Prognosis in Supracondylar Fractures.

The purpose of this paper is to analyse the causes of permanent disability after supracondylar fractures of the humerus in children. By so doing I hope to show what degree of residual displacement can be accepted without detriment to the patient, and that which must be corrected to obtain an elbow of normal appearance and a full range of movement. A survey of the literature reveals many conflicting attitudes towards this fracture. It is agreed that accurate reduction is desirable, but there is variance of opinion about the cause of permanent deformity. Sandegaard (1943) analysed a large number of supracondylar fractures and concluded that anatomical reduction was important; he recommended that all severely displaced fractures should be treated by open reduction and nail fixation. On the other hand Sins (1939) after reviewing 330 fractures suggested that open operation was not justified because of the uniformly good results of closed manipulation, even when accurate reduction had not been obtained. Attenborough (1953) described functionally good results after extensive remodelling in four patients in whom the fractures had been left substantially unreduced. It is agreed that cubitus varus is an undesirable result but its cause is still vaguely understood. It has been suggested that the injury may cause a differential growth of bone and that varus deformity follows overgrowth of the lateral metaphysis (Brewster and Karp 1940). But most authors attribute deformity to a mechanical effect caused by an inaccurately reduced fracture. Formerly cubitus varus was thought to be the result of a residual displacement of the distal fragment in a medial direction (Sins 1939), but recently rotation and angulation have been considered. Many believe that the sole cause of a varus deformity is incomplete correction of medial rotation (Laurence 1956, French 1959), and this concept has been used to advocate novel forms of treatment (H#{248}yer 1952, Madsen 1955). In contrast, retrospective studies of patients with cubitus varus (King and Secor 1951, Smith 1960) suggested that medial angulation is the relevant deformity. In general much attention is given in the literature to individual methods of treatment of supracondylar fractures ; but there is little to assist in predicting the outcome of a fracture which is not perfectly reduced. Most papers attempt to draw statistical comparisons between series of cases : few attempt to read lessons from careful study of the individual patient.