The prognostic value of the fracture level in the treatment of Gartland type III supracondylar humeral fracture in children

Abstract

A small proportion of children with Gartland type III supracondylar humeral fracture (SCHF) experience troubling limited or delayed recovery after operative treatment. We hypothesised that the fracture level relative to the isthmus of the humerus would affect the outcome. We retrospectively reviewed 230 children who underwent closed reduction and percutaneous pinning (CRPP) for their Gartland type III SCHFs between March 2003 and December 2012. There were 144 boys and 86 girls, with the mean age of six years (1.1 to 15.2). The clinico-radiological characteristics and surgical outcomes (recovery of the elbow range of movement, post-operative angulation, and the final Flynn grade) were recorded. Multivariate analysis was employed to identify prognostic factors that influenced outcome, including fracture level. Multivariate analysis revealed that a fracture below the humeral isthmus was significantly associated with poor prognosis in terms of the range of elbow movement (p < 0.001), angulation (p = 0.001) and Flynn grade (p = 0.003). Age over ten years was also a poor prognostic factor for recovery of the range of elbow movement (p = 0.027). This is the first study demonstrating a subclassification system of Gartland III fractures with prognostic significance. This will guide surgeons in peri-operative planning and counselling as well as directing future research aimed at improving outcomes.

Displaced supracondylar humeral fractures: influence of delay of surgery on the incidence of open reduction, complications and outcome

“…Further prognostic factors including the level of the fracture and the patient age at time of surgery have been proved important. Kang et al [47] revealed that fractures below the humeral isthmus are associated with poor outcome after surgical treatment. Commonly used classification systems as the classifications according to Gartland [41], Baumann [48], Lagrange and Rigault [49] or the AO Pediatric Comprehensive Classification of Long Bone Fractures [50] do not lay stress on the fracture level and therefore do not detect this prognostic factor.…”

Emergency or Delayed Surgical Treatment of Unstable Supracondylar Humeral Fractures in Children?

“…(15). Fracture is more common in boys (Table 1); this is explained by the fact that boys are more restless than girls (16). Despite the high incidence, we still do not have a generally accepted treatment for this fracture.…”

Effect of fracture location on rate of conversion to open reduction and clinical outcomes in pediatric gartland type 3 supracondylar humerus fractures

“…In supracondylar fractures, periosteum is detached from distal fragment. Small amount of distal fragment with torn periosteum in low-level supracondylar humerus fractures could make closed reduction challenging with risk of dynamic unstable fixation which is stated by Kang et al [11] The small distal fracture fragment precludes insertion of the wires from the appropriate points, and the inserted wires have reduced holding power, which makes it difficult to achieve closed reduction. These factors all demonstrate that fracture configuration is an important guide in planning surgical treatment and assessing clinical outcomes in supracondylar humerus fractures in children.…”

“…[3,4] Various studies have suggested associations between conversion to open reduction and factors such as time to operation, patient weight, surgeon experience, and excessive edema around the fracture; [5] however, no consensus has been reached regarding which patients are more likely to require conversion to open reduction. [6][7][8][9][10][11] Gartland type III fractures occur in the distal humerus and may be located above the isthmus (high level) (Fig. 1) or at/ below the isthmus (low level) (Fig.…”