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Open Reduction Techniques for Supracondylar Humerus Fractures in Children

Wingfield, Jessica Jane MD; Ho, Christine Ann MD; Abzug, Joshua M. MD; Ritzman, Todd F. MD; Brighton, Brian K. MD, MPH

JAAOS - Journal of the American Academy of Orthopaedic Surgeons: December 2015 - Volume 23 - Issue 12 - p e72–e80
doi: 10.5435/JAAOS-D-15-00295
Instructional Course Lecture
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Supracondylar humerus fractures are the most common elbow fractures in children. Displaced supracondylar humerus fractures that are associated with neurologic and/or vascular injuries are treated with timely reduction through closed techniques. When closed techniques fail, reduction by open methods is indicated. Controversy exists as to which surgical approach yields the best outcomes in terms of cosmetic and functional results, while minimizing postoperative complications. Open reduction, when indicated, has been shown to yield good outcomes when closed reduction methods fail.

From the Department of Orthopaedic Surgery, University of Texas Southwestern Medical School (Dr. Wingfield), and Texas Scottish Rite Hospital for Children, Dallas, TX (Dr. Ho), University of Maryland, Timonium, MD (Dr. Abzug), Akron Children’s Hospital, Akron, OH (Dr. Ritzman), and Carolinas HealthCare System/Levine Children’s Hospital, Charlotte, NC (Dr. Brighton).

This article, as well as other lectures presented at the Academy’s 2015 Annual Meeting, will be available in March 2016 in Instructional Course Lectures, Volume 65.

Dr. Ho or an immediate family member serves as a board member, owner, officer, or committee member of the Pediatric Orthopaedic Society of North America. Dr. Abzug or an immediate family member is a member of a speakers’ bureau or has made paid presentations on behalf of Checkpoint Surgical and serves as a paid consultant to Axogen. Dr. Ritzman or an immediate family member serves as an unpaid consultant to Apto Orthopaedics/Austin Bioinnovation Institute of Akron and has stock or stock options held in Apto Orthopaedics. Dr. Brighton serves as a paid consultant to DePuy and serves as a board member, owner, officer, or committee member of the Pediatric Orthopaedic Society of North American and the American College of Surgeons. Neither Dr. Wingfield nor any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this article.

Received June 08, 2015

Accepted July 12, 2015

Supracondylar humerus fractures are the most common elbow fracture injuries in children.1,2 Approximately 95% of these injuries are classified as extension-type patterns resulting from forced hyperextension of the elbow after a fall onto an outstretched arm.3 Fractures can be classified based on their direction of displacement in both the sagittal and the coronal planes, which has implications for the involvement of neural or vascular structures. The literature suggests that the standard of care for Gartland type III fractures is surgical management with closed reduction techniques and percutaneous pin fixation.4-6 Open reduction and percutaneous pin fixation is an acceptable method of treatment of those supracondylar humerus fractures that are not amenable to reduction by closed methods.2,5 However, no clear consensus exists regarding a preferred surgical approach when open reduction of a displaced supracondylar humerus fracture is indicated.

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Indications for Open Reduction

The most commonly reported indication for treatment with open reduction is failed treatment with closed methods.5 Additional indications for open treatment of supracondylar humerus fractures include débridement of open fractures, compartment syndrome, and neurologic and/or vascular injury that requires open exploration and potential repair.2,5,7

The most commonly cited cause of inability to achieve a satisfactory closed reduction is the interposition of the brachialis muscle, with button-holing of the metaphyseal spike through the muscle.1,7 Entrapment of the brachial artery and neurologic structures, such as the median nerve, has been reported.1,2 Interposition of the periosteum or joint capsule within the fracture site has also been described as a common cause of failed closed reduction. Ay et al7 reported an occurrence rate of 45.8% for proximal fragment metaphyseal spikes button-holing through the brachialis muscle, with capsular interposition occurring at a rate of 32.7% in cases requiring open reduction after failure of initial closed attempts.

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Neurovascular Injury Patterns Based on the Direction of Displacement

Specific implications for neurologic or vascular injury exist based on the direction of displacement of the distal fragment as well as the proximal metaphyseal spike. Some authors advocate selection of a surgical approach based on the direction of displacement.5 In a series of 65 cases requiring open reduction, a medial approach was used for posterolaterally displaced fractures as well as flexion-type injuries.5 A lateral approach was used for posteromedially displaced fractures. Direct posterior displacement was addressed through an anterior cubital fossa approach. The authors noted that the direction of exposure was chosen to avoid disruption of the intact periosteum because disruption could further destabilize the fracture or interrupt the blood supply.5 Furthermore, the direction of displacement has been shown to be a predictor of the nerve injury pattern. Posterolateral displacement is associated with median nerve and anterior interosseous nerve injuries (Figure 1). Ulnar nerve injuries most commonly occur with flexion-type deformities (Figure 2). Posteromedial displacement is associated with radial nerve injuries5,7-9 (Figure 3). Whereas posteromedial displacement is the most common injury pattern in displaced type III injuries, posterolateral displacement appears to be more prevalent among irreducible fractures.5,7

Figure 1

Figure 1

Figure 2

Figure 2

Figure 3

Figure 3

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Approaches for Open Reduction

Because of the instability and difficulty in maintaining reduction in supracondylar humerus fractures that require open reduction, it is highly recommended that the surgery be performed on a radiolucent arm board or hand table; use of the image intensifier portion of a C-arm fluoroscopy machine is not recommended. In these cases, it may be necessary to obtain a lateral fluoroscopic view of the fracture by rotating the arc of the fluoroscopy beam to 90° because the fracture may be too unstable to rotate the arm to obtain a lateral view. The surgical table should be rotated to 90° to align the fluoroscopic arm parallel with the bed. The authors’ preference is to position the fluoroscopy machine to approach from the head of the bed so that the C-arm is easily rotated for a lateral fluoroscopic view without the image intensifier hitting the bed (Figure 4). A radiolucent arm table or Plexiglass is used for the patient’s injured arm. Especially in toddlers and small children, the injured arm must be brought distal enough on the radiolucent table to facilitate complete fluoroscopic visualization. The fluoroscopy arm can then be easily rotated to a lateral view if needed. Folded towels under the elbow may be used to elevate the arm from the table to aid in obtaining a lateral view.

Figure 4

Figure 4

Regardless of the surgical approach used, once the fracture has been opened, reduction and fixation of the fracture is still often difficult and problematic because of the complete lack of stability related to the extensive periosteal stripping in these injuries. The reduction is often most stable at 90° of flexion, with a small folded towel under the distal fragment and the surgeon’s fingers manually holding the reduction of the metaphyseal spike to the distal piece. An assistant must then drive Kirschner wires (K-wires) “blind” across the fracture site. If provisional fixation can be obtained with this method, the fracture is often stable enough for the surgeon to remove his or her fingers, hyperflex the elbow, and pin the fracture using traditional closed methods. The initial provisional K-wires may then be removed. In situations in which no assistant is available, two retrograde K-wires can be placed percutaneously into the distal fragment up to the level of the fracture site. The fracture is then reduced and held by the surgeon’s fingers while the K-wires are driven across the proximal cortex. Because these fractures tend to be very unstable, the surgeon may prefer to use a cross-pinned configuration rather than an all-lateral pin construct, especially because the ulnar nerve can be visualized and protected in an open approach. However, preference for the use of cross-pins versus an all-lateral pin construct is controversial and highly surgeon-dependent.

The literature suggests multiple options exist for surgical approaches when open reduction is indicated, including anterior, posterior, medial, lateral, and variations of these. Approaches should allow for reduction that results in anatomic alignment, access to involved neural and/or vascular structures, and satisfactory cosmetic and functional outcomes while minimizing postoperative complications.1

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Authors’ Preference

Similar to Reitman et al,5 our preference is to use a surgical approach that is based on the location of the metaphyseal spike and the displacement of the distal fragment. Often, the dissection has already been accomplished by the metaphyseal spike, and the periosteum has been disrupted (Figure 5). This approach allows direct visualization of anatomic structures trapped or displaced by the metaphyseal spike. Care must be taken in planning the incision to avoid areas of skin compromise. Dissecting through skin that is already traumatized may lead to skin necrosis and complications in wound healing (Figure 6).

Figure 5

Figure 5

Figure 6

Figure 6

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Anterior Approach

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).

Figure 7

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.

Figure 8

Figure 8

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.

Figure 9

Figure 9

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).

Figure 10

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.

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Posterior Approach

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.

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Lateral Approach

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.

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Medial Approach

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.

Figure 11

Figure 11

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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

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Functional Outcomes

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.

Table 1

Table 1

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Cosmetic Outcomes

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

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Radiographic Outcomes

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

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Complications

Infection

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.

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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

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Vascular Injury

No iatrogenic vascular injuries have been reported during open reduction procedures for supracondylar humerus fractures.

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Compartment Syndrome

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

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Trochlear Osteonecrosis

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

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Nonunion

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

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Summary

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.

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References

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.

1. Pretell Mazzini J, Rodriguez Martin J, Andres Esteban EM: Surgical approaches for open reduction and pinning in severely displaced supracondylar humerus fractures in children: A systematic review. J Child Orthop 2010;4(2):143–152.
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 and internal fixation for supracondylar humerus fractures in children. J Pediatr Orthop 2001;21(2):157–161.
6. Kasser JR: Percutaneous pinning of supracondylar fractures of the humerus. Instr Course Lect 1992;41:385–390.
7. Ay S, Akinci M, Kamiloglu S, Ercetin O: Open reduction of displaced pediatric supracondylar humeral fractures through the anterior cubital approach. J Pediatr Orthop 2005;25(2):149–153.
8. Brown IC, Zinar DM: Traumatic and iatrogenic neurological complications after supracondylar humerus 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.
        19. Shakir H, Malik FA, Khalid W: Displaced supracondylar fractures of humerus in children treated with open reduction and cross K-wire fixation. JPMI 2010;24(4):301–306.
          Keywords:

          supracondylar humerus; open reduction; surgical technique; pediatric; elbow

          © 2015 by American Academy of Orthopaedic Surgeons