A retrospective study was done on the outcome of supracondylar femoral fractures treated with retrograde or supracondylar intramedullary nails. Between January 1998 and December 2000, 69 patients were treated with Russell Taylor nails, 30 at Kalafong Hospital and 39 at Pretoria Academic Hospital. Injuries had resulted from motor vehicle accidents in 27 patients, from falls in 32 and from gunshots in 10. There were 13 open fractures and 14 patients had multiple injuries, including three head injuries and two vascular injuries. Using the AO classification, 40 fractures were graded type A and 29 type C. The mean age of the 18 female and 51 males was 45 years (17 to 90). Senior registrars performed the surgery. In all cases, the knee was opened for the procedure. Four patients died from their injuries. The mean time to union was 13 weeks. Four patients had poor range of motion. Complications included two cases of superficial sepsis and three of deep sepsis. There were two cases of delayed union and three of fixation failure. In one patient the fixation impinged on the patella. We find this a good way of treating supracondylar femoral fractures

The aims of this study was to determine the incidence of malnutrition in children with supracondylar fractures. It was hypothesised that the presence of malnutrition will increase the severity type of fractures. The study was a retrospective, cross-sectional study at a single institution. Children between 0 years and 12 years of age, who sustained documented supracondylar fracture treated surgically as a result of low velocity trauma were included in the study. Patients who sustained high velocity trauma, who had known bone disorders or had incomplete chart data, were excluded from the study Data was captured from children's’ notes who have been treated surgically for supracondylar fractures from casualty, theatre and the clinic notes. The nutritional status of children and fracture grade were identified and the two sets of data were compared against each other to try to identify a possible relation between fracture severity and malnutrition. Data was analysed in STATA and 5% level of significance was used to signify statistically significant associations. 150 patients were identified and included in the study. The majority of patients reviewed were in the normal nutritional range according to their z-scores. The severity of the fracture was not only associated with a poorer nutritional status however children with high and low z-scores (over weight as well as undernourished children) had the more severe fracture patterns, while children with normal z-scores had a fracture patterns of varying severity. Children who were malnourished were more likely to sustain more severe fracture types. The results highlighted the need for all children to have a good nutritional status as this may play a role in preventing more complex fractures

Abstract. INTRODUCTION. The anatomic distal femoral locking plate (DF-LCP) has simplified the management of supracondylar femoral fractures with stable knee prostheses. Osteoporosis and comminution seem manageable, but at times, the construct does not permit early mobilization. Considerable soft tissue stripping during open reduction and internal fixation (ORIF) may delay union. Biological plating offsets this disadvantage, minimizing morbidity. Materials. Thirty comminuted periprosthetic supracondylar fractures were operated from October 2010 to August 2016. Fifteen (group A) were treated with ORIF, and fifteen (group B) with closed (biological) plating using the anatomical DF-LCP. Post-operatively, standard rehabilitation protocol was followed in all, with hinged-knee-brace supported physiotherapy. Clinico-radiological follow-up was done at 3 months, 6 months, and then yearly (average duration, 30 months), and time to union, complications, failure rates and function were evaluated. Results. Average time to union was 4.5 months (range, 3–6 months) in group A, and 3.5 months (range, 2.5–5 months) in group B. Primary bone grafting was done in twelve patients (all group A). At final follow-up, all fractures had healed, and all (but two) patients were walking unsupported, with no pain or deformity, with average knee range of motion (ROM) of 90° (range, 55 to 100°). Two patients had superficial infection (group A), two had knee stiffness (group A), one had shortening of 1.5cm (group B) and one had valgus malalignment of 10 degrees (group B). Conclusion. Biological plating in comminuted supracondylar fractures about stable TKA prostheses is an excellent option, may obviate need for bone grafting, and reducing complications

Introduction. This study aimed to compare MIPO and IMNr in the treatment of supracondylar femur fracture following TKA in respect of fracture healing, complications and functional results. Materials and Methods. A retrospective analysis was made of 32 supracondylar femur fractures classified according to the Rorabeck classification, comprising 20 cases treated with MIPO and 12 with IMNr. The two techniques were compared in respect of ROM, KSS, SF-12 scores, intraoperative blood loss, surgery time, and radiological examination findings. Results. No significant difference was determined between the two groups in respect of age, gender and fracture type, or in the median time to union (MIPO 4.3 months, IMNr 4.2 mths) (p >0.05). In the MIPO group, 2 patients had delayed union, so revision surgery was applied. The mean postoperative ROM was comparable between IMNr and MIPO (86.2 °vs 86 °, p > 0.05). The mean Knee Society Score (KSS) and SF-12 score did not differ between the IMN and MIPO groups. (p>0.05). Reduction quality in the sagittal plane was better in the MIPO group and no difference was determined in coronal alignment. Greater shortening of the lower extremity was seen in the IMNr group than in the MIPO group. (20.3 vs 9.3mm, p<0.05). Perioperative blood loss was greater (2 units vs.1.2 units) and mean operating time was longerin the MIPO group. (126.5 min vs 102.2 min, p<0.05). Conclusion. In patients with good bone stock, supracondylar femur fracture following TKA can be treated successfully with IMN or MIPO. IMN has the advantage of less blood loss and a shorter operating time. Reduction quality may be improved with the MIPO technique. Both surgery techniques can be successfully used by orthopaedic surgeons taking a case-by-case approach

The Gartland extension-type supracondylar humerus fracture is the most common elbow fracture in the paediatric population. Depending on fracture classification, treatment options range from nonoperative treatment such as taping, splinting or casting to operative treatments such as closed reduction and percutaneous pinning or open reduction. Classification variability between surgeons is a potential contributing factor to existing controversy over nonoperative versus operative treatment for Type II supracondylar fractures. The purpose of this study was to investigate levels of agreement in classification of extension-type supracondylar humerus fractures using the Gartland classification system. A retrospective chart review was conducted on patients aged 2–12 years who had sustained an extension-type supracondylar fracture and received either operative or nonoperative treatment at a tertiary children's hospital. De-identified baseline anteroposterior (AP) and lateral plain elbow radiographs were provided along with a brief summary of the modified Gartland classification system to surgeons across Canada, United States, Australia, United Kingdom and India. Each surgeon was blinded to patient treatment and asked to classify the fractures as Type I, IIA, IIB or III according to the classification system provided. A total of 21 paediatric orthopaedic surgeons completed one round of classification, of these, 15 completed a second round using the same radiographs in a reshuffled order. Kappa values using pre-determined weighted kappa coefficients were calculated to assess interobserver and intraobserver levels of agreement. In total, 60 sets of baseline elbow radiographs were provided to survey respondents. Interobserver agreement for classification based on the Gartland criteria between surgeons was a mean of 0.68, 95% CI [0.67, 0.69] (0.61–0.80 considered substantial agreement). Intraobserver agreement was a mean of 0.80 [0.75, 0.84]. (0.61–0.80 substantial agreement, 0.81–1 almost perfect agreement). Radiographic classification of extension-type supracondylar humerus fractures at baseline demonstrated substantial agreement both between and within surgeon raters. Levels of agreement are substantial enough to suggest that classification variability is not a major contributing factor to variability in treatment between surgeons for Type II supracondylar fractures. Further research is needed to compare patient outcomes between nonoperative and operative treatment for these fractures, so as to establish consensus and a standardized treatment protocol for optimal patient care across centres

Paediatric supracondylar fractures are the most common elbow fracture in children, and is associated with an 11% incidence of neurologic injury. The goal of this study is to investigate the natural history and outcome of motor nerve recovery following closed reduction and percutaneous pinning of this injury. A total of 246 children who underwent closed reduction and percutaneous pinning following supracondylar humerus fractures were prospectively enrolled over a two year period. Patient demographics (age, weight), Gartland fracture classification, and associated traumatic neurologic injury were collected and analyzed with descriptive statistics. Patients with neurologic palsies were separated based on nerve injury distribution, and followed long term to monitor for neurologic recovery at set time points for follow up. Of the 246 patient cohort, 46 patients (18.6%) sustained a motor nerve palsy (Group 1) and 200 patients (82.4%) did not (Group 2) following elbow injury. Forty three cases involved one nerve palsy, and three cases involved two nerve palsies. No differences were found between patient age (Group 1 – 6.6 years old, Group 2 – 6.2 years old, p = 0.11) or weight (Group 1 – 24.3kg, Group 2 – 24.5kg, p = 0.44). A significantly higher proportion of Gartland type III and IV injuries were found in those with nerve palsies (Group 1 – 93.5%, Group 2 – 59%, p < 0 .001). Thirty four Anterior Interosseous Nerve (AIN) palsies were observed, of which 22 (64.7%) made a full recovery by three month. Refractory AIN injuries requiring longer than three month recovered on average 6.8 months post injury. Ten Posterior Interosseous Nerve (PIN) palsies occurred, of which four (40%) made full recovery at three month. Refractory PIN injuries requiring longer than three month recovered on average 8.4 months post injury. Six ulnar nerve motor palsies occurred, of which zero (0%) made full recovery at three month. Ulnar nerve injuries recovered on average 5.8 months post injury. Neurologic injury occurs significantly higher in Gartland type III and IV paediatric supracondylar fractures. AIN palsies remain the most common, with an expected 65% chance of full recovery by three month. 40% of all PIN palsies are expected to fully recover by three month. Ulnar motor nerve palsies were slowest to recover at 0% by the three month mark, and had an average recovery time of approximately 5.8 months. Our study findings provide further evidence for setting clinical and parental expectations following neurologic injury in paediatric supracondylar elbow fractures

Introduction: Closed reduction and percutaneous pinning techniques for displaced supracondylar fractures of the humerus in children have overcome disastrous ischemic complications and long inpatient treatment. Closed reduction of those highly unstable fractures and the demanding pin placement itself are potential sources of failure for the inexperienced reflected by the rate of cubitus varus which is still about 5 to 15% in recent series. Rotational primary and residual displacement has to be appreciated to prevent permanent cosmetic deformity. Malrotation is the major source of instability since bicolumnar support is lost which allows the distal fragment to tilt. Anatomy: The transverse section of the distal humerus is the key to all stability related problems faced in supra-condylar fractures of the humerus in children. In the supracondylar region the radial and ulnar column are only connected by a thin bony wafer which results from the presence of the cubital and olecranon fossa. In case of a fracture. In case of a fracture rotation leads to decrease of bony contact and hence to instability. Epidemiology: Elbow fractures account for 7–10% of all pediatric fractures whereof 80–90% are located at the distal humerus with 80% involvement of the supracondylar region. Most of the supracondylar fractures occur between ages 5 and 10 years. Mechanism of injury: Fall from a height, usually from a household object in the age group < 3 years or from a playground equipment in children > 4 years on the outstretched nondominant arm (indirect elbow trauma). 96% of all supracondylar fractures are extension type injuries. Open fractures, mostly grade 1, occur when the anterior spike of the proximal fragment pierces through the brachialis muscle and the skin of the cubital fossa. Their incidence is about 1–3% in major referral centers. Differential diagnosis: Supracondylar fractures have to be differentiated from transcondylar fractures and dislocations of the elbow. In a supracondylar fracture the fracture line stays proximal to the distal humerus physis. If it runs across it, it is most likely a supracondylar fracture. Dislocations of the elbow typically after the age of 10 years. Neurologic compromise: Fracture related peripheral neuropathies have an incidence of 10 to 17%. With rare exceptions concomitant nerve lesion recover spontaneously within a time range of 1 to 4 months. The rate of iatrogenic nerve injuries is 3%–16% with the ulnar nerve being the most susceptible due to inadvertent pinning. Despite a high recovery rate, they are a nuisance for the patients. Vascular compromise: Early recognition of vascular compromise with subsequent reduction and fixation of the fracture and avoidance of extreme flexion at the elbow have decreased the incidence of ischemic complications. An initially absent radial pulse is found in up to 19% in displaced fractures. Closed reduction restores pulsation in about 80%. Patients with postreduction lack of pulse or poor capillary refill should undergo vascular revision. There is still controversy regarding the management of a post reduction pink, warm but pulse less hand with adequate capillary refill. Simple observation and conservative management leads to a favourable clinical outcome in most cases but cold intolerance or exercise induced ischemic symptoms is a potential sequel. Treatment:. Undisplaced fractures: simple immobilisation e.g. collar and cuff. Incomplete displacement: in case of malrotation and/or age-related unacceptable extension (> 20° in patients older than 6 years) closed reduction and pinning otherwise conservative management. Complete displacement: Attempt for closed reduction and percutaneous pinning. Irreducibility is found in up to 22%. Open reduction is most widely as a last resort. Complications:. Infection. Occasionally, superficial infection after pinning occurs despite all preventive measure (wires left protruding through the skin should not be covered by plaster to prevent rubbing; pin care instruction for the parents; regular follow-up for pin site inspection). Cubitus varus. Most common complication with an overall incidence of about 20%. As a malunion in the coronal plane it has no capacity for remodelling. Although this deformity is mainly a cosmetic problem and does not interfere with the range of motion, it may be a functional problem in some activities e.g. in apparatus gymnastics. Malunion/Stiffness. Even after perfect reduction, lack of full extension is common and usually takes over 6 months to improve. Impaired range of motion may be prolonged or even persistent due to an underlying pathology. Malunion is the most common one. In the sagittal plane, antecurvation leads to hyperextension and reduced flexion of the elbow. Significant remodelling with growth can only be expected below the age of 6 and in antecurvations of less than 20°. Rotatory malunion with an anterior spur restrains flexion. Complete remodelling of the spur usually takes place even in older children. Volkmann’s contracture represents the most severe complication after supracondylar fractures. Fortunately, it has become a rarity. Conclusion:. The human factor, in view of the particular anatomy of the supracondylar region and the extreme fracture instability seems to be more decisive for the end result than any biomechanical differences of various pin configurations. Repeat instruction by an experienced surgeon for proper reduction technique, assessment of achieved reduction and technically correct pin placement is crucial to further improve the outcome of this challenging fracture

Introduction A review of the the treatment of supracondylar fractures of the distal femur is presented. Methods The material presented consists of a review of published literature and personal experience. Results The introduction of the Condylar Blade Plate by the AO in the 1960s revolutionized the treatment of this injury. Numerous publications over the last 30 years attest to the superiority of the modern AO methods. The Comprehensive Classification of the supracondylar fractures greatly helps surgeons in decision making. The mid-line medial parapatelar surgical approach is preferred to the classical lateral incision. A lateral parapatellar incision has been in use recently in conjunction with the LISS and CLCP. A detailed understanding of the surgical anatomy of the distal femur prevents technical misadventures in securing stable fixation. Atraumatic reduction techniques have been developed to prevent devitalization of intermediate fragments which permits bridge plating and obviates the need of bone grafting multifragmentary fractures. Previously, failure to bone graft multifragmentary fractures was the commonest cause of failure of fixation. Current fixation devices are the classic condylar plate, the dynamic condylar screw, the condylar buttress plate, and the retrograde supracondylar femoral nail and the most recently developed LISS and the condylar locked compression plate. The choice of implant depends on the specific fracture pattern and associated soft tissue injury, concomitant apendicular and system injuries, the patient’s age and the presence of osteoporosis. The open supracondylar fracture presents unique problems which require careful judgement and staging in reconstruction. Even if they become infected, with proper stabilization 80% will still achieve satisfactory results. The supracondylar fracture in the presence of a total knee replacement is an absolute indication to surgical stabilization. It and osteoporosis present specific challenges which require specialized techniques of fixation for successful resolution. Polytrauma with multisystem injuries and certain specific concomitant articular injuries such as patellar fractures or fractures of the tibial plateau prejudice the outcome of treatment. Conclusions With modern surgical treatment, young patients with isolated Type A, Type B and C1 or C2 fractures can expect a normal knee as the outcome of treatment. Type C3 fractures and open fractures continue to be a challenge and their outcome depends on the degree of initial articular cartilage destruction, the degree of bone fragmentation and displacement, and on the degree of soft tissue damage. Articular cartilage injury and severe osteoporosis continue to be the two most important unsolved problems in fracture surgery

Introduction A review of the the treatment of supracondylar fractures of the distal femur is presented. Methods The material presented consists of a review of published literature and personal experience. Results The introduction of the Condylar Blade Plate by the AO in the 1960s revolutionized the treatment of this injury. Numerous publications over the last 30 years attest to the superiority of the modern AO methods. The Comprehensive Classification of the supracondylar fractures greatly helps surgeons in decision making. The mid-line medial parapatelar surgical approach is preferred to the classical lateral incision. A lateral parapatellar incision has been in use recently in conjunction with the LISS and CLCP. A detailed understanding of the surgical anatomy of the distal femur prevents technical misadventures in securing stable fixation. Atraumatic reduction techniques have been developed to prevent devitalization of intermediate fragments which permits bridge plating and obviates the need of bone grafting multifragmentary fractures. Previously, failure to bone graft multifragmentary fractures was the commonest cause of failure of fixation. Current fixation devices are the classic condylar plate, the dynamic condylar screw, the condylar buttress plate, and the retrograde supracondylar femoral nail and the most recently developed LISS and the condylar locked compression plate. The choice of implant depends on the specific fracture pattern and associated soft tissue injury, concomitant apendicular and system injuries, the patient’s age and the presence of osteoporosis. The open supracondylar fracture presents unique problems which require careful judgement and staging in reconstruction. Even if they become infected, with proper stabilization 80% will still achieve satisfactory results. The supracondylar fracture in the presence of a total knee replacement is an absolute indication to surgical stabilization. It and osteoporosis present specific challenges which require specialized techniques of fixation for successful resolution. Polytrauma with multisystem injuries and certain specific concomitant articular injuries such as patellar fractures or fractures of the tibial plateau prejudice the outcome of treatment. Conclusions With modern surgical treatment, young patients with isolated Type A, Type B and C1 or C2 fractures can expect a normal knee as the outcome of treatment. Type C3 fractures and open fractures continue to be a challenge and their outcome depends on the degree of initial articular cartilage destruction, the degree of bone fragmentation and displacement, and on the degree of soft tissue damage. Articular cartilage injury and severe osteoporosis continue to be the two most important unsolved problems in fracture surgery

The current incidence of periprosthetic supracondylar femoral fractures around total knee arthroplasties (TKAs) is 0.3% to 2.5%, but may well be increasing. An acceptable treatment is to insert a supracondylar nail, but not all TKAs will permit the passage of a supracondylar nail. Method: We ascertained the ten most common TKA prostheses currently used in the United Kingdom from the National Joint Registry (NJR) Report published in September 2005. We used samples of each prosthesis with a saw bone model and checked their compatibility for accepting a supracondylar nail. Results: We present the dimensions of the intercondylar notches of the top ten TKA prostheses, which account for over 90% of TKAs performed over the last year nationally. Our reference chart demonstrates which of these are suitable for use with supracondylar nails. Discussion: Most of the TKAs commonly used in the UK will allow supracondylar nailing for fixation of peri-prosthetic fractures. There are, however, notable exceptions and our chart provides a quick and easy reference for knee surgeons involved in these cases

The purpose of this study was to evaluate functional outcome following supracondylar femur fractures using patient-based outcome measures. Patients having sustained supracondylar femur fractures between 1990 and 2004 were identified from the fracture databases of two level-one trauma centres. Three patient-based outcome measures, the Short Form-36 (SF-36) Version two, the Short Musculoskeletal Functional Scale (SMFA), and the Lower Extremity Functional Scale (LEFS) were used to evaluate functional outcome. Each patient’s medical record was also reviewed to obtain information regarding potential predictors of outcome, including age, gender, fracture type (AO classification), presence of comorbidities, smoking status, open vs. closed fracture, and occurrence of complications. Univariate and multivariate models were then used to identify significant predictors of outcome, as reflected in the SMFA bother and dysfunction scores. Sixty-one patients (thirty-five males and twenty-six females) with an average age (at time of injury) of 53 ± 18 years consented to participate. The average length of follow-up was 64 ± 34 months from the time of injury. Mean SF-36 V2 scores were lower than Canadian population norms indicating decreased function or greater pain, while mean SMFA scores were higher than published population norms indicating greater impairment and bother. The mean LEFS score was 40.78 ± 15.90 out of a maximum score of eighty. At the univariate level, the presence of complications was a significant predictor of both the SMFA bother (p=0.002) and dysfunction scores (p=0.015), while positive smoking status was a significant predictor of the bother score (p=0.002). Based on a multivariate linear regression model, the presence of complications (p=0.013) and positive smoking status (p=0.011) were both significant predictors of a higher SMFA bother score. In the multivariate model for SMFA dysfunction score, the presence of complications (p=0.014) and the presence of comorbidities (p=0.017) were significant predictors of a higher score. Comparing SF-36 and SMFA scores with published population norms, supracondylar femur fractures were associated with residual impact. Based on our analysis, smoking, the presence of medical comorbidities at the time of fracture, and the occurrence of complications following fracture repair were the main predictors of poorer patient outcomes following supracondylar femur fracture

Technology within medicine has great potential to bring about more accessible, efficient, and a higher quality delivery of care. Paediatric supracondylar fractures are the most common elbow fracture in children and at our institution often have high rates of unnecessary long term clinical follow-up, leading to an inefficient use of healthcare and patient resources. This study aims to evaluate patient and clinical factors that significantly predict necessity for further clinical visits following closed reduction and percutaneous pinning. A total of 246 children who underwent closed reduction and percutaneous pinning following supracondylar humerus fractures were prospectively enrolled over a two year period. Patient demographics, perioperative course, goniometric measurements, functional outcome measures, clinical assessment and decision making for further follow up were assessed. Categorical and continuous variables were analyzed and screened for significance via bivariate regression. Significant covariates were used to develop a predictive model through multivariate logistical regression. A probability cut-off was determined on the Receiver Operator Characteristic (ROC) curve using the Youden index to maximize sensitivity and specificity. The regression model performance was then prospectively tested against 22 patients in a blind comparison to evaluate accuracy. 246 paediatrics patients were collected, with 29 cases requiring further follow up past the three month visit. Significant predictive factors for follow up were residual nerve palsy (p < 0 .001) and maximum active flexion angle of injured elbow (p < 0 .001). Insignificant factors included other goniometric measures, subjective evaluations, and functional outcomes scores. The probability of requiring further clinical follow up at the 3 month post-op point can be estimated with the equation: logit(follow-up) = 11.319 + 5.518(nerve palsy) − 0.108(maximum active flexion). Goodness of fit of the model was verified with Nagelkerke R2 = 0.574 and Hosmer & Lemeshow chi-square (p = 0.739). Area Under Curve of the ROC curve was C = 0.919 (SE = 0.035, 95% CI 0.850 – 0.988). Using Youden's Index, a cut-off for probability of follow up was set at 0.094 with the overall sensitivity and specificity maximized to 86.2% and 88% respectively. Using this model and cohort, 194 three month clinic visits would have been deemed medically unnecessary. Preliminary blind prospective testing against the 22 patient cohort demonstrates a model sensitivity and specificity at 100% and 75% respectively, correctly deeming 15 visits unnecessary. Virtual clinics and automated clinical decision making can improve healthcare inefficiencies, unclog clinic wait times, and ultimately enhance quality of care delivery. Our regression model is highly accurate in determining medical necessity for physician examination at the three month visit following supracondylar fracture closed reduction and percutaneous pinning. When applied correctly, there is potential for significant reductions in health care expenditures and in the economic burden on patient families by removing unnecessary visits. In light of positive patient and family receptiveness toward technology, our promising findings and predictive model may pave the way for remote health care delivery, virtual clinics, and automated clinical decision making

Supracondylar femoral fractures challenge even the most experienced trauma surgeon. Fracture comminution often extends into the articular surface, increasing the risk of joint stiffness and post-traumatic arthritis. This is a preliminary prospective report of 42 supracondylar femoral nailing procedures performed on 41 patients between July 2000 and March 2001. The mean age of the 21 women and 20 men was 62 years. Five fractures were compound. Classified according to AO classification, there were 28 type-AIII fractures, 10 type-AII, two type-CIII and two type-CII. In all cases a percutaneous surgical technique was used and a 13-mm x 250-mm supracondylar nail inserted. The mean operative time was 70 minutes. Mean follow-up was four months (2 to 10). There were no deep or superficial infections and no implant failures. Twenty fractures healed with no shortening within four months. The mean flexion arc was 105° (5° to 130°). Eight patients with osteoporosis had 1 cm to 2 cm of shortening, which did not affect functional outcome. Of the 20 patients whose fractures united, 17 had no pain and three had mild anterior knee pain. A single patient had 8° of valgus angulation at the fracture site. This study shows that supracondylar femoral nailing provides improved fracture stabilisation both in elderly patients with osteoporotic metaphyseal bone and in younger patients with extensively comminuted fractures. Percutaneous techniques eliminate the need for extensive surgical dissection, shorten operation times and reduce blood loss

Statement: This is the first report of a supracondylar femoral fracture following ACL reconstruction using a transfixation pin. Methods: A 38 yr old secretary was admitted for an elective ACL reconstruction. The operative procedure involved harvesting of the hamstrings, with drilling of an 8 mm tibial tunnel and the graft fixed with a 10 × 35mm screw. Femoral tunnel placement was performed arthroscopically and fixation of the graft in the tunnel was using the Arthrex system. No untoward events were recorded in the notes. Post-operatively, the patient was mobilised according to the surgeons standard guidelines. At 6 week review, the patient complained of increasing pain, inability to fully weight bear and a decreased range of movement. 35 fixed flexion deformity, 30 degrees external rotation and 20 degrees of valgus of the leg. Radiographs revealed a transverse supracondylar fracture extending through the level of the pin fixation. Subsequent surgery involved an osteotomy to correct the deformity and application of a lateral femoral plate After fixation direct inspection of the retained anterior cruciate ligament, revealed and intact graft that functioned through the full range of movement. At nine months, the patient is fully weight bearing has returned to her pre-injury sporting level and has a range of movement of 0–110 degrees. There was no objective knee instability and the patient is satisfied with the outcome. Femoral fractures have rarely been reported in the literature following ACL reconstruction and these are usually associated with drilling of an enlarged femoral tunnel. We report a rare case of a transverse supracondylar femoral fracture following ACL reconstruction, with the fracture occurring through the fixation tract not the femoral tunnel

Purposes of study. Evaluation of the pre-operative documentation of neurovascular status in children presenting with Gartland Grades 2 and 3 supracondylar fractures and the development of an Emergency Department Proforma. Methods and results. A retrospective case-note review was performed on patients with Gartland Grade 2 and 3 supracondylar fractures observed in a two-year period from July 2008 – July 2010. 137 patients were included; sixteen patients (11.7%) sustained a Gartland Grade 2a fracture, sixty patients (43.8%) a Gartland Grade 2b fracture and sixty-one (44.5%) a Gartland Grade 3 fracture. Mean patient age at presentation was 5.59 years (range 12 months to 13 years). Nineteen patients (13.9%) had evidence of neurological deficit at presentation and thirteen patients (9.5%) presented with an absent radial pulse. Only twelve patients (8.8%) and nineteen patients (13.9%) respectively had a complete pre-operative neurological or vascular assessment documented. Regarding the individual nerves, fifty-nine (43.1%) patients had median nerve integrity documented, fifty-five (40.1%) ulnar nerve and forty-nine (35.8%) radial nerve integrity documented. Only eighteen patients (13.1%) had their anterior interosseous nerve function documented. Ten patients (7.3%) had post-operative neurological dysfunction, consisting of eight ulnar nerve injuries, and two radial nerve injuries. vi) Conclusions. Pre-operative documentation of neurovascular status in children with displaced supracondylar fractures was poor. Documentation of anterior interosseous nerve examination was particularly poor. We propose the introduction of a proforma (Liverpool Upper-limb Fracture Assessment – LUFA) to increase documentation of neurovascular assessment and optimise emergency department evaluation of children presenting with upper limb injuries

All skeletally immature patients who presented with a supracondylar fracture between 01/09/2013 and 24/11/2015 (n = 50) were used to compare the current management of supra-condylar fractures of the humerus in children to the standards set by the BOAST 11 guidelines. 8.1% did not have full documentation of their neurovascular assessment. 93.9% underwent surgery within 24 hours of presentation. Average time to theatre for neurovascularly compromised patients was 4 hours 46 minutes. 81.8% were managed with 2 K-wires as recommended. Only 39.4% of the patients had their wires removed within 3 – 4 weeks. Only 6.1% had the recommended 2 mm wires. AO recommends the use of 2mm wires if 2 lateral wires are used whereas the BOAST 11 guideline recommends 2mm wires where possible. The results clearly demonstrate a need for further education and awareness of the BOAST 11 guidelines. Of particular interest is the documentation of patients' neurovascular status for appropriate management and for medico-legal purposes. Long term outcome comparison of surgical fixation with 2mm and 1.6mm wires would be useful to support the use of 2mm wires as recommended by the professional consensus in the BOAST 11 guidelines

In a prospective, consecutive study we reviewed the results of 32 supracondylar femoral fractures treated by Smith & Nephew intramedullary supracondylar nailing between January 1996 and October 2002. The mean age of 23 women and nine men was 67 (58 to 89). All fractures were closed. Two patients had associated upper limb fractures. In four cases, fractures occurred around total knee prostheses. Four patients had previously undergone ipsilateral total hip replacement or had had a sliding hip screw. On the AO classification the majority of fractures were type-33A1 and A2; seven fractures were classified as C1 and C2. The patients were placed in the supine position on a radiolucent operating table with the knee in 30° of flexion. Postoperatively a hinged knee brace was applied and worn until union. Supported, progressive knee movement was introduced from day one. Partial weight-bearing was permitted as soon as pain subsided and continued until there were radiological signs of union. Within three to six months all but two fractures united. These united after prolonged bracing. There was no sepsis or fixation failure. A functional range of knee movement was observed in all patients. Retrograde intramedullary nailing is a safe and successful method of management of supracondylar femoral fractures in the elderly and offers a minimally invasive alternative

Purpose: To investigate the mode of presentation, management and outcome of ischaemic contracture following a supracondylar fracture with a pink, pulseless hand. Methods: We reviewed the database at our tertiary referral unit to identify cases over a 20 year period who had been referred for complications of a supracondylar fracture and/or a Volkmann’s ischaemic contracture. Results: We identified 20 children with Volkmann’s ischaemic contracture following a supracondylar fracture. Of these, 4 patients (mean age 5, range 2–11) were referred to us with evidence of an ischaemic contracture but they had always had a pink albeit pulseless hand. Two of these 4 had undergone vascular exploration at 48 hours and at 72 hours but despite this developed an ischaemic contracture. The 2 patients with the most severe contractures have undergone surgical intervention for their contracture, and 2 were managed conservatively with splinting. All 4 cases have residual problems with hand function (mean follow-up 5.5 years, range 2–11). Conclusions: Volkmann’s ischaemic contracture should be a preventable condition. The pink albeit pulseless hand is at increased risk of ischaemic muscle and nerve damage and should not be ignored as the consequences are potentially devastating. Significance: Clinicians must consider whether they feel that their management protocols for the pink, pulseless hand are robust and defensible

Internal fixation for supracondylar fracture of the femur after total knee arthroplasty (TKA) is technically difficult and troublesome because the distal bony fragment is often osteoporotic and too small to fix by screws or K-wires. In addition, the femoral component interferes with the screws or K-wires to be inserted from distal direction for fixation of the fracture. Patients and Methods. Four knees in 4 patients (all female; average age, 81.5 +/− 2.6 years) with the fracture after TKA were treated with revision TKA. Follow-up period was between six months and 3 years postoperatively. Operative technique. All operations were performed with the patient in the supine position and using a curved anterior (Payer) approach with or without osteotomy of the tuberositas tibiae. The femoral component was removed with detachment from fractured bony fragments. New femoral component with long stem for fixation of the fracture were inserted with bone cement in each case. Post-operative regimen. On the third postoperative day the patient began flexion and exension exercise of the operated knee joint with a rehabilitation programmed by clinical path under the supervision of a physiotherapist. The use of crutches for ambulation was begun on the 10. th. to 14. th. postoperative day, and the extent of weight bearing was allowed individually according to the stability of the fixation of the fracture. The time to full weight bearing in each patient was 3 to 8 weeks postoperatively. Results. Postoperative courses were uneventful in all of the cases. The supracondylar fracture of the femur was rigidly fixed and healed radiographically within 8 weeks postoperatively in each case. The JOA scores were improved in all od the cases. The mean Japanese Orthopaedic Association (JOA) scores for the knees improved to 90 points postoperative. No femoral components had definite radiographic evidence of loosening and were re-revised. Discussion. In the current study of short-term results of revision total knee arthroplasty for treatment of supracondylar fracture of the femur after total knee with osteoporosis, the component have shown to remain stable in weight bearing conditions and functioned well. Fracture healing and good clinical outcome, evaluated according to the JOA score, were achieved in all cases. Longer-term outcome should be the subject of further investigation. Conclusion. The revision TKA was a successful method for treatment of the supracondylar fracture after TKA

Aim: To report the results of supracondylar nailing of periprosthetic fractures of the distal femur above total knee replacement. Methods: Six displaced peri-prosthetic fractures of the distal femur in six female patients were treated with titanium supracondylar nail (Depuy ACE) between October 1997 and November 1999. The mean age was 68 years (42–92). Four patients had history of rheumatoid arthritis and two had previously undergone bilateral total hip replacement. None of the patients was reported to have anterior notching of the distal femur. Six fractures were equally distributed between right and left side. Low velocity trauma was the cause of fracture in all patients. The knee implants were in place for an average period of 36 months (3 wk to 48 months). The average follow up was 20 months (6–36). Results: All fractures healed in an average period of 14.6 weeks (12–18). One patient suffered another fall and sustained a fracture of the shaft of the femur above the nail. This was treated with exchange nailing using a long supracondylar nail with good result. All fractures healed in a satisfactory alignment. There were no cases of infection, loss of reduction and implant failure. All patients achieved their pre-injury functional status. The average ROM at the knee was 86.6 degrees (70–100). At latest follow up, none of the prostheses showed any signs of loosening and two patients had undergone total knee replacement on the contralateral side. Conclusion: Supracondylar nailing is a satisfactory method of managing periprosthetic fractures of the distal femur above a well-þxed implant