European Journal of Cardiovascular Medicine

Supracondylar fracture of the humerus in children is the most common skeletal injury around the elbow. Peak incidence is observed in the 4 - 8 year age range due to different causes, mainly ligamentous laxity, violent remodeling and structure of the humerus, i.e. flat transition tube at the lower end of the humerus(1).Supracondylar humerus fractures involve thin portion of the bone through olecrenon fossa are described in the early writings of hippocrates4 . Fracture is more common in boys and left sided dominance. Minimally displaced fractures will be managed conservatively by closed reduction and above elbow cast. Regarding the position of immobilization some adopt hyper flexion, some ninety degree flexion and some extension. Displaced fractures need closed or open reduction followed by internal fixation. Regarding the type of fixation some advocate lateral pinning and some cross pinning, and, in the past, even transverse pins were used to hold the reduction. Crossed pinning have more stability than lateral pinning but some chance of ulnar nerve injury. Regarding the reason for cubitus varus deformity, some say growth arrest of medial condyle and some say medial comminution is the reason.  Supracondylar fracture of the humerus is noted for its complications due to the inherent instability of the fracture, close proximity of the brachial artery, three major upper extremity nerves and poor radiographs, and inconsistent understanding of the reduction and mode of management and, lastly, patient compliance with care.The aims objective of this study is to compare the clinical outcome of fracture fixation by closed reduction versus open reduction.

Thirty patients with supracondylar humerus fracture were admitted in MGM hospital, Warangal during the period from August 2024 to April 2025. Out of the 30 patients, 15 were treated with a closed reduction and the remaining 15 were treated with an open reduction (after a failed attempt at a closed reduction) followed by a K-wire fixation.

 Inclusion Criteria

• Age group between 5 - 15 years.
• Early presentation.
• No associated fractures in the same limb.
• Not treated elsewhere.

Exclusion Criteria

• Age < 5 years, > 15 years.
• Open fractures.
• Associated neurovascular injury.

Initially, radiological assessment consisted of anteroposterior and lateral films, Jones' view is evaluated after manipulation with or without pinning. In anteroposterior films – Baumann’s angle was measured. In lateral films – anterior humeral line, crescent sign and the fish tail sign were noted. In Jones' view assessment of the coronal alignment of the distal fragments was done.

For classification, we used

Gartland classification with Wilkins modification

Type I -    Undisplaced.

Type II -   Displaced with intact posterior cortex / anterior cortex.

Type III - Displaced with no bone contact.

Type IV -Further classified into two types (Wilkins modification) depending upon the displacement type. a) posteromedial b) posterolateral

Image1: Xray of Type III Gartland fracture

For type III fractures, initially closed reduction was attempted. After fixation, the elbow is protected by the pop slab and cuff and collar. Open reduction and K-wire fastening done if 2 to 3 attempts of failed closed reduction

Open Reduction Technique

We did posterior (triceps reflecting) approach to lower end humerus to reduce the fracture. In this technique, patients are placed in the opposite side of the lateral decubitus position and the elbow is kept in the flexion position on one side. The skin incision and the subcutaneous tissue are made from7 cm upper to 2 cm lower than the olecranon by a posterior midline method. Subcutaneous arteries were coagulated; subcutaneous tissues were dissected off the muscle and fascia of triceps without separating the muscle. The ulnar nerve is examined and maintained safely during surgery. Then the muscle of triceps is dissected from both sides and along the intermuscular septum.. Therefore, all the regions of medial and lateral epicondyle, and supracondylar ridge and joint are exposed, and the proximal part is exposed as much as the surgeon needs. In this approach, we do not need to cut the triceps mechanism. After an open fracture reduction, the pins are positioned either medially or laterally or two pins are positioned laterally, depending on the size of the distal fragment and the intraoperative stability. Pins can be left in place slightly longer after an open reduction than after a closed reduction. When the pin is removed, a healthy callus can be identified at fracture, usually 3 to 4 weeks after injury. Results were graded as excellent, good, fair and poor according to the Flynn’s criteria (3).

Excellent

• Loss of movement 0 - 5 (Functional)
• Loss of carrying angle 0 - 5⁰ (Cosmetic)

Good

• Loss of movement 5 - 100 (Functional)
• Loss of carrying angle 5 - 10⁰ (Cosmetic)

Fair

• Loss of movement 10 - 150 (Functional)
• Loss of carrying angle 10 - 15⁰ (Cosmetic)

Poor

• Loss of movement more than 150 (Functional)
• Loss of carrying angle more than 15⁰ (Cosmetic)

In the present study, 66.66 % were male and 33.33 % were female. 66.66 % were in the 5 – 8 years age group, 30 % in the 9 - 12 years age group, 3.33 % in the 13 - 15 years age group. 60 % had left side fracture and 40 % had right side fracture.

Table 1; Demographic distribution

In a total of 30 supracondylar fractures of humerus, our favoured method was cross pinning.

We used 1 lateral and 1 medial pin in 20 cases, and 2 lateral pins in 9 cases and 2 lateral pins and 2 medial pins in one case

Image 2: Post operative X ray

Diagram 1: Types of pinning

Post operatively, one patient had a pin tract infection, one patient had ulnar nerve palsy, 2 patients developed cubitus varus deformity and two patients had restriction of movements.

In 86.67 % of the cases, the change in the carrying angle was less than 10 degrees. According to Flynn’s criteria³ results of our study are analysed. In our sample, 73.33% of 30

patients were good to excellent and 20 % showed average and 6.66 cases showed bad outcomes.

Table2: Grades of Flynn criteria

Twenty-four patients had an acceptable range of motion only with a loss of 0 - 10⁰, six patients had inadequate motion with a loss of more than 10⁰, of whom three were treated with closed reduction and three patients with an open reduction. Out of 30 cases two (6.66 %) cases had a carrying angle loss in excess of 10⁰.     

Table 3; Loss of carrying angle

Table 4; Loss of Terminal flexion

Pin site infection developed in 1 case of closed reduction. Elbow stiffness developed in 1 case of closed reduction and 2 cases of open reduction. Surgical site infection noted in one case of open reduction.

In our study, two cases had limitations on the mobility of the elbow after an open reduction and internal fixation, and a sufficient range of motion was achieved with physiotherapy. In 2 cases, a small degree of cubitus varus was observed due to the unsatisfactory reduction and fixation of the fragment in a poor place. Of the two, one was dealt with by a closed reduction, and the other by an open reduction. In the case of a closed reduction, the degree of Cubitus varus was higher.

Musa et al.⁶ observed in 30 cases of type III Gartland fracture handled by crossed percutaneous pinning over a duration of 2 years. The age range was between 2 and 13 years with an average age of 7.06 years.

Table 5; Side involvemen

Table 6; Age and Sex distribution

C Charles A Rockwood⁴ found that the peak occurrence of supracondylar humerus fracture in children occurred in the latter part of the first decade of life. In this report, the average age is 10 years (range 5 – 15 years) and the most common age group affected was between 5 – 8 years (46.67 %). In their research, 230 patients had a fracture of the supracondylar humerus

Pirone A M et al.⁵ have found that boys (119) are more affected than girls (111). Robert D Ambrosia⁹ found that the incidence of supracondylar humerus fracture was 63 per cent in males and 37 per cent in females. In our study, the prevalence of supracondylar humerus fracture is 56.66 per cent in males and 43.33 per cent in females.

Robert D Ambrosia⁹ found that the left elbow involvement was 64 percent, and that the right-side involvement was 36 per cent of his cases of supracondylar humerus fracture in babies. In the present study, 33 % of the

Pirone A M et al.⁵ recorded migration of one side pin out of 96 cases treated with closed reduction and percutaneous pinning. In our study, we never saw this problem because in all pinning cases, after application, we bent k-wires outside the skin.

Musa et al.² found a 10 % occurrence of iatrogenic ulnar nerve injury with percutaneous pinning crossed in their report. Balakumar and Madhuri¹⁵ observed an occurrence of 6 % iatrogenic nerve injury in patients with a supracondylar fracture of the humerus and consisted mainly of percutaneous pinning damage to the ulnar nerve. Gurkan et al.¹³ recorded 4.5 % of cases of ulnar nerve injury following a medial approach reduction. The trigger may have been nerve stretching during reduction manoeuvres. In contrast, no cases of iatrogenic ulnar nerve injury were detected after an open reduction. In our study one case (3.33)% had Ulnar nerve injury.

In their study, Devkota et al.⁸ noted loss of reduction postoperatively in 1.96 % cases. Lee et al.¹⁰ observed the same to be 7 %, while Balakumar and Madhuri¹¹ observed postoperative reduction loss in 18.2 % of cases in their study. In our  study, loss of reduction was noted at the time of the first postoperative X-ray in one case(3.3%).

In our study, the findings are evaluated according to Flynn's parameters based on the change of the carrying angle and the loss of range of movement.

In a study of 106 patients with displaced supracondylar humerus fracture treated with closed reduction and percutaneous pinning, Franke et al¹³ showed good to excellent results with 10.7 % satisfactory results and 4.6 % unsatisfactory results. In this study of 135 subjects with a displaced fracture of the supracondyle of the humerus.

Ababneh et al.¹⁴ had good to excellent results in 82 % of patients, satisfactory results in10% cases and 8 per cent of subjects had poor results. 22 (86.66 %) of the 30 patients in our study showed good to outstanding results, satisfactory results in 6 cases and 2 (13.33 %) cases showed poor results, one was handled with a closed reduction and one with an open reduction.

Table 7: Flynn’s criteria grade

CONCLUSION: 

Supracondylar humerus fracture is one of the most common injuries of elbows in children. The most common cause for injury is fall on the extended hand. In view of serious  complications associated with this fracture, need immediate reduction. The treatment is based on complete anatomical reduction of the fracture fragments. If there are loss of reduction and a need for repeated manipulation and closed reduction with splint or cast immobilization is needed.

In particular, cast therapy is prescribed for undisplaced fractures. When used for displaced fractures, there is a risk of re-displacement after the swelling subsides. The use of lateral and medial pin fixation offers more protection than lateral pins alone. In order to have rigid fixation, the pins must proceed into the opposite cortex. A smooth pin is preferable to threaded pin. Open reduction and K-wire fastening without triceps splitting is an option of treatment for displaced supracondylar humerus fracture in children, as reduced postoperative stiffness, good functional recovery and effective period of hospitalization is 1 to 2 days.

In our study, there were not much differences in postoperative recovery, functional outcomes and complications between percutaneous pinning and open cross-wiring reduction in well displaced fractures. It is assumed that these findings support the use of percutaneous pinning in the first section, which is easier and less violent than the open reduction.

Conflict of interest:       None

Financial implications; Ni

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