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Percutaneous fixation with Kirschner wires is recommended for supracondylar fractures of the humerus with displacement in children. The advantages of this easy technique are demonstrated.
Supracondylar fractures of the humerus have to be defined using delimitations. In children they amount to 10-16% of the upper extremity fractures and nearly always occur as extension types. Children between the age of 5 and 10 are involved most frequently. Errors of treatment and unfavourable results of therapy demonstrate the relevant difficulties. Conservative, semi-operative, and surgical forms of therapy do not compete with one another. The frequency of the open reduction is increasing. The results of treatment with various forms of therapy do not exhibit essential differences.
Of seven young children with epiphyseal separation in the distal end of the humerus and medial displacement of the distal fragment, five had significant cubitus varus (10 to 15 degrees) at follow-up. This rare injury therefore is one that is likely to produce that residual deformity.
Out of 87 displaced supracondylar fractures of the humerus in children, 17 were treated by open reduction and internal fixation, in eight cases because of vascular complications (with or without neurological complications) and in nine cases after unsatisfactory closed reduction. In the eight cases with vascular impairment, evacuation of the haematoma, reduction of the fracture and division of the fascia of the forearm caused a return of the radial pulse. Median nerve paralysis, in the four cases with neurological complications as well, recovered within 7 months. Fractures fixed with one pin only redislocated and needed an additional reduction--this procedure was associated with impairment of the range of motion. In spite of the selection of the most severe cases for surgery, the end result was excellent in all cases expect one and considerably better than previous results of closed reduction. Rotational deformity, however, did not decrease with age and growth.
In this paper, we discuss the results of osteosynthesis of humerus shaft fractures by means of "Bündelnagelung" basing on an overall statistic. The often feared and reproached rotational instability and malposition actually seldom occur. Motional stability allows an early physiotherapy.
We treated 14 cases of fracture of the shaft of the humerus with the functional method published by A. SARMIENTO in 1977, consisting of a plastic sleeve and early introduction of functional activity. The results were excellent, healing time and restoration of motion have been rapid.
This study reports on follow-up controls of 53 children with fractures of the humerus near the elbow-joint. 31 children had supracondylar fractures, 11 condylar fractures and 11 other lesions of the lateral epicondylus. The examination was carried out with special attention to functional aspects. A new own method for measuring the flexion force of the elbow is described. Baumanns angle and the dia-epiphyseal angle were taken into consideration when examining the X ray pictures. We obtained the best results when treating supracondylar fractures by Baumann's extension method. All condylar fractures should be operated on. The follow-up results were also excellent in the operatively fixed fractures of the lateral epicondylus.
The authors report 20 cases of internal fixation of the humerus by the internal route, they discuss the place of internal fixation among other therapeutic methods and recall the advantages of the supratrochlear internal route, more simple to carry out and always atraumatic. This method is however only used where orthopedic treatment has failed.
We have treated 16 consecutive cases of pathological fractures of the humerus with multiple Ender's nails introduced distally and without opening the fracture site. Stabilization was satisfactory in all cases and provided good pain relief and allowed early return of function. The technique is straightforward and has advantages over other methods of fixation.
The method of closed reduction and percutaneous K-wire fixation has been used for treatment of 20 children with displaced supracondylar fracture of the humeral bone. No infection, vascular or neural complication has been observed. In all cases good clinical and radiological results have been achieved. The authors conclude the method presented above should be used as a treatment of choice for displaced supracondylar fracture of the humerus in children.
During a six-year period we prospectively studied eight children who presented with supracondylar fractures of the humerus and of the forearm on the same side. They were treated by prompt closed reduction, percutaneous fixation with Kirschner wires, and appropriate management of neurovascular and soft-tissue injuries. The results were assessed clinically and radiographically at a minimum of 12 months after injury. According to a clinical scoring system they were acceptable in seven children and poor in one.
The mode of treatment used in 6 cases of combined supracondylar fracture of the humerus and ipsilateral forearm fracture is presented. Results were rated good, fair and poor according to both functional and radiological assessments. Three cases were good and 3 fair. One stage reduction of both fractures with plaster of Paris immobilization or olecranon traction has been performed. The results achieved are corresponding with those presented in the bibliography.
The subdermal vascular network skin flap of neck-shoulder-humerus (SVN flap) has been used to repair large defects of the face and neck in 33 cases in last ten years. The greatest flap was 9 cm x 27 cm. Clinical applications showed that SVN flap had many advantages including big size, thinness and high viability.
The authors evaluate retrospectively in a group of 121 children with a dislocated supracondylar fracture in 1984-1993 the results of different therapeutic methods. The highest percentage of excellent and satisfactory results was recorded in children treated by closed reposition with percutaneous pinning with Kirschner wires (88%). In open reposition with Kirschner wires 60% of the results were excellent of satisfactory. The lowest percentage of excellent and satisfactory results was recorded when fixation with a plaster bandage was used (48%). The highest percentage of poor results was observed in surgical reposition with internal fixation (37%). The cause of failure in the majority of patients is according to the authors inadequate reposition of fragments. The authors discuss different types of treatment. They recommend non-surgical reposition with percutaneous pinning, even for less dislocated extension supracondylar fractures of the humerus as well as for fractures complicated by vascular injuries.
Humeral shaft fractures are amenable to conservative treatment. In this article, the authors define their indications and methods of treatment of gunshot-caused fractures of the humerus. They emphasize use of a humeral fracture brace. Successful fracture brace treatment requires attention to and comprehension of proper technique. When used appropriately, fracture bracing is safer, less expensive, and more effective than surgical alternatives.
Isolated avulsion fracture of the lesser tuberosity of the humerus has been reported in few instances. We present a case in a 15-year-old boy who was injured 2 years earlier. Clinical, radiological and interoperative findings are presented and discussed.
The evaluation of 174 humeral shaft fractures treated operatively in our institution and a literature review are used to illustrate the indications for operative treatment. For some indications, the authors prefer Hackethal's bundle nails. A simple operative technique and a small approach incision far distant from the fracture site, which prevents the fracture hematoma, and the very low complication rate are the advantages of this method, making it an alternative to plating and even to bracing. Operative treatment is clearly indicated for compound fractures grades II and III. As the humerus--unlike the tibia--has a good soft tissue envelope, plating can be carried out without the danger of insufficient soft tissue coverage. Complete radial palsy is also an indication for primary operative nerve revision, followed by stable osteosynthesis, preferably with plate. In our series primary radial palsies were observed in 47 (27%) of cases; on revision we found 5 cases of nerve division and 2 of impingement between fragments. Further absolute indications are the rare injuries to the brachial artery, bilateral fractures, and combination with a forearm fracture ("floating elbow"). Closed fractures without concomitant injuries can generally be managed conservatively. We have treated 84 of these fractures with Hackethal's nails. The only serious complications were one non-union (1.2%) and one deep infection (1.2%).
The results of fifteen cases of non-union of the humerus following treatment of the fracture by internal fixation are presented. In these cases there are skin, soft tissue and bone problems which complicate the treatment, which is therefore not free of complications. The authors advocate endomedullary nailing accompanied by bone grafting as the simplest and safest procedure.