Open Reduction of Displaced Pediatric Supracondylar Humeral Fractures through the Anterior Cubital Approach

Author(s): Ay, S; Akinci,; Kamiloglu, S; Ercetin, O

Source: J Pediatr Orthop 25(2): 149-153, 2005.

Summary:

Surgical exposure of supracondylar humeral fractures can be accomplished by a variety of  techniques.  This article deals with open reduction of displaced pediatric supracondylar fractures via an anterior approach.  The authors prefer closed reduction and percutaneous pinning for displaced type II fractures.  However, displaced type III fractures are treated with open reduction to ensure anatomic alignment.  The authors admit to previously using a posterolateral approach but have switched to the anterior cubital approach. The study consisted of 61 children treated via an anterior cubital approach and Kirschner wire fixation between the years 1996 and 2002.  Fifty-nine fractures were closed and 2 were open.  Five children had associated fractures.  Forty-two fractures were displaced in a posterolateral direction and 19 were posteromedial.  The surgical technique consists of a transverse incision across the antecubital fossa. The subcutaneous tissue is dissected by blunt technique.  Vascular insufficiency warrants exposure of the brachial artery.  In displaced fractures, the brachialis muscle is commonly torn and the fracture site is easily visible.  The fracture hematoma is removed and any soft-tissue interposition is removed with an elevator.  Closed reduction is accomplished by direct pressure along the proximal fragment to push the distal humerus in a posterior direction.  The fracture is reduced and crossed Kirschner wires are used for fixation.  The Kirschner wires are removed four-weeks after surgery and x-ray and clinical follow-up is performed.

The brachialis muscle was penetrated by the proximal fragment in 90% of patients.  In 45% of these cases the proximal fragment was found to be buttonhole through the brachialis, which prohibited anatomic reduction.   In approximately 30% of children, the joint capsule was found interposed between the fragments.  No cases required direct vascular repair.  A few cases of transient nerve palsies were seen. These resolved spontaneously following reduction and pinning. All fractures were reduced in the anatomic position.  Results were excellent in 44 cases and good in 17 cases.  Gunstock or other angulatory deformities were not seen in any of the cases.

The authors report anterior cubital incision and direct reduction of supracondylar humeral fractures.  The results are impressive with regard to outcome and few complications.  Frequently, interposed materials such as the brachialis muscle or joint capsule were found to prohibit anatomic reduction.  No cases of angulatory deformity were reported in the entire series.  I think this report lends support to primary open reduction through the anterior cubital approach as an option for treating supracondylar fractures.  The surgeon must be aware of the anatomic structures during the approach and those structures that may prohibit reduction.  This article lends credence for a comparison of open verses closed reduction with regards to clinical outcomes.
 


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