European Journal of Cardiovascular Medicine

Supracondylar fractures are the most common elbow fracture recorded in children, accounting for approximately 60% of fractures around the elbow and 13-15% of all pediatric fractures ^[1]. These fractures are prevalent in the non-dominant hand between the ages of 5 and 8, with boys being more afflicted than girls ^[2-4]. These fractures are categorised into three categories according to their displacement. The fragmented portion is not displaced in type I, displaced with intact posterior cortex in type II, entirely displaced in type III, and completely displaced with periosteal stripping in type IV ^[5].

Complications arise as a result of intrinsic fracture instability, proximity to the brachial artery, three major nerves of the upper extremity, inadequate radiographs, poor interpretation of reduction and modality of maintenance of reduction, and, finally, patient compliance with therapy. The treatment goal for displaced supracondylar humerus fractures in children is anatomic reduction. Open reduction is recommended if closed reduction cannot achieve the desired anatomic reduction. This can be done without increasing the risk of problems.Fractures that do not respond to closed reduction are surgically treated with open reduction and pinning. Open reduction can be performed using anterior, posterior, medial, or lateral surgical techniques ^[6].

Supracondylar fracture of the humerus is one of the rare fractures that, when treated appropriately, may not throw the surgeon's reputation into question. Still, when treated incorrectly, it will undoubtedly bring shame to even the most well-known surgeon.

There is little debate on how to manage an undisplaced or slightly displaced fracture, however, there are several options for treating a completely displaced fracture. Others have developed blind pining following reduction or pinning under X-ray control. Some even advise accepting an inadequate closed reduction and performing an osteotomy to fix the deformity later. However, severe treatment, including surgery management, is frequently indicated in the elbow region. It is no longer true that a supracondylar fracture is not bad.

To evaluate the Functional outcome of type 3 supracondylar fracture of the humerus in children treated by open reduction and internal fixation by k-wires.

Study Design: Hospital-based prospective study.

Study area: The study was conducted in the Department of Orthopaedics.

Study Period:  February 2024 to July 2024.

Study population: All the children with Gartland type III fracture who presented to the orthopaedic outpatient or casualty.

Sample size: The study consisted of a total of 20 subjects.

Sampling Technique:  Simple Random technique.

Inclusion Criteria:

1. Age between five to twelve years.
2. No previous fracture in the same elbow.
3. Simple type 3 supracondylar humerus fracture.

Exclusion criteria:

1. Age less than five years and more than twelve years.
2. Open fractures.
3. Surgically unfit patients.

Ethical consideration: Institutional Ethical committee permission was taken before the commencement of the study.

Study tools and Data collection procedure:

A detailed history of the mode of injury was obtained from the parents as well as the patient. Out of the twenty cases, eight patients (40%) sustained fractures due to a fall while playing and the remaining twelve patients due to a fall from the cycle. Most of the cases had a history of falling on outstretched hands. All patients presented with pain, swelling, “S” shaped deformity of the lower arm and inability to move the affected elbow. On examination, all patients had diffuse swelling all around the elbow and puckering of the skin was seen at the site of fracture in 4 cases. All patients had shortening of the arm as compared to the normal side. The average period from injury to presentation was ten hours, the mean age being 8.8 years. There were 16 boys and 4 girls. 14 patients presented with involvement onthe left side and 6 patients on the right side.

Associated injuries included:

• Median nerve injury in 2 cases. These were traumatic neuropraxia and recovered completely in 10-12 weeks.
• Vascular Injury: In 3 patients the radial pulse was feeble, but the patient was able to move his fingers feebly and the character of the pulse became normal after open reduction and internal fixation with K-wires.
• X-ray of the elbow was taken in 2 planes anteroposterior& lateral. 20 cases of Gartland’s Grade III type of supracondylar fractures were included in the series. These were further grouped into #s with postero medial, postero lateral & posterior displacement.
• Out of these 20 cases, 6 had posterior-medial, eleven had posterior-lateral, 2 had posterior displacement, one case was of flexion type
• Out of twenty cases, 5 were given one trial and 2 cases were given two trials of closed reduction under sedation, taking care to maintain good radial artery pulsation.
• In 3 cases the radial artery pulsation had to be restored by open reduction and internal fixation.
• Check X-ray of the patients who underwent closed reduction was taken. They proved unsatisfactory and admitted for open reduction & internal fixation reasons.
• There was no re-establishment of the shaft condylar angle to at least 20 degrees.
• There was rotation in the horizontal plane (crescent sign).
• Inability to restore the radial pulse by closed reduction.
• Irreducibility secondary to soft tissue interposition i.e. periosteum and capsule.

The remaining thirteen cases were taken up for primary open reduction and internal fixation, the reasons being.

• Extensive separation of the fracture fragments.
• Severe vascular compromises even at the slightest attempt of manipulation.
• Routine blood investigations and urine examinations were done on admission. Injection tetvacand injection ciprofloxacin I.V. were given preoperatively.
• The average range of period from injury to surgery was 24-36 hours.

Collected data entered in the Microsoft Excel sheet. Data analysis was done by SPSS software Version 20. Continuous variables were categorised as either normal or abnormal and the patients in either category were reported as proportion. Pearson's chi-square test also known as the Chi-square test for independence and the Chi-square test of association was used to detect if there was any relationship between two categorical variables. ANOVA was used to compare the two means. A p-value of 0.05 is taken as significant.

TABLE 1: FLYNN’S CRITERIA

Failures:

1 case (6%) had poor results, which is considered as failure. This case had a limitation of elbow movement of more than 20O flexion, and cubitusvarus of 20O, associated with medial pillar comminution.

Table 2: Type of Displaced Fractures

Table 3: Type of displacement

Supracondylar fractures of the humerus in children are common injuries and complete displacement of the fragments occurs in many of the cases. Vascular complicationsare preventable to a great extent. However, cubitusvarus deformity seems to be the most common complication with any of the methods of treatment.It was observed that the upper and lower fragments became rotated in relation to each other. The fracture surface at that particular level consists of an extremely narrow edge rarely more than 4 to 5 mm. The many so-called reductions were obtained by the “rotation of the fragments” resulting in their locking. When such a reduction was obtained deformity was a sure outcome.

The average change in the carrying angle was greater, in the group that was treated by manipulation and immobilization only. Skeletal traction is the only method besides surgery, which can prevent the error of internal or rarely external rotation that persists after manipulative reduction or even skin traction. This however requires precision management of the traction system and confines the child to the bed.

In the present series, all the patients have been followed up for one year. Six patients were in addition subjected to local massage by an osteopath according to their history, but clinico-radiologically showed no evidence of myositis ossificans. The considerable soft tissue oedema is an expression of the underlying injury and its severity, and it indicates a regional vascular compromise. Immediate exploration in these cases achieves good soft tissue decompression, allows ease of reduction, and as a result of the anatomic restoration of the span of soft tissue, the progression of oedema was arrested.

The flexion type of S.C. fractures is much less common than the extension types, with a reported frequency ranging from less than 1% to 10% of S.C. fractures. It must be remembered that the posterior periosteum is torn, and the anterior periosteum now functions as a tension band by extending the arm. Having the elbow extended is awkward, and it does not control the proximal migration of the fracture. Open reduction and pinning are therefore recommended for displaced flexion type of S.C. fractures.

Complications were encountered;

Feeble radial pulse in three cases, before reduction. The pulse had returned immediately after open reduction. Two cases of median nerve involvement were noted pre operatively which were transient and recovered spontaneously over the period of ten to twelve weeks. Pin tract entry wound irritation was seen in two of the cases, which presented as points of hypergranulation tissue on the skin. This could have been avoided by burying the K wires subcutaneously.

These minor complications like pin tract entry wound irritation had no influence whatsoever on the final functional result. There was not a single case of secondary nerve lesion of Volkmann’s ischaemia or myositis ossificans.

There was associated disruption of the capsule of the elbow joint which as a rule, in some cases, was partially excised to facilitate reduction. The distal fragment could be delivered out of the wound partly on exposure of the fracture. Excision of the posterior capsule of the elbow in part has not affect the mechanics, vascularity of the regional physis or on the overall function of the elbow. The single most important factor that decides the overall prognosis in a given patient is the extent of pillar comminution. Pillar comminution was seen in five of the twenty cases on exploration. Perfect anatomic realignment of the pillars then becomes difficult. In such situations we suggest first, the anatomic restoration and stabilization of the pillar that is not comminuted, followed by that of the comminuted pillar.

The restoration of the olecranon fossa anatomy is an index of the anatomy of the overall restoration. The elbow is then passively extended, and one can compare the resultant carrying angle intraoperatively. We retain the implants for six weeks, follow up with the patient radiologically, and decide on implant removal when there is evidence of reunion. In three cases we have accepted fixation in varus position. This was necessary in order to achieve a stable reduction, which was possible only in varus position and was attributed to the degree of pillar comminution. the poor results in this series are associated with medial pillar comminution.

The overall results at the end of one year are as follows;

• Excellent (54%)
• Good (30%)
• Fair (10%)
• Poor (06%)

This evaluation thus takes into account strictly the resultant change in the carrying angle, when it comes to classifying the results, despite the good range of elbow movement at the end of one year. In all cases, the distal fragment anatomy was thoroughly defined by a wide exposure, which necessitated exposure of the distal fragment up to the level of the epicondyles on either side. The distal fragment exposure must include complete visualization of the olecranon fossa. The K wires are introduced through the epicondylar region and the wires must lie in the same coronal plane.

In none of the patients, there was a neuro-vascular complication as against the possibility of such a complication in methods employing percutaneous pinning 54. From an economic standpoint, all our patients were discharged from the hospital on average after four days. The patient turnover is thus rapid unlike in those protocols of treatment where overhead traction or Dunlop traction is advocated. Conservative management of displaced supracondylar fractures requires adequate facilities in the hospital for the maintenance of the traction system as well as for the nursing care of the children. This is a luxury that hospitals as well as patients in developing countries cannot afford.

Table 4: Comparison of Occurrence of Cubitus Varus & Decreased Range of Motion with Other Modalities of Treatment

Table 5: Comparison of results of present series with other series

Posterior open reduction of childhood supracondylar fractures does not result in significant loss of elbow mobility and should not be avoided on this basis. In a country with high hospitalization expenditures and congested wards, operational treatment of these fractures allows for rapid patient turnover. This has significant economic implications for a developing country like ours. We strongly recommend open reduction and internal fixation with K wires for displaced supracondylar fractures in children for the reasons described above.

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