Because most supracondylar humerus fractures are extension-type injuries and because indications for open reduction of these injuries include exploration of the potentially injured neurovascular bundle, the anterior approach has the most utility (Figure 7).
An incision for the anterior approach is made in a transverse or “lazy S” fashion centered over the flexion crease of the antecubital fossa. Although our preference is to typically start with the transverse limb of the incision, the planned “lazy S” skin incision may be extended laterally, medially, proximally, and distally to gain exposure to structures if needed. Blunt dissection is used to complete the traumatic exposure down to the level of the proximal metaphyseal fragment. If the soft tissues have been disrupted by the sharp anterior metaphyseal spike of bone, then the dissection has been done for the surgeon (Figure 8). When this approach is used to extract interposed periosteum or muscle bellies from the fracture site, care should be taken to stay lateral to the biceps tendon to avoid potential iatrogenic neurologic or vascular injury.
The neurovascular bundle can be identified proximal to the fracture site, medial to the biceps tendon and muscle belly, and then carefully protected during any deeper dissection to the fracture site (Figure 9). However, blunt dissection should be performed carefully because the neurovascular bundle can be displaced into a nonanatomic position secondary to the injury. Interposed structures are then freed from the fracture site and a reduction is obtained under direct visualization and by palpation.
Reduction may be obtained by applying direct posterior pressure on the proximal fragment while the assistant pulls traction and flexes the elbow with direct pressure on the olecranon.7 When there is a significant amount of proximal displacement and shortening of the distal fragment, a baby Hohmann retractor or Freer elevator can be used to obtain traction and length by levering on the distal fragment with the tip of the instrument while balancing the shaft of the tool on the proximal metaphysis as a fulcrum. Careful, gentle pressure is required because rough force may lead to iatrogenic fracture of the metaphyseal cortex from the instrument. In addition, baby Hohmann or other retractors should be used to carefully protect the neurovascular structures during reduction to prevent iatrogenic injury.
One advantage of using the anterior approach is the ability to extend the incision to expose neurologic and/or vascular structures if they require exploration and/or repair.7,10,11 The neurovascular bundle can be safely identified proximal to the zone of injury and then carefully dissected to the fracture site. Often, the nerve and artery are intact but are trapped in fascial bands at the fracture, or the adventitial tissue is kinked in the fracture site; these structures can be simply and gently released from the offending structures.
Some clinicians also advocate the use of the anterior approach in patients in which vascular exploration of the brachial artery is anticipated.7,10 However, expertise in vascular surgery may be required in these situations, and availability of a surgeon with experience in end-to-end microanastomosis, vein grafts, and patch grafts should be considered before embarking on exploring the avascular hand (Figure 10).
Although the anterior approach has the most utility, great care is required by the surgeon to avoid iatrogenic injury to the anterior neurovascular structures.
Posterior triceps-sparing techniques, as well as those that require division of the tricipital aponeurosis, have been described.12,13 An incision made over the posterior distal humerus favors the medial side of midline. The ulnar nerve should be carefully identified and protected from the dissection. The distal tendinous portion of the triceps is incised and reflected laterally and medially to gain exposure to the distal humerus. The dissection is then carried down to expose the proximal metaphyseal spike. The interposed muscle or structures are removed and a reduction is achieved. The triceps is then reapproximated and repaired.13 Concerns regarding the potential disruption to the blood supply, resulting in osteonecrosis, have been raised with this approach.13-15 Additional uncertainties include increased rates of postoperative stiffness by adding a posterior dissection to an injury with an existing traumatic anterior soft-tissue injury.13,14,16 Because of these risks and the fact that typical soft-tissue interposition precluding reduction is anterior and remote from this approach, the posterior approach is rarely, if ever, used in our practice.
The lateral approach may be used for posteromedially displaced fractures in which the metaphyseal spike is buttonholed in the brachioradialis or lateral fascia. An incision is made over the lateral supracondylar ridge, the fascia is divided, and the plane between the brachioradialis and triceps is identified. The dissection is carried directly onto bone. The triceps can be reflected posteriorly and the brachioradialis carried anteriorly. If an extensile approach is required, the distal intermuscular plane is developed in Kocher’s interval between the anconeus and the extensor carpi ulnaris. In adults, dissection of >6 cm proximal to the lateral epicondyle is contraindicated to avoid injury to the radial nerve. Because there are no published studies regarding radial nerve anatomy in children, we advise surgeons to proceed with caution when the lateral approach is extended proximal to the metaphysis. Hematoma is removed from the fracture site and trapped structures are freed. Reduction is obtained under direct visualization and confirmed by fluoroscopy.
The medial approach is useful for posterolaterally displaced fractures and flexion-type fractures that cannot be reduced closed typically because of entrapment of the ulnar nerve; the medial approach allows direct access and visualization of the interposed nerve.
An incision is made over the medial aspect of the elbow after the medial epicondyle is palpated as an anatomic landmark. Dissection is carried down to the level of the ulnar nerve, which is carefully mobilized and protected from the surgical field. The exposure is carried down using blunt dissection until the distal aspect of the proximal fragment is identified by reflecting the brachialis muscle.16
Hematoma is evacuated and any trapped structures are released (Figure 11). Reduction is obtained by traction and manual pressure or by leverage with an elevator if necessary. For flexion-type injuries, folded sterile towels are placed under the olecranon and the elbow is positioned in extension to assist in reduction of the distal fragment. The reduction is confirmed by direct visualization and palpation and/or fluoroscopy before definitive K-wire fixation is obtained.
Results of Open Reduction
Multiple studies have described the functional, cosmetic, and radiographic outcomes of the various surgical approaches when open reduction is indicated.1,4,5,7,10,12,17
The primary determinate of functional outcome is postoperative range of motion. Flynn et al18 defined zero to 5° as an excellent outcome for loss of motion in the sagittal plane, whereas 5° to 10° is deemed a good result, 10° to 15° is a fair result, and >15° is characterized as a poor result (Table 1). In a systematic review by Pretell Mazzini et al,1 the authors reported a high frequency of poor results within the posterior approach group according to the criteria of Flynn et al.18 In a series comparing the open posterior triceps-sparing approach with a closed reduction cohort, 48% of patients requiring open reduction had fair to poor results using the criteria of Flynn et al18 and the Baumann angle to assess functional outcome results.12 Ay et al7 described a series of 61 patients with displaced supracondylar humerus fractures treated with open reduction through an anterior approach. Using the criteria of Flynn et al,18 they reported that 72.8% of patients had excellent results, 27.2% had good results, and no patients had fair or poor results. Ersan et al10 reported 50% excellent results and 47.4% good results from a lateral approach technique for open reduction evaluated according to the criteria of Flynn et al.18 Yaokreh et al4 reported 76% excellent or good results in their series of 25 patients who required open reduction using a medial approach. Supracondylar humerus fractures treated through open techniques, excluding the posterior approach, demonstrate favorable functional results similar to closed methods. The original study by Flynn et al18 of supracondylar humerus fractures treated with closed reduction and percutaneous fixation reported 98% satisfactory results in 52 cases with long-term follow-up.
Changes in the carrying angle as well as scar formation are cited as reasons for poor results. The criteria of Flynn et al18 are the most widely accepted measure of postoperative cosmetic outcomes (Table 1).
Higher rates of unsatisfactory cosmetic results have been reported with the posterior and lateral approaches.1,7,10,12 In the posterior approach with a triceps-sparing technique, 26% of the patients reported by Aktekin et al12 experienced fair to poor cosmetic outcomes according to the criteria of Flynn et al.18 Some authors have suggested that the posterior and lateral approaches do not allow surgeons to adequately address medial comminution, resulting in coronal plane abnormalities and alterations to the carrying angle.1 In one series of 32 patients requiring open reduction using an anterior approach, excellent cosmetic results were reported, with a low percentage of postoperative coronal plane deformities.7 Other clinicians have also reported 99% excellent or good results with the anterior approach.10 Open reduction via the medial approach has been associated with lower rates of changes in the carrying angle, with reported rates of 4% to 6%.4,19
Scar formation based on anatomic location of an incision has also been described as a cosmetic outcome. In a study of 84 patients who underwent open reduction and K-wire fixation, Ersan et al10 reported 2 cases of hypertrophic scar formation in 38 cases using a lateral incision; no cases were reported in 46 patients with an anterior cubital fossa incision. In posteriorly based incisions, rates of hypertrophic scar formation of up to 17% have been reported.12
Radiographic outcomes assessed in reviewed studies primarily measured radiographic time to union. In a systematic review of seven series by Pretell Mazzini et al,1 the authors found no significant difference based on anatomic approach regarding the radiographic time to union. The authors reported an average union time of 4.5 weeks for the lateral approach, 4.7 weeks for the medial approach, 4 weeks for the posterior approach, and 4 weeks for the anterior cubital fossa approach. In one series that was not included in this systematic review, 23 patients requiring open reduction through a posterior triceps-sparing approach had an average time to union of 7 weeks.12
Aktekin et al12 reported on 23 patients treated with open reduction through a posterior incision. In two patients, a superficial infection developed that required treatment with oral antibiotics; an additional two patients had wound dehiscence that resolved with local wound care that did not require further surgical treatment. None of these complications occurred in patients who presented with open fractures. In a systematic review of 226 cases examining various surgical techniques, no significant difference in the rates of postoperative infections was found, although there was a trend toward higher rates in the medial approach group that did not reach statistical significance.1 All reported cases resolved with oral antibiotics alone and did not require surgical treatment.
Iatrogenic Nerve Injury
In a series of 25 patients treated with open reduction through the medial approach, no cases of iatrogenic nerve injury were reported.4 Similarly, Ersan et al10 reported on a series of 84 patients, with 46 patients undergoing open reduction via an anterior incision; no cases of iatrogenic nerve injury were reported. In that same series, 38 patients were treated with open reduction via a lateral incision. Postoperative ulnar nerve symptoms developed in one patient; the authors did not use an additional medial incision to facilitate the placement of a medially based pin. The patient’s symptoms resolved following pin removal. In a review of 226 open reductions by Pretell Mazzini et al,1 the authors reported a 2.21% rate of iatrogenic nerve injury, with the ulnar nerve being most commonly involved. There was no statistically significant difference in the rate of nerve injury among the various approaches; however, there was a trend toward higher rates with both the lateral and posterior incisions where medially and laterally based pins were commonly used.1
No iatrogenic vascular injuries have been reported during open reduction procedures for supracondylar humerus fractures.
Compartment syndrome is a very rare complication of supracondylar humerus fractures. In our review of the literature, there were no reported cases of postoperative compartment syndrome after treatment with open reduction and percutaneous pin fixation.2,4,5,7,10,12,17
We are unaware of any reported cases of trochlear osteonecrosis in patients who underwent open reduction of a supracondylar humerus fracture through an anterior, lateral, or medial approach.4,7,10 However, in a series of 23 patients undergoing open reduction through a posterior technique, there were two reported cases of trochlear osteonecrosis.12 These complications support published results that a posterior dissection places the trochlear blood supply at risk in the pediatric patient.3,13,14 This complication results in limited elbow extension following trochlear resorption, leading to instability, proximal migration of the ulna, and subsequent posterior impingement of the olecranon onto the distal humerus.12
We were unable to find any reported cases of nonunion in displaced supracondylar humerus fractures in children that were managed with open reduction and percutaneous pin fixation1,4,5,7,10,12,17
Displaced supracondylar humerus fractures are common injuries in the pediatric population. The first line of treatment of these injuries is closed reduction and fixation with percutaneous pins. When treatment with closed reduction fails, reduction with open techniques is indicated and demonstrates favorable results. Multiple surgical approaches exist, including anterior, posterior, lateral, medial, and variations of these techniques. Many authors advocate the use of the anterior cubital fossa incision because it allows access to potentially injured neural and/or vascular structures and yields consistently good cosmetic and functional outcomes with low complication rates. The posterior approach is associated with the least satisfactory outcomes, most notably limitations in sagittal plane motion, as well as reported concerns with trochlear osteonecrosis and cosmetic outcomes. However, when comparing open reduction approaches in terms of infection rates, compartment syndrome, time to union, and iatrogenic nerve injury, no significant differences have been found among the different surgical approaches. Some authors advocate for the use of medial or laterally centered incisions based on the direction of displacement of the distal fragment to address potential nerve injuries around the displaced metaphyseal spike. Open reduction, when indicated, has been shown to yield good outcomes when closed reduction methods fail.
Evidence-based Medicine: Levels of evidence are described in the table of contents. In this article, reference 17 is a level II study. References 1, 10, and 12 are level III studies. References 2, 4, 5, 7-9, 13, 15, 16, 18, and 19 are level IV studies.
References printed in bold type are those published within the past 5 years.
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and pinning in severely displaced supracondylar humerus
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2. Koudstaal MJ, De Ridder VA, De Lange S, Ulrich C: Pediatric supracondylar humerus
fractures: The anterior approach. J Orthop Trauma 2002;16(6):409–412.
3. Tachdjian MO: Pediatric
Orthopedics. Philadelphia, PA, WB Saunders, 2014, vol 5, pp 1265–1293.
4. Yaokreh JB, Gicquel P, Schneider L, et al.: Compared outcomes after percutaneous pinning versus open reduction
in paediatric supracondylar elbow
fractures. Orthop Traumatol Surg Res 2012;98(6):645–651.
5. Reitman RD, Waters P, Millis M: Open reduction
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fractures in children. J Pediatr Orthop 2001;21(2):157–161.
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7. Ay S, Akinci M, Kamiloglu S, Ercetin O: Open reduction
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supracondylar humeral fractures through the anterior cubital approach. J Pediatr Orthop 2005;25(2):149–153.
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fractures in children. J Pediatr Orthop 1995;15(4):440–443.
9. Campbell CC, Waters PM, Emans JB, Kasser JR, Millis MB: Neurovascular injury and displacement in type III supracondylar humerus
fractures. J Pediatr Orthop 1995;15(1):47–52.
10. Ersan O, Gonen E, İlhan RD, Boysan E, Ates Y: Comparison of anterior and lateral approaches in the treatment of extension-type supracondylar humerus
fractures in children. J Pediatr Orthop B 2012;21(2):121–126.
11. Weisel SW: Operative Techniques in Pediatric
Orthopaedics. Philadelphia, PA, Lippincott Williams and Wilkins, 2010, pp 21–24.
12. Aktekin CN, Toprak A, Ozturk AM, Altay M, Ozkurt B, Tabak AY: Open reduction
via posterior triceps sparing approach in comparison with closed treatment of posteromedial displaced Gartland type III supracondylar humerus
fractures. J Pediatr Orthop B 2008;17(4):171–178.
13. Gruber MA, Healy WA III: The posterior approach to the elbow
revisited. J Pediatr Orthop 1996;16(2):215–219.
14. Kasser JR, Beaty JH: Supracondylar fractures of the distal humerus, in Beaty JH, Kasser JR (eds): Rockwood and Wilkins’ Fractures in Children, ed 6. Philadelphia, PA, Lippincott Williams and Wilkins, 2006, pp 543–589.
15. Naji UK, Zahid A, Faheem U: Type III supracondylar fracture humerus: Results of open reduction
and internal fixation after failed closed reduction. Rawal Med J 2010;35:156–159.
16. Kumar R, Kiran EK, Malhotra R, Bhan S: Surgical management of the severely displaced supracondylar fracture of the humerus in children. Injury 2002;33(6):517–522.
17. Kaewpornsawan K: Comparison between closed reduction with percutaneous pinning and open reduction
with pinning in children with closed totally displaced supracondylar humeral fractures: A randomized controlled trial. J Pediatr Orthop B 2001;10(2):131–137.
18. Flynn JC, Matthews JG, Benoit RL: Blind pinning of displaced supracondylar fractures of the humerus in children: Sixteen years’ experience with long-term follow-up. J Bone Joint Surg Am 1974;56(2):263–272.
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Keywords:© 2015 by American Academy of Orthopaedic Surgeons
supracondylar humerus; open reduction; surgical technique; pediatric; elbow