Background: Supracondylar humerus fractures (SCHF) are the most common pediatric elbow fractures, with Gartland type-III being completely displaced and unstable. Achieving accurate reduction in these fractures is often difficult. This case report presents an innovative joystick technique using the proximal fragment to facilitate closed reduction and stable fixation. Case Presentation: A 6-year-old girl sustained a Gartland type-III SCHF of the left humerus following a fall. Closed reduction under fluoroscopy was performed using a 3 mm K-wire inserted laterally into the distal humerus to manipulate the proximal fragment as a joystick. Once satisfactory alignment was obtained, cross K-wire fixation was done, and an above-elbow slab applied. Results: The operation lasted 20 minutes with minimal fluoroscopy exposure. Postoperative radiographs at 2 and 4 weeks showed excellent alignment and healing. After K-wire removal at 4 weeks, full elbow motion was restored. Functional outcome assessed by Flynn’s criteria was excellent. Conclusion: The proximal joystick technique is a simple, safe, and effective modification for closed reduction of Gartland type-III SCHFs in children. It reduces operative time, improves reduction accuracy, and minimizes iatrogenic injury risk.

Supracondylar fractures of the humerus (SCHFs) are among the most frequently encountered injuries in pediatric orthopedic practice, constituting nearly 27% of all pediatric fractures and about 55–75% of all elbow fractures in children [1]. These injuries are most often seen in children aged between 5 and 10 years, a period during which the supracondylar region of the humerus is structurally vulnerable due to its thin cortical bone and ongoing physeal development. SCHFs are broadly categorized into extension-type fractures (98%) and the less common flexion-type fractures (2%). The extension-type fracture usually results from a fall on an outstretched hand when the elbow is in hyperextension, leading to a posterior displacement of the distal fragment relative to the proximal humerus [2]. The Gartland classification system remains the gold standard for describing these fractures and guiding treatment decisions. According to this classification, type I fractures are nondisplaced, type II are displaced with an intact posterior cortex, while type III and type IV fractures are completely displaced and unstable, necessitating operative management. The primary goals of surgical intervention in these cases are to achieve accurate anatomical reduction, stable fixation, and restoration of full elbow function with minimal complications. Among surgical options, closed reduction and percutaneous pin fixation with K-wires is widely accepted as the preferred treatment modality, owing to its effectiveness and minimally invasive nature. The use of crossed K-wire fixation has demonstrated excellent outcomes in maintaining reduction and promoting early functional recovery [3]. However, open reduction—though sometimes necessary—has been associated with a higher incidence of postoperative complications such as loss of motion, stiffness, myositis ossificans, infection, hypertrophic scar formation, and a greater risk of iatrogenic neurovascular injury [4]. Therefore, newer closed reduction techniques are continually being explored to enhance precision and safety while minimizing surgical trauma. One such promising approach is the Joystick maneuver technique, wherein the distal fracture fragment is manipulated under fluoroscopic guidance using a temporary K-wire or instrument as a “joystick” to achieve proper alignment and reduction. This method provides better control during reduction, especially in displaced and unstable fractures, reducing the need for repeated manual manipulations. In the current case, we have modified this concept by utilizing the proximal fragment as a joystick, allowing improved leverage and directional control during reduction. This innovative adaptation aims to decrease operative time, limit multiple reduction attempts, and reduce the risk of physeal and soft-tissue injury, thereby enhancing surgical safety and precision in pediatric SCHF fixation. The aim of this case report is to describe the application and outcomes of a novel joystick-assisted reduction technique using the proximal fragment as the guiding lever in the management of a displaced supracondylar humerus fracture in a pediatric patient. This modification offers a simple, reproducible, and cost-effective alternative to conventional reduction methods. By detailing the operative steps, intraoperative handling, and postoperative recovery, this report seeks to contribute to the existing body of knowledge on minimally invasive fracture management. The present case highlights the potential of this technique to reduce iatrogenic physeal damage, shorten operative duration, and improve alignment accuracy without increasing complications. It may serve as a useful adjunct for orthopedic surgeons managing difficult reductions, particularly in cases where traditional closed methods are challenging. This case thus provides valuable insight into how a simple biomechanical modification can enhance both efficiency and safety in pediatric supracondylar fracture fixation.

Patient Presentation: A 6-year-old female child presented with a history of a slip and fall while playing, resulting in an injury to her left elbow. On examination, there was pain, swelling, and restricted movement of the left elbow, with the left forearm being supported by the opposite limb. Tenderness was elicited over both the medial and lateral epicondyles of the distal humerus. Active and passive movements were markedly painful and restricted. Radiological Evaluation: Plain radiographs of the left elbow in anteroposterior and lateral views confirmed a supracondylar fracture of the left humerus. Surgical Procedure: Under general anesthesia, the affected limb was thoroughly scrubbed, painted, and draped in a sterile manner. As per standard pediatric fixation, a 2.0 mm Kirschner wire (K-wire) was chosen for its adequate strength to stabilize the fracture fragments [9]. Using fluoroscopic guidance, closed reduction was attempted by applying longitudinal traction and counter-traction, followed by pronation and flexion of the elbow to approximately 40 degrees while exerting anterior pressure over the olecranon process. The reduction was initially checked under fluoroscopy in external rotation with the elbow flexed to 90°, and the lateral image was confirmed. A 2 mm K-wire was then advanced percutaneously through the lateral epicondyle to stabilize the lateral column. However, during attempts to reduce the medial column, it was observed that the medial epicondylar fragment remained unstable and rotated internally, leading to posterior displacement relative to the proximal shaft. To address this instability, a 3 mm K-wire was introduced laterally through the distal third of the humerus, crossing the contralateral cortex. The proximal fragment was then manipulated as a joystick, allowing controlled correction of the rotational deformity and proper alignment of the medial column. Once satisfactory alignment was achieved under fluoroscopy, another 2 mm K-wire was inserted percutaneously at a 45° oblique angle from the medial epicondyle, carefully avoiding injury to the ulnar nerve. After confirming the anatomical reduction in both anteroposterior and lateral views, minor joystick adjustments were made to correct residual rotational deformities. The K-wire used as the joystick was then removed, and fracture stability was reassessed by gently moving the elbow joint through its range of motion. An above-elbow posterior slab was applied with the elbow flexed at 90° and the forearm in a neutral position. Postoperative Care and Follow-up: The patient was discharged with instructions for regular aseptic dressings and immobilization. Follow-up evaluations were performed at 2 weeks, 4 weeks, 2 months, 6 months, and 1 year postoperatively, and annually thereafter. Postoperative Evaluation and Measurements: Comprehensive postoperative assessment was carried out through radiographic analysis of anteroposterior and lateral views. The following measurements were evaluated at 4 weeks after pin removal: • Baumann’s Angle: The angle between a line perpendicular to the humeral shaft and another line parallel to the capitellar growth plate [5]. • Perpendicular Distance: The distance from the anterior humeral line to the anterior margin of the capitellum, indicating proper sagittal alignment [6]. • Hourglass Angle: The angle formed by lines bisecting the olecranon and coronoid fossae on lateral radiographs, resembling an hourglass shape; its apex represents the humeral isthmus [7]. • Humero-condylar Angle: The angle between the long axis of the humeral shaft and a line bisecting the capitellum, reflecting the alignment of the distal condyles [8]. These parameters collectively confirmed anatomical reduction and satisfactory healing, ensuring restoration of the elbow’s functional alignment and stability.

Supracondylar fractures of the humerus (SCHF) remain one of the most common pediatric fractures and are typically straightforward to diagnose using clinical evaluation and radiographic imaging. However, a meticulous neurovascular assessment is essential, as these fractures may be associated with significant soft tissue injury. Clinical signs such as skin puckering and ecchymosis indicate underlying soft tissue trauma and should alert the clinician to potential vascular compromise. Radiographic evaluation, particularly the Baumann angle, plays a crucial role in assessing medial column comminution and the accuracy of reduction. In 1959, Gartland classified SCHFs into three types [10]: Type I, non-displaced or minimally displaced (<2 mm); Type II, displaced (>2 mm) with an intact posterior cortex; and Type III, completely displaced with fracture ends separated and rotated, often accompanied by neurovascular injury and soft tissue complications. Type III fractures present a particular challenge due to instability, complexity of reduction, and the risk of long-term deformities if not properly managed. The most frequent late complication of SCHF is cubitus varus deformity [10], often seen following type-III injuries. This deformity may later lead to tardy posterolateral instability and poor functional outcomes [11]. Earlier studies attributed cubitus varus to asymmetric growth of the distal humerus [12], but subsequent research demonstrated that malunion, rather than growth arrest, is the predominant cause [13]. Therefore, accurate and stable reduction is essential to achieving optimal outcomes and preventing deformity. In 1948, Swenson first described closed reduction with percutaneous pinning (CRPP) for SCHF, reporting excellent clinical results [13]. Since then, CRPP has become the gold standard treatment for Gartland type-III fractures [14]. Although many refinements to this technique have been developed to improve reduction quality [21], residual deformity can occur due to the limited remodeling potential of the elbow [15]. The joystick technique, proposed by Novais et al., was introduced as a method for managing multidirectionally unstable SCHFs, allowing controlled manipulation of the distal fragment using a temporary Kirschner wire [16]. Their study demonstrated favorable outcomes with minimal complications. However, inserting the joystick wire directly into the distal fragment may interfere with subsequent fixation. In such cases, the technique can be modified to manipulate the proximal fragment instead, facilitating reduction while maintaining a closed approach and avoiding open surgery. In the present case, the proximal fragment was used as a joystick by inserting a 3 mm K-wire through the distal third of the humerus, providing improved control during reduction and correction of rotational deformity. This modification helped align the fragments actively under fluoroscopic guidance rather than passively approximating them. The entire operative duration was only 20 minutes, reflecting reduced fluoroscopy exposure and minimal manipulation. The literature supports the effectiveness of joystick-assisted reduction. Novais et al. [16] reported excellent postoperative outcomes, with mean differences in range of motion (ROM) and carrying angle between the injured and normal elbow being 4.38 ± 1.65° and 11.63 ± 1.65°, respectively. Similarly, Pei et al. [17] observed satisfactory results using leverage manipulation, with 96.3% of patients showing <10° loss in ROM or carrying angle at final follow-up. Wang et al. [18] also found that 68.75% of children with type-III fractures had only 0–5° loss in ROM and alignment after treatment using a joystick method. Further supporting the concept, Dong et al. [19] recommended inserting a single K-wire through the proximal fragment (1 cm above the fracture end) to correct rotational deformity, achieving excellent outcomes in 72.22% of cases with improved Baumann angles (73.8 ± 5.7°) and reduced fluoroscopy use. These findings align with our experience, where the joystick technique using the proximal fragment enabled controlled correction with minimal invasiveness and excellent radiological alignment. Although crossed pinning is traditionally considered more stable biomechanically than lateral pinning [20], several clinical studies report no significant difference in maintaining reduction between the two configurations [21]. The current case demonstrates that a modified joystick-assisted closed reduction, combined with percutaneous pin fixation, can achieve stable fixation and satisfactory alignment while minimizing operative time, radiation exposure, and risk of complications. Overall, this case supports the innovative joystick modification as an effective, reproducible, and minimally invasive method for managing type-III supracondylar fractures in children, offering an alternative to open reduction in difficult cases.

The present case demonstrates that the innovative joystick technique is a safe, simple, and efficient method for closed reduction of Gartland type-III supracondylar humerus fractures in children. By utilizing the proximal fragment as a joystick, this approach allows precise manipulation, improved reduction quality, and reduced operative time without increasing the risk of complications. The technique does not require complex instrumentation or advanced surgical expertise, making it a practical and easily adoptable procedure in pediatric orthopedic practice. The successful clinical and radiological outcome in this case underscores the potential of this method to serve as a valuable alternative to conventional closed reduction techniques.

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