SC fracture

Much attention has been directed to the problem of malreduction of supracondylar fractures of
the humerus in children. In the past, cubitus varus or valgus frequently was thought to occur
because of growth arrest of the distal humeral physis, rather than because of malreduction of the
fracture. Wilkins, reviewing 4520 fractures in 31 major series, made several pertinent
observations: (1) 97.7% of the fractures were of the extension type, and only 2.2% were of the
flexion type; (2) most occurred in boys, especially between ages 5 and 8 years; and (3) a
Volkmann ischemic contracture occurred in 0.5% of the fractures; the radial, median, and ulnar
nerves were involved in that order of frequency.
Prevention of cubitus varus or valgus by obtaining as anatomical a reduction as possible is
necessary. It is no longer acceptable to hear not bad for a supracondylar fracture. Dameron
listed, depending on the type of fracture, four basic types of treatment: (1) side-arm skin traction,
(2) overhead skeletal traction, (3) closed reduction and casting with or without percutaneous
pinning, and (4) open reduction and internal fixation. Gartland proposed a useful classification
for supracondylar fractures: type I, undisplaced; type II, displaced with intact posterior cortex;
and type III, displaced with no cortical contact. His classification also noted whether the fracture
is displaced posteromedially or posterolaterally. Type I nondisplaced fractures can be
satisfactorily treated closed with external fixation, such as a plaster cast. Type II fractures are
displaced and are difficult to reduce and to hold reduced by external methods. Type III fractures
are displaced posteromedially or posterolaterally with no cortical contact, and the periosteum
may be stripped; reduction is difficult, and maintaining reduction is almost impossible without
some form of internal fixation (Fig. 33-70).

Fig. 33-70 Internal fixation of supracondylar fracture. A and B, Severely displaced type III supracondylar fracture. C and D, After
closed reduction and percutaneous pinning. E and F, Good result soon after removal of pins.

An occasional author has mentioned holding the reduction by extension of the elbow to get good
radiographs and to avoid any cubitus varus or valgus. Obtaining satisfactory radiographs to
determine whether any cubitus varus or valgus is present seems to be the biggest problem in the
treatment of these fractures. Various methods of overhead traction and side-arm traction have
been recommended. Better radiographs sometimes can be taken in these positions, although
lengthy hospitalization is required. The three most common reasons for residual cubitus varus or
valgus deformity are (1) the inability to interpret poor radiographs and acceptance of less than
adequate reduction, (2) the inability to interpret good radiographs because of a lack of
knowledge of the pathophysiology of the fracture, and (3) the loss of reduction. The lateral

radiograph seems to be no problem. The Jones view in the anteroposterior plane should be taken
properly with the elbow flexed maximally, the cassette underneath the elbow, and the tube at a
90-degree angle to the cassette. The Baumann angle and any offset at the fracture site, tilting, or
angulation should be observed. An anterior spike on the lateral view usually implies rotation
rather than posterior displacement. A crescent sign, described by Marion et al., implies tilt
medially or laterally (Fig. 33-71).

Fig. 33-71 Crescent sign. A, Normal lateral view of elbow. B, In varus deformity, part of ulna overlies distal humeral epiphyses,
producing crescent sign.
(Redrawn from Marion J, LaGrange J, Faysse R, et al: Les fractures d l'extremite inferieure de l'humerus chez l'enfant, Rev Chir
Orthop 48:337, 1962.)

Attempts have been made to correlate various radiographic measurements with adequate fracture
reduction. The Baumann angle (Fig. 33-72) is the most frequently cited method of assessing
fracture reduction and has been reported to correlate well with the final carrying angle, not to
change significantly from the time of initial reduction to final follow-up, and not to be obscured
or invalidated by elbow flexion or pronation. The common formula is that a change of 5 degrees
in the Baumann angle corresponds to a 2-degree change in the clinical carrying angle.
Williamson et al. found that an average of 72 degrees (range 64 to 81 degrees) could be
considered a normal Baumann angle, and that as long as the angle did not exceed 81 degrees,
cubitus varus would not occur. A template can be used to make measurement of this angle easier
(Fig. 33-73). Dodge found, however, that orientation of the x-ray beam more than 20 degrees
from perpendicular in the cephalad-caudad direction invalidates the measurement. Webb and
Sherman found the Baumann angle to correlate with the carrying angle, but inaccuracy of
measurement increased in young children and adolescents, so they recommended its use only in
comparison with the normal elbow. Using CT, Mohammad et al. found the Baumann angle to be
an inaccurate indicator of the carrying angle in the treatment of displaced supracondylar
fractures.

Fig. 33-72 Baumann angle. a, Midline diaphysis of humeral shaft. b, Line perpendicular to midline. c, Line through physis of
lateral condyle. Angle A is original Baumann angle. Angle B is more commonly used currently.

Fig. 33-73 Measurement of Baumann angle with overlay grid of angles.

(Redrawn from Williamson DM, Coates CJ, Miller RK, et al: Normal characteristics of the Baumann (humerocapitellar) angle: an
aid in assessment of supracondylar fractures, J Pediatr Orthop 12:636, 1992.)

Oppenheim et al. and others suggested that the humeral-ulnar-wrist angle is the most consistent
and accurate method of approximating the true carrying angle. In an unpublished study, O'Brien
et al. reported that the metaphyseal-diaphyseal angle (Fig. 33-74) was more accurate than the
Baumann angle in determining the adequacy of reduction.

Fig. 33-74 Metaphyseal-diaphyseal angle. On anteroposterior radiograph, transverse line is drawn through metaphysis at its widest
point, and longitudinal line is drawn through axis of diaphysis; angle is measured between lateral portion of metaphyseal line and
proximal portion of diaphyseal line. A, Normal angle is 90 degrees. B, Angle greater than 90 degrees indicates varus angulation. C,
Angle less than 90 degrees indicates valgus angulation.
(Courtesy of R.E. Eilert, MD.)

In this fracture, cubitus valgus causes little problem, primarily because the carrying angle is 5 to
7 degrees of physiological valgus, and anything more than this is an accentuation of the normal.
Conversely, cubitus varus produces a distasteful cosmetic deformity, but only rarely any
limitation of motion. Many authors have shown that pure posterior displacement causes little
deformity, and that pure horizontal rotation likewise causes little deformity because rotation is
adequately compensated for at the shoulder joint. Coronal tilting can occur with opening of the
lateral aspect of the fracture site, causing angulation into a varus position, or with impaction of
the medial side of the fracture site, resulting in cubitus varus (Fig. 33-75). As noted by Wilkins
and others, horizontal rotation predisposes to coronal tilting, and a combination of horizontal
rotation, coronal tilting, and posterior displacement can result in a three-dimensional deformity
of cubitus varus (Fig. 33-76). The crescent sign and the fishtail sign anteriorly imply angulation
and rotation. When they are seen on the lateral view, the anterior or Jones view should be studied
closely for loss of the Baumann angle, coronal tilting secondary to lateral displacement, or
medial impaction at the fracture site. By a mechanism that is not completely understood, varus
tilting is reduced by pronation of the forearm that closes the fracture laterally (Fig. 33-77).
Whether external immobilization or pin fixation is used, the forearm should be placed in the
pronated position to decrease the varus tilt and resultant cubitus varus.

Fig. 33-75 Mechanism of coronal tilting. A, Impaction of fracture medially. B, Tilting of fragment medially. C, Horizontal rotation.
(Redrawn from Marion J, LaGrange J, Faysse R, et al: Les fractures d l'extremite inferieure de l'humerus chez l'enfant, Rev Chir
Orthop 48:337, 1962.)

Fig. 33-76 Three static components that combine to produce cubitus varus. A, Horizontal rotation. B, Coronal tilting. C, Anterior
angulation.
(Redrawn from Wilkins KE: Fractures and dislocations of the elbow region. In Rockwood CA Jr, Wilkins KE, King RE, eds:
Fractures in children, Philadelphia, 1984, Lippincott.)

Fig. 33-77 Reduction of lateral tilt by pronation of forearm. A, Supination opening fracture laterally. B, Pronation closing fracture
laterally.
(Redrawn from Abraham E, Powers T, Witt P, et al: Experimental hyperextension supracondylar fractures in monkeys, Clin Orthop
Relat Res 171:309, 1982.)

Closed reduction with splint or cast immobilization traditionally has been recommended for
displaced supracondylar fractures, but loss of reduction and the necessity of repeated
manipulations have been reported frequently to cause elbow stiffness and physeal damage.
Pirone et al. reported that closed reduction and casting of displaced fractures resulted in a lower
percentage of good results and higher percentages of early and late complications compared with
skeletal traction, percutaneous pinning, and open reduction; they recommended cast treatment
only for undisplaced fractures. Criteria for closed reduction are easy reduction, stable fracture,
minimal swelling, and no vascular compromise. Several authors have described reduction of the
fracture in extension and maintenance of the reduction through the use of the triceps bridge by
holding the elbow in flexion if the pulse and vasculature tolerate this. Mapes and Hennrikus,
using Doppler ultrasonography, concluded that in displaced extension supracondylar fractures,

extending the elbow and supinating the forearm enhance vascular safety. Chen et al. reported
good results using manipulation, reduction, and immobilization with the elbow in full extension
in a plaster slab. Bosanquet and Middleton reported good results with skin traction in full
extension. They attributed the lack of cubitus varus or valgus deformity to good radiographic
techniques. Skeletal traction using an olecranon pin or screw applied with side-arm or overhead
positioning also has been recommended because of the advantages of increased mobility,
decreased pain and swelling, and improved alignment. Ippolito et al. reported good results at
long-term follow-up in 81% of nondisplaced and 78% of displaced fractures treated
conservatively. Their treatment regimen included overhead skeletal traction for 2 to 10 days until
reduction of the overriding fragments was obtained, further reduction of the fracture with the
patient under general anesthesia, and application of a long plaster cast, including the traction
bow, with the elbow in 90 degrees of flexion and the forearm pronated. The overhead traction
position was maintained for another 2 to 3 days, after which the long plaster cast was connected
to a shoulder spica cast. Kramhft et al. reported excellent or good results in 60 severely
displaced supracondylar fractures after closed reduction and vertical skeletal traction with a
screw in the olecranon. Agus et al. treated 13 fractures that were complicated by delayed
reduction, extensive swelling, or unsuccessful reduction manipulations with skeletal traction.
They reported excellent results in 11 of 13 fractures. Most displaced Gartland type II and
reducible type III fractures are treated by percutaneous pinning.
Closed Reduction and Percutaneous Pinning

As noted by Dameron, closed reduction is difficult not only to achieve, but also to maintain
because of the thinness of bone of the distal humerus between the coronoid and olecranon, where
most supracondylar fractures occur. For this reason, many authors have described percutaneous
pinning techniques, and these techniques have become the treatment of choice for most
supracondylar fractures. In the past, because of the need to avoid vascular compromise,
compartment syndrome, swollen landmarks, and possible nerve damage, displaced supracondylar
fractures were treated as emergencies. With percutaneous pin fixation being the treatment of
choice and in some cases open reduction, general anesthesia and an operating team frequently
are required. As a result, some have challenged the concept of emergent treatment. Gupta et al.,
Mehlman et al., and Leet et al. all reported no difference in emergency treatment (<8 hours) and
urgent treatment (>8 hours but <24 hours) concerning the need for open reduction, longer
hospital stay, unsatisfactory results, or perioperative complications (compartment syndrome,
iatrogenic nerve injury, pin track infection). These authors believe that surgical intervention can
be emergent or urgent as deemed appropriate by the surgeon. They all agree, however, that gross
malalignment needs to be temporarily reduced as an emergency, with definitive treatment being
done in less than 24 hours.
Swenson, Casiano, and Flynn et al. used two crossed pins. Arino et al. recommended two lateral
pins, and Foster and Paterson used two lateral divergent pins (Fig. 33-78). Skaggs et al. used
three lateral pins if the fracture was considered unstable with only two lateral pins. Haddad et al.
and Shim et al. used two pins laterally and one medially. In animal studies, Herzenberg et al.
found that medial and lateral pin fixation provides more stability than lateral pinning alone.
Wilkins recommended placing the initial pin medially so that it would aid in the reduction.

Fig. 33-78 Pinning of supracondylar fracture. A, Two lateral pins are inserted parallel, crossing fracture site and opposite medial
cortex. B, Divergent pins crossing same structures.
(Redrawn from Arino VL, Lluch EE, Ramirez AM, et al: Percutaneous fixation of supracondylar fractures of the humerus in
children, J Bone Joint Surg 59A:914, 1977.)

Graves and Beaty reported good results in 61 of 64 (95%) type III supracondylar fractures
treated with closed reduction and percutaneous pinning. Of the three fractures with
unsatisfactory results, two had been fixed in a varus position with medial and lateral pins, and
one fixed in good alignment with two lateral pins had lost fixation and position postoperatively.
They recommended medial and lateral pinning for added stability, but noted that if bony
landmarks cannot be palpated because of edema or if injury to the ulnar nerve with a medial pin
is of concern, lateral pinning alone may be preferred.
Transient or permanent ulnar nerve damage is rare in all reports. Royce et al. reported
neurological complications in four of 143 children (2.7%) after Kirschner wire fixation of
supracondylar fractures. Late ulnar neurapraxia occurred in two patients, and in the other two
patients nerve injuries (one ulnar and one radial) were caused by insertion of the Kirschner wires.
Skaggs et al. noted an incidence of 4% ulnar nerve palsy with use of a medial pin and 15% ulnar
nerve palsy when the elbow was acutely flexed with insertion of a medial pin. No ulnar nerve
palsies occurred when only lateral pins were used. These authors noted no difference in the
maintenance of the fracture reduction between the two fixation methods (medial and lateral), and
they recommend avoiding hyperflexion of the elbow during medial pin insertion. Lyons et al.
described ulnar nerve palsies after closed or open reduction and percutaneous pinning for
supracondylar fractures in 17 patients who had normal neurological examinations preoperatively.
Only four patients had the medial pins removed, and two others had explorations, which showed
no interruption of the nerve. Although all patients had complete return of function eventually,
many did not have complete return of function until after 4 months. The authors concluded that
nerve palsies occurring after percutaneous pinning of the supracondylar fracture usually resolve
spontaneously.
Because of these complications, Royce et al. recommended two lateral wires for fixation if the
fracture is stable after closed reduction. For comminuted or unstable fractures, medial and lateral
pins are used. To prevent nerve injury when a medial pin is used, Royce et al. and Gordon et al.
recommended using a small incision over the medial epicondyle and placing a drill guide on the
bone, through which the wire is inserted. The pins should be angulated superiorly approximately
40 degrees and posteriorly 10 degrees. The pins must continue into the opposite cortex to provide
solid fixation. Smooth pins are preferred. Some authors have advised placing the patient prone
with the elbow flexed rather than supine. We routinely use the supine position; however, we have
tried the prone position, and it does provide easier accessibility for pin placement, but orientation

of the fragments with the patient prone is difficult even when the image intensifier is being used.
We use two lateral pins and use a medial pin only if the fracture seems to be unstable
intraoperatively.
Percutaneous fixation after closed reduction has the advantage of providing excellent stability of
the supracondylar fracture in any position of the elbow (Fig. 33-79). The ultimate result is only
as good as the initial reduction, however, and does not depend on the placement of the pins. If
the fracture is not satisfactorily reduced and is held in an unsatisfactory position with pins, the
outcome is unsatisfactory, just as if no pin fixation were used. Aronson and Prager evaluated the
quality of reduction by measuring the Baumann angle after reduction; they accepted the
reduction if the Baumann angle of the fractured extremity was within 4 degrees of that of the
normal extremity. Although 21% of the fractures treated in this manner have a small degree of
residual cubitus varus, this is primarily because a poor position was accepted at the time of
pinning.

Fig. 33-79 Closed reduction and percutaneous pinning of supracondylar fracture. A and B, Severely displaced type III
supracondylar fracture. C and D, After closed reduction and percutaneous pinning. Smooth pins crossed and caught opposite cortex.
E and F, At 2 years, normal architecture including alignment.

Fig. 33-80 A, Rotational deformity and displacement evaluated with image intensification; anatomical correction of these
deformities must be obtained before elbow is fixed. B, Accurate position of pins ensured by image intensification during procedure.
(Redrawn from Aronson DD, Prager BI: Supracondylar fractures of the humerus in children: a modified technique for closed
pinning, Clin Orthop Relat Res 219:174, 1987.)

The flexion type of fracture occurs in only 2% to 3% of all supracondylar fractures, according to
Wilkins. In displaced flexion fractures, Fowles and Kassab noted that ulnar nerve lesions are
common, the reduction is more difficult, and the results are worse than in extension fractures.
They noted these anteriorly displaced fractures should be considered for accurate reduction and
percutaneous pinning.
AFTERTREATMENT

A long arm posterior plaster splint is worn for 3 weeks. Ulnar, radial, and median nerve function
should be checked after anesthesia. The pins are removed at 3 weeks, and another posterior splint
is applied. At 4 weeks, the splint is removed, intermittent active range-of-motion exercises are
started at home; they should be taught by the physical therapist to the child and the parent,
explaining that the child is to carry out his or her own active range-of-motion program. Passive
motion and forceful manipulative motion must be avoided in a child because they decrease the
range of motion and frighten the child.
AFTERTREATMENT

Aftertreatment is the same as for fixation with crossed pins (see Technique 33-14).
Open Reduction and Internal Fixation

Open reduction and internal fixation of supracondylar fractures are indicated when closed
reduction is unsatisfactory. In a type III displaced fracture with no cortical contact and
completely detached periosteum, or with the fracture fragment puckering or even penetrating
the skin (open fracture), a satisfactory closed reduction may be impossible. If after one or two
attempts at closed reduction with the child under general anesthesia the fragments cannot be
reduced and held by percutaneous pinning, open reduction and internal fixation are indicated.
According to Rasool and Naidoo, manipulation should be avoided in displaced type III
posterolateral supracondylar fractures with neurovascular deficit if clinical evidence indicates
that the fracture fragment has buttonholed through the brachialis muscle because the
neurovascular bundle may be trapped in the fracture site. If the elbow is so severely swollen that
a closed reduction cannot be maintained, olecranon traction can be used for several days,
followed by closed or, if necessary, open reduction. Other indications for open reduction include
open fractures that require irrigation and dbridement and fractures complicated by vascular
injury. Possible complications of open reduction include infection, vascular injury, myositis
ossificans, excessive callus formation with residual stiffness, and decreased range of motion.
Gruber and Hudson treated 31 difficult fractures with open reduction and internal fixation and
obtained satisfactory results even in the most severe fractures.
If open reduction and internal fixation are to be done, they should be performed emergently (<8
hours) or urgently (24 hours) or after the swelling has decreased, but not later than 5 days after
injury because the possibility of myositis ossificans apparently increases after that time. We
prefer an anterior or lateral approach. Kekomki et al. used an antecubital approach. Danielsson
and Pettersson used a medial approach. Kumar et al. used a medial approach in uncomplicated
cases. In patients with brachial artery compromise, an anteromedial approach was used, and in
patients with radial nerve palsy, lateral and medial approaches are recommended. Reitman et al.
recommended a medial approach for posterolaterally displaced fractures, a lateral approach for
posteromedially displaced or flexion-type fractures, and an anterior approach for posteriorly
displaced fractures. Exposure was through the disrupted periosteum so that the fractures were not
devascularized further or destabilized. When vascular compromise was present, the exposure was
anterior. In their report of 65 fractures, 46 fractures were irreducible, 16 had associated vascular
compromise, eight were open, and one had postreduction nerve palsy and nonanatomical
reduction. Twenty patients had brachialis entrapment usually associated with a transverse

fracture pattern with bayonet apposition, and nine patients had flexor-pronator origin entrapment
usually associated with an oblique fracture pattern extending from proximal-lateral to distalmedial with posterolateral displacement.
All studies reported good results using open reduction and internal fixation of severely displaced
fractures that could not be reduced or had significant vascular embarrassment. They also
recommended fasciotomy at the same time. Although rare, deep infections, nerve injuries,
myositis ossificans, cubitus varus, and limited elbow motion can occur.
AFTERTREATMENT

A posterior plaster splint is applied, and the radial pulse and neurological function are checked
after anesthesia. The pins are removed at 3 to 4 weeks, and an active, not passive, range-ofmotion program is started.
Early Complications

Neurological compromiseusually a neurapraxiais reported to occur in 3% to 22% of patients

with supracondylar fractures. Any of the peripheral nervesmedian, anterior interosseous,
radial, or ulnarmay be damaged, and mixed nerve lesions have been reported.
In a young child, it often is difficult to determine the neurological status of the upper extremity
postoperatively. We described a passive assist sign in which the child assists in carrying out
passive motor function of the involved hand using the contralateral hand. This test is useful
because it shows that the child understands the command (request), and that movement of the
part is not painful (without a compartment syndrome), but that the child cannot perform active
extension or flexion of the hand. When this sign is observed, it should be a warning that a nerve
deficit may be present.
Complete return of nerve function is usual, although this may require several months. Some
authors recommend surgical exploration if nerve function has not returned within 6 to 8 weeks of
reduction, whereas others recommend allowing a minimum of 2 to 4 months for resolution.
Continued nerve palsies after fracture may indicate nerve entrapment in the fracture callus. Culp
et al. reported 18 neural injuries in children with supracondylar humeral fractures, nine of which
resolved spontaneously an average of 2.5 months after injury. The remaining nine lesions were
explored at an average of 7.5 months after injury. Neurolysis was performed on eight, and one
completely lacerated nerve required grafting. These authors concluded that observation should be
the initial approach, but if clinical or electromyographic evidence of neural function is not
present at 5 months after injury, exploration and neurolysis are indicated. If the nerve is in
continuity, the prognosis after neurolysis is excellent. Amillo and Mora reported 25 neural
injuries at the elbow joint in children. Findings at surgery revealed discontinuity of the affected
nerve trunk in eight patients; 17 had a constrictive lesion with the nerve trunk in continuity. The
surgical technique in eight involved repair by interfascicular grafting and epineural suture, and in
17 repair was by neurolysis. Excellent results were found in nearly 80% of the continuous lesions
treated by neurolysis. In discontinuous lesions, 66% had excellent results with grafting.

Injury to the brachial artery occurs in 10% of patients with supracondylar fractures. Often the
problem is corrected after the fracture has been reduced and circulation returns to normal. Most
authors recommend close observation of vascular status after reduction; if circulation does not
return to normal (with the elbow flexed to <45 degrees) within about 5 minutes, consultation
with a vascular surgeon is recommended, and surgical exploration of the brachial artery may be
necessary. Besides the clinical signs of capillary refill and pulse, Doppler measurements or a
pulse oximeter have been recommended for evaluating circulation after reduction. Vasli reported
the use of Doppler waveform analysis in which the equipment is connected to a spectrum
analyzer, producing a picture of the velocity waveform that can be compared with the normal
extremity and interpreted easily. An arteriogram usually is not recommended, unless entrapment
or severing of the artery is suspected. Sabharwal et al. used a combination of segmental pressure
monitoring, color-flow duplex scanning, and magnetic resonance angiography in evaluating
patency of the brachial artery and collateral circulation across the elbow.
Shaw et al. reported Kirschner wire stabilization of supracondylar humeral fractures in 17
patients with signs and symptoms of vascular impairment. Arteriogram was not obtained in any
patient. In three patients in whom satisfactory blood supply to the hand was not present after
reduction, the brachial artery was explored, and circulation was restored. The remaining 14
patients had normal follow-up and no late vascular complications. Based on these findings, the
authors concluded that arteriography is not indicated before reduction of supracondylar fractures.
Garbuz et al. reported 22 children with a supracondylar fracture and an absent radial pulse. They
concluded that the initial treatment for children who have displaced supracondylar fractures with
an absent radial pulse should be closed reduction, Kirschner wire fixation, and immobilization in
less than 90 degrees of flexion. Children with a well-perfused hand but an absent radial pulse
after satisfactory closed reduction do not require routine exploration of the brachial artery.
Garbuz et al. and Rang did not recommend open reduction even if the distal pulse is absent after
reduction; they noted that the pulse usually returns within 1 or 2 weeks after reduction, often
quite suddenly. Unusually severe ischemic pain after reduction is an indication of vascular
problems. Disappearance of the radial pulse with attempts at fracture reduction (not in an acutely
flexed position) implies interposition of the artery in the fracture site and requires surgical
exploration.
Compartment syndrome is an uncommon but serious complication of supracondylar fractures.
Compartment syndromes occur as the result of hypoxic damage caused by interruption of the
circulation to the muscles. Any evidence of compartment syndrome requires vascular
consultation, compartment pressure measurements, and possibly fasciotomy. Battaglia et al.
noted in 29 children with supracondylar fractures that pressures in the deep volar compartment
were significantly elevated compared with pressures in other compartments. Pressures were
significantly higher closer to the elbow within each compartment. Fracture reduction did not
have a consistent immediate effect on pressures. The effect of elbow flexion on postreduction
pressures also was evaluated; flexion beyond 90 degrees produced significant pressure elevation
and should be avoided. Fasciotomy is recommended in the presence of clinical signs of
compartment syndrome, such as undue pain and a palpable firmness in the forearm. Wilkins
pointed out that the morbidity caused by fasciotomy is minimal, whereas that caused by an
untreated compartment syndrome is much greater. The general indications for fasciotomy are (1)
clinical signs such as demonstrable motor or sensory loss, (2) compartment pressures greater

than 35 mm Hg (slit or wick catheter technique) or greater than 40 mm Hg (needle technique),

and (3) interrupted arterial circulation to the extremity for more than 4 hours. Numerous
techniques have been advocated for fasciotomy of the forearm, but the standard Henry approach
(Fig. 33-81), as recommended by Eaton and Green and Gelberman et al., is used most often.

Fig. 33-81 A, Henry approach to volar aspect of forearm. B, Henry approach to superficial and deep compartments of forearm.
(Redrawn from Rorabeck CH: A practical approach to compartmental syndromes: III. Management, Instr Course Lect 33:102,
1983.)

Late Complications

Cubitus varus is the most common angular deformity that results from supracondylar fractures in
children. Cubitus valgus, although mentioned in the literature as causing tardy ulnar nerve palsy,
rarely occurs and is more often caused by nonunion of lateral condylar fractures. Beals noted that
the normal carrying angle increases from childhood to adulthood. For this reason, an increase in
valgus is not as cosmetically noticeable as a complete reversal to a varus position.
Several causes for cubitus varus have been suggested. Medial displacement and rotation of the
distal fragment have been cited most often, but Smith proved in his experimental studies that
varus tilting of the distal fragment was the most important cause of change in the carrying angle.
He also showed that rotation of the distal fragment does not cause cubitus varus, but is the most
important factor leading to medial tilt. Labelle et al. found varus tilting of the distal fragment to
be the cause of deformity in all of their patients with cubitus varus after supracondylar fracture.
Growth disturbance in the distal humerus, especially overgrowth of the lateral condyle, can
occur. Kasser noted that osteonecrosis and delayed growth of the trochlea, with relative
overgrowth of the normal lateral side of the distal humeral epiphysis, is a rare cause of
progressive cubitus varus deformity after supracondylar fracture. This progressive growth
abnormality cannot be prevented by stabilization of the distal fragment.
Davids et al. described lateral condylar fractures after malunited supracondylar fractures of the
humerus with subsequent cubitus varus deformity. They postulated that torsional moment and
shear force generated across the capitellar physis by a fall are increased with varus
malalignment. They suggested that posttraumatic cubitus varus may predispose a child to
subsequent lateral condylar fracture, and that this deformity should be viewed as more than just a
cosmetic problem.
Rotational malalignment may occur, but is not a significant deformity. Malrotation of the distal
humerus is compensated for to a large degree by the shoulder joint. As a result, the rotational
component in cubitus varus deformities is of little consequence, and all that is necessary for

correction of the cubitus varus deformity is a lateral closing wedge osteotomy. Occasionally, a
hyperextension deformity requires the addition of a flexion component.
Three basic types of osteotomies have been described: a medial opening wedge osteotomy with a
bone graft, an oblique osteotomy with derotation, and a lateral closing wedge osteotomy. King
and Secor described the medial opening wedge osteotomy. The disadvantages of this osteotomy
are that it gains length, which is not a problem in the upper extremity, and it creates a certain
amount of inherent instability. Lengthening the medial aspect of the humerus also can stretch and
damage the ulnar nerve, unless it is transposed anteriorly. An oblique osteotomy can be
beneficial, but the derotation described is probably unnecessary for the reasons given earlier.
Amspacher and Messenbaugh reported good results with an oblique osteotomy fixed with
cortical screws, but this procedure attempts to correct a two-plane deformity with one osteotomy
and requires rotation to correct the varus deformity. Uchida et al. described a three-dimensional
osteotomy for correction of cubitus varus deformity, in which medial and posterior tilt and
rotation of the distal fragment can be corrected if necessary (Fig. 33-82).

Fig. 33-82 Three-dimensional osteotomy for correction of cubitus varus deformity. Medial and posterior tilt is corrected. After
osteotomy, distal fragment is compacted with proximal fragment by adding external rotation using wedge of humeral cortex. Bone
graft is added if necessary.
(From Uchida Y, Ogata K, Sugioka Y: A new three-dimensional osteotomy for cubitus varus deformity after supracondylar fracture
of the humerus in children, J Pediatr Orthop 11:327, 1991.)

In our experience and that of others, a lateral closing wedge osteotomy is the easiest, the safest,
and inherently the most stable osteotomy. The primary difference in the types of lateral closing
wedge osteotomies are the methods of fixation, which include the use of two screws and a wire
attached between them, plate fixation, compression fixation, crossed Kirschner wires, and
staples; some have used no fixation. In the literature, Kirschner wire fixation is the most
prevalent method of holding the osteotomy. We also have used this method frequently.
Loosening of the fixation with recurrent deformity has been noted, however, as well as pin track
infections, osteomyelitis, skin slough, nerve palsy, and rarely aneurysm of the brachial artery.
Roach and Hernandez reported their results of corrective osteotomy for cubitus varus deformity
and noted that unstable internal fixation allowed the osteotomy fragments to slip into a varus
position in many patients. They attributed this to nonrigid internal fixation and recommended a
two-hole lateral plate and a percutaneous medial pin to increase stability.
Voss et al. described a uniplanar supracondylar closing wedge humeral osteotomy with preset
Kirschner wires for correction of posttraumatic cubitus varus deformity in 36 patients. They
described their technique as being simple with good correction and minimal complications (Fig.
33-83). Hui et al. described a laterally based closing wedge osteotomy through a medial incision.

They used image intensification and ulnar nerve isolation to prevent nerve complications in 11
children with cubitus varus (Fig. 33-84). None had a prominent lateral condyle, and the operative
scars were well concealed along the medial aspect of the elbow. One patient had transient ulnar
nerve paresis with residual varus.

Fig. 33-83 A, Wedge to be removed from affected arm is determined on preoperative radiograph. B, Preset Kirschner wires and
incomplete osteotomy.
(Redrawn from Voss FR, Kasser JR, Trepman E, et al: Uniplanar supracondylar humeral osteotomy with preset Kirschner wires for
post-traumatic cubitus varus, J Pediatr Orthop 14:471, 1994.)

Fig. 33-84 Kirschner wires delineate wedge to be made.

French used two parallel screws that are attached by a single figure-of-eight wire that is
tightened for fixation. Bellemore et al. reported their results using a modified French technique
in 27 children with cubitus varus after supracondylar fractures. Their primary indication was
unacceptable cosmetic deformity. They compared three sets of children who had a closing wedge
osteotomy: (1) children with external fixation alone, such as a plaster cast; (2) children with
Kirschner wire fixation; and (3) children with a modified French technique. Their results as to
loss of fixation, correction of deformity, and complications were superior using the modified
French technique, and they concluded that this method is safe and satisfactory (see Fig. 33-86).

Fig. 33-86 A and B, Clinical photograph and radiograph of moderate cubitus varus secondary to supracondylar fracture. C and D,
Clinical photograph and radiograph after French technique of supracondylar osteotomy.
(From Bellemore MC, Barrett IR, Middleton RWD: Supracondylar osteotomy of the humerus with correction of cubitus varus, J
Bone Joint Surg 66B:566, 1984.)

DeRosa and Graziano reported good and excellent results in 10 of 11 patients with a step-cut
osteotomy technique fixed with a single cortical screw (see Fig. 33-87). The one patient with a
poor result had persistent varus caused by unrecognized fracture of the cortical spike, which
caused loss of fixation. They reported no ulnar or radial nerve injuries, infections, nonunions, or
hypertrophic scars, and all patients retained preoperative ranges of motion. They concluded that
this osteotomy with single-screw fixation is a safe procedure that can correct multiple planes of
deformity, but they emphasized the importance of careful preoperative planning and special
attention to surgical detail.

Fig. 33-87 A, Osteotomy designed to correct cubitus varus deformity of 13 degrees. Distal fragment can be rotated to correct
additional deformity. B, After wedge removal and closure, screw is used for fixation.
(Redrawn from DeRosa GP, Graziano GP: A new osteotomy for cubitus varus, Clin Orthop Relat Res 236:160, 1988.)

If a more extensive osteotomy is needed, Kim et al. recommended the use of a simple step-cut
translation osteotomy and fixation with a Y-shaped humeral plate for firm fixation that allows
early movement of the joint. They treated cubitus varus or valgus secondary to supracondylar or
lateral condylar fractures in older children and young adults with this method and obtained good
clinical results (see Fig. 33-88).

Fig. 33-88 Step-cut translation osteotomy. A, After humerus-elbow-wrist angle is determined on anteroposterior radiograph, initial
transverse osteotomy line is made about 0.5 to 1 cm superior to olecranon fossa and perpendicular to axis of humerus. Triangular
area indicates area to be resected. B and C, Cubitus varus is corrected by rotating distal fragment and translating it medially after
completing initial transverse osteotomy. Triangular overlapping of proximal and distal humeral portions means that resection is
indicated. For cubitus varus, degree of correction increases as location of apex moves medially. D and E, Cubitus valgus is
corrected by rotating distal part of humerus medially and translating it laterally according to anatomical shape of normal elbow. F,
Fixation of osteotomy site.
(From Kim HT, Lee JS, Yoo CI: Management of cubitus varus and valgus, J Bone Joint Surg 87A:771, 2005.)

TECHNIQUE 33-17
Lateral Closing Wedge Osteotomy

Voss et al. (see Fig. 33-83)

After standard preparation and draping and inflation of the tourniquet, approach the
elbow through a lateral incision.

With fluoroscopic guidance, insert two Kirschner wires into the lateral condyle before
osteotomy, and advance them just distal to the planned distal cut (see Fig. 33-83A). Be
prepared to advance these proximally after the closing wedge osteotomy has been
made.

Make a closing wedge osteotomy laterally, leaving the medial cortex intact (see Fig.
33-83A and B).

Weaken the medial cortex using drill holes and a rongeur. Apply a forceful valgus
stress to complete the osteotomy with the forearm in pronation and the elbow flexed.

Close the osteotomy, and advance the Kirschner wires from the lateral condyle into
the medial cortex of the proximal fragment (see Fig. 33-83B).

Leave the wires buried under the skin. A third wire can be used if necessary for
stability.

Close the wound in layers, and splint the arm in 90 degrees of flexion and full
pronation.

AFTERTREATMENT

The wires are removed at approximately 6 to 8 weeks after surgery, and a range-of-motion
program is started.
TECHNIQUE 33-18
Lateral Closing Wedge Osteotomy (Medial Approach)

Place the patient supine, and apply a tourniquet.

Make a medial incision. Protect the ulnar nerve during the entire procedure. Also use
bipolar diathermy to prevent neural damage from leakage of diathermy current.
Expose the distal humeral metaphysis through the posteromedial intramuscular plane.

Insert Kirschner guidewires to delineate the wedge, and confirm with image
intensification (see Fig. 33-84).

Perform a laterally based closing wedge osteotomy with a power saw parallel to the
guidewires. Use an osteotome to complete the wedge excision at the far cortex.

Correct internal rotation of the distal fragment in all cases with severe deformity.
Translate the distal fragment medially to reduce the lateral condylar prominence.

Insert two crossed Kirschner wires percutaneously for fixation.

AFTERTREATMENT

The elbow is immobilized in a long-arm cast for 3 to 4 weeks, at the end of which the transfixing
Kirschner wires are removed, and protected elbow mobilization is initiated.

TECHNIQUE 33-19
French

Expose the distal humerus through a posterior longitudinal incision.

Split the triceps muscle and aponeurosis, detach the lateral half of the triceps from its
insertion, and reflect it proximally; the posterior surface and lateral border of the
humerus are now visible, and the ulnar nerve can be exposed.

Insert two drill points to act as guides in making the osteotomy, and check their
position by radiographs. Before the bone is divided, insert one screw above and one
screw below the drill points and parallel with them; insert the distal screw in the
anterior part of the distal fragment and the proximal screw in the posterior part of the
proximal fragment (Fig. 33-85).

Using a reciprocating motor saw, excise the wedge of bone from between the drill
points; divide the bone, but leave the periosteum intact medially to act as a hinge.

Approximate the cut surfaces, and correct the rotation deformity by rotating the distal
fragment externally until the distal screw is directly distal to the proximal screw.
Maintain this position by tightening a wire loop around the heads of the two screws.

Close the wound. With this type of fixation, the danger of damaging the physis is
minimized (Fig. 33-86).

Fig. 33-85 French closing wedge osteotomy using screw and wire fixation.
(Redrawn from French PR: Varus deformity of elbow following supracondylar fractures of the humerus in children, Lancet
2:439, 1959.)

AFTERTREATMENT

Aftertreatment is the same as for the modified French technique described next.
TECHNIQUE 33-20
French, Modified by Bellemore et al.

Make a posterolateral incision. Split the triceps, detach it from its insertion, and reflect
it proximally. Lift the middle two thirds of the muscle from the humerus
subperiosteally, protecting the neurovascular bundle.

Outline a laterally based wedge on the bone, ending just short of the medial cortex.
Place one screw in the lateral cortex proximally, above the proposed osteotomy, and
another distally, below the proposed osteotomy, at an angle approximating that of the
wedge to be resected. Resect the wedge with an oscillating saw, leaving its apex intact

at the medial cortex.

Extend the elbow, and close the wedge by fracturing the medial cortex, carefully
retaining a periosteal hinge.

Place the forearm in supination, and evaluate the carrying angle. If it is satisfactory,
tighten a wire loop around the heads of the screws to appose the cut surfaces firmly. If
necessary, correct any rotational deformity at this time by offsetting the distal screw.
Derotate the distal fragment, correct for rotational deformity, and align it with the
superior screw. Tighten the wires around the screw heads.

AFTERTREATMENT

The elbow is flexed 90 degrees with the forearm in neutral rotation in a posterior plastic splint
for 3 weeks. An active mobilization program is started at that time.
TECHNIQUE 33-21
Oblique Osteotomy with Derotation
Amspacher and Messenbaugh

With the patient prone and a pneumatic tourniquet in place, expose the elbow
posteriorly through a longitudinal incision that fashions a tongue of triceps fascia and
divides the triceps muscle in line with its fibers (see Technique 1-85). Expose
subperiosteally the supracondylar part of the humerus, protecting the radial and ulnar
nerves in the periphery of the wound.

Use an oscillating saw to make an oblique osteotomy about 3.8 cm proximal to the
distal end of the humerus, directing it from posteriorly above to anteriorly below;
complete it anteriorly with an osteotome. Tilt and rotate the distal fragment until the
internal rotation and cubitus varus have been corrected.

With the fragments in proper position, fix them with a screw inserted across the
middle of the osteotomy.

AFTERTREATMENT

The arm is immobilized in a long-arm splint or cast until union is solid at 4 to 6 weeks.
TECHNIQUE 33-22
Step-Cut Osteotomy
DeRosa and Graziano

With the patient prone and a tourniquet inflated, make a posterior approach to the
distal humerus (see Technique 1-85), and reflect the triceps tendon, protecting the
ulnar and radial nerves.

Using a template constructed preoperatively, make a lateral closing wedge osteotomy

in the metaphyseal region superior to the olecranon fossa. Place the apex of the
template (angle to be corrected) medially with the superior margin perpendicular to
the humeral shaft. Join the inferior margin to the superior margin to outline the

osteotomy (Fig. 33-87A). Remove the osteotomy wedge, leaving a lateral spike of
bone on the distal fragment. Some trimming of the lateral part of the proximal
fragment may be necessary for close approximation of the osteotomy.

Temporarily fix the osteotomy with crossed Kirschner wires, and examine the arm for
any remaining deformity. If necessary, correct rotational malalignment and
hyperextension deformity. Insert a cortical screw as a lag screw through the lateral
spike into the proximal fragment, and remove the Kirschner wires (Fig. 33-87B).

Close the wound in a routine manner, and apply a long-arm cast with the elbow in
slight flexion and the forearm in full supination.

AFTERTREATMENT

The cast is removed at 4 weeks, and active range-of-motion exercises are begun. A posterior
shell is used for protection between exercise periods until union is obtained.
AFTERTREATMENT

The arm is protected in a removable long-arm splint, brace, or cast with the elbow in 90 degrees
of flexion and the forearm in neutral rotation. Active range-of-motion exercises are started 2 to 3
weeks after the operation. When there is a flexion contracture of the elbow, passive assisted
range-of-motion exercises are implemented at 5 or 6 weeks postoperatively.
Separation of the Entire Distal Humeral Epiphysis

In young children, the entire distal humeral epiphysis may separate from the humerus in the same
area in which supracondylar fractures occur in older children. Although this area is thicker in
young children, it is weaker because it is epiphyseal cartilage (Fig. 33-89). DeLee et al. classified
these separations into three groups based on the age of the child and the degree of ossification of
the lateral condylar epiphysis. Group A fractures are seen in infants before the secondary
ossification center of the lateral condyle appears. These usually are Salter-Harris type I physeal
injuries. Because of the lack of ossification of the epiphysis, they can be mistaken for elbow
dislocations. According to Barrett et al. and others, these fractures can occur as a birth injury or
in newborns, but more important, they can be caused in this age group by child abuse. Group B
fractures occur in children 1 to 3 years old, when the ossification center of the lateral condylar
epiphysis is definitely present, and may be Salter-Harris type I or II fractures. Group C fractures
occur in older children and produce a large metaphyseal fragment, displaced most commonly
laterally, but possibly medially or posteriorly. Group A and B fractures almost always are
displaced medially or posteromedially.

Fig. 33-89 Horizontal lines indicate proximal area, where supracondylar fracture occurs, and distal area, where physeal fractureseparation occurs in wider part of distal humerus in younger age group.
(Redrawn from Mizuno K, Hirohata K, Kashiwagi D: Fracture-separation of the distal humeral epiphysis in young children, J Bone

Joint Surg 61A:570, 1979.)

Although separation of the entire epiphysis is rare, it must be differentiated from a dislocation of
the elbow in newborns and from a lateral condylar fracture, which usually is a Salter-Harris type
IV epiphyseal separation, in older children (Fig. 33-90). This complete separation usually is a
Salter-Harris type II fracture and does not require open reduction and internal fixation, in
contrast to most lateral condylar fractures. Radiographically, the radial head and proximal ulna
are displaced as a unit in relationship to the distal humerus in this epiphyseal fracture-separation
(Fig. 33-91). If this relationship, usually posteromedial, is seen and stays equidistant, the
diagnosis of separation of the entire distal humeral epiphysis should be considered. In older
children in whom the lateral epiphysis is ossified, a constant relationship is maintained between
the visible epiphysis and the radial head. If significant displacement, angulation, or rotation is
present, closed or open reduction and percutaneous pinning may be indicated.

Fig. 33-90 Elbow injuries that may be confused clinically. A, Normal elbow before three centers of ossification appear. B,
Separation of entire distal humeral epiphysis. C, Dislocation of elbow. D, Lateral condylar fracture.
(Redrawn from Mizuno K, Hirohata K, Kashiwagi D: Fracture-separation of the distal humeral epiphysis in young children, J Bone
Joint Surg 61A:570, 1979.)

Fig. 33-91 Fracture-separation of entire distal humeral epiphysis displaced posteromedially. Note radial head and proximal ulna
displacing as a unit in relation to distal humerus.
(Redrawn from Barrett WP, Almquist EA, Staheli LT: Fracture separation of the distal humeral epiphysis in the newborn, J Pediatr
Orthop 4:617, 1984.)

Yates and Sullivan, Akbarnia et al., Hansen et al., and others noted that arthrography or MRI is
more accurate than standard radiography in the diagnosis of some elbow injuries in young
children. They emphasized that distal humeral injuries in young children can be extremely
difficult to diagnose because the cartilaginous ossification centers may not be visible on the
radiographs; this is especially true in young children in whom the ossific nucleus of the

capitellum is not present. With arthrography, using single or double contrast, these authors were
able to confirm a diagnosis and alter treatment in numerous children. Some children thought to
have condylar fractures actually had transverse epiphyseal fracture-separations (Salter-Harris
type II fractures), and several thought to have intraarticular fractures had supracondylar fractures.
Some children originally considered for surgery were treated nonoperatively after an accurate
arthrographic diagnosis. Because they are noninvasive procedures, ultrasonography and MRI are
being used to identify nonossified fracture fragments and to establish the diagnosis. This physeal
separation injury is included here to emphasize that open reduction and internal fixation are not
always necessary because the separation is a Salter-Harris type I or II fracture and would
remodel, according to DeLee et al., because it is in the plane of flexion and extension of the
elbow. Wilkins showed that most of these fractures remodel without residual deformity, and he
stated that many open reductions with internal fixation occurred because these injuries were
confused with supracondylar or lateral condylar fractures.
In a small child, a group A fracture usually can be reduced satisfactorily and immobilized in a
posterior plaster splint. In an older child with a group C fracture, treatment recommendations
include closed reduction with the patient under general anesthesia and cast immobilization. If the
fracture is displaced medially, a pronated position probably should be used after reduction. After
satisfactory reduction, a long-arm cast or a posterior plaster splint should be applied if the
separation is stable. If the fracture is unstable after satisfactory closed reduction, smooth pins can
be used to stabilize the fracture, similar to the treatment for supracondylar fractures, to prevent
the complications of malunion or nonunion (see Closed Reduction and Percutareous Pinning
earlier). Holda, Manoli, and LaMont noted in seven patients that the separated fragment was
almost always medially displaced, and five had mild cubitus varus. Because of this, they
recommended treating these fractures aggressively, as with displaced supracondylar fractures, to
prevent cubitus varus from a malunion. If a satisfactory reduction could not be obtained or
maintained, open reduction and internal fixation with pins were done. Mizuno et al., before the
report of DeLee et al., reported six patients in whom open reduction and internal fixation were
done, in some because of confusion over the diagnosis. They recommended an arthrogram to aid
in diagnosis and gentle closed reduction; if reduction was unsatisfactory, open reduction and
internal fixation with smooth pins were done. Because this is a Salter-Harris type I or II fracture
with remodeling potential, open reduction and internal fixation are indicated only in fractures
with severe displacement that cannot be reduced and held by closed methods.
TECHNIQUE 33-24
Open Reduction and Internal Fixation
Mizuno et al.

Approach the distal humerus through a long posterior longitudinal incision. Carry the
soft-tissue dissection down to the subperiosteal area, and retract the ulnar nerve
medially. Detach the triceps insertion with a cartilaginous piece of the olecranon, and
reflect it posteriorly and superiorly to expose the fracture.

Clean away any debris, including small hematomas and fracture fragments. Expose
both fragments, and gently reduce the epiphyseal separation.

Insert crossed Kirschner wires through the lateral and medial humeral condyles as for

a supracondylar fracture.

Irrigate the wound copiously. Apply a posterior splint with the elbow at 90 degrees of
flexion. Check the radial pulse.

AFTERTREATMENT

Aftertreatment is the same as for open reduction of supracondylar fractures (see Technique 3316).
TECHNIQUE 33-16
Anterior Approach

Prepare and drape the arm in the usual fashion with the patient supine.

Make a curved incision over the lateral humeral condyle, beginning about 2 cm distal
to the olecranon and carrying it proximally for about 6 cm above the condyle. Dissect
the soft tissue, including the anconeus and common extensor origins, and retract these
anteriorly and posteriorly. Ensure the radial nerve is retracted posteriorly. A large
hematoma may require evacuation before the fracture can be seen.

If an anterior approach is to be used, develop a plane between the biceps and

brachialis tendons. Release the biceps aponeurosis, while protecting the brachial
artery. Retract the biceps and brachialis muscle medially and the brachioradialis
laterally. Protect the radial nerve and posterior interosseous artery.

Observe the supracondylar fragment, and note its alignment with the proximal
fragment. Use a small curet to remove any hematoma at the fracture site. Note any
interdigitations on the ends of the bone, and by matching them, reduce the fracture.

Use two crossed Steinmann pins in a manner similar to that described for
percutaneous pinning. Image intensification simplifies pin placement, as does a power
drill. Cut the pins off outside the skin for easy removal later.

Close the incision in layers.