INTRODUCTION

Supracondylar fracture of humerus is an extra-articular fracture occurring

in the distal metaphyseal region of humerus and do not involve the physes. It is

almost exclusively a fracture of the immature skeleton, seen in children and young

teenagers.1 Their correct management is necessary in order to avoid catastrophic

complications as these are the most common paediatric fractures requiring

surgery.2

The metaphyseal flare of the distal humerus connects the diaphysis of the

humeral shaft to the epiphysis. The metaphysis is thinned both anteriorly due to

coronoid fossa and posteriorly due to olecranon fossa, to accommodate the ulna

during flexion and extension respectively. These fossae are separated only by a

thin bony septum so this configuration predisposes to injury at distal humerus level

and represents a zone of weakness.

The olecranon engages with the olecranon fossa and acts as a fulcrum, the

bone begins to break at first anteriorly, and the fracture progresses posteriorly. If

the energy is high, the posterior cortex disrupts, and finally complete posterior

displacement of the distal fragment occurs with the posterior periosteum acting as

a hinge. This is the mechanism of extension-type fractures, which represent 97% to

99% of the total fractures.3

 Flexion injuries result from direct trauma to the posterior aspect of the

distal humerus or falling onto a flexed elbow. These type of fracture represents 1%

to 3% of cases.4 Here the anterior periosteum acts as a hinge, and the progression

of the injury goes from the posterior to the anterior part of the distal humerus.

Supracondylar fractures of the elbow account for 16.6% of all fractures in

paediatric patients.5 Supracondylar fractures of the humerus account for 55%to

80% of total elbow fractures in children and up to 2/3rd of paediatric elbow injuries

requiring hospitalization.6 Their incidence has been estimated at 177.3 per 100

000.7 These are the second most frequent of upper limb fractures after distal radius

fractures.8,9 Approximately 5 to 10 % of children have an associated ipsilateral

distal radius fracture, forearm and proximal humerus fracture.

Supracondylar fractures usually occur as a result of a fall from height or

from sports. These fractures can occur throughout childhood, the median age is

approximately six years, with higher incidence between five and eight years.3

Following this there is decline in incidence in both sexes equally. This fracture is

more common in males.10,11

The fracture has a left sided predominance because when a child

falls from a height or while playing sports, he/she makes an attempt to hold on

to something with the dominant arm and thus lands on ground with the non-
dominant arm thus affecting the non-dominant arm more frequently.12 The non-

dominant arm is involved 1.5 times more frequently.3

Gartland classified supracondylar fractures in 195913 with a classification

system that differentiates extension supracondylar fractures according to the degree

of displacement of the distal fracture fragment. The most common mechanism of

injury is when a patient falls onto an outstretched hand with the arm fully

extended.

According to Gartland, Type I is undisplaced or minimally displaced

fracture, Type II is displaced but incomplete with an intact posterior cortex there

may also be coronal angulation and medial column disruption. In 1984, Wilkins14

modified Gartland’s classification specifically with reference to Type II and III

fractures. Type II was subdivided into Type IIA - stable with posterior angulation,

and type IIB – unstable posteriorly angulated and rotated. Type III fractures are

displaced fractures with no cortical contact.

This can be further subdivided into IIIA- posteromedial displacement and

IIIB- posterolateral displacement. A further modification of the Gartland

classification has been described; Type IV fracture with multi-directional

instability.15 Type IV fractures are usually a result of high energy injury and are

unstable in both flexion and extension.

 An alternative classification system described in 2006 AO Pediatric

Comprehensive classification classified these fracture with regard to the degree of

displacement at four levels. Type I- no displacement; Type II- displacement in one

plane; Type III- rotation of the distal fragment with displacement in two planes;

Type IV- rotation with displacement in three planes.16

Elbow deformity in the form of S shaped deformity is usually the most

striking aspect in displaced extension-type fractures. Extensive ecchymosis, soft-

tissue swelling and skin puckering indicate severe trauma. Skin puckering appears

when the proximal fragment transects the brachialis muscle, ‘puckering’ the deep

dermis. For this reason, when skin puckering is present, severe displacement and

soft-tissue damage and neurovascular compromise should be suspected.

Concomitant upper-limb fractures not only cause a more severe trauma and

instability, but also create increased difficulty in treatment and an increased

incidence of neurovascular injuries or compartment syndrome.17,18,19

 Neurovascular examination should be performed in detail. Vascular

compromise exists in up to 10% to 20% of displaced fractures.6,20,21 Vascular

compromise can be caused by arterial rupture, kinking, compression, spasm or

intimal lesion and incidence increases depending on the degree of dislocation.22

The vascular status may be classified into one of the three categories

1) Hand well perfused (warm and red), radial pulse present.

2) Hand well perfused (warm and red), radial pulse absent.

3) Hand poorly perfused (cool and blue or blanched), radial pulse absent.

The relative incidence of nerve injuries after supracondylar humerus

fractures is reported with 12–20% due to traumatic tenting or entrapment and with

2–6.5% iatrogenic lesions during closed reposition or percutaneous pinning.23 In

neurological examination the median and anterior interosseous nerve (AIN) is most

commonly involved and assessed with active flexion of the distal interphalangeal

joint of index and thumb. For the radial nerve, thumb extension is done, for ulnar

nerve assessment, first interosseous contraction is done. The risk of specific nerve

injury with regard to the median, anterior interosseous, radial, posterior

interosseous and ulnar nerves has not been well-defined in the literature. Individual

reports of neurapraxia have ranged from 0% up to 17% for median, 21% for

anterior interosseus nerve, 10% for radial nerve, 4% for posterior interosseus

nerve, and 12% for ulnar nerve respectively.24,25,26,27

 Standard antero-posterior and lateral radiographs of the elbow are taken.

Bauman’s angle and radio capitellar line are usually looked for in the antero-

posterior radiographs and fat pads and anterior humeral line is visualized in the

lateral radiographs. Treatment includes both non-operative and operative methods

with the goal of restoring normal elbow anatomy and function.

The initial management of supracondylar humerus fractures in

emergency conditions includes splint immobilization of the extremity. In displaced

fractures, however, open or closed reduction can be performed. Cast

immobilization, traction, and percutaneous pin fixation can be performed following

closed reduction.28 Open reduction should be performed in the presence of

circulatory problems due to fracture fragments, open fracture, failure in closed

reduction, accompanying forearm fractures or irreducible fractures.29,30,31

Closed reduction and percutaneous pinning may involve postoperative

complications such as cubitus varus deformity. Cubitus varus deformity is the most

common residual deformity after supracondylar fracture of the humerus in

children.32,33,34

Open reduction provides precise anatomical reduction by enabling the

direct removal of the trapped structures.35,36 However, open reduction internal

fixation reportedly results in several complications, including a higher risk of

infection than in closed reduction, restriction of range of motion, and possible

unsightly and or painful scarring.35,37

Therefore this study was conducted to study the functional and

radiological outcome after surgical management of supracondylar fracture humerus

in children using percutaneous pinning or open reduction internal fixation with

Kirschner wires is a systematic randomized comparative study between the

functional and radiological outcomes of the above procedure.

 REVIEW OF LITERATURE

In 1634- Pare mentioned about supracondylar fracture of humerus in his

“Treatise of Fracture”.

DeSault, who was the Chief to Surgery in 1805 emphasized the importance

of alignment of supracondylar fracture in obtaining functional results.38

In 1893 Smith noted that extension type of supracondylar fracture of

humerus should be reduced with elbow in full flexion and pronation.39

In 1948 Swenson40 introduced his percutaneous pinning method. He found

that the use of transfixing wires in the treatment of difficult cases of supracondylar

fractures of the humerus in children is especially useful for patients who have such

extensive swelling about the elbow, and that immobilization in acute flexion,

following a closed reduction, cannot be carried out. Traction by olecranon wire is

not necessary, since the transfixing wires maintain the original reduction until

union occurs. The danger of Volkmann's ischemia is lessened in such cases, since

splinting in acute flexion is not necessary. Richard Volkman described the dreaded

complication of ischemic contracture.

In 1953 Atten Borough41 studied remodeling of humerus following this

fracture and concluded that unlike lateral and AP shift, rotation and tilt are also

corrected by remodeling. The aim should be a perfect anatomical repositioning of

the fragments attained by closed reduction. Open reduction will help gaining

anatomic reduction but will be followed by varying degrees of stiffness in the

elbow. He in his study concluded that remodeling is rapid and it will restore almost

normal anatomy and good function even with severely displaced fractures.

In 1951 Vernon P. Thompson stated that it is the fracture above the

elbow joint and if the surgeon does not manhandle the joint with repeated forcible

manipulations or insults the soft tissue by performing an open surgery there may be

useful elbow motion even if there is residual deformity present.

In 1956 Lawrance, in his review of 100 cases concluded that

absent radial pulse alone without other signs of ischemia are not always of

serious consequence, but it should be regarded as a warning sign.

In 1959 French studied varus deformity following this fracture and

found that it is the commonest late deformity in supracondylar fracture of humerus

and is caused by failure to correct rotational displacement of distal fragment

thereby concluding that effect of varus tilt is increased by internal rotation

deformity.42

In 1961 Casiano showed that following percutaneous pinning, leaving pins

protruding outside the skin produced no increased risk of infection and facilitates

easy removal.43
 In 1965 Sherwin and Staples showed that following supracondylar fracture

brachial artery, brachial vein, median nerve can be dislodged at the fracture site.44

Accompanied by the brachial vein and median nerve, the artery comes to lie

posterior to the distal end of the proximal fragment of the humerus and to pass

through the fracture site before resuming its normal situation anterior to the distal

fragment of humerus. In this position, the artery is vulnerable and vasospasm or

actual direct damage may occur on attempted manipulation of the fracture. When

faced with these clinical findings, urgent exploration of the brachial artery through

the ante cubital space should be carried out.

Smith Lyman in 1967 observed that it is difficult to assess the rotation

and alignment of distal fragment on X-ray therefore open reduction internal

fixation with crossed K wires should be the method of choice.45 Change in the

carrying angle of the elbow after supracondylar fractures of the humerus is caused

by medial or lateral angulation of the distal fragment. The angulation may be

obscured on roentgenograms, but on inspection of the posterior surface of the

elbow in the flexed position it may be obvious clinically.

According to Flynn JC et al, in 1974 concluded that percutaneous

pinning after closed reduction of supracondylar fractures has several benefits.

Duration of hospital stay is reduced. The fracture can be splinted in a safe

position without any fear of loss of reduction. The risk of compartment

syndrome also reduces. Reduction and percutaneous pinning of these troublesome

fractures provided stability, vascular safety, simplified management, and

consistently satisfactory appearance and function of the elbow in seventy-two

patients. Difficulty in mastering the technique was the only major disadvantage,

and was overcome by using a simple holding bracket during the pinning. The

study also showed that rotation of distal fragment doesn’t result in varus

deformity but predisposes to varus tilt and angulation of distal fragment which

produces the deformity, and remodeling also cannot correct it.46 The study showed

that the fixation with K-wires did not disturb the growth potential of the distal end

of the humerus. Cubitus varus, when it occurred, was a result of imperfect

reduction rather than growth disturbance.

Soltanpur et al devised an indigenous method for reducing flexion

type of supracondylar fracture of humerus in 1978. In this method the

condylar mass is pushed posteriorly along the axis of the forearm and the

hand is rotated to full supination while the elbow is held in flexion to correct

deformities.47 Flexion-type supracondylar fractures are challenging to treat

because, unlike extension-type fractures, it is difficult to take advantage of the

intact periosteal hinge to stabilize the fracture fragments during percutaneous

pinning. The ‘push–pull’ is a safe, effective, and easy method to treat unstable
flexion-type supracondylar fractures in children with good radiographic

postoperative outcomes.

Lewis Zionts, Harry A, Mckellop and Richard Hathaway48 in their

study of supracondylar fractures of the humerus found using a human cadaver

model, they measured the resistance to internal rotation of the distal fragment of

simulated supracondylar fractures, fixed with four different configurations of pins.

The maximum stability was provided by two crossed pins placed from the medial

and lateral condyles. In comparsion the torque required to produce 10 degrees of

rotation averaged 37 per cent less with use of two lateral parallel pins and 80 per

cent less with use of two lateral crossed pins (p < 0.05 for both which was

significant). The average torque required to produce 10 degrees of rotation with

use of three lateral pins was 25 percent less than with use of two medial and lateral

crossed pins, although the difference was not significant. The two crossed pins

placed from the medial and lateral condyles provided the greatest resistance to

gross rotational displacement, this method may be preferable for most fractures.

But they concluded that alternative of three lateral pins, or even two lateral parallel

pins, may be considered when marked swelling of the elbow makes safe placement

of a medial pin difficult. Fixation with two lateral crossed pins should be avoided.

In a population based study during 2000-2009 Eira Kuoppala et al found

out that flexion type supracondylar fractures of humerus although rare are usually
severe type of injuries resulting in both short and long term complications

regardless of the type of original surgical fixation used.49 During the study period,

the rate of flexion-type fractures was 1.2% (7 out of 606 supracondylar humeral

fractures). The mean annual incidence was 0.8 per 105. Four fractures were

multidirectionally unstable, according to the Gartland and Wilkins classification.

All but one were operatively treated. Reduced range of motion, changed carrying

angle, and ulnar nerve irritation were the most frequent short-term complications.

Finally, in the long-term follow-up, mean carrying angle was 50% more in injured

elbows (21°) than in uninjured elbows (14°). 4 patients out of the 7 achieved a

satisfactory long-term outcome according to Flynn’s criteria.

David Skaggs et al in 2001 in their study concluded that lateral pins alone

provide adequate fixation of unstable supracondylar fractures of the humerus.50 The

use of only lateral pins prevents iatrogenic injury to the ulnar nerve. If a medial pin

is used, the elbow should not be hyperflexed during its insertion. A crossed pin

configuration is believed to be mechanically more stable than lateral pins alone;

however, the ulnar nerve can be injured with the use of a medial pin. It has not

been proved that the added stability of a medial pin is clinically necessary since, in

young children, pin fixation is always augmented with immobilization in a splint or

cast. He in his retrospective study reviewed the results of reduction and Kirschner

wire fixation of 345 extension-type supracondylar fractures in children.

Maintenance of fracture reduction and evidence of ulnar nerve injury were

evaluated in relation to pin configuration and fracture pattern. There was no

difference with regard to maintenance of fracture reduction, as seen on antero-

posterior and lateral radiographs, between the crossed pins and the lateral pins.

Ulnar nerve injury was not seen in the 125 patients in whom only lateral pins were

used. The use of a medial pin was associated with ulnar nerve injury in 4% (six) of

149 patients in whom the pin was applied without hyperflexion of the elbow and in

15% (eleven) of seventy one in whom the medial pin was applied with the elbow

hyperflexed. Two years after the pinning, one of the seventeen children with ulnar

nerve injury had persistent motor weakness and a sensory deficit.

Shim Jong et al in 2002 treated this fracture with three percutaneous pin

fixation, two laterally and one medially and advised that fixing fracture with two

lateral pins first allows elbow to be extended for safe placement of medial pins.51

The authors investigated 63 consecutive patients (average age 6 years 6 months)

who underwent cross-fixation with three Kirschner wires after reduction of a

completely displaced supracondylar fracture (type 3) of the humerus. All fractures

were reduced and fixed by inserting two parallel Kirschner wires in the lateral side,

followed by one crossed medial Kirschner wire under fluoroscopic guidance.

Lateral pins were inserted in parallel or divergent fashion to ensure stability. With

a medial crossed pin insertion, the elbow was carefully extended for easy palpation
and protection of the ulnar nerve without displacing the reduced fracture. Skin

incision for detection of the ulnar nerve before medial K wire fixation was not

required. There was no iatrogenic ulnar nerve injury caused by the K wires. The

clinical outcome of the surgery after an average of 17 months was investigated: 62

(98.4%) of the 63 patients studied showed a “satisfactory” result. Cross-fixation

with three K wires is considered an effective and safe method for avoiding ulnar

nerve injury in the treatment of a completely displaced supracondylar fracture of

the humerus in children.

RS Ayenger, R Singh, CM Badole, KR Patond in 2003 concluded that

skeletal traction had no added advantage over immediate closed reduction and

percutaneous pinning. Moreover it required a longer hospital stay. Infection and

joint stiffness was also common in patients undergoing traction. The author

suggested that traction should be given only in patients with gross elbow swelling

and only closed reduction and percutaneous pinning should be preferred in grade II

and grade III displaced supracondylar fracture of humerus.52

Reza Omid, Paul D. Choi and David L. Skaggs in 2008 concluded that

operative fixation is indicated for most type-II and III supracondylar humeral

fractures in order to prevent malunion. In case of subtle medial comminution, if

treated non-operatively, these fracture were likely to lead to unacceptable varus

malunion. Computed tomography angiography was not indicated for a pulseless

limb, as it delayed fracture reduction, which usually corrects the vascular problem.

They advised that a high index of suspicion was necessary to avoid missing an

impending compartment syndrome, especially when there was a concomitant

forearm fracture or when there was a median nerve injury, which may mask the

symptoms of compartment syndrome in the limb. Along with these they concluded

that lateral entry pins have been shown, in biomechanical and clinical studies, to be

as stable as cross pinning if they were well spaced at the fracture line, and they are

not associated with the risk of iatrogenic ulnar nerve injury.53

In 2010 Jessica C. et al54 did a meta-analysis in 5154 patients.

Among these patients, traumatic neurapraxia occurred in 11.3% patients.

Anterior inter osseous nerve injury predominated in extension-type fractures,

representing 34.1% of associated neurapraxias; meanwhile, ulnar neuropathy

occurred most frequently in flexion-type injuries, representing 91.3% of

associated neurapraxias. Nerve injury induced by lateral-only pinning

occurred at a weighted event rate of 3.4%, while the introduction of a medial

pin elicited neurapraxia in 4.1% patients. Lateral pinning carried increased

risk of median neuropathy. They concluded that nerve injury associated with

extension type fractures, anterior interosseous neurapraxia ranks highest,

whereas of flexion-type neuropathy, ulnar nerve injury predominates. Medial

pinning carries the greater overall risk of nerve injury as compared with
 lateral-only pinning and that the ulnar nerve is at risk of injury in medially

pinned patients.

In 2013 Lukraz M55 did a study which included 67 patients with injuries

of the arterials in supracondylar fractures of the humerus. In 32 (47 %) patients,

there was lack of radial pulse with cold and pale hand syndrome before reduction.

In 26 of them, all those symptoms disappeared immediately after closed reduction.

Radial pulse returned in a mean time of 25 min (range 2–65 min). In other 6,

pulseless pink hand with lack of radial pulse after reduction was observed.

However, in all patients, proper capillary refill with sufficient oxygen saturation on

the index finger of affected limb recovered immediately after anatomical reduction

in the fracture. All those children were treated conservatively with good results no

more than 3 h after the injury (mean 1 hour and 10 min). Reduction and

stabilization of the fracture by two K-wires (lateral or medial and lateral) were

performed under general anesthesia and then confirmed by anteroposterior and

lateral X-ray views. In the follow-up study, very good or good results (according to

Flynn’s criteria) were achieved in all 32 patients. In those 6 patients with pulseless

pink hand symptoms, radial pulse returned no later than on third day after injury.

Good or very good vascular status was achieved confirmed by ultrasound

examination of the artery during follow-up. No growth disturbances of the limb or

some late vascular insufficiency was observed the remaining 35 (53 %) patients
were treated surgically. Surgical exploration of the brachial artery was performed

in 34 patients within no more than 3 hour after injury (mean 2 hour and 10 min).

Pulseless, pale and cold hand syndrome with severe pain in the upper limb region

was identified. In all of them, the initial attempt at a closed reduction was

unsuccessful in restoring the radial pulse and proper capillary refill with oxygen

saturation on the index finger of the affected limb. He concluded that children who,

after satisfactory closed reduction, have a well-perfused hand but absent radial

pulse do not require routine exploration of the brachial artery. However,

anatomical reduction in the fracture is mandatory. Conservative treatment should

be applied unless additional signs of vascular compromise appear. Thus, in case of

blood circulation disturbance, the exploration of cubital fossa should be performed

only if circulation is not restored after closed reduction. In such case, surgical

exploration of the artery is recommended.

Eduardo N. Novais, Marco A.P Andrade, Davi C. Gomes in 2013

concluded in their study that to avoid aggressive and frustrating attempts of closed

reduction and further open reduction of multidirectionally unstable (type IV)

supracondylar fracture of humerus in children, joystick pinning can be done during

pinning technique.56 Multi directionally unstable supracondylar fracture of the

distal humerus presents with severe instability in both flexion and extension. They

in their retrospective study evaluated 8 children (4 boys and 4 girls) with a mean
age at presentation of 7.6 years (range, 5.3 to 10.9 years) who underwent closed

reduction and percutaneous fixation using a joystick technique for the treatment of

multi directionally unstable supracondylar fractures. Clinical and functional results

were assessed by the system described by Flynn. After an average follow-up of

14.5 months (range 12 to 24 months), there was no difference between the injured

upper extremity and the contralateral side according to cosmetic, functional, and

radiographic evaluation. There was no complication such as pin-site infection, loss

of fixation, mal-union, cubitus varus, iatrogenic nerve injury, or need for further

surgery.

KC Bhogendra Bahadur et al in 2018 in their study concluded that closed

or open reduction doesn’t have significant advantage on function and union rate

among one another but closed reduction and percutaneous pinning with limited

attempt should be preferred to open reduction and internal fixation with Kirschner

wire for the advantage of reducing surgical time, avoiding surgical scar and

exposure to anaesthetic agents.57 Retrospective comparison study was done on

eighty seven cases of Type III supracondylar fracture of distal humerus underwent

operative procedure. Fifty four (54) cases underwent CRPP and 33 cases were

managed with ORIF with Kirschner wire, and they were followed up till 6 months

post-operatively. The mean time for radiological union in patient who underwent

CRPP was 4.37±0.94 weeks and that for the patient who underwent ORIF was
4.45±0.13 weeks, 83.3% of CRPP group and 78.8% in ORIF group had excellent

functional outcome and only 3% in ORIF group had poor functional outcome.

Saarinen Aj, Helenius I.et al in 2019 in their study of the effect of surgical

speciality on outcomes of pediatric supracondylar fracture of humerus concluded

that risk of unacceptable reduction and complications were significantly higher in

children operated on by pediatric surgeons rather than orthopaedic surgeons with

more incidence of open reductions among pediatric surgeons.58A retrospective

review of 108 children (0 to 16 years) treated for displaced humeral supracondylar

fractures (Gartland II or III) requiring closed or open reduction under general

anaesthesia were included. The patient charts and radiographs were evaluated to

identify type, grade and neurovascular complications. Operative performance

(operative time, quality of reduction, need for open reduction, complications) of

residents, paediatric surgeons and orthopaedic surgeons were evaluated. It was

concluded that there was statistically significant differences in the incidence of

unacceptable reduction, complications and the usage of crossed pin configuration

between the surgical specialties. Patients would benefit from the practice of

assigning the operative treatment of displaced supracondylar fractures to

orthopaedic surgeons.

Ali M Siddiq K Makki MKH et al in 2020 in their study of the outcome of

percutaneous pinning among children with displaced supracondylar fracture of

humerus concluded that percutaneous pinning is an effective procedure in type III

supracondylar fractures of the humerus in children with few complications like less

operative trauma and no scar formation.59All 254 patients were diagnosed

radiographically, and those presenting within 1st week of injury, were included,

and patients with a history of previous surgery or trauma over the arm, compound

fracture and neurovascular compromise, were excluded. All patients were operated

for the fracture (closed reduction and pinning under image intensifier).The follow

up was completed at 6 weeks postoperatively by Flynn's criteria. Out of 254

patients 59 (23.2%) showed excellent, 94 (37%) good, 49 (19.3%) fair and 52

(20.4%) poor outcome based on Flynn’s criteria.

In 2020 Vito Pavone60 et al concluded that in surgical pinning of

supracondylar fracture of humerus, supine intraoperative positioning is not

superior to prone as in both groups satisfying outcome were achieved. The supine

position is the ordinary placement during surgery but recent findings have shown

prone position as an efficient alternative. Despite a more challenged airway

management prone position achieves a fracture reduction more easily to perform

and, at the same time, a safer pins placement can be performed avoiding excess of

elbow flexion. Surgery is usually performed in the supine position; otherwise the

prone position allows an easier fracture reduction and a safe placement of pins.

The aim of study was to compare the clinical and radiographic results of the
treatment of displaced supracondylar fracture of humerus, comparing two different

intra-operative positioning. All treated subjects were clinically evaluated according

to Flynn’s criteria and Mayo elbow performance score, and radiographically,

including the measurement of the Baumann angle. The authors concluded that it is

surgical experience that is crucial in positioning.

K. Chandra Sekhar Rao61 in 2020 did a comparative study in 30 patients

with supracondylar fracture of humerus. Closed reduction was done in 15 patients

and 15 patients were treated by open reduction. Outcome was calculated on basis

of Flynn scale. 26 patients stayed in sufficient range of motion, 4 patients had

insufficient motion, of which 3 were treated with closed reduction and 1 with open

reduction. Twenty six (86.66%) of 30 patients showed good to excellent results

and four (13.33%) showed mediocre to poor results. Out of four cases, one had

underwent closed reduction and three had underwent open reduction. They

concluded that there were no significant differences in postoperative reliability,

functional outcomes and complications between percutaneous pinning and open

cross-wiring reduction. It is assumed that these findings support the use of

percutaneous pinning in the first section, which is easier and less violent than the

open reduction.
 AIMS AND OBJECTIVES

1. To evaluate comparative functional and radiological outcome in

supracondylar fracture humerus patients after closed reduction percutaneous

pinning and open reduction internal fixation with Kirschner wires.

2. To evaluate the complications of the procedure by both treatment options.

 MATERIALS AND METHOD

A prospective systematic randomized comparative study “Comparison of

functional and radiological outcome in supracondylar fracture humerus treated by

closed reduction percutaneous pinning and open reduction internal fixation in

children” was conducted in Department of Orthopaedic Surgery, Indira Gandhi

Medical College Shimla (H.P.) over a period of one year from September 2020 to

September 2021. A total of 30 admitted and operated cases of fracture

supracondylar humerus were included in this study and were systematically

allocated randomly into two groups.

All these patients were called for follow-up, radiological and functional

outcomes were evaluated after proper analysis as per protocol and assessment of

disability and health was done using appropriate instruments as mentioned in the

proforma and annexure.

Inclusion criteria

1 Patients having supracondylar fracture of humerus Gartland Type IIIA

and Type IIIB.

2 Age group from 3 to 16 years.

3 Patients with or without neurovascular involvement.

Exclusion criteria

1 Patients in whom surgery was contraindicated.

2 Patients having open supracondylar fracture of humerus.

3 Patients with associated ipsilateral upper limb fracture.

Figure 1: Clinical image demonstrating Figure 2: Clinical image demonstrating

blisters and swelling over the anterior blisters over medial aspect of elbow in
aspect of elbow following supracondylar fracture of humerus
supracondylar fracture of humerus Gartland type III
Gartland type III

On arrival of the patient in emergency, history was elicited from patient

and closed attendant.Patient was assessed as per annexure IV and admitted (Figure

1,2). Blood investigations and radiological assessment were done. Investigations

included complete haemogram with emphasis on the values of haemoglobin, red

cell count, haematocrit, total and differential leucocyte count, platelet count. Other

investigations included renal function test (serum urea and creatinine); serum

electrolytes and random blood sugar. Viral markers for HIV1 and HIV2, hepatitis

B and hepatits C was also done. X-ray chest postero anterior view was done.

Patient was also assessed for COVID 19 sensitivity and was only operated after

TrueNat or RTPCR negative report. Radiological investigation in the form of

antero posterior, lateral radiographs of the elbow were obtained (Figure3,4). Pre-

anaesthetic checkup was done by anaesthetist before surgery. Patients were kept

fasting for 8 hours for solid food; 4 hours for milk; 2 hours for clear fluid.

Intravenous fluids were given as per need.

Figure 3: Supracondylar fracture right humerus Gartland Type IIIA

 Figure 4: Supracondylar fracture left humerus Gartland Type IIIB

Prior to the day of surgery in main OT and just before surgery in

emergency OT written and informed consent for surgery was taken from the

patient’s parent/guardian (Annexure III). Patient’s attendants were informed about

the diagnosis, treatment options and were counselled regarding possible

complications of both surgery and anaesthesia. Preparation of the extremity was

done. Intravenous antibiotics that is 3rd generation cephalosporin was given at the

time of induction before applying tourniquet. The affected limb was cleaned for

surgery by scrubbing with betadine solution and wrapping it in a sterile towel.

 Figure 5: Instruments and Kirschner wires of
various sizes used in CRPP and ORIF

OPERATIVE APPROACH

General anaesthesia was given to every patient.

Closed Reduction and stabilization with percutaneous pinning

Patient was placed supine with affected upper limb free of the table on an arm

trolley.

Figure 6: Position of patient for Closed Reduction Internal Fixation

 Traction was applied along the longitudinal axis with elbow in position of

deformity (Figure 6). At the same time counter traction was given by an assistant

by holding proximal portion of arm. Medial or lateral displacements and rotation

were corrected by applying valgus or varus forces respectively. After the

correction of all displacements and rotation, position was confirmed under

fluoroscopic control. Posterior displacement and angulation was then corrected by

flexing the elbow and applying posteriorly directed force from anterior aspect of

proximal fragment and anteriorly directed force from posterior aspect of distal

fragment.

The elbow was kept in flexed and pronated or supinated position

depending upon the stability of the fracture with the help of a leucoplast.

Reduction was confirmed under fluoroscopy control in two views: Antero-

posterior view and lateral view. Part was cleaned and draped from lower third of

forearm to upper third of arm with help of betadine and sterilium and cleaned with

dry gauge followed by application of betadine solution (Figure 7).

 Figure 7: Intraoperative image demonstrating fracture reduction
maintained by taping elbow in hyperflexed position.

After confirming satisfactory alignment, first K-wire is inserted from the

lateral condyle of humerus to the proximal fragment (Figure 8,9,10) which was

confirmed under fluoroscopic control in AP and Lateral view. In majority of cases

two K-wires were inserted from lateral condyle of humerus (Figure 11,12,13) to

the proximal fragment initially followed by medial K-wire insertion. Another K

wire was inserted from the medial epicondyle in extension after palpating ulnar

nerve and passed into lateral cortex of proximal fragment (Figure 14,15,16). The

number of Kirschner wire used depended upon the stability of fracture. Following

K-wire insertion reduction of fracture and position of wires was confirmed in both

AP and lateral view under fluoroscopic control. Elbow range of motion was then

assessed. Radial artery was palpated. Above elbow slab in 70-90 degree of elbow

flexion was applied after confirming palpation of radial artery.

 Figure 8:Intraoperative image demonstrating
introduction of Kirschner wire from lateral
condyle of humerus

Figure 9:C-arm image showing Figure 10: C-arm image showing

percutaneous pinning with one Kirschner percutaneous pining with one Kirschner
wire in anteroposterior view from lateral wire in lateral view from lateral
condyle of humerus condyle of humerus
 Figure 11: Intraoperative image
demonstrating insertion of 2
Kirschner wires from lateral
condyle of humerus

Figure 12: C-arm image showing Figure 13: C-arm image showing
percutaneous pinning with two Kirschner percutaneous pinning with two
wires in anteroposterior view Kirschner wires in lateral view
 Figure 14: Medial Kirschner wire insertion
in extension

Figure 15: C-arm image showing Figure 16: C-arm image showing
percutaneous pinning with three percutaneous pinning with three
crossed Kirschner wires in lateral Kirschner wires in anteroposterior
view. view.
Open reduction internal fixation

Open reduction internal fixation was done under general anaesthesia.

Patient was given lateral position (Figure 17) with fractured elbow facing the

surgeon, with side supports placed beneath the arm, the forearm was left to hang

freely with the elbow flexed. Tourniquet was applied over proximal 1/3rd of arm.

Figure 17: Lateral Position of the patient for Open

Reduction internal Fixation with tourniquet in situ

A pneumatic tourniquet was applied in the proximal end of upper limb

with patient in lateral position. Tourniquet pressure was set at 50-70 mmHg more

than the patient’s systolic blood pressure. Longitudinal skin incision was given

over the posterior aspect of distal one fourth humerus curved over the ulnar aspect

(Figure 18,19). Bleeders were electrocoagulated and further soft tissue dissection

was done (Figure 20). Ulnar nerve was identified and isolated with help of infant
feeding tube (Figure 21).A tongue shaped flap of triceps muscle was reflected

(Figure 22,23) with its apex at musculotendinous junction and fracture haematoma

was evacuated and fracture site was reached (Figure 24). Reduction was achieved

under direct vision by assessing medial pillar, lateral pillar and olecranon fossa and

maintained with K- wires (Figure 25). Surgical site was washed thoroughly with

normal saline.The ends of the K-wires were bend and cut afterwards and kept

inside the skin (Figure 26).Triceps was sutured back at its musculotendinous

junction (Figure 27,28) followed by subcutaneous tissue and skin closure (Figure

29). Posterior slab was applied in 70-90 degree of flexion (Figure 30). A window

was made after slab application anteriorly over the wrist for palpating radial pulse.

Figure 18: Intraoperative image Figure 19: Intraoperative image demonstrating

demonstrating skin marking for incision on skin incision on the posterior arm slightly
the posterior arm slightly curved away curved away from the olecranon
from the olecranon
Figure 20: Soft tissue dissection after Figure 21:Intraoperative image
skin incision demonstrating fat layer and demonstrating retracted triceps muscle
triceps muscle underneath it and isolation of ulnar nerve held in a
loop of infant feeding tube.

Figure 22: Intraoperative image Figure 23: Intraoperative image

demonstrating tongue shaped flap of demonstrating reflection of triceps flap
triceps and joint capsule visible underneath.
 Figure 24 :Intraoperative photograph
demonstrating triceps flap and
fracture site

Figure 25: Intraoperative image demonstrating reduced coloumns and Kirschner wire in
situ one from medial side and one from lateral side
 Figure 26 : Intraoperative photograph
demonstrating layer wise closure of triceps
muscle with Kirschner wires cut and bend
away from ulnar nerve and kept beneath the
skin.

Figure 27 : Intraoperative image Figure 28 : Suturing back of tongue

demonstrating positioning back of shaped triceps flap at its
tongue shaped triceps flap musculotendinous junction with
negative suction drain placed
underneath the flap.
Figure 29: Image demonstrating Figure 30: Application of above
subcutaneous closure of the surgical elbow slab in supination
incision and application of skin
stappler

Figure 31: X-ray image showing AP Figure 32: X-ray image showing
view with two Kirschner wires following Lateral view with two Kirschner wires
open reduction and internal fixation following open reduction and internal
fixation
 Post-operatively, operated limb was elevated on, active movements of

fingers was advised. Careful observation at regular intervals was done for any

neurovascular deficit. 3rd generation cephalosporin and analgesics were given.

Check X-rays in AP and lateral views were taken on post operative day 1(Figure

31,32). On Post-operative day 2 and 5, dressing was changed and condition of the

operative wound was examined. Antiseptic dressing was done with betadine and

normal saline (Figure 33). Above elbow slab was reapplied following dressing. If

wound was healthy patient was discharged and advised to follow up in OPD.

Figure 33: Second post-operative day

wound picture following open reduction
and internal fixation with Kirschner
wires and removal of drain.
 Sutures were removed on 14thpost operative day in outpatient department

and the limb was kept in above elbow slab. Care was taken of pin tract infection

and surgical site infection till Kirschner wire removal and suture removal. Above

elbow slab was removed at 4 weeks. Patients were put on physiotherapy and active

range of motion exercises for elbow. Kirschner wires were removed for both the

groups at 6 weeks.
 STATISTICAL ANALYSIS

The data obtained was tabulated and statistically analyzed using social science

system version SPSS 20.0 software. All data was presented as Mean ± SD.

Categorical variables were presented as frequencies and percentage. The

comparison of normally distributed continuous variables between the groups were

compared using Chi-square test or fisher’s exact test as appropriate. Non nominal

distribution continuous variables were compared using Mann Whitney U test. For

all statistical tests a p-value of less than 0.05 was considered to be statistically

significant.
 Observations and Results

This prospective systematic randomised controlled study was conducted in the

Department of Orthopaedic Surgery, Indira Gandhi Medical College, Shimla over
a period of one year from September 2020 to September 2021. Thirty patients in
age group of 3-16 years were included in this study who underwent either closed
reduction percutaneous pinning or open reduction internal fixation for reduction of
supracondylar fracture of humerus Gartland type III A and B,

Closed reduction percutaneous pinning group – 15 patients who underwent closed

reduction percutaneous pinning.

Open reduction internal fixation group – 15 patients who underwent open

reduction and internal fixation.

Table 1
Distribution according to age of patients between Closed reduction
percutaneous pinning and Open reduction internal fixation group
Age group CRPP Group ORIF Group p value
(n=15) (n=15)
3-5 years 4 (26.7%) 2 (13.3%) -

6-10 years 11 (73.3%) 11 (73.3%)

>10 years 0 2 (13.3%)

Mean age in years 6.53±2.03 7.73±2.28 0.14

Patients in 3-5 year age group in CRPP group were 4 patients (26.7%) and in ORIF

group were 2 patients (13.3%). In 6-10 years the age distribution in CRPP group

was 11 patients (73.3%) and in ORIF group was 11 patients (73.3%). In

> 10 years there were 2 patients (13.3%). Mean age in CRPP group was 6.53±2.03

years and in ORIF group was 7.73±2.28 years.

 Table 2

Distribution of patients according to gender between CRPP and ORIF group

Gender CRPP Group ORIF Group
(n=15) (n=15)
Male 8 (53.3%) 8 (53.3%)

Female 7 (46.7%) 7 (46.7%)

The male gender in CRPP group were 8 patients (53.3%) and in ORIF group were
8 patients (53.3%). Female gender in CRPP group 7 patients (46.7%) and in ORIF
group were 7 patients (46.7%).
 Table 3

Distribution of patients according to Age and Gender

Age group Male Female Total

3-5 years 3 3 6 (20.0%)

6-10 years 12 10 22 (73.3%)

>10 years 1 1 2 (6.7%)

Total 16 (53.3%) 14 (46.4%) 30 (100.0%)

In 3-5 years 3 male (10%) and 3 female (10%) patients were present. Total 6
patients (20%) were present in this group. In 6-10 years 12 male (40%) patients
were present and 10 female (33%) patients were present. In > 10 years 1 male
patient was present and 1 female patient was present. Total 2 patients (6.7%) were
present.
 Table 4

Distribution of patients according to side involvement in CRPP and ORIF

group
Side CRPP Group ORIF Group p value
(n=15) (n=15)
Left 8 (53.3%) 9 (60.0%) 0.71

Right 7 (46.7%) 6 (40.0%)

Left side involvement in CRPP group was 8 patients (53.3%) and in ORIF group
was 9 patients (60%). Right side involvement in CRPP group was 7 patients
(46.7%) and in ORIF was 6 patients (40%). No statistical significant difference
was observed between the two groups (p value 0.71).
 Table 5

Distribution of patients according to gender and side of involvement

Side Male Female Total

Left 9 (56.2%) 8 (57.1%) 17 (56.7%)

Right 7 (43.8%) 6 (42.9%) 13 (43.3%)

Total 16 (53.3%) 14 (46.4%) 30 (100.0%)

Left side involvement was present in 9 male (56.2%) patients and 8 female patients
(57.1%). Right side involvement was present in 7 male patients (43.8%) and in 6
female patients (42.9%).
 Table 6

Distribution of patients according to type of displacement in CRPP and ORIF

group
CRPP Group ORIF Group p value
Type of displacement
(n=15) (n=15)

Type III A- Posteromedial 9 (60.0%) 10 (66.7%) 0.70

Type III B- Posterolateral 6 (40.0%) 5 (33.3%)

In CRPP group number of cases of posteromedial displacement were 9 patients

(60%) and posterolateral displacement were 6 patients (40%). In ORIF group
posteromedial displacement were 10 patients (66.7%) and posterolateral
displacement were 5 patients (33.3%). No statistical significant difference was
observed between the two groups (p value 0.70).
 Table 7

Distribution of Nerve involvement in CRPP and ORIF group (pre-

operatively)
Nerve involvement CRPP Group ORIF Group p value
(n=15) (n=15)
Nil 13 (86.7%) 14 (93.3%) 0.59

Anterior interosseous nerve 1 (6.7%) 1 (6.7%)

Radial nerve 1 (6.7%) 0

In CRPP group 13 patients (86.7%) were with no nerve involvement, anterior

interosseous nerve involvement was in 1 patient (6.7%) and radial nerve
involvement was in 1 patient (6.7%). In ORIF group 14 patients (93.3%) were
without nerve involvement, anterior interosseous nerve involvement was in 1
patient (6.7%). No statistical significant difference was observed between the two
groups (p value 0.59).
 Table 8

Distribution of patients according to Vascular involvement in CRPP and

ORIF group (pre-operatively)
Vascular CRPP Group (n=15) ORIF Group (n=15) p value
involvement
Nil 13 (86.7%) 14 (93.3%) 1.0

Yes 2 (13.3%) 1 (6.7%)

No vascular involvement was present in 13 patients (86.7%) in CRPP group and in

14 patients (93.3%) in ORIF group. In CRPP group 2 patients (13.3%) had
vascular involvement and in ORIF group 1 patient (6.7%) had vascular
involvement No statistical significant difference was observed between the two
groups (p value 1).
 Table 9

Comparison of Loss of movement in degrees in CRPP and ORIF group at

follow up
Loss of movement CRPP Group ORIF Group p value
(n=15) (n=15)
At 2 weeks 4.07±1.33 8.13±1.33 <0.001

At 6 weeks 4.60±1.29 6.67±1.29 <0.001

At 12 weeks 3.47±1.30 5.13±1.06 0.001

At Final follow up 3.47±1.30 4.4±1.05 0.04

Loss of movement at elbow joint at 2 weeks postoperative in CRPP group was 4.07
± 1.33 degrees and in ORIF group was 8.13 ± 1.33 degrees and was statistically
significant with p value < 0.001. At 6 weeks postoperatively loss of movement in
CRPP group was 4.60 ± 1.29 degrees and in ORIF group was 6.67±1.29 degrees
and was statistically significant with p value < 0.001. At 12 weeks postoperative
loss of movement in CRPP group was 3.47 ± 1.30 degrees and in ORIF group was
5.13±1.06 degrees and was statistically significant with p value 0.001. At final
follow up postoperative loss of movement in CRPP group was 3.47 ± 1.30 degrees
and in ORIF group was 4.4±1.05 degrees and was statistically significant ( p value
0.04).
 Table 10

Comparison of Loss of movement (degree) in Posteromedial displacement

(IIIA) during follow up in CRPP and ORIF group
Loss of movement CRPP Group ORIF Group (n=10) p value
(n=9)

At 2 weeks 4.22±1.56 7.9±1.59 0.662

At 6 weeks 4.78±1.56 6.7±1.49 0.75

At 12 weeks 3.67±1.41 5.1±0.99 0.054

At Final follow up 3.67±1.41 4.4±0.96 0.04

At 2 weeks, 6 weeks and 12 weeks follow up in posteromedial (IIIA) displacement

in CRPP and ORIF group comparison of loss of movement was not statistically
significant(p value > 0.05). At final follow up the mean of loss of movement in
CRPP group was 3.67 ± 1.41degrees and in ORIF group was 4.4 ± 0.96 degrees
and was statistically significant with p value 0.04.
 Table 11

Comparison of Loss of movement (degree) in posterolateral displacement

(IIIB) during follow in CRPP and ORIF group
Loss of movement CRPP Group ORIF Group (n=5) p value
(n=6)
At 2 weeks 3.83±0.98 8.6±0.54 0.06
At 6 weeks 4.33±0.81 6.60±0.89 0.82
At 12 weeks 3.17±1.16 5.2±1.3 0.69
At Final follow up 3.17±1.16 4.4±1.3 0.52

Comparison of loss of movement in posterolateral (IIIB) group in postoperative

follow up between CRPP and ORIF group was not statistically significant during
all follow up period. At final follow up loss of movement in CRPP group was 3.17
± 1.16 degrees and in ORIF group was 4.4 ± 1.3 degrees with p value of 0.52.
 Table 12

Comparison of Loss of carrying angle in CRPP and ORIF group during

follow up
Loss of carrying CRPP Group ORIF Group p value
angle (n=15) (n=15)
2 weeks 1.53±0.74 1.13±0.83 0.83

6 weeks 1.93±0.88 1.73±0.88 0.80

12 weeks 2.53±0.91 2.4±0.91 0.95

Final follow up 3.07±0.96 2.87±0.91 0.73

Comparison of loss of carrying angle in CRPP and ORIF group was not
statistically significant (> 0.05) postoperatively at all follow up periods. In
postoperative period, 2 weeks, 6 weeks, 12 weeks and final follow up in CRPP
group the loss of carrying angle was 1.53±0.74 degrees, 1.93±0.88 degrees,
2.53±0.91 degrees and 3.07±0.96 degrees respectively and in ORIF group was
1.13±0.83 degrees, 1.73±0.88 degrees, 2.4±0.91 degrees and 2.87±0.91 degrees
respectively.
 Table 13

Comparison of Loss of carrying angle (degrees) in posteromedial

displacement (IIIA) during follow up in CRPP and ORIF group
Loss of carrying CRPP Group (n=9) ORIF Group p value
angle (n=10)
2 weeks 1.56±0.88 1.2±0.91 0.88

6 weeks 2.0±1.0 1.7±0.82 0.25

12 weeks 2.78±0.83 2.4±0.96 0.34

Final follow up 3.11±0.92 2.9±0.99 0.62

Comparison of loss of carrying angle in posteromedial (IIIA) group during follow

up between CRPP and ORIF group was not statistically significant at all follow up
periods. At final follow up the loss of carrying angle in posteromedial
displacement (IIIA) in CRPP group was 3.11 ± 0.92 degrees and in ORIF group
was 2.9 ± 0.99 degrees with p value of 0.62.
 Table 14

Comparison of Loss of carrying angle in posterolateral displacement (IIIB)

during follow up in CRPP and ORIF group
Loss of carrying CRPP Group (n=6) ORIF Group (n=5) p value
angle
2 weeks 1.5±0.54 1.0±0.70 0.66

6 weeks 1.83±0.75 1.8±1.09 0.09

12 weeks 2.17±0.98 2.40±0.89 0.77

Final follow up 3.0±1.09 2.8±0.83 0.94

Comparison of loss of carrying angle in posterolateral displacement (IIIB) between

CRPP and ORIF was not statistically significant during all follow up periods. At
final follow up the loss of carrying angle in posterolateral displacement (III B) in
CRPP group was 3 ± 1.09 degrees and in ORIF group was 2.8 ± 0.83 degrees with
p value of 0.94.
 Table 15

Comparison of Baumann’s angle in CRPP and ORIF group at follow up

Baumann’s angle CRPP Group ORIF Group p value
(n=15) (n=15)
At 2 weeks 76.87±2.82 75.67±2.61 0.23

At 6 weeks 77.27±2.52 75.67±2.61 0.09

At 12 weeks 77.93±2.54 75.93±2.68 0.04

At Final follow up 78.20±2.33 76.87±2.13 0.11

No statistical significant difference was observed in Baumann’s angle in

postoperative and follow up period in CRPP and ORIF group (p value > 0.05).
Baumann’s angle at postoperative period, 2 weeks, 6 weeks, 12 weeks and at final
follow up in CRPP group was 76.73 ± 2.78 degrees, 76.27 ± 2.82 degrees, 77.27 ±
2.52 degrees, 77.93 ± 2.54 degrees and 78.20 ± 2.33 degrees respectively and in
ORIF group 75.53 ± 2.64 degrees, 75.67 ± 2.61 degrees, 75.67 ± 2.61 degrees,
75.93 ± 2.68 degrees and 76.87 ± 2.13 degrees respectively.
 Table 16

Comparison of Baumann’s angle in posteromedial displacement (IIIA) during

follow up in CRPP and ORIF group
Baumann’s angle CRPP Group (n=9) ORIF Group p value
(n=10)
At 2 weeks 76.89±3.06 75.60±3.09 0.59

At 6 weeks 77.33±2.64 75.60±3.09 0.35

At 12 weeks 78.0±2.73 75.80±3.15 0.16

At Final follow up 78.11±2.66 76.80±2.62 0.40

Comparison of Baumann’s angle in posteromedial displacement (IIIA) between

CRPP and ORIF was not statistically significant during all follow up periods. At
final follow up baumann’s angle in CRPP group was 78.11 ± 2.66 degrees and in
ORIF group was 76.80 ± 2.62 degrees with p value of 0.40.
 Table 17

Comparison of Baumann’s angle (degree) in posterolateral displacement

(IIIB) during follow up in CRPP and ORIF group
Baumann’s angle CRPP Group (n=6) ORIF Group (n=5)

At 2 weeks 76.83±2.71 75.80±1.48

At 6 weeks 77.17±2.56 75.80±1.48
At 12 weeks 77.83±2.48 76.20±1.64
At Final follow up 78.33±1.96 77.0±0.70

Comparison of Baumann’s angle in posterolateral displacement (IIIB) between

CRPP and ORIF was not statistically significant during all follow up periods. At
final follow up baumann’s angle in CRPP group was 78.33 ± 1.96 degrees and in
ORIF group was 77 ± 0.70 degrees.
 Table 18

Comparison of Postoperative neuro-vascular involvement in CRPP and ORIF

group
Postoperative neuro- CRPP Group ORIF Group p value
vascular involvement (n=15) (n=15)
Nil 13 (86.7%) 14 (93.3%) 0.59

Anterior interosseous 1 (6.7%) 1 (6.7%)

nerve
Radial nerve 1 (6.7%) 0

There was no neuro-vascular involvement in postoperative period in 13 patients

(86.7%) in CRPP group and in 14 patients (93.3%) in ORIF group. 1 patient
(6.7%) in CRPP group had anterior interosseous nerve involvement and in ORIF
group 1 patient (6.7%) had anterior interosseous nerve involvement. 1 patient
(6.7%) in CRPP group had radial nerve involvement. No statistical significant
difference was observed between the two groups (p value 0.59).
 Table 19

Postoperative complications in CRPP and ORIF group

Complications CRPP Group ORIF Group (n=15) p value
(n=15)
Nil 13 (86.7%) 13 (86.7%)

Superficial surgical 0 1 (6.7%)

site infection 0.26
Lateral pin tract 2 (13.3%) 0
infection
Medial & lateral pin 0 1 (6.7%)
tract infection

No postoperative complications were seen in 13 patients (86.7%) in CRPP group

and 13 patients (86.7%) in ORIF group. One patient (6.7%) in ORIF group had
superficial surgical site infection and no patient in CRPP group had superficial site
infection. Two patients (13.3%) in CRPP group had lateral pin tract infection. One
patient (6.7%) in ORIF group had both medial and lateral pin tract infection. No
statistical significant difference was observed (p value 0.26).
 Table 20

Comparison of Duration of hospital stay (days) in CRPP and ORIF group

CRPP Group ORIF Group p value
(n=15) (n=15)
Duration of hospital stay 2.87±1.40 6.60±2.41 <0.001
(days)

The mean duration (days) of hospital stay in CRPP group was 2.87 ± 1.40 days and
in ORIF group was 6.60 ± 2.41 days and was statistically significant with p value
of < 0.001.
 Table 21

Comparison of postoperative Functional outcome in CRPP and ORIF group

Functional outcome CRPP Group ORIF Group p value
(n=15) (n=15)
Excellent 15 (100.0%) 13 (86.7%) 0.14

Good 0 2 (13.3%)

Fair 0 0

Poor 0 0

In CRPP group 15 patients (100%) had excellent outcome. In ORIF group 13

patients (86.7%) had excellent outcome, 2 patients (13.3%) had good outcome. No
statistical significant difference was observed between the two groups p value of
0.14.
 Table 22

Cosmetic outcome between CRPP and ORIF group

Cosmetic CRPP Group ORIF Group
outcome (n=15) (n=15)

Excellent 15 (100.0%) 15 (100.0%)

Good 0 0

Fair 0 0

Poor 0 0

In CRPP group all 15 patients (100%) had excellent cosmetic outcome. In ORIF
group all 15 patients (100%) had excellent cosmetic outcome.
 CASES

CASE 1

Figure 1: Pre operative Xray AP view Figure 2: Pre operative Xray lateral view
depicting supracondylar fracture depicting supracondylar fracture humerus
humerus Gartland type IIIB. Gartland type IIIB.

Figure 3: 6 weeks post operative X Figure 4: 6 weeks post operative X

ray depicting lateral view with ray depicting AP view with Kirschner
Kirschner wires in situ following wires in situ following CRPP.
CRPP.
Figure 5: Post operative X ray AP Figure 6: Post operative X ray
view after removal of Kirschner lateral view after removal of
wires following CRPP. Kirschner wires following CRPP.
Figure 7: Postoperative image depicting Figure 8: Postoperative image depicting
elbow extension elbow flexion

Figure 9: Post operative images depicting

assessment of carrying angle
 Case 2

Figure 10: Preoperative Xray depicting Figure 11: Preoperative Xray depicting
lateral view with fracture supracondylar AP view with fracture supracondylar
humerus Gartland type IIIA humerus Gartland type IIIA

Figure 12: 6 weeks post operative Figure 13: 6 weeks follow up X ray
follow up X ray AP view with lateral view with Kirschner wires in situ
Kirschner wires in situ following following CRPP.
CRPP.
Figure 14: Post operative X ray AP Figure 15: Post operative X ray
view after removal of Kirschner wires lateral view after removal of
following CRPP. Kirschner wires following CRPP.
Figure 16: Postoperative image depicting Figure 17: Postoperative image depicting
elbow extension elbow flexion

Figure 18: Postoperative image

depicting assessment of carrying
angle
 Case 3

Figure 19: PreoperativeX ray depicting AP Figure 20: Preoperative Xray depicting
view with fracture supracondylar humerus lateral view with fracture supracondylar
Gartland type IIIA. humerus Gartland type IIIA.

Figure 21: 6 weeks post operative Figure 22: 6 weeks post operative
follow up X ray AP view with follow up X ray lateral view with
Kirschner wires in situ following ORIF. Kirschner wires in situ following ORIF.
Figure 23: Post operative X ray lateral Figure 24: Post operative X ray AP
view after removal of Kirschner wires view after removal of Kirschner wires
following ORIF. following ORIF.
 Figure 26: Postoperative image depicting elbow flexion

Figure 25: Postoperative image depicting elbow

extension

Figure 27: Postoperative image Figure 28: Post operative image

depicting assessment of carrying depicting scar mark over the
angle posterior aspect of elbow.
 Case 4

Figure 29: Pre operative X ray Figure 30: Pre operative X ray
depicting AP view with fracture depicting lateral view with fracture
supracondylar humerus Gartland supracondylar humerus Gartland
type IIIA. type IIIA.

Figure 31: 6 weeks post operative Figure 32: 6 weeks post operative follow
follow up X ray AP view with up X ray lateral view with Kirschner
Kirschner wires in situ following wires in situ following ORIF.
ORIF.
Figure 33: Post operative X ray AP view Figure 34: Post operative X ray lateral
after removal of Kirschner wires view after removal of Kirschner wires
following ORIF. following ORIF.
 Figure 35: Postoperative image depicting elbow extension

Figure 36: Postoperative image depicting elbow flexion

Figure 37: Postoperative image Figure 38: Postoperative image

depicting assessment of carrying depicting scar mark following ORIF
angle
 DISCUSSION

Supracondylar fracture of humerus is one of the most common fracture

seen in children.62 Various complications associated with this fracture are nerve

palsy, vascular injury, cubitus varus deformity.63 It is therefore managed with

minimal manipulation and anatomical reduction of elbow to obtain excellent

results. Open surgery ensures anatomical reduction but main complications of

ORIF are infection and stiffness of elbow.63

Percutaneous Kirchner wire fixation for supracondylar humerus in children

offers simple, safe and affordable treatment.64

This prospective systematic randomised controlled study was conducted in the

Department of Orthopaedics, IGMC, Shimla over a period of one year from

September 2020 to September 2021. Thirty patients in age group of 3-16 years

were included in this study who underwent either closed reduction percutaneous

pinning or open reduction internal fixation for reduction of supracondylar fracture

of humerus Gartland type III A and B.

Closed reduction percutaneous pinning group – 15 patients who underwent closed

reduction percutaneous pinning.

Open reduction internal fixation group – 15 patients who underwent open

reduction and internal fixation.

Age

In our study, mean age (years) in CRPP group was 6.53 ± 2.03 years and in ORIF

group was 7.73 ± 2.28 years.

The most common age in both groups was 6-10 years with 11 patients (73.3%) in

each group with total of 22 patients (73.3%) in this age group.

Musa et al65 observed in 30 cases of type III Gartland fracture done by crossed

percutaneous pinning over a duration of 2 years. The age range was between 2-13

years with average age of 7.06 years.

C. Charles A Rockwood66 found in his study done in 230 patients who had

supracondylar humerus fracture that peak occurrence in children occurred in latter

part of first decade of life. In this the average age was 10 years (range 5-15 years)

and most common age group affected was between 5-8 years (46.67%).

In a study done by Ramsey et al67 average age was 7 years.

Age of patients in our study are comparable to the other studies.

Gender

In present study the male distribution in CRPP group was 8 patients (53.3%) and in

ORIF group were 8 patients (53.3%). Female in CRPP group, 7 patients (46.7%)
and in ORIF group were 7 patients (46.7%). Male children are slightly higher as

compared to female (M:F::8:7).

Pirone A M68 et al found that boys (119) are more affected than girls (111).

Robert D Ambrosia 69 found that incidence of supracondylar humerus fracture was

63% in males and 37% in females.

In study done by Rao KCS61 et al the prevalence of supracondylar humerus was

56.66% in males and 43.33 % in females.

Study done by Fowles et al70 observed that 89 patients (81%) were male and 21

patients (19%) were female.

The results of our study are comparable to the other studies. Male children are

more involved as they participate more in outdoor activities.

Side

In our study left side involvement in CRPP group was in 8 patients (53.3%) and in

ORIF group was in 9 patients (60%). Right side involvement in CRPP group was 7

patients (46.7%) and in ORIF was 6 patients (40%). Suggesting left side

involvement was more as compared to right side.

Robert D Ambrosia69 found that left elbow involvement was 64% and right side

involvement was 36% in children.

Study done by Rao KCS et al61 found that frequency of supracondylar fracture was

higher on left side (66.67%).

Fowles et al70 observed 57% left side involvement and 43% right side involvement.

Results of our study are similar to the other studies which show preponderance of

left side involvement. This is because when a child falls from height he/she makes

an attempt to hold on to something with the dominant arm and thus lands on

ground with non dominant arm.

Type of displacement

In present study, number of cases of posteromedial (type IIIA) displacement in

CRPP group were 9 patients (60%) and posterolateral (IIIB) displacement were 6

patients (40%). In ORIF group posteromedial (IIIA) displacement were 10 patients

(66.7%) and posterolateral (IIIB) displacement were 5 patients (33.3%).

Suggesting that posteromedial (IIIA) displacement is more common than

posterolateral displacement (IIIB).

Pirone A H et al68 analysed 230 cases of supracondylar humerus fracture and found

that 94 fractures were posteromedially displaced, 22 were posterolaterally

displaced and 21 were posteriorly displaced.

Wilkins et al71 observed 75% posteromedial displacement and 25% posterolateral

displacement in supracondylar humerus fracture.

Saad et al72 concluded that 90% patients had posteromedial displacement and 10%

patients had posterolateral involvement.

Posteromedial displacement (type IIIA) is more common than posterolateral

displacement (type IIIB) and is comparable with the other studies.

Nerve involvement in CRPP and ORIF group

No nerve involvement was present in 27 patients in both CRPP and ORIF group.

Anterior interosseous nerve involvement was present in 2 patients (13.4%) and

radial nerve involvement was in present in 1 patient (6.7%). Most common nerve

involvement was anterior interosseous nerve.

Pirone et al68 observed 16 patients (26.6%) had radial nerve injury, 18 patients

(30%) had medial nerve injury and 4 patients (6.6%) had ulnar nerve injury.

Saad et al72 observed that 2 patients (28.57%) had median nerve injury and 2

patients (28.57%) had ulnar nerve injury.

Most common nerve involvement in other studies was median nerve compared to

other nerve injuries which was similar to our study.

Vascular Involvement in CRPP and ORIF group

No vascular involvement was present in 27 patients. 3 patients had vascular

involvement.
Jeffrey et al73 observed 8 patients (64%) having vascular involvement.

Pirone et al68 concluded that 22 patients (36.6%) had feeble radial artery.

Saad et al72 observed 1 patient (20%) had vascular involvement.

In the present study, vascular involvement was 11.1% which is less as compared to

the other studies. This can be due to, in other studies patients maybe included of

Gartland type IV.

Loss of movement in CRPP and ORIF group

The loss of movement postoperatively in CRPP group was significantly lower as

compared to ORIF group. At final follow up postoperatively loss of movement in

CRPP group was 3.47 ± 1.30 degrees and in ORIF group was 4.4 ± 1.05 degrees.

In a study by Rao KCS et al61 one patient out of 15 patients (6.6%) who underwent

ORIF had limited mobility of elbow and sufficient range of motion was achieved

with physiotherapy.

Movements at elbow joint in Posteromedial displacement (IIIA) and

Posterolateral displacement (IIIB) in CRPP and ORIF group

At final follow up the mean loss of movement in posteromedial displacement in

CRPP group was 3.67 ± 1.41 degrees and in ORIF group was 4.4 ± 0.96 degrees

and was statistically significant with p value 0.04.

On comparison of loss of movement in posterolateral (IIIB) group in postoperative

follow up between CRPP and ORIF group was not statistically significant during

all follow up period ( p value > 0.05).

In a study by Sachin et al74 in type IIIA fractures, mean loss of range of motion

was 16.6 degrees and in type IIIB fractures there was mean loss of range of motion

was 11.8 degrees in closed reduction group. In operative group mean loss of range

of motion was 5.8 degrees in IIIA and 8.8 degrees in IIIB.

The results were comparable to our study.

Carrying Angle in CRPP and ORIF group

At final follow up in CRPP group the loss of carrying angle was 3.07 ± 0.96

degrees and in ORIF group was 2.87 ± 0.91 degrees.

Study done by Rao KCS et al61 two patients had small degree of cubitus varus due

to unsatisfactory reduction and fixation of fragment. One had undergone closed

reduction and other was done by open reduction. In case of closed reduction the

degree of cubitus varus was higher.

The incidence of cubitus varus after pinning of supracondylar humerus fracture

was recorded as 6% by Lee et al.75

Wael et al76 reported 8.6% of cubits varus after closed pinning in supracondylar

humerus fracture.

Topping et al77 demonstrated occurrence of cubitus varus in one patient (4.3%) out

of 43 patients treated with closed reduction and percutaneous pinning.

Results of the other studies also suggest that after closed reduction there are more

chances of postoperative deformity compared to open reduction and internal

fixation as anatomical reduction occurs in open reduction.

Carrying Angle in Posteromedial displacement (IIIA) and Posterolateral

displacement (IIIB) in CRPP and ORIF group

At final follow up mean of loss of carrying angle in posteromedial displacement

(IIIA) in CRPP group was 3.11 ± 0.92 degrees and in ORIF group was 2.9 ± 0.99

degrees and was not statistically significant with p value of > 0.05.

At final follow up mean of loss of carrying angle in posterolateral displacement

(IIIB) in CRPP group was 3 ± 1.09 degrees and in ORIF group was 2.8 ± 0.83

degrees and was not statistically significant with p value > 0.05.

In a study by Sachin et al74 in type IIIA fractures, mean loss of carrying angle was

10 degrees and in type IIIB fractures mean loss of carrying angle was 14.6 degrees

in closed reduction percutaneous group. In operative group mean of loss of

carrying angle in IIIA was 4.8 degrees and in IIIB was 6.8 degrees.
Baumann’s Angle in CRPP and ORIF group

In present study, postoperative period Baumann’s angle in CRPP group was

76.73±2.78 degrees and in ORIF group was 75.53±2.64 degrees. In final follow up

Baumann’s angle in CRPP group was 78.20±2.33 degrees and in ORIF group was

76.87±2.13 degrees.

No statistical significant difference was observed in Baumann’s angle in

postoperative and follow up period in CRPP and ORIF group.

In a study done by Umur F.L. et al78 in 86 patients, 43 patients were treated

conservatively and 43 patients were treated surgically. The Baumann angle

measured on follow up radiographs at postoperative 24 months was similar in both

groups without significant statistical difference.

Neuro-vascular involvement in CRPP and ORIF group

There was no neuro-vascular involvement in postoperative period in 27 patients.2

patients had anterior interosseous nerve involvement and in 1 patient (6.7%) in

CRPP group had radial nerve involvement similar to as in preoperative period.

Postoperative complications in CRPP and ORIF group

No postoperative significant complications were seen in 26 patients (86.7%).One

patient (6.7%) in ORIF group had superficial surgical site infection. Two patients
(13.3%) in CRPP group had lateral pin tract infection. One patient (6.7%) in ORIF

group had both medial and lateral pin tract infection.

The incidence of pin tract infections reported by Wael et al76 was 8.6%.

Devkota et al79 reported 7.84% incidence of pin tract infection.

Pirone et al68 observed two cases of superficial pin tract infection in 96 patients

treated with closed reduction and pinning.

Bashyal et al80 noted total infection rate of 1% (6 of 622) and deep infection rate of

0.2%.

Duration of hospital stay in CRPP and ORIF group

The mean duration (days) of hospital stay in CRPP group was 2.87 ± 1.40 days and

in ORIF group was 6.60 ± 2.41 days.

In a study done by Nacht et al81 average duration of hospital stay after

supracondylar humerus surgery was 4.2 days after open reduction.

Aronson and Prager82 observed that average duration of hospital stay was 3.45

days after closed reduction and percutaneous pinning.

Postoperative Functional outcome in CRPP and ORIF group

In our study using Flynn criteria, in CRPP group 15 patients (100%) had excellent

outcome. In ORIF group 13 patients (86.7%) had excellent outcome and 2 patients

(13.3%) had good outcome.

Study by Rao KCS et al61 showed that 26 (86.66%) out of 30 patients had excellent

to good results and 4 (13.33%) showed average to poor results. One was done with

closed reduction and three were operated with open reduction.

Ababneh et al83 observed excellent and good results in 87% of patients and 8% had

poor results in closed reduction and percutaneous fixation. In open reduction and

wire fixation excellent results were in 55% patients, good results in 19% patients

and poor results in 22%.

In a study done by Aronson et al82 of 20 patients of supracondylar fracture 16

patients (61.5%) had excellent outcome, 9 patients (34.5%) had good outcome and

1 patient (3.8%) had fair outcome.

The results of the above studies were comparable to our study which showed

closed reduction percutaneous pinning had better results as compared to open

reduction and internal fixation.

Postoperative cosmetic outcome in CRPP and ORIF group

Using Flynn criteria in our study, in CRPP group all 15 patients (100%) had

excellent cosmetic outcome. In ORIF group all 15 patients (100%) had excellent

cosmetic outcome.

In Flynn criteria the carrying angle loss of 10 degrees or more is not regarded as a

good result. Mild varus deformity of elbow may not be important as implied by

Flynn’s criteria. Hence in our study in both CRPP and ORIF group had excellent

outcome on comparing carrying angle loss at final follow up.

 SUMMARY

The present study was conducted in 30 patients of supracondylar fracture humerus

in age group of 3-16 years. The patients were prospective systematic randomised

into 2 groups of 15 each. 15 patients underwent closed reduction and percutaneous

pinning.15 patients underwent open reduction and internal fixation.

Following findings were found as follows :-

1. Maximum number of patients were in age group of 6-10 years.

2. 16 patients were male and 14 patients were female.

3. 17 patients had left side involvement and 13 patients had right side

involvement.

4. 19 patients had posteromedial (IIIA) displacement and 11 patients had

posterolateral (IIIB) displacement.

5. Preoperatively no nerve involvement was present in 27 patients. Anterior

interosseous nerve involvement was present in 2 patients (13.4%) and radial

nerve involvement was in present in 1 patient (6.7%) and was similar

postoperatively.

6. No vascular involvement was present in 27 patients. 3 patients (10%) had

vascular involvement.
7. The loss of movement postoperatively in CRPP group was significantly

lower as compared to ORIF group (p value < 0.001).

8. Loss of movement was significantly higher in ORIF group compared to

CRPP group in both IIIA and IIIB. Loss of movement in ORIF group in IIIA

was 4.4 ± 0.96 degrees and in IIIB was 4.4 ± 1.3 degrees and in CRPP group

in IIIA was 3.67±1.41 degrees and in IIIB was 3.17±1.16 degrees.

9. Loss of carrying angle in CRPP and ORIF group at final follow up was not

statistically significant (p value >0.05).

10. Loss of carrying angle was higher in CRPP group compared to ORIF group

in both type IIIA and IIIB. In CRPP in IIIA loss of carrying angle was 3.11

± 0.92 degrees and in IIIB was 3 ± 1.09 degrees. In ORIF in IIIA loss of

carrying angle was 2.9 ± 0.99 degrees and in IIIB was 2.8 ± 0.83 degrees.

11. No postoperative complications were seen in 26 patients (86.7%).One

patient (6.7%) in ORIF group had superficial surgical site infection. Two

patients (13.3%) in CRPP group had lateral pin tract infection. One patient

(6.7%) in ORIF group had both medial and lateral pin tract infection.

12. The mean duration (days) of hospital stay in CRPP group was 2.87 ± 1.40

days and in ORIF group was 6.60 ± 2.41 days.

13. Flynn criteria was used for postoperative functional outcome. In CRPP

group 15 patients (100%) had excellent outcome. In ORIF group 13 patients

(86.7%) had excellent outcome and 2 patients (13.3%) had good outcome.
 CONCLUSIONS

At the end of our study, the following conclusions were drawn :-

1. Closed reduction percutaneous pinning has better functional outcome and

better cosmetic results with less duration of hospital stay as compared to

open reduction and internal fixation.

2. Open reduction with internal fixation of displaced supracondylar fracture of

humerus allows decompression of haematoma and anatomical reduction

under vision.

3. Good range of movement present in closed reduction and percutaneous

pinning as compared to open reduction and internal fixation.

4. We recommend Close Reduction and percutaneous pinning as the ideal

treatment for management of the supracondylar fracture in children.

 Limitations

1. Follow up is short therefore extrapolating results of the study to a

larger population is difficult.

2. Due to Covid-19 pandemic the number of patients had to be restricted

to 15 in each group and follow up was difficult as patient were not

compliant.

3. Number of patients studied was less so larger group studied is

required for extrapolating data into general population.

4. Difficulty in measuring carrying angle due to limited extension

postoperatively.
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