title: Treatment of multidirectionally unstable supracondylar humeral fractures in children. A modified Gartland type-IV fracture.
abstract: BACKGROUND
  There is an uncommon subset of supracondylar humeral fractures in children that are so unstable they can displace into both flexion and extension. The purposes of this study were to describe this subset of supracondylar fractures and to report a new technique of closed reduction and percutaneous pinning for their treatment.
  
  
  METHODS
  In a retrospective review of 297 consecutive displaced supracondylar humeral fractures in children treated operatively at our institution, we identified nine that were completely unstable with documented displacement into both flexion and extension as seen on fluoroscopic examination with the patient under anesthesia. We used a new technique for closed reduction and fixation of these fractures, and then we assessed fracture-healing and complications from the injury and treatment.
  
  
  RESULTS
  All nine fractures were treated satisfactorily with closed reduction and percutaneous pinning. The complication rate associated with these unstable fractures was no higher than that associated with the 288 more stable fractures. Seven of the nine fractures were stabilized with lateral entry pin placement, and two fractures were stabilized with crossed medial and lateral pins. None of the patients had a nonunion, cubitus varus, malunion, additional surgery, or loss of motion.
  
  
  CONCLUSIONS
  In rare supracondylar fractures in children, multidirectional instability results in displacement into flexion and/or extension. This fracture can be classified as type IV according to the Gartland system, as it is less stable than a Gartland type-III extension supracondylar fracture. These fractures can be treated successfully with a new technique of closed reduction and percutaneous pinning, thus avoiding open reduction.
authors.affiliation: Childrens Hospital Los Angeles, 4650 Sunset Boulevard, #69, Los Angeles, CA 90027, USA.
authors.forename: K K
authors.initials: KK
authors.lastname: Leitch
authors.forename: R M
authors.initials: RM
authors.lastname: Kay
authors.forename: J D
authors.initials: JD
authors.lastname: Femino
authors.forename: V T
authors.initials: VT
authors.lastname: Tolo
authors.forename: S K
authors.initials: SK
authors.lastname: Storer
authors.forename: D L
authors.initials: DL
authors.lastname: Skaggs
mesh_terms: D001858:Bone Nails; D001864:Bone Wires; D002648:Child; D005500:Follow-Up Studies; D005592:Fracture Fixation / Q000379:methods*; D017102:Fracture Healing; D006801:Humans; D006810:Humeral Fractures / Q000000981:diagnostic imaging / Q000601:surgery*; D011859:Radiography; D016059:Range of Motion, Articular; D012189:Retrospective Studies; D016896:Treatment Outcome