European Journal of Cardiovascular Medicine

Among the elbow fractures, supracondylar fractures are the most common in paediatric age group of 4 to 9 years. Extension type supracondylar fractures are more common than the flexion type fracture.¹This fracture is more common in non-dominant limb and common in males.^2,3 The fracture most commonly occurs due to fall on an outstretched hand.^4,5In the modern time, the operative treatment with closed reduction and percutaneous pinning is being preferred over the open reduction  internal fixation and conservative treatment.^6,7The lateral only pinning is relatively less stable than combined medial and lateral pinning but it does notpossessan iatrogenic complication of ulnar nerve damage. Various retrospective studies have concluded that the lateral alone pinning is clinically as effective as the crossed pinning method for the management of supracondylar fractures.^8-10Various complications such as permanent nerve injuries, malunion, angular deformity, rotational deformity,  myositisossificans, Volkmann’s ischaemic contracture,  joint stiffness, can occur in  patients who are treated by  local quack manipulations and  do not opt for hospital based treatment.¹¹

The study was a prospective study conducted from June 2023 to March 2024 in the Department of Orthopaedics, Government Medical College Kathua, India. The study was approved by the Institutional Ethics Committee wide Reference no. IEC/GMCK/114.After taking informed consent from the parents/guardian of the patient and explaining the procedure, the patients were admitted and evaluated in terms of history and clinical examination. Radiological and blood investigations were done. Patients were optimised and prepared for surgery. Pre-anaesthetic check up was done. Two X-ray views were taken: Anteroposterior and Lateral views, along with adjacent joints were taken. The fractures were classified as per Modified Gartland Classification.¹²The final follow up was done at the end of 3 months. A total of 28paediatric patients in the age group between 4 to 11 years, having closed fracture, with modified Gartland classification type IIB and type III fractures, duration of injury less than 7 days, without any associated trauma were included in the study. The patients having open fractures, quack manipulations and massages, and Gartland type I and IIA fractures were excluded from the study.

After achieving reduction through percutaneous pinning, functional and radiological outcome was assessed by the range of motion and carrying angle using the Flynn criteria. Radiological healing of the fracture was also assessed at subsequent follow ups.

Modified Gartland’s Classification.

Type I - Nondisplaced

Type II - Displaced (with intact posterior cortex)

IIA - Intact posterior cortex, hinged in extension. No rotation/ translation.

IIB- Intact posterior cortex, hinged in extension with some degree of rotational displacement/ translation.

Type III - Displaced (no cortical contact); a) posteromedial b) posterolateral

Operative Procedure

Patient was kept over the table in a supine position and general anaesthesia was given.  Under C-arm guidance, longitudinal traction and counter -traction was given to reduce the fracture in transverse plane, and following flexion, pushing the olecranon anteriorly and pronation of the involvedforearm the deformity in the sagittal plane was corrected.

Two Kirschner wires of 2 mm in each diameter were passed through the capitellum, physis, lateral column in a divergent pattern and the opposite cortex proximally was engaged.The Kirschner wires were bent and cut to keep them outside the skin. The pin site dressing was done. Above elbow back slab was given in mid-prone position for three weeks.

Figure 1: Preoperative X-rays

Figure 2: Post-operative x rays                                                                                          

Post-operative follow up

After the surgery,patients were examined for distal neurovascular status in immediate post-operative period. The patients were advised to keep the limb elevated and do active finger movements to prevent post-operative swelling. The above elbow slab and Kirschner wires were removed at 3 to 4 weeks after clinical examination when the fracture site was non tender and following radiological examination when the fracture showed the features of bone union. The patientswereadvised for active physiotherapy of the elbow, shoulder and wrist to prevent stiffness of the joints. Carrying angle and elbow range of motion were noted at the subsequent follow ups to see the functional outcome. Anterior humeral line,Baumanns angle and Humerocapitellar angle were noted in the postoperative X-Rays to check the radiological outcome.

The study included28 patients.Out of 28 patients, 12 patients had Gartland type IIB fractures and 16 patients had Gartland type III fractures. Mean age of the patients was 7.5 years (range, 4 to 11 years). 08 patients were less than 6 years old, and 20 patients were more than 6 years old.  Out of 28 patients, 10 were males and 18 were females.

16 patients had fracture on the left side and 12 patients had fracture on the right side.

Table 1: Showing various parameters of the present study.

The functionalresults of treatment were assessed as per the Flynn criteria.³In type IIB fractures, the functional outcome was excellent in 9 patients, good in 3 patients. In type III fractures, the functional outcome was excellent in 12 patients, good in 3 patients, fair outcome in 1 patient. Two patients with neurological injury had median nerve injury during the trauma each in Gartlandtype IIB and type III fractures. At final follow up, the mean Baumann angle in type IIB fracture was 73.2+/-4, and in type III fracture was 74.3+/-5.2. At final follow up, the humerocapitellar angle in type IIB fracture was 34.4+/-3.9, and in type III fracture was 35.2+/-4.9.Overall, as per Flynn grade in all the patients in our study, results were excellent in 21 (75%) cases, good in 6 (21.4%) cases, and fair in 1 (3.6%) case. The callus formation was seen at 2- 3 weeks post-operatively. Radiographic union was noted in the patients with a mean time of 4.2 weeks (range; 3.2 to 6.2 weeks).

Supracondylar fracture fixation needs an expert surgeon. These days timely closed reduction and fixation is preferred over open reduction and internal fixation. Many studies reveal that closed reduction and pinning have better results.^13-16The pronation position places the medial periosteum on tension and the lateral compressive force closes the lateral edge to avoid varus alignment.^17,18If there is no perioisteal hinge in the fracture, it becomes unstable in flexion and extension. This multidirectional instability is classified as Gartland type IV.¹⁹Such fractures must be treated by internal fixation. Skaggs et al.in their study found that there was no ulnar nerve palsy and no reduction was lost in 124 children managed by two lateral entry pins.²⁰In another study by Skaggs etal. of 204 patients over Gartland type III fractures found that the pin configuration whether lateral or medial did not affect the Baumann’s angle.⁸ There was no difference in results by both the methods of pinning in a study conducted by Reynolds and Jackson.²¹

Table 2: Flynn criteria for grading supracondylar fractures.

In the present study, the mean carrying angle loss was 5.14 +/- 2.22 and the mean loss of elbow range of motion was 8.10 +/-3.20.In a study concluded by Rajput SS et al. mean loss of carrying was 4 degree and mean loss of elbow range of motion was 5 degree.²²In a study concluded by Singh et al. mean loss of carrying was 4.12+/- 2.11 degree and mean loss of elbow range of motion was 8.04+/-3.65 degree.²³These results of the present study were similar to the existing literature.

Table 3:Comparison of functional results at final follow up with various studies.

In the present study, functional results were evaluated on the basis of carrying angle and flexion and extension range of motion of elbow joint.The results were graded as excellent in 75 % cases, good in 21.4% cases and fair in 3.6% cases. The results of the present were similar to the previous studies, Flynn et al,Vito P et al,Kocher et al. andSingh et al.^3,24,25,23

Table 4:Comparison of radiological results at final follow up with various studies.

In the present study, radiological results were evaluated on the basis ofBaumann Angle, Humerocapitellar Angle, Anterior humeral line. The mean Baumann Angle was 73.12+/-4.66,meanHumerocapitellar Angle was 32.8+/-3.5. In 53.6% cases, Anterior humeral line passed through the middle third. The results in the present study were similar to the existing literature, Takamasa et al.,Gopinathan et al.,IvankaMadjar- Simic et al.^26,28,30

Limitations of the present study:

The present study had few limitations. The sample size was small and the follow up period was shorter. The study was non randomised. The number of cortices in the K- wire fixation was not taken into consideration.

In the management of paediatric supracondylar fractures, closed reduction with  percutaneous  pinning is the best method  of surgical treatment for modified  Gartland type II and Type III fractures. It is easier, safer, has no blood loss, healing is quicker, cosmetically good, and is cost effective  method of surgical treatment with good functional results in paediatric patients.

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