Chapter 27 How Should We Treat Elbow Fractures in Children?
Fractures of the child’s elbow are a touchstone of pediatric orthopedics, and often the heaviest contributor to operative emergency lists. The relatively low level of evidence in the literature belies a relatively large clinical load, a high level of comfort, and confidence among pediatric orthopedic surgeons, and fulfilled high expectations of good results from patients. Many principles and tenets of pediatric orthopedic practice have not been tested or proved scientifically, and many never will be. For example, the common practice of closed reduction and pinning for displaced supracondylar fractures is based on Level III evidence1; yet, there is little expectation that Level I or II evidence comparing pinning with flexion strapping or casting is desirable or forthcoming, the latter treatment methods having been largely abandoned. Is there a problem with this? Perhaps there is.
SUPRACONDYLAR FRACTURES: ACUTE TREATMENT
Closed Reduction and Percutaneous Pinning
Level III evidence has been instrumental in defining closed reduction and percutaneous pinning as the current treatment for displaced supracondylar fractures. The first such comparative study, in 1979 by Prietto,2 retrospectively compared 27 patients treated with Dunlop’s traction (at one hospital) with 20 patients treated with closed reduction and percutaneous pin fixation. Clinical “gunstock” varus malunion occurred in 9 of 27 patients treated with traction (33%) and 1 of 20 patients with percutaneous pinning (5%). Mean hospital stay was 17 days for the traction group and 3 for the pinned group. Complications were low, and functional results were good in each group.
A much larger retrospective comparative study (Level III evidence) was published in 1988.1 A total of 325 patients with displaced extension supracondy-lar fractures were treated by 1 of 4 methods, and 230 returned for late review. Treatments compared were closed reduction and casting (130), closed reduction and percutaneous K-wire fixation (78), traction (15), or open reduction and internal fixation (7). Among 130 patients initially treated with a flexion cast, 29 had the treatment discontinued because of problems with forearm circulation; 14 had varus malunion, of whom 8 had osteotomies, 6 had loss of motion, and 1 experienced development of a Volkmann’s ischemic contracture. Among 78 patients treated with K wires primarily plus 18 converted from casting to K-wire fixation, there were 3 varus malunions, of whom 1 had an osteotomy, 2 had loss of motion, and no patients had ischemia of muscle, although several had an initially absent radial pulse with an otherwise well-perfused hand. Pin placement was crossed medial and lateral pins in 47, and 2 lateral pins in 49 patients. No pin-related nerve complications with either placement were reported, and there were two superficial pin infections. About 78% of patients in the pinning group had both the carrying angle and range of motion within five degrees of the contralateral side at final follow-up; this was true of only 51% of the patients in the group treated with casts. The series was neither randomized nor prospective, and only 230 of 325 potential patients returned for a late review. Among those reviewed, the outcomes were much better and the complication rates lower in the closed reduction and percutaneous pinning group, and this remains the best available evidence supporting this practice. In summary, a large, well-done, retrospective cohort study (Level III evidence) supports closed reduction and percutaneous pinning of all displaced supracondylar fractures over closed reduction and plaster immobilization.
Crossed Pins or Lateral Entry Pins
A large retrospective series (Level III evidence) was published in 20013 comparing the results of lateral pins versus crossed pins in 345 displaced extension-type supracondylar fractures. The configuration of the pins did not affect the maintenance of reduction. Fracture displacement was noted on 4% (4/103) of radiographs where lateral pins were used, 3% (4/120) where crossed pins were applied without hyperflexion, and 2% (1/58) where crossed pins were applied with hyperflexion. Ulnar nerve injury was not seen in the 125 patients in whom only lateral pins were used. The use of a medial pin was associated with ulnar nerve injury in 4% (6) of 149 patients in whom the pin was applied without hyperflexion of the elbow and in 15% (11) of 71 in whom the medial pin was applied with the elbow hyperflexed. Because the maintenance of reduction was equal with lateral or crossed pins, but the ulnar nerve injury rate was greater with crossed pins, the authors conclude that lateral pins alone provide adequate fixation. Two smaller Level III comparative studies had reached this conclusion previously.4,5 A subsequent prospective Level IV study6 reports on 124 consecutive unselected displaced supracondylar fractures with no loss of reduction and no nerve injuries using lateral entry pins only, 2 pins for more stable, and 3 pins for less stable fracture patterns.
Two Level I studies (prospective, randomized trials) have since been performed addressing the question of lateral pins versus crossed pins.7,8 Both trials were small. The first trial, with good methodologic quality, found no differences in minor loss of reduction (1/24 crossed, 6/28 lateral), ulnar nerve injury (none), or major loss of reduction (none).7 The second trial, with less complete description of the methodologic issues, had 5 ulnar nerve injuries among 34 patients with crossed pins, and 2 ulnar nerve and 1 radial nerve injuries among 32 patients with lateral entry pins.8 Although these are Level I studies, which remove selection bias, the small number of patients does not allow a precise estimation of the rate of rare events such as nerve injuries or loss of reduction. A systematic review pooling all data from previously published case and comparative series reports an iatrogenic nerve injury rate of 1.9% for lateral entry pins and 3.5% for crossed pins (among 1909 patients), and a loss of reduction rate of 0.7% for lateral entry pins and 0% for crossed pins (among 1455 patients).9 Evidence from the Level I studies alone is insufficient to decide about treatment because the series are small relative to the expected outcome rate, and because one of the studies had a high complication rate inconsistent with the rest of the literature.
One Level III retrospective study used a case–control design to analyze anatomic details of the medial pin placement comparing 18 patients with ulnar nerve injury with 72 patients without injury.10 The medial pin was inserted with much more anterior to posterior angulation (12.1 ± 11.7 degrees) in the group with ulnar nerve injuries compared with the group without (1.6 ± 11.0 degrees). Although this article gives some guidance on how to place a medial pin, the authors mention in the discussion that they have abandoned routine use of the medial pin in favor of lateral entry pinning, which was not discussed.
A final Level III retrospective study used a case–control design comparing 8 fractures that lost fixation with 271 that remained well reduced.11 In each case with lost fixation, a technical error of initial pin placement was (retrospectively) identified: single pins in the distal fragment, lack of bicortical purchase, and lack of 2 mm separation of pins at the fracture site.
Open Reduction versus Closed Reduction
Open reduction has been used selectively for closed supracondylar fractures that are “irreducible” and are mentioned in many series, but with no standard definition of “irreducible” or indeed of an acceptable reduction, it is difficult to judge what is being compared. One article12 compares a policy of primary open reduction of 44 consecutive patients with a policy of closed reduction and pinning in 55 subsequent patients treated at the same institution (Level III evidence). Although the open reduction group was observed longer (35 vs. 21 months), more patients in the open reduction group were stiff at final follow-up examination (38%) than in the closed reduction group (20%), defining stiffness as 10 degrees or more loss of motion compared with the other side. No differences were reported in infections (three open, two closed) or ulnar nerve lesions (two open, two closed). The authors conclude that closed reduction with percutaneous pinning is preferable to a routine policy of open reduction.
Flexion Supracondylar Fractures
Flexion supracondylar fractures are much less common than extension-type injuries and have been thought to be less stable and more difficult to reduce because the posterior periosteum is torn at the fracture site with a flexion injury. A retrospective comparative cohort (Level III) from a single center found the rate of flexion injuries to be 3%, and reported 31% open reductions for flexion injuries compared with 10% for extension injuries and 19% preoperative ulnar nerve symptoms for flexion injuries compared with 3% for extension injuries.13
Pulseless Hand
Two case series from 1996 drew opposite conclusions from similar clinical material regarding the pulseless pink hand. The first was a case series of seven patients with a pulseless arm, all of whom had a “seemingly viable” hand after closed reduction and pinning, were treated by arterial exploration with vein grafting3 or microdissection vessel mobilization,4 and did well at follow-up.14 The authors of this first study recommend routine arterial exploration and repair for a pulseless but viable hand.
A larger case series of 22 children with a supracondylar fracture and an absent radial pulse on admission included 15 with a well-perfused hand after closed reduction and K-wire fixation, of whom 5 had no radial pulse. All patients with a well-perfused hand were treated with observation, including the five without a pulse, and none had any clinical circulatory problems at follow-up examination. Seven patients who had a cold white hand after closed reduction of the fracture underwent arterial exploration with or without repair. The authors conclude that routine exploration of the brachial artery is unnecessary in the circumstance of a pink, perfused hand with an absent radial pulse after closed treatment of a supracondylar fracture.15
One year later, a case series of 13 patients with pulseless, pink hands treated by closed with or without open10 reductions and various vascular treatments including vein patch angioplasty4 was published and included more information on the fate of the vessel using follow-up magnetic resonance angiography. Late magnetic resonance angiograms obtained on 10 patients showed occlusion or restenosis at the brachial artery in 5 patients, including 2 of 3 who had had a successful vein patch. Collateral flow was excellent in all arms with brachial artery compromise on magnetic resonance angiography, all patients had a palpable radial pulse on follow-up examination, and no patient had claudication or cold intolerance. Based on this experience, the authors recommend close observation instead of immediate invasive treatment for pink, viable hands without a radial pulse after reduction because regardless of repairing the vessel in the short term, arms were reliant on collateral circulation over the long term anyway, and none had poor clinically results.16
Timing of Treatment
Several retrospective cohort studies (Level III evidence) have compared early (<8 hours after presentation) versus late (>8 hours after presentation) treatment of closed supracondylar fractures without vascular compromise. The first of these was published in 200117 and showed no difference in complications, no compartment syndromes in either group, and equal low rates of conversion to open reduction, pin infections, and iatrogenic nerve injuries among 52 patients treated at less than 8 hours compared with 146 patients treated at more than 8 hours. The recommendation from the article was that treatment of closed supracondylar fractures without vascular compromise could be delayed beyond 8 hours without compromising patient outcome. Similar findings and conclusions came from subsequent Level III studies18,19 showing no differences in position at healing either. A single Level III study drew the opposite conclusion comparing 126 patients treated less than 8 hours after presentation who had an 11.2% open reduction rate, with 45 patients treated more than 8 hours after presentation who had a 33% open reduction rate.20 The overall open reduction rate in the latter article is much greater than that suggested in the general literature; without well-defined criteria for performing an open reduction, it is an imperfect measure of outcome. In summary, the balance of the Level III evidence suggests that patients with closed fractures without vascular compromise have equivalent outcomes whether the surgery is performed immediately or is delayed beyond 8 hours after presentation.
Physical Therapy
A randomized study with blinded outcome assessment (Level I) compared 22 patients treated with physiotherapy (30 minutes 3 times per week, passive stretching plus active exercises) with 21 patients not receiving physiotherapy. There was about 10 degrees more flexion-extension range at 12 and 18 weeks in the physiotherapy group, but no difference at 1 year. The authors conclude that postoperative physical therapy is unnecessary for routine care.21
VARUS MALUNIONS OF SUPRACONDYLAR FRACTURES
The most common late complication of supracondylar fractures treated surgically is varus malunion, also known as “gunstock” deformity for its characteristic appearance. The deformity occurs readily in untreated fractures because the narrow fracture surface seen on the lateral means instability with any rotation, and the tendency is for the distal fragment to internally rotate, then tip into varus. A variety of osteotomies has been described to treat the cosmetic deformity of a supracondylar fracture healed in varus, and two comparative studies describe the results of these osteotomies.
The first study describes itself as a randomized trial,22 but patients were treated with one of two osteotomies in alternation, so true randomization did not occur and the study is best categorized as Level II evidence. Treatments compared were the French technique and a dome osteotomy. The French technique used a lateral closing wedge osteotomy with an intact medial hinge that was closed by tightening a wire around unicortical screws above and below the osteotomy. The dome osteotomy was complete and was stabilized temporarily with an external fixator, then definitively with crossed Kirschner wires. Both osteotomies adequately corrected the carrying angle and had similar cosmetic results. Complications were greater in the dome group. Elbow stiffness was seen in 2 of 13 patients with the French osteotomy and 5 of 12 with the dome. Correction was reported as inadequate in 2 of 13 patients with the French osteotomy and 1 of 12 with the dome. The dome group also had one infection, one nerve palsy, and one vascular complication. The authors report that the dome osteotomy was more technically difficult and had a greater complication rate, and recommended use of the French technique.
A prior Level III study had compared the French technique with fixation with Kirschner wires or a plaster cast and had reported better cosmetic results and fewer complications with the French technique,23 although numbers were small in all groups. In summary, Level II and III evidence supports the use of the French technique of supracondylar osteotomy to treat varus malunion.
LATERAL CONDYLE FRACTURES: ACUTE TREATMENT
Diagnosis of Displacement
The degree of fracture displacement is considered important in the treatment of lateral condyle fractures but can be difficult to judge on plain radiographs. A prospective cohort (Level II evidence) showed that the internal oblique radiograph was more sensitive than a plain anteroposterior radiograph at detecting displacement in 30 of 54 patients.24 Both sonography and magnetic resonance imaging (MRI) have been suggested as adjuncts to plain radiographs, particularly where plain radiographs show minimal or no displacement. In this circumstance, a fracture with an intact articular cartilage hinge might be treated with immobilization, whereas a complete fracture might be treated with percutaneous pinning. High-resolution sonography showed intact cartilage hinge in four of six patients, none of whom had subsequent displacement on plain radiographs after nonoperative management, and showed fracture through the joint cartilage in two of six children with confirmation by MRI or intraoperative findings.25 A larger study used MRI on 16 patients, 12 of whom had plain radiograph displacement of less than 3 mm. Of those 12 patients, 10 had intact joint cartilage on MRI, and none displaced; 2 had broken joint cartilage, and 1 displaced. The authors conclude that MRI was useful in identifying stable fracture patterns with intact joint cartilage.26 Similar use of the MRI had been reported previously.27 In conclusion, Level II evidence exists that internal oblique radiographs are more sensitive at detecting displacement than anteroposterior radiographs. For undisplaced fractures, Level IV evidence has been reported that MRI is useful in confirming an intact joint cartilage, in which case the fracture would not be expected to displace with immobilization alone.
Undisplaced or Minimally Displaced Fractures
A retrospective, comparative series (Level III evidence) describes 30 fractures with initial displacement of less than 2 mm, of which 17 were treated in a long arm cast and 13 were treated with closed or open K-wire stabilization.28 Of 17 treated in a cast, 5 displaced, 4 of these required later surgery, and at final follow-up, there were 2 nonunions and 2 malunions. Of the 13 patients treated operatively, 2 lost reduction and had malunions; there were no nonunions.
A larger case series (Level IV) reported on 95 fractures treated without surgery for initial displacements less than 2 mm; 93 healed with plaster immobilization, and 2 displaced and were treated with open K-wires and healed.29
Displaced Fractures
The retrospective comparative series described earlier (Level III evidence)28 included 67 displaced fractures, of which 10 were treated without surgery despite an initial displacement of 2 mm or more. These 10 fractures had been initially deemed undisplaced or minimally displaced by the treating surgeons but were reclassified as displaced more than 2 mm on review. Of these 10, 4 displaced farther and 2 were treated with surgery; at healing, 5 healed adequately, 3 were nonunions, and 2 were malunited. By comparison, among the other 57 displaced fractures initially treated with surgery, 4 displaced, 1 was revised, and 5 malunions and no nonunions occurred.
A retrospective comparison of the clinical and radiographic outcomes after open reduction compared 12 displaced fractures with anatomic position after treatment with 10 with 2 to 6 mm of residual displacement.30 Among 10 patients with residual displacement, 9 experienced development of a radiographic “fishtail” deformity indicating growth disturbance in the central physis, and 2 had marked restriction of flexion/extension. Among 12 with anatomic reduction, there were no radiographic deformities seen and none had stiff elbows.
A larger case series (Level IV evidence) showed 1 nonunion among 104 displaced lateral condyle fractures treated with open reduction and 3 weeks of K-wire immobilization,31 suggesting that this time period is adequate for healing of operatively stabilized fractures. Although the evidence is of lower quality, a consistent recommendation for accurate reduction and K-wire immobilization of displaced lateral condyle fractures can be made.
MEDIAL EPICONDYLE FRACTURES: ACUTE TREATMENT
A long-term comparative series (level III evidence) compared three treatments: closed treatment, open reduction and internal fixation, and primary excision of the epicondyle. Follow-up periods averaged 33 years (30–61 years). Among 19 patients treated with long arm casting, 17 had a nonunion radiographically. All had stable elbows to valgus stress testing, and two had minor symptoms related to the elbow. Among 17 patients treated with open reduction and internal fixation, all had radiographic union, all were stable, and three had minor symptoms. Among six patients treated with excision of the epicondylar fragment, four had constant pain, ulnar paraesthesias, and an unstable elbow. The authors conclude that despite a high rate of radiographic nonunion, the functional results suggest that nonoperative management was recommended for medial epicondyle fractures displaced 5 to 15 mm. Excision of the fragment should be avoided because results are poor.32
A second retrospective comparative study (Level III evidence) reviewed 43 children 2 to 5 years after open23 or closed20 management of displaced medial epicondyle fractures and also concluded that closed management was preferred. Bony union was seen in 87% of those treated surgically and 55% of those treated closed, but 39% of those treated surgically had ongoing symptoms (pain, stiffness) at the elbow at medium-term follow-up compared with 5% of those treated without surgery.33
RADIAL NECK FRACTURES: ACUTE TREATMENT
Radial neck fractures best exemplify the pervasive selection bias in operative versus nonoperative retrospective cohorts. In 1978, a retrospective cohort (Level III evidence) observed 43 children with radial neck fractures for 8 years (range, 1–18 years).34 Among 23 patients treated without surgery, 19 had a “good” outcome, and among 14 treated with surgery, only 5 had a “good” outcome. However, among those treated without surgery, only 1 had an initial displacement greater than 60 degrees, whereas among 14 treated with surgery, 7 had an initial displacement greater than 60 degrees.34 Such a cohort allows us to recommend nonoperative treatment for less severe fractures but does not help with treatment decisions on more severe fractures because we do not know whether to ascribe the bad outcomes to the severity of the fracture or to the operative intervention.
A later retrospective cohort study (Level III evidence) reported on 100 patients treated by immobilization, closed reduction, or open reduction, and again found a disappointingly large number of painful, stiff elbows among those treated with open reductions compared with better results with closed reduction or no reduction.35 Again, this cohort can only suggest how to treat the less severe fractures because the poor results in the more severe fractures may be related to the severity of the injury or to the operation itself.
In 1992, a case series (Level IV evidence) of 36 consecutive fractures displaced more than 30 degrees reported 33 successful reductions using a percutaneous K-wire technique, of which 31 had full motion at follow-up examination.36 No internal fixation was used to maintain the reduction. Subsequent case series combining closed or percutaneous reduction with stabilization by a flexible intramedullary nail introduced through the distal radial metaphysic have reported similarly good results.37,38 The consensus in the recent literature indicates that closed or percutaneous reduction techniques, perhaps supplemented by intramedullary fixation, generally gives good results where it is possible. The bias in the recent literature is that the cases are selected and reported based on the success of the technique; therefore, although we may be whittling away at the group of potential bad outcomes with perhaps a more sophisticated set of tools, we still have little information about the results of all badly displaced fractures, including those (if any) that cannot be reduced by the means described. Furthermore, the case series described earlier cannot inform us when, if ever, intramedullary fixation is required to supplement closed or percutaneous reduction.
SUMMARY
Table 27-1 summarizes the literature on elbow fractures around common clinical presentations or questions. Little controversy exists surrounding closed reduction and pinning as the main treatment for supracondylar fractures, or open reduction and pinning as the main treatment for displaced lateral condyle fractures. The current state of the literature, however, does not allow us to confidently assert whether pinning or cast treatment is better for undisplaced lateral condyle fractures, which are common. In addition, displaced medial epicondyle fractures may be treated open or closed depending on the trade-off between radiographic union and residual symptoms. The literature regarding treatment of radial neck fractures is fraught with bias. However, it is fairly clear that avoiding open operations is likely to lead to better patient outcomes. More recent literature arms us with percutaneous reduction and fixation techniques that have good results when they can be applied successfully. Little in the literature addresses the preferred treatment of pediatric elbow trauma in settings devoid of c-arms and Kirschner wires, even though such settings are the reality of most of the children in the world.
| STATEMENT | LEVEL OF EVIDENCE/GRADE OF RECOMMENDATION | REFERENCES |
|---|---|---|
| Supracondylar Fractures | ||
| Closed reduction and lateral entry percutaneous pinning is acceptable initial treatment for displaced supracondylar fractures. | A | 7 |
| Closed reduction and lateral entry percutaneous pinning is the preferred initial treatment for displaced supracondylar fractures. | B, C | 1, 3–6 |
| A viable, pulseless hand after closed reduction and percutaneous pinning can be treated by observation rather than routine arterial exploration. | C | 15, 16 |
| Surgical treatment of closed supracondylar fractures without vascular compromise may be delayed 8 hours or more after presentation without increasing complications. | B | 17–19 |
| Varus malunion after supracondylar fracture is best treated with the French osteotomy. | B | 22, 23 |
| Lateral Condyle Fractures | ||
| Cast treatment or percutaneous pinning can be used for undisplaced lateral condyle fractures. | B, C | 28, 29 |
| Accurate open reduction and pinning is the preferred treatment for displaced lateral condyle fractures. | B, C | 28, 30, 31 |
| Medial Epicondyle Fractures | ||
| Displaced medial epicondyle fractures treated operatively have a greater rate of fracture union and a greater rate of pain, stiffness, or other symptoms compared with those treated without surgery. | B (probable selection bias) | 32, 33 |
| Radial Neck Fractures | ||
| Radial neck fractures treated by no reduction or closed reduction have less pain, stiffness, and complications than those treated by open reductions. | B (probable selection bias) | 34, 35 |
| Most displaced radial neck fractures can be successfully reduced by percutaneous K-wire manipulation. | C | 36 |
| Displaced radial neck fractures that can be reduced by closed or percutaneous techniques can be stabilized by intramedullary titanium nails with good outcomes. | C | 37, 38 |
1 Pirone AM, Graham HK, Krajbich JI. Management of displaced extension-type supracondylar fractures of the humerus in children. J Bone Joint Surg Am. 1988;70:641-650.
2 Prietto CA. Supracondylar fractures of the humerus. A comparative study of Dunlop’s traction versus percutaneous pinning. J Bone Joint Surg Am. 1979;61:425-428.
3 Skaggs DL, Hale JM, Bassett J, et al. Operative treatment of supracondylar fractures of the humerus in children. The consequences of pin placement. J Bone Joint Surg Am. 2001;83-A:735-740.
4 France J, Strong M. Deformity and function in supracondylar fractures of the humerus in children variously treated by closed reduction and splinting, traction, and percutaneous pinning. J Pediatr Orthop. 1992;12:494-498.
5 Topping RE, Blanco JS, Davis TJ. Clinical evaluation of crossed-pin versus lateral-pin fixation in displaced supracondylar humerus fractures. J Pediatr Orthop. 1995;15:435-439.
6 Skaggs DL, Cluck MW, Mostofi A, et al. Lateral-entry pin fixation in the management of supracondylar fractures in children. J Bone Joint Surg Am. 2004;86-A:702-707.
7 Kocher MS, Kasser JR, Waters PM, 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;89:706-712.
8 Foead A, Penafort R, Saw A, Sengupta S. Comparison of two methods of percutaneous pin fixation in displaced supracondylar fractures of the humerus in children. J. 2004;12:76-82.
9 Brauer CA, Lee BM, Bae DS, et al. A systematic review of medial and lateral entry pinning versus lateral entry pinning for supracondylar fractures of the humerus. J Pediatr Orthop. 2007;27:181-186.
10 Ozcelik A, Tekcan A, Omeroglu H. Correlation between iatrogenic ulnar nerve injury and angular insertion of the medial pin in supracondylar humerus fractures. J Pediatr Orthop B. 2006;15:58-61.
11 Sankar WN, Hebela NM, Skaggs DL, Flynn JM. Loss of pin fixation in displaced supracondylar humeral fractures in children: Causes and prevention. J Bone Joint Surg Am. 2007;89:713-717.
12 Ozkoc G, Gonc U, Kayaalp A, et al. Displaced supracondylar humeral fractures in children: Open reduction vs. closed reduction and pinning. Arch Orthop Trauma Surg. 2004;124:547-551.
13 Mahan ST, May CD, Kocher MS. Operative management of displaced flexion supracondylar humerus fractures in children. J Pediatr Orthop. 2007;27:551-556.
14 Schoenecker PL, Delgado E, Rotman M, et al. Pulseless arm in association with totally displaced supracondylar fracture. J Orthop Trauma. 1996;10:410-415.
15 Garbuz DS, Leitch K, Wright JG. The treatment of supracondylar fractures in children with an absent radial pulse. J Pediatr Orthop. 1996;16:594-596.
16 Sabharwal S, Tredwell SJ, Beauchamp RD, et al. Management of pulseless pink hand in pediatric supracondylar fractures of humerus. J Pediatr Orthop. 1997;17:303-310.
17 Mehlman CT, Strub WM, Roy DR, et al. The effect of surgical timing on the perioperative complications of treatment of supracondylar humeral fractures in children. J Bone Joint Surg Am. 2001;83-A:323-327.
18 Carmichael KD, Joyner K. Quality of reduction versus timing of surgical intervention for pediatric supracondylar humerus fractures. Orthopedics. 2006;29:628-632.
19 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;88:380-381.
20 Walmsley PJ, Kelly MB, Robb JE, et al. Delay increases the need for open reduction of type-III supracondylar fractures of the humerus. J Bone Joint Surg Br. 2006;88:528-530.
21 Keppler P, Salem K, Schwarting B, Kinzl L. The effectiveness of physiotherapy after operative treatment of supracondylar humeral fractures in children. J Pediatr Orthop. 2005;25:314-316.
22 Kumar K, Sharma R, Maffulli N. Correction of cubitus varus by French or dome osteotomy: A comparative study. J Trauma. 2000;49:717-721.
23 Bellemore MC, Barrett IR, Middleton RW, et al. Supracondylar osteotomy of the humerus for correction of cubitus varus. J Bone Joint Surg Br. 1984;66:566-572.
24 Song KS, Kang CH, Min BW, et al. Internal oblique radiographs for diagnosis of nondisplaced or minimally displaced lateral condylar fractures of the humerus in children. J Bone Joint Surg Am. 2007;89:58-63.
25 Vocke-Hell AK, Schmid A. Sonographic differentiation of stable and unstable lateral condyle fractures of the humerus in children. J Pediatr Orthop B. 2001;10:138-141.
26 Horn BD, Herman MJ, Crisci K, et al. Fractures of the lateral humeral condyle: Role of the cartilage hinge in fracture stability. J Pediatr Orthop. 2002;22:8-11.
27 Kamegaya M, Shinohara Y, Kurokawa M, Ogata S. Assessment of stability in children’s minimally displaced lateral humeral condyle fracture by magnetic resonance imaging. J Pediatr Orthop. 1999;19:570-572.
28 Launay F, Leet AI, Jacopin S, et al. Lateral humeral condyle fractures in children: A comparison of two approaches to treatment. J Pediatr Orthop. 2004;24:385-391.
29 Bast SC, Hoffer MM, Aval S. Nonoperative treatment for minimally and nondisplaced lateral humeral condyle fractures in children. J Pediatr Orthop. 1998;18:448-450.
30 Rutherford A. Fractures of the lateral humeral condyle in children. J Bone Joint Surg Am. 1985;67:851-856.
31 Thomas DP, Howard AW, Cole WG, Hedden DM. Three weeks of Kirschner wire fixation for displaced lateral condylar fractures of the humerus in children. J Pediatr Orthop. 2001;21:565-569.
32 Farsetti P, Potenza V, Caterini R, Ippolito E. Long-term results of treatment of fractures of the medial humeral epicondyle in children. J Bone Joint Surg Am. 2001;83-A:1299-1305.
33 Wilson NI, Ingram R, Rymaszewski L, Miller JH. Treatment of fractures of the medial epicondyle of the humerus. Injury. 1988;19:342-344.
34 Vahvanen V, Gripenberg L. Fracture of the radial neck in children. A long-term follow-up study of 43 cases. Acta Orthop Scand. 1978;49:32-38.
35 D’souza S, Vaishya R, Klenerman L. Management of radial neck fractures in children: A retrospective analysis of one hundred patients. J Pediatr Orthop. 1993;13:232-238.
36 Steele JA, Graham HK. Angulated radial neck fractures in children. A prospective study of percutaneous reduction. J Bone Joint Surg Br. 1992;74:760-764.
37 Stiefel D, Meuli M, Altermatt S. Fractures of the neck of the radius in children. J Bone Joint Surg Br. 2001;83:536-541.
38 Schmittenbecher PP, Haevernick B, Herold A, et al. Treatment decision, method of osteosynthesis, and outcome in radial neck fractures in children: A multicenter study. J Pediatr Orthop. 2005;25:45-50.
