Anterior Versus Posterior Surgical Approaches to Pediatric Supracondylar Humerus Fracture

Document Type : RESEARCH PAPER

Authors

1 Department of Orthopaedic Surgery, Isfahan University of Medical Sciences, Isfahan, Iran

2 Department of Radiology, Isfahan University of Medical Sciences, Isfahan, Iran

3 Kashani University Hospital, Isfahan University of Medical Sciences, Isfahan, Iran

Abstract

Objectives: Gartland type III supracondylar humerus fractures frequently occur as traumatic injuries in 
children and often require surgical intervention. This study aimed to compare the efficacy of anterior 
and posterior surgical approaches to treating these fractures.
Methods: This retrospective study analyzed 48 patients under the age of 10 with Gartland type III fractures. These 
patients were treated with either the anterior (n=23) or the posterior approach (n=25). At three and six months postsurgery, elbow range of motion (ROM), complications, and functional/cosmetic outcomes were assessed using 
Flynn's criteria.
Results: No significant differences were found between the groups regarding age or gender. At three months, the 
anterior group showed significantly better extension (-8.26° vs. -13.20°, P=0.032), but this difference was not 
significant at six months. No significant differences were observed in flexion, pronation, or supination at any time 
point. Both groups showed significant ROM improvements from three to six months (P<0.001); however, these 
improvements were slightly below the normative values (P<0.05). The overall complication rates were low and 
comparable between the two approaches (anterior: 8.70%; posterior: 12.00%; P=0.700), primarily comprising 
reversible ulnar nerve injuries and superficial infections. Furthermore, based on Flynn's criteria, there were no 
significant differences in functional or cosmetic outcomes, with most patients achieving excellent or good results in 
both groups.
Conclusion: Both anterior and posterior approaches for pediatric Gartland type III supracondylar humerus fractures 
resulted in satisfactory outcomes. Therefore, the choice of surgical approach will depend on patient-related factors 
and surgeons’ preferences.
 Level of evidence: III

Keywords

Main Subjects


1. Okubo H, Nakasone M, Kinjo M, Onaka K, Futenma C, Kanaya 
F. Epidemiology of paediatric elbow fractures: a retrospective 
multi-centre study of 488 fractures. J Child Orthop. 2019; 
13(5):516-521. doi:10.1302/1863-2548.13.190043.
2. Vaquero-Picado A, González-Morán G, Moraleda L. 
Management of supracondylar fractures of the humerus in 
children. EFORT Open Rev. 2018; 3(10):526-540. 
doi:10.1302/2058-5241.3.170049.
3. Schuller A, Hahn S, Pichler L, et al. Correlation of Fall Height, 
Fracture Severity and Clinical Outcome in Pediatric 
Supracondylar Fractures-A Retrospective Analysis with an 
Observation Period of 20 Years. Children (Basel). 2023; 
10(3):510. doi:10.3390/children10030510.
4. Anjum R, Sharma V, Jindal R, Singh TP, Rathee N. 
Epidemiologic pattern of paediatric supracondylar fractures 
of humerus in a teaching hospital of rural India: A prospective 
study of 263 cases. Chin J Traumatol. 2017; 20(3):158-160. 
doi:10.1016/j.cjtee.2016.10.007.
5. Li M, Xu J, Hu T, Zhang M, Li F. Surgical management of 
Gartland type III supracondylar humerus fractures in older 
children: a retrospective study. J Pediatr Orthop B. 2019; 
28(6):530-535. doi:10.1097/bpb.0000000000000582.
6. Shah M, Agashe MV. Supracondylar Humerus Fractures: 
Classification Based Treatment Algorithms. Indian J 
Orthop.2021; 55(1):68-80. doi:10.1007/s43465-020-00285-
2.
7. Reisoglu A, Kazimoglu C, Hanay E, Agus H. Is pin 
configuration the only factor causing loss of reduction in the 
management of pediatric type III supracondylar fractures? 
Acta Orthop Traumatol Turc. 2017; 51(1):34-38. 
doi:10.1016/j.aott.2016.11.003.
8. Loubani E, Bartley D, Forward K. Orthopedic Injuries in 
Pediatric Trauma. Curr Pediatr Rev. 2018; 14(1):52-58. 
doi:10.2174/1573396313666170911140044.
9. Tomaszewski R, Pethe K, Kler J, Rutz E, Mayr J, Dajka J. 
Supracondylar Fractures of the Humerus: Association of 
Neurovascular Lesions with Degree of Fracture Displacement 
in Children-A Retrospective Study. Children (Basel). 2022; 
9(3):308. doi:10.3390/children9030308.
10. Tunku-Naziha TZ, Wan-Yuhana W, Hadizie D, et al. Early 
Vessels Exploration of Pink Pulseless Hand in Gartland III 
Supracondylar Fracture Humerus in Children: Facts and 
Controversies. Malays Orthop J. 2017; 11(1):12-17. 
doi:10.5704/moj.1703.005.
11. Graff C, Dounas GD, Todd M, Sung J, Kumawat M. Management 
of Traumatic Nerve Palsies in Paediatric Supracondylar 
Humerus Fractures: A Systematic Review. Children (Basel). 
2023; 10(12):1862. doi:10.3390/children10121862.
12. Pavone V, Vescio A, Accadbled F, et al. Current trends in the 
treatment of supracondylar fractures of the humerus in 
children: Results of a survey of the members of European 
Paediatric Orthopaedic Society. J Child Orthop. 2022; 
16(3):208-219. doi:10.1177/18632521221106379.
13. Banshelkikar S, Sheth B, Banerjee S, Maaz M. Functional 
outcome of supracondylar humerus fracture in children with 
the use of pin configuration as per Bahk classification. J Clin Orthop Trauma. 2021; 13:78-81. 
doi:10.1016/j.jcot.2020.08.012.
14. Usman R, Jamil M, Hashmi JS. Management of Arterial Injury 
in Children with Supracondylar Fracture of the Humerus and 
a Pulseless Hand. Ann Vasc Dis. 2017; 10(4):402-406. 
doi:10.3400/avd.oa.17-00050.
15. Uludağ A, Tosun HB, Aslan TT, Uludağ Ö, Gunay A. 
Comparison of Three Different Approaches in Pediatric 
Gartland Type 3 Supracondylar Humerus Fractures Treated 
With Cross-Pinning. Cureus. 2020; 12(6):e8780.
doi:10.7759/cureus.8780.
16. Kashyap A, Ravoof A, Karigowda H, Lakkireddy M, Srikanth E. 
Comparative Study of the Functional Outcome of Elbow Joint 
in Supracondylar Fractures of Children Treated With k Wire 
Fixation Using Lateral and Posterior Approaches. Cureus. 
2022; 14(8):e28232. doi:10.7759/cureus.28232.
17. Kokly S, Castagna A, Aarabi M. Triceps-sparing Posterior 
Approach for Supracondylar Humeral Fracture in Children. 
Arch Bone Jt Surg. 2019; 7(5):416-421. 
doi:10.22038/ABJS.2018.20640.1533.
18. Zwerus EL, Willigenburg NW, Scholtes VA, Somford MP, 
Eygendaal D, van den Bekerom MP. Normative values and 
affecting factors for the elbow range of motion. Shoulder 
Elbow. 2019; 11(3):215-224. 
doi:10.1177/1758573217728711.
19. Kotte SHP, Viveen J, Koenraadt KLM, The B, Eygendaal D. 
Normative values of isometric elbow strength in healthy 
adults: a systematic review. Shoulder Elbow. 2018; 
10(3):207-215. doi:10.1177/1758573217748643.
20. Lombard C, Teixeira P, Germain E, et al. Elbow Stiffness 
Imaging: A Practical Diagnostic and Pretherapeutic Approach. 
J Clin Med. 2021; 10(22) doi: 10.3390/jcm10225348.
21. Su Y, Nan G. Evaluation of a Better Approach for Open 
Reduction of Severe Gartland Type III Supracondylar 
Humeral Fracture. J Invest Surg. 2021; 34(5):479-485. 
doi:10.1080/08941939.2019.1649766.
22. Gerami MH, Naderian R, Nemati A, Abdoos P, Saeedi F. 
Anterior approach versus posterior approach for the open 
reduction of displaced pediatric supracondylar humerus 
fracture. J Orthop. 2023; 42:70-73. 
doi:10.1016/j.jor.2023.07.014.
23. Yavuz İ A, Özdemir G, Akgül T, Yılmaz B, Çiçekli Ö, Yazar EA. 
Comparison of 4 surgical approaches in pediatric Gartland 
type 3 supracondylar humerus fractures treated by open 
reduction and pinning: A multicenter study. Acta Orthop 
Traumatol Turc. 2023; 57(2):50-54. 
doi:10.5152/j.aott.2023.22049.
24. Das R, Borthakur B, Agarwala V, Ghosh S. Evaluation of 
anterior approach in failed closed reduction and delayed 
presentation of supracondylar humerus fractures in children. 
J Orthop. 2022; 30:51-58. doi:10.1016/j.jor.2022.02.006.
25. Ay S, Akinci M, Kamiloglu S, Ercetin O. Open reduction of 
displaced pediatric supracondylar humeral fractures through 
the anterior cubital approach. J Pediatr Orthop. 2005; 
25(2):149-53. doi:10.1097/01.bpo.0000153725.16113.ab.
26. Türkmen F, Toker S, Kesik K, Korucu İ H, Acar MA. 
Comparison of lateral versus triceps-splitting posterior 
approach in the surgical treatment of pediatric supracondylar 
humerus fractures. Ulus Travma Acil Cerrahi Derg. 2016; 
22(5):483. doi:10.5505/tjtes.2016.74606.
27. Fatah RMN, Amin BRM, Mahmud HA, Yusif AJ. Assessment of 
the outcome of anterior versus posterior approach in the 
management of displaced pediatric supracondylar humerus 
fracture. Open J Orthop. 2016; 6(5):113-119. 
doi:10.4236/ojo.2016.65017. 
28. Dunham CL, Castile RM, Havlioglu N, Chamberlain AM, Lake 
SP. Temporal Patterns of Motion in Flexion-extension and 
Pronation-supination in a Rat Model of Posttraumatic Elbow 
Contracture. Clin Orthop Relat Res. 2018; 476(9):1878-1889. 
doi:10.1097/corr.0000000000000388.
29. Ausó-Pérez JR, Rodríguez-Blanes GM. Comprehensive 
Analysis of Pediatric Supracondylar Fractures in the 
Emergency Department; A Single Center Experience. Bull 
Emerg Trauma. 2020; 8(3):142-147. 
doi:10.30476/beat.2020.83195.
30. Terpstra SES, Burgers P, van der Heide HJL, Witte PB. 
Pediatric Supracondylar Humerus Fractures: Should We 
Avoid Surgery during After-Hours? Children (Basel). 2022; 
9(2):189. doi:10.3390/children9020189.
31. Ersan O, Gonen E, Arik A, Dasar U, Ates Y. Treatment of 
supracondylar fractures of the humerus in children through 
an anterior approach is a safe and effective method. Int 
Orthop. 2009; 33(5):1371-5. doi:10.1007/s00264-008-0668-
y.
32. Holt JB, Glass NA, Shah AS. Understanding the Epidemiology 
of Pediatric Supracondylar Humeral Fractures in the United 
States: Identifying Opportunities for Intervention. J Pediatr 
Orthop. 2018; 38(5):e245-e251. 
doi:10.1097/bpo.0000000000001154.