1 Introduction

The treatment of displaced supracondylar humerus fractures (SHFs) is a challenging problem which needs a strict vigilance and a proper management protocol.¹ Closed reduction and percutaneous pinning is recommended as the treatment of choice.² However, open reduction is indicated for irreducible fractures, vascular compromise, open fractures² and in those that cannot be reduced satisfactorily by closed methods.^3,4 Delayed presentation of displaced supracondylar fractures is common in developing countries.⁵ Its management guidelines are not clear. Several methods are described, including open reduction.⁶ Operative treatment is considered the best option for delayed presentation of fractures.⁵

Systematic reviews recommend prospective investigation of treatment options for SHFs that cannot be reduced by closed reduction,^7,8 and high quality level of evidence based studies on anterior approach are still limited^9,10 in literature. A direct anterior approach for open reduction can be used in most patients because it provides the best access to anatomic structures that hinder reduction viz. brachialis or joint capsule,¹¹ to neurovascular structures and to fracture site. The aim of our study was a prospective assessment, evaluation and comparison of the clinical outcome of open reduction with K-wires through anterior approach in delayed presentation and failed closed reduction of SHFs of children.

2 Materials and Methods

This was a single centre prospective cohort study conducted between June 2019 and May 2020. 26 children of Gartland II and III SHFs <15 years age,¹² with either delayed presentation i.e. duration of injury >7 days^5,13 or failed closed reduction after two closed attempts^14–16 were included in the study. 15 patients with failed closed reduction were allocated as Group A, and 11 patients with delayed presentation at admission were allocated as Group B. Open fractures, SHFs associated with other upper limb fractures, previous operations or fractures of elbow, neurovascular deficits, neuromuscular injuries, anatomical or congenital abnormalities or variations were excluded from the study.

The data analysis was done by an independent statistician to eliminate bias. Unpaired t-test for numerical data and Fischer's exact test or Freeman-Halton extension of Fischer's exact test for categorical data were used. A p-value of <0.05 was considered significant.

All patients were operated upon as soon as possible after necessary preoperative workup (Fig. 1A and B). The procedure was carried out in supine position under general anaesthesia with tourniquet control. The operation time was recorded from start of incision till the patient was weaned off from general anaesthesia.

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Fig. 1 Preoperative anteroposterior (A) and lateral (B) radiographs of elbow joint of a failed closed reduction Gartland III fracture. Immediate postoperative anteroposterior (C) and lateral (D) radiographs of elbow joint showing crossed K-wire configuration: 2 lateral-1 medial.

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2.1

2.1 Operative procedure

A 3–8 cm transverse incision was made following the flexor crease (Fig. 2A). Blunt dissection was done through the subcutaneous tissue (Fig. 2B). Biceps and brachialis were retracted medially, and brachioradialis laterally¹⁷ and neurovascular structures were identified and protected (Fig. 2C). If constrained, the brachial artery, median nerve or radial nerve¹⁶ was freed from the fracture site. If brachialis muscle was torn, the fracture site was approached through this rent with the thumb.¹⁸ Reduction was facilitated by pushing the proximal fragment with thumb while pulling the distal part with fingers³ positioned on the posterior aspect of olecranon;¹⁸ traction was performed on the forearm while flexing the elbow. When repositioning was difficult, a periosteal elevator was introduced between the fracture fragments¹⁵ to act as a lever. After confirming fracture reduction under fluoroscopy, the elbow was positioned on a folded towel. The K-wire was placed against lateral condyle, checked under AP fluoroscopy and then pushed through the skin into the cartilage (Fig. 2D). In the sagittal plane, the K-wire was started a bit anterior to the plane of fracture and angulated about 10–15° posteriorly. The pin was then advanced with a drill. After pins placement, the elbow was extended, reduction was fluoroscopically rechecked. When lateral pins did not stabilize the fracture, or there was an oblique fracture pattern, a medial pin was considered. After placing lateral entry pins, the elbow was fully extended; the medial epicondyle was palpated posterior to the center plane of distal humerus. A small skin incision was made anteriorly on the medial epicondyle to expose and protect the ulnar nerve. A drill guide was used to prevent binding of the perineural soft tissues. After desired pin placement, the nerve was inspected for impingement or kinking throughout flexion-extension arc of motion. The wires were bent and cut 1–2 cm off the skin. Vascular status was re-assessed. Sterile gauze was placed around the wires. If brachialis muscle was badly torn, it was repaired. The wound was closed back in layers.

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Fig. 2 (A) transverse incision made in anterior approach, (B) subcutaneous dissection done to expose the muscles, (C) intermuscular plane developed between biceps and brachialis medially and brachioradialis laterally, (D) placement of percutaneous K-wires.

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2.3

2.3 Follow up

The complete follow up assessment was done by a different team of orthopaedic surgeons to eliminate bias. Follow up was done after 2, 4, 8, 12, 24 weeks and 1 year. Suture removal was done in the 2nd week and active ROM exercises for shoulder and fingers were initiated. The long arm slab and K-wires were removed in 4 weeks after assessing clinical union (absence of tenderness to palpation). AP and lateral elbow radiograph were taken out of the splint (Fig. 3) to assess radiological union, early re-displacement, loss of reduction or rotational mal-alignment. Passive and active-assisted ROM exercises, superficial thermotherapy for elbow were initiated at 4 weeks. If full ROM was not achieved by 8 weeks, elbow physiotherapy was advised. Patients who had restriction of ROM were followed up at 12 and 24 weeks for assessment and appropriate physiotherapy.

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Fig. 3 Anteroposterior (E) and lateral (F) radiographs of elbow joint at 4 weeks showing union.

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At 1 year, final Range of Motion and carrying angle of both elbows was assessed clinically (Fig. 4) using goniometer. True AP and lateral elbow radiographs of both elbows were taken for measurement of difference in Baumann's angle. The outcome was being assessed by using the modified criteria¹⁹ developed by Flynn²⁰ (Table 1). The lower of the two ratings was considered for overall rating⁵ and varus deformity was graded as poor.^21–23

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Fig. 4 Clinical photographs showing assessment of flexion (G) and extension (H) range of motion, and carrying angle (I) during final follow up at 1 year.

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Table 1 Modified Flynn's criteria for outcome of supracondylar fractures.

Outcome	Rating	Cosmetic factor (carrying angle loss)	Functional factor (flexion loss)
Satisfactory	Excellent	0–5°	0–5°
	Good	6–10°	6–10°
	Fair	11–15°	11–15°
Unsatisfactory	Poor	>15°	>15°

3 Results

The overall mean age of the patients was 8.23 ± 2.75 years (range: 3–13 years). Peak incidence was found in the age group 5–8 years. 15 (57.69%) were male, and 11(42.31%) were female children. Left elbow was predominantly involved in 16 (62.54%) patients. The non-dominant arm was involved in 15 (57.69%) cases; the right-handed children were two times more likely to fracture their left hands, whereas the left-handed persons were slightly more likely to fracture their dominant hand. Majority cases (57.69%) sustained injury after fall from height, followed in order by injury after fall from ground level and Motor Vehicle Accident with 3 (11.54%) cases each. 6 (23.08%) patients were classified into Gartland type II- all type IIb, 20 (76.92%) patients were type III. Amongst type III, 7 (35%) patients had posteromedial (IIIa), and 13 (65%) patients had posterolateral (IIIb) displacement. All (100%) Group A fractures were Gartland III variety. Amongst Group B, 6 (54.55%) fractures were Gartland II, and 5 (45.45%) fractures were Gartland III variety. All the fractures were of extension variety. The distribution of the above mentioned variables for Group A and B are summarized in Table 2. There is no significant difference with respect to age, sex ratio, side involvement or arm dominance but there is a significant difference in Gartland variety of fractures between the two groups (Table 2).

Average time from injury to presentation of Group A was 16.73 ± 9.79 h (range: 4–40 h). Average delay of presentation of Group B was 10.45 ± 2.50 days (range: 8–15 days). In Group A, 1 patient received treatment at a rural health centre in the form of long posterior arm slab and 1 patient received manipulation by a bonesetter before presenting to us. In Group B, 3 patients received treatment by manipulation from a bonesetter, 2 patients received quack massage and 1 patient received some form of indigenous treatment with local massage and manipulation before presenting to us. This makes a total of 6 (54.55%) delayed patients who resorted to some forms of alternative medicine or quack or bonesetter as first line. All these patients had severe elbow swelling at presentation. Parents of 2 patients neglected the trauma of their child, 2 parents reported poor financial condition and 1 parent did not specify any reason for late presentation.

Average time from admission to surgery was 9.50 ± 6.28 h (range: 3–24 h). In Group A and Group B, it was 9.87 ± 5.88 h (range: 3–20 h) and 9.00 ± 7.04 h (range: 4–24 h) respectively, with no significant difference (p = 0.743).

Operative findings seen in Group A included 8 (57.14%) patients with brachialis muscle interposition between fracture fragments, 5 (35.71%) patients with a circumferential tear of periosteum and 1 (7.14%) patient with joint capsule interposed between the fragments causing inadequate closed reduction. Findings in Group B were inconspicuous due to muscle oedema and formation of fibrous tissue and soft tissue adhesions. Additionally, 2 patients who presented at Day 14 and Day 15 showed formation of callus around the fracture.

15 (57.69%) patients had 2 lateral K-wires. 6 (23.08%) patients had 1 lateral-1 medial K-wires. 5 (19.23%) patients had 2 lateral-1 medial K-wires. There is a significant difference regarding pin configuration between the groups (Table 3).

The mean operative time was 42 ± 6.25 min. In Group A and Group B, it was 43.20 ± 6.41 min and 40.36 ± 5.94 min respectively, with no significant difference (p = 0.256).

The average length of hospitalization was 4.58 ± 1.17 days. In Group A and Group B, it was 4.53 ± 0.99 days (range: 4–7 days) and 4.64 ± 1.43 days (range: 4–8 days) respectively, with no significant difference (p = 0.839).

1 (3.85%) patient developed a pin tract infection in the second post-operative week for which K-wire was removed in the second week, posterior long arm slab continued for 4 weeks, and oral antibiotic was given following culture and sensitivity. The infection resolved with 7 days of oral antibiotic.

The overall mean loss of Baumann's angle was 3.04 ± 1.68°; in Group A and Group B, it was 3.07 ± 1.75° and 3.00 ± 1.67° respectively with no significant difference (p = 0.952). No case of cubitus varus was recorded in our study.

All the patients regained full extension. No case of elbow hyperextension was noted. The overall mean loss of flexion was 3.46 ± 3.57°; in Group A and B, it was 3.27 ± 4.01° and 3.73 ± 3.04° respectively with no significant difference (p = 0.742). The overall mean loss of carrying angle was 2.23 ± 1.97°; in Group A and Group B, it was 2.13 ± 2.13° and 2.36 ± 1.80° respectively with no significant difference (p = 0.769). The distribution of Flynn's functional and cosmetic outcome for Group A and Group B are shown in Table 4. There is no significant difference in terms of the functional and cosmetic outcome between the two groups.

The overall outcome according to Flynn's criteria is: 21 (80.77%) patients had excellent results, 4 (15.38%) patients had good results, and 1 (3.85%) patient had fair result. None of the patients had poor results. The distribution of overall outcome in terms of Flynn's criteria for the two groups is shown in Table 5.

4 Discussion

Our results are comparable with literature in connection with the following demographic data: The fracture occurs in the peak age group of 5–8 years.^24,25 Males are predominantly affected.^3,12,24 The left side and non dominant extremity is frequently more injured.^2,24,25 The most common mechanism of injury is fall from height.^12,26 Among irreducible fractures, posterolateral displacement is two times more prevalent than posteromedial displacement although many studies indicate that posteromedial displacement is two to three times more prevalent than posterolateral displacement.² Vast majority of the fractures are extension type (95–98%).^24,27

Although closed reduction and percutaneous pinning is the preferred treatment of choice for displaced SHFs,^2,9 closed reduction fails in up to 25% cases and intra-operative reduction attempts often do not yield satisfactory results.⁴ Open reduction is indicated in such situation^3,4 because of higher incidence of stiffness and neurovascular complications encountered after repeated manipulations.^4,5 Delayed presentation of SHFs is a familiar scenario for developing countries.⁵ We encountered bonesetters, quacks, poor economic status, parents’ neglect, delayed referral from rural health centre, and various indigenous forms of treatment as reasons for which patients presented late in our study. Factors like lack of medical facilities, social and financial constraints,²⁸ illiteracy, lack of awareness, superstitions, cost, fear of surgery and availability provoke rural people to seek such treatments despite increased morbidity and disastrous complications.²⁴ Devnani et al.²⁹ reported the mean time of delayed presentation of 9 days, closely similar to our study (10.45 days). A major concern with delayed presentation is the inability to achieve satisfactory closed reduction because of swelling, thus producing higher chance of conversion to open reduction with literature reporting rate of conversion from <3% up to 46%.⁶ Our study also shows around 55% of delayed presentation patients with severe swelling. Operative treatment is considered the best option for such fractures.⁵

All failed closed reduction fractures in our study were of Gartland III variety which was statistically significant. Beck et al.³⁰ also showed that Gartland III factures was a statistically significant independent risk factor for closed reduction failure. Sun et al.³¹ additionally showed that Gartland III supracondylar fracture is a significant risk factor to warrant open reduction. The most common operative finding for failed closed reduction in our study was brachialis entrapment between fracture fragments, which is also documented in literature as the most common cause for failure of closed reduction. Other causes include joint capsule interpositioning, and entrapment of neurovascular structures-median nerve and brachial artery.^2,11,15,16 In delayed presentation, dorsal or posterior callus formation poses difficulty in fracture reduction as anterior approach does not give surgeon full exposure to remove the callus from the dorsal side of the fracture. Hence, posterior or dorsal callus formation should alert the surgeon regarding the use of anterior approach in our experience. Regarding K-wire configuration, both crossed-wire and lateral-wire fixation present satisfactory functional results. Crossed-wire fixation has a higher risk of iatrogenic neurologic injury, but show greater fixation stability, with a lower incidence of loss of fracture reduction.³² More than two wires are sometimes used particularly when fractures are unstable, either with three lateral wires or three to four wires in cross wire configuration.³³ Our study also showed more crossed pin configuration in failed closed reduction cases that was statistically significant. This correlates with all the fractures being severely displaced (Gartland III) in that group. Our operative time range was 28–53 min that is consistent with the range of 25–66 min amongst various studies;^3,17 the length of hospitalization was 4–8 days which also tallies with the range of 1–8 days documented in studies.^19,25

Complications reported with open reduction of SHFs by various approaches include infections-pin tract infection and wound infection, iatrogenic nerve/vascular injuries, scar problems, stiffness, delayed union, malunion, nonunion, trochlear osteonecrosis, compartment syndrome, cubitus varus.^5,9,16,34 Complications reported with anterior approach are minimal and shown in Table 6. Comparison of previous studies conducted on anterior approach with our study show similar or better results of our study (Table 6). Though many studies have previously been done on anterior approach, high quality level of evidence based studies, based upon anterior approach, are still limited.^9,10 Our prospective cohort study provides an in-depth analysis of the success of the anterior approach in delayed presentation and failed closed reduction of SHFs. Percutaneous leverage/joystick methods^35–38 using K-wire for fracture reduction have also been found effective in cases of failed closed reduction (Table 7). Herzog et al.³⁹ used percutaneous Schanz pin in the distal third of posterior humeral diaphysis for fracture reduction in such failed cases. Mini-open approaches¹⁷ are also described for reduction of irreducible fractures; however, opening the fracture site helps fracture hematoma decompression and decreases chances of Volkmann's ischaemic contracture.⁴⁰ Our study also advocates for this evidence as we did not encounter any case of compartment syndrome or Volkmann's ichaemic contracture. Joint decompression effect further may also improve hyperflexion posture that is crucial during maintaining the fracture in reduced position.⁴¹ Nevertheless, percutaneous leverage methods have their own limitations. Percutaneous leverage is impossible in older children due to tension in the triceps brachii and is recommended only for children ≤12 years.⁴² Percutaneous joystick leverage technique is completely ineffective in cases where the proximal fragment gets buttonholed in the brachialis muscle.²⁸ It is inappropriate for comminuted SHFs⁴³ and is contraindicated for posterior cortex communited fractures and in situations where neurovascular entrapment within fracture occurs.⁴⁴ Kao et al.⁴⁵ reported 2 cases of loss of reduction out of 34 Gartland III SHFs using percutaneous pin leverage technique. Yi-An Li et al.⁴¹ cautioned that a blind approach with a pin from the posterior site may endanger the nerves and arteries in the anterior aspect of the elbow.

Other approaches viz. posterior approach, lateral and medial approach have also been used for open reduction, but carry various disadvantages. Various published reports show poor visibility through medial and lateral approaches.³ Tiwari et al.⁵ reported avascular necrosis of trochlea as a potential complication with the use of mediolateral triceps sparing approach. Gruber and Hudson⁴⁶ found correlation of elbow motion restriction with posterior approach. Carcassonne et al.⁴⁷ advocated against the use of posterior approach as it injures the extensor structures in the presence of an already scarred anterior soft tissues. Lal and Bhan¹³ reported 85% incidence of myositis ossificans, 35% incidence of alteration of carrying angle and almost always restricted elbow movement with the use of posterior approach in delayed open reduction of SHFs. Omid et al.⁴⁸ recommended against use of posterior approach because of the high rate of loss of motion and risk of osteonecrosis. Mazzini et al.⁹ in their systematic review reported high frequency of poor functional and cosmetic outcomes with posterior approach. The pin tract infection rate tendency was higher with medial approach. There was a higher tendency to ulnar nerve injury with posterior and lateral approaches.⁹

We opine that the surgical goals for open reduction of SHFs should be exact anatomical reduction, firm fixation, and full range of motion, aesthetic cosmesis and no/minimal complications. With the anterior approach, we evaluated very satisfactory outcome in failed closed reduction and delayed presentation of SHFs. It allows safe, unimpeded access to fracture, facilitative fracture reduction and K-wire fixation, and visualization of structures that hinder reduction. This approach does not make any additional soft tissue damage, because it crosses through an area most commonly affected through trauma. It is cosmetically satisfactory; the skin incision mends aesthetically without any scar formation.

The limitations of our study include the limited number of patients and short duration of follow up. More studies need to be done with a larger sample size and longer duration of follow up for further analysis.

With the insights gained from our prospective cohort study, we found the anterior approach to be a technically demanding procedure which requires a learning curve for expertise. The surgeon needs to be well versed with the normal anatomy and exposure of neurovascular structures because the transverse incision does not give full exposure and visualization of the fracture fragments and the reduction is to be achieved directly with feedback from the thumb. Dorsal or posterior callus formation in delayed presentation should alert the surgeon as the exposure does not enable the surgeon to fully visualize the dorsal/posterior side. Placement of percutaneous K-wire is similarly a critical step, as entry of K-wires cannot be directly envisioned and requires experience to assess K-wire positioning with indirect feedback from the thumb.

5 Conclusion

We have experienced the anterior approach as a very safe, rational, efficient and satisfactory technique of treating SHFs in children with failed closed reduction or delayed presentation. It carries very low morbidity and excellent cosmetic and functional results in our study. The anterior approach can be the preferred method of choice for treating failed closed reduction or delayed presentation of SHFs.

Informed consent

Informed consent was obtained from all individual participants included in the study. Additional informed consent was obtained from all individual participants for whom identifying information is included in this article.

Ethical approval

All the procedures performed in our study involving human participants were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

CRediT authorship contribution statement

Rajdeep Das: Conceptualization, Methodology, Investigation, Software, Data curation, Writing – original draft, Writing – review & editing. Bipul Borthakur: Writing – review & editing, Software, Validation, Formal analysis, Resources, Visualization, Supervision, Project administration. Vikash Agarwala: Writing – original draft, Software, Validation, Formal analysis, Visualization, Supervision, Project administration. Shantasree Ghosh: Writing – original draft, Writing – review & editing, Visualization, Software, Resources.