New closed reduction technique for fractures

Supracondylar humeral fractures in children are common.1,2 They are usually encountered between the age of five and eight3 and account for around 60% of all elbow fractures in this age group,4 owing to the fact that, in the first decade of life, the tensile strength of the collateral ligaments and joint capsule of the elbow are greater than the bone itself.5 There are two types of supracondylar fracture, extension and flexion, with extension being the most common. The position of the limb and hand during a fall will determine the type of fracture sustained. The commonest mechanism of the injury is a fall onto the outstretched hand. There is evidence that this is due to the production of a bending moment by the olecranon on the distal humerus after a fall on the extended arm.6 The flexion type of fracture, however, usually results from a direct fall forcing the elbow into flexion.7 Extension type supracondylar fractures have been classifed by Gartland 8 primarily by the degree of displacement. Type I is an undisplaced fracture, type II is a hinge fracture with the posterior cortex intact and type III is a completely displaced fracture. Wilkins further sub classifies the type III group9 into III A and III B. Sub type III-A represents a distal fragment rotated posteromedially and sub type III-B rotated posterolaterally. The conventional treatment for a stable fracture is to place the elbow in a flexed position in a sling or an above elbow back slab.10 Unstable type II and III fractures, however, require anatomical reduction and stable fixation, usually with percutaneous Kirschner wires.11 There are numerous pinning techniques, each having their proponents.12-16 Two crossed Kirschner wires, one medial and one lateral, have been shown to be biomechanically superior to two lateral pins fixations in axial rotation.17,18 The treatment of displaced supracondylar fracture by closed reduction still remains a challenge. In recent years there has been an increasing trend for open operative fixation of these displaced fractures.19 Several methods have been described for closed reduction including longitudinal/ counter traction, Dunlop’s skin traction, skeletal traction in a brace, lateral external fixation, straight-arm lateral traction, and overhead olecranon traction.20-23

Standard technique for children

 The standard technique for displaced humeral supracondylar fractures in children involves longitudinal counter traction with pin transfixation either open or closed.24,25 Achieving closed reduction can be a difficult task, and surgeons may have to resort to open reduction and fixation.19,26 Open reduction can caus more soft tissue damage and, of course, the risk of infection is higher than for a closed reduction. A new, consistently reproducible technique of closed reduction of type III extension supracondylar fractures has been undertaken at The Luton and Dunstable Hospital NHS Foundation Trust, led by orthopaedic surgeon Mr Elrasheid A Saed.