Cutting edge Orthopedics

Supracondylar Humerus Fractures • 13  Non-operative Management Indications for nonsurgical management of supracondylar humerus fractures include Gartland Type I fractures without neurovascular injury or instability [5, 8, 48, 49]. The lateral radiograph needs to be carefully assessed for displacement. If the anterior humeral line intersects the capitellum ossifi- cation center, the fracture is considered nondisplaced or minimally displaced, and non-operative treatment is recommended [19]. The AP radiograph should also be utilized to measure Baumann’s angle and rule out medial impaction that could lead to cubitus varus deformity [8]. When a non- displaced fracture is identified, initial treatment consists of a long arm cast with the elbow flexed 60°–90° [5, 9, 48]. Patients are typically immobilized for approximately 3 weeks, and then range of motion exercises are initiated [48, 50]. Range of motion typically returns in approximately 4–9 weeks with normal activities [51, 52]. Formal therapy is rarely required [8, 9, 52, 53], and equivalent range of motion outcomes can be expected at 1 year with or without physical therapy [53]. There is controversy regarding the best treatment for Type II fractures. Recommendations range from treating all Type II fractures with closed reduction and casting [54] to treating only Type IIA fractures with closed reduction and casting [55, 56] and to treating all Type II frac- tures with closed reduction and percutaneous pinning [5, 22, 34, 49, 57]. Despite supracondy- lar humerus fractures typically occurring in young children, only about 20% of the longitudinal growth of the humerus occurs distally [5, 12]. Therefore, a near-anatomic reduction is essential to decrease the risk of malunion [5, 9, 19]. The rationale for a trial of nonsurgical management is to limit the number of potentially unnecessary percutaneous fixations [58]. However, previous studies have reported a 23 [58] to 28% [54] loss of reduction in Type II fractures treated non- operatively. Additionally, an outcomes assessment of closed reduction and casting for Type II fractures indicated that up to 80% of children had residual deformity in the sagittal plane, 47% had deformity in the coronal plane, and 44% had rotational deformity [59]. Excellent functional outcomes have been reported in the majority of children in a cohort of Type II fractures that underwent immobilization without reduction; however, mild cubitus varus deformities, increased elbow extension, and decreased elbow flexion were reported [60]. In this cohort, patients with Type IIA fractures had a higher rate of sagittal plane deformity (83%) than Type IIB fractures (53%); however, the patient cohort consisted of predominantly Type IIA fracture types [59]. In a series of 69 Type II fractures that all underwent closed reduction and percutaneous pinning by Skaggs and colleagues (2004), no cases of loss of reduction were identified radiographically or clinically [61]. Percutaneous pinning eliminates the need for weekly radiographs in the office but requires a procedure performed in the operating room [9]. Closed Reduction and Percutaneous Pinning Indications Indications for closed reduction and percutaneous pinning (CRPP) include fractures that have dis- placed during attempted non-operative management and all Type III fractures [9]. Additionally,