Closed reduction and percutaneous pinning has become the most common technique for the treatment of Type III displaced supracondylar humerus fractures in children. The purpose of this study was to evaluate whether the loss of reduction in lateral K wiring is non-inferior to crossed K wiring in this procedure. A prospective randomised non-inferiority trial was conducted. Patients aged three to seven presenting to the Emergency Department with a diagnosis of Type III supracondylar humerus fracture were eligible for inclusion in the study. Consenting patients were block randomised into one of two groups based on wire configuration (lateral or crossed K wires). Surgical technique and post-operative management were standardised between the two groups. The primary outcome was loss of reduction, measured by the change in Baumann's angle immediately post –operation compared to that at the time of K wire removal at three weeks. Secondary outcome data collected included Flynn's elbow score, the humero-capitellar angle, and evidence of iatrogenic ulnar nerve injury. Data was analysed using a t-test for independent means. A total of 52 patients were enrolled at baseline with 23 allocated to the lateral pinning group (44%) and 29 to the cross pinning group (56%). Six patients (5 crossed, 1 lateral) received a third wire and one patient (crossed) did not return for x-rays at pin removal and were therefore excluded from analysis. A total of 45 patients were subsequently analysed (22 lateral and 23 crossed). The mean change in Baumann's angle was 1.05 degrees, 95% CI [-0.29, 2.38] for the lateral group and 0.13 degrees, 95% CI [-1.30, 1.56] for the crossed group. There was no significant difference between the groups in change in Baumann's Angle at the time of pin removal (p = 0.18). Two patients in the crossed group developed post-operative iatrogenic ulnar nerve injuries, while none were reported in the lateral group. Preliminary analysis shows that loss of reduction in Baumann's angle with lateral K wires is not inferior to crossed K wires in the management of Type III supracondylar humerus fractures in children. The results of this study suggest that orthopaedic surgeons who currently use crossed K wires could consider switching to lateral K wires in order to reduce the risk of iatrogenic ulnar nerve injuries without significantly compromising reduction

The purpose of this study was to investigate if there is a relationship between the timing of reduction of displaced supracondylar humerus fractures in children and post-operative complications and open reduction rate and to evaluate the usefulness of the definition of early (eight hours or less following injury) and delayed (more than eight hours following injury) treatment used in the literature. The case notes of children who were treated at our institution for a Gartland grade 2b and 3 supracondylar humerus fracture between July 1995 and June 2002 were reviewed. We identified 431 patients with a Gartland grade 3 and 141 patients with a Gartland grade 2b fracture. The time from injury to surgery ranged from 2 hours to 13 days. The average time to reduction was 12 hours for grade 3 injuries and 21 hours for grade 2b injuries. None of the patients had an initial closed reduction in the emergency department. 229 patients were treated early with two compartment syndromes, five ulnar nerve, one lateral cutaneous nerve of the forearm, one median nerve - and one radial nerve palsy, one septic arthritis, one pin site infection, six open reductions; one re-manipulation was required for loss of reduction. The delayed group consisted of 343 patients with six ulnar nerve, three median nerve, one radial nerve and one lateral cutaneous nerve of the forearm palsy, three pin site infections, five open reductions; re-manipulation was required in one patient. All nerve palsies recovered post-operatively. The open reduction rate was two percent. The majority of displaced supracondylar humerus fractures in children do not need to be operated on as an emergency. Operation of fractures not associated with a neurovascular compromise within eight hours of the injury does not seem to reduce the rate of significant complications and open reduction rate. In contrary the most severe complication, the development of a compartment syndrome was only seen in the early group. We did not identify an association between complication rateS and a time threshold. Therefore the differentiation between early and delayed treatment used in the literature seems to be arbitrary and not useful

Purpose: The treatment algorithm for supracondylar humerus fractures in children under age seven is well-established. However, the best treatment option for these fractures in older children (8–14 year olds) is debated. The purpose of this study was to assess the efficacy of closed versus open fixation methods of this fracture type in older children. We hypothesize that closed reduction and percutaneous pinning (CRPP) is as effective as open reduction and internal fixation (ORIF). Method: A retrospective chart review was completed of all patients 8–14 years old treated for supracondylar humerus fractures at one centre from 2000–2007. IRB approval was obtained for this study. Demographics, treatment methods, pre- and post-operative complications, functional and radiographic outcomes were reviewed. Values are reported as mean ± standard deviation. Results: Seventy-eight eligible patients were identified: 60 (76.9%) were treated with CRPP, and 18 (23.1%) were treated with ORIF. Demographics and fracture characteristics were similar between the CRPP and ORIF groups, although patients treated with ORIF were older (p< 0.001) and weighed more (p< 0.001). The ORIF group had higher post-operative complication rates (p=0.016). Five patients treated with CRPP required additional surgery (3 underwent ORIF; 2 underwent repeat CRPP) compared with none in the ORIF group. Children treated with ORIF had greater limitations on active flexion (99.7o ± 18.2 ORIF, 140.5o ± 23.5 CRPP, p< 0.001) and active extension (34.3o ± 19.0 ORIF, 11.9o ± 21.2 CRPP, p< 0.001) at first follow-up. Limitations in active flexion persisted in the ORIF group, but not in the CRPP group, at time of last follow-up (120o ± 14.8 versus 150.4o ± 17.8, p< 0.001). There were no group differences in active extension at last follow-up (p=0.093). On radiographs, significant differences between the groups existed for Bauman’s angles (15.5o ± 5.5 ORIF, 19.3o ± 4.9 CRPP, p=0.013) and carrying angle (12.4o ± 5.7 ORIF, 16.6o ± 5.4 CRPP, p=0.008). Radiographic union was achieved in all cases. Conclusion: Open and closed surgical fixation are both acceptable treatment options for supracondylar humerus fracture in older children. While ORIF appears to result in reduced range of motion, no further operations were required for fracture alignment in this group

The treatment of supracondylar humeral fractures in children continues to evolve. The currently fashionable treatment for displaced fractures is closed reduction and the insertion of at least two K-wires. This usually requires the patient to have a second surgery to remove the K-wires, and may result in significant scarring. The senior author has used the straight arm method to treat displaced supracondylar fractures. We have reviewed the long term results of seven children treated by the straight arm method. No patient had a scar, no patient had a cubitus varus and all children regained a full range of movement. This method offers excellent results with no risk of iatrogenic nerve injury, scarring, or second surgery

During the period 2004–2009, 35 children were admitted to the emergency department,(24 males:11 females), aged 3–14 years old,(MEAN 8,45 years), with supracondylar humeral fractures (33 extension type and 2 flexion type). All fractures were closed and result of sports injuries or games and were treated with closed reduction under general anesthesia and percutaneous k-w fixation. The postoperative follow-up lasted from 6 months to 4 years. The Bauman’s angle was evaluated postoperatively on the operated and normal elbow and was 76, 6 ±1° and 74, 7 ±0, 6°. According to Flynn’s criteria the functional outcome was excellent in 29 cases. In 6 cases where the Bauman’s angle was greater than 10–15° there has been observed varus deformity (4 cases), valgus deformity (1 case), and flexion deficit (1 case). The percutaneous k-w fixation and preservation of Bauman’s angle with carrying angle too, on supracondylar humeral fractures on children is a safe solution to avoid future complications

We studied the outcome of displaced supracondylar fractures in 98 children treated over three years to December 2000. In 74 patients fractures were treated by closed reduction and percutaneous K-wire fixation. Through a direct posterior approach, open reduction was obtained in the other 24. Postoperatively the elbow was immobilised in a posterior cast in 30° flexion for three to four weeks. The cast and K-wires were removed in the clinic and the elbow mobilised. In patients treated by closed reduction, the mean range of movement (ROM) was 10° to 120° at the one-month follow-up. There was a cubitus varus deformity in four patients. One patient developed pintract infection. There were five neurological complications, of which only one (ulnar nerve) was surgical. The mean ROM of patients treated by open reduction was 15° to 110° at the one-month follow-up. Pre-operatively two patients in this group had a neurological deficit (one median and one radial nerve), which had improved at follow-up. Treatment of supracondylar humeral fractures in children by closed reduction and percutaneous K-wires is safe and reliable. Where open reduction is necessary, a posterior approach is more acceptable cosmetically and does not lead to functional loss

The aims of this study were (1) to assess whether rotational stability testing in Gartland III supracondylar fractures can be used intra-operatively in order to assess fracture stability following fixation with lateral-entry wires and (2) to quantify the incidence of rotational instability following lateral-entry wire fixation in Gartland type III supracondylar humeral fractures in children. Twenty-one consecutive patients admitted with Grade III supracondylar fractures at the Children's Hospital at Westmead were surgically treated according to a predetermined protocol. Following closed fracture reduction, 2 lateral-entry wires were inserted under radiographic control. Stability was then assessed by comparing lateral x-ray images in internal and external rotation. If the fracture was found to be rotationally unstable by the operating surgeon, a third lateral-entry wire was inserted and images repeated. A medial wire was used only if instability was demonstrated after the insertion of three lateral wires. Rotational stability was achieved with two lateral-entry wires in 6 cases, three lateral-entry wires in 10 cases and with an additional medial wire in 5 cases. Our results were compared to a control group of 24 patients treated at our hospital prior to introduction of this protocol. No patients returned to theatre following introduction of our protocol as opposed to 6 patients in the control group. On analysis of radiographs, the protocol resulted in significantly less fracture position loss as evidenced by change in Baumann's angle (p<0.05) and lateral rotational percentage (p<0.05). We conclude that the introduction of rotational stability testing allows intra-operative assessment of fracture fixation. Supracondylar fractures that are rotationally stable intra-operatively following wire fixation are unlikely to displace post-operatively. Only a small proportion (26%) of these fractures were rotationally stable with 2 lateral-entry wires. This may be a reflection of either the fracture configuration or inability to adequately engage the medial column

Supracondylar fractures of the humerus are the most common type of elbow fractures in children. The unique anatomy of the elbow and the high potential for complications associated with elbow fractures make their treatment difficult. Although the current trend in the literature is to treat them by closed reduction and per-cutenous pinning, open reduction and cross pinning is an alternative treatment especially in the case of technical insufficiencies. This retrospective study was performed to understand the clinical results after open reduction and cross pin fixation in 205 children (mean age 7.4 years) with completely displaced supracondylar fractures of the distal humerus between 1994 and 2002. The operation was performed within 5 days after the injury. The posterior skin approach was used but bone was reached through both sides of triceps muscle which was kept intact. The results were assessed according to Flynn’s cosmetic and functional criteria after 48 months of mean follow up. No patient had neurological or circulatory complication. All the fractures healed and none of them had rotation, recurvation or cubitus valgus deformity. Four children had mild cubitus varus deformity. There were 190 (93%) excellent, 15 (7%) good cosmetic outcome and 170 (83%) excellent, 21 (10%) good, 8 (4%) average, 6 (3%) weak functional outcome. We still prefer open reduction and cross pinning in the management of unstable supracondylar humeral fractures in children. We find it safer and believe this approach avoids unpleasant complications. Also excellent results can be achieved without being exposed to high doses of radiation

Introduction: The preferred treatment for displaced supracondylar humeral fractures in children is closed reduction and percutaneous pinning. Cross-wiring techniques are biomechanically superior to parallel lateral wiring techniques. The purpose of this study was to review our experience with a novel cross wiring technique performed entirely from the lateral side. This avoids the potential for ulnar nerve injury in these difficult cases. Patients and Methods: We collected all children with supracondylar fractures of the distal humerus who were manipulated and wired by one surgeon, using a lateral cross wiring technique. Patient demographics, mechanism of injury, fracture classification (Gartland’s classification) and associated neurovascular injuries were noted. At follow-up (12 weeks), range of motion and carrying angle were measured. Results: Twenty patients were identified and reviewed. There were 8 female and 14 male patients, mean age 10 years (range 2–11). Two fractures were Type II, 12 were Type IIIA and 6 were Type IIIB. Three patients had signs of an anterior interosseous nerve injury and one patient had a brachial artery laceration. All fractures were reduced, cross-wired from the lateral side, and rested in an above elbow slab. Wires were removed at 4 weeks. At follow-up, all children had a full range of motion and the mean carrying angle was 17° (range: 15–20). All three patients with pre-operative nerve injuries had full recovery of nerve function. Conclusions: Lateral cross wiring of supracondylar fractures represents a real option in the treatment of these injuries. It offers the biomechanical advantages of traditional cross-wiring without the risk of nerve injury