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Natural History

Stiffness and pain in the elbow are the results of failure of treatment. Varus or valgus deformity, frequently seen following improperly treated supracondylar fractures in children, is not as significant a problem in adults as is stiffness.

In order to prevent stiffness, all periarticular and intra-articular fractures require early active motion. Prolonged plaster immobilization leads to irreversible joint stiffness. Traction, although it affords some degree of immobilization and pain relief, and although it permits early active motion, does so only within a limited arc of movement. Furthermore, although traction may improve the position of displaced intra-articular fragments, it almost never leads to the accurate joint reduction required for the return of normal function. Finally, traction which requires bed rest and prolonged hospitalization for at least 6 weeks is economically no longer an acceptable form of treatment.

Early attempts at open reduction and internal fixation relied on screws, Kirschner wires, and occasionally on plates for stability (Fig. 6.4). Although the radiological appearance of the fracture was frequently improved, the need for postoperative plaster immobilization, which was carried out for 3-6 weeks or longer, resulted in a considerable degree of elbow stiffness. Internal fixation without the use of compression was not stable. Attempts at early active movement resulted not only in an increased incidence of malunion or nonunion, but also in stiffness. The patients felt severe pain because of instability and were unable to execute the required range of movement.

Passive manipulation of these fractures rarely improved the result and was sometimes disastrous because it led to myositis ossificans, which permanently marred the result. Controversy continued and, whereas most surgeons were opposed to any form of surgical intervention (Keon-Cohen 1966; Riseborough and Radin 1969), others championed the operative approach (Bickel and Perry 1963; Miller 1964). The opponents of surgical intervention felt that the results of internal fixation were extremely bad (Keon-Cohen 1966) and that stiffness was the result of surgical dissection, necessary for the exposure of all components of the fracture and insertion of the internal fixation. Inability to achieve a reasonable reduction by manipulation and traction was considered to be the only indication for an open reduction and internal fixation.

The champions of the surgical approach have clearly outlined the disadvantages of closed treatment. Manipulation and traction often fail to restore perfect joint alignment. Thus the patient not only faces stiffness, but pain from joint incongruity and post-traumatic osteoarthritis. Traction is often required for 4-6 weeks before sufficient stability is gained to permit guarded mobilization. Traction may not be possible because (a) the patient may not a a

Fig. 6.4. a Screw fixation of a supracondylar fracture of the humerus. b Note, in this tomograph of this fracture, the malreduction of the joint and the nonunion of all fracture lines. c In another patient, the threaded Compere wire failed to provide adequate stability, and the outcome of the supracondylar fracture was nonunion

Fig. 6.4. a Screw fixation of a supracondylar fracture of the humerus. b Note, in this tomograph of this fracture, the malreduction of the joint and the nonunion of all fracture lines. c In another patient, the threaded Compere wire failed to provide adequate stability, and the outcome of the supracondylar fracture was nonunion

b c tolerate the imposed supine position because of age or temperament; or (b) because of associated injuries that demand mobilization. Furthermore, traction may have to be discontinued because the anticipated satisfactory reduction is not obtained. Unfortunately, this decision is often reached at an inopportune time for an open reduction. Because of delay, the fragments will have usually become matted together by callus, softened by disuse and hyperemia, and the joint will have become stiff because of the trauma and inactivity. And finally as already stated no health care delivery system can afford to have a patient hospitalized and maintained in traction for such a long period of time, particularly when a surgical intervention provides a satisfactory solution.

The advocates of surgical treatment (Bickel and Perry 1963; Miller 1964) have further pointed out the following. In the displaced fracture, an anatomical reduction of the joint can be obtained only by operative means. Furthermore, in the absence of any inherent stability of the bony fragments, the reduction can only be maintained by internal fixation. Open reduction and internal fixation hasten ambulation of the patient and active motion of the elbow.

The development by the AO group of stable internal fixation, utilizing compression as the keystone of stability, and the development of new implants and operative techniques have greatly increased the scope of surgery for the supracondylar fracture. Of particular help in the treatment have been the small cortex b a c and cancellous screws, the one-third tubular plates, the small limited contact-dynamic compression (LC-DC) plates, and the small reconstruction plates and more recently the LCP. They have made it possible to achieve the goals of internal fixation, namely, stable fixation and early motion.

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