Type-III supracondylar fracture humerus: results 0f open reduction and internal fixation after failed closed reduction

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1 Original Article Type-III supracondylar fracture humerus: results 0f open reduction and internal fixation after failed closed reduction ABSTARCT Objective Naji ullah Khan, Zahid Askar, Faheem ullah Department of orthopaedic, Khyber Teaching Hospital, Peshawar. To evaluate short term results of open reduction and internal fixation after failed close reduction in Gartland Type III Supracondylar fracture of humerus in our institution. Patients and Methods This prospective study was conducted at the Orthopedic Department of Khyber Teaching Hospital, Peshawar from January, 2008 to March, Seventy-five patients of type-iii supracondylar fracture of humerus were included in the study. Informed consent was obtained from all patients. Under general anesthesia, closed reduction was attempted first. After failure of closed reduction, an open reduction and internal fixation with cross K-wires was performed. Fortnightly follow up was carried out for two months then monthly for six months. The clinical outcome was assessed using Flynn criteria Results Out of 75 patients, 47 were male and 28 were female. Left side was involved in 52 patients and right side in 23. Mean age was 6.7 years with age range from 3 to 12 years. Excellent or good results were obtained in 70 (93.3%) patients and fair or poor in 5 (6.7%). Conclusions We conclude that these fractures need to be managed aggressively and open reduction and internal fixation of severely displaced supracondylar fractures of the humerus is a safe option when a satisfactory reduction cannot be obtained by 2-3 attempts on closed method. (Rawal Med J 2010;35: ). Key words Supracondylar fracture, open reduction, internal fixation, close reduction INTRODUCTION Supracondylar fracture (SF) of the humerus is the most common fracture around the elbow in children and represents approximately 3% of all fractures in children. 1,2

2 These fractures are seen in the first decade of life especially between ages 5 and 8 years. 3,4 SF of humerus are caused by fall on out stretched hand and is divided into two types, extension type and flexion type % of the fractures are extension type and 2.2% are flexion type. 3 Extension type are further classified as describe by Gartland according to the degree of displacement of the distal fragment. 2,6 Type I is undisplaced fracture, type II is displaced with intact posterior cortex, and type III is completely displaced with no contact between the fragments (Fig 1). 7 The treatment modalities include side arm traction, overhead skeletal fraction, closed reduction and casting with or without percutaneous pinning and open reduction and internal fixation. 8,9 Type III SF of humeral are usually treated by closed reduction and percutaneous K-Wires fixation, but open reduction and fixation is performed if an adequate reduction cannot be obtained by closed manipulation Close manipulations should be avoided in displaced type-iii postrolateral SF with neurovascular deficit as the neurovascular bundle may be trapped in the fracture site. 4,14 The indications for open reduction and internal fixation (ORIF) are failed closed reduction, open fractures that needs debridement and irrigation, and fractures complicated by vascular injuries. 4 Open reduction must be carried out carefully to prevent complications like varus or valgus deformities, myositis ossifican, stiffness of the elbow, neurovascular complications and compartment syndrome. 15,16 The purpose of this study was to evaluate the short term results of open reduction and internal fixation after failed close reduction in Gartland Type III SF in our circumstances. PATIENTS AND METHODS This prospective study was conducted at the Orthopedic Department of Khyber Teaching Hospital Peshawar from January, 2008 to March, patients with closed Gartland type III SF of humerus were included in the study. Patients included were children 3 to 12 years of age. Those with vascular injury were excluded from the study.

3 Fig 1. Gartland classification of supracondylar fracture. Type I. Undisplaced fracture. Type II. Fracture is displaced with intact posterior cortex. Type III. Fracture is completely displaced with no contact between the fragments. All patients were admitted through Accident and Emergency department. Detail history and clinical examination was performed on admission after obtaining written and informed consent. The patients were either put on side arm traction or placed in posterior splint for temporary stabilization. Distal neurovascular status was monitored closely. Patients were prepared for next day surgery.

4 Surgical Technique Under general anesthesia, closed reduction was attempted first; in the event of its failure, a pneumatic tourniquet was applied and posterior midline incision was given. Ulnar nerve was identified, dissected and isolated. After elevating triceps muscle, the fracture side was cleaned, reduced and fixed with 2 cross K-wires of appropriate diameter. In most patients, Brachialis was found to be interposed between the two fragments and was responsible for the failed closed reduction. The ends of the wires were left outside the skin for easy removal later on. Skin was closed and posterior slab was applied. Table1. Flynn criteria for fracture assessment. RESULTS Cosmetic Factor-Loss of Carrying Angle(Degree) Functional Factors-Loss of Motion (Degree) Excellent Good Fair Poor >15 >15 The patients were follow up fortnightly for 2 months and then monthly for 6 months. At two weeks, sutures were removed and posterior slab was reapplied. At six weeks, K-wires and slab were removed without anesthesia after taking a radiograph of the elbow. Range of motion exercises were started and final assessment was made at 6 month using Flynn criteria 17 (table 1). RESULTS All 75 patients completed their follow up; there were 47 (62.7%) male and 28 (37.3%) female. Left side was involved in 52 (69.3%) patients and right side in 23(30.7%) patients. Mean age was 6.7 years (age from 3 to 12). Table 2. Outcome of procedure according to Flynn criteria. Number Percentage Excellent % Good % Fair 3 4.0% Poor 2 2.7%

5 Excellent or good results were obtained in 70 (93.3%) patients (Table 1). Poor result was because of myositis ossificians in 1 (1.3%) patient and cubitues varus deformity in the other one. Transient ulnar nerve palsy occurred in 3 (4.0%) patients which completely recovered in three months. Pin tract infection in 6(8.0%) patients, which resolved with local care and oral antibiotic. Deep infection and compartment syndrome were not encountered in our series. DISCUSION Supracondylar fractures of humerus are one of the commonest childhood injuries and account for 60% of all fractures about the elbow in children. 18 In the treatment of type-iii fractures the main difficulty of closed reduction and casting is the need to hyperflex the elbow beyond 120 o to maintain reduction, which is not always possible due to loss of radial pulse on hyperflexion. Failure to do so increases the risk of losing reduction, due to loss of supporting effect of the triceps muscle. Another difficulty in closed reduction is that coronal tilt is not always appreciated on radiograph, and the fact unveils itself only when deformity has already occurred. The aim of surgical treatment is to safely create an adequately stable construct to prevent axial rotation and coronal or sagittal tilt to avoid post-operative deformity. 21 Closed reduction and percutaneous K-Wires fixation is the treatment of choice for the reducible fracture, but percutaneous pin fixation needs image intensifier and is associated with iatrogenic ulnar nerve injuries. 22 Some surgeons would reserve ORIF for open fractures or for those associated with vascular injury, 23 as there is 1.4% incidence of myositis ossificans and no neurovascular deficit. 24 The results of our study were comparable to both local and international studies. In our study, excellent and good results of 93.3% are comparable to ealier studies of Kamath 25 (92.5%), Philip 26 (82%), Kumar 27 (84%), Ababneh 28 (87%) and Umer 29 (100%). Another study reported good to excellent results in 91.8%, similar to our results. 30 Iatrogenic ulnar nerve injury was observed in 3 patients who recovered in three months without intervention. Overall patient satisfaction with regard to functional was excellent. CONCLUSION Type III SF need to be managed aggressively and ORIF of severely displaced SF of humerus is a safe option when a satisfactory reduction cannot be obtained by 2-3 attempts of closed method

6 Correspondance: Naji ullah Khan Postgraduate Medical officer, House No: 13, Street No 1, Canal lane near Abpara market, University Town, Peshawar. address: Tel: Received: July 22, 2010 Accepted: August 23, 2010 REFRENCES 1. Minkowitz B, Busch MT. Supracondylar fracture of humerus, current trends and controversies. Orthop Clin North Am 1994;25: Din SU, Ahmed I. Percutaneous crossed pin fixation of supracondylar humeral fracture in children. J Postgrad Med Inst 2003;17: Wilkins KE. The operative management of supracondylar fractures. Orthop Clin North Am 1990;21: Canale ST. Fracture and dislocations in children. In: Canale ST, Beaty JH, editor. Campbell s operative orthopaedics. 11 th ed. Philadelphia: Mosby 2008: Bajwa GR. Evaluation of results of medical approach following operative treatment of supracondylar fractures in children: a study of 60 consecutive cases. J Pak Orthop Assoc 2009;21: Wilkins KE. Fractures and Dislocation of the Elbow Region. In Wilkins KE, King RE (eds). Fractures in Children. Philadelphia, JB Lippincott Company 1991;3: Gartland JJ. Management of supracondylar fracture of humerus in children. Surg: Gynecol Obstet 1959;109: Khan MS, Sultan S, Ali MA, Khan A, Younis M. Comparison of percutaneous pinning with casting in supracondylar humeral fractures in children. J Ayub Med Coll Abottabad 2005;17: Dameron TB. Transverse fractures of the distal humerus in children. Instr Course Lect 1981;30:224.

7 10. France J, Strong M. Deformity and functions in supracondylar fractures of the humerus in children variously treated by closed reduction and splinting, traction and percutaneous pinning. J Pediatr Orthop 1992;12: Paradis G, Lavallee P, Gagnon N, Lemire L. Supracondylar fractures of the humerus in children. Technique and results of crossed percutaneous K-wire fixation. Clin Orthop 1993;297: Nacht JL, Ecker ML, Chung SMK, Lotke PA, Das M. Supracondylar fractures of the humerus in children treated by closed reduction and percutaneous pinning. Clin Orthop 1983; 177: Cheng JCY, Lam, TP, Shen WY. Closed reduction and percutaneous pinning for Type III displaced supracondylar fractures of the humerus in children. J Orthop Trauma 1995;9: Rasool MN, Naidoo KS. Supracondylar fractures. Posterolateral type with brachialis muscle penetration and neurovascular injury. J Pediatr Orthop 1999;19: Shim JS, Lee YS. Treatment of completely displaced supracondylar fracture of humerus in children by cross-fixation with three kirschner wires. J Pediatr Orthop 2002;22: Lee SS, Mahar AT, Miesen D, Newton PO. Displaced pediatric supracondylar humerus fractures: Biomechanical analysis of percutaneous pinning techniques. J Pediatr Orthop 2002;22: Flynn JC, Mattews JG, Beriot RL. BUCD pinning of displaced supracondylar fracture of humerus in children. J Bone Joint Surg 1974;56-A: Yadav UB, Singhal R, Tonk G, Aggarwal T, Verma AN. Crossed pin fixation in displaced supracondylar humerus fractures in children. Indian J Orthop 2004;38: Boparai R, Sharma R, Kapila R, Pandher DS, Diwan RP. Supracondylar fractures in children-closed reduction vs open reduction. Indian J Orthop 2006;40: Labelle H, Bunnell WP, Duhaine M, Poitras B. Cubitus varus defor mity following supracondylar fracture of the humerus in children. J Pediatr Orthop 1982;2:

8 21. Gordon JE, Patton CM, Luhmann SJ, Bassett GS, Schoenecker PL. Fracture stability after pinning of displaced supracondylar distal humerus fracture in children. J Pediatr Ortho.2001;21: Skaggs DL, Hale JM, Bassett J, Kaminsky C, Kay RM, Tolo VT. Operative treatment of supra condylar fractures of the humerus in children. The consequences of pin placement. J Bone Joint Surg (Am) 2001;83: Mostafavi HR, Spero C. Crossed pin fixation of displaced supracondy lar humerus fractures in children. Clin Ortho Relat Res 2000;376: Wilkins KE. Fractures and dislocations of the elbow region. In: Rockwood CA, Wilkins KE, King RE, eds. Fractures in Children. 3rd ed. New York:JB: Lippincott; 1991;p Kamath SU. Open reduction and internal fixation of severely displaced humeral supracondylar fractures in children. Indian J Orthop 2003;37: Philip FC, William Mc, Mervyn L. An Analysis of open reduction of irreducible supracondylar fractures of the humerus in children. Canad J Surg 1998;41: Kumar R, Kiran EK, Malhotra R, Bhan S. Surgical management of the severely displaced supracondylar fractures of the humerus in children. Injury 2002;33: Ababneh M. Shannak A, Agabi S, Hadadi S. The treatment of displaced supracondylar fractures of the humerus in children. A comparison of three methods. Int Orthop 1998;22: Umar M, DSousa OP. Supracondylar fractures of humerus in children. An analysis of different treatment modalities at the Agha Khan University Hospital Karachi. Pakistan. Pak J Surg 1991;7: Diri B, Tomak Y, Karaismailoglu TN. The treatment of displaced fractures of the humerus in children (an evaluation of three different treatment methods). ULUS Trauma Derg 2003;9:62-9.

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