|Year : 2020 | Volume
| Issue : 1 | Page : 42-46
The tansen technique – A new, easy, reliable, safe and cost effective, technique in closed reduction and percutaneous fixation of type 3 supracondylar fracture of the humerus in children
Bhim Bahadur Shreemal, Tul Bahadur Pun, Dipak Maharjan
Department of Orthopedics, United Mission Hospital, Tansen, Nepal
|Date of Submission||09-Aug-2019|
|Date of Decision||22-Nov-2019|
|Date of Acceptance||26-Dec-2019|
|Date of Web Publication||19-Jun-2020|
Bhim Bahadur Shreemal
Department of Orthopedics, Unit 3, CMC, Vellore, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Introduction: Closed reduction and internal fixation with K wires is the standard of care for Gartland type III supracondylar fractures of children since they are too unstable for nonoperative treatment. Occasionally closed reduction of these fractures could be difficult using standard technique warranting open reduction which is associated with additional complications. We report a new intrafocal reduction technique and its results which can be used to reduce difficult supracondylar fractures reliably thus avoiding open reduction and its complications in most instances. Materials and Methods: Consecutive series of twenty-one patients who were treated successfully using intrafocal reduction (Tansen) technique from January 2014 to December 2015 were followed up for minimum of 6 months. Duration of operation, any intraoperative technique-related complication, and number of intraoperative image intensifier images were reviewed. Children were followed up at 3 weeks, 6 weeks, 3 months, and 6 months for the adequacy of reduction, for loss of reduction of fixation and fracture healing as well as a range of motion, complications, and functional outcome using Flynn's criteria. Results: The average operation time was 30.5 ± 10.5 min. The average number of intraoperative images was 15 ± 5. The average time and number of intraoperative images were not affected by the experience of the surgeon. Average healing was 6.1 ± 2 weeks. All patients achieved a satisfactory cosmetic and functional result. There was no significant loss of initial reduction on follow up. The minor complication rate was 16%. There was no technique-specific complication. Conclusion: Our simple intrafocal technique using artery forceps – “Tansen Technique” – gives an acceptable reduction in difficult supracondylar fractures which would otherwise require open reduction. It is cost-effective, consistent, has a short learning curve, and is a safe technique with potential use in day-to-day practice.
Keywords: Closed reduction and internal fixation, Gartland type III, intrafocal reduction, supracondylar fracture, Tansen technique
|How to cite this article:|
Shreemal BB, Pun TB, Maharjan D. The tansen technique – A new, easy, reliable, safe and cost effective, technique in closed reduction and percutaneous fixation of type 3 supracondylar fracture of the humerus in children. CHRISMED J Health Res 2020;7:42-6
|How to cite this URL:|
Shreemal BB, Pun TB, Maharjan D. The tansen technique – A new, easy, reliable, safe and cost effective, technique in closed reduction and percutaneous fixation of type 3 supracondylar fracture of the humerus in children. CHRISMED J Health Res [serial online] 2020 [cited 2021 Feb 26];7:42-6. Available from: https://www.cjhr.org/text.asp?2020/7/1/42/286891
| Introduction|| |
Widely displaced Gartland type III and type IV fractures pose difficulty in closed reduction and pinning by conventional methods particularly when a presentation is delayed which is common in many developing countries due to lack of awareness, inaccessibility, and unaffordability of healthcare services.,,, Difficulty in closed reduction is the most common indication for open reduction and percutaneous pinning which is inherently associated with many complications., Therefore it is advisable to avoid it whenever possible. Several techniques have been described for assisting closed reduction including the K wire joystick technique and leverage technique for the distal fragment.,,,, We have been using an intrafocal reduction technique using an artery clamp which seems to be an easy, reliable, safe useful technique in Closed reduction and percutaneous fixation of these fractures thus avoiding the open reduction in most of the difficult supracondylar fractures. The aim of this study is to report the surgical technique, its indications, learning curve, complications associated with it, related additional cost if any, and the result of the use of this reduction technique, “The Tansen Technique”– named after the town in Nepal where our center was – in consecutive series of patients operated at our center from January 2014 to December 2015.
| Materials and Methods|| |
Twenty-one children, supracondylar fractures requiring Tansen technique for reduction with adequate follow up were enrolled in our study. Patients with open fractures and those with vascular injuries for which open reduction was done were excluded. Informed consent was obtained from a parent or guardian as was available. The study was approved by the institutional review board. The protocol followed was similar for all patients. Patients in the emergency department were given above-elbow splint around 80 degrees of flexion and elevated over pillow sling. In the absence of intolerable pain, neurovascular injury and/or compartment syndrome the operation was done at the earliest (following day). Whenever reduction was difficult by conventional method intrafocal reduction technique using artery forceps, Tansen Technique' was used. Duration of surgery, number of intraoperative radiography imaging and intraoperative complication were noted. Postoperative imaging was not done. The stab wound in the back of the distal arm was allowed to heal without sutures.
“The TANSEN technique”
The patient positioning
The patient was positioned supine with the affected elbow out of the operating table by the side with no additional support and the affected shoulder at the edge of the table. The surgeon operated from the axillary area and the assistant stood at the head end. The image intensifier (II) was positioned so that the C-arm came from the lateral side inwards and the elbow was moved as required to get anterior-posterior and lateral images [Figure 1].
Under II guidance, reduction was first achieved in the coronal plane with the use of controlled traction–counter traction with the forearm in supination. The nondrilling hand's thumb was used to help reduce the distal fragment [Figure 2]. Whenever “pucker sign” was present, the milking maneuver was performed to disengage the bone from the soft tissue before applying traction. Traction with elbow in 90 degrees of flexion was useful in these cases. With the thumb stabilizing the distal fragment firmly, the arm was externally rotated at the shoulder and elbow flexed to ninety degrees and traction was given by the assistant to correct the displacement in the sagittal plane. It was noted that while rotating, the entire arm rotated, the proximal as well as a distal part in toto to avoid rotational malalignment [Figure 2].
|Figure 2: Reduction in coronal plane by traction and thumb pressure on the distal fragment and in sagittal plane using traction and counter traction|
Click here to view
When reduction was not achieved with the conventional technique, the “Tansen Technique” was resorted to.
The tansen technique
An II was used for this technique. After the correction in the coronal plane, the elbow was flexed and shoulder fully externally rotated to get the lateral view in the C-arm as described earlier. A midline posterior stab incision was made using a size 11 blade [Figure 3]. A curved artery forceps was advanced with tip distally and concavity facing away from the posterior humerus. The tip was inserted into the fracture site [Figure 4]. The forceps was then rotated through 180 degrees while in the medullary canal or anterior to the anterior cortex of the distal fragment. The artery forceps flexed the extended distal fragment while the tip hinged on the proximal fragment [Figure 5]. The force on the hinge was adjusted till the desired reduction was achieved as evidenced by the restoration of distal humerus contour and appearance of teardrop image in C-arm. The coronal plane reduction was re-checked the artery in place [Figure 6]. The forceps was kept as close to the midline as possible to get good control of the fragments and to prevent rotational malalignment.
|Figure 3: Marking entry point under C-arm guidance for introduction of intrafocal reduction tool (artery forceps)|
Click here to view
|Figure 5: Reduction forceps turned and levered onto the anterior aspect of proximal fragment or intramedullary canal and distal ward leverage force given to achieve reduction using soft tissue tension|
Click here to view
|Figure 6: Reduction checked under C-arm while reduction forceps is maintaining reduction|
Click here to view
When well reduced, keeping the fracture reduction in tension with the artery forceps, K wires were passed as desired percutaneously, either crossed or divergent according to the surgeon's preference [Figure 7]. Throughout the procedure, the radial pulse was palpated repeatedly to ensure that the artery is not injured. Fracture fixation stability was checked with gentle stress in varus, valgus as well and internal and external rotation. The pins were bent and left outside the skin to be removed at the review. The stab wound was not sutured routinely [Figure 8]. Elbow was placed in the above elbow slab with a gauze piece over the wound and pin tract and elbow in 80 degrees of flexion and forearm in the neutral position. Patients were routinely discharged the next day.
|Figure 8: Pin left outside, stab wound left unsutured, and healed wound follow-up|
Click here to view
Cases were followed up every 3 weeks in the case of <5-year-old children and every 4 weeks for older children for a period of 3 months and then at 6 months and in a year. Pin tract, posterior stab wound, and neurological status were assessed clinically. Signs of healing, loss of fracture reduction were assessed radiologically. K wires were removed in 3 weeks for small children and 4 weeks for older children after X-ray followed by a session of physiotherapy as an outpatient. Children with significant stiffness were followed up more frequently. Children were again followed up at 6 weeks for assessment of an adequate range of movement at the elbow. They were seen again at 6 months for function. Flynn's criteria were used to look at cosmetic and functional results.
Summary statistics were used for reporting demographic and clinical characteristics. One sample t-test was used to find the significance for the variables, duration of surgery, number of intraoperative radiography, intraoperative complications, healing, loss of reduction, loss of carrying angle difference, and loss of arc of motion (AOM) at final follow-up. Differences will be considered significant at P < 0.05. All the statistical analysis was performed using SPSS 25.0. (IBM Corp, Chicago, IL, USA).
| Results|| |
Of the 398 children with displaced supracondylar fractures from January 2014 to December 2015, requiring closed reduction and pinning, in twenty-eight patients conventional reduction was difficult, and therefore, intrafocal artery forceps-assisted reduction (Tansen technique) was attempted, of which 25 had successful reduction. Three (10.71%) patients required open reduction and were excluded from the study. Twenty-one (84%) of 25 patients were followed up to 6 months at least and were available for analysis. The mean follow-up time was 13.5 ± 4.5 months. Of these 18 patients were Gartland type III and three were Gartland type IV. The average operation time was 30.5 ± 10.5 min. Four surgeons with varying years of experience were involved in operation all of whom had at least 6 months of experience treating supracondylar fractures regularly. There was no significant difference in the duration of surgery depending on the increasing number of years of experience of the surgeon indicating that the technique we describe is easy to learn provided that the surgeon is already familiar with the closed treatment of supracondylar fractures. The average number of intraoperative images was 15 ± 5. Again, there was no significant difference in the number of intraoperative radiography required depending on the experience of the surgeon. Average healing was 6.1 ± 2 weeks. All patients achieved a satisfactory cosmetic and functional result. There was no significant loss of initial reduction on follow-up. There was no technique-specific complication. The minor complication rate was 16%. Three patients developed pin tract infection requiring regular dressing and oral antibiotics. There was one patient with ulnar nerve palsy postoperative which resolved completely after pin revision. There was no complication associated with the posterior stab wound.
There was no nonunion, myositis ossificans or Volkmann's ischemic contracture. There was no significant difference between Baumann's angles measured immediately after surgery and at final follow-up (P = 0.192) with mean Baumann's angle at final follow-up being 75.5° ± 2.5°, and mean postoperative Baumann's angle being 76° ± 2.0°. The loss of reduction was 2 ± 1.22 (1.44–2.56). Loss of carrying angle compared to the uninjured side at the final follow-up was 0°–5° in 12 (57.14%), 5°–10° in 8 (38.1%), and 10°–15° in 1 (4.8%). Loss of AOM compared to the normal side was <5° in 15 (71.4%), 5°–10° in 5 (23.8%) and 10°–15° in 1 (4.8%). According to Flynn's criteria 15 children had excellent (71.4%) outcomes, 5 (23.8%) had a good outcome and 1 (4.8%) had a fair outcome. All patients had a satisfactory outcome [Table 1].
| Discussion|| |
Closed reduction and percutaneous fixation is the standard of care ever since Swenson first described it in 1948. Restoration of normal distal humerus relationships is important to prevent late complications since the remodeling capacity is poor in the distal humerus. Widely displaced fractures are common and when they present late the closed reduction can be difficult especially in an older child with good musculature. Open reduction if used is associated with stripping off of the soft tissue sleeve which adds to the trauma, and it is associated with a higher incidence of infection, myositis ossificans and elbow stiffness which could affect the function in the long run.,, We, therefore, have a very cautious approach to open reduction and we do so when there is an open injury, neurovascular injury and when all closed reduction techniques have been exhausted. It is in this group of patients that intrafocal artery forceps assisted reduction technique, “Tansen technique,” comes in handy. Authors believe that closed reduction should be attempted and all possible techniques should be explored before opting for open reduction. The “Tansen technique” avoids having to open most of these difficult fractures thus preventing complications related to open reduction. The incidence of open reduction for displaced supracondylar fracture reported in the literature is variable ranging from 3% to 46%. Our technique avoided open reduction of the fracture in 25 of 28 (89.28) “difficult cases.” After using this technique, our open reduction rate for displaced supracondylar fracture is <1% (3 out of 398). The average duration of surgery and the number of intraoperative radiographs were comparable to other studies indicating the safety of this procedure., There was no need for a specialized instrument and no additional expense was involved in the study since all we used was a curved artery clamp which is easily available in any hospital with basic operation theatre set up. This makes the technique to be adopted easily in any resource-poor setting. 100 percent of the patients in our series had satisfactory outcomes. This is in keeping with other studies in the literature where they have used other methods of closed reduction.,,, Nineteen (90.44%) had excellent and good outcome while 9.5% of patients had a fair outcome. We did not have significant loss of reduction in any of our fractures even though other studies report a significant number of fractures with loss of reduction postoperatively. One of the possible reasons would be that we routinely used at least three K wires in older children and children with bulky musculature and immobilized in slab till K wire removal. We had no technique-specific complication in our series. There is a theoretical chance of anterior neurovascular injury in our by the tip of blunt curved artery forceps which is used for manipulation. This can be reliably avoided by staying either intramedullary or staying close to the bone when levering the proximal fragment posteriorly. It is done under II guidance to avoid plunging the forceps in too far anteriorly.
We had one patient with ulnar nerve palsy which was related to our pin placement and not to the reduction technique. The nerve palsy was treated with urgent exploration and revision of offending k wire and there was complete recovery of the nerve at final followup. The assistant feels the hand for any twitching through the drilling procedure to ensure that the nerve is not injured during surgery.
Percutaneous pin leverage-assisted techniques have been described in literature for displaced supracondylar fracture,,,, and have been found to be useful; but, to the best of our knowledge, nobody has published a simple, easily reproducible, easy to learn, inexpensive technique that can give reliable results and is safe can be practiced by any surgeon who takes care of elbow fractures in children regularly.
Our study is limited by small sample size. We are also unable to compare it with open reduction as the number of open reduction in our center was very few. Patients were not followed up till adulthood; so, we are unable to comment on any late complications. Radiation dosage was not standardized to look at safety. The technique can theoretically cause damage to the neurovascular structures anteriorly and there is some chance of infection in the stab wound but if done gently with care the complication associated with the technique is negligible. There is the theoretical chance of rotational malalignment using this technique but a strong soft tissue tension achieved during the procedure and the maintenance of that soft tissue balance during the whole leverage procedure with artery forceps in place seems to favor an acceptable reduction which was confirmed by our findings.
| Conclusion|| |
The “Tansen Technique” helps in avoiding open reduction in most difficult supracondylar fractures. It is effective, safe, and easy to perform without the need for special instruments and at no additional cost. We recommend this technique as one of the methods to try and achieve closed reduction in difficult supracondylar fractures before deciding for open reduction.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Omid R, Choi PD, Skaggs DL. Supracondylar humeral fractures in children. J Bone Joint Surg Am 2008;90:1121-32.
Beaty JH, Kasser JR. Fractures about the elbow. Instr Course Lect 1995;44:199-215.
Chai KK, Aik S, Sengupta S. Supracondylar fractures of the humerus in children – An epidemiological study of 132 consecutive cases. Med J Malaysia 2000;55 Suppl C:39-43.
Young S, Fevang JM, Gullaksen G, Nilsen PT, Engesæter LB. Deformity and functional outcome after treatment for supracondylar humerus fractures in children: A 5- to 10-year follow-up of 139 supracondylar humerus fractures treated by plaster cast, skeletal traction or crossed wire fixation. J Child Orthop 2010;4:445-53.
Leitch KK, Kay RM, Femino JD, Tolo VT, Storer SK, Skaggs DL. Treatment of multidirectionally unstable supracondylar humeral fractures in children. A modified Gartland type-IV fracture. J Bone Joint Surg Am 2006;88:980-5.
Aktekin CN, Toprak A, Ozturk AM, Altay M, Ozkurt B, Tabak AY. Open reduction via posterior triceps sparing approach in comparison with closed treatment of posteromedial displaced Gartland type III supracondylar humerus fractures. J Pediatr Orthop B 2008;17:171-8.
Novais EN, Andrade MA, Gomes DC. The use of a joystick technique facilitates closed reduction and percutaneous fixation of multidirectionally unstable supracondylar humeral fractures in children. J Pediatr Orthop 2013;33:14-9.
Pei X, Mo Y, Huang P. Leverage application on Gartland type IV supracondylar humeral fracture in children. Int Orthop 2016;40:2417-22.
Dong L, Wang Y, Qi M, Wang S, Ying H, Shen Y. Auxiliary Kirschner wire technique in the closed reduction of children with Gartland Type III Supracondylar humerus fractures. Medicine (Baltimore) 2019;98:e16862.
Lee HY, Kim SJ. Treatment of displaced supracondylar fractures of the humerus in children by a pin leverage technique. J Bone Joint Surg Br 2007;89:646-50.
Sawaizumi T, Takayama A, Ito H. Surgical technique for supracondylar fracture of the humerus with percutaneous leverage pinning. J Shoulder Elbow Surg 2003;12:603-6.
Swenson AL. The treatment of supracondylar fractures of the humerus by Kirschner-wire transfixion. J Bone Joint Surg Am 1948;30A:993-7.
Srivastava S. The results of open reduction and pin fixation in displaced supracondylar fractures of the humerus in children. Med J Malaysia 2000;55 Suppl C:44-8.
Oh CW, Park BC, Kim PT, Park IH, Kyung HS, Ihn JC. Completely displaced supracondylar humerus fractures in children: Results of open reduction versus closed reduction. J Orthop Sci 2003;8:137-41.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]