Treatment of grossly dislocated supracondylar humerus fractures after failed closed reduction: a retrospective analysis of different surgical approaches.

INTRODUCTION: The supracondylar humerus fracture (SCHF) is one of the most common pediatric injuries. Highly displaced fractures can be very challenging. If closed reduction fails, the therapy algorithm remains controversial.

MATERIALS AND METHODS: In total, 41 patients (21 boys and 20 girls) with irreducible Gartland type III SCHF, treated with open reduction through three different approaches and cross-pin fixation, were retrospectively evaluated. The mean follow-up was 46 months (min.: 12, max.: 83, SD: 23.9). The Mayo elbow performance score (MEPS) as well as the quick disabilities of arm, shoulder and hand (qDASH) score were used to assess the functional outcome. Baumann's angle and the anterior humeral line (AHL, Roger's line) were obtained from follow-up radiographs. Time to surgery, postoperative nerve-palsy, rate of revision surgery, and complication rate were examined.

RESULTS: Two revision surgeries were reported. One due to inadequate reduction and one due to secondary loss of reduction. In this context, the AHL was a sufficient tool to detect unsatisfactory reduction. According to the MEPS the functional outcome was excellent (> 90) in 37/41 patients and good (75-89) in 4/41 at the final visit. Fair or poor results were not documented. The qDASH score was 1.8 (min.: 0, max.: 13.6, SD: 3.4). There were no significant differences between the utilized surgical approaches. An iatrogenic injury of the ulnar nerve was not reported in any case. Overall, one heterotopic ossification without impairment of the range of motion and one preliminary affection of the radial nerve were documented.

CONCLUSION: In the rare case of an irreducible SCHF, an anatomical reduction can be achieved by open approaches with excellent functional outcome and a high grade of patient satisfaction. All described open approaches can be utilized with a high safety-level.