Session VII - Pediatrics

Pediatric Supracondylar Humerus Fractures: Long-Term Follow-Up and Comparison of Operative Treatment Methods

Richard T. Davis, BS; John T. Gorczyca, MD; Kevin Pugh, MD, University of Kentucky Medical Center, Lexington, KY

Purpose: To evaluate the short-term and long-term results of pediatric supracondylar humerus fractures treated operatively at our medical center, with attention to treatment method.

Methods: A retrospective analysis of all children treated operatively for supracondylar humerus fracture at the University of Kentucky Medical Center from Jan. 1991 - Dec. 1996 yielded 89 patients. The age range was from 21 months to 14 years. Sixty-three patients had completely displaced extension-type supracondylar humerus fractures (Type III); 23 had angulated extension-type supracondylar humerus fractures (Type II); two had Salter II fractures of the distal humerus, and one had an oblique-shear fracture of the distal humerus. The fractures were stabilized by closed reduction and percutaneous pinning (CRPP) with crossed medial and lateral K-wires in 69 patients, CRPP with K-wires placed only on the lateral side in 17 patients, CRPP with 2 medial K-wires in one patient, open reduction and crossed medial and lateral K-wires in one patient, and closed reduction and splinting in one patient.

Medical records were reviewed and all x-rays were evaluated for quality of reduction, maintenance of reduction, and clinical result. We then attempted to contact all patients by mail, telephone and home visits in order to perform long-term clinical and, in some cases, radiographic follow-up examination. Only 33 patients could be located, and complete examination of both upper extremities was performed on these patients at an average of 34 months postoperatively. The results were graded according to Flynn's criteria. Seven other patients had long-term results documented in their chart but did not have comparison to the uninjured arm for grading by Flynn's criteria.

Results: No patient suffered from compartment syndrome or Volkmann's ischemic contracture. There was one iatrogenic palsy to the ulnar nerve in a patient with a Type III fracture and an associated brachial artery injury who underwent open reduction and crossed medial and lateral K-wire fixation. This patient's follow-up was limited to six weeks, so his long term outcome is not known.

Early postoperative fracture displacement occurred in four (6%) of 63 patients with Type III fractures. Displacement occurred in one (2%) of 54 fractures stabilized with crossed medial and lateral K-wires, whereas it occurred in two (25%) of eight fractures stabilized with lateral wires only (p=0.041). The one fracture treated with closed reduction and splinting alone displaced postoperatively and underwent reoperation with crossed medial and lateral K-wires. Critical analysis of the two fractures that displaced with lateral wires only revealed that the K-wires were placed in suboptimal position.

The long-term results in the 33 patients who could be located were excellent in 18 (55%), good in seven (21%), fair in one (3%), and poor in 7 (21%) patients. Of the 40 patients with long-term follow-up, five (12%) healed with coronal plane malalignment greater than 10 degrees, which resulted in gunstock deformity. There was no statistically significant relationship between treatment method and gunstock deformity. None of the patients with gunstock deformity, however, had compromised activity due to the deformity and all had full elbow extension and at least 130 degrees of elbow flexion.

Discussion and Conclusions: The results of this study indicate that the dreaded complication of compartment syndrome and Volkmann's ischemic contracture is uncommon with early reduction and percutaneous stabilization of pediatric supracondylar humerus fractures. Iatrogenic injury to the ulnar nerve did occur in one patient in whom crossed medial and lateral K-wires had been placed. Isolated lateral K-wire stabilization of distal humerus fractures avoids injury to the ulnar nerve, but proper pin placement is essential to avoid postoperative fracture displacement.

Good or excellent results by Flynn's criteria were achieved in 76% of our patients with long-term follow-up. Gunstock deformity occurred in 5 (12%) of 40 patients with long-term follow-up. Although gunstock deformity after a supracondylar humerus fracture can be a serious cosmetic concern, it does not preclude an excellent functional result. When gunstock deformity is not taken into consideration, 85% of the patients with long-term follow-up had good or excellent functional results.