An analysis of open reduction of irreducible supracondylar fractures of the humerus in children.

OBJECTIVES

To review experience with irreducible supracondylar fractures requiring open reduction in children, and to propose guidelines for an open approach to supracondylar fractures.

DESIGN

A chart review.

SETTING

The Children's Hospital of Eastern Ontario (CHEO), a pediatric centre with a large referral base.

PATIENTS: Forty-one children (18 boys 23 girls, average age 7 years), who had open reduction of irreducible supracondylar fractures at the CHEO over a 10-year period (1985 to 1995). Of these 41 children, 7 were lost to direct follow-up.

INTERVENTIONS: After closed reduction of displaced supracondylar fractures of the humerus failed, all patients underwent open reduction and percutaneous fixation in the operating room. Before operation, 6 had no radial pulse, 5 lost their pulse with flexion after reduction and 4 had unstable fracture patterns.

MAIN OUTCOME MEASURES: Assessment of elbow range of motion and carrying angle, distal neurovascular status and radiographic measurement of the Baumann angle and the humerocapitellar angle.

RESULTS

In 25 children, the humerus was found to have "buttonholed" through the brachialis muscle; 1 had entrapment of the common flexor muscle at its origin and 1 had entrapment of the triceps. In 15 children there was entrapment or tethering of the median nerve and radial nerve or brachial artery, or both, but this was not predictive of preoperative neurovascular deficit, which was recorded in 21 patients (fully recovered). At follow-up, the Baumann angle and the humerocapitellar angle differed by an average of 2 degrees and 5.3 degrees respectively compared with the unaffected arm. Range of motion was satisfactory in 94% of patients, and there was no significant cubitus varus.

CONCLUSION

Open reduction of supracondylar fractures is a safe and effective procedure, for which orthopedists should should lower their threshold, given certain appropriate indicators.