Management of Grossly Displaced Paediatric Supracondylar Humeral Fractures with Delayed Presentation by Closed Reduction and Percutaneous Pinning

Background: Management guidelines are not yet clear for these patients who present late with displaced supracondylar fracture. The aim of this prospective study was to evaluate the clinical, radiological and functional outcome following closed reduction and percutaneous pinning of widely displaced supracondylar fractures of the humerus presenting 24 hours or more after injury.
Patients and Methods: This prospective study was conducted at the Orthopaedic and Trauma Department of Dr Pinnamaneni Siddartha Institute of Medical Sciences and Research Foundation, Chinnoutpalli from January 2010 to July 2011. A total of 44 children were included in this study who had displaced supracondylar fracture of humerus presenting late ie, after 24 hours after injury and within a week. They were treated with closed reduction of the fracture and percutaneous pinning. Follow-up was done up to 12 months.
Results: Patients were assessed on the basis of Flynn’s criteria, there were 37 excellent, 6 good results and fair results in 1 case. There were 25 boys and 19 girls. The average age of the patients was 7.5 years (range: 4 to 12 years). Fall on the outstretched hand was the mechanism of injury in 36 patients, and the other 8 patients were pedestrians struck by a motor vehicle. Non-dominant extremity was more commonly involved (30 patients). In 24 patients the fracture was displaced posteromedially (54.54%), in 18 patients posterolaterally (40.90%), and 2 patients had isolated posterior displacement (2.54%). The average delay in presentation was 57.56 hours (range: 1 day to 6 days). The mean time to surgery after presentation was 9.83 hours (range: 4 hours to 13 hours) and the mean time to surgery after trauma was 67.39 hours. Sixteen patients had one or more attempts of reduction by massaging by a quack and in 2 patients it was attempted by a qualified surgeon before they presented to us. 26 patients (59.09) visited a quack prior to presentation to us. There was a direct relation between duration of delayed presentation and the times of manoeuvre. Sixteen patients (36.36%) had neurologic complications at presentation to the emergency room of which three had median nerve palsy (6.81%) where as seven (15.90%) had isolated anterior interosseous nerve palsy and six (13.6%) had radial nerve palsy all patients showed total neurological recovery at 12 weeks follow-up. Six patients (13.63%) had vascular compromise at initial presentation of which five patients had feeble radial pulse and one had absent radial pulse, but capillary filling was adequate in all. The pulse was restored within 24 hours in all patients following reduction.
Conclusion: Our preliminary results support our recommendation ie, closed reduction and percutaneous pin fixation as an effective treatment option for grossly displaced supracondylar fractures presenting late but requires good and careful judgment and also technique by the surgeon to avoid complications. Our results also support the chances of spontaneous recovery of peripheral nerve palsy and brachial artery spasm post reduction over a period of time in majority of cases though they present late.