Supracondylar humerus fracture is one of the most common injuries in children, accounting for 50–80% of all paediatric elbow fractures . During the past 5 years, more than 600 patients were treated for supracondylar humerus fracture in our department. About 12% of the patients were children older than 10 years of age. The main goals in paediatric supracondylar fracture treatment are as follows: achievement of normal cosmetic view of elbow, full recovery of elbow movements and protecting the patient from neurovascular complications that may occur. A common complication of paediatric supracondylar fractures is cubitus varus . Biomechanical tests have shown that stress and strain of the medial part of the distal humerus are greater than the lateral part under the axial load. Internal rotation of the distal fragment is the major predisposing factor to varus deformity and is necessary for coronal varus tilt . Stable reduction and fixation are important to prevent displacement of the distal fragment and postoperative deformity . The appropriate strength of fixation was different because the stress of the fracture varies with age and type. Several studies have shown higher incidence of displacement of supracondylar humerus fractures in older children . Satisfactory results can be achieved in Gartland type I and II fractures through closed reduction and immobilization by plaster or percutaneous pinning, which is not feasible in Gartland type III fractures as the fracture is usually associated with extremely swelling in the elbow region. Closed reduction may fail in situations such as delayed presentation and shortage of imaging facility. Soft tissue injuries and stripping of the periosteum resulting from repeated manual reduction were similar to those with open reduction. Percutaneous pinning may be dangerous as surface marking of bony landmarks is difficult. Royce et al.  treated 143 children with percutaneous crossed K-wires and described three ulnar secondary nerve palsies. Therefore, open reduction and internal fixation have been accepted for these widely displaced fractures with severe swelling not allowing acceptable closed reduction and primary neural disruption.
Four different surgical approaches have been described and every approach has its own advantages [9–11,18]. Anterior incision offers the advantage of a smaller scar and easy access to structures that might be injured between the fractured fragments. Ersan and colleagues reported that all 46 patients achieved satisfactory results on comparison of the anterior and lateral approach in the treatment of extension-type supracondylar humerus fractures in children. However, it is more technically demanding and excessive retraction of the wound can injure the ulnar nerve. The posterior approach is better than the other approaches in manipulation of fracture fragments, but it leads to poor functional results because of soft tissue injuries and fibrous surgical scars . Medial and lateral open reduction approaches lead to similar cosmetic outcomes and functional results. However, Weiland et al.  reported a higher incidence of cubitus varus with the use of the lateral approach, which does not allow complete visualization of the medial column communication and tilt. The medial approach provides good visualization, ensuring the restoration of the medial column, and it is a method that induces the least incision scar. At the same time, the influence on the elbow appearance is minimal because the medial approach is hidden.
In our study, three patients showed poor functional results, whereas none of the patients showed poor cosmetic results. We believe that more follow-up and physical training under the guidance of rehabilitation doctors may be needed to improve the range of motion in the elbow. Several studies have reported that iatrogenic ulnar nerve injuries are encountered in about 6% of patients with supracondylar fractures during percutaneous pinning, including direct penetration or laceration of the nerve or tacking down the nerve sheet in a nonanatomical position . The medial approach allows fracture reduction under visual guidance, which limits the risk of ulnar nerve injury, and has been recommended by several authors . The middle finger of the surgeon touches the broken end of the fracture through the medial incision to assist reduction. Anatomical reduction can always be achieved under the assistance of the finger. In our study, we did not encounter any iatrogenic ulnar nerve palsy. This finding was in agreement with many studies.
In the management of Gartland type III fractures, different pin configurations are used. Yaokreh et al.  reported that the postoperative secondary displacement rates were 10.4% in a case-series of cross-wire fixation. Flynn et al.  described three 72 (4.2%) patients with a cosmetically unsatisfactory result because of loss in the carrying angle. Shim and Lee  reported one patient with a cubitus varus deformity in their series of 63 (1.6%) patients treated by cross-fixation with three K-wires. Crossing of the pins in the fracture site is associated with secondary displacement. Skaggs et al.  recommended using three diverging lateral epicondylar pins when concerns arose about the stability of the fixation. The internal fixation should be more stable for older children. Several studies have shown that cross pinning provides more stable fixation than lateral diverge or parallel pinning, and reduces the incidence of cubitus varus because of the displacement of the distal part of the fracture [9,10]. In our study, fractures were fixed with three crossed K-wires (two inserted from the lateral side, followed by one from the medial side). Keeping the lateral K-wires apart and the cross points of these three K-wires proximal to the fracture line can lead to more stable fixation. No loss of reduction was found in our series. However, the carrying angle of the injuried elbow reduced 10°–15° compared with the contralateral side in two patients. It may be because the medial cortical compression remained when the lateral cortical continuity was restored. Considering the cosmetic factor, we should compare the injured side with the normal side to ensure that the carrying angle of elbows is similar.
In terms of our method of treatment, none of these patients had a significant cubitus varus or iatrogenic ulnar nerve injury. Also, no Volkmann ischaemic contractures or compartment syndromes were observed. All patients were followed up from 12 to 15 months, which may be considered adequate for screening possible complications. One limitation of this study was the lack of a control group for comparison.
All authors have participated sufficiently in this work concerning conception and design of this study, drafting the article, critical revision for important intellectual content, and final approval.
There are no conflicts of interest.
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