Supracondylar fractures in children: Current concepts and treatment considerations

Most pediatric orthopedists treat displaced supracondylar humerus fractures by closed reduction and pinning to avoid persistent elbow deformity and to minimize the risk of compartment syndrome. To safely perform the procedure, an anesthesiologist skillful in administering to children and intubating small airways is essential. The technique requires fluoroscopy and an able assistant.

This Orthopedics Today Round Table will address the recommendations of four experienced surgeons, especially considering the recognition of vascular or nerve injuries and how to obtain the best outcome when treating supracondylar fractures in children.

Robert E. Eilert, MD
Moderator

Round Table Participants Moderator Robert E. Eilert, MD Children’s Hospital Colorado Aurora, Colo. Howard R. Epps, MD Fondren Orthopedic Group Houston Charles T. Mehlman, DO, MPH Cincinnati Children’s Hospital Medical Center Cincinnati Steven L. Frick, MD Carolinas Medical Center Charlotte, N.C. David L. Skaggs, MD Children’s Hospital Los Angeles Los Angeles Image: Walter Urie Photography

Robert E. Eilert, MD: When do you operate? Namely, what amount of displacement and with what timing consideration?

Howard R. Epps, MD: My indications for surgery are when the anterior humeral line no longer intersects the capitellum, and when there is coronal plane displacement with either impaction or lengthening of the medial column. I will fix closed fractures without neurovascular compromise the following day irrespective of the amount of displacement — and I think there is ample evidence in the literature to support this. For open fractures and those with neurologic or vascular compromise, I prefer to fix that day whenever time is available and there is anesthesia clearance.

David L. Skaggs, MD: I will operate on all type III fractures, and almost all type II fractures. The only exception in type II fractures is if the anterior humeral line is almost touching the capitellum in a child who is 3 years old or younger, in which case I feel the limited amount of remodeling may be sufficient. In terms of timing, any sign that there is limited perfusion and urgent. I would also consider puckered skin, severe swelling, ante-cubital ecchymosis and a concomitant forearm fracture signs of significant soft tissue damage, which would lead me to operate early and not wait until the next day Having a trauma room available at 6 AM is useful for fractures which may be in the gray zone between an emergency, but not good to wait until the end of the next day.

Steven L. Frick, MD: I operate on all type III supracondylar humerus fractures, on type II fractures when the anterior humeral line does not touch the ossified capitellum and on any fracture that has varus malalignment. In general, my philosophy is that if the fracture needs to be reduced, I believe that percutaneous pin fixation is indicated to maintain the reduction until fracture union. Some type II fractues are amenable to closed reduction, casting and careful follow-up radiographic surveillance, but that is rare in my practice.

Regarding timing, I believe the only fractures that are emergencies (surgery as soon as possible) are fractures with severe vascular compromise (pulseless, without distal perfusion), forearm compartment syndrome or open fractures. In the urgent category (surgery within a few hours) are fractures with no distal pulse palpable but good perfusion, fractures with neurological deficits and fractures with a brachialis sign. I prefer not to wait until the next day for these cases. In other cases of type III fractures, with intact distal circulation and nerve function, I am comfortable with waiting until “the light of day,” and have not personally had complications related to waiting or had more difficulty achieving an acceptable reduction.

I believe a few things are important when deciding to wait until the next day: 1) the patient’s extremity should be splinted in 30° to 40° of elbow flexion, 2) the patient should be monitored closely, with pulse oximetry on the involved hand and frequent checks overnight every 2 hours to 3 hours to insure that the distal circulation and nerve function is maintained, and 3) that the patient should remain comfortable without an increase in agitation, anxiety or need for increasing doses of analgesics.

Charles T. Mehlman, DO, MPH: Although modified a bit by later authors, the classification scheme introduced by John J. Gartland, MD, in 1959 seems to have pretty much stood the test of time. As orthopedists, we agree most regarding what we are willing to call a type III, and we disagree much more frequently when trying to differentiate between type II and I fractures. I think that we can all agree that type II and III fractures are the ones for which we wish to perform and maintain a stable reduction. In radiographic terms, I would say that in general, I want to reduce any type II fracture that has lost intersection of the anterior humeral line with the capitellar growth center on the lateral radiograph and I certainly want to reduce all type III fractures. I would submit that when it is a type II fracture, you are performing a simple uniplanar “flex the elbow” reduction, while a type III fracture has more moving parts, and thus, demands multiplanar attention (with the classic type III reduction recipe being laid out very well by Mercer Rang in his classic textbook).

Also beware of the so-called type IV fracture that the Los Angeles Children’s group has described, as it is even more difficult. If a type II fracture reduces nicely and holds that reduction at 80° or 90° of flexion, I will cast that child and not necessarily add percutaneous pins. Everyone else gets pinned. I think that casting in such situations can be performed safely by using the fiberglass stretch-relax technique described by Jon Davids, MD, and Steven L. Frick, MD, in addition to paying close attention to not overpadding the antecubital fossa.

The precise timing of when to operate on a displaced supracondylar humeral fracture continues to generate healthy discussion. The only people who can definitively answer the question of when to operate are the treating orthopedic surgeons, as they know the patient best. For the patient without vascular concerns or sensory deficits, there is what I would call abundant evidence from multiple articles from multiple centers that say its OK to splint such a patient in relative extension, admit them to the hospital for proper monitoring and arrange to perform the surgery early the next morning. Any number of things may push the orthopedic surgeon to operate sooner, including pain not easily controlled with typical medications, marked fracture displacement with tenting of the skin and any concerning changes in neurovascular status.

A type III supracondylar fracture in a 2-year-old child who fell off a slide is shown. The involvement of the medial column prevents stabilization with lateral pin constructs. Images: Epps HR

Eilert: What pinning pattern do you favor and why? What are your indications for open reduction?

Epps: I can manage most supracondylar fractures with lateral pin constructs. There are some fracture patterns that cannot be treated with lateral pins alone — like oblique fractures when the distal fragment includes the medial column. For those I use crossed pins.

I use the number of pins required to achieve stability. With type II fractures, that usually means two pins and three pins for type III fractures. I do not hesitate to increase these numbers if stability warrants it. I prefer to gently flex and extend the elbow under fluoroscopy on the lateral view to assess stability.

I perform an open reduction for open fractures after irrigation and debridement, and for fractures that I cannot get adequately reduced by closed means.

Skaggs: For 99% of fractures, I will use lateral entry pin; two lateral pins for type II fractures and three pins for type III fractures. The rare oblique fracture type, which is more or less parallel to lateral entry pins, may require a medial pin as well. I believe the literature is fairly clear that three lateral pins, properly placed with good separation at the fracture site, provide sufficient fixation, so there is little reason to risk iatrogenic injury to the ulnar nerve with a medial pin.

Indications for open reduction include: not being able to obtain adequate fracture reduction by closed reduction, a rubbery feeling when attempting a closed reduction particularly in the setting of the median nerve injury, a loss of pulse following fracture reduction (in which case we must assume the brachial artery or adjacent tissue is trapped in the fracture site), loss of median nerve function following reduction, or the uncommon case in which there is a median or anterior interosseous nerve injury combined with the pulseless hand — in this case, we must assume there is a high chance of the artery and/or nerve being trapped at the fracture site.

Frick: I prefer lateral entry pins with two pins typically sufficient for more stable fracture patterns, and a third pin added for severely displaced fractures on initial radiographs or fractures that are unstable during fluoroscopic examination after the initial two pins are placed. The first two pins should cross at the level of the fracture with maximal spread between the pins on the AP view, with one pin crossing the fracture in the lateral third of the distal humerus and one crossing in the medial third. A third pin is added between these two if needed. I will occasionally use a medial pin if the fracture line is more oblique and on the medial side exits more proximally, making it difficult to cross the fracture with a lateral entry pin in the medial third of the distal humerus and still get purchase in the proximal fragment. In these cases, I will place two lateral entry pins first, extend the elbow and place a percutaneous medial pin starting in the middle to anterior aspect of the medial epicondyle.

My indications for an open reduction are open fractures, fractures with no distal pulse or perfusion (cold, white hand), fractures with intact circulation preoperatively that lose distal circulation after reduction, fractures with intact neurological function that postoperatively have a neurological deficit and an imperfect reduction (beware gap at fracture site) and lastly, inability to attain an acceptable reduction.

A major difficulty in assessing the literature on supracondylar humerus fractures in children is that many authors list the rate of open reduction, especially in papers comparing early to late surgery for displaced fractures, but few define the indications for open reduction or define an acceptable reduction. An acceptable reduction is one that is not in varus (normal Baumann angle) and has restoration of either the anterior humeral line intersecting the capitellum or reconstitution of the normal humeral condylar angle. Mild translation and rotational malalignment is acceptable because of remodeling potential and shoulder range of motion.

Mehlman: Pin pattern matters. I think that the two most significant biomechanical papers that can help guide us here are the classic study by Lewis Zionts in 1994 and the recent contribution by Peter Newton’s biomechanical research team. These studies teach us that a nice divergent two distal lateral entry pin pattern is usually enough for a well reduced supracondylar and, for slightly imperfect reductions, one should consider adding either a third lateral pin or a safely placed medial pin. Zenios studied these principles clinically and agreed that if the surgeon sees signs of instability after their first two lateral pins, adding either a third lateral pin or a medial pin was indicated. Within the context of a randomized clinical trial performed at Boston Children’s, Mininder S. Kocher, MD, has shown us that it is still possible to safely place medial pins. I feel that this is an important skill that we need to continue to teach our orthopedic surgery residents.

This question speaks to how much imperfection the surgeon is willing and able to accept before deciding to convert from a closed reduction and percutaneous pinning (CRPP) plan to a true open reduction and internal fixation (ORIF). I am aware of only a couple published articles that begin to address this point. In 1953, Attenborough published some powerful remodeling images of four boys between 5 years and 7 years of age. A study from Hebrew University in Jerusalem found that residual translation on the lateral radiograph was much less important than re-establishment of humerocondylar angle.

Clearly, we need to do our best to also restore Baumann’s angle on the AP radiograph. Large supracondylar humeral fracture series usually reflect single digit convert to open reduction rates. I think that if you see double digit open reduction rates you probably have surgeons who are too determined to achieve an absolutely anatomic reduction, which of course is simply not necessary in most cases.

I have done my best to adhere to the following rules regarding how much “slop” can be accepted in association with CRPP: 1) never accept gap, as gap can be very bad because it may indicate that important soft tissue structures are entrapped in the fracture site, 2) accept up to 30% translation on the lateral (often a rotational spike) provided humerocondylar angle is judged to be okay and 3) accept up to 25% translation on the AP, provided there is no gap and Baumann’s angle has been restored. Using these criteria, I have converted once from CRPP to ORIF in my 15 years of practice, and I would estimate that I have pinned over 1,000 supracondylars at this point in my career.

Eilert: What is your protocol for dealing with a pulseless extremity?

Epps: My protocol depends on the apparent perfusion of the pulseless hand. If the hand is dusky, with sluggish capillary refill, I try to get them reduced in the operating room as soon as possible, having notified the vascular surgeons that their assistance might be needed. If the fracture reduces and the perfusion status improves, I treat them like any other fracture but may observe them overnight if the pulse has not returned. Of course, if the perfusion does not improve after reduction, I get the vascular surgeons involved. An irreducible fracture in this scenario suggests that vital structures may be trapped in the fracture site so this is another indication for open reduction. Many patients are transferred in with “pulseless” supracondylar fractures that have a warm hand, brisk capillary refill and a normal neurologic examination. I treat these like the fractures without a concern about the vascular status.

Skaggs: Our protocol for dealing with the pulseless supracondylar fracture in one phrase is, “reduce the fracture.” The longer answer is that the first step is assessment and perfusion is best assessed by hand color; pink or red being being well perfused and white having no perfusion. The temperature is assessed with a well perfused and being warm in a poorly perfused hand being cool. In a we would like to see capillary refill of less than 2 seconds, but one must be aware that if there is venous congestion, such as tying a rubber band around your finger, capillary refill will be <2 seconds. This is a relatively subjective test. There is little place for a preoperative Doppler or arteriogram as that will not change the course of action and may slow up treatment. Gentle traction may be applied in the elbow flexed up to about 30° to 40° at presentation, which frequently is enough to bring the pulse back.

This postoperative radiograph was taken after closed reduction with percutaneous fixation using medial and lateral K-wires.

In a series of 33 pulseless supracondylar fractures, we recently reported that preoperative hand perfusion is the key predictor of outcome. Twenty-four children with a pulseless maintained a well-perfused hand after fracture reduction. Even though the pulse returned in only half of these children, no child developed a compartment syndrome we needed a vascular repair or any further surgery. In nine patients who presented with a poorly perfused hand, four of these patients required vascular repair and two patients developed a compartment syndrome. Going forward, if a patient presents with a pulseless poorly perfused hand, one should prepare the family and the possibility of a compartment syndrome and vascular repair and perhaps notify the vascular surgeon.

Following fracture reduction, if the hand is warm and well-perfused but there is not a palpable pulse, I would admit the patient for 48 hours observation. While some recommend vascular consultation and possible arterial repair, I do not agree with that. A series of arterial repairs in the pulseless supracondylar fracture by Sabharwal demonstrated that stenosis and clotting of the repaired artery is common. A recent review article in the vascular surgery literature suggested there is little benefit in use of Doppler or angiography in the pulseless supracondylar (Griffin KJ, et al. Eur J Vasc Surg 2008). These vascular surgeons went on to say “a child with a pink pulseless and post fracture reduction can be managed expectantly unless additional signs of vascular compromise develop, in which case an exploration should be undertaken.”

Frick: The pulseless extremity with a cold, poorly perfused hand goes emergently to the operating room for exploration of the antercubital fossa and fracture through an anterior approach. Arteriography is not indicated except in the rare case of multiple sites of injury in the extremity. The perfused, pulseless supracondylar humerus fracture is urgent and ideally goes to the operating room immediately or within a few hours of presentation. A careful neurological examination is performed to assess for concomitant nerve injury, especially a complete median nerve palsy. Patients with a complete median nerve palsy are at risk for a “silent” compartment syndrome or ischemia as they cannot feel the forearm. The ability to actively move the fingers using forearm musculature is documented and carefully followed postoperatively. Presence or absence of Doppler signal at the wrist is documented preoperatively.

In the operating room, a milking maneuver is performed if needed, followed by a standard reduction. Inability to obtain a good reduction with a feeling of soft tissue interposition between the fragments or persistent gap at the fracture site is a relative indication for open reduction. Once a satisfactory reduction is achieved, stable pin fixation is obtained and then the elbow is placed in about 60° to 70° of flexion, and the forearm compartments and distal circulation are reassessed. I will observe patients who have return of palpable pulse, but will also observe patients in whom the pulse is not palpable, but who have brisk capillary refill in the fingers, soft forearm compartments and a Doppler signal at the radial artery. Vascular consultation is obtained if there is no Doppler signal at the wrist or if the capillary refill is poor.

The elbow is immobilized in 60° to 75° of flexion in a fiberglass above-elbow cast, with the cast split to accommodate swelling, and a space cut out for palpation and Doppler evaluation of the radial pulse postoperatively. In addition, pulse oximetry is placed on the thumb or index finger on the injured side. In patients with complete median nerve palsy, the cast is bi-valved and the anterior half removed so that the volar forearm can be easily palpated postoperatively. Patients are admitted for observation and are checked frequently for at least 12 hours after surgery to insure there is not any change from the preoperative neurological examination, and that the patient can actively move fingers and has no pain with passive stretch of the fingers.

Mehlman: I think that this is an important patient-safety related question and an area where there is quality improvement opportunity. The definition of a pulseless supracondylar is one where medical professionals (often multiple) cannot feel a radial pulse. No published norms exist for what we should consider “normal” regarding hand-held Doppler signals, so even if you hear something we should not define presence of a pulse based on this. Pulselessness is a bad thing. It is not normal. Pulselessness plus neurapraxia to one or more nerves is even worse. Based on available English language literature, when a supracondylar is determined to be pusleless, a true arterial injury is present in over 80% of cases.

Pulseless supracondylars really come in at least three clinically distinct flavors: 1) pulseless and not perfused, 2) pulseless and neurapraxia of one or more nerves, and 3) pulseless and perfused. For want of a better term, pulseless and not perfused ones are “easy.” You activate the emergency broadcast system, get them reduced and pinned, reassess perfusion and make decisions often in conjunction with small vessel vascular repair specialists. If you have a pulseless and perfused, and one or more nerves asleep, there is a growing body of literature that says treat it more like it was pulseless and not perfused (i.e., treat more aggressively). Pulseless and perfused supracondylars continue to generate the most debate.

Pulseless and perfused supracondylars represent an epidemiologically distinct group that are at higher risk of permanent complications. Reasonably, rapid closed reduction and percutaneous pin fixation should be performed after which the pulse returns in up to 75% of children. The other 25% of pulseless and perfused patients are the ones that should continue to worry us. Most busy pediatric orthopedic surgeons have seen their fair share of pulseless and perfused patients who seemed to do fine within the context of a few weeks or few months of clinical follow-up, and some have even seen the pulse return by the 1 week to 3 weeks follow-up visit. Clearly, the celestial committee has built in a system of collateral vessels aimed at keeping hands from becoming necrotic and falling off; thus, the distal capillary refill will stay wonderful even in many of those situations where there is no palpable radial pulse. However, I would submit to you that even the child with a full blown Volkmann’s ischemic contracture has great capillary refill, and therefore, this should not be the only variable we focus on. What we are really worried about is the flow to the deep volar compartment from the proximal ulnar portion of the arterial tree (also considered to be the most variable). When this deep volar compartment becomes starved for arterial flow, Volkmann’s ischemic contracture may ensue. What we need is a capillary bed to check regarding the deep volar compartment.

So when faced with a patient who is persistently pulseless and perfused following CRPP, I routinely order an intraoperative color flow doppler duplex arterial study. This noninvasive study, involving jelly and an ultrasound probe, has been shown to be very reliable in larger arteries like the brachial artery. If this study shows anything other than proper blood flow from a brachial artery into radial and ulnar arteries, our small vessel vascular repair specialists are consulted.

Eilert: How do you assure complete documentation of neurovascular status preoperatively and postoperatively in a teaching program?

Epps: This is always a challenge — particularly since many of these fractures occur in young children who may not cooperate. In these cases, I suggest that the resident document which findings they were unable to assess. This suggests that at least an effort was made.

Skaggs: We are actually running a prospective study on this subject at this time. The attending surgeon must examine the patient preoperatively and postoperatively and fill out a data sheet. My suspicion is that a number of “iatrogenic” nerve injuries may really have just been missed on the preoperative exam.

Frick: A thorough and well-documented physical examination is very important in the preoperative assessment of children with supracondylar humerus fractures. Educating the residents that generalized recordings in the chart such as “neurovasc intact” are not helpful and are not appropriate for patients with these injuries. An individual assessment of the median, radial and ulnar motor and sensory function should be documented, as well as the status of the radial pulse and the capillary refill of the hand. Attendings should demand detailed examinations from residents for each supracondylar fracture patient, and should educate them about the importance and clinical relevance of accurate recording of the patient’s examination findings.

Mehlman: I think the best short answer here is repetitive examinations both preoperatively and postoperatively by multiple members of the medical team.

Certainly, the emergency department triage nurse and the emergency medicine physician offer two opportunities for neurovascular assessment in the preoperative setting. Beyond this, we would consider a normal vascular status to be one where distal capillary refill is judged to be about 2 seconds and the radial pulse at the wrist is easily palpated, with both of these things being the same on the uninjured arm. All too often following successful CRPP, the wrist area is covered by a cast or splint such that the radial pulse is never palpated again before discharge. After surgery, a well placed cut-out of the dressing or cast should be added such that any nurse or doctor can easily palpate the radial pulse as they wish. The price is right for this small additional safety measure. Normal distal upper extremity neurologic function is illustrated by appropriate sensory and motor function of the radial, ulnar and median nerves – the so called “RUM test.” The motor portion of this exam can be operationalized as “paper, rock, scissors” for radial nerve, median nerve and ulnar nerve motor function. Specific testing of the anterior interosseous nerve (AIN) is also important in conjunction with precise sensory testing of the median nerve (at least a firm pinch test) to prove that it is truly AIN only and not a high median nerve palsy. If it is determined that patients have impaired sensation, then they are at higher risk for compartment syndrome and similar complications. Such patients deserve more urgent reduction and stable internal fixation and continued in-patient assessment of their vascular and neurologic status. In the near future, we feel that the electronic medical record offers some powerful opportunities to standardize the neurovascular examination performed and subsequently documented by nurses and doctors.

References:

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• Zionts LE, McKellop HA, Hathaway R. Torsional strength of pin configuratrions used to fix supracondylar fractures of the huemrus in children. J Bone Joint Surg Am. 1994; 76:253-256.
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• Robert E. Eilert, MD, can be reached at Department of Orthopaedic Surgery, Children’s Hospital Colorado, 13123 E. 16th Avenue, B060, Aurora, CO 80045; 720-777-6600; email: robert.eilert@childrenscolorado.org.
• Howard R. Epps, MD, can be reached at Fondren Orthopedic Group, LLP, 7401 S. Main St., Houston, TX 77030; 713-799-2300; email: epps@fondren.com.
• Steven L. Frick, MD, can be reached at Department of Orthopedic Surgery, Carolinas Medical Center, PO Box 32861, Charlotte, NC 28232; 704-381-8873; email: steven.frick@carolinashealthcare.org.
• Charles T. Mehlman, DO, MPH, can be reached at Cincinnati Children’s Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, Ohio 45229; 513-636-4785; email: charles.mehlman@chmcc.org.
• David L. Skaggs, MD, can be reached at Children’s Hospital Los Angeles, Division of Orthopaedic Surgery, 4650 Sunset Blvd., M/S 69, Los Angeles, CA 90027; 323-669-24658; email: dskaggs@chla.usc.edu.
• Disclosures: Mehlman is an unpaid consultant for Stryker Orthoapedics and receives royalities from Oakstone Medical Publishing; Eilert, Epps, Frick and Skaggs have no relevant financial disclosures.