title: Treatment of flexion-type supracondylar fractures in children: the 'push-pull' method for closed reduction and percutaneous K-wire fixation.
abstract: Flexion-type supracondylar fractures are challenging to treat because, unlike extension-type fractures, it is difficult to take advantage of the intact periosteal hinge to stabilize the fracture fragments during percutaneous pinning. Some authors have described closed reduction of these fractures with the elbow in extension, followed by percutaneous K-wire fixation. However, percutaneous pinning with elbow in extension is technically difficult, time consuming, and usually requires the help of a skilled assistant because of persistent fracture instability. To circumvent these difficulties, we utilized a 'push-pull' maneuver, which simplifies the closed reduction and fixation of these difficult fractures. We describe the surgical technique for the 'push-pull' method and report radiographic outcomes of a case series of children with flexion-type supracondylar fractures treated using this technique. A retrospective review of medical records and radiographs of all children who underwent operative treatment of a flexion-type supracondylar humeral fracture using the 'push-pull' method in a tertiary-level children's hospital between January 2009 and January 2014 was carried out. Radiographic outcomes were reported using descriptive statistics. There were a total of nine patients (five females, four males), average age 9.8 years (4-14 years). Seventy-eight percent (7/9 patients) of the children had type III injuries, whereas 22% (two children) had type II injuries. The average duration of surgery was 41 min (24-60 min). No intraoperative or postoperative complications were recorded. Postoperative radiographic measures showed that the anterior humeral line passed through the middle third of capitellum in 78% of patients (7/9 patients), whereas it passed posterior to it in 22% (two patients). The average humerocapitellar angle was 30° (21-44°) and the anterior coronoid line was unbroken in 44% (4/9 patients). The average humeroulnar angle was 13° (8-20°) of valgus. The 'push-pull' is a safe, effective, and easy method to treat unstable flexion-type supracondylar fractures in children with good radiographic postoperative outcomes.
  
  
  METHODS
  level IV.
authors.affiliation: aDivision of Paediatric Orthopaedics, IWK Health Centre, Halifax, Nova Scotia, Canada bDivision of Paediatric Orthopaedics, Sidra Medical and Research Center, Doha, Qatar.
authors.forename: Chukwudi
authors.initials: C
authors.lastname: Chukwunyerenwa
authors.forename: Benjamin
authors.initials: B
authors.lastname: Orlik
authors.forename: Ron
authors.initials: R
authors.lastname: El-Hawary
authors.forename: Karl
authors.initials: K
authors.lastname: Logan
authors.forename: Jason J
authors.initials: JJ
authors.lastname: Howard
mesh_terms: D000293:Adolescent; D001864:Bone Wires; D002648:Child; D002675:Child, Preschool; D004550:Elbow / Q000601:surgery; D004551:Elbow Joint / Q000601:surgery*; D005260:Female; D005593:Fracture Fixation, Internal; D005594:Fracture Fixation, Intramedullary; D006776:Hospitals, Pediatric; D006801:Humans; D006810:Humeral Fractures / Q000601:surgery*; D006811:Humerus / Q000601:surgery; D008297:Male; D016059:Range of Motion, Articular; D012189:Retrospective Studies; D062606:Tertiary Care Centers; D016896:Treatment Outcome; D000092464:Elbow Injuries