Abstract

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Objective:
A retrospective review of 59 supracondylar femoral fractures occurring in 56 children between1991 and 2004 (14 years) was performed to assess treatment methods and outcomes.
Design:
Patient ages ranged from 1month to 15 years, with a mean of 3.2 years (median 1.5 years). There were 6 high-energy injuries and 34 as a result of the child being dropped or a fall. Abnormal bone contributed to 17 fractures in 14 patients with minimal trauma.
Intervention:
Displaced fractures were managed by reduction and fixation. Undisplaced fractures were treated by plaster immobilisation.
Results:
Manipulation, with or without percutaneous “K” wire fixation was adequate in the management of majority of these fractures. Two children had a stiff knee with the remainder recovering to their pre-injury status.
Conclusion:
Our experience from this study suggests that impacted, undisplaced and minimally displaced supracondylar femur fractures are well managed in a long leg or pipe stem cast. Reduction and stabilisation better manage displaced high-energy fractures.
(Keywords: Supracondylar fracture, Femur, Children).

Introduction

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Supracondylar non-physeal femoral fractures in children are said to be rare, though Smith et al (1) found that these fractures comprised 12% of femoral fractures in their unit. Undisplaced supracondylar fractures of the femur are more common in children with paralytic disorders (1). Little has been published on this injury, though well-known authors (2, 4, and 5) have commented on the difficulty of managing these fractures. The literature did not seem to accord with our experience of this fracture, so we reviewed our cases to assess their treatment and outcomes for this injury.

Methods

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We defined supracondylar fractures as a fracture of the distal metaphysis, up to a distance equal to the condylar width from the joint line (AO/OTA classification). We excluded diaphyseal fractures and metaphyseal fractures involving the distal femoral physis, which is a more common and more serious injury (3, 4, and 5).
Retrospective data of 56 patients treated for 59 supracondylar femoral fractures between 1991 and 2004 were obtained from our database. This is the largest series reported of this type of fracture. Case notes and X-rays were reviewed to obtain age, date and mechanism of injury, concurrent medical conditions, associated injuries, treatment, follow up and outcomes.

Results

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We identified 56 patients with 59 fractures. There were 28 males and 28 females. The ages of our children ranged from 1 month to 15 years giving a median age of 1.5 years and a mean age of 3.2 years. The annual incidence varied between 2 and 8 patients. There were 28 right and 31 left-sided fractures.
The mechanism of injury in the 42 children with normal bone was being dropped or a fall in 36, the result of a road traffic accident in 6. Two of the fractures after a fall occurred in children who had recently come out of a hip spica after treatment for developmental dysplasia of the hip and were presumably secondary to plaster osteoporosis.
28 fractures were undisplaced, 7 were minimally displaced and 22 were greenstick fractures. There was one displaced and one grade 1 compound displaced fracture. Four children had additional injuries in the form of a diaphyseal fracture of the contra-lateral femur (1), a stable pelvic fracture (1) or head injury (2).
There were 17 fractures in children with abnormal bone due to cerebral palsy (4), Myelomeningocoele or Sacral agenesis (6), leukaemia (2), Batten’s disease (2), rickets (1), Di George syndrome (1), and Spondyloepiphyseal dysplasia after leg lengthening (1). These fractures occurred after minimal or unrecognised trauma.
Treatment:
The compound displaced fracture was debrided, reduced and fixed with retrograde titanium nails. The closed displaced fracture was reduced closed and fixed with percutaneous crossed K wires. Initial traction with a Thomas splint or Gallows traction and then a plaster hip spica was used in 7 patients. The remaining 50 patients were placed in a long leg or pipe stem plaster.
Complications:
Backup of the titanium nails was managed by trimming them. The fracture healed well and the nails were removed at 1 year. Plaster pressure sores occurred in 2 insensate patients. Two children had residual knee stiffness, though they have been stiff pre-injury due to spasticity. One patient re-fractured after returning too soon to contact sports. The re-fracture was treated conservatively and united in a good position.
Post healing X-rays showed no residual deformity in our review group.
Follow-up varied from 2 weeks in a 1month infant to 11 months in an open fracture.

Discussion

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Femoral supracondylar fractures comprised 7.5% of femoral fractures in our unit between 1991 and 2004. Smith et al found this fracture comprised 12% (7% displaced, 5% undisplaced) of femoral fractures in their unit, but Butcher & Hoffman (4) reported that in their experience displaced femoral supracondylar fractures made up only 1% of femoral fractures. Only 3% of our fractures were significantly displaced with a further 49% being greenstick or minimally displaced. Our findings are therefore very similar to those reported previously in smaller series.
Smith et al (1) reported three patterns of injury for femoral supracondylar fractures: –
(i) A low energy injury in normal bone resulting in an undisplaced fracture.
(ii) A low energy injury in abnormal bone resulting in a displaced fracture.
(iii) A high-energy injury resulting in a displaced fracture.
The majority of our patients had undisplaced or minimally displaced fractures, which were treated conservatively.
Out of fifty-six patients, fourteen with seventeen fractures (29% of fractures) had abnormal bone due to underlying medical conditions. This compares well with the 33% with predisposing medical conditions noted by Smith et al. None required surgical intervention. Nine patients in this group sustained accidental fractures at the hands of their parents or siblings.
Six displaced fractures resulted from being hit by moving vehicles but only two were significantly displaced.
Despite a median age of 1.5 years, none of the patients our series was found to have sustained a non-accidental injury (NAI). NAI should be considered in children presenting with a fracture aged less than 12 months and in all children with disability. Our patients were much younger than those described by Smith et al (1) whose mean age was 6 years 10 months.
Immobilisation in a long leg or pipe stem plaster was adequate treatment for most of our cases. The maximum period of immobilisation was six weeks, with a median value of three weeks. We discharged patients after obtaining check x-rays confirming fracture healing in good alignment. We did not re-operate on any patients for malunion. Our displaced fractures in normal bone were reduced and fixed, with no resulting malunions. The patients with displaced fractures and abnormal bone were not managed aggressively as all were wheelchair bound with low requirements. Two patients had residual stiffness but it was unclear how much stiffness was present before the fracture as a consequence of the underlying medical problem. Indeed, pre-fracture stiffness may have been a predisposing factor for the fracture in addition to abnormal bone.

Conclusion(s)

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Our experience from this study suggests that impacted, undisplaced and minimally displaced supracondylar femur fractures are well managed in a long leg or pipe stem cast. Reduction and stabilisation better manage displaced high-energy fractures.

Reference(s)

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1. Smith NC, Parker D, McNicol D.Supracondylar fractures of the femur in children. Journal of Paediatric Orthopaedics 21:600-603, 2001.
2. Eid A M, Hafez MA. Traumatic injuries of the distal femoral physis. Retrospective study on 151 cases Injury 33:251-255, 2002.
3. Butcher CC, Hoffman EB. Supracondylar fractures of the femur in children. Supracondylar fractures of the femur in children: closed reduction and percutaneous pinning of displaced fractures. Journal of Pediatric Orthopaedics. 2005 Mar-Apr; 25(2):145-8.
4. Rang. Femoral shaft fractures, In Rang M, Ed. Children’s fractures. Philadelphia: Lippincott, 277-9, 1983
5. Staheli LT, Fractures of the shaft of the femur. In: Rockwood CA Jr, Wilkins KE, and King RE. Fractures in children Vol 3, 4th Edition. Philadelphia: Lippincott-Raven, 669-752, 1996.

Source(s) of Funding

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No financial or personal benefit obtained from anyone or any institution 

 

Competing Interests

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No conflict of interest. No financial or personal benefit obtained from anyone or any institution 

 

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