Original article  515
Is open reduction necessary for pediatric T-condylar fractures
of the humerus?
İsmail Eralp Kaçmaza, Can Doruk Basaa, Vadym Zhamilova, Ali Reisoğlua,
İhsan Akanb and Haluk Ağuşa
The aim of this study was to investigate the outcomes of
closed reduction and percutaneous pinning (Kirschner
wire fixation) as a less invasive method for the treatment
of pediatric T-condylar fractures of the humerus compared
with open reduction and pinning. Among pediatric
patients who were diagnosed with T-condylar fractures
of the humerus between 2010 and 2017, those who
underwent closed reduction and percutaneous pinning
were retrospectively evaluated. The surgical technique
Downloaded from http://journals.lww.com/jpo-b by BhDMf5ePHKbH4TTImqenVNPUfnk57qBdDFH+duIl3Zj8XAkygc7ccn9k4lIkZM0k on 12/08/2019
used was to restore joint alignment through closed
reduction and then to insert a pin parallel to the joint
surface to stabilize the intercondylar fracture. Then, the
supracondylar fracture was fixed with crossed pins. At
1-year follow-up, rotation, angulation, and joint range of
motion were evaluated. Patient satisfaction was assessed
subjectively using the visual analogue scale. Early and
late postoperative Baumann angles were measured. All
patients were male, and the mean age was 10.8 ± 4.6
years. The mean follow-up duration was 16.5 ± 7.2 months,
and the mean union duration was 7.4 ± 2.3 weeks. None
Introduction
Elbow fractures are among the most common types of
fractures observed in children, and supracondylar frac-
tures constitute 50% of all elbow fractures [1,2]. Although
supracondylar fractures are frequently observed, inter-
condylar fractures of the distal humerus are rare [3–5].
For example, in the study by Maylahn and Fahey [6]
which involved 300 pediatric patients with elbow trauma,
intercondylar fractures were detected in only six (2%)
patients.
It has been shown that during a high-energy trauma such
as a fall from a height, the olecranon enters between the
humerus condyles like a wedge, splitting the condyles
apart. Given their intra-articular involvement, intercon-
dylar fractures are more complex than supracondylar frac-
tures [7–9].
Treatment options for pediatric T-type distal humerus
fractures include conservative or surgical management.
Although some of these fractures can be treated with
conservative methods, ~ 85% require surgical treatment
[1,2]. However, optimum timing of surgery still remains
a controversial issue. Although some studies advocate
early surgery, others suggest delayed intervention. For
example, Ağuş et al. [10] studied the outcomes of skeletal
1060-152X Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2019 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
of the patients had any rotational deformities, but two
had 5° of varus, one had 5° of valgus, two had a flexion
contracture of 10°, and one had a flexion contracture
of 40°. The only complication observed was a pin-tract
infection, which developed in one patient. The mean visual
analogue scale score was 9.25 ± 1. In pediatric patients
with T-condylar humerus fractures, closed reduction and
percutaneous pinning may be a good alternative to open
reduction and pinning, because it is less invasive and does
not cause additional complications J Pediatr Orthop B
28:515–519 Copyright © 2019 Wolters Kluwer Health, Inc.
All rights reserved.
Journal of Pediatric Orthopaedics B 2019, 28:515–519
Keywords: closed, humerus, percutaneous, supracondylar
a
Department of Orthopaedics and Traumatology, Tepecik Training and Research
Hospital and  bDepartment of Orthopaedics and Traumatology, İzmir Özel
Tınaztepe Hospital, İzmir, Turkey
Correspondence to İsmail Eralp Kaçmaz, MD, Tepecik Training and Research
Hospital, İzmir 35180, Turkey
Tel: + 90 532 775 8500; e-mail: dr_eralp@hotmail.com
traction and delayed percutaneous fixation on patients
whose fractures could not be treated by closed reduc-
tion and reported that no complications occurred with
delayed percutaneous pinning. They emphasized that in
case of a failed reduction, skeletal traction and delayed
percutaneous pinning may be a good treatment alterna-
tive. Although most studies on the treatment of pediatric
T-condylar fractures consist of small case series, the com-
monly accepted view is to treat these fractures by open
reduction and rigid internal fixation [8,11,12]. However,
previous studies have shown that open reduction may
lead to iatrogenic injuries such as peripheral soft tissue
damage and result in postoperative joint stiffness [13,14].
Therefore, some surgeons tend to avoid open reduction.
On the contrary, there are studies reporting complications
such as nonunion, avascular necrosis, and epiphyseal
growth arrest in patients receiving conservative treatment
[15]. Therefore, to prevent the development of deform-
ities, surgical methods are preferred over conservative
methods for the treatment of displaced and comminuted
fractures. The most commonly used surgical techniques
are open or closed reduction and percutaneous pinning.
There are numerous studies reporting successful out-
comes with these methods [10,16–18].
DOI: 10.1097/BPB.0000000000000620
516  Journal of Pediatric Orthopaedics B  2019, Vol 28 No 6
Studies have shown that open reduction and pinning
yield good functional outcomes in T-type of fractures
[19]. In addition to these methods, there are also studies
describing closed reduction and percutaneous screw fixa-
tion in pediatric patients for T-type fractures [9,20].
The generally accepted treatment protocol for intercon-
dylar fractures of the humerus is open reduction with
screw or pin fixation, because it is easier to ensure the
stable anatomical reconstruction of the intra-articular
fracture with this method [21]. However, studies have
shown that 22% of patients who undergo open reduction
experience complications such as wound site problems,
union-related problems owing to periosteal injury, het-
erotopic ossification, and iatrogenic nerve injury [14]. In
addition, the large soft tissue dissection performed dur-
ing open reduction may result in vascular complications
and elbow stiffness [9,20,21]. It has been shown that the
posterior periosteal stripping performed during the tri-
ceps-splitting and triceps-sparing techniques may result
in the devascularization of the fractured bone fragments
and may compromise fracture union [5,22]. Moreover, it
has been reported that the intact periosteum should be
protected because it can assist with fracture stability and
facilitate the closed reduction of the fracture [12]. In light
of the aforementioned data, closed reduction with per-
cutaneous pinning seems to be a reasonable alternative.
However, literature regarding this subject is still scarce,
and it is hard to draw a definitive conclusion. We aimed to
evaluate the outcomes of pediatric T-condylar fractures
treated by closed reduction and percutaneous pinning
(Kirschner wire fixation) in terms of stability, joint range
of motion, union rate, and complications.
Patients and methods
Among pediatric patients who were diagnosed with
supracondylar humerus fractures in the emergency
department between 2010 and 2017, 15 patients who had
T-condylar fractures and who underwent closed reduc-
tion and percutaneous pinning were retrospectively eval-
uated. The study was approved by the institutional ethics
committee. Patients older than 18 years, patients with
open fractures, and those with neurovascular pathologies
were not included in the study. Seven patients whose fol-
low-up records were missing were excluded. As a result,
eight patients were included in the study. Preoperative
assessment was performed with the anteroposterior and
lateral radiographs taken in the emergency department.
None of the patients underwent computed tomography
imaging for diagnostic purposes because the fractures
could be clearly interpreted on plain radiographs.
All patients received a single-dose broad-spectrum anti-
biotic before the surgery. The surgery was performed
under general anesthesia. A tourniquet was applied but
not inflated. First, the closed reduction of the intercondy-
lar parts of the fracture was obtained, and the reduction
Copyright © 2019 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
was checked under a C arm. Then, the epicondyles were
compressed mediolaterally with a bone holding clamp.
The reduction and stability of the distal fragments were
checked using medial and lateral images obtained under
the C arm. Then, for fracture fixation, a transverse pin
was passed as perpendicular as possible to the intercon-
dylar fracture line and as parallel as possible to the joint
surface. We used cortical continuity and radiologically
ossified articular surface continuity in the anterior–pos-
terior and lateral fluoroscopy images. Cortical continuity
in the anterior–posterior views and anterior humeral line
passing through the capitellum in the lateral view were
considered as appropriate reduction criteria. We compare
these criteria with the contralateral elbow. The criteria
for acceptable reduction were defined as the absence
of varus or valgus deformities, anterior humeral line
transecting capitellum, minimal rotation, and minimal
translation. Then, crossed pins were passed through the
medial and the lateral epicondyles into the proximal frag-
ment for fixation. Thus, the fracture was first converted
into a supracondylar fracture through the fixation of the
condylar fragments and then treated like a simple supra-
condylar fracture of the humerus. The quantity and posi-
tions of the pins used were determined according to the
configuration of the fracture (Fig.  1). At the end of the
procedure, a long arm splint was applied with the elbow
in 90° flexion.
All patients were discharged on the first postoperative
day after a control radiograph was taken. Two weeks after
the surgery, the patients were reevaluated with anter-
oposterior and lateral radiographs in terms of reduction
loss. The splint was removed on the fourth week, and
the patients were instructed to start active and passive
exercises. The pins were removed on the sixth week. At
1-year follow-up, the affected extremity was compared
with the healthy extremity in terms of rotation, angula-
tion, and joint range of motion. In addition, patient sat-
isfaction was assessed subjectively using visual analogue
scale (VAS) scores (Fig.  2a–d). Early postoperative and
late postoperative Baumann angles were measured on
the anteroposterior and lateral radiographs retrieved from
the hospital database.
Results
The mean age was 10.8 ± 4.6 (5–18) years, and all patients
were male. The trauma mechanism was a fall from a
height (2–6 m) in all patients. The fractured side was the
dominant arm in three patients and nondominant arm in
five patients.
All patients had type 3 fractures according to the
Gartland classification, and the mean follow-up duration
was 16.5 ± 7.2 months. The mean union duration was
7.4 ± 2.3 weeks. At the end of the follow-up period, two
patients had an extension deficit of 10° and one patient
had an extension deficit of 40°. At the end of follow-up

Fig. 1
Surgical technique (1, 2, and 3 indicate the order of pin placement. Additional pins may be used as necessary to ensure stability).
period, two patients had 5° of varus, and one patient had
5° of valgus. Compared with the other arm, no growth
disturbance was observed in the operated arm in any of
the patients. One patient developed pin-tract infection
but was treated successfully with antibiotics without the
need for debridement. The mean Baumann angles were
74.3° ± 9.6° and 75.4° ± 9.4° on postoperative day 1 and on
the third month, respectively. At 1-year follow-up, patient
satisfaction was evaluated using the VAS score. The mean
VAS score was found to be 9.3 ± 1 (Table 1) [23].
Discussion
Treatment methods used for T-condylar humerus frac-
tures may be listed as skeletal traction, long arm casting
after closed reduction, closed reduction with percutane-
ous pinning, and open reduction with internal fixation
[16,17]. However, as these types of fractures are uncom-
mon, there is no consensus regarding their treatment [8].
One of the accepted treatment methods for preventing
joint stiffness and enabling early mobilization in inter-
condylar fractures of the humerus is open reduction with
plate and/or screw fixation [21]. There are also studies
reporting good outcomes after conservative treatment
in pediatric fractures with no/minimal intra-articular
displacement and comminution [9,24]. In the literature,
there are complications including ulnar nerve injury, pin-
tract infection, pin migration, reduction loss, and non-
union or malunion [25,26]. In the 77 patient series by
Kundel et al. [14], the complications reported were iatro-
genic nerve injury (16%), heterotopic ossification (49%),
deep tissue infection (8%), and implant-related problems
requiring revision surgery (5%). It has been reported that
Copyright © 2019 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Closed reduction in T-condylar fractures Kaçmaz et al. 517
open surgery may result in joint stiffness owing to iat-
rogenic soft tissue damage [13,14]. Given the reported
complications of open reduction, the closed reduction
and percutaneous pinning method has started to gain
ground in the treatment of T-condylar pediatric fractures.
In the study of Papavasiliou and Beslikas [8], it has been
shown that flexion contractures and valgus deformities
are more common after open reduction compared with
closed reduction with percutaneous pinning.
In this study, three patients had an extension deficit.
On the contrary, none of the patients included in the
study experienced nonunion/malunion, nerve damage,
or heterotopic ossification. It may be difficult to relate
the limitation of movement of these three patients to
the technique, because T-type fractures occur as a result
of high-energy trauma with extensive soft tissue injury,
which is generally the reason of limited range of motion.
Compared with the literature, fewer complications were
observed in our study group, but this may be owing to
the small size of our series, given the fact that T-condylar
fractures are a rare entity.
Ruiz et al. [20] described a method in which one of the
supracondylar columns was first stabilized with pin-
ning. Then, the other distal fragment was fixed to this
restored part using a transverse pin. Kanellopoulos and
Yiannakopoulos [9] reported successful results with pin
fixation of the distal fragments followed by osteosynthesis
to stabilize the supracondylar component of the fracture
using two (medial and lateral) elastic titanium nails. As a
different method, Abraham et al. [27] reported successful
results in a 19-patient series in which the integrity of the
518  Journal of Pediatric Orthopaedics B  2019, Vol 28 No 6

Fig. 2

(a) Preoperative radiograph, (b) radiograph on postoperative day 1, (c) radiograph on 1-year follow-up, (d) clinical photographs of the patient
showing range of motion at the elbow on 1-year follow-up.

Table 1  Demographic data and patient outcomes [23]

Pin configuration

Age Union Visual analogue

N (years) Side Sex Gartland type Medial Lateral Transverse week Flexion Extension Varus Valgus scale score Flynn criteria

1 5 Left Male 3 1 2 1 8 140 0 0 0 10 Excellent

2 7 Left Male 3 2 2 1 10 150 0 0 0 10 Excellent
3 15 Right Male 3 1 3 2 6 140 40 0 0 9 Poor
4 11 Right Male 3 1 2 1 6 150 10 0 0 9 Good
5 6 Left Male 3 1 1 1 8 150 0 5 0 10 Excellent
6 11 Left Male 3 1 2 1 11 150 0 0 0 10 Excellent
7 14 Left Male 3 3 2 1 4 120 10 5 0 7 Good
8 18 Right Male 3 1 3 6 150 0 0 5 9 Excellent

lateral and medial columns was restored using crossed passed through the medial and the lateral epicondyles
pins. In this study, first, a transverse pin was passed par- into the proximal fragment, to achieve the remaining
allel to the elbow joint to convert the fracture into a sim- fixation. Although the number of cases in our series was
ple supracondylar fracture. Then, two crossed pins were limited, the outcomes were found to be favorable.

Copyright © 2019 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

Given the rarity of T-condylar humerus fractures, our
study has some limitations. The most important limitation
is the small number of cases in our series. On the contrary,
the fact that all surgical procedures were carried out in
the same clinic, which is a center that frequently accepts
pediatric trauma patients, is a strength of our study.
Conclusion
We believe that closed reduction and percutaneous pin-
ning is a surgical method that may be used for the treat-
ment of pediatric T-condylar fractures, because it is less
invasive than open techniques, has fewer complications,
and is easily applicable. Prospective studies with wider
series and longer follow-up durations are needed for a
better understanding of the results of closed reduction
and percutaneous pinning in such fractures.
Acknowledgements
The authors thank Filiz Ölmez Eltez for the images and
photo editing.
Conflicts of interest
There are no conflicts of interest.
References
1 Shrader MW. Pediatric supracondylar fractures and pediatric physeal elbow
fractures. Orthop Clin North Am 2008; 39:163–171
2 Fayssoux RS, Stankovits L, Domzalski ME, Guille JT. Fractures of the distal
humeral metaphyseal–diaphyseal junction in children. J Pediatr Orthop
2008; 28:142–146.
3 Vallila N, Sommarhem A, Paavola M, Nietosvaara Y. Pediatric distal
humeral fractures and complications of treatment in Finland: a review of
compensation claims from 1990 through 2010. J Bone Joint Surg Am
2015; 97:494–499.
4 Kasser JR, Richards K, Millis M. The triceps-dividing approach to open
reduction of complex distal humeral fractures in adolescents: a Cybex
evaluation of triceps function and motion. J Pediatr Orthop 1990;
10:93–96.
5 Weiland AJ, Meyer S, Tolo VT, Berg HL, Mueller J. Surgical treatment of
displaced supracondylar fractures of the humerus in children. Analysis
of fifty-two cases followed for five to fifteen years. J Bone Joint Surg Am
1978; 60:657–661.
6 Maylahn DJ, Fahey JJ. Fractures of the elbow in children; review of three
hundred consecutive cases. J Am Med Assoc 1958; 166:220–228.
7 Evans EM. Supracondylar-Y fractures of the humerus. J Bone Joint Surg Br
1953; 35-B:371–375.
8 Papavasiliou VA, Beslikas TA. T-condylar fractures of the distal humeral
condyles during childhood: an analysis of six cases. J Pediatr Orthop 1986;
6:302–305.
9 Kanellopoulos AD, Yiannakopoulos CK. Closed reduction and
percutaneous stabilization of pediatric T-condylar fractures of the humerus.
J Pediatr Orthop 2004; 24:13–16.
Copyright © 2019 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Closed reduction in T-condylar fractures Kaçmaz et al. 519
10 Agus H, Kalenderer O, Kayali C, Eryanilmaz G. Skeletal traction and
delayed percutaneous fixation of complicated supracondylar humerus
fractures due to delayed or unsuccessful reductions and extensive swelling
in children. J Pediatr Orthop B 2002; 11:150–154.
11 Jarvis JG, D’Astous JL. The pediatric T-supracondylar fracture. J Pediatr
Orthop 1984; 4:697–699.
12 Re PR, Waters PM, Hresko T. T-condylar fractures of the distal humerus in
children and adolescents. J Pediatr Orthop 1999; 19:313–318.
13 Gupta R. Intercondylar fractures of the distal humerus in adults. Injury
1996; 27:569–572.
14 Kundel K, Braun W, Wieberneit J, Ruter A. Intraarticular distal humerus
fractures. Factors affecting functional outcome. Clin Orthop Relat Res
1996; 332:200–208.
15 Beaty JHKJ. Physeal fractures, apophyseal injuries of the distal humerus,
avascular necrosis of the trochlea, and T-condylar fractures. In: Rockwood
& Wilkins. Fractures in Children. Philadelphia: Lippincott Willams &
Wilkins; 2001; pp. 623–703.
16 Diri B, Tomak Y, Karaismailoglu TN. The treatment of displaced
supracondylar fractures of the humerus in children (an evaluation of three
different treatment methods). Ulus Travma Acil Cerrahi Derg 2003;
9:62–69.
17 Mazda K, Boggione C, Fitoussi F, Pennecot GF. Systematic pinning
of displaced extension-type supracondylar fractures of the humerus in
children. A prospective study of 116 consecutive patients. J Bone Joint
Surg Br 2001; 83:888–893.
18 Shim JS, Lee YS. Treatment of completely displaced supracondylar fracture
of the humerus in children by cross-fixation with three Kirschner wires. J
Pediatr Orthop 2002; 22:12–16.
19 Stroh DA, Sullivan BT, Shannon BA, Sponseller PD. Treatment of a
pediatric T-type intercondylar humerus fracture with hybrid percutaneous
pinning and external fixation. Orthopedics 2017; 40:e1096–e1098.
20 Ruiz AL, Kealey WDC, Cowie HG. Percutaneous pin fixation of
intercondylar fractures in young children. J Pediatr Orthop B 2001;
10:211–213.
21 Julfiqar Pant A, Huda N, Ahmed W. Closed reductions and percutaneus ‘k’
wire fixation for adolescent intercondylar fractures of the distal humerus.
J Clin Diagn Res 2013; 7:1666–1668.
22 Remia LF, Richards K, Waters PM. The Bryan–Morrey triceps-sparing
approach to open reduction of T-condylar humeral fractures in adolescents:
cybex evaluation of triceps function and elbow motion. J Pediatr Orthop
2004; 24:615–619.
23 Flynn JC, Matthews JG, Benoit RL. Blind pinning of displaced
supracondylar fractures of the humerus in children. Sixteen years’
experience with long-term follow-up. J Bone Joint Surg Am 1974;
56:263–272.
24 Hamdi MF, Aloui I, Zrig M, Nouira S. Intercondylar fracture of the distal
humerus in youth: two case reports. Ulus Travma Acil Cerrahi Derg 2009;
15:518–519.
25 Kalenderer O, Reisoglu A, Surer L, Agus H. How should one treat
iatrogenic ulnar injury after closed reduction and percutaneous pinning
of paediatric supracondylar humeral fractures?. Injury 2008; 39:
463–466.
26 Ponce BA, Hedequist DJ, Zurakowski D, Atkinson CC, Waters PM
Complications and timing of follow-up after closed reduction and
percutaneous pinning of supracondylar humerus fractures – follow-up after
percutaneous pinning of supracondylar humerus fractures. J Pediatr Orthop
2004; 24:610–614.
27 Abraham E, Gordon A, Abdul-Hadi O. Management of supracondylar
fractures of humerus with condylar involvement in children. J Pediatr Orthop
2005; 25:709–716.