الفهرس 
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Abstract
The supracondylar fracture of the humerus is the
commonest fracture about the elbow in children. It
occurs where the humerus is widest and thinnest at
the level of the olecranon fossa. Its management is
one of the most clifficult of all injuries in chi l.dc;
hood. So the aim of our work is the retrospective comparative
study and evaluation of different lines of treat~
mente Our study was done on thirty patients having various
types of supracondylar f zact ure of the humerus admitted and
treated in multicentre.
Our cases were subjected to clinical study including
diagnosis of the fracture and the assessment of the results
and radiographic examination to confirm the diagnosis,
clear up the details of the fracture to guide the
method of reduction. to show the adequacy of reduction,
to know the cause of stiffness not responding to physio~
therapy. and to Rssess the osteotomy done for the correction
of cubitus varu~.
Results of our work were as follow:
_ The supracondylar fracture of the humerus was
6’].’37’f001. t&t-al ’elbow fractures.
_ The age varied from 1 to 12 years with the majority
of the cases betwean 5 and 8 years and the average
of 6 years.
- The ratio of male to female affection was
5:1.
- The left arm was more affected (63.33%) than
the right arm.
_ The commonest cause of extension type was
indirect trauma in the form of fallon the hand with
an outstretched arm, while the sole cause of the flexion
type was the direct trauma in the form of fall
on the flexed elbow.
- The incidence of extension type was 86.67% ,
while the flexion type was 13.33%.
_ The incidence of varus type was 56.67%, while
the valgus type was 30%.
- The closed type formed the vast majority of
the cases (96.67%) while, the open type was rare
(3.33%) •
- The transverse fracture was commoner (76.67%)
than the oblique fracture (20%). The comminuted fracture
was rare (3.33%).
Grade II was commoner (76.67%) than grade III
(20%). Grade I was rare (3.33%).
Mild swelling was present in grade I and
most of cases of grade II, while moderate and severe
swelling were present in the remainder of grade II and
all the cases of.grade III.
IT
Most of the cases ~eceived immediately after
txauma showed mild swellL~, while most of the delayed
cases (77.77%) showed mode~ate and seve~e swelling.
- The~e wexe 2 cases (6.67%) with ossociated f~actu~
es in the same ext~emity. One case with fracture
of the surgical neck of the humerus and another with
greenstick fracture of the middle thi~d of ulna.
Radial pulse was absent in only one case (3.33%)
because of the spasm of the brachial artery, so i\
~eappeared after the reduction.
The treatment of extension type was more
difficult than the flexion type. Extension type
showed a higher incidence of poor results ( 57.69%)
than the flexion type (25%).
100 % of g~ade I showed excellent results.
Grade II had less incidence of poo~ results
(52.17%) than grade III ( 66.67% ).
The incidence of poor ~esults in the comminuted
f~acture was higher ( 100%) than the oblique
fractures ( 66.67% ) ,and still th~~ the transve~
se f~acture ( 47.83% ).
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._ The cases wi th mild swelling gave better
xesults than with modexate and sevexe swelling. Mild
swelling had an incidence of poox results (28.57%)
less than moderate and severe swelling (75 %).
- The cases received immediately aftex trauma
showed a highex incidence of satisfactory results
(52.38% ) than delayed cases ( 33.33 %).
_ The cases treated by immobilization only
needing no manipulation ( group I ) showed the highest
incidence of satisfactory results (80%). Those
treated by manipulative reduction and immobilization
in flexion ( group II ) showed an incidence of
satisfactoxy results of 40%. The flexion type of
fractuxe treated by manipulative xeduction and immobilization
in extension (group IV ) showed satisfactory
xesults of an incidence of 66.67%. The extension
type of fracture treated by manipulative reduction
and immobilization in full extension of the elbow
and supination of the foxearm (.group III) showed
satisfactoxy results accoxding to the range of motion,
but poor xesults accoxding to the caxrying angle with
cubitus varus because of ignorance of change of plastex
when it became loose. The case trea ted by open xed uction
and internal fixation with 2 ~ossed Kixschnex
w Lres aft ez 2 nnnipulative trials (group V ) showed
poor result with loss of 70° of extension mevement.
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With xepeated attempts of ~eduction, the
incidence of satisfactory xesults decxeased. The incidence
of satisfactory xesults was 58.33% with one
tXial, 25% with 2 txials and 20% with 3 txials.
- Thexe was a highex incidence of satisfactoxy
results with 4 weeks (62.5%) than with 3 weeks
immobilization (42.86%) which was still higher than
with 6 weeks immobilization (37.5 %).
_ The incidence of poor results with inefficient
immobilization (81.82%) was highex than with
efficient immobilization (36.84 % ).
- Active excexcises in the form of elbow
flexion-extension movements and the forearm xotation
excexcises led to gxadual xecovexy of movements
aftex the xemoval of the plastex. Recovexy of extension
was faster than flexion. It occurred usually
after 2 weeks while flexion xecovexed slowly usually
after one month and may up to 6 months. Thexe was
only one case which was txeated by open xeduction and
intexnal fixation in which extension movement had a
slow progxess for 4 months aftex vmich 70° limitation
of extension persisted. Passive stretching, massage
and / or intensive active excercises led to stiffness.
The commonest complication was the loss of
flexion (80 %). It was 60% in group I , 90% in group
II ,in group III thexe was one case with 5°
limitation of flexion ( excellent ~ange ) and another
with 15° ( good range ) and in group IV it was
33.33%. The average loss of flexion was 18.5°. The
causesof loss of flexion were the delay in treatment,
repeated manipulations, inadequate ~eduction with residual
backward tilting, p~ematu~e removal of the plaste~,
long period of immobilization, inefficient immobilization
due to igno~ance of change of plast~
after it became loose and not performing check x-ray
at the fifth day to detect any redisplacement, passive
st~etching, massage and I or intensive active exce~
cises performed afte~ the ~emoval of plaster. It was
more disabling than loss of extension.
_ Loss of extension had an incidence of 13.33%.
It was 20% in group I, 5% in group II , 33.33% in
group IV and 100% in group V. The causes wez e
long pe~iod of immobilization in flexion, p~emature
removal of the plaste~, intensive active excercises,
in group IV residual forward tilt and in group
V two trials of manipulative ~eduction before open
reduction which was pe~formed by the injurious posterio~
surgical app~oach. This last 9ase produced
disfigurement and disability.
- Cubitus varus was the second common complication
(73.33%). It was 20% in group I, 85% in group II,
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100% in group III ( because of inefficient immobilization),
66.67%· in group TV • It occurred
moxe in vaxus type of fxacture (93.33%) than va-
19us type (85.7%). It was more in those immobilized
in supination (138.89%) .than midposition (85.71%)
and still than pronation (0%). The average decrease
of car ry ing angle was 18°. The causes of cubitus varus
were the init ial medial tilt ( in the case neglected
for 12 days), the residual medial tilt,
internal rotation, both of them, inefficient immobilization
leading to redisplacement and / or immobilization
in supination or midposition of the varus
fractuxes. The internal rotation predisposed to
medial tilt which was the direct cause of cubitus
vaxus. When the medial tilt was associated With internal
rotation, the decrease in carrying angle became
greater. It pxoduced cosmetic deformity but did not
affect the function. It could not be corrected by later
xemodelling.
-Cubitus valgus had an incidence of 3.33%. It
was 5% of group II. It was one case with 1° increase
of carxying angle. The cause was immobilization
of valgus type of fxacture with pronation of
the forearm. It had no influence on the function
or shape of elbow. It could not be corrected by
later remodelling.
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_ Rotation deformity was always internal. It was
23.33% of the series and 35% of group II • The causes
were residual internal rotation and / or inefficient
immobilization leading to redisplacement. The internal
rotation was corrected spontaneously after 7 months.
The rotational deformity did not affect the function
of the elbow. but the external rotation 0f the
shoulder was limited without affection of the function.
_ Hyperextension deformity was of higher degree
(90) and higher incidence (50%) in group III than
in group II ( 3° and 5° with incidence of 10 %).
It was caused by backward tilting.
_ Predictability of the clinical result can be
made Qecause we found a relation between the results
and radiographic findings. We found that undisplaced
fractures and fractures with backward or forward
tilt of less than 15° gave normal movements.The
comminuted fracture gave stiffness. Back<vard tilt
of 15° or more gave limited flexion to a less degree
than that of tilt. The forward tilt gave limited extension.
We cannot predict hyperextension deformity
because not all the cases with backward tilting produced
it. The intarna L rotation gave internal rotation
deformity which later corrected spontaneously.
The absence of medial or lateral tilting in the presence
of efficient immobilization produced no change
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of caxxying angle. Medial ox latexal tilt of less
than 10° pxoduced no change of caxxying angle.
Medial tilt of 10° ox moxe gave cubitus vaxus. Vaxus
fxactuxes immobilized in supination ox midposition
gave cubitus vaxus. Valgus fxactuxes immobilized
in pxonation gave cubitus valgus. Internal
xotation gave cubitus vaxus. Bad xeduction has
a high incidence (75%) of pooz zesuLts, We cannot
pxedict the clinical xesu1t in open xeduction and
intexnal fixation fxom the postreduction X- xay
because accuxate anatomical reduction was achieved
and still thexe was limited extension.
So we
be adopted
fxactuxe:
can conclude that,
accoxding to the
the txeatment
presentation of
must
each
The treatment must be done immediately.
Undisplaced and minimally displaced fractuxes
axe txeated by postexiox plastex slab in
110° flexion of the elbow.
The xeduction under genexal anaesthesia must
be done in the presence of ovexxiding; 50 %
ox less of bony contact, backwaxd tilting of
15° ox more, latexal ox medial tilting of 10°
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o~ mo~e and/o~ rotation. The reduction must
be tried once as fax as possible. It must be
done under general anaesthesia. Whateve~ the
method of treatment adopted, varus f~actures
must be immobilized in pronation and valgus
fractures must be immobilized in supination o~
midposition. Four weeks immobilization must
be perfo~med. rhe plaste~ must be changed when
it loosens. Check x-ray must be done at the
fifth day. ,
The cases of extension type with mild swelling
must be treated by manipulative ~eduction and
immobilization in 1200 flexion of the elbow
taking ca~e to co~~ect the car~ying angle while
the elbow is extended •
The cases of extension type with mode~ate to seve~
e swelling a~e bette~ t~eated with manipulative
reduction and immobilization with full
extension of the elbow taking ca~e to change
the plaster at the tenth day.
The flexion type must be t~eated by manipulative
reduction and immobilization with the extension
of the elbow taking ca~e to change the plaste~
when it loosens.
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Open reduction must be done in conjunction with
exploration of brachial artery only in the cases
with vascular complication not responding to
conservative measures. In the cases with inadequate
reduction it is better to accept the
disalignment and later to correct the deformity
by osteotomy than to do open reduction and
internal fixation which produces later stiffness
and disability.
After the removal of the plaster, physiotherapy
in the form of active excercises should be instructed
to gain full range of motion. However,
several months are required to gain full range
This must be emphasized to the parents before
removal of the plaster. It is better to mention
it several times during the period the arm
is in the cast, otherwise the tendency is to
expect a miraculous restoration of motion as
soon as tre cast has been remove.