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Scientific Articles   |    
Lateral External Fixation—A New Surgical Technique for Displaced Unreducible Supracondylar Humeral Fractures in Children
Theddy Slongo, MD1; Timo Schmid, MD1; Kaye Wilkins, DVM, MD2; Alexander Joeris, MD1
1 Department of Surgical Pediatrics, Children's Hospital, University of Berne, CH-3010 Berne, Switzerland. E-mail address for T. Slongo: theddy.slongo@insel.ch. E-mail address for T. Schmid: timo.schmid@insel.ch. E-mail address for A. Joeris: alexander.joeris@insel.ch
2 Department of Orthopedics and Pediatrics, University of Texas Health Science Center at San Antonio, 560 Grandview Avenue, San Antonio, TX 78209
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Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.
Investigation performed at the Department of Surgical Pediatrics, Children's Hospital, University of Berne, Berne, Switzerland

The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2008 Aug 01;90(8):1690-1697. doi: 10.2106/JBJS.G.00528
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Abstract

Background: Percutaneous Kirschner wire fixation represents the classic treatment for displaced supracondylar humeral fractures in childhood. This type of treatment first requires satisfactory reduction of the fracture. Failure to achieve a satisfactory reduction or inadequate stabilization can result in instability of the fracture fragments, which can result in either an unsatisfactory cosmetic or functional outcome. In our experience, these problems can be overcome with the use of a small lateral external fixator.

Methods: Between 1999 and 2005, thirty-one of 170 Gartland type-III supracondylar humeral fractures were treated with a lateral external fixator. The outcome of treatment was analyzed with regard to limb alignment, elbow movement, cosmetic appearance, and patient satisfaction.

Results: In twenty-eight of the thirty-one patients, a satisfactory reduction was achieved with closed methods. All children except one had a normal or good range of movement. The cosmetic result was excellent in all cases. All of the children and their parents stated that they would choose this treatment again.

Conclusions: The use of a small lateral external fixator seems to be a safe alternative for the treatment of displaced supracondylar fractures of the humerus when a closed reduction appears to be unattainable by means of manipulation alone or when sufficient stability is not achieved with standard methods of Kirschner wire fixation.

Level of Evidence: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

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    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    Rahij Anwar
    Posted on August 14, 2008
    External Fixator for Supracondylar Fractures in Children: Is it Safe?
    University Hospital Of Lewisham, London SE13 6LH. UK

    To the Editor,

    We read the article ‘Lateral External Fixation For Displaced Unreducible Humeral Fractures in Children’ with great interest. We agree that the treatment of irreducible supracondylar fractures is challenging and often requires open reduction. In our experience, excessive swelling around the elbow and soft tissue interposition are perhaps the most common causes of failure of closed reduction. It is, therefore, difficult to understand how the administration of Schanz pins could reduce the completely displaced and rotated distal fragment without opening the fracture site. Alternatively, forced closed reduction of such a fracture and its subsequent maintenance with an external fixator might cause entrapment of the neurovascular structures at the fracture site leading to disastrous complications. Thus, we prefer open reduction as it allows careful clearance of all soft tissues from the fracture site and permits anatomic reduction of the fracture before fixation with K-wires.

    Due to the peculiar flattened and rounded shape of the distal humerus, the placement of Shanz pins may be quite challenging, especially if the distal fragment is small and the elbow is grossly swollen. The risks of pin slippage and neurovascular damage are high.

    The authors also used a Kirschner wire to achieve additional stability which casts doubt on the real need for the addition of an ‘external device’ which is unsightly and difficult to handle, especially in children. Another cross wire would probably achieve the same or better result instead of an external fixator. Accurately reduced fractures stabilized with K-wires rarely fail with the open method. Good range of movement is generally achieved with excercises.

    The risk of neurovascular complications, lack of compliance, pin site care and social embarrassment are issues that need to be considered, when treatment with external fixator is being offered, particularly to a child.

    In our opinion, a majority of surgeons and patients/parents would still feel more comfortable and confident with open reduction and fixation with wires for an irreducible supracondylar fracture of the humerus rather than resorting to ‘closed’ external fixation.

    The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

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