TYPE III SUPRACONDYLAR FRACTURES OF THE HUMERUS IN CHILDREN: AN ANALYSIS OF CLOSED VERSUS OPEN REDUCTION

Abstract

To compare the clinical and radiographic outcomes of Type III supracondylar fractures of the humerus in children managed either by open reduction and internal fixation versus those treated by closed reduction and percutaneous pinning. The indications for open reduction included an inability to obtain a satisfactory reduction by closed means; open fractures and fractures with vascular compromise after closed reduction.

Retrospective chart and radiograph review over a ten year period (1995–2005), with two hundred and thirty-six children with Type III fractures treated at a Level One pediatric hospital within a universal health-care system.

One hundred and seventy by closed reduction and percutaneous pinning and sixty-six by open reduction. The left arm was involved in one hundred and forty-eight cases and twenty-five patients had vascular compromise at presentation but no cases required vascular repair. There were ten open fractures in the open reduction group. The anterior approach was employed in twenty-nine patients, anteromedial in twenty-two and anterolateral, medial and lateral in equal preference. Entrapped structures included brachialis muscle in thirty-four patients, periosteum in eighteen, radial nerve in two, medial nerve in two, and the brachial artery in one. According to Flynn’s criteria, the open reduction group had an excellent or good outcome in 90% of cases while the closed reduction group had an 80% excellent or good outcome.

In this study of displaced Type III supracondylar fractures, there was a higher rate of open reduction than was initially anticipated. There was a higher rate of excellent and good outcomes in the ORIF group but this may be due to a relatively short follow-up in the closed reduction group. Post reduction stiffness would likely dissipate and allow a higher rate of excellent and good outcomes in the closed reduction group. An anterior approach or variation of an anterior approach is best suited to visualise the anatomy and structures hindering the reduction. Despite this, there was no clinical or radiographic difference between the approaches employed. In conclusion, open reduction and internal fixation if displaced Type III supracondylar fractures is a safe and effective procedure. An anterior approach is recommended to identify and relieve the soft tissue obstacles to a suitable reduction. Significance: This study furthers the literature that proposes to lower the threshold for open versus closed reduction of displaced supercondylar fractures in children.