Issn Print: 0890-5339
Publication Date: 1997/08/01
Excerpt
Supracondylar fractures are of great interest. The current debate is not whether to fix them, but how. The partisans are either intramedullary nailers or users of plates and screws. There are conventional and special appliances in both camps. It is refreshing, then, to have a collected series of cases that uses the third dimension of osteosynthesis: external fixation. Marsh et al. have collected and reported 13 cases of adult patients with supracondylar fractures treated with a uniaxial external fixator. Because I am an old partisan of uniaxial external fixation for supracondylar fractures, these patients bring to my mind the special problems of treating supracondylar fractures in fixators. Indeed, one of my original patients, a botany professor at the University of Vermont, had a successful result with treatment to union in a fixator, but after this course of therapy his family's private foundation, which usually takes on projects like bicycle paths in Stowe, Vermont, purchased my first fracture table and intramedullary instruments and started me on the route to interlocking nailing. This trail led ultimately to the intramedullary supracondylar nail. That aside, the thirteen patients in this article come from different clinical sources with differing patient problems. Their only common link is that the physician who managed them elected to pursue union in external fixation. Note that although a sizable portion of the patients were polytrauma patients and many had vascular injuries or open fractures, there were no established protocols. There are patients with a low injury severity score (9 points) and those with a high injury severity score (41 points). The investigators give their method for placement of the fixator. On occasion, the investigators opened the knee to improve the quality of the reduction. However, with this technique it is not possible to achieve compression between the condyles. Note that there was a considerable incidence of settling at the fracture site and occurrence of varus deformity after fixator removal. Does this mean that as long as the fracture is held in reasonable alignment and allowed to settle that the interdigitation of the fracture fragments promotes union? This series then lends support to the concept that a supracondylar fracture has to be allowed to "fall together." This falling together can be achieved either with a sliding plate, with oval holes in a nail, or with a telescoping fixator, as used in this series.
Dr. Annoch Lewart, one of the early users of interlocking nails for supracondylar fractures, told me once that to make an omelet you have to break some eggs. I am learning what that means: to fix a broken bone you have to do something. The authors of this article have a distaste for periosteal stripping. The concept of placing a plate on a bone carries with it cost to soft tissue, although these costs can be reduced with so-called biologic plating techniques. However, problems of equal severity are encountered with intramedullary stabilization as well as with external fixation. With medullary nailing, it may be necessary to instrument the trochlea; therefore, a retrograde nail could be a "cartilage-destructive" technique. Similarly, the disadvantage of a fixator is the creation of fistulas between bone and skin through the pin tracts. Patients are not insensitive to this problem. They clearly prefer methods where nothing is "sticking through the skin." This article provides a good collection of experiences. The results show that carrying a supracondylar fracture to union in a fixator is possible. The problems of the method are demonstrated realistically. This account challenges orthopedic traumatologists to look for ways to improve the care of supracondylar fractures.
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