Volume 04 / Issue 02 / June 2016
boa.ac.uk
Page 48
JTO Peer-Reviewed Articles
Supracondylar humeral
fractures in children - have
we stopped thinking?
Christopher Colton & Fergal Monsell
Neurovascular Injury
Although it is unlikely that Hippocrates corresponded in Latin, we
respect his attributed primum non nocere as a central tenet of
medical practice. Those of us who undertake the management of
distal humeral fractures in children would do well to hold to this.
We also benefit from the wisdom
of Santayana1 who told us that
“Those who cannot remember
the past are condemned to repeat
it”, yet supracondylar humeral
fractures in children appear to be
exempt from the rules and reason
that govern the contemporary
management of other injuries.
The purpose of this essay is to
examine the conventional dogma
associated with this common
fracture, and to question some of its
firmly-held beliefs, even should this
require the sacrifice of sacred cows.
The authors’ view is that
preservation of neurological
function, the prevention of further
neurological injury and the
avoidance of ischaemic muscular
damage are of fundamental
importance in management.
Christopher Colton
Fergal Monsell
Good function is to be expected
in the majority of cases and the
current paradigm of prevention
of cosmetic deformity at all costs
is not only illogical, but also
potentially harmful.
The management of neurovascular
complications of this fracture
generates much heated debate,
which is perhaps not surprising, as
the consequences of permanent
neurological injury, or a critically
ischaemic limb, are devastating.
Nerve injuries are common and are
estimated to occur in 12% to 20%
of all such displaced fractures, with
the anterior interosseous nerve
predominating2-5.
The majority will recover without
treatment and the difficulty
arises in identifying those that
require exploration. Formal
documentation of neurological and
vascular function at the time of
presentation is the first standard
for practice in BOAST 116.
Frequent reassessment during the
period following reduction and
stabilisation, whether by open or
closed means, is also necessary
to identify an iatrogenic injury,
which has a reported incidence of
2% to 6% in some series7,8.
Ramachandran et al.9
recommended exploration of any
nerve injured during reduction
and stabilisation of fracture, in the
presence of neuropathic pain, a
complete lesion with sympathetic
paralysis, or a nerve lesion with
progressive acute deterioration.
Single assessment provides
but a snapshot, whereas it is a
trend towards deterioration that
Volume 04 / Issue 02 / June 2016
boa.ac.uk
Page 49
© 2016 British Orthopaedic Association
Journal of Trauma and Orthopaedics: Volume 04, Issue 02, pages 48-51
Title: Supracondylar humeral fractures in children – have we stopped thinking?
Authors: Christopher Colton & Fergal Monsell
frequently determines the need
for surgical exploration.
Mangat et al.10 suggested
management strategies
for the perfused, pulseless
hand, following stabilisation
of displaced fractures. They
reported a sub-group with
tethering, or entrapment, of nerve
and vessel at the fracture site
and their recommendation was
that the patient presenting with
co-existing anterior interosseous,
or median nerve palsy and a
pink, pulseless hand warranted
early neurovascular exploration.
Blakey et al.11 reported that
23/26 children with a pink
and pulseless hand following
supracondylar humeral fracture,
at a mean interval of three
months following injury, were
found to have an established
ischaemic contracture of the
forearm and hand.
They recommended “urgent
exploration of the vessels and
nerve in the child with pink,
pulseless hand, not relieved by
reduction, with persistent and
increasing pain, suggestive of a
deteriorating neurological injury
and critical ischaemia”.
The authors’ view is that the
majority of the recommendations
made by Ramachandran et al.
should inform decisions on
nerve exploration9.
The controversy surrounding the
limb with potential ischaemia
is in our view, due in part,
to the surrogate methods of
assessment of limb perfusion.
The fundamental goal is to
avoid muscle ischaemia with
consequent contracture, and
assessment must assess
muscle perfusion, albeit
indirectly.
Pulse, digital colour, capillary
refill and mechanical methods,
including pulse oximetry, do not
satisfy this requirement. The
simplest clinical test for evolving
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muscle ischaemia is pain on
passive digital extension and/or
flexion.
In our view, the decision
to explore a vascular injury
or decompress a muscle
compartment should be based
largely on the presence and
deterioration of muscle stretch
pain in the period following injury
or reduction of the fracture.
We consider that the majority
of fractures can be managed
without exploration of the
neurovascular structures and
have highlighted specific
clinical situations in which
rapid exploration is required.
>>
Volume 04 / Issue 02 / June 2016
boa.ac.uk
Page 50
JTO Peer-Reviewed Articles
Reduction and Fixation
The presence of such deformity
often worries uninformed
parents, but most will be
reassured by knowing that
this can be corrected at
any time, but preferably at
skeletal maturity, by a planned
geometric osteotomy via
healthy soft tissues.
As early as 1903, Prof. Niehans
of Bern used intramedullary
pinning to stabilise displaced
supracondylar humeral fractures in
children, but after open reduction12.
In 1988, Pirone stated:
“Percutaneous Kirschner-wire
fixation is advocated as the
method of choice for the majority
of (such) displaced fractures”13.
In 2014, Ladenhauf stated:
“Today, the preferred treatment
of displaced supracondylar
humerus fractures in children is
immediate closed reduction and
percutaneous fixation with two
or three lateral pins. In case of
instability of the medial column,
a medial pin may be used, but
possibility of iatrogenic ulnar nerve
injury should be considered”14.
Closed reduction with
transcutaneous pinning has
now become the promulgated
orthodoxy for such fractures and
BOAST states that: “These injuries
require early surgical treatment;
ideally on the day of admission…
surgical stabilisation should be
with bicortical wire fixation”6.
Such dogma deserves careful and
thoughtful re-examination as the
therapeutic pendulum appears to have
become stuck at one of its poles.
Quality of reduction
For successful intraosseous
pinning, the reduction must be
anatomical. The cross-sectional
form of the humerus at the
fracture site is dumbbell-shaped
and if these dumbbells are
imperfectly aligned, the target area
for safe intraosseous pin insertion
is greatly limited (Figure 1).
Extraosseous pin insertion risks
damage to important anatomical
Figure 1: Any residual fracture displacement reduces the safe corridor for
intraosseous pin insertion.
structures, as well as increasing the
chances of a failed fixation. For
this reason alone, reduction must
be achieved to an anatomical,
or near-anatomical position and
requires careful monitoring with
image intensification. Whereas
these problems need not
necessarily contraindicate closed
reduction and intraosseous
pinning, such valid caveats are
rarely stressed.
Powered insertion of Kirschner
wires generates heat in the tissues
and an important point that
passes largely unstated is that the
pins should be inserted with an
oscillating drill or by hand in health
systems where such equipment
is unavailable. Thermal injury of
the physis, through which the pins
are inserted is a danger, especially
if multiple attempts are made to
insert any one pin.
Hunter and Slongo stated: “When
placing (inserting) wires across
the growth plate, repeated drilling,
starting several wires from a single
point, and very peripheral insertion
must be avoided to minimise
damage to the proliferation zone.”15
As educators of future generations
of orthopaedic and fracture
surgeons, we must condemn
multiple passes of a wire across
the physis in an attempt to
stabilise an imperfectly reduced
fracture. Such a technique of
multiple physeal penetrations,
in other anatomical situations, is
sometimes exploited to secure
epiphysiodesis.
Cubitus varus
It is not unreasonable to examine
current practice in the context
of why reduction and fixation
are so strongly advocated. With
the exception of cases with
vascular and neurological deficits,
surgery is performed exclusively
to avoid cubitus varus following
malreduction.
Cubtius varus rarely, if ever, results
in any functional deficit. It is purely
a cosmetic problem in most, if not
all cases and usually only evident
when the patient is standing in
the “anatomical position”.
In 1986, Ippolito et al. reviewed
22 patients with cubitus varus
following such fractures treated
non-operatively, and none had
a functional deficit16. Similarly,
Labelle et al. found no functional
deficit in 63 patients with residual
cubitus varus17.
The debate has not yet been
joined over what degree of varus
malunion is acceptable. There
is a gathering medicolegal storm
over whether malreduction
leading to cubitus varus
is negligent and therefore
compensatable.
In a medico-legal context,
supporting a position that any
residual deformity is negligent is
illogical and redefines reductio
ad absurdum.
If this be agreed, the surgical
profession needs to recognise
that it is sometimes better
to treat such fractures
without immediate operative
intervention, recognising the
likelihood of subsequent cubitus
varus, which may or may not
require later surgical remedy.
Debate is urgently necessary
over the degree of acceptable
cubitus varus and if we surgeons
neglect to do this, the legal
profession will exploit such
inattention.
Alternative management
strategies
It has to be recognised that
many children with displaced
supracondylar humeral fractures
are treated in health-care
settings where resources such
as image intensification are
unavailable and the use of
“closed” pinning without such
control is hazardous, for all the
reasons explored above.
Volume 04 / Issue 02 / June 2016
boa.ac.uk
Page 51
© 2016 British Orthopaedic Association
Journal of Trauma and Orthopaedics: Volume 04, Issue 02, pages 48-51
Title: Supracondylar humeral fractures in children – have we stopped thinking?
Authors: Christopher Colton & Fergal Monsell
The alternative options would
then be open reduction and
pinning, splintage after attempted
reduction (accepting the risk
of cubitus varus), or traction,
involving methods that include
straight-arm and overhead
olecranon traction (Figure 2).
for another. Yun et al. described an
ingenious technique19 that corrects
distal humeral deformity, without
secondary lateral translation
(Figure 3).
There is no place in modern
surgery for corrective
osteotomies to be conducted
without detailed preoperative
planning and geometric
precision. The correction of a
cosmetic deformity demands a
cosmetically perfect result.
Some authors advocate
stabilisation of such osteotomies
using external fixation20 and
whilst this provides a potentially
attractive alternative; it has not
become an established part of
contemporary practice.
Figure 2: Overhead traction via
an olecranon screw. The arm is
elevated, thereby reducing pain and
swelling: the forearm falls naturally
into pronation, encouraging the
correction of varus.
The latter two therapeutic options
should not be allowed to fall into the
oubliette of paediatric orthopaedic
history, for want of a rather broader
approach than the current dogma
of Pirone, Ladenhauf and the BOA’s
standard treatment protocol.
Summary
The majority of perfused but
pulseless hands can be managed
expectantly, provided there is no
evidence of evolving muscular
ischaemia.
The majority of peripheral nerve
injuries, which are caused at the
time of injury and present at the
time of first assessment, can
also be managed expectantly,
provided there is no evidence of
neuropathic pain, or deterioration
over a period of 8 to 12 hours.
the AO Foundation. He is currently
enjoying life as an educator,
boulevardier and master diver.
The current dogma of reduction
and transcutaneous pinning of all
displaced supracondylar humeral
fractures in children should be
approached in a more analytical
fashion than the simple ex
cathedra statements that abound.
It is a demanding surgical
procedure with risks for patients
of the unwary and formulaic
surgeon, and there are alternative
management strategies for underresourced health care systems.
Fergal Monsell is a Consultant
Orthopaedic Surgeon at the Royal
Hospital for Children in Bristol.
He was an ABC travelling fellow,
Past President of the British Limb
Reconstruction Society and a
Member of the Politburo of the
Society for Children’s Orthopaedic
Surgery. He is a member of the
editorial board of the Bone and
Joint Journal and specialty editor for
paediatrics. He is married to Ros, has
three grown-up children and to his
credit is a lifelong Spurs supporter.
Attitudes to cubitus varus
malunion, in both surgical and
medicolegal contexts, bear careful
scrutiny and osteotomies to
correct cubitus varus malunion
require meticulous planning and
precise, geometric execution.
Christopher Colton is Professor
Emeritus in Orthopaedic and
Accident Surgery at the University of
Nottingham and was a Consultant
Orthopaedic, Trauma and Paediatric
Orthopaedic Surgeon at Nottingham
University Hospital for more than 20
years. He was an ABC Travelling
fellow, BOA President, Founding
Trustee and Lifetime Honorary
Member of the Board of Trustees of
Correspondence
Email: [email protected]
Email: [email protected]
References
References can be found online at
www.boa.ac.uk/publications/JTO
or by scanning the QR Code.
Correction of cubitus varus
malunion
In 1959, French described
a somewhat crude valgus
osteotomy for the correction of
cubitus varus18. It unfortunately
produced the so-called “chicane”
deformity, with excessive lateral
condylar prominence, as does
any such osteotomy that fails
to translate medially the distal
humeral fragment.
Regrettably, such ugly corrections
are still practised today, thereby
exchanging one cosmetic deformity
Figure 3: Yun osteotomy: A triangle of bone is excised as shown in the left hand diagram: the angle at B is the desired
angle of valgus correction. The distal humeral fragment is then rotated and medially translated so that the original point A
is moved to point C. The pair of diagrams on the right show how the longitudinal axis of the humeral diaphysis now passes
through the lateral portion of the trochlea – the anatomical norm – and the osteotomy if stabilised with crossed pins.
References
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3. Dormans JP, Squillante R, Sharf H. Acute neurovascular complications with supracondylar humerus fractures in
children. J Hand Surg [Am] 1995;20:1-4.
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fractures in children. J Pediatr Orthop 1993;13:502-5.
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