Displaced supracondylar fractures of the humerus in children

Displaced supracondylar fractures of the humerus in children / Reply

Harish, S

Sir,

I read with interest the article in the March 2000 issue by O’Hara, Barlow and Clarke 1 entitled `Displaced supracondylar fractures of the humerus in children’. They have mentioned that the fractures were classified according to the Wilkins modification of the Gartland system and have gone on to classify the fractures as I, IIA, IIB and III. This is not how Wilkins’ modification has been described.2 The correct version of the classification is I, II and III with two subgroups in III. A protocol has been suggested for the management of these common, yet difficult fractures based on their version of Wilkins’ modification. The classification system appears to have been misquoted in their paper and causes confusion.

S. HARISH, FRCS Peterborough Hospitals NHS Trust Peterborough, UK.

1. O’Hara LJ, Barlow IW, Clarke NMP. Displaced supracondylar fractures of the humerus in children. J Bone Joint Sung (BrJ 2000;82-B:204-10.

2. Wilkins KE. Fractures and dislocations of the elbow region. In: Rockwood CA, Wilkins KE, King RE, eds. Fractures in children. Vol.

3. 4th edition. Philadelphia: Lippincott-Raven Publishers, 1996:680.

Authors’ reply:

Sir

Wilkins1 proposed a modification to the Gartland2 system in 1984. He recognised that a displaced supracondylar humeral fracture may be greenstick in nature with an intact posterior cortex. He noted that this greenstick injury may also have a rotary component. A fracture with an intact posterior cortex and angulation only was termed type IIA and that with a rotary component type IIB3. Gartland made no reference to the greenstick injury in his system, merely classifying it in regard to the severity of displacement: non-displaced, minimal to moderate and severely displaced. In his original article there is a radiograph of a fracture which is completely displaced with no cortical contact and this is classified as moderately displaced.

Wilkins termed the completely displaced supracondylar fracture with no cortical contact as type III. A type-IIIA fracture has posteromedial and type IIIB posterolateral displacement. These subtypes determine which neurovascular structures are most likely to be injured and which pin should be placed first.4 This subclassification, however, does not affect the ultimate management of these injuries, as both the type-IIIA and the type-IIIB fractures require closed/open reduction and stabilisation with Kirschner (K-) wires.4 We believe that it is fundamental in the treatment of these injuries to appreciate the difference between the type-IIA and type-IIB injuries, since this has a direct bearing on their management. Type-IIA injuries rarely require supplementary K-wire stabilisation, whereas we strongly recommend pin fixation of the type-IIB fracture. We did not subclassify the type-III fractures in our series since this would not alter the management.

Mr Harish has commented that the current edition of Fractures in children by Rockwood, Wilkins and King5 subclassifies the type-III injury and not the type-II fracture. The possibility of malrotation of the type-II injury is in fact discussed in the text, but it is not represented in the Table on page 680. While this is unfortunate, this text was published before our recommendations for the treatment of the type-IIB injury. We did not cite the current edition in our bibliography and refer Mr Harish to the earlier work of Wilkins3 for a more comprehensive discussion of the classification of supracondylar fractures in children. We hope that this has clarified any confusion.

L.J. O’HARA FRCS I.W. BARLOW, FRCS Orth N. M. P. CLARKE, ChM, FRCS Southmaption General Hospital, UK.

1. Wilkins KE. Fractures and dislocations of the elbow region. In: Rockwood CA Jr, Wilkins KE, King RE, eds. Fractures in children. Vol. 3. Philadelphia: LB Lippincott, 1984:363-575.

2. Gartland JJ. Management of supracondylar fractures of the humerus in children. Surg Gynecol Obstet 1959;109:145-54.

3. Wilkins KE. Supracondylar fractures of the humerus. In: Operative management of upper extremity fractures in children. AAOS Monograph Series, 1994.

4. Wilkins KE. The operative management of supracondylar fractures. Orthop Clin North Am 1990;21:269-89.

5. Wilkins KE. Fractures and dislocations of the elbow region. In: Rockwood CA Jr, Wilkins KE, King RE, eds. Fractures in children. Vol. 3. Philadelphia: Lippincott-Raven, 1996:680.

Copyright British Editorial Society of Bone & Joint Surgery Aug 2000

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