Background: There is an uncommon subset of supracondylar humeral
fractures in children that are so unstable they can displace into both flexion
and extension. The purposes of this study were to describe this subset of
supracondylar fractures and to report a new technique of closed reduction and
percutaneous pinning for their treatment.
Methods: In a retrospective review of 297 consecutive displaced
supracondylar humeral fractures in children treated operatively at our
institution, we identified nine that were completely unstable with documented
displacement into both flexion and extension as seen on fluoroscopic
examination with the patient under anesthesia. We used a new technique for
closed reduction and fixation of these fractures, and then we assessed
fracture-healing and complications from the injury and treatment.
Results: All nine fractures were treated satisfactorily with closed
reduction and percutaneous pinning. The complication rate associated with
these unstable fractures was no higher than that associated with the 288 more
stable fractures. Seven of the nine fractures were stabilized with lateral
entry pin placement, and two fractures were stabilized with crossed medial and
lateral pins. None of the patients had a nonunion, cubitus varus, malunion,
additional surgery, or loss of motion.
Conclusions: In rare supracondylar fractures in children,
multidirectional instability results in displacement into flexion and/or
extension. This fracture can be classified as type IV according to the
Gartland system, as it is less stable than a Gartland type-III extension
supracondylar fracture. These fractures can be treated successfully with a new
technique of closed reduction and percutaneous pinning, thus avoiding open
Level of Evidence: Therapeutic Level IV. See Instructions
to Authors for a complete description of levels of evidence.