Supracondylar fracture of the humerus is one of the most common fracture (only after clavicle and both bone forearm fracture) in the paediatric age group with a male predominance accounting for 16% of all paediatric fractures and 60% of all paediatric elbow fractures, classically occurring as a result of fall on an outstretched hand [1,3]. It is of two types- extension type most common (95-98%) and flexion type less common (<5%). Extension type injury is more common than flexion type [4]. It is frequently found in the non-dominant extremity. The flexion type is common in elderly children [5]. The Gartland classification is a commonly used system for the evaluation and treatment of supracondylar humerus fractures in children. [6]. Type I injuries are immobilized with an above elbow slab for 3 to 4 weeks, with radiographic alignment checked at 1 week. Type IIA injuries can be treated with closed reduction and slab or percutaneous pinning, whereas type IIB injuries should have closed reduction and percutaneous pinning to prevent coronal and/or rotational malalignment. Types III injuries also are treated with closed reduction and percutaneous pinning, as are flexion-type injuries, with possible open reduction and internal fixation if closed reduction is unsuccessful [6].

Table 1: Gartland Classification of the supracondylar humerus:

The purpose of the study was to compare the presentation and postoperative results of children treated by open reduction and closed reduction for completely displaced Gartland type III supracondylar humerus fractures (SCFs). Criteria taken into consideration were final (functional and cosmetic) outcomes, period of hospitalization, the time needed for healing and the expected common complications.

The surgical technique for Group 2 (close reduction) was as follows.

An elbow support device was placed at the lateral edge of the table to keep the joint stable during the k-wire fixation. After anesthesia (general/regional), painting and draping were done and the fracture was reduced closely under C-arm intensifier. Two crossed k-wires were introduced laterally and medially without using a tourniquet.

In both groups, a P.O.P. above-elbow slab was applied. Group 1 patients stayed in the hospital for 5 days while Group 2 stayed for only 2 days in the hospital. One check dressing on the second postoperative day of group 1 patient was done during their stay at the hospital. Postoperative check X-ray was done of all patients of both groups 1 & 2 and they were discharged from the hospital on oral medication.

Group 1 patients received prophylactic antibiotics (Amoxicillin syrup) till stitch removal in addition to painkillers. Also group 1 patient required two additional follow-ups at eight postoperative days (for check dressing) and 11 postoperative days for stitch removal. Both groups’ patients were called at four weeks for k-wire removal. Active range of motion and early physiotherapy started on the day of wire removal (after 4 weeks)

Schedule of follow-up of Group1: 8^th POD,11^th POD,2^nd week, 4^th week, 6^th week,3^rd month,6^th month. Schedule of follow-up of Group2: 2^nd week, 4^th week, 6^th week, 3rd month, 6th month.

During the postoperative period in hospital and after discharge from the hospital, during follow-up we assessed the patient based on the accuracy of the reduction and looking for possible early complications such as nerve injury, compartment syndrome, range of motion, presence of any malunion or cubitus varus and presence of infection

We depended on the Flynn et al. (7) criteria of evaluation to assess the results regarding any deformity and range of motion at the elbow joint Statistical data were presented by mean ± SD (standard deviation) and percentage. Analysis of data was done using SPSS version 22, utilizing independent sample t-test and one-way ANOVA according to p-value (P ≤ 0.05).

Table 5: Comparison of sex distribution in each group:

Table 6: Comparison of side distribution in each group:

Table 7: Comparison of both groups using Flynn Criteria:

As per the Flynn et al. criteria of evaluation, we obtained the following results.

In group 1: Out of a total of 33 patients, we reported 22 patients (66.7%) scored an excellent result, 8 patients (24.2%) scored a good result, 2 patients (6%) scored a fair result, and only one patient (3%) scored a poor result (Table 7).

In group 2: Out of a total of 17 patients, we reported 11 patients (64.7 %) scored an excellent result, 5 patients (29.4%) scored a good result, 1 patient (5.9%) had a fair result, and no patient had a poor result (Table 7).

Complications like pin tract infection occurred in 3 patients (1 from group 1 and 2 from group 2) and ulnar nerve palsy was seen in two patients of group 2. Pin tract infection recovered after daily dressing and a short course of antibiotics.

Ulnar nerve palsy also recovered in both the patients after 6 weeks. Statistically, there were no significant differences (P > 0.05) between patients of both groups regarding the Flynn et al. criteria.

when closed reduction failed, open reduction and internal fixation by cross-pinning were done [21]. In a study by D'Ambrosia normal elbow motion resulted following each method of closed treatment but open reduction caused some loss in extension [22]. In a study conducted by Devkota et al, they found closed reduction and percutaneous K– wire pinning in the management of supracondylar fractures of the humerus in children is safe as regards avoidance of vascular complications, effective in obtaining good results and relatively economical regarding hospitalization [23].

The disadvantage is the need for proficiency and the availability of C– arm fluoroscopy. In a study by Flynn et al, percutaneous pinning after closed reduction of supracondylar fractures has got several advantages (7). Immediate fixation of these fractures reduces the duration of hospital stay.

There were two cases of ulnar nerve neurapraxia (11.7%) in the closed treatment group which was probably due to a bad trial of pin entry medially. This result is comparable to other studies [24,27]. In studies by (Cemal Kazim Oglu), there was a high percentage of ulnar nerve insult in both types of treatment post-operatively, where it was 9.7% in the closed reduction group versus 5.4% in the ORIF group 928).

Both cases of ulnar nerve injury recovered spontaneously within 6 weeks. This is consistent with most cases [28, 29]. In this study, only the crossed-pin method of fixation was used, as we think it is sufficient to provide good stability, and it is mentioned in many articles [9,29,33]. As a comparison, although both techniques do not carry a significant rate of complication, in group 1, there was a longer post-operative hospitalization time.

Additionally, there is the cosmetically permanent surgical scar, which is a special concern for female patients.

In our study, we found no significant difference in the outcome for patients with Gartland type III supracondylar humerus fractures treated either by open reduction (Group1) or by close reduction (Group2) as per the Flynn et al. evaluation criteria. Although the sample size was relatively small, we recommend the closed reduction technique as the first choice of treatment, if C-arm facilities are available.