Open reduction can be a reasonable, safe and effective choice in complex paediatric supracondylar humeral fractures operative treatment

Abstract

BACKGROUND

Supracondylar humeral fractures are among the most common paediatric injuries. Displacement and consequent need for reduction impose operative treatment. Restoration of the anatomy of the distal part of the humerus prevents deformities and functional disorders of the elbow and upper limb. Stable K-wire fixation can be succeeded either by closed or open reduction method.

AIM

To investigate the safety and efficacy of open reduction method in the operative treatment of Gartland type III and IV supracondylar humeral fractures in children.

METHODS

We retrospectively studied 131 cases of paediatric supracondylar humerus fractures of Gartland type III-IV treated operatively by open reduction and pinning between 2001 and 2023 in our department. All patients underwent clinical and radiological examination recording elbow range of motion, function and deformity.

RESULTS

The standard lateral approach was carried out in all patients while in 47 cases (35.9%) additional medial approach was used. Average follow-up time was 5.4 years (1-14 years). Fracture healing was completed at 4-6 weeks. The average operative time was 50 min (range: 37-75 minutes, SD: 11.307) and the average duration of radiation exposure based on image intensifier usage time was 20 seconds (range: 7-45 seconds, SD: 9.864). No infections or iatrogenic neurovascular complications were recorded and the functional outcome regarding range of motion, Patient-Reported Outcome Measures (Disabilities of the Arm, Shoulder, and Hand questionnaire, Mayo Elbow Performance Scores) at 2-year follow-up was satisfying.

CONCLUSION

Open reduction and K-wire fixation provide very satisfactory outcome in supracondylar fractures of the humerus in children with reduced radiation burden. Moreover, the risk of neurovascular injuries due to manipulations of closed reduction, is minimized while complications related to surgical approaches are insignificant provided there is expertise.

Key Words: Supracondylar paediatric humeral fracture; Gartland classification; Open reduction; Cross pinning; Gunstock deformity; Pink pulseless hand; Neurapraxia; Vascular injury

Core Tip: Complex supracondylar humeral fractures in children are treated operatively. Though closed reduction by Blount’s method and pinning is the treatment of choice, open reduction can be reasonable in cases of gross displacement, neurovascular compromise and difficulty in closed reduction. Intra- and post-operative complication rates, functional outcome and reduce in radiation burden define open reduction as a safe and effective operative method.

INTRODUCTION

Supracondylar humeral fractures (SCHF) comprise 50%-75% of elbow fractures and approximately 12%-17% of all fractures in childhood, affecting mostly children 5-7 years old with a slightly higher rate (7%) in boys. Supracondylar region of the humerus at this age has a decreased anterior-posterior diameter due to bone remodeling, being vulnerable to fractures. The left or nondominant side, sustains such fractures more frequently[1-5].

Paediatric SCHF are often described as of flexion type (2%) or extension type (98%). Though Arbeitsgemeinschaft fur Osteosynthesefragen/Association for the Study of Internal Fixation classifies such fractures in detail, older descriptive classifications are still in use. Modified Gartland classification includes 4 types regarding displacement, posterior distal humeral cortex contact, and medial column comminution or impaction on plain radiographs. Medial comminution may imply a malrotation that cannot be easily appreciated in X-rays[4,6-8].

Fracture blow and displacement may injure neurovascular structures of elbow. Brachial artery can be thrombosed or ruptured compromising limb perfusion and neurapraxia is the most common (12%) neurologic deficit[9].

Restoration of the anatomy of the distal humerus is important for preventing functional impairment, developmental deformity and disability. Displaced and comminuted SCHF of Gartland type III-IV must be reduced and stabilized. Though closed reduction and percutaneous pinning is a widely used technique, open reduction may be unavoidable in severely displaced fractures due to soft tissue entrapment or concomitant neurovascular injury necessitating exploration. Though it is used only in 2-16% of SCHF according to the literature, findings of our study suggest that open reduction can be useful in disordered paediatric SCHF[10].

MATERIALS AND METHODS

Between 2001 and 2023, 131 children with SCHF were treated operatively with open reduction and pinning under general anaesthesia in our department. According to Gartland classification 55 (42%) were of type III and 76 (58%) of type IV. Seventy-nine (60.3%) were boys and 52 (39.7%) girls with a mean age of 6.5 years (1.5-14 years). Pink pulseless hand was recorded pre-operatively in 69 patients (52.7%) and anterior interosseous nerve (AIN) neurapraxia in 36 cases (27.5%). There was one open (Gustilo II) fracture of Gartland type IV with brachial artery and AIN transection (Table 1). Open reduction was utilized in all cases by the reason of severe displacement of the fracture, excessive soft tissue oedema or obesity, neurovascular injury, and difficulty or failure of closed reduction. Attempts of closed reduction in the operating theater with the child under general anaesthesia took place in most of the cases except for the open fracture, taking of course, into account fracture’s characteristics for the eagerness of the manipulations. Fixation was achieved using K-wires. A long arm splint was placed in all patients for 2 weeks postoperatively.

Table 1 Patients’ demographics, type of fracture and concomitant neurovascular injuries.

Variable		Patients, n = 131	%
Age	6.5 years	-	-
	(18 months-14 years)
Sex	Male	79	60.3
	Female	52	39.7
Side	Right	46	35.1
	Left	85	64.9
Gartland type	III	55	42
	IV	76	58
Pink pulseless hand		69	52.7
AIN neurapraxia		36	27.5
Open fracture	Gustilo II with brachial artery and AIN nerve rupture	1	0.76

AIN: Anterior interosseous nerve.

Operative and image intensifier usage time, approaches and number of K-wires used were recorded. Time of fracture healing, nerve recovery and surgical complications (including malunion and deformity, decreased range of motion (ROM) and stiffness, infection and neurovascular iatrogenic injuries) were also recorded during post-operative follow-up in 3 weeks, 6 weeks, and 12 weeks. Postoperative functional outcome was evaluated using Disabilities of the Arm, Shoulder, and Hand questionnaire (DASH) and Mayo Elbow Performance Scores at 2 years post-operatively.

RESULTS

Open reduction and percutaneous pinning (ORPP) was carried out by the standard lateral approach in all patients and in 47 (28.2%) cases fracture complexity necessitated additional medial approach. K-wires configuration (number and side of application) varied but all K-wires were left out of the skin for removal (Table 2). The average operative time was 50 minutes (range: 37-75 minutes, SD: 11.307), the average duration of radiation exposure based on image intensifier usage time was 20 seconds (range: 7-45 seconds, SD: 9.864) and hospital stay was 2.8 days on average (range: 2-7 days).

Table 2 K-wires configuration and surgical approaches used for open reduction and percutaneous pinning.

Variable	Lateral K-wire(s)	Medial K-wire(s)	Patients, n = 131	%
Open reduction	1	1	6	4.6
	2	1	67	51.1
	2	0	33	25.2
	3	0	15	11.5
	3	1	7	5.3
	4	0	3	2.3
Lateral approach			131	100
Medial approach			0	0
Lateral + medial approach			47	35.9

Pink pulseless hand was recorded in 69 patients pre-operatively, but the vascular dysfunction resolved after fracture reduction and stabilization without requiring further intervention. Vascular exploration and repair (bypass using vein graft) of the ruptured brachial artery was needed in the case of open SCHF in which AIN was also primarily repaired with end-to-end coaptation. Complete recovery of the nerve injuries (36 cases with AIN neurapraxia) was recorded within 6 months.

In all cases, K-wires were removed at 4-6 weeks post-operatively, depending on child’s age, fracture comminution and healing radiological evaluation of healing progress. Restoration of the anatomy was evaluated at the time of pin removal by Baumann’s angle (mean: 71°, range: 67°-80°), the ulnohumeral angle (mean: 9°, range: 4°-17°) and the shaft-condylar angle (mean: 40°, range: 33°-43°). Residual rotational deformity of 5°-10° was present in 17 cases, roughly estimated by radiological and clinical examination in order to avoid the burden of a computed tomography-scan.

The mean follow-up time was 5.4 years (range: 2-14 years). No post-operative wound or pin tract infection and perioperative iatrogenic neurovascular complication were recorded. There was a satisfying outcome regarding ROM and Patient-Reported Outcome Measures (DASH, Mayo Elbow Performance Score) at 2 years (Table 3). Valgus deformity of 28° without functional deficit was marked in 1 case operated at the age of 7.

Table 3 Functional outcome regarding range of motion and patient-reported outcome measures (Disabilities of the Arm, Shoulder, and Hand questionnaire, Mayo Elbow Performance Scores).

Variable	Average	Range	SD
Flexion	142°	130°-152°	-
Extension	5°	3°-14°	-
Supination	91°	78°-102°	-
Pronation	77°	73°-87°	-
DASH	0.76	0-5	1.008
MEPS	99.7	95-100	1.202

DASH: Disabilities of the Arm, Shoulder, and Hand questionnaire; MEPS: Mayo Elbow Performance Score.

DISCUSSION

SCHF are common in childhood[1]. Clinical evaluation of deformity and surrounding soft tissues must include detailed neurovascular evaluation and documentation. Gartland classification helps in determining further management.

Displaced and comminuted SCHF of types III and IV are treated operatively and 1.6-2.0 mm K-wires are used for fixation. Unless there is no pulse, or clinical signs suggesting compromised vascularity, night-time operating is not necessary[11].

The method of reduction is a debatable issue[12,13]. In paediatric orthopaedic practice close reduction and percutaneous pinning is the treatment of choice. With the child under general anaesthesia, according to Blount’s method traction applied on the upper arm for 5-10 minutes and manipulation counteracting the displacement of humeral condyles under fluoroscopy can reduce the fracture and stabilization is achieved by percutaneous pinning usually using 2 crossed or divergent lateral K-wires. Though the procedure is considered atraumatic, its main disadvantage is the radiation burden both for the patient and the personnel of the operating theatre. In addition, closed manipulation may be intricate and strenuous, further stressing further soft tissues. A gap at the fracture site on X-rays can be the result of soft tissue interposition. The well-known “brachialis sign” or puckering of the anterior skin indicates that the proximal fragment has button-holed through the brachialis. Possible entrapment of neurovascular structures in the fracture site poses them at risk of serious iatrogenic damage. Such lesions can be also caused during percutaneous pinning (especially medial) which can turn out to be a demanding step especially in grossly unstable SCHF of Gartland type IV[14-16].

Pin configuration is another point of interest. Lateral pins must be divergent without crossing at the fracture site to prevent rotation but crossing K-wires seem to be biomechanically superior. However, medial pinning by close technique predisposes to iatrogenic ulnar nerve injury[10,17-19]. Furthermore, the application of multiple K-wires can obtain adequate stability in case a pin must be removed due to nerve irritation detected post-operatively[20-23].

Open reduction decreases the aforementioned risks, and therefore, it was applied in the studied group of patients due to the severity of the injury regarding fracture displacement and comminution, soft tissue oedema and concomitant neurovascular disorder and especially in cases initial attempts of closed restoration of the anatomy failed. Moreover, difficulty in percutaneous pinning increases in type IV together with the risk of neurovascular injury during closed reduction manipulations.

Though four approaches (lateral, medial, anterior, posterior) can be used, lateral column approach is usually sufficient for an uneventful and precise reduction. Additional medial approach may be useful in case of severely displaced, comminuted and unstable fractures. Especially the medial column comminution and impaction, can provoke varus malalignment and malrotation. Interposed soft tissues preventing reduction can be gently disengaged allowing an anatomic reduction. Furthermore, reduction is maintained, K-wires application is significantly simplified and surrounding anatomical structures are not jeopardized. Of course, the use of the image intensifier is inevitable for evaluating the reduction in at least anteroposterior and lateral views, but the radiation exposure (20 seconds on average, range 7-45 seconds) is significantly lower than in closed method according to the literature. However, predictably, operating time is elongated (50 minutes, range 37-75 minutes) (Figure 1)[24,25].

Figure 1 Typical ecchymosis in elbow fossa often suggesting vascular injury in a 4-year-old female with a right supracondylar humeral fracture of type IV according to modified Gartland classification. A: Clinical and radiological presentation; B: The fracture was fixed after open reduction by lateral and medial approach; C: The K-wires were removed 1 month post-operatively; D: Right elbow X-rays at the age of 19 years.

Moreover, while open reduction prevents additional vascular injury, it is prerequisite in case of vascular injury. Preoperative meticulous vascular assessment of the limb by palpation or Doppler ultrasonography is extremely critical in SCHF as brachial injury complicates 12%-15% of cases[26]. Normal skin color, temperature and digital capillary refill time without palpable pulses indicate a “pink pulseless hand” which is a common condition regarding SCHFs. Perfusion is preserved by abundant collateral circulation in case of brachial artery compression or kinking. On the other hand, if signs of limb ischaemia (low temperature, delayed or absent capillary refill time, paraesthesias or loss of motor function) are present, serious damage of brachial artery must be suspected. Bruising or puckering of the skin in the antecubital region may be indicative of brachial injury. Intimal lesion causing thrombosis or wall rupture must be dealt urgently as a surgical emergency. Moreover, though compartment syndrome associated with SCHF is rare (0.1%-0.3%), the risk increases in case of pre-operative poor perfusion[27,28]. An early vascular surgical consultation can be useful to avoid delay in deciding to proceed with an exploration[11]. Exploration and reconstruction of brachial artery can be carried out by Orthopaedic or Vascular surgeons using the anterior approach though fracture treatment is troublesome through it[10,29,30]. However, in most of the cases, arterial supply is completely restored in a “red pulseless hand” as soon as fracture is reduced, as it happened in 69 cases of our study. On the other hand, there was no intra-operative vascular damage recorded in our material.

Nerve injuries co-exist in 10%-20% of SCHF[31-33]. Though all nerves passing the elbow are in danger, median or AIN palsy is the commonest concomitant neurologic lesion. The radial and ulnar nerves are injured less frequently. Particularly in extension type fractures (nearly 98% of all SCHF), AIN is mostly injured due to contusion of the dorsal part of the median nerve (where the AIN fascicles lie) and nerve’s restricted mobility the interosseous membrane of the forearm. Absence of pulses indicating injury to the brachial artery can be associated with neuropraxia in 11.3% of fractures due to proximity of neurovascular structures. In flexion type fractures, the ulnar nerve is mostly vulnerable[34,35]. In most cases, concomitant neurologic deficits recover spontaneously within 1-3 months[36]. A neurologic deficit diagnosed after closed reduction manipulation also necessitates open exploration of the nerve, and release or repair may be needed. In our series, apart from 1 case of AIN rupture that was repaired with end-to-end anastomosis, there were 36 cases of SCHF with AIN neurapraxia and 1 case of AIN rupture that was repaired with end-to-end anastomosis. All nerve injuries fully recovered on an average of 57 days (range: 28-105). Furthermore, since special care must be taken to protect nerves and especially the ulnar nerve from mechanical and thermal injury during humeral medial column K-wire fixation, open or mini open medial approach may be safer (Figure 2)[11,37]. No iatrogenic ulnar nerve injury has been recorded even in cases medial K-wires were applied percutaneously by closed technique.

Figure 2 Significant anterior elbow haematoma, pink pulseless hand and anterior interosseous nerve palsy in an 8-year-old male with a Gartland type IV supracondylar humeral. A: Clinical presentation; B: Radiological examination; C: Open reduction by lateral approach was unsuccessful due to periosteum and flexor muscles interposition on medial side requiring an enlarged medial approach and ulnar nerve exploration and protection; D: Four K-wires were applied (3 Lateral and 1 medial); E: K-wires were removed 5 weeks post-operatively. Normal pulses were palpable in hand 12 hours post-operatively and anterior interosseous nerve palsy recovered in 6 weeks.

Obesity is positively predictive for ORPP in SCHF in children. Higher body mass index is associated with a higher incidence of SCHF and more severe Gartland types due to impaired bone metabolism; it also makes closed reduction more difficult[38-41]. Therefore, ORPP is the preferable treatment technique in obese children.

According to meta-analysis of Transtrum et al[38] in 2024, apart from obesity, SCHF displacement, and concomitant nerve deficits are also more likely to require open reduction. Considering all these factors, there is no reluctance to use open reduction in paediatric Gartland type III-IV SCHF in our department. Our results are comparable with those of closed reduction which is widely used[42]. Average operative time was 50 minutes (range: 37-75 minutes). Fracture healing was succeeded in all patients within 4-6 weeks depending on the age of the child. In a mean follow-up period of 5.4 years (range: 2-14 years), the outcome was favorable regarding ROM which was full except for an insignificant residual extension lack of 5° on average (range: 3°-14°) and functional tests with the average DASH score at 0.76 (range: 0-5) and the average Mayo Elbow Performance Score at 99.7 (95-100). In addition to the effectiveness and safety of open reduction, radiation exposure in the operating theatre is significantly reduced to 20 seconds (range: 7-45 seconds) compared to corresponding values of closed reduction, found in literature[24]. The average hospital stay was 2.8 days (2-7) which is longer than the time found in the literature for such fractures (1.9 days for open reduction and internal fixation and 1.2 days for close reduction and percutaneous pinning) but not prohibitive[38].

Perfect reduction cannot be always achieved even with open technique and deformity in varus, hyperextension or internal rotational deformity is often marked. Fortunately, bone remodeling potential especially in children under 6 years of age can correct moderate deformities in sagittal plane, preventing functional defect (Figure 3)[43,44]. Apart from some cases with small degree of internal rotation or anterior angulation, no case of varus deformity was recorded in our study. However, there was only one case of significant valgus deformity (28°) regarding a 7-year-old boy. Postoperative X-rays revealed unsatisfactory reduction, but elbow deformity complication (most commonly in varus) SCHF can also be the result of traumatic or iatrogenic physeal injury and growth arrest[45]. Though according to Flynn’s criteria for cosmetic evaluation, such deformity indicates poor result, there was no functional deficit or ulna nerve pathology (Figure 4)[16].

Figure 3 Malrotation can be easily missed, and it is poorly corrected by remodeling. A: A 10-year-old male with a Gartland III supracondylar humeral fracture with marked internal rotation of the condyles; B: Despite open reduction and both column pinning, residual rotational deformity can be noticed by cortex mismatching in anteroposterior and lateral X-rays (orange arrows indicate cortex discontinuity); C: X-rays in 3 months follow-up with satisfactory functional outcome.

Figure 4 Deformity can be the result of improper reduction or physeal growth arrest (traumatic and iatrogenic). A: A 7-year-old male with a Gartland type III supracondylar humeral fracture; B: Open reduction via lateral approach and stabilization by 3 Lateral K-wires with incomplete reduction on axial and sagittal level; C and D: In 9-year follow-up there is significant (28°) valgus deformity marked on X-rays (in comparison with the contralateral elbow); E: Elbow range of motion is normal during physical examination.

No other postoperative complications (e.g., loss of reduction, wound or pin tract infection, compartment syndrome) were marked. Scar formation in surgical wounds may be a non-negligible cosmetic complication, though according to Yavuz et al[10], Flynn’s cosmetic and functional outcomes are not discouraging.

Though our study evaluates open reduction and pinning of SCHFs, the effectiveness of proper close technique is not in doubt. The open method was mainly used in the past while closed reduction predominates nowadays. However, both techniques are useful depending on SCHF’s special characteristics and providing relevant surgical skills and technical requirements are fulfilled.

The main limitation of this retrospective study is the lack of a comparative group of patients treated with closed reduction. In order to evaluate the efficacy of open reduction, study focuses on Gartland type III and IV fractures for which open reduction was decided evaluating clinical radiographical and intra-operative findings. However, a comparison between closed and open reduction results would be more conclusive and of course, prospective RCTs provide more accurate evaluation of each method effectiveness.

CONCLUSION

Open reduction is an effective and safe method for pinning fixation of displaced SCHF in children. Though closed reduction method prevails in the literature, orthopaedic surgeons treating paediatric trauma should not be reluctant to apply it. Soft tissue entrapment can make closed reduction difficult increasing the risk of iatrogenic neurovascular injury during manipulations, and the radiation exposure as well. Open technique can simplify and improve the reduction while complication rates and mid- and long-term functional results are comparable with those of the closed method. Of course, good knowledge of the anatomy of the immature elbow and surgical expertise are prerequisites for mitigating the common risks of surgical approaches of the elbow.