research-article2018

Feature

Staying out of trouble

with paediatric
supracondylar
2
fractures
A review of pitfalls and
controversies

S
upracondylar fractures most commonly incomplete ossification, and soft-tissue swell- of injury and detailed review of the preoperative
occur in children aged between five and ing are common and can cloud the picture. radiograph. A clue may be the lack of an oblique
seven years,1 and are usually the result Extension-type fractures can be divided into line distal-anterior to proximal-posterior on the
of accidental trauma rather than non- posteromedial (75%) and posterolateral (25%) lateral radiograph. It is essential to try to identify
accidental injury, although the latter should be subtypes;4 posterolateral displacement has an these injuries preoperatively to allow better pre-
considered in children under 18 months old.2 increased risk of median nerve and brachial operative planning, as flexion-type fractures are
The majority (~98%) are extension-type,1 artery injury, and entrapment of these struc- often more technically challenging to reduce
with relative posterior displacement of the distal tures in the fracture site must be considered if (the reduction technique is in extension rather
fragment and the proximal fragment pressing there is difficulty in reducing postero­ lateral than in flexion) and have an increased rate of
into the tissues anteriorly (Fig. 1). Extension- fractures. Flexion-type supracondylar fractures open reduction.5
type supracondylar fractures are commonly account for around 2% of supracondylar frac-
classified by Wilkin’s modification of the Gartland tures and result from direct trauma with the Which fractures require fixation?
classification, which can also be used to guide elbow joint in flexion, or a fall onto a flexed Undisplaced (Gartland type 1) fractures are
management.3 Close review of the radiographs elbow.1 Flexion-type fractures can often be almost universally treated conservatively.
preoperatively is essential, as poor radiographs, picked up by a careful review of the mechanism However, it is important to study the antero­

Bone & Joint360 | volume 7 | issue 3 | june 2018

 A. I. W. Mayne D. M. Campbell
MBChB, MRCS (Ed), Specialty Registrar, FRCSEd (Tr&Orth), Consultant Paediatric
Department of Trauma and Orthopaedics, Orthopaedic Surgeon, Department of Trauma and
Ninewells Hospital, Dundee, UK Orthopaedics, Ninewells Hospital, Dundee, UK
email: alistairmayne@hotmail.co.uk

Table I. Indications for emergency treatment of injury with the placement of the medial K-wire.
supracondylar fractures While proponents argue there is little in the way
Indication
of increased risk, there are multiple studies
showing higher rates of iatrogenic ulnar nerve
Absent radial pulse
injury using the crossed-wire technique.19 A
Skin compromise
systematic review in 2010 reported that crossed
Compartment syndrome
pinning results in one extra nerve injury for
Open contaminated fracture
every 28 patients treated, compared with
lateral-­only pinning.19 Iatrogenic injury of the
ulnar nerve may occur via direct-wire penetration
risk of neurovascular injury, but there have now
or, more commonly, through narrowing of the
been multiple studies that have reported safe,
cubital tunnel. To reduce the rate of iatrogenic
delayed management of supracondylar frac-
ulnar nerve injury with medial wire placement
tures, with no effect on rate of open reduction,
(the ulnar nerve is extremely mobile in children
operating time, length of hospital stay, or com-
and may not be exactly where expected),20 cur-
plication rates.10-15 However, a multicentre paper
rent British Orthopaedic Association (BOA) guid-
Fig. 1 Pathoanatomy of a posterolaterally dis- reported 11 cases of compartment syndrome
ance advocates that “techniques to avoid ulnar
placed Gartland III extension-type supracondylar developing among children who had presented
nerve injury should be employed”.21 We rec-
fracture. Illustration courtesy of Mr A. Faulkner. with low-energy injuries and an intact radial
ommend a mini-open technique to assist with
pulse. The authors questioned if the pendulum
placement of the medial wire.
has swung too far towards delayed surgery,
posterior radiograph carefully for any signs of An alternative is placement of two or three
thereby putting some patients at risk of second-
varus or valgus impaction (indicative of a
ary compartment syndrome.16 This has re-
lateral wires, the ‘lateral-only’ method. Lateral 3
grade 2 injury). Clinical comparison of the car- wire configurations help to overcome risk of
emphasized the need for close monitoring of
rying angle of the contralateral elbow is very injury to the ulnar nerve, although cadaveric
these patients, and the individual nature of each
useful in assessing coronal plane malalign- studies have shown inferior mechanical stabil-
case must be considered to ensure that children
ment. Above-elbow back slabs have been ity.22-24 However, other studies have failed to
with absolute indications for emergency sur-
shown to provide superior pain-relief to collar replicate these findings, reporting comparable
gery (Table I)17 are identified early. Additionally,
and cuff immobilization.6,7 biomechanical stability.25-27 The most recent
fractures with posterolateral displacement of
Gartland grade 2 fractures are usually divided meta-analysis (2016) comparing crossed-wire
the distal fragment should be considered for
into grade 2a, in which the distal fragment is fixation to lateral-only fixation included 13 stud-
urgent fixation, as these injuries place the
posteriorly angulated, and grade 2b, in which ies (seven randomized controlled trials and six
median nerve and brachial artery at increased
the distal fragment is both angulated and prospective comparative cohorts) and reported
risk; therefore, careful evaluation of these patients
rotated. For stability without Kirschner wire that the rate of iatrogenic ulnar nerve injury was
is essential if surgery is to be delayed.18 Fractures
(K-wire) stabilization, > 120° of elbow flexion is 4.1% in the crossed-pin group versus 0.3% in
with median nerve involvement will need care-
recommended to minimize the risk of displace- the lateral-only group, and reported no differ-
ful monitoring as the paraesthesia may mask
ment.8 However, hyperflexion of the elbow has ence in terms of radiographic outcomes, func-
the pain of incipient compartment syndrome.
been shown to predispose to increased com- tion, or other surgical complications between
partmental pressures,9 and therefore most cen- the two groups.28
How should the fracture be fixed?
tres now routinely K-wire all type 2 fractures. Despite the higher risk of iatrogenic nerve
How should the wires be configured?
All Gartland grade 3 fractures should be injury with use of a medial K-wire, there remains
stabilized as these are unstable injuries, and Controversy remains regarding optimal wire a risk of iatrogenic nerve injury with all methods
conservative management is associated with configuration, with the complications driving of fixation, emphasizing the importance of a
complications and a poorer functional outcome. the debate being risk of iatrogenic nerve injury detailed preoperative neurovascular assessment.
and loss of stability of the fixation construct. Surgeon familiarity and experience is likely to be
When should the fracture be Traditional fixation has involved crossed- the main determining factor in the wire configu-
treated? wire fixation, i.e. one medially placed wire and ration used and success of treatment, with each
Traditionally, displaced supracondylar fractures one laterally placed wire. The problem with this method having advantages and disadvantages.
were treated in an emergency manner due to method is the risk of iatrogenic ulnar nerve We would advocate live screening following

Bone & Joint360 | volume 7 | issue 3 | june 2018

 Table II. Key British Orthopaedic Association (BOA) technical recommendations for surgery on paediatric supracondylar fractures

Recommendation
Surgical stabilization should be with bicortical Kirschner wires (K-wires)
If a medial wire is used, “techniques to avoid ulnar nerve injury” should be used and documented in the operation note
2 mm wires should be used if possible
A perfused limb does not require brachial artery exploration whether or not the radial pulse is present

of the operating surgeon to ensure that an accu-

rate neurovascular examination has been under-
taken and recorded, and we advocate recording
preoperative neurovascular status on the opera-
tion note.
Reassuringly, outcomes following nerve injury
in supracondylar fractures (even iatrogenic) are
generally good, as the majority are neuropraxias
and usually recover spontaneously within three
to six months.39-41 If the nerve has not recovered
Fig. 2a Fig. 2b Fig. 2c
by three months, nerve conduction studies should
Assessing hand neurological supply in children. a) Testing the anterior interosseous nerve (AIN): ask the be arranged and the case discussed with the
child to make an ‘OK’ sign, which indicates integrity of the index finger flexor digitorum profundus (FDP) local peripheral nerve unit.
and the flexor pollicis longus (FPL). This requires the child to flex his or her interphalangeal joints (IPJs). b)
Testing radial motor function: ask the child to give a ‘thumbs up’ sign, which tests the extensor pollicis lon- What do you do with the pink
gus. c) Testing ulnar motor function: ask the child to make a starfish sign, which tests the finger abductors. pulseless hand?

Up to 20% of displaced supracondylar fractures

fixation with a lateral-only technique and the may be lacking because neurovascular assess- present with an absent pulse.42 Vascular com-
use of a medial wire if the fixation appears ment can be difficult due to pain and anxiety or plications are usually caused by injury to the
unstable. In very young children, it can be tech- age of these patients. In addition to this, a lack of brachial artery, which can suffer a broad range
4 nically challenging to use lateral-only wires and familiarity of the junior medical team to assess of complications ranging from simple vascular
medial wires may be needed. Larger K-wires these nerves can be a problem. With the changes spasm, to intimal tear, interruption through
have been shown to provide superior biome- in on-call patterns and the introduction of ‘hos- kinking, or direct laceration.43 Patients with an
chanical stability and therefore the BOA advise pital at night’ in many institutions, junior doctors absent pulse and cool, white hand require
that 2 mm wires should be used, if possible unfamiliar with musculoskeletal and neurologi- urgent fracture reduction and restoration of the
(Table II).22 However, in practice, 1.6 mm cal examination are often asked to care for these circulation.41 BOA guidance recommends that
K-wires need to be used for smaller children, patients during out-of-hours periods. Davidson36 children presenting with an ischaemic limb
including most under six years of age. described assessment of neurological function should be discussed with the vascular team
using the ‘rock, paper, scissors’ game. The median prior to operative reduction.26 In cases of ischae-
nerve flexes the wrist and fingers into a rock, the mia, reduction of the fracture often restores the
How do you recognize and avoid
radial nerve extends the fingers to make paper vascular supply; therefore, fracture reduction
nerve injury?
and the ulnar nerve claws the ring and little fin- should not be delayed whilst waiting for angi-
Neurological injury, most commonly a transient ger during scissors, as well as abducting the ography studies.44 In cases where fracture
neuropraxia, is apparent in 11.3% of displaced index and middle finger.37 Another method, as reduction does not result in spontaneous return
supracondylar fractures.29 Injury of the median shown in Figure 2, is to ask the child to give of perfusion, urgent surgical exploration of the
nerve is the most common neurological injury thumbs up (radial nerve), make the ‘OK’ sign brachial artery should be undertaken. Symptoms
– this often presents as an anterior interosseous (AIN), and make a starfish sign (ulnar nerve). It is of complete median nerve dysfunction in con-
nerve (AIN) palsy but the pathoanatomy is an crucial that findings are well documented to junction with an absent pulse have been shown
injury to the fasicles of the AIN within the identify patients requiring urgent intervention to be a strong predictor of nerve and vessel
median nerve (the AIN fascicles are located at and to allow changes in neurovascular status to entrapment, and this is an indication for urgent
the dorsal aspect of the median nerve prior to be monitored over time. In very young or unco- surgical exploration.45
emerging as the AIN distal to the elbow).30,31 operative patients, the tactile adherence test can The pink, pulseless hand is a more common
Nerve injuries may result from traction, direct also be extremely useful: when a ballpoint pen is presentation and causes much debate. These are
trauma, or ischaemia of nerves.32,33 lightly drawn across the skin, there is loss of fric- often not treated as an emergency, with most
Preoperative documentation of neurovascu- tion due to loss of tactile adherence in an anhi- surgeons opting to rely on the presumption
lar status in supracondylar fractures is often drotic area resulting from autonomic nerve that the collateral blood supply is sufficient to
poor, particularly of the AIN.34,35 Documentation dysfunction.38 Ultimately, it is the responsibility maintain circulation.46 However, a systematic

Bone & Joint360 | volume 7 | issue 3 | june 2018

 Pulseless
supracondylar fracture

Cold, white, ischaemic

Pink, perfused hand
hand

Inform Urgent reduction

vascular of fracture
team

Pulse returns Patient

Emergency reduction remains
of fracture pulseless but
perfused

Hand remains Restoration of

pulseless pulse
Inpatient monitoring
for 48 hours

Exploration of
brachial artery 5
Fig. 3 Management of pulseless supracondylar fractures

review in 2010 that included 331 cases of pulse- Summary evidence questions this common assumption,47
less supracondylar fractures questions this com- Supracondylar fractures remain a challenging and these children should be treated in an urgent
mon practice, reporting that 70% of the pink, fracture to treat, and there continues to be debate manner. If the pulse does not return in patients
pulseless fractures had a documented brachial on the various controversies surrounding man- with a perfused upper limb, patients require care-
artery injury.47 The authors state that as up to agement. Undisplaced fractures can be managed ful inpatient monitoring for 48 to 72 hours,
20% of the population have some variation in conservatively, with the majority of surgeons watching for delayed vascular compromise.
the arterial anatomy of the upper arm,37,48,49 electing to fix displaced fractures with either
collateral circulation cannot be relied upon with crossed or lateral-only K-wires. Crossed K-wires The authors would like to acknowledge the art-
certainty. Management of pink, pulseless supra- provide a stronger biomechanical construct, work contribution of Mr A. Faulkner, Specialist
condylar fractures with no abnormal neurology which comes at the cost of increased risk of iatro- Registrar, East of Scotland Deanery (Figure 1).
remains controversial; however, urgent opera- genic ulnar nerve injury. The majority of supra-
tive reduction and reassessment of vascular condylar fractures can be treated in a semi-urgent References
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© 2018 The British Editorial Society of Bone & Joint Surgery. DOI: 10.1302/2048-0105.73.360607

Bone & Joint360 | volume 7 | issue 3 | june 2018