How Safe Is the Operative Treatment of Gartland Type 2 Supracondylar Humerus Fractures in Children?

Author(s): Skaggs DL, Sankar WN, Albrektson J, Vaishnav S, Choi PD, Kay RM

Source: J Pediatr Orthop, 2008; 28:139-141.

Summary:

The treatment of supracondylar humerus fractures has evolved toward operative fixation for Type III fractures.  Type I fractures are treated by casting alone.  Type II fracture management remains controversial with advocates for close reduction and casting alone vs. close reduction and pinning.  The goal of this study was to determine the optimum treatment for Type II supracondylar fractures. 

A single tertiary care Children’s hospital was the setting for this study.  There were 189 children with Type II fractures that had minimum of 6 weeks follow-up.  Data was obtained including demographics, x-ray findings, and operative information.  In addition, the number of complications was recorded and patients were classified based on the Flynn criteria for outcome.  The average age of the 189 children was 4.5 years.  In 133 patients, 2 lateral-entry pins were used for fracture fixation, and in the remaining 53 patients a third pin were added. Minimal follow-up was limited to 8.7 weeks until fracture union had occurred. There were no cases of cubitus varus or cubitus valgus.  No ulnar nerve palsies were noted and there was no need for re-operation secondary to lose of alignment.  Most of the patients had full range motion at the time of discharge, although there was some limitation requiring therapy.  According to the Flynn criteria, 181 patients had excellent results, 2 were rated as good and 2 as fair.  4 patients developed pin-track infection; 1 resolved after oral antibiotics, 2 required I.V. antibiotics, and 1 patient required irrigation and debridement.  No intraoperative complications were noted.  There were no surgical or anesthetic complications.  The overall motion was normal in a 174 patients, at an average of 8.7 weeks after surgery.  Twelve of the remaining 15 patients lacked less than or equal to 10 degrees of flexion or extension.  These children were likely to improve with normal activity range of motion.  Only 2 patients required formal physical therapy. 

The advantages of pin fixation are the ability to immobilize the elbow in lesser degrees of flexion, which limits the risk of compartment syndrome.  In addition, rigid pin fixation prevents loss of reduction.  The authors make a strong case for pin fixation of displaced Type II supracondylar fractures; however, these authors are well experienced in the methods of closed reduction and lateral-entry pin fixation.  Furthermore, the authors do not discuss the amount of sagittal or coronal malalignment that warrants pin fixation.  At our institution, we prefer closed reduction and pinning when the anterior humeral line does not touch the capitellum.  Lesser degrees of angulation will remodel over time, although the remodeling is slower at the distal humerus compared to the proximal humerus.