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ORIGINAL ARTICLE
Year : 2015  |  Volume : 15  |  Issue : 2  |  Page : 193-198

Management of displaced supracondylar fracture of the humerus in children


1 Department of Orthopedics, Burdwan Medical College and Hospital, Burdwan, West Bengal, India
2 Department of Physiology, Burdwan Medical College and Hospital, Burdwan, West Bengal, India
3 Department of Pathology, Burdwan Medical College and Hospital, Burdwan, West Bengal, India

Date of Web Publication6-May-2015

Correspondence Address:
Arunima Chaudhuri
Krishnasayar South, Borehat, Burdwan - 713 102, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1319-6308.156374

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  Abstract 

Background: There have been controversies regarding the ideal method of treatment of displaced supracondylar fractures of the humerus in children. Aims: The aim was to treat displaced supracondylar fractures of the humerus in children by conservative method and if results are not acceptable then by operative method and evolve a management protocol which will provide minimum complications with available facilities. Materials and Methods: This prospective study was conducted in a tertiary care hospital in a time span of 1-year. Ninety patients with Gartland's Type II and Type III fractures were initially subjected to closed manipulative reduction, of which acceptable reduction could be achieved only in 27 patients. Sixty-three patients who had unacceptable results were subjected to operative treatment. The final results of the treatment were assessed using the criteria of Flynn et al. Results: Among the Gartland's Type II fracture patients, acceptable reduction was achieved in 9 patients. Among Type III fracture, acceptable reduction was achieved in 18 patients (25%). The conservative treatment yielded excellent results for 9 patient and good for 9 patients. Of the 63 patients subjected to operative treatment, 15 patients had excellent result (23.81%), 24 good (38. 10%), 15 fair (23.81%), and 9 poor (14.29%). Satisfactory result was achieved in 39 patients (61.90%). Conclusion: Closed reduction in case of supracondylar displaced fracture of the humerus in children still remains an option in a developing country. It may be, followed by closed operating techniques when results are not acceptable as this delay does not affect functional outcome.

  Abstract in Arabic 

لافطلأا دنع ةحازنملا ةيدضعلا ةمقللا قوف روسك جلاع
حازنملا يدضعلا ةمقللا قوف رسك جلاعل لثملأا بولسلأاي قلعتي اميف لادج كلانه ناك :ةساردلا ةيفلخ. لافطلأا ىدل
اذإو يظفحتلا بولسلأاب لافطلأا ىدل حازنملا يدضعلا ةمقللا قوف روسكلا جلاع :ةساردلا فادهأ تاناكملإا عم ىندلأا اهدح يف تافعاضملا نوكت ثيح ةحارجلا بولسأب وأ ةلوبقم جئاتنلا نكت مل.ةحاتملا
تلمش دق و دحاو ماع ةرتف يف ةيثلاثلا ةياعرلا ىفشتسم يف ةساردلا تيرجأ :اهدارفأ و ةساردلا جهنم ؛روسكلا عاجرإ ةلواحمل اوعضخ ؛ةثلاثلاو ةيناثلا نيتجردلا نم روسكب اوبيصأ اضيرم 90 ةساردلا جلاعلل اوعضخأف ؛ةيضرم ريغ ىضرملا نم 63 جئاتن تناكو .حلاعلل اضيرم 27 باجتسا ثيح.)نورخآو نيلف ( رايعم مادختساب ةيئاهنلا جئاتنلا مييقت مت دقو يحارجلا
باحصأ امأ .ةيناثلا ةجردلا نم روسكلا باحصأ نم ىضرم 9 ىدل روسكلا عاجرإ مت :جئاتنلا تناك دقف يظفحتلا جلاعلا اما .)%25 ( اضيرم 18 جلاعلل باجتسا دقف ةثلاثلا ةجردلا نم روسكلا اوعضخأ نيذلا ىضرملا امأ .نيرخآ ىضرم 9 ىدل ةديج جئاتن و ن ىضرم 9 ىدل ةزاتمم جئاتن هل 24 جئاتن تناكو )%23.81( ةزاتمم مهنم اضيرم 15 جئاتن دقف )اضيرم 63( يجارجلا جلاعلل 9 جئلتن تناك و )%23.81 ( ةلوبقم مهنم اضيرم 15 جئلتن تناكو )%38.10 ( ةديج مهنم اضيرم.)%61.9 ( اضيرم 39 ىدل ةيضرملا جئاتنلا تققحت دقو . )%14,29 ( ةيضرم ريغ ىضرم
نادلبلا يف ارايخ دعي لازي لا لافطلأا ىدل ةيدضعلا ةمقللا قوف ةحازنملا روسكلا ةداعإ :جاتنتسلاا رثؤي لا ريخاتلا اذه نلأ ةيضرم ريغ جئاتنلا نوكت ثيح ةيحارج تاينقتب بحاصي نأ نكمي و ةيمانلا.ةيفيظولا جئاتنلا يف

Keywords: Functional outcome, operative management, supracondylar humerus fracture in children


How to cite this article:
Dharmadevan SV, Ghosh S, Chaudhuri A, Datta S, Sirdar BK, Roy DS. Management of displaced supracondylar fracture of the humerus in children. Saudi J Sports Med 2015;15:193-8

How to cite this URL:
Dharmadevan SV, Ghosh S, Chaudhuri A, Datta S, Sirdar BK, Roy DS. Management of displaced supracondylar fracture of the humerus in children. Saudi J Sports Med [serial online] 2015 [cited 2023 Jun 10];15:193-8. Available from: https://www.sjosm.org/text.asp?2015/15/2/193/156374


  Introduction Top


Supracondylar fractures of the humerus are the most common elbow fractures in children and adolescents accounting for 50-70% of all elbow fractures. [1],[2] When a child falls with an outstretched arm, and elbow in hyperextension, the force of the fall is transmitted through the olecranon process to the weak supracondylar region, causing a supracondylar fracture. [2],[3]

Supracondylar fractures may result in significant neurovascular compromise. Posterolateral fracture displacement is correlated with a median nerve and vascular compromise, and posteromedial fracture displacement is strongly correlated with radial nerve injury. These fractures of the distal humerus are frequently problematic in terms of diagnosis, treatment, and complications. There have been controversies in opinion regarding the ideal method of treatment of displaced supracondylar fractures. Several treatment modalities have been recommended including closed reduction and plaster immobilization, open reduction and internal fixation, traction, and closed reduction and percutaneous pinning. [3],[4],[5],[6],[7] Over the past decade, these supracondylar fractures have gone from being treated as an emergency to being treated the day after admission. There is still no consensus on which supracondylar humerus fractures can be treated in a delayed fashion, and delayed treatment may increase the need for an open reduction. [8],[9],[10],[11] The "pulseless" supracondylar fracture remains an emergency. The second recent trend is that divergent lateral pinning has replaced cross-pinning as it has reduced complications like ulnar nerve injuries. Closed reduction and percutaneous pin fixation are the treatment of choice for completely displaced (Type III) extension supracondylar fractures of the humerus in children, although controversy persists regarding the optimal pin-fixation technique. [11],[12],[13],[14],[15]

The time of intervention did not show significant outcome in results in many studies. [15],[16] Hence, the present study was conducted to treat displaced supracondylar fractures of humerus in children by conservative method and if results were not acceptable then by operative method and evaluate the outcomes of treatment to evolve a management protocol which will provide minimum complications with available facilities.


  Materials and methods Top


This prospective study was conducted in a tertiary care hospital in West Bengal hospital in a time span of 1-year, after taking approval of the institutional ethical committee. Children who presented to during this period in Orthopedic Department with displaced supracondylar fracture humerus (Gartland's Type II and Type III fractures) were included [Figure 1]. Written consent was obtained from the parents of all patients.
Figure 1: Preoperative X-ray

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Inclusion criteria

All children with displaced, that is, Type II and Type III supracondylar fracture of the humerus were included in the study, except those who met exclusion criteria.

Exclusion criteria

Open fracture; presented late, that is, more than 1-week after the injury; fracture which were associated with neurovascular complications; fracture associated with life-threatening injuries; fracture associated with medical diseases like diabetic mellitus, tuberculosis, etc.

Ninety patients were included in the study. The patients were of the age group of 2 years to 11 years. There were 60 males and 30 females. All the injuries followed an accidental trauma, which included fall while playing, fall from height or fall from a bicycle.

Management protocol

All children who presented with a suspected supracondylar fracture humerus were thoroughly evaluated. A detailed history was taken including an enquiry into the mode of injury and the time of injury. Vascular status of the limb was given special attention. The median, radial, and ulnar nerves were tested. The child was then sent for radiological investigation for the diagnosis and to classify the fracture.

All the patients were initially managed by conservative method, that is, manipulation and reduction under general anesthesia followed by cast immobilization. The result of the reduction was assessed clinically as well as radiologically. Those patients in whom reduction was unstable or inadequate were subjected to operative treatment. Operative treatment given was closed reduction and percutaneous pinning under image intensifier.

Method of closed reduction and casting

The procedure is done under general anesthesia. Charnley's technique was used for the reduction. The elbow is gently extended, and the surgeon gave longitudinal traction with the elbow in mid flexion, by gripping the patient's wrist and forearm; the assistant gave counter traction by gripping proximal arm. This longitudinal traction helped the fracture fragment to disengage themselves and also the release of the surrounding soft tissues if incarcerated between the fragments. The fracture fragments usually come into line by this longitudinal traction, thus correcting medial-lateral as well as rotational displacement. The correction of these displacements was checked at this stage by palpating the supracondylar ridges.

For the correction of the posterior displacement, while maintaining the traction the lower humerus was gripped using the surgeon's passive hand. The thumb of the passive hand was kept over the olecranon. While maintaining the traction elbow was gradually flexed. A continuous counter traction was applied during this procedure using the passive hand of the surgeon, the direction of which was changed progressively according to the degree of flexion of the elbow. When the elbow reached 90° of flexion, the shaft of humerus was pulled backward while the distal fragment was pushed forwards using the thumb of the passive hand. This step corrected the posterior displacement.

The flexion of the elbow was then continued further to the maximum possible limit at which the radial pulse was palpable at its normal volume. The displacement of the distal fragment determines the position of immobilization of the forearm, that is, pronation for posteromedial type and supination for posterolateral type.

The achievement of reduction was checked clinically after the procedure. The ease at which the acute flexion is attained is an indirect evidence of achieving the correction. Once the reduction is achieved, the point of elbow should be in line of the axis of the humerus and slightly in front of it. Once a clinically satisfactory reduction was obtained; the limb was immobilized using a plaster cast.

The position of the reduction was then assessed by taking the radiograph. An acceptable position was determined by the anterior humeral line transecting the capitulum, a Baumann angle of 70-80° and an intact olecranon fossa.

Method of closed reduction and percutaneous pinning

Operation was done either under general anesthesia or regional block. With the patient supine under fluoroscopic image intensifier, closed reduction was done. The fracture reduction was checked by anteroposterior and lateral views using the image intensifier. As the pure anteroposterior view is difficult to interpret, the reduction was checked by rotating the arm slightly medially and laterally to view the columns of the distal humerus.

Once an anatomic or nearly anatomic reduction was achieved, further stabilization was done by percutaneous pinning using Kirschner wire (K-wire) introduced through the lateral side. The diameter of K-wire was selected according to the age of the patient, that is, 1.5 mm for those 8 years or less, 1.8 mm if between 9 and 11 years and 2 mm for those above 11 years. The pin was introduction through the lateral epicondyle at an angle of 40° from the axis of the humeral shaft and 10° posteriorly and passing proximally to engage the medial cortex. The second pin was placed 5-10 mm proximal to the first pin ensuring the engagement of the medial cortex. The second pin was placed either parallel to the first one or crossed it proximal to the fracture [Figure 2] and [Figure 3].
Figure 2: Fixation of fracture (Immediate post operative)

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Figure 3: Fixation of fracture (3 weeks after fixation)

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The final reduction and the position of the pins were checked under image intensifier. The ends of the pins were cut off, bend, and left out through the skin. The limb was immobilized in a long arm posterior slab with forearm in neutral, and elbow flexed <90°.

After treatment

Distal vascularity was checked postoperatively by assessing the capillary refilling. Ulnar, radial and median nerve functions were checked after recovery from anesthesia. Active movements of the fingers were encouraged. The immobilization was continued for 4 weeks. Pins were removed after 3 weeks [Figure 4]. Intermittent active - range-of-motion exercises were started. Passive motion and forceful manipulative motion were strictly avoided.
Figure 4: United fracture

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Follow-up

Patients were evaluated at 2 weekly intervals. At each visit, questions were asked regarding pain, restriction of motion and satisfaction with appearance of the elbow. The elbow was examined with special reference to carrying angle and the arc of flexion-extension of both injured and uninjured elbow. The carrying angle was measured by the standard technique with elbow extended and forearm supinated as far as possible. The presence of other complication if any, like myositis ossificans were also noted during the follow-up.

Assessment of the results

The final results of the treatment were assessed using the criteria of Flynn et al. The criteria of Flynn et al. are based on cosmetics as well as functional factor. Loss of carrying angle in degrees defines the cosmetic factor, and the loss of motion in degree defines the functional factor. The degree of loss of carrying angle and loss of motion of the injured elbow was compared with that of the uninjured elbow. The function was graded in 5° intervals of the total arc of flexion and extension and the cosmetic appearance of the elbow was graded in 5° intervals of changes in carrying angle.


  Results Top


In the present series, 90 patients with displaced (Gartland's Type II and III) supracondylar fracture humerus were included. The age of the patients ranged from 2 years to 11 years. The mean age of the patient was 6.8 years. Most of the fracture were found the age group 6-8 years (66.7%). Sixty patients were males and the rest 30 were females. The fracture was in the left side in 57 patient (63.33%) and 33 in the right side (36.67%). None of the patients had bilateral fracture. Eighteen patients had Gartland's Type II fracture (20%) while 72 had Type III fracture (80%).

The entire 90 patients were initially subjected to closed manipulative reduction, of which acceptable reduction could be achieved only in 27 patients (30%). Among the Gartland's Type II fracture patients, acceptable reduction was achieved in 9 patients (50%). Among Type III fracture, acceptable reduction was achieved in 18 patients (25%).

The 63 patient who had unacceptable results after closed manipulative reduction were subjected to operative treatment. The period of follow-up ranged from 2 months to 15 months, with an average of 5.97 months. During the finale follow-up, the loss of motion and the loss of carrying angle of the affected elbow on comparison of the normal side were noted. The final result was graded according to the Flynn et al. criteria. The conservative treatment yielded excellent results for 9 patient and good for 9 patients. Of the 63 patients subjected to operative treatment, 15 patient had excellent result (23.81%), 24 good (38. 10%), 15 fair (23.81%), and 9 poor (14.29%). Satisfactory result (excellent and good combined) was achieved in 39 patients (61.90%). On comparison, conservative treatment achieved 20% satisfactory result while operative treatment had 66.91% satisfactory outcome. Pin tract infection was seen in 9 patients, all of which were superficial and healed after removal of the pins and with oral antibiotics and regular dressing [Table 1].
Table 1: The overall results of the operative treatment (Flynn et al. criteria)

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  Discussion Top


Closed operative management yielded excellent results in 23.81% cases, good in 38.1% cases in the present series. The obtained results and minor complications reported signify this technique as a viable treatment method for displaced Type II and III supracondylar fractures in children. [7],[8]

Seventy children with displaced Type II and III supracondylar fractures of the humerus were managed with percutaneous lateral cross-wiring technique from January 2006 to January 2007 by Farley FA et al [6] 2008. Functionally, all patients achieved satisfactory results while cosmetically, 91.4% of patients had satisfactory results, and 8.6% had unsatisfactory results. The most frequently occurring complications were minor pin tract infection in 6 patients, deep infection in 2 patients, and 32 patients suffered excessive granulation tissue formation mostly around the proximal pin. There was no iatrogenic neurological injury either for the ulnar or for the radial nerves. We also did not have any neurological complications. Pin tract infection was seen in 9 patients, all of which were superficial and healed after removal of the pins and with oral antibiotics and regular dressing.

Pullagura M et al [8] in 2013 retrospectively reviewed 81 children with displaced supracondylar fractures (64 Gartland Type III and 17 Type IIA). Of these, 46 children were treated within 6 h of presentation, and 35 were treated later. The rate of open reduction was higher in children treated early (23%) than in late cases (11%). There was no significant difference in the postoperative outcomes and complications between the groups. Hence, we first managed all our subjects conservatively, followed by operative interventions in case of unacceptable reductions as delay in treatment is found not to affect functional outcomes in different studies.

Kocher MS et al in 2007 [10] compared the efficacy of lateral entry pin fixation with that of medial and lateral entry pin fixation for the operative treatment of completely displaced extension supracondylar fractures of the humerus in children. No patient in either group had a major loss of reduction. There was no significant difference between the rates of mild loss of reduction, which occurred in 6 of the 28 patients treated with lateral entry and one of the 24 treated with medial and lateral entry. There were no cases of iatrogenic ulnar nerve injury in either group. There were also no significant differences between groups with respect to the Baumann angle, change in the Baumann angle, humeral capitellar angle, change in the humeral capitellar angle, Flynn grade, carrying angle, elbow flexion, elbow extension, total elbow range of motion, return to function, or complications. We used lateral pin fixation technique in the present study.

A study in 2012 [11] of the consecutive series of 1297 pediatric patients with surgically treated supracondylar humerus fractures was retrospectively reviewed. Major complications including reoperation, loss of fixation, or compartment syndrome were rare. We also had no such complications in the present series.

Choi et al. [12] reviewed 1255 supracondylar humerus fractures in children treated operatively over 12 years at one institution. Thirty-three (of 1255) patients presented with a pulseless supracondylar humerus fracture (2.6%). The patients were divided into 2 groups: Those at presentation whose hand was well perfused (n = 24) or poorly perfused (9). None (0 of 24) of the well-perfused patients underwent vascular repair; 3 had open reduction. Of the 21 well-perfused patients undergoing closed reduction and pinning, 11 (of 21) had a palpable pulse after surgery, and 10 (of 21) remained pulseless but well perfused; all did well clinically. Of the 9 patients in the poorly perfused group, 4 underwent vascular repair, and compartment syndrome developed in 2 during the postoperative period. In just over half of patients with a poorly perfused hand (5 of 9), fracture reduction alone was the definitive treatment. In the present series, none of our patients presented as pulseless supracondylar fracture.

Between 1998 and 2004, 422 displaced supracondylar humerus fractures underwent operative reduction and fixation by Fayssoux et al. [13] A retrospective review revealed that 14 (3.3%) of these fractures occurred at the metaphyseal-diaphyseal junction just proximal to the olecranon fossa. In 8 patients, the fracture line was oblique (Group A), and in 6 patients, the fracture line was transverse (Group B). All patients were treated by closed reduction and K-wire fixation and had at least 1-year follow-up. Eighty-six consecutive children treated surgically from April 2005 to June 2007 for displaced supracondylar humeral fractures were reviewed by Han et al. [14] The children were divided into two groups: Early if treated within 12 h after injury and delayed if treated later than that. Forty pediatric patients underwent surgery in the early group and 46 in the delayed group. There were no significant differences between the two groups in perioperative complications such as pin tract infection, iatrogenic nerve injury, compartment syndrome, and conversion to open surgery. For open surgery, both the clinical results and perioperative complications were not affected by delaying for more than 12 h after injury.

In a retrospective study, Walmsley et al. [15] examined whether the timing of surgery affected perioperative complications or the need for open reduction. There were 171 children with a closed Type III supracondylar fracture of the humerus and no vascular compromise. They were divided into two groups: Those treated <8 h from presentation to the accident and emergency department (126 children) and those treated more than 8 h from presentation (45 children). There were no differences in the rate of complications between the groups.

Sibinski et al. 16] examined differences in the rate of open reduction, operating time, length of hospital stay and outcome between two groups of children with displaced supracondylar fractures of the humerus who underwent surgery either within 12 h of the injury or later. There were 77 children with Type III supracondylar fractures. Of these, in 43 the fracture was reduced and pinned within 12 h and in 34 more than 12 h after injury. Bivariate and logistical regression analysis showed no statistical difference between the groups. The number of perioperative complications was low and did not affect the outcome regardless of the timing of treatment. We also had similar results though our subjects were operated late.


  Conclusion Top


Closed reduction in case of supracondylar displaced fracture of the humerus in children still remains an option in a developing country like India, where availability of image intensifier still remains a problem. It may be, followed by closed operating techniques when results are not acceptable as this delay does not affect functional outcome.

 
  References Top

1.
Shrader MW. Pediatric supracondylar fractures and pediatric physeal elbow fractures. Orthop Clin North Am 2008;39:163-71, v.  Back to cited text no. 1
    
2.
Benedetti Valentini M, Farsetti P, Martinelli O, Laurito A, Ippolito E. The value of ultrasonic diagnosis in the management of vascular complications of supracondylar fractures of the humerus in children. Bone Joint J 2013;95-B: 694-8.  Back to cited text no. 2
    
3.
Oakley E, Barnett P, Babl FE. Backslab versus nonbackslab for immobilization of undisplaced supracondylar fractures: A randomized trial. Pediatr Emerg Care 2009;25:452-6.  Back to cited text no. 3
    
4.
Garg S, Weller A, Larson AN, Fletcher ND, Kwon M, Schiller J, et al. Clinical characteristics of severe supracondylar humerus fractures in children. J Pediatr Orthop 2014;34:34-9.  Back to cited text no. 4
    
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Mangat KS, Martin AG, Bache CE. The 'pulseless pink' hand after supracondylar fracture of the humerus in children: The predictive value of nerve palsy. J Bone Joint Surg Br 2009;91:1521-5.  Back to cited text no. 5
    
6.
Farley FA, Patel P, Craig CL, Blakemore LC, Hensinger RN, Zhang L, et al. Pediatric supracondylar humerus fractures: Treatment by type of orthopedic surgeon. J Child Orthop 2008;2:91-5.  Back to cited text no. 6
    
7.
El-Adl WA, El-Said MA, Boghdady GW, Ali AS. Results of treatment of displaced supracondylar humeral fractures in children by percutaneous lateral cross-wiring technique. Strategies Trauma Limb Reconstr 2008;3:1-7.  Back to cited text no. 7
    
8.
Pullagura M, Odak S, Pratt R. Managing supracondylar fractures of the distal humerus in children in a district general hospital. Ann R Coll Surg Engl 2013;95:582-5.  Back to cited text no. 8
    
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Blakey CM, Biant LC, Birch R. Ischaemia and the pink, pulseless hand complicating supracondylar fractures of the humerus in childhood: Long-term follow-up. J Bone Joint Surg Br 2009;91:1487-92.  Back to cited text no. 9
    
10.
Kocher MS, Kasser JR, Waters PM, Bae D, Snyder BD, Hresko MT, 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;89:706-12.  Back to cited text no. 10
    
11.
Fletcher ND, Schiller JR, Garg S, Weller A, Larson AN, Kwon M, et al. Increased severity of type III supracondylar humerus fractures in the preteen population. J Pediatr Orthop 2012;32:567-72.  Back to cited text no. 11
    
12.
Choi PD, Melikian R, Skaggs DL. Risk factors for vascular repair and compartment syndrome in the pulseless supracondylar humerus fracture in children. J Pediatr Orthop 2010;30:50-6.  Back to cited text no. 12
    
13.
Fayssoux RS, Stankovits L, Domzalski ME, Guille JT. Fractures of the distal humeral metaphyseal-diaphyseal junction in children. J Pediatr Orthop 2008;28:142-6.  Back to cited text no. 13
    
14.
Han QL, Wang YH, Liu F. Comparison of complications and results of early versus delayed surgery for Gartland type III supracondylar humeral fractures in pediatric patients. Orthop Surg 2011;3:242-6.  Back to cited text no. 14
    
15.
Walmsley PJ, Kelly MB, Robb JE, Annan IH, Porter DE. Delay increases the need for open reduction of type-III supracondylar fractures of the humerus. J Bone Joint Surg Br 2006;88:528-30.  Back to cited text no. 15
    
16.
Sibinski M, Sharma H, Bennet GC. Early versus delayed treatment of extension type-3 supracondylar fractures of the humerus in children. J Bone Joint Surg Br 2006;88:380-1.  Back to cited text no. 16
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1]


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