The authors used the following protocol to treat displaced supracondylar fractures in children. First , closed reduction under general anesthesia with fluoroscopic control and lateral percutaneous pinning using two parallel Kirschner wires was undertaken. The wires had to be separated by at least 10 mm and be greater than 1.6 mm in diameter. If closed reduction failed, open reduction and internal fixation by cross-pinning was performed using a medial approach with identification of the ulnar nerve. The Kirschner wires had to cross above the fracture site and be greater than 1.6 mm in size. Six different surgeons used this protocol over the course of the study. The protocol was applied to 116 patients over a two-year period and follow-up was more than one year. Thirty were type II and 86 type III fractures were included. Five type III fractures had associated distal ischemia, which resolved after reduction of the fracture. Treatment was performed as soon as possible after injury.
Ninety patients underwent closed reduction and pinning while open reduction was required in 26. Clinical and radiological evaluation was completed at follow-up and graded according to rigorous criteria. Eight patients were lost to follow-up during the first year. Ninety-nine of the remaining patients had an excellent result (< 5„a loss of carrying-angle and < 5„a loss of motion). Five patients had a good result (5-10„a loss of carrying-angle and/or 5-10„a loss of motion) and four had a poor result (> 15„a loss of carrying-angle and/or >15„a loss of motion). The poor results occurred secondary to technical errors resulting in malreduction with cubitus varus.
The authors applied a standardized protocol with strict operative detail to a fracture that is notoriously difficult to treat. The lateral Kirschner wires were placed at least 10 mm apart to avoid rotation of the fragment around a single axis. Similarly, cross-pinning was performed with the wires intersecting above the fracture to avoid spinning of the distal fragment. Although some would argue that percutaneous pin fixation for type II fractures is not always required, one cannot dispute their results in this subgroup (23 excellent and 1 good). Type III fractures are more difficult to treat and excellent or good results were achieved in 96% of the patients. All four poor results occurred in this group and were related to technical errors. The impressive results support the use of this protocol with careful attention to surgical detail to treat extension-type displaced supracondylar fractures.