Supracondylar humeral fractures in children

TEN YEARS EXPERIENCE IN A TEACHING HOSPITAL

J. Mangwani,
R. Nadarajah,
J. M. H. Paterson
From The Royal
London Hospital,
London, England

J. Mangwani, MS(Orth),
MRCS, Specialist Registrar
Colchester General Hospital,
Turner Road, Colchester CO4
5JL, UK.

R. Nadarajah, MRCS,
Specialist Registrar
Queen Elizabeth Hospital
NHS Trust, Stadium Road,
Woolwich, London SE18
4QH, UK.

J. M. H. Paterson, FRCS,
Consultant Paediatric
Orthopaedic Surgeon
Department of Trauma and
Orthopaedics
The Royal London Hospital,
Whitechapel, London E1
1BB, UK.
Correspondence should be
sent to Mr J. Mangwani at 24
Pastoral Way, Warley,
Brentwood, Essex CM14
5WF, UK; e-mail:
jmangwani@hotmail.com
2006 British Editorial
Society of Bone and
Joint Surgery
doi:10.1302/0301-620X.88B3.
16425 $2.00
J Bone Joint Surg [Br]
2006;88-B:362-5.
Received 21 February 2005;
Accepted after revision
20 July 2005
362

Although supracondylar fracture is a very common elbow injury in childhood, there is no

consensus on the timing of surgery, approach for open reduction and positioning of fixation
wires. We report our ten-year experience between 1993 and 2003 in 291 children.
Most fractures (285; 98%) were extension injuries, mainly Gartland types II (73; 25%) and
III (163; 56%). Six (2%) were open fractures and a neurovascular deficit was seen in 12 (4%)
patients. Of the 236 children (81%) who required an operation, 181 (77%) were taken to
theatre on the day of admission. Most (177; 75%) of the operations were performed by
specialist registrars. Fixation was by crossed Kirschner wires in 158 of 186 (85%) patients
and open reduction was necessary in 52 (22%).
A post-operative neurological deficit was seen in nine patients (4%) and three (1%)
required exploration of the ulnar nerve. Only 22 (4%) patients had a long-term deformity,
nine (3%) from malreduction and three (1%) because of growth arrest, but corrective
surgery for functional limitation was required in only three (1%) patients.

An aggressive approach for accurate reduction

and stabilisation of these fractures is justified
by the low incidence of long-term deformity
and neurological complications. Most of these
fractures occur during the day and can be
treated safely on twilight operating lists without breaching National Confidential Enquiry
into Patient Outcome and Death (NCEPOD)
recommendations.
Supracondylar fractures are a very common
elbow injury and represent approximately
16.6% of all childhood fractures.1 Extensiontype injuries occur in 95% of cases2 and associated neurovascular injuries are reported in
between 5% and 30%.3-6
Treatment is based on the degree of displacement. The preferred method is closed reduction and percutaneous pinning.7-9 Open reduction is indicated for irreducible fractures, vascular compromise and open injuries.10,11 Medial,
lateral, posterior and anterior approaches have
been used and methods of fixation include lateral parallel, lateral divergent or crossed Kirschner (K-) wires.
Emergency treatment has been recommended to avoid vascular compromise and
compartment syndrome.1,3,12-16 However, recent
studies17-20 suggest that delay does not influence outcome.
There is lack of consensus on the timing of
surgery, approach for open reduction and posi-

tioning of wires used for fixation. We therefore

reviewed our experience of the injury.

Patients and Methods

We retrospectively reviewed the management
of children younger than 15 years of age with
supracondylar humeral fractures who presented to the Royal London Hospital between
1993 and 2003.
Notes and radiographs were reviewed for
demographics, site and mechanism of injury,
time of presentation, clinical and radiological
features, time to definitive treatment, type of
operation, complications and outcome. Deformity was defined as a difference of appearance
between the injured and uninjured elbow, sufficient to be apparent to the patient and/or parents.

Results
A total of 341 children with unilateral supracondylar fractures was treated during the study
period. We excluded 50 fractures because of
inadequate records. The remaining 291 children had full documentation with a mean follow-up of 30 months (four to 60). The mean
age at injury was 6.4 years (nine months to 14
years) and 186 (64%) were boys.
The injury occurred at home in 180 (62%)
patients, at school in 67 (23%), in a playground in 41 (14%) and in a road traffic accident in three (1%).
THE JOURNAL OF BONE AND JOINT SURGERY

50

45

45

40

40

35

35

30

Patients (%)

Patients (%)

SUPRACONDYLAR HUMERAL FRACTURES IN CHILDREN

30
25
20
15

363

25
20
15
10

10

0
< 1 hr

1 to 2 hrs 2 to 3 hrs 3 to 4 hrs

> 4 hrs

0800 to 1200 1200 to 1600 1600 to 2000 2000 to 0000 0000 to 0800

Time

Time of presentation (24-hr scale)

Fig. 1

Fig. 2

Time between injury and presentation to the Accident and Emergency

Department.

Time of day when the fractures presented.

VOL. 88-B, No. 3, MARCH 2006

40
35
30
Patients (%)

The cause of injury was a fall from a height in 163 (56%)

cases and a fall at ground level in 125 (43%). Two fractures
resulted from personal assault in a playground.
A total of 224 (77%) children presented within two
hours of injury, but 20 (7%) presented more than four
hours later (Fig. 1). Their times of arrival at hospital are
shown in Figure 2.
Clinical findings. In 177 children (61%), the dominant arm
was injured. Only six cases (2%) were open injuries.
Nine children (3%) had concurrent fractures, namely
seven ipsilateral forearm fractures, one femoral shaft fracture and one open tibial fracture. The initial examination
was usually performed by a junior doctor. Swelling was
documented in 282 (97%) fractures but deformity was
noted in only 76 (26%).
Neurological examination was documented in 285
(98%) patients, with paraesthesiae noted in nine (3%) and
numbness in three (1%).
Vascular examination was documented in 288 (99%)
patients, with no evidence of impairment in 274 (94%). A
weak radial pulse was recorded in nine patients (3%) and
significant impairment with diminished capillary refill and
discoloration of the fingers was seen in six (2%).
Radiological findings. Extension-type injuries were seen in
285 (98%) patients. The fractures were subdivided into
Gartland types21 I (55 patients; 19%), II (73; 25%) and III
(163; 56%).
Nature of treatment. A total of 236 (81%) patients underwent operation for type II and III fractures. Closed reduction without fixation was performed in 57 (24%), of whom
five required remanipulation and K-wire stabilisation.
Closed reduction and fixation was carried out in 127
(54%) patients. Open reduction was necessary in 52 (22%)
fractures. The surgical approach for open reduction was
lateral in 26 (50%), medial in 21 (40%) or posterior in five

25
20
15
10
5
0
0 to 6 hrs

6 to 12 hrs

> 12 hrs

Next
working day

Time
Fig. 3
Time between presentation and operation.

(10%). There was loss of reduction in the two patients

where only one K-wire was used for fixation.
K-wire fixation in 186 fractures used cross-configuration
in 158 (85%), lateral divergent in 17 (9%) and lateral parallel in nine (5%). Most of the operations (177; 75%) were
performed by specialist registrars at various stages of training.
Most operations (181; 77%) were on the day of admission (Fig. 3) and 45 children (19%) had surgery after 2230
hours, of whom seven (16%) had neurovascular impairment.
Complications and outcome. A post-operative neurological
deficit was seen in seven (3%) of 236 cases that required
operative intervention. Three (1%) underwent exploration

364

J. MANGWANI, R. NADARAJAH, J. M. H. PATERSON

of the ulnar nerve. In all patients, the ulnar nerve showed

various degrees of bruising. No repairs were necessary and
the outcome was good in all patients. The remainder recovered spontaneously within six months.
The majority (224; 77%) of patients were discharged
within two to three days. A total of 12 patients (4%) had a
long-term deformity (3% for malreduction and 1% for
growth arrest of the distal humerus). A cubitus varus deformity was more common (nine; 3%) than valgus (three;
1%). Corrective surgery for functional limitation was
required in only 1%.

Discussion
In our series, the mean age at fracture was 6.4 years, similar
to other reports.22-24 Our gender ratio was 1.8:1 boy to girl.
This agrees with a Chinese study25 where boys were more
commonly affected after the age of four years but contrasts
with a North American study,13 which showed girls more
prone to such fractures.
Our location of injury is significantly different from the
other studies which showed a much lower percentage of
fractures occurring at home.13,25 This may be due to the
location of our hospital where a relatively large number of
children live in apartment blocks without access to sports
facilities.
Our cause of injury was falling from a height in 56% but
from ground level in 42% contrasts with 70% and 9%,
respectively, in a North American study.13 Our study
reports the dominant arm to be injured more commonly
compared with other studies,13,24 where the non-dominant
humerus was involved.
A possible explanation is that in our series there were
fewer children falling from playground equipment where
there is a tendency to hang on with the dominant hand. In
contrast, many of our children fell from ground level where
as a natural reflex, there is a tendency to land on the dominant extended arm.
Our rates of open fracture (six; 2%) and pre-operative
nerve injury (12; 4%) and concurrent fractures (nine; 3%)
are consistent with the reported literature.13,25-29
In our study, 244 patients (84%) presented between
08:00 and 20:00 hours, most commonly between 12:00
and 16:00 hours. This contrasts with the North American
study,13 in which 55% of the patients presented between
18:00 hours and midnight. These observations are important in relation to the timing of operation. As most of our
fractures occurred during the day, we suggest that they
should be dealt with on a twilight operating list without
breaching the NCEPOD recommendations.30
In our series, 163 patients (56%) had a type III fracture,
a markedly higher proportion than in other series.9,23,24,28
Flexion-type fractures were seen in six patients (2%) compared with a range between 1% and 11% in the literature.25,31,32
Open reduction was necessary in 52 (22%) of our
patients. The rate of open reduction reported in the litera-

ture varies from 1.3% to 46%.17,33-38 Our relatively high

open reduction rate may be because of the higher proportion of severely displaced fractures (56%) and to the experience of the surgeons; 75% of operations were undertaken
by specialist registrars).
The six patients (2%) presenting with significant vascular impairment and an absent radial pulse underwent emergency reduction and fixation without pre-operative
angiography. In five patients, the limb regained perfusion
after manipulative reduction. In one patient, the brachial
artery was explored and was found to be thrombosed. We
agree with others6,25 that a pre-operative angiogram in such
a limb-threatening situation may lead to unnecessary delay.
Iatrogenic nerve injury was seen in nine patients (3%),
which is similar to the 3.6% reported in a literature review.18
Three patients required exploration of the ulnar nerve. All
had crossed K-wires with a mini-open approach for medial
wire placement. There were no iatrogenic nerve injuries with
lateral wires. We believe a lateral divergent configuration
may be the safest without compromising stability.
Long-term deformity was seen in 12 patients (4%). Even
allowing for the possibility that more recent cases have yet
to demonstrate growth disturbance and deformity, this is
still much less than the 30% incidence in other series.39
Only 1% required corrective osteotomy and this was for
functional limitation rather than cosmetic concerns. We
believe our low rate of long-term deformity is due to accurate reduction and stable fixation.
No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.

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