Supracondylar fractures are common in children. Subtypes include various fracture lines that extend into the joint and involve either one of condyles. The fracture pattern can be Y or T in shape. Failure to recognize these vertical components may lead to inadequate fracture reduction fixation. The purpose of this study is to highlight the uncommon extension supracondylar fracture with fracture lines towards the joint. Over an 18-year period, the authors identified 26 children with comminuted distal humeral fractures. Twenty-two patients were available for a minimum of two-year follow-up. Three fracture subtypes were identified with involvement of the medial condyle, intercondylar or lateral condyle component. In all cases, the growth plates were open. Nineteen fractures underwent closed reduction and Kirschner wire fixation. One patient was treated with open reduction and the last two patients with long arm cast immobilization. X-rays and clinical assessment were used to grade outcome. The authors highlight the surgical approach to these difficult fractures. The fracture is reduced similar to the type II or type III extension supracondylar fracture. The condylar component is fixed first with Kirschner wires and manual reduction. Careful attention along the medial side is necessary to avoid injury to the ulnar nerve. Once the condylar component is stabilized, reduction is verified through intraoperative fluoroscopy. Reduction of the smaller component is then performed in a similar fashion using Kirschner wires. In essence, a jigsaw puzzle type reduction is performed with a larger component reduced first followed by reduction of the second component.
The results indicate excellent or good outcome in 82% of the patients. The best outcomes were seen in patients fixed with two lateral and two medial Kirschner wires or two lateral and one medial wire. Complications included cubitus varus in three elbows and a stiff elbow in one patient. The stiff elbow patient suffered the greatest trauma of all the children included. The main point of this article is to highlight that supracondylar fractures can have a vertical extension into the joint. Recognition of the fracture pattern is paramount to success. Reduction of the larger component to the shaft followed by the smaller component achieves the best outcome. Multiple Kirschner wires are necessary in all fragments. There are three distinct fracture patterns that involve either the medial condyle component, lateral condyle component, or true intercondylar vertical extension through the distal fragment. The authors suggest that this be labeled a type IV fracture and be expanded to the Gartland classification of supracondylar fractures.
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