therapy of reported e reported may well monia in- of primary »roportion 1, all mild Jiminated THE HUMERUS IN CHILDREN FEMORAL NECK FRACTURE has been termed the “unsolved fracture.” In a similar vein, supracondylar fracture of the humerus in children might be called the “misunder- stood fracture.” By common consent, this is the most frequent fracture seen about the bow in children. Blount states the inci- dence is 60 per cent. At the Fitzgerald. Mercy Hospital the incidence was 50 cent from 1953 through 1957. In spite of its incidence, however, cases of severe residual bony deformity and dreaded Volkmann's ». In a recent 100 epi- (precoma he treat. therapy lutamate ere tabu: ammonia ement in nediate contracture continue to be se Ps article in the French literature, Fevre and i Jiuer discuss in some detail ther results in Tenet the operative treatment of 17 cases of estab- — lished Volkmann’s contracture. In 10-of these 17 cases, the initial trauma was a joe supracondylar fracture of the humerus. ae ‘Although methods of management for ae tating to observe the trepidation with which far fhe of trauma, approach a fresh supracondylar fracture. In many instances, th tion is justified because of the tragic com- plications that might ensue from this injury and the radical modifications in routine treatment that might be involved to prevent permanent functional loss, permanent cos- metic deformity, or damage to the overly- ing neurovascular structures. In his earlier years, the surgeon’s confidence in his method of management is not strengthened by the fact that the opinions of authorities differ regarding reduction, immobilization, and % J Hy R. Goma U cerebro- Sur Rawoats, is follow: fxicity of vxcation, after care. No problem should exist in the wdifuson larger teaching centers where all types of erated a3 skilled help and advice are available. How- 324, From the Fitsgerald.Merey Hospital, Darby, Pennsylvania MANAGEMENT OF SUPRACONDYLAR FRACTURES OF JOHN J. GARTLAND, M.D., F.A.CS., Philadelphia, Pennsylvania ever, a large proportion of these cases arc seen in suburban and rural hospitals where, in the ma Since cases of residual bony deformity and Volkmann’s contracture continue to be scen, it is evident that the simple basic principles underlying the management of this fracture are still not universally under- stood by all those called upon to treat this injury. If one becomes responsible for the treatment of these cases, methods of man- agement must be adopted that prove prac- tical and successful from both the patient's and the doctor’s standpoint. This article is presented to re-emphasize the principles underlying the treatment of 1, trained help is minimal this common injury and to discuss a method of management which has proved prac and successful for any situation, and ¢ cially for hospitals where trained constant orthopedic supervision is not available, and where much of the immediate after care is supervised by personnel not yet fully trained in the management of fracture cases TYPES OF FRACTURE By definition the fracture line in this in- jury crosses the supracondylar area of the distal humerus, just proximal to the articu- lar surface of the elbow joint. The fracture line may be transverse and jagged, or, less commonly, it may run obliquely upward and backward, beginning on the anterior surface of the humerus just proximal to the distal articular surface. This results in a small distal fragment composed of the lower articulating end of the humerus but which is attached the elbow joint and fore- arm, and a larger proximal fragment which is the anteriorly spiked humeral s146 Surgery, Gynecology & Obstetrics + August 1959 In the vast majority of cases, the distal fragment is displaced posteriorly but may, rarely, be displaced anteriorly depending on the direction of the fracturing force. The direction of the fracture line usually has an important bearing on treatment. As a rule, the fragments separated by a transverse fracture line are more easily reduced and held. ‘Those separated by a long oblique fracture line are frequently more difficult to reduce and often slip during the postreduc- tion period. The small distal fragment is most often intact but may be comminuted with extension into the lateral condyle, and medial condyle, or through one of the epi- physeal plates. It is important to remember that the dis- tal fragment is usually also rotated on the proximal fragment, more frequently inter- nally. There are, therefore, two positional deformities to be corrected at reduction. If the rotary displacement is not corrected, it results in permanent abnormality of the carrying angle. Inadequate reduction of the posterior displacement results in limitation of flexion or extension. Ir serves no useful purpose to subdivide these fractures further into dicondylar or transcondylar types. They are all fractures of the supracondylar area of the humerus, varying only in the degree of displacement and comminution. Normally, the distal articular surface of the humerus tilts forward at an angle of approximately 30 degrees with the shaft. The pathologic anatomy of this fracture, therefore, results in a loss of this angle plus a rotational spin of the distal fragment. Three types of supracondylar fractures are seen clinically. One is the non- displaced type, second is the minimal to moderately displaced type, and thirdly, the severely displaced fracture (Figs. 1, 2, and 3). The only question, then, that should con- cern the surgeon is what method of treat ment will give the best result in each type. TREATMENT Successful treatment of this injury in- volves adequate reduction and adequate immobilization. It is well to remember that the typical patient is an otherwise healthy active child, and the immobilizing appara- tus will soon be called upon to withstand the stresses and strains of childhood. To be truly successful, treatment methods should be simple so that they can give consistent results in the smaller hospitals where trained orthopedic help is minimal. Every child with a suspected elbow frac~ ture should have an x-ray examination of both elbows. Immediate check should be made to determine the presence or absence of circulatory embarrassment or nerve damage. Treatment should be undertaken ‘as soon as the diagnosis is established. This is one injury that brooks no delay. Swelling about the elbow enlarges with delay and in- creases the incidence of complication, both bony and vascular. Fracture with no displacement. In these cases the fracture line is almost always transverse, and there is no posterior displacement of the distal fragment and no rotational deformity. ‘The angle of the forward tilt of the distal articulating surface of the humerus may be normal, or may be decreased down as far as zero degrees. There will be generalized swelling about the elbow joint, sometimes moderately severe. As a rule, there will be no evidence of nerve or vascular complica tion. In the presence of negligible or no dis» placement, no actual reduction is necessary. ‘The injured arm is immobilized in a padded posterior plaster splint extending from the ‘metacarpal heads, with the forearm in neu- tal rotation, to a comfortable height be- neath the axilla. The forearm is flexed to 75 or 80 degrees. The position of acute flexion is unnecessary and only further compresses an already swollen elbow. The plaster splint is held in place by circular gauze bandage loosely applied so there are no tight edges cutting across the front of the flexed elbow. ‘The status of the pulse is again checked after application of the splint. ‘The child is re-examined within a 24 hour period with special attention to elbow swell Feo placer ing, r: After and a the el long perio taken im thi motio neede secon, is ev: witho Fra child: condy hospi cause mani anest place accut nerve ment tion « In displ: poste formimber that healthy g appara- tand the i. To be ds should consistent re trained bow frac- nation of nould be + absence idertaken red. This Swelling y and in- ion, both of the ne distal s may be as far as neralized ometimes e will be omplica- + no dis- ecessary. padded irom the in neu- tb ced to 7 e flexion presses er splint bandage at edges 1 elbow. ed after 24 hour w swell- Gartland: MANAGEMENT OF SUPRACONDYLAR FRACTURES OF HUMERUS IN CHILDREN Fo. 1. Roentgenogram showing minimal to no dl placement. ing, radial pulse, finger sensation, and pain: After 1 week, the plaster splint is removed degree of flexion. The the elbow in the sar long arm cast is removed after a further period of 3 weeks and a reentgenogram is taken, If healing is adequate, as it usually is in this type of fracture at 4 weeks, active motion and hor soaks are started. No formal sed or physical therapy treatments are needed. No p second person or by the carry is ever indicated. Full fu without deformity can be expected Fracture with moderate displacement. All children with moderately displaced supra condylar fractures should be admitted to the hospital for at least a 48 hour period be- cause these fractures require a gentle closed yn under a general ssive stretching either of weights tional return manipulative reducti anesthetic (0 realign the posteriorly dis- placed and rotated small distal fragment accurately. The incidence of vascular and nerve complication increases with displace~ ment and swelling, making careful observa- tion of the patient mandatory In the great majority of cases of moderate displacement, accurate reduction of the posterior displacement and rotational de- formity can be obtained by gentle closed 47 manipulation (Fig. 4). Immobilization is torior plaster splint, as is used on the non. displaced fractures, with the elbow flexed wal rotation. The rule of thumb he immobilized elbow is to flex the elbow to the point where the radial pulse weaker hen extend it 10 to 15 degrees. In the vas majority of cases, the final position of elbow flexion lies between 75 and 80 de ©. 3. Roentgenogram ii ie withoat defor children with oe only hospi place aces Wf the Tae ccular e6s¢ is Jot sonks ave sare sures show Hing, making tiene mandatory slacemnent and 10 obtained by ly dispiae with displ xl. No formal eased 3 tte t F period be Re reigenogea i this Fo148 Surgery, Gynecology & Obstetrics » August 1959 The volume of the pulse is noted as soon as the splint is applied. The status of the reduction is checked by x-ray examina- ion as soon as possible, and careful watch is kept on the pati jon, and amount of forearm pain with finger motion. The posterior splint is removed at the end of 1 week, and a long- arm circular cast applied with the elbow in the same degree of flexion and the forearm in neutral rotation, The long arm cast is re- moved after a further period of 5 weeks, and hecked by x-ray active motion and examination. Grad hot soaks can then be started. Occasionally, a moderately displaced fracture will be seen that proves to be un: stable, and the reduction cannot be main- tained by the plaster methods described. These are almost always oblique fractures ind require overhead skeletal traction, as Jescribed in the next section, curate reduction and immobilization. The Fro, 4. a, Roen displacement. Prereduction view. b, which was taken after manipulativ gram of fracture with moderat ion is maintained for 2 to skeletal trai weeks. A long-arm plaster cast is then ap- for a further period of 3 to 4 weeks. tures with severe displacement, especially if the fracture line is tr se, and if the distal fragment is not comminuted, reduce readily with closed manipulation, and prove stable in the postreduction period. ‘These are handled by the plaster method already described. A greater number of severely dis- placed fractures occur in which the fracture line is oblique, These are unstable fractures and the reduction cannot be maintained by plaster immobilization. These fractures re quire overhead skeletal waction as their primary definitive treatment. Properly, skeletal traction in these cases should be set up in the operating room under the usual operating room conditions, and using general anesthesia. A threaded Kirsch- ner wire of adequate gauge is used. The wire is inserted with a hand drill through both cor ulna, a from th the uln; yoke is the elb plaster and wr from h The for Enougt to hold The checkec hours. factory week j the enc and th cast is flexed tinued If theGartland: MANAGEMENT OF SUPRACONDYLAR FRACTURES OF HUMERUS IN CHILDREN Fio. 5.4, being palpably thicker than opps stment by Lateral view 0 years later. Complet both cortices of the prominent border of the ulna, about 114 inches distal to the ole- cranon tip. It is better to insert the wire from the medial aspect to avoid damage to the ulnar nerve. A yoke is attached to the wire and the wire ends are corked. The yoke is then attached to the rope and pulley system, and traction is instituted with the arm suspended over the patient's chest, with the elbow flexed to 90 degrees, A volar plaster splint is bandaged to the forearm and wrist to prevent the wrist and hand from hanging in a “wrist-drop” position. The forearm is suspended in a wide sling. Enough weight is added to the traction just to hold the shoulder slightly off the bed. The status of the fragments should be r checked by x-ray examination within hours. If reduction is complete and satis- factory, traction is maintained for a 2 to 3 week period as the immobilizing agent. At the end of this time, traction is discontinued and the wire removed. A long-arm plaster cast is applied immediately with the fore- arm in neutral rotation, and the elbow is flexed to 90 degrees. Immobilization is con- tinued for a total period of 6 weeks (Fig. 5). roentgenogram reveals un- If the rechecl 19. ¢- ty Oleeranon skeletal traction ele after 2 weeks in skeletal traction satisfactory reduction, the solution is not to increase the amount of traction. It is better to manipulate the fragments manually into place under a second anesthesia without disturbing the traction force, tinue the traction as the immobilizing agen If necessary nanipulation could be carried out after several days, if the Once even another position is not acceptable. ceptable reduction has been obtained, the traction is maintained for 2 to 3 weeks, fol lowed by a long-arm cast for a total immo- bilization period of 6 weeks (Fig. 6) In all cases in which the distal fragment is comminuted and in most compound frac- tures, overhead skeletal traction is the treat- ment of choice. In most compound cases, it is usually the sharp spike on the anteriorly displaced proximal humeral fragment that perforates the volar skin surface. It follows, therefore, that in this situation the fracture line will be oblique and the distal fragment will be severely displaced. After debride- ment of the wound, primary skeletal trac- tion insures good reduction and adequate immobilization, and allows the wound to be observed and dressed without compromising the reduction.150 Surgery, Gynecology & Obstetrics » August 1959 face of degree displac formity growth of flexi Pers If not subseq limitec ing, tt reduct «success be ins * those ductio beliew a disp Res or rot céptat lowing face 0 displa teratic cubity Resid freque pecial indur: deterr (ya with ¢ the fil joint, poster (Fig be m: stabil tal Cir comp This have end Fic. 6. a, Prereduction fl showing severe dixplacement. b, Closed manip sfc and olecranon skeltal traction instituted. This efit check xray fn af traction. Present position not acceptable. chi patirnt had 1 closed manipula further manipulations under anesthesia after skeletal traction instituted, "This ip ance 4 years later. Range of motion and physical eppearance completely normal. COMPLICATIONS AND THEIR MANAGEMENT has been performed, a postreduction roent- pracondylar —_genogram may show a partial reduction of a fracture arise because of: (1) inadequate re-_ posteriorly displaced distal fragment, per- duction, (2) circulatory impairment, her- sistent overriding of the fragments, or a ulded by a weak or absent radial pulse, and residual lateral or medial displacement. 3) rarely, damage to the nerves passing Partial reduction of a posteriorly dis. fracture site placed distal fragment is acceptable pro: After closed reduction vided the angle of the distal articular sur-Gartland: MANAGEMENT OF SUPRACONDYLAR FRACTURES OF face of the humerus measures, at least, zero degrees with the shaft. Persistent posterior displacement is not acceptable. Angular de- formity, at this site, does not correct with growth, and results in permanent limitation of flexion. Persistent overriding is never acceptable. If not too great, it sometimes corrects with subsequent growth, but most often results in limited elbow function, Persistent overrid- ing, therefore, justifies farther attempts at reduction. If a second manipulation is not successful. overhead skeletal traction should be instituted and the fracture managed as those with severe displacement. Open duction with or without metal fixation is not believed to be indicated in the weatment of a displaced closcel supracondylar fracture Residual lateral or medial displacement or rotation of céptable and justifies lowing this deformity to remain, even in the face of accurate reduction of the posterior displacement, will lead to a permanent al- teration in the carrying angle with either a cubitus valgus or cubitus varus deformity Residual rotation of the distal fragment is frequently difficult to detect clinically pecially when palpation is through a swollen. indurated elbow area. Its presence can be determined if 3 x-ray views are obtained: (1) a true anteroposterior view of the arm with the shoulder and elbow joints visible on the film, (2) a true lateral view of the elbow joint, and (3) a Jones view, or an antero- posterior view through the flexed elbow (Fig. 7). If this type of displacement cannot be maintained in reduction because of in- stability at the fracture line, overhead skele- tal traction should be instituted Circulatory impairment. The most dreaded complication of a supracondylar fracture is, an extremely weak or absent radial pulse any significance, is not ac manipulation, AL This may be present before reduction, or he reduction, and may have several causes. An absent radial pulse may appear after may be due to direct impingement of the neurovascular structures on the distal sharp end of the anteriorly displaced proximal HUMERUS IN CHILDREN 151 Fs. 7. Jones view of freshly reduced displaced supra condylariractire fragment, or may be due to compression of the vessels at the elbow secondary to sever swelling, or, rarely, may be because of a lacerated or torn brachial artery Cases have been reported in which the radial pulse has remained absent, but the fingers. maintained good capillary flow because of adequate collateral circula: tion, This is a fortunate circumstance but should not be depended upon. An absent radial pulse in the presence of a supracon lar fracture demands maximum effort as to its cause and correction. If ignored or un: corrected within a 6 to 8 hour period, Volk- mann’s ischemic contracture may result. In these cases mechanical occlusion of the venous circulation with ischemia and edema at the elbow, accompanied by vasosp the arterial cree, results in subsequent fibro- sis of the volar musculature of the forearm. and hand with severe crippling plication is entirely preventable When faced with an absent radial pulse152 Surgery, Gynecology & Obstetrics « August 1959 in a fresh supracondylar fracture, first thought should be given to reducing the fracture. The neurovascular structures are intimately bound to the distal fragment Posterior displacement of the distal frag- ment causes the bundle to impinge on the distal sharp end of the anteriorly displaced proximal fragment. Therefore, if direct bone impingeiient is the cause of the absent radial pulse, the surest way of relieving compres- sion of the brachial vessels is to reduce the fragments. Following reduction, the radi pulse should again be strong. The fracture is then immobilized in the indicated manner. ‘everal situations in regard to the radial pulse may present themselves. If direct bone impingement is the cause of the absent radial pulse, adequate reduction should re- store the pulse, If the reduction is not adequate, further attention should be given to the fracture with either a remanipulation or the institution of overhead skeletal trac- ion, If the reduction is adequate and the pulse remains precarious, search should be made immediately for another cause. The most common cause of circulatory impairment is antecubital edema with sub- fascial tension and arterial vasopasm. In such a case, on first appearance the “pulse be adequate, but, after reduction, it disappear with any attempt to flex the elbow, even to a right angle, As de- scribed in earlier communications (3, 5). the mixture of hyaluronidase and procaine offers an effective nonoperative method to relieve subfascial tension caused by edema and hemorrhage with great rapidity. The hyaluronidase rapidly disperses the offend- ing fluid collection, and the procaine, which under the influence of the enzyme diffuses through a much wider area, relaxes any degree of arterial spasm present, Fifteen hundred turbidity reducing units of hya- luronidase mixed in 3 to § cubic centimeters of 1 per cent procaine injected into and about the antecubital fossa and into the fracture site will suffice to soften the elbow and restore the pulse in about 30 minutes, if this is the cause of the circulatory im= pairment. The fragments are then im- mobilized by either plaster or overhead skeletal traction, depending on the type of fracture. One may be faced with a situation in which radial pulse, absent before reduc- tion, continues absent following reduction. The first step would be immediately to check the position of the fragments by x-ray examination, If the reduction proves satis- factory, the next measure would be the local injection of hyaluronidase and pro- caine as previously described. If the results from this are not completely satisfactory, it should be combined with a stellate ganglion block. If these measures are carried out correctly, the outcome will be satisfactory and surgical fascial release, specifically to relieve subfascial edema, will be unneces- sary. Attention must also be given con- currently to maintaining the reduced frac- ture by either plaster fixation or overhead skeletal traction, IF all these measures prove unsuccessful, one is probably dealing with a torn ot lacerated brachial artery. At this point, immediate exploration of the artery is indi. cated, with either repair or grafting in mind. Preliminary arteriography is believed to be an unnecessary hazard and is not recom mended. Verve damage. Primary damage to the nerves passing over the elbow joint is un- common with a supracondylar fracture. Swetching or contusion injuries to the median and ulnar nerves have been reported, but are rare. Occasionally, injury to the deep muscular branch of the radial nerve is noted. ‘The nerve damage in almost all cases is temporary and disappears in time without any specific treatment. It is important to pick up any evidence of nerve damage, if present, before the fracture is reduced. Its presence, however, does not modify the (reatment except to sce that further trauma is not given to the injured nerve. Definitive fracture care should be carried out just as if no nerve damage was present.luce ion. to ray tise the oro ults nit ion out ory ful, int, Gartland: MANAGEMENT OF SUPRACONDYLAR FRACTURES OF HUMERUS IN CHILDREN 153 AFTER CARE When the surgeon views the postreduction films, it is well to bear in mind what con- stitutes an acceptable reduction. The aim of treatment is to restore the normal anterior angulation of the distal articular surface of the humerus, phus the reduction of any medial or lateral displacement or rotation of the distal fragment. Partial reduction of a posteriorly displaced distal fragment is acceptable proviced the angle of the distal articular surface of the humerus measures at least 0 degrees with the shaft. Mild residual overhang of the anterior surface of the proximal humeral fragment will resorby with growth and will not cause a flexion block. Acceptance of a negative angle at the distal articular surface of the humerus guarantees a flexion block because angular deformities are not improved by subsequent bone growth. Persistent posterior displace- ment, persistent overriding, persistent me~ dial or lateral displacement, and residual rotation are not acceptable, ‘The duration of immobilization will vary from 4 to 6 weeks. In cases not requiring reduction, healing will be sufficient at the end of 4 weeks to start unprotected active motion. In cases in which manipulative reduction or skeletal traction is required, immobilization can usually be removed after 6 weeks. If it is planned to immobilize a supracondylar fracture for 6 weeks, it is wise to recheck position by x-ray examina- tion at 3 weeks. A study of Colles’ fractures (4) showed a surprising amount of the re~ duction to be lost while the wrist was in the cast. If the cast is loose at the time of the 3 week check, it should be replaced. If this film shows loss of reduction, it is quite po: sible to regain it at this time. It is imposs at 6 weeks. Formal physical therapy is not required in these cases, Forceful passive stretching and the carrying of weights should be expressly forbidden. Children possess their ‘own special brand of magic and will regain full function if left to their own devices and if the surgeon has done his part le Myositis ossificans is rarely seen as a ‘complication of a supracondylar fracture. Tt is quite frequently seen as a complication of posterior dislocation of the elbow, par- ticularly if associated with fracture of the radial head. ‘The reason for this can be seen in the anatomy of the area. The anterior elbow capsule is thin and loosely attached to the humerus. The brachialisanticus muscle overlies the anterior joint capsule and is attached to it. Anterior distocation of the distal humerusat the elbow tears through the anterior capsule and brachialis muscle and the subsequent hemorrhage into the fibers of the brachialis muscle organizes and becomes ossified. In most supracondylar fractures. the anterior joint capsule remains intact and the hemorrhage is. dissipated throughout the area because an escape route exists between the fragments. If myositis ossificans should complicate a supracondylar fracture, it frequently disappears if the im- mobilization is prolonged another 6 to 8 weeks. If it should not regress, operative re- moval of the anterior bone block should be postponed for 1 year. Early surgical inter- vention results in the formation of more bone. ‘Occasionally, residual bony deformity is seen as a complication in the follow-up period and results either in impairment of function or cosmetic deformity. With but 1 exception, this complication means the original reduction was inadequate. Subse- quent growth over a long period of time may frequently correct a flexion block due to residual overriding, but it does not lessen a residual angular deformity, and never corrects residual rotation or displacement. Incomplete reduction of the posterior dis- placement results in limitation of flexion, and, ifsevere, requires an angular osteotomy of the distal humerus to restore an anterior angle. Incomplete reduction of medial oF lateral displacement or rotation results in a cosmetic deformity due to cubitus valgus or cubitus varus. These are rarely associated. with functional impairment. Correction of the carrying angle deformity requires a154 Surgery, Gynecology & Obstetrics » August 1959 rotational osteotomy of the distal humerus. The 1 exception occurs when the original fracture line injures the epiphyseal line at the distal humerus and the slow develop- ment of a carrying angle deformity in the late follow-up period becomes evident sec~ ondary (© unequal bone growth. Here the deformity is cosmetic and will require a rotational osteotomy. Tardy ulnar neuritis may be seen as a late complication in eases of supracondylar fracture. Its development is almost always secondary to a residual cubitus valgus de- formity and requires an anterior transposi tion of the ulnar nerve for its treatment. Rarely, a symptomatic neuroma may form in the ulnar nerve because of irritation from the olecranon wire in cases in which overhead skeletal traction had been used. ‘The prognosis in supracondylar fracture should be excellent in regard to function and cosmetic alignment. Almost all the cases not classed as good or excellent are the result of inadequate reduction or improper management of complications. Except for problems arising from compounding, actual laceration or contusion of the neurovascular structures, or epiphyseal damage, all com- plications of supracondylar fractures are believed to be preventable, REFERENCES 1, Brounr, Water, Fractures in Children, Baltimore: ‘The Williams & Wilkins Co., 1954 2, Favas, Mapeer, and Juoer, Jean. Treatment ofthe Sequels of Volkinann's chemi contracture. Rev, thie orthop., Par, 1980, 43° 439, 3, Ganreand, J. Jy and MacAuseasp, W. Roy Jn. Use of hyaluronidase in soft tissue injury and it fluence fon experimental bone repair. Arch Surgy 1954, 68 Sos-3ie me * 4, Ganrano, J. Jo and Wetey, CW. Eval heated Colley Iractures. J. Bone Surg, 1931, 895-90. 5. Machustoyp, W. Ro Jus Gamma, J, J and Hatioce, H.'The use ol hyaluronidase i ofthopae dic surgery. J. Bone Surg.y 1953, 35 08-03 SUR INT HARI Indian Puts ithe guin: chro: Gerb views aorti Eiser prob medi lacer conc rapic hem such atiny hosp with tina thor duri sion