Pediatric patients have unique patterns of musculoskeletal injury as a result of exposure to different mechanisms of injury and differences in skeletal maturity. Certain fracture patterns are more common during the early stages of skeletal development than at skeletal maturity. Subsequently, management strategies change with advancing skeletal development.1
The supracondylar region of the humerus is a common site of fracture in children. In a pediatric population, it is the second most common fracture and the most common fracture to require surgical fixation.2–5 Although supracondylar humerus (SCH) fractures are very common in children, they are rarely seen at skeletal maturity. The age distribution of patients with SCH fractures shows a peak at age 7 years, with a low incidence in patients older than 18 years.2,6
The goal of this study was to compare the mechanism of injury and additional injuries, defined as injuries (bony, neurologic, or vascular) in addition to an isolated SCH fracture, and treatment strategies for SCH fractures in toddlers (<3 years) and older children (≥3 to 12 years). Specifically, this study focused on Gartland type III SCH fractures, the most troublesome fracture pattern. Examining differences and establishing a fundamental understanding of the features of SCH fractures in toddlers will help to guide treatment in this unique patient population.
Materials and Methods
Because of the low incidence of Gartland type III SCH fractures in toddlers, this analysis was conducted as a retrospective cohort study. After institutional review board approval was obtained, patients who were treated at a major tertiary pediatric trauma center between 2000 and 2015 were reviewed for inclusion in this study. For inclusion in the toddler group, patients were required to have sustained a Gartland type III SCH fracture before their third birthday. Patients were excluded if insufficient radiographic or clinical data were available. For inclusion in the older patient group, patients had to be between 3 and 12 years old at the time of injury.
From each chart, several factors were collected and compared, including demographics, additional injuries, mechanism of injury, physical location where the trauma occurred, number of pins, configuration of pins, postoperative complications, need for return to the operating room, length of follow-up, and compliance with the treatment plan.
Analysis was conducted with Excel version 2013 (Microsoft, Redmond, Washington), and Stata 14.2 (StataCorp, College Station, Texas). Statistical methods included standard descriptive statistics as well as chi-square or Fisher's exact test for all categorical variables and Student's t test for all continuous variables.
The toddler group included 94 patients (age range, 0.42–2.98 years), and the older patient group included 378 patients (age range, 3.00–12.34 years). In the toddler group, mean age was 2.11±0.64 years; in the older group, mean age was 6.32±1.89 years. Overall, 50% of the study participants were girls. Of the toddler group, 59% of patients were girls, and of the control group, 48% of patients were girls.
Most SCH fractures in toddlers occurred in the home (67%), whereas most fractures in older children occurred outside the home (P<.001). In older children, the most common site of injury was a playground (48%). For both groups, fall was the most common mechanism of injury. In the toddler group, 9 cases of suspected nonaccidental trauma (NAT) resulted in SCH fracture (9.6%). In the older children, only 1 case of SCH fracture resulted from suspected NAT. The incidence of NAT was significantly higher in toddlers (P<.001).
Additional injuries were more common in the older group (P<.001). Of the older children, 107 (28.3%) had an injury in addition to SCH fracture, whereas only 8 toddlers (8.5%) had an additional injury. Among older children, anterior interosseous palsy was the most common additional injury, seen in 15.3%. Among toddlers, anterior interosseous palsy was seen significantly less often, occurring in only 1 patient (P<.001). For toddlers, the most frequent additional finding was a pink hand with undetectable or decreased pulse, occurring in 5 patients (5.3%). This finding was seen in 35 (9.3%) older children. Although this finding was more common in older children, the difference was not statistically significant (P=.22). Medial nerve palsy was seen among 33 older children (8.7%), but there were no cases in toddlers. The study population included only 1 case of compartment syndrome, which occurred in the older patient group (Table 1).
Despite the differences in the etiology of injury and the presence of additional injury, data on the characteristics of the fractures showed several similarities between groups. No statistically significant difference was found in the incidence of open fractures (P=.59), although 5 open fractures occurred in older children and none occurred in toddlers. Mean age of patients with an open fracture was 6.01±2.0 years. Most of the fractures were extension-type fractures (97.8%). Flexion-type fractures were equally represented in both age groups (P=.42) (Table 1).
Treatment patterns differed for toddlers and older patients. Most patients (94.3%) were treated with closed reduction and percutaneous pinning, and a small number of patients required open surgery. Failure of closed reduction and the need for neurovascular exploration were both indications for conversion from closed reduction and percutaneous pinning to open surgery. Although 26 older children required open surgery, only 1 toddler required this treatment (P=.03). The configuration of pin fixation varied from 2 to 5 pins. Configurations of 2, 3, and 4 pins were used in both toddlers and older children; a configuration of 5 pins was used only once, in an older patient. Statistically significant variation was seen in the number of pins used to achieve fixation, with older patients requiring more pins on average (P<.001). Pin constructs with both medial and lateral entry points were used for patients in both age groups. Medial pins were used more often for toddlers (37.2%) than for older patients (18.3%) (P<.001) (Table 2). The study found 5 cases of postoperative ulnar nerve injury, all among older children. Of the 5 ulnar nerve injuries, 3 occurred in patients with crossed pin configurations.
Treatment Characteristics and Outcomes
Mean length of follow-up was 3.46±4.46 months. No difference was found between groups for mean length of follow-up (P=.83). Patients were evaluated for compliance with the treatment plan. Of the toddlers, 63.8% completed the treatment plan compared with 72.2% of older patients. No statistical difference was found (P=.11).
Cubitus varus was the most common complication among toddlers, affecting 7 (7.4%) in addition to 2 older children (0.5%); this difference was statistically significant (P<.001). Loss of reduction also was significantly more common among toddlers than among older children (P=.02). It occurred in 4 toddlers (4.3%) and 4 older children (1.0%) (Table 2). In addition, 4 toddlers (4.3%) returned to the operating room for additional treatment compared with 8 older children (2.1%). This difference was not statistically significant (P=.22).
Gartland type III SCH fractures are severe injuries for which operative intervention is the treatment of choice.7 Although this injury is most commonly seen in school age children, it also occurs in toddlers. This study was designed to investigate differences in SCH fractures between a group of toddlers and a group of older children to help inform management of these injuries. It is important for clinicians to recognize the unique features of SCH fractures occurring in toddlers. The data in this study provide novel insight into these differences and help to provide targeted care for toddlers.
Review of the toddlers with SCH fracture at a tertiary care center showed that these injuries more commonly occur at home in this age group, confirming previous work by Farnsworth et al.8 Additionally, the incidence of toddlers presenting with injuries that raised suspicion for NAT was significantly higher than that for older children. In the current toddler patient population, the rate of suspected NAT was an alarming 9.6%. Therefore, when evaluating a young child with SCH fracture, the clinician should have high suspicion for NAT. A thorough physical examination, in addition to examination of the injured elbow, should be performed. Additionally, a detailed history of the report of the event surrounding the injury should be documented. If red flags for NAT are noted, including an inconsistent account of the incident or a report of the injured child acting beyond the capabilities expected for the child's age, professionals from other disciplines, including child abuse specialists, may need to be involved. Identifying NAT is crucial; data show that failure to identify NAT and subsequent return to an unsafe environment can result in further injury in 50% of children and mortality in 10%.9 Therefore, orthopedic evaluation of an injured toddler with SCH fracture may be a critical point in the safety of these patients.
Additional injuries were more common in older patients, but also occurred among toddlers. This discrepancy may be explained by the difficulty of obtaining a reliable tertiary examination in a toddler with a fracture. Neurovascular assessment often is challenging in toddlers. Although no standard assessment method was used in this study, all patients were treated by fellowship-trained pediatric orthopedic surgeons at a tertiary care level I pediatric trauma hospital. In the absence of dedicated neurovascular assessment tools for very young children, the authors recommend that treating clinicians perform a comprehensive and thorough examination to avoid the possibility of missing subtle neurologic deficits.10
In the current study, toddlers were treated with medial pins more often than older children. The 2012 American Academy of Orthopaedic Surgeons clinical practice guideline for the treatment of pediatric SCH fractures recommended the use of 2 to 3 laterally introduced pins and cautioned against the use of medial pins because of the risk of ulnar nerve injury.11 However, the data cited in this recommendation included very little dedicated analysis of patients as young as those reported in the current study. The current data show that a medial pin can be a safe option for children younger than 3 years with SCH fracture because no cases of iatrogenic ulnar nerve injury occurred among the 35 toddlers who were treated with a medial pin. Although the authors do not recommend standard use of a medial pin to treat SCH fractures occurring in toddlers, they believe that, for these very young patients, a medial pin can be a safe option when deemed necessary by the treating surgeon. Unfortunately, because this study was a retrospective review, the authors cannot determine the exact reasons why a medial pin was used more commonly in toddlers. The authors speculate that there may have been multiple contributing factors, including less lateral bone stock in smaller elbows, necessitating a medial pin to achieve adequate fixation, and skeletal immaturity, resulting in fractures with low lateral fracture lines that would prohibit the placement of sufficient lateral pins to allow for adequate fixation. The use of medial pins was supported by Mehlman et al12 in a population of very young children with SCH fractures. In that study, infants who were treated with fixation of the lateral column only were 4.7 times more likely to experience loss of reduction vs comparably aged children who were treated with bicolumnar fixation.
Considerable research has been conducted to evaluate the contribution of pin configuration to loss of reduction and poor outcomes after SCH fracture7,13,14 as well as the biomechanical stability of different configurations.15,16 Despite the volumes of literature on the biomechanical stability of different pin constructs,7,13–16 no studies have reported the efficacy of these pin structures in a distinct population of toddlers with SCH fractures. Based on the current data on the predilection for toddlers to have cubitus varus and lose reduction, thorough intraoperative testing of the pin construct is recommended. The authors prefer this approach to ensure that each pin has bicortical fixation, as visualized on anteroposterior, lateral, and oblique fluoroscopic images, and they recommend gentle stress testing under fluoroscopy at the end of the procedure. These steps allow for confirmation of satisfactory reduction and testing for construct stability. This evaluation should occur, regardless of whether all lateral entry pins are used or if the fracture pattern necessitates a medial pin.
The retrospective nature of this study led to several limitations. In assessing neurovascular injury, no standardized criteria were used to define a deficit. Because patients were treated by various providers, differing thresholds for identifying a neurovascular deficit may have affected data collection. Similarly, no standardized method was used to assess suspicion for NAT. Therefore, further investigation into the mechanism of injury was at the individual discretion of the care team. Finally, no protocols were in place for pin construct. Therefore, all surgical decisions were at the discretion of the treating surgeon, and prospective studies with standardized criteria and protocols are needed to confirm these preliminary findings.
Despite design-based limitations, this is the largest study to date to address SCH fractures in a toddler population. It provides novel insight into the differences between type III SCH fractures in toddlers and older patients. Knowledge of these differences will help physicians who treat toddlers with SCH fractures to provide more targeted care and can provide a platform for future prospective studies.
- Silber JS, Flynn JM. Changing patterns of pediatric pelvic fractures with skeletal maturation: implications for classification and management. J Pediatr Orthop. 2002;22(1):22–26. doi:10.1097/01241398-200201000-00006 [CrossRef] PMID:11744848
- Landin LA, Danielsson LG. Elbow fractures in children: an epidemiological analysis of 589 cases. Acta Orthop Scand. 1986;57(4):309–312. doi:10.3109/17453678608994398 [CrossRef] PMID:3788491
- Beaty JH, Kasser JR, Rockwood CA, Wilkins KE. Rockwood and Wilkins' Fractures in Children, 7th ed. Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2010.
- Abzug JM, Herman MJ. Management of supracondylar humerus fractures in children: current concepts. J Am Acad Orthop Surg. 2012;20(2):69–77. doi:10.5435/JAAOS-20-02-069 [CrossRef] PMID:22302444
- Cheng JC, Shen WY. Limb fracture pattern in different pediatric age groups: a study of 3,350 children. J Orthop Trauma. 1993;7(1):15–22. doi:10.1097/00005131-199302000-00004 [CrossRef] PMID:8433194
- Otsuka NY, Kasser JR. Supracondylar fractures of the humerus in children. J Am Acad Orthop Surg. 1997;5(1):19–26. doi:10.5435/00124635-199701000-00003 [CrossRef] PMID:10797204
- Kocher MS, Kasser JR, Waters PM, et al. Lateral entry compared with medial and lateral entry pin fixation for completely displaced supracondylar humeral fractures in children: a randomized clinical trial. J Bone Joint Surg Am. 2007;89(4):706–712. doi:10.2106/00004623-200704000-00002 [CrossRef] PMID:17403790
- Farnsworth CL, Silva PD, Mubarak SJ. Etiology of supracondylar humerus fractures. J Pediatr Orthop. 1998;18(1):38–42. doi:10.1097/01241398-199801000-00008 [CrossRef] PMID:9449099
- Green M, Haggerty RJ. Physically Abused Children. Philadelphia, PA: WB Saunders; 1968.
- Wright E. Evaluating a paediatric neurovascular assessment tool. J Orthop Nurs. 2007;11(1):20–29. doi:10.1016/j.joon.2006.12.004 [CrossRef]
- Mulpuri K, Hosalkar H, Howard A. AAOS clinical practice guideline: the treatment of pediatric supracondylar humerus fractures. J Am Acad Orthop Surg. 2012;20(5):328–330. doi:10.5435/JAAOS-20-05-328 [CrossRef] PMID:22553105
- Mehlman CT, Denning JR, McCarthy JJ, Fisher ML. Infantile supracondylar humeral fractures (patients less than two years of age): twice as common in females and a high rate of mal-union with lateral column-only fixation. J Bone Joint Surg Am. 2019;101(1):25–34. doi:10.2106/JBJS.18.00391 [CrossRef] PMID:30601413
- Skaggs DL, Cluck MW, Mostofi A, Flynn JM, Kay RM. Lateral-entry pin fixation in the management of supracondylar fractures in children. J Bone Joint Surg Am. 2004;86(4):702–707. doi:10.2106/00004623-200404000-00006 [CrossRef] PMID:15069133
- Sankar WN, Hebela NM, Skaggs DL, Flynn JM. Loss of pin fixation in displaced supracondylar humeral fractures in children: causes and prevention. J Bone Joint Surg Am. 2007;89(4):713–717. PMID:17403791
- Lee SS, Mahar AT, Miesen D, Newton PO. Displaced pediatric supracondylar humerus fractures: biomechanical analysis of percutaneous pinning techniques. J Pediatr Orthop. 2002;22(4):440–443. doi:10.1097/01241398-200207000-00005 [CrossRef] PMID:12131437
- Larson L, Firoozbakhsh K, Passarelli R, Bosch P. Biomechanical analysis of pinning techniques for pediatric supracondylar humerus fractures. J Pediatr Orthop. 2006;26(5):573–578. doi:10.1097/01.bpo.0000230336.26652.1c [CrossRef] PMID:16932093
|Flexion-type fracture||3 (3.2%)||7 (1.9%)||.42|
|Open fracture||0 (0%)||5 (1.3%)||.59|
|Additional injury||8 (8.5%)||107 (28.3%)||<.001|
|Pulseless hand||5 (5.3%)||35 (9.3%)||.22|
|Anterior interosseous nerve palsy||1 (1.1%)||58 (15.3%)||<.001|
|Median nerve palsy||0 (0%)||33 (8.7%)||<.001|
Treatment Characteristics and Outcomes
|Characteristic or Outcome||No.||P|
|Medial pin||35 (37.2%)||69 (18.3%)||<.001|
|Open reduction||1 (1.1%)||31 (8.2%)||.01|
|Cubitus varus||7 (7.4%)||2 (0.5%)||<.001|
|Loss of reduction||4 (4.3%)||4 (1.1%)||.02|