Supracondylar fractures are quite common in children. For the orthopaedists who treat them, the choice of treatment has always been clear for the type-I fracture (simple immobilization) and for the type-III fracture (operative reduction and fixation). The more difficult decision has involved the type-II fracture. The use of less aggressive treatment is supported by arguments such as: “It doesn’t look that bad,” and “The extension deformity will likely remodel.” The use of more aggressive treatment is supported by arguments such as: “The extension deformity might not remodel,” and “It’s easier to reduce and fix now than to perform an osteotomy later.” So, what is the right thing to do?
Hadlow et al. found that the use of pinning in forty-eight patients with a type-II supracondylar fracture would have resulted in 77% (thirty-seven patients) having an unnecessary procedure1. Parikh et al. reviewed the cases of twenty-five elbows treated with closed reduction and casting and found that 28% (seven elbows) had loss of reduction, 20% (five elbows) had delayed surgery, and 8% (two elbows) had unsatisfactory outcomes by the Flynn criteria2. These studies suggest that reduction and casting should be used as the initial treatment for the type-II fracture.
In contrast, Skaggs et al. treated sixty-nine type-II fractures with closed reduction and pinning3. There was no loss of reduction of any fracture. There was also no clinically evident cubitus varus, hyperextension, or loss of motion. There were no iatrogenic nerve palsies, and no patient required additional surgery. One patient had a pin-track infection. In a review of 189 type-II fractures treated by closed reduction and pinning, there were no malunions, delayed unions, or nerve or vascular injuries4. There were four pin-track infections, which resolved. These studies suggest that closed reduction and percutaneous pinning is safe and appropriate.
What about the extension deformity? Will it remodel with growth? The distal humeral physis contributes only 20% to the length of the humerus. Most of this occurs in the first three years of life5. It appears, therefore, that nonreductive treatment may be appropriate for toddlers (less than three years old) with a type-II fracture with some extension. For the older child (eight to ten years), only 10% of humeral growth remains, so reductive treatment with or without pinning is appropriate as remodeling is not likely to correct the hyperextension at the distal end of the humerus.
In their study, Dr. Moraleda and his coinvestigators reported on the long-term follow-up of patients treated with simple immobilization. While they found excellent functional results in the majority of patients, they also found mild residual hyperextension, mild decrease in flexion, and mild cubitus varus deformity in a substantial number of patients. The high prevalence of late cubitus varus deformity (26.1%) is likely to be surprising to most orthopaedists.
Practically, this study indicates that the natural history of the type-II fracture is not entirely benign. For children, with the exception of toddlers, treatments that involve reduction and pin fixation should likely be recommended.