Double joystick technique – a modified method facilitates operation of Gartlend type-Ⅲ supracondylar humeral fractures in children : Journal of Pediatric Orthopaedics B

Secondary Logo

Journal Logo

Advanced Search
Original Article

Double joystick technique – a modified method facilitates operation of Gartlend type-Ⅲ supracondylar humeral fractures in children

Li, Guangyao; Cheng, Xiqing; Zhang, Jingye; Sun, Yun; Cao, Zhiyuan; Liu, Yourao

Author Information

Affiliated Hospital of Jiujiang University, Jiujiang, Jiangxi Province, PR China

Received 14 August 2022 Accepted 16 February 2023.

Correspondence to Yourao Liu, Affiliated Hospital of Jiujiang University, No. 57, Xunyang East Road, Jiujiang, Jiangxi Province 332000, PR China Tel: +86 15179296488; e-mail: [email protected]

This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

Journal of Pediatric Orthopaedics B ():10.1097/BPB.0000000000001083, April 25, 2023. | DOI: 10.1097/BPB.0000000000001083
  • Open
  • PAP

Abstract

Supracondylar humerus fractures (SCHFs) account for 27% of all pediatric fracture types and 55–75% of elbow fractures in children, which are classified into two types: extension (98%) and flexion (2%) [1–3]. It has a risk of complex complications including neurovascular injury, compartment syndrome, reduction loss, and cubitus varus, some of which require repeated operations, greatly causing patients suffering. Fortunately, the incidence of many complications has been dramatically reduced by modern techniques, whereas the rate of cubitus varus leading to poor prognosis is still as high as 30% [4]. Therefore, more attention should be paid to SCHF in children.

According to the Gartland classification: type-Ⅲ fracture ends are completely separated without periosteal hinge, which is characterized by difficult reduction and severe instability, and easily results in elbow dysfunction [4,5]. These features might prompt surgeons to select open surgery for better reduction; however, numerous studies comparing closed Kirschner wiring to open reduction for the treatment of type-Ⅲ fractures have found that closed reduction has better outcomes with fewer complications [6–8]. Hence, closed reduction and percutaneous pinning (CRPP) is a preferred treatment for type-Ⅲ SCHF, and satisfactory reduction is the key to an excellent outcome [9].

Currently, various approaches have been developed to enhance the quality and efficiency of closed reduction for type-Ⅲ SCHF, among which joystick technology using Kirschner wire is a focal point [10–14]. Pei et al. [11] corrected anteroposterior (AP) angulation displacement using single leverage assistance for 27 children, with a rate of excellent and good outcomes was 96.3%. According to Dong et al. [12], a single Kirschner wire can be utilized to rotate the distal fragment in the sagittal plane until a satisfactory reduction of fracture ends, which can significantly improve the efficiency of operation. Interestingly, Wei et al. [13] improved the stability of the distal fragment for better alignment by applying a single trans-olecranon pin and obtained great results in 22 kids with multidirectionally unstable SCHF; however, we found that the rotational displacement of fracture ends is hardly corrected by using a single joystick in practice. Consequently, we attempted to improve this technique and found that two joysticks could be more efficient for operation. In this research, we evaluated the effectiveness of the double joystick technique during closed reduction of children with type-III SCHF through follow-up, and expect to conclude a more practical approach.

Methods

Patient information

From June 2020 to June 2022, 41 children with Gartland type-Ⅲ SCHF underwent CRPP at our hospital. Inclusion criteria: fresh closed injury of type-Ⅲ SCHF; aged 14 or less; affected limb had an intact function before trauma; complete clinical and radiographic data. Exclusion criteria: pathological fractures; with surgical contraindications or refusal of surgery. Finally, five (12.20%) cases were excluded due to incomplete data or loss to follow-up.

The data of 36 (87.80%) patients were collected from the electrical medical record system, including general information (age, sex, weight, etc), clinical information (injury history, operation time, complications, etc), and follow-up information (elbow motion, Baumann angle, carrying angle, etc). At each follow-up, X-ray examination and the Flynn criterion [15] were required to evaluate the outcome. All data were recorded by special personnel, and angle variables were independently measured three times by two senior orthopedists who did not participate in this study, and the average values of three times were recorded. This investigation was approved by the Affiliated Hospital of Jiujiang University Clinical Research Ethics Committee.

Double joystick technique

The patient was placed in a supine position with the affected shoulder and the C-arm extremity near the edge of the operating table after general anesthesia. Then, routine safeguarding, disinfection, and sheet laying were performed. A 2.0 mm Kirschner wire can provide enough strength for holding the fracture fragment and is often chosen [12].

First, the stability of the fracture ends was tested by image C-arm. Next, the manual reduction was attempted by finger extrusion during continuous axial traction at 40° elbow (Fig. 1a). After the initial reduction, a 2.0 mm Kirschner wire (main joystick) was inserted into the distal fragment through the olecranon (Fig. 1b). The main joystick was pushed up or down to correct angulation displacement in the sagittal plane, then was drilled into the medullary cavity of the distal humerus for temporary fixation after confirming rough reduction (Fig. 1c). Later, another 2.0 mm Kirschner wire (auxiliary joystick) was introduced laterally through the distal third of the humerus to penetrate the contralateral cortex (Fig. 1d), and fine reduction in the coronal plane was achieved by rotating or pushing the auxiliary joystick combined with a careful manipulation of another fragment.

F1
Fig. 1:
Closed reduction and percutaneous pinning through the double joystick technique for Gartland type-Ⅲ SCHF in a 3-year-old girl. (a) The broken ends of the fracture were separated and rotated, which were unstable. (b) Continuous axial traction was performed, and a 2.0 mm Kirschner wire (main joystick) was inserted into the distal fragment through the olecranon. (c) Pushing up or down the main joystick to correct the displacement in the sagittal plane and then drilled into the medullary cavity of the distal humerus for temporary fixation. (d) Another 2.0 mm Kirschner wire (auxiliary joystick) was introduced laterally through 1/3 of the distal humerus to penetrate the contralateral cortex. (e) The C-arm is rotated to an anteroposterior (AP) view showing the reduction of the distal fragment in the coronal plane. (f) The C-arm is rotated again to the lateral view. The sagittal displacement, angulation, and rotation of the two fracture ends are corrected by manipulation of two Kirschner wires. (g) Fixation of the distal fragment using one 2.0 mm Kirschner wire inserted laterally through the capitellum. (h) A second 2.0 mm Kirschner wire was introduced through the medial epicondyle of the humerus for further fixation. (i) A third 2.0 mm Kirschner wire was introduced laterally through the capitellum to complete the fixation, then two joysticks were removed to test elbow function. (j) Final C-arm AP and lateral views confirm the anatomic reduction of SCHF. SCHF, supracondylar humerus fracture.

When reduction in the image C-arm was basically satisfactory (Fig. 1e and f), a 2.0 mm Kirschner wire should be percutaneously inserted from the capitellum across the fracture line to engage the contralateral cortex (Fig. 1g). It should be noted that minor adjustment by two joysticks could still be made at this time, especially the rotational deformity. When the positive and lateral reduction was satisfactory, a second 2.0 mm Kirschner wire was inserted through the medial epicondyle of the humerus to fix the fracture ends (Fig. 1h). Finally, a third 2.0 mm Kirschner wire was introduced laterally through the capitellum to complete the fixation. After removing the two joysticks, the elbow motion and the stability of fracture ends were tested again (Fig. 1i and j). Three pin tails posited outside were cut and bent, and then the affected elbow was fixed at less than 70° flexion with a cast.

X-ray examination was performed 4 weeks after the operation to observe fracture healing. Once the fracture line is blurred, the three pins and cast should be removed and elbow exercises should be started. The recovery of elbow function was reviewed every 3–6 months in the outpatient department, which was evaluated by the range of motion (ROM), radiographs, and Flynn’s criteria and compared with the contralateral elbow at the last follow-up.

Statistical analysis

The statistical analysis was conducted by using SPSS software (version 22.0; Chicago, Illinois, USA). The measurement data were expressed as the means ± SD. Paired-sample T-test was used to compare differences. When P < 0.05, the difference was considered statistically significant.

Results

A group of 36 (36/41) patients, including 29 (80.56%) boys and seven (19.44%) girls, most of whom were 5–10 years old (Fig. 2). Their average age was 6.33 ± 2.68 years (range, 1–12 years), and their mean BMI was 18.63 kg/m2. There were more injuries on the left (61.11%) than right (38.89%). All fractures were of the extension type, with the most distal fragments radially displaced (55.56%) according to the radiograph. In addition, 22 (61.11%) children lived in the town, and the average interval between injury and operation was 23.46 ± 13.26 h (range, 4–54 h). The average time of surgery and hospital stay were 26.61 ± 7.51 min (range, 17–50 min) and 4.64 ± 1.23 days (range, 3–7 days), respectively.

F2
Fig. 2:
Categorical statistics of the general information of patients.

There were no complications regarding tissue infection, iatrogenic nerve damage, reduction loss, or cubitus varus during the follow-up (12.85 ± 6.13 months). Fractures healed in all patients, with a mean time of 5.53 weeks. In addition, the average Baumann angle of the affected elbow was 73.43 ± 3.78° (range, 66–85°) (Table 1). Although the average carrying angle (11.33 ± 2.17°), flexion angle (0.89 ± 3.23°), and extension angle (143.03 ± 5.15°) of the injured elbow were less than those of the contralateral elbow (P < 0.05), the mean ROM difference between the two sides was only 3.39 ± 1.59° (range, 0–9°). Furthermore, all patients obtained satisfactory recovery (36, 100%), with excellent (33, 91.67%) and good (3, 8.33%) outcomes at the last follow-up (Table 2).

Table 1 - Clinical information and follow-up results of included patients
Parameters Minimum Maximum Mean ± SD
Preoperative time (h) 4 54 23.46 ± 13.26
Operation time (min) 17 50 26.61 ± 7.51
Hospital stay (days) 3 7 4.64 ± 1.23
Follow-up time (months) 3 24 12.85 ± 6.13
Carrying angle (°) 5 15 11.33 ± 2.17*
Flexion angle (°) 129 150 143.03 ± 5.15*
Extension angle (°) -5 8 0.89 ± 3.23*
ROM difference (°) 0 9 3.39 ± 1.59
Baumann angle (°) 66 85 73.43 ± 3.78
ROM, range of motion.
*Comparsion of the affected side and the intact side, P < 0.05.

Table 2 - Follow-up outcome according to Flynn’s criteria
Results Rating Functional factor: motion loss (°) Cosmetic factor: carrying angle loss (°)
Satisfactory Excellent 0–5 (33, 91.67%) 0–5 (33, 91.67%)
Good 5–10 (3, 8.33%) 5–10 (3, 8.33%)
Fair 10–15 (0) 10–15 (0)
Unsatisfactory Poor >15 (0) >15 (0)

Discussion

SCHF is one of the most common fracture types in children, which is not hard to be diagnosed by clinical evaluation and radiographic examination; however, the physician must take note of vascular and neurologic examinations, especially the skin puckering combined with ecchymosis, which is a sign of considerable soft tissue injury. X-ray is a routine examination, but initial radiographs sometime show no evidence of a fracture except for a posterior fat-pad sign that is easily misdiagnosed. It is essential to identify the comminution of the medial column through the Baumann angle. In 1959, Gartland first classified SCHF into three types [5]: Type-Ⅰ is non-displaced or slightly displaced (<2 mm); Type-Ⅱ is displaced (>2 mm) with anterior cortex fracture; and Type-Ⅲ is severely displaced with fracture ends completely separated and rotated, often accompanied by complex complications, challenging treatment, and poor prognosis.

Cubitus varus is the most common complication following SCHF [16], which often leads to poor recovery with tardy posterolateral instability, particularly in type-Ⅲ fractures [17]. A previous study described that cubitus varus deformity was caused by unequal growth in the distal part of the humerus [18]; however, the most recognized reason for cubitus varus in children with SCHF is malunion rather than growth arrest [19–21]. Therefore, satisfactory reduction is crucial for an excellent outcome, which should be as close to the normal state as possible. In 1948, Swenson used percutaneous pinning during closed reduction to treat SCHF and obtained great clinical outcomes [19]. Then, CRPP has been widely applied and numerous studies further developed various methods that can effectively enhance its reduction quality [10–14], but the overall outcome is not ideal due to the limited remodeling ability of the elbow [4]. In this study, we have achieved better reduction using the double joystick technique, with 100% of patients obtaining satisfactory results.

Similar to other reports [1–4], 36 patients were mainly boys (80.56%), most of whom were 5–10 years old. It is worth noting that although obesity’s effect on long-term outcomes after CRPP of SCHF is uncertain [22], two of three boys who rated good were found to have a BMI > 28 kg/m2 in this group. Therefore, more follow-up research is required to deeply explore this matter and find a more accurate index of childhood obesity. In addition, the average interval between injuries (23.46 ± 13.26 h) in our study is more than other reports [13,14], possibly because most patients lived in the town and required multiple referrals. This situation indicated that the awareness and treatment of type-Ⅲ SCHF in primary hospitals is inadequate, and a more practical approach is urgently needed. Besides, the reason why our hospital stay (4.64 ± 1.23 days) is longer than in other studies is that anxious parents mostly ask for postoperative observation for a few days in the hospital.

Regarding the complications of type-Ⅲ fractures, the prevalence of absent pulse is as high as 20% [23]. Several researches have recommended angiography or duplex ultrasound to be an unnecessary test that has no bearing on treatment, and it is an emergency that the affected arm is pulseless with signs of poor perfusion [24,25]. Furthermore, Delniotis et al. [23] proposed that if the affected limb is pale, cold, and pulseless, urgent surgery should be conducted, and immediate exploration should be performed when the pulse cannot return or deterioration of the neurovascular status occurs. It is remarkable that excessive flexion or extension may compromise the limb’s vascularity, and cast fixation at less than 70° flexion is recommended [26]. As for neurologic injuries, its rate had been reported to be 49%, but in most recent studies it has ranged between 10 and 20% [27]. Direct nerve contusion by the proximal fracture end is the most common, particularly the anterior interosseous nerve, which spontaneously recovers within 3–6 months [28,29]. Thus, closed reduction should first be attempted when nerve damage is associated with a closed SCHF. In our group, five of 36 children had finger numbness and completely recovered within 3 months after surgery. In addition, the compartment syndrome (rate from 0.1 to 0.3%) as a tricky matter is more common in type-Ⅲ than others, of which early detection and intervention usually lead to good results [9]. Meanwhile, Ramachandran et al. [30] emphasized that ecchymosis and severe swelling should alert the compartment syndrome potential even in the situation of an intact radial pulse with a good capillary refill. More attention must be paid to children with median nerve damage, as they will not gain pain in the volar compartment.

Traditionally, type-III SCHF was treated as an urgent procedure soon after admission; however, British Orthopedic Association Standards of Trauma guidelines [9] advocated that night-time operating is not necessary unless there is no pulse or signs of threatened skin viability. Moreover, Han et al. [31] have shown that a delay in operation, regardless of whether it is closed or open, for more than 12 h after trauma does not influence the outcomes of SCHF. Hence, it is permissible to delay such type-III fractures in the absence of trained assistants and staff, especially at night. On the other hand, the supine position as an ordinary placement in operation has the advantages of minimal time, allows for standard anesthesia management, and easily switches to an anterior approach when open reduction is needed [32]. Furthermore, Pavone et al. [33] proposed that the prone position could be seen as an efficient alternative, which can achieve an easier reduction with safer pin placement and more comfortable use of the C-arm, despite there being similar outcomes between the supine and prone positions. We considered that the best strategy is to perform the operation under full preparation and choose the appropriate surgical position according to the individual.

CRPP has been a gold standard treatment for type-Ⅲ SCHF [1,4,9]. If there is less operation time, the less fluoroscopy and repeated manipulation would be. In this study, the period between initial reduction and final fixation with the cast was deemed as the operation time. Although our average operation time (26.61 ± 7.51 min) was similar to other reports [10–14], the lower SD indicated less fluctuation each time and the efficiency of the double joystick technique. Moreover, this difference may be caused by different inclusion criteria (including type-Ⅱ and type-Ⅲ fractures) and definitions of operation time (may exclude the time of plaster fixation) [10–14], so our data is still valid. On the other side, despite there being a statistical difference in carrying angle between the two elbows at the last follow-up (Table 1), all patients achieved (91.67%) and good (8.33%) results without complications, and the ROM difference was only 3.39 ± 1.59°. Novais et al. [10] reported an excellent outcome of the joystick technique with average differences in ROM and carrying angle between two elbows were 4.38 ± 1.65° and 11.63 ± 1.65°, respectively. Pei et al. [11] also obtained great results by leverage application and measured the angle varies of the affected elbow at the last follow-up: 26 (96.30%) patients had 0–10° loss of carrying angle and ROM, and one (3.70%) had 10–15° loss. Furthermore, Wang et al. [14] used their joystick technique to treat 36 type-Ⅱ and 32 type-Ⅲ fractures and found that 22 (68.75%) children had 0–5° loss of ROM and carrying angle in the type-Ⅲ group. Therefore, our method is safe and useful compared to the other studies [10–14]. And this difference may be caused by the short follow-up time or small sample size.

Generally, the CRPP is easier to correct lateral displacement or AP angulation than to repair the rotational displacement of type-Ⅲ fractures, which is particularly the main cause of failure [34]. To improve the success rate of CRPP, Novais et al. [10] used a single joystick technique for the treatment of multidirectionally unstable SCHF in eight children, who obtained excellent outcomes meaning both the carrying angle and elbow motion were lost < 5°; however, it is difficult to laterally pin through the distal fragment in the low-position SCHF, and the stability of pin is not enough. Therefore, Wei et al. [13] further applied a trans-olecranon pin to improve the stability of distal fragment for multidirectionally unstable SCHF that could effectively reduce the surgical time (25.3 ± 9.1 min) and enhance reduction quality (Baumann angle: 72.4 ± 2.3°) with fewer complications. Considering that the proximal fracture fragment is also rotated, Dong et al. [12] recommended that a single Kirschner wire be introduced from back to front through the unilateral cortex at 1.0 cm above the proximal fracture end to correct the rotational deformity, and found that 72.22% cases obtained excellent recovery with the average Baumann angle (73.8 ± 5.7°) and frequency of fluoroscopy (4.3 ± 1.1 times) were better than traditional reduction group; however, we found it is not easy to reduce two fracture ends using a single pin in the practice. Furthermore, percutaneous pinning through the unilateral cortex may sometimes not be stable enough. Even the leverage-assisted reduction method can effectively correct AP angulation, but hardly correct the rotational displacement of type-Ⅲ fractures. Therefore, we improved the joystick technique as two Kirschner wires were inserted through the olecranon and the 1/3 of the distal humerus to manipulate two fragments, respectively. Then the two fracture ends were actively aligned with each other under manipulation, just like a jigsaw puzzle, rather than a fragment passively approaching one another.

Reviewing the literature, there is no consensus on the Kirschner wire fixation for SCHF [35–38]. Although the cadaveric model study has illustrated that crossed pinning can provide better stability than lateral pinning [38], many clinical studies have shown that there is no obvious difference between the two methods in maintaining fracture reduction [35–37]. In our view, a three-wires crossed configuration is necessary when the coronal plane present on one side is high with another side collapsed. If the fracture line is flat in the coronal plane, the fixation method could be chosen according to personal proficiency. On the other hand, it has been reported that the risk of iatrogenic ulnar nerve injury is increased eight-fold by cross-needle threading [39]. Interestingly, Li et al. [8] suggested that the incidence of nerve injury could be dramatically reduced when a microincision is assisted before medial needle threading. In our experience, touching the path of the ulnar nerve and then using the thumb to push the ulnar nerve away from the expected puncture point, while medial pinning at mild elbow flexion, can effectively protect the nerve. And there was no case of iatrogenic nerve injury in our study, which also verified the effectiveness of this method.

There are still some limitations to this research. First, we did not include previous cases that underwent manual reduction alone for comparison, owing to our proficiency and success rate of closed reduction have been improved significantly over time, and there is no special meaning for the difference. Second, we did not collect the data on the Baumann angle of the contralateral elbow because of a possible violation of the no-harm principle, and assessment of elbow motion with the carrying angle may be sufficient to evaluate the outcome. Third, the precise occurrence rate of open reduction may not be assessed because of the limitation of cases; however, this study has presented an effective method of the double joystick technique for type-Ⅲ SCHF, which could be easily popularized and applied.

Conclusion

The outcomes show that the double joystick technique is a practical method for closed reduction of Gartland type-Ⅲ SCHF in children, which has the advantages of less operation time and better reduction quality without raising the risk of complications. Furthermore, there is no complex manipulation, no high requirements, and a relatively short learning curve for beginners, which could be conducive to promotion and application in primary hospitals.

Acknowledgements

This study was supported by funds from the Science and Technology Plan of Jiangxi Health Commission, China (SKJP220210875). The funders had no role in the study design, the data collection and analysis, the decision to publish, or the preparation of the manuscript.

Conflicts of interest

There are no conflicts of interest.

References

1. Zorrilla SNJ, Prada-Canizares A, Marti-Ciruelos R, Pretell-Mazzini J. Supracondylar humeral fractures in children: current concepts for management and prognosis. Int Orthop 2015; 39:2287–2296.
2. Khoshbin A, Leroux T, Wasserstein D, Wolfstadt J, Law PW, Mahomed N, et al. The epidemiology of paediatric supracondylar fracture fixation: a population-based study. Injury 2014; 45:701–708.
3. Young S, Fevang JM, Gullaksen G, Nilsen PT, Engesæter LB. Parent and patient satisfaction after treatment for supracondylar humerus fractures in 139 children: no difference between skeletal traction and crossed pin fixation at long-term followup. Adv Orthop 2012; 2012:958487.
4. Kumar V, Singh A. Fracture supracondylar humerus: a review. J Clin Diagn Res 2016; 10:RE01–RE06.
5. Gartland JJ. Management of supracondylar fractures of the humerus in children. Surg Gynecol Obstet 1959; 109:145–154.
6. Weiland AJ, Meyer S, Tolo VT, Berg HL, Mueller J. Surgical treatment of displaced supracondylar fractures of the humerus in children. analysis of fifty-two cases followed for five to fifteen years. J Bone Joint Surg Am 1978; 60:657–661.
7. Kazimoglu C, Cetin M, Sener M, Aguş H, Kalanderer O. Operative management of type III extension supracondylar fractures in children. Int Orthop 2009; 33:1089–1094.
8. Li M, Xu J, Hu T, Zhang M, Li F. Surgical management of Gartland type III supracondylar humerus fractures in older children: a retrospective study. J Pediatr Orthop B 2019; 28:530–535.
9. British Orthopaedic Association Trauma C. Supracondylar fractures of the humerus in children. Injury 2021; 52:376–377.
10. Novais EN, Andrade MA, Gomes DC. The use of a joystick technique facilitates closed reduction and percutaneous fixation of multidirectionally unstable supracondylar humeral fractures in children. J Pediatr Orthop 2013; 33:14–19.
11. Pei X, Mo Y, Huang P. Leverage application on Gartland type IV supracondylar humeral fracture in children. Int Orthop 2016; 40:2417–2422.
12. Dong L, Wang Y, Qi M, Wang S, Ying H, Shen Y. Auxiliary Kirschner wire technique in the closed reduction of children with Gartland type III supracondylar humerus fractures. Medicine (Baltim) 2019; 98:e16862.
13. Wei YS, Liu WL, Bai R, Li D-H, Zhao Z-Q, Wang Y, et al. The use of a transolecranon pin joystick technique in the treatment of multidirectionally unstable supracondylar humeral fractures in children. J Pediatr Orthop B 2020; 29:452–457.
14. Wang SB, Lin BH, Liu W, Wei G-J, Li Z-G, Yu N-C, et al. Modified closed reduction and percutaneous kirschner wires internal fixation for treatment of supracondylar humerus fractures in children. Curr Med Sci 2021; 41:777–781.
15. 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; 56:263–272.
16. Labelle H, Bunnell WP, Duhaime M, Poitras B. Cubitus varus deformity following supracondylar fractures of the humerus in children. J Pediatr Orthop 1982; 2:539–546.
17. O’Driscoll SW, Spinner RJ, McKee MD, Kibler WB, Hastings H, Morrey BF, et al. Tardy posterolateral rotatory instability of the elbow due to cubitus varus. J Bone Joint Surg Am 2001; 83:1358–1369.
18. Palmer EE, Niemann KM, Vesely D, Armstrong JH. Supracondylar fracture of the humerus in children. J Bone Joint Surg Am 1978; 60:653–656.
19. Swenson AL. The treatment of supracondylar fractures of the humerus by kirschner-wire transfixion. J Bone Joint Surg Am 1948; 30A:993–997.
20. Campbell CC, Waters PM, Emans JB, Kasser JR, Millis MB. Neurovascular injury and displacement in type III supracondylar humerus fractures. J Pediatr Orthop 1995; 15:47–52.
21. Ho CA. Cubitus varus – it’s more than just a crooked arm!. J Pediatr Orthop 2017; 37(Suppl 2):S37–S41.
22. DiBartola AC, Thakur N, Singh S, Quinion CD, Samora JB. Do obese children have poor patient-reported outcomes after closed reduction and percutaneous pin fixation of supracondylar humerus fractures? J Pediatr Orthop 2021; 41:e337–e341.
23. Delniotis I, Ktenidis K. The pulseless supracondylar humeral fracture: our experience and a 1-year follow-up. J Trauma Acute Care Surg 2018; 85:711–716.
24. Schoenecker PL, Delgado E, Rotman M, Sicard GA, Capelli AM. Pulseless arm in association with totally displaced supracondylar fracture. J Orthop Trauma 1996; 10:410–415.
25. Scannell BP, Jackson JB 3rd, Bray C, Roush TS, Brighton BK, Frick SL. The perfused, pulseless supracondylar humeral fracture: intermediate-term follow-up of vascular status and function. J Bone Joint Surg Am 2013; 95:1913–1919.
26. Seehausen DA, Kay RM, Ryan DD, Skaggs DL. Foam padding in casts accommodates soft tissue swelling and provides circumferential strength after fixation of supracondylar humerus fractures. J Pediatr Orthop 2015; 35:24–27.
27. Hockensmith LH, Muffly BT, Wattles MR, Snyder EN, McFarland BJ, Jacobs C, et al. Evaluating perioperative complications surrounding supracondylar humerus fractures: expanding indications for outpatient surgery. J Pediatr Orthop 2021; 41:e745–e749.
28. Shore BJ, Gillespie BT, Miller PE, Bae DS, Waters PM. Recovery of motor nerve injuries associated with displaced, extension-type pediatric supracondylar humerus fractures. J Pediatr Orthop 2019; 39:e652–e656.
29. Brown IC, Zinar DM. Traumatic and iatrogenic neurological complications after supracondylar humerus fractures in children. J Pediatr Orthop 1995; 15:440–443.
30. Ramachandran M, Skaggs DL, Crawford HA, Eastwood DM, Lalonde FD, Vitale MG, et al. Delaying treatment of supracondylar fractures in children: has the pendulum swung too far? J Bone Joint Surg Br 2008; 90:1228–1233.
31. Han QL, Wang YH, Liu F. Comparison of complications and results of early versus delayed surgery for Gartland type III supracondylar humeral fractures in pediatric patients. Orthop Surg 2011; 3:242–246.
32. De Pellegrin M, Fracassetti D, Moharamzadeh D, Origo C, Catena N. Advantages and disadvantages of the prone position in the surgical treatment of supracondylar humerus fractures in children. a literature review. Injury 2018; 49(Suppl 3):S37–S42.
33. Pavone V, Vescio A, Riccioli M, Culmone A, Cosentino P, Caponnetto M, et al. Is supine position superior to prone position in the surgical pinning of supracondylar humerus fracture in children? J Funct Morphol Kinesiol 2020; 5:57.
34. Herzog MA, Oliver SM, Ringler JR, Jones CB, Sietsema DL. Mid-America Orthopaedic Association Physician in training award: surgical technique: pediatric supracondylar humerus fractures: a technique to aid closed reduction. Clin Orthop Relat Res 2013; 471:1419–1426.
35. Zhao JG, Wang J, Zhang P. Is lateral pin fixation for displaced supracondylar fractures of the humerus better than crossed pins in children? Clin Orthop Relat Res 2013; 471:2942–2953.
36. Maity A, Saha D, Roy DS. A prospective randomised, controlled clinical trial comparing medial and lateral entry pinning with lateral entry pinning for percutaneous fixation of displaced extension type supracondylar fractures of the humerus in children. J Orthop Surg Res 2012; 7:6.
37. Yousri T, Tarassoli P, Whitehouse M, Monsell F, Khan WS. Systematic review of randomized controlled trials comparing efficacy of crossed versus lateral K-wire fixation in extension type Gartland type III supracondylar fractures of the humerus in children. Ortop Traumatol Rehabil 2012; 14:397–405.
38. Zionts LE, McKellop HA, Hathaway R. Torsional strength of pin configurations used to fix supracondylar fractures of the humerus in children. J Bone Joint Surg Am 1994; 76:253–256.
39. Abbott MD, Buchler L, Loder RT, Caltoum CB. Gartland type III supracondylar humerus fractures: outcome and complications as related to operative timing and pin configuration. J Child Orthop 2014; 8:473–477.
Keywords:

children; closed reduction; fracture; joystick technique; supracondylar humerus

Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc.