Intrafocal joystick technique for closed reduction and percutaneous fixation of late-presenting supracondylar fractures of the humerus

Background: Pediatric supracondylar humeral fractures are common and challenging injuries. The preferred approach is early closed reduction and percutaneous pinning; however, this fails in up to 25% of patients, and conversion to open reduction, especially in late-presenting patients, has been reported in 3% to 46% of patients due to severe swelling or skin problems around the elbow. This study presents a reduction technique that uses a temporary intrafocal Kirschner wire to allow indirect and more effective manipulation of the distal fragment, facilitating closed reduction in difficult situations. Methods: This study retrospectively evaluated the results of an intrafocal joystick technique that was used to aid closed reduction in 15 patients with late-presenting, displaced supracondylar humeral fractures with unfavorable soft-tissue conditions around the elbow. The mean patient age was 6 +/- 2.7 yr and the mean injury-to-surgery interval (delay) was 4 +/- 2.7 days. Baumann's angle, humerocapitellar angle, the anterior humeral line-capitellum relationship were used for radiographic evaluation of the initial reduction and throughout the follow-up that lasted for a mean of 9.4 +/- 3.6 mo. The functional and cosmetic outcomes were assessed according to Flynn's criteria and the Mayo Elbow Performance Index. Results: None of the patients could be successfully treated with the standard method. The intrafocal joystick technique succeeded in achieving acceptable closed reduction in 12 of 15 patients; the remaining three patients required open reduction and internal fixation. All fractures united, and wires were removed at a mean of 5.4 +/- 1.6 wk. Functional range of motion was regained after a mean period of 7.2 +/- 3.5 wk, while full elbow range of motion was regained after a mean period of 12.2 +/- 3.5 wk. According to Flynn's criteria and the Mayo Elbow Performance Index, all patients had an excellent result. Conclusions: The intrafocal joystick technique for closed reduction and percutaneous fixation of irreducible supracondylar fractures of the humerus in certain difficult situations can effectively and safely achieve satisfactory radiographic and functional outcomes and decrease the need for conversion to an open reduction. Open reduction and internal fixation are essential in some patients but should only be used after all techniques of closed reduction and percutaneous fixation have failed.