing wedge osteotomy, a simple lateral approach may be sufficient. 2. For the dome or more complex osteotomies, the posterior triceps splitting approach is preferred, because it provides easy access to the osteotomy surface. Splitting the triceps has been shown not to weaken significantly the elbow extensor mechanism (BL96 ). 60. What type of post operative stabilisation should be used? Cross wire fixation is probably the simplest and most commonly used fixation, especially for the uniplanar osteotomies. Again, it must be emphasised that the wires should not cross at the osteotomy site as this construct is unstable to rotation. 61. Because of the inherent instability of these osteotomies what other methods of fixation have been advocated? Some have utilised a simple mini external fixator with success ( KA03, LE96 ). Others have resorted to the more complex Ilizarov method of both achieving and maintaining the correction ( HA00, KA00 ). 62. What is the clinical outcome? Simple uniplanar osteotomies usually provide a satisfactory functional and cosmetic outcome as long as the varus component is fully corrected. 63. Not all cases have a satisfactory outcome. What are the two major causes of failure? 1. Providing inadequate fixation. 2. Obtaining incomplete correction ( HE94, IP90 ). 64. Everybody agrees that cubitus varus is a cosmetic problem but are there any functional consequences to this structural deformity? The attitude towards the negative effects of cubitus varus has changed considerably. In the past it was defined as being only a cosmetic deformity with essentially no functional consequences (LA82 ). During the past two decades, numerous reports have surfaced in the literature describing functional problems occurring in individuals with this deformity. 1. One of the first functional problems was recognition that patients with cubitus varus are more at risk in developing lateral condyle fractures ( DA94 ) or total distal humeral physeal fractures ( TA98 ). 2. Another functional problem that has surfaced is the late development of ulnar nerve dysfunction. This is due to alteration of the anatomy from the malunion of the distal humerus in which the stability of the ulnar nerve is altered, as it lies on the medial side. This alteration has been found to cause direct compression of the ulnar nerve from a fibrous band between the two heads of the flexor carpi ulnarus ( AB95B ), osteoarthritic spurs ( FU95 ), medial displacement of the triceps tendon ( OG86) and/or medial dislocation of the ulnar nerve over the medial epicondyle (SP98, SP99 ). 8

9 3. The hypoplasia of the medial distal articular surface along with stretching of the radial collateral ligament seen in cubitus varus has resulted in some of the patients developing posterior lateral rotary instability of the elbow ( AB97, MO96, OD01 ). 4. Cases of recurrent posterior dislocation of the radial head have also been associated with cubitus varus ( AB95A). 5. For some unexplained reason, patients with cubitus varus have been reported to be predisposed to posterior instability of the ipsilateral shoulder ( GU02 ) V. MYOSITIS OSSIFICANS 65. What are the usual clinical characteristics of myositis ossificans? It is usually manifest by the delayed onset of a loss of elbow motion. A large mass of heterotopic ossification often can be palpated in the anterior musculature of the distal arm just behind the brachialis muscle. This can be visualised radiographically as either a small radio opaque area in the soft tissues or a very large area of poorly organised heterotopic calcification. 66. What factors contribute to the development of myositis ossificans (MO) following the reduction of a supracondylar fracture? 1. The development of myositis ossificans (MO) has been seen following repeated manipulations during the reduction process ( PI88 ). 2.Physical therapy or massage post reduction has also been shown to produce MO ( SI39 ). 3. MO has also been reported as a complication following delayed open reductions of supracondylar fractures ( LA91 ). However, it can occur for unknown reasons, having been described as a simple uncomplicated fracture that was not subjected to manipulation or vigorous physical therapy ( HA01 ). 67. What is the usual treatment once it develops? Simple observation is all that is usually needed. In a long term study, Aitken and Co workers ( AI43 ) found that after two years the myositis had completely resolved with a full return of elbow motion. IV AVASCULAR NECROSIS OF THE TROCHLEA 68. The following clinical scenario is usually indicative of what post fracture complication? A seven year old female sustains a Type III extension supracondylar fracture without any complications. She underwent a successful closed reduction. The fracture was secured with pins and placed in a cast with a complete recovery of function and motion. Eighteen months post injury, the patient began to experience a loss of elbow motion. This is the classic history of the development of partial avascular necrosis of the trochlear which produces a fishtail deformity of the distal humerus. 69. What factors contribute to the development of avascular necrosis of the trochlea? Injuries to the distal humerus in which the fracture line passes very distally can disrupt the nursing vessels that supply the ossification centres of the trochlea. 70. What is unique about the blood supply to this area? Two vessels supply the trochlea in the skeletally immature individual ( HA57 ). 1. The lateral ossification centre is supplied by an intraosseous vessel that traverses through the physeal plate. 2. The medial ossification centre is supplied by an extra articular vessel that nourishes the medial ossification centre of the trochlea. 71. How can fractures in this area affect the vessels? 9

10 10 A very distal fracture can disrupt these vessels. The lateral vessels are especially vulnerable. If it is disrupted, the blood supply to the lateral ossification centre may be affected, producing necrosis of the lateral ossification centre. This is manifest radiographically as a fishtail deformity of the distal humerus ( MO84 ). REFERENCES AB95(A). Abe, M., T. Ishizu, et al. "Recurrent posterior dislocation of the head of the radius in post-traumatic cubitus varus." Journal of Bone & Joint Surgery British Volume. 77B: 582, Four patients who had injured the lower end of the humerus in childhood with resulting cubitus varus developed recurrent posterior dislocation of the head of the radius after further injury to the elbow. Dislocation occurred when the forearm was supinated and spontaneous reduction took place on pronation. At operation the lateral ligament complex was seen to be lax and elongated. After tightening of the ligament and with a supracondylar osteotomy of the humerus to correct the cubitus varus the recurrent dislocation was eliminated. AB95(B). Abe, M., T. Ishizu, et al. "Tardy ulnar nerve palsy caused by cubitus varus deformity." Journal of Hand Surgery - American Volume. 20A: 5, Fifteen patients with tardy ulnar nerve palsy caused by cubitus varus deformity were studied. All patients had a history of previous fracture of the humerus during childhood. The mean interval between fracture and onset of symptoms was 15 years. The severity of the palsy was classified as McGowan's grade I in 12 patients, grade II in 2 patients, and grade III in 1 patient. The mean carrying angle was -2 degrees before surgery. X-ray films showed a shallow ulnar nerve groove, a dysplastic humeral trochlea, medial shift of the ulna, and deformity of the medial epicondyle. The ulnar nerve was explored in all but one patient. Operative findings suggested that the main cause of the palsy was compression by a fibrous band running between the two heads of flexor carpi ulnaris. Surgical steps included release of the fibrous band in 14 patients with anterior subcutaneous transposition of the ulnar nerve in 5 of those patients. A corrective osteotomy was done in 11 patients who requested correction of the varus deformity. Traumatic cubitus varus deformity should be recognized as another cause of cubital tunnel syndrome. AB97. Abe, M., T. Ishizu, et al. "Posterolateral rotatory instability of the elbow after posttraumatic cubitus varus." Journal of Shoulder & Elbow Surgery. 6: 405-9, AI43. Aitken AP, Smith L, Balckette CW. Supracondylar fractures in children. A J Surg 59:161,1943. An extensive review of supracondylar fractures in children in which two cases of myositis ossificans (MO) were observed. At two years follow up the MO had completely resolved with a full recovery of motion. BA89. Bamford DJ, Stanley D. Anterior interosseous nerve paralysis: an underdiagnosed complication of supracondylar fracture of the humerus in children. Injury. 20:294, An early article noting that this injury is often missed. Stated that the deficit

11 11 may not be clinically apparent on a casual exam. The deficit must be evaluated. Most commonly seen in posterolateral fractures. BA98. Barrett, I. R., M. C. Bellemore, et al. "Cosmetic results of supracondylar osteotomy for correction of cubitus varus." Journal of Pediatric Orthopedics. 18: 445, From 1984 to 1995, 19 patients with cubitus varus resulting from supracondylar humeral fractures underwent lateral closing-wedge osteotomies at The Royal Alexandra Hospital for Children. As the indication for osteotomy in all cases was the cosmetically unacceptable cubitus varus, we reviewed the cosmetic results. Seventeen patients were available for review. Subjective reports from patients and parents, as well as objective clinical assessment by one of the authors, were used to assess these results. According to our grading system, 12 (76%) patients had excellent results. These patients and their parents were satisfied with the cosmetic results, and there was no clinical evidence of a bony prominence over the lateral condylar region or an unsightly operative scar. One patient had a poor result with a lateral bony prominence and an unsightly scar, both of which were clinically obvious. We report that lateral closing osteotomies in children who have not yet reached skeletal maturity produce excellent cosmetic results. BE84. Bellemore, M. C., I. R. Barrett, et al. "Supracondylar osteotomy of the humerus for correction of cubitus varus." Journal of Bone & Joint Surgery - British Volume. 66B: 566, Cubitus varus is the most common complication of supracondylar fracture of the humerus in children. Although function of the elbow is not greatly impaired, the deformity is unsightly. It usually results from malunion, since growth disturbance of the humerus after this fracture is uncommon. The normal carrying angle can be restored by supracondylar osteotomy. This operation was done in 32 patients over a ten-year period, 16 of them using the technique described by French (1959). The results in 27 patients are reviewed in the light of previous reports. French's method proved safe and satisfactory. BE99. Beslikas, T. A., J. M. Kirkos, et al. "Supracondylar humeral osteotomy in children with severe posttraumatic cubitus varus deformity." Acta Orthopaedica Belgica. 65: 65, The authors report the results of corrective osteotomy of the humerus in 11 children with severe posttraumatic cubitus varus deformity. The average carrying angle on the affected side was degrees, and there was an average internal rotation deformity of the distal humerus of 22 degrees. Flexion and extension of the injured elbow were severely limited. A supracondylar lateral wedge osteotomy of the humerus was performed keeping the medial cortex intact. Two K-wires served as levers to correct the angular and rotational deformity of the elbow and then as fixation material to hold the osteotomy fragments. Postoperatively we immobilized the elbows in 90 degrees flexion for 3 to 4 weeks. There was no loss of the postoperative osteotomy alignment in most cases. Recurrence of mild varus deformity (-5 degrees and -7 degrees) occurred in only two patients. At the end of the follow-up we observed excellent results in 9 patients with an average carrying angle of 7.2 degrees (range 5-10 degrees). BL96. Blasier, R. D. "The triceps-splitting approach for repair of distal humeral malunion in children. A report of a technique.[comment]." American Journal of Orthopedics (Chatham, NJ). 25: 621, Repair of cubitus varus in a child requires a distal humeral osteotomy. The triceps-splitting surgical approach was used for repair of distal humeral malunion in 10 children. Six patients had repair of cubitus varus, 3 had fixation of a fresh

12 12 fracture, and 1 had repair of a nonunion. No problems with healing were noted. Triceps weakness and elbow stiffness did not occur. The triceps-splitting approach is particularly well suited for repair of cubitus varus in children because, compared with the lateral approach, it is cosmetically favorable, avoids ulnar and cutaneous nerves, does not damage extensor function, provides excellent visualization of the osteotomy site, and does not result in joint stiffness. BR95. Brown IC, Zinar DM. Traumatic and iatrogenic neurological complications after supracondylar humerus fractures in children.[comment]. Journal of Pediatric Orthopedics. 15:440, A retrospective review of 162 displaced supracondylar fractures in children at Los Angeles County Harbor-UCLA Medical Center from revealed 23 neural injuries. These injuries occurred in 19 patients whose ages ranged from 5-11 years of age. There were 12 radial, six ulnar, and five median neuropathies detected. Four of the ulnar nerve injuries and one radial nerve injury were iatrogenic, resulting from both percutaneous pinning and open reduction and internal fixation. All of the deficits resolved spontaneously within a range of 2-6 months. The average time to resolution for traumatic injuries was 2.3 months. Fifty-eight percent of these injuries were found to be associated with a Holmberg type III fracture pattern and 42% with a type IV supracondylar fracture. CA93. Cairns RA, MacKenzie WG, Culham JA. Urokinase treatment of forearm ischemia complicating supracondylar fracture of the humerus in three children. Pediatric Radiology. 23:391, Proposed lysing an arterial thrombus by injecting the lytic enzyme urokinase directly in the obstructed artery to dissolve the clot. Was successful in three cases. Subsequently this technique has not been reported in the literature. CA95. Campbell CC, Waters PM, Emans JB, Kasser JR, Millis MB. Neurovascular injury and displacement in type III supracondylar humerus fractures. J Pediatr Orthop 15:47, From July 1987 to January 1991, 59 consecutive type III supracondylar humerus fractures in children were identified at Children's Hospital, Boston. Twentynine patients (49%) had evidence of neurovascular compromise. The median nerve was involved in 15 (52%) of these patients and was associated with posterolateral displacement in 87% of cases. The radial nerve was involved in eight (28%) of these patients and was associated with posteromedial displacement in every case. Injuries to the brachial artery occurred in 11 (38%) of these patients and was associated with posterolateral displacement in 64% and posteromedial displacement in 36% of cases. We conclude that posterolateral displacement in type III supracondylar humerus fractures is strongly associated with median nerve injuries. Posteromedial displacement is responsible for injuries. Posteromedial displacement is responsible for injuries to the radial nerve in virtually every instance. Brachial artery injuries may occur with either type of displacement. Neurovascular injury is higher than previously reported in these fractures. CH94. Chess, D. G., J. L. Leahey, et al. "Cubitus varus: significant factors." Journal of Pediatric Orthopedics. 14: 190, For better understanding of the etiology of "post-supracondylar fracture cubitus varus," an in vitro anatomic experiment was performed. Elbow models were precisely photographed in 256 combinations of 10 degrees increments of varus angulation, posterior angulation, internal rotation, and/or flexion contracture. Varus angulation was the most important single factor contributing to deformity. Addition of flexion contracture or posterior angulation to a given varus angulation decreased apparent deformity, whereas addition of internal rotation worsened the deformity.

13 13 Control of varus angulation in the clinical setting, by whatever method, should minimize post-supracondylar fracture cubitus varus. CO96. Copley LA, Dormans JP, Davidson RS. Vascular injuries and their sequelae in pediatric supracondylar humeral fractures: toward a goal of prevention. Journal of Pediatric Orthopedics. 16:99, Between 1988 and 1994, 128 consecutive children with grade III supracondylar humeral fractures presented for treatment at our hospital. Seventeen had absent or diminished (detected with Doppler but not palpable) radial pulses on initial examination. Fourteen of these 17 children recovered pulse (palpable) after reduction and stabilization of their fractures. The remaining three had persistent absence of radial pulse. Each of these three children was explored immediately and found to have a significant vascular injury requiring repair. Two of the 14 children who had initially regained their pulses had a progressive postoperative deterioration in their circulatory status during the first h, including loss of the radial pulse. Both of these children had arteriograms that identified vascular injuries. Both underwent exploration and bypass grafting. One of these two children had been transferred 48 h after injury, resulting in delay of management of his vascular impairment. Despite exploration, vascular repair, and fasciotomy, he ultimately developed Volkmann's ischemic contracture. All five children with significant vascular injuries had absent or diminished radial pulses on presentation. Immediate reduction and fixation followed by careful evaluation and treatment of ischemia were associated with excellent outcome in four of the five children. CR93. Cramer KE, Green NE, Devito DP. Incidence of anterior interosseous nerve palsy in supracondylar humerus fractures in children. Journal of Pediatric Orthopedics. 13:502, A retrospective review of 101 supracondylar humerus fractures in children between the ages of 0 and 11 years identified 15 patients with neural lesions. All were associated with displaced fractures, and 10 (66%) required open reduction for definitive fracture management. Six of these lesions were isolated anterior interosseous nerve palsies and four other patients had an anterior interosseous nerve injury in combination with another nerve injury, producing a sensory deficit. Two patients had a complete median nerve palsy. Only three patients had nerve lesions that did not involve the anterior interosseous nerve. The incidence (15%) of neural lesions in this study is similar to that reported elsewhere, but the incidence of anterior interosseous nerve lesions, particularly those occurring as an isolated injury, is much higher than has been reported previously. Because an anterior interosseous nerve palsy results in motor loss only, this injury may be easily overlooked. CU90. Culp RW, Osterman AL, Davidson RS, Skirven T, Bora FW, Jr. Neural injuries associated with supracondylar fractures of the humerus in children. Jour Bone & Joint Surg. 72A:1211, A retrospective review of displaced extension-type supracondylar fractures of the humerus in 101 children who were seen consecutively revealed eighteen associated neural injuries in thirteen children. Nine of the neural injuries in eight patients spontaneously resolved at a mean of 2.5 months (range, 1.5 to five months) after injury. The remaining nine lesions in five patients were explored at a mean of 7.5 months (range, five to fourteen months) after injury, because clinical and electromyographic studies showed no return of function. Neurolysis was performed on eight of the nerves that were explored (in five patients), and the remaining radial nerve was found to be completely lacerated and needed nerve-grafting. The length of follow-up after neurolysis averaged twenty-five months (range, thirteen to forty-four months). All five patients had functional recovery, as documented by range-of-

14 14 motion, grip-strength and lateral pinch-strength, and von Frey and two-pointdiscrimination sensory testing. The patient who had had nerve-grafting never recovered neural function, and tendon transfers were needed. We concluded that observation and supportive therapy is the preferred initial approach for children who have a neural injury associated with a closed, displaced supracondylar fracture of the humerus. However, if there is no clinical or electromyographic evidence of return of neural function at five months after injury, exploration and neurolysis should be performed. If the nerve is in continuity, the prognosis after neurolysis is excellent. DA91. Danielsson, L. G., S. Hussein, et al. "Staple fixation of osteotomy for cubitus varus. A simple technique used in 11 children." Acta Orthopaedica Scandinavica. 62: 55, Eleven children with a persistent varus deformity of 15 degrees or more were operated on with a supracondylar lateral closing-wedge osteotomy. The osteotomy was stabilized with a staple after predrilling for the legs of the staple. No displacement occurred in the osteotomy. The results were excellent in all the cases. DA94. Davids, J. R., M. F. Maguire, et al. "Lateral condylar fracture of the humerus following posttraumatic cubitus varus." Journal of Pediatric Orthopedics. 14:466, Posttraumatic cubitus varus is widely regarded as just a cosmetic deformity. Six cases of lateral condylar fracture of the humerus in children with preexisting cubitus varus due to prior elbow fracture are presented. Five occurred following malunited extension-type supracondylar fractures of the humerus; the other occurred following a lateral condylar fracture complicated by lateral overgrowth. All cases were treated by anatomic reduction (two closed, four open) and percutaneous pinning of the lateral condylar fracture. Three of the six cases subsequently underwent supracondylar osteotomy of the distal humerus to correct the underlying varus malalignment. Biomechanical analysis suggests that both the torsional moment and the shear force generated across the capitellar physis by a routine fall are increased by varus malalignment. Posttraumatic cubitus varus may predispose a child to subsequent lateral condylar fracture and should be viewed as more than just a cosmetic deformity. DE95. De Boeck, H., P. De Smet, et al. "Supracondylar elbow fractures with impaction of the medial condyle in children." Journal of Pediatric Orthopedics. 15: 444, We reviewed the cases of 13 children with supracondylar elbow fractures with impaction of the medial wall. The displacement was underestimated in two patients and treated as a minimally displaced fracture by simple immobilization without reduction, resulting in a cubitus varus deformity. In one patient, the correct diagnosis was made, but treatment by reduction was refused by the parents. A loss of carrying angle of 10 degrees resulted from this. Two patients referred for treatment of cubitus varus were treated elsewhere for the initial injury: one by reduction and plaster cast immobilization and the other by simple immobilization without reduction. Two children with a supracondylar fracture with buckling of the medial condyle without prominent deformity were not reduced and showed no deformity at follow-up. Six children with collapse of the medial condyle, treated by closed reduction and percutaneous pinning, all had a normal carrying angle at follow-up. We believe that this method is safe to prevent varus angulation. DE88. DeRosa, G. P. and G. P. Graziano. "A new osteotomy for cubitus varus." Clinical Orthopaedics & Related Research. (236): 160, From 1974 to 1986, a step-cut technique of distal humerus valgus osteotomy using one cortical screw for fixation was used to correct cubitus varus deformity in 11

15 15 patients. The results were graded as excellent, eight patients, good, two, and poor, one. The poor result was secondary to persistent varus. The average humeral-elbowwrist angle in the ten patients with valgus correction roentgenographically measured 9.3 degrees. The average amount of correction was 28.4 degrees. All patients retained their preoperative level of elbow motion. There were no radial or ulnar nerve injuries, nonunions, infections, or hypertrophic scars. The osteotomy requires careful preoperative planning and special attention to surgical detail. Large amounts of deformity may be corrected safely with a low complication rate. [References: 16] DE97. Devnani, A. S. "Lateral closing wedge supracondylar osteotomy of humerus for post-traumatic cubitus varus in children." Injury. 28: 643, Cubitus varus deformity following mal-union of a supracondylar fracture of the humerus in children causes no functional disability, but surgical correction is often requested to improve the appearance of the arm. Maintaining the correction after supracondylar osteotomy is a difficult aspect of the operative treatment and remains controversial. Nine children aged between 6 and 12 years (average 8 years and 11 months) underwent lateral closing wedge supracondylar osteotomy of the humerus, for deformity ranging between 10 and 20 degrees (average 13 degrees). The correction required ranged between 16 and 30 degrees (average 21 degrees). The osteotomy was internally fixed with a two hole marrow plate. At follow-up, which ranged between 3 months and 6 years (average 34 months), six patients were graded as good, two as satisfactory and one as a poor result. One patient had transient radial nerve palsy which recovered ompletely in 2 months. The patient who was graded poor had undercorrection of the deformity at the original operation. There was no incidence of loss of correction due to implant failure. Complete section of the bone to allow medial displacement of the distal fragment is recommended, thereby avoiding lateral bony prominence at the elbow. DO95. Dormans JP, Squillante R, Sharf H. Acute neurovascular complications with supracondylar humerus fractures in children. J of Hand 20A:1, We retrospectively reviewed 200 pediatric patients with acute type 3 extension type supracondylar fractures. Nineteen patients with nerve injuries were identified representing a 9.5% incidence of associated neurologic injury. All were associated with closed supracondylar fractures. The nerve injuries included seven anterior interosseus nerve palsies, four median nerve palsies, five radial nerve palsies and three ulnar nerve palsies. There were five vascular injuries, one was associated with a median nerve palsy. Three of these five patients required open exploration and one of these required arterial bypass. All other patients were treated with closed reduction and percutaneous pin fixation. Anterior interosseus nerve injury was the most common nerve injury in this series of pediatric supracondylar fractures. Diagnosis of this lesion may be subtle and was made in a delayed fashion in two patients in this series. Return of function occurred in all patients 6 to 16 weeks after the injury without surgical intervention. Anterior interosseus nerve injury may be more common than previously recognized and warrants a careful initial neurologic examination to identify this lesion. DO79. Dowd, G. S. and P. W. Hopcroft. "Varus deformity in supracondylar fractures of the humerus in children." Injury. 10: 297, Eighty cases of supracondylar fracture of the humerus at the elbow in children have been analysed. The post-reduction radiograph of the fracture was classified depending on the residual deformity present and related to the loss of carrying angle and cubitus varus deformity at the time of follow-up. Fifty-four percent of the displaced fractures showed a loss of carrying angle greater than 5 degrees, and of these 23 per cent developed cubitus varus deformity. Eighty-five per cent of those cases with a loss of carrying angle greater than 10 degrees showed either residual tilt