Does coexistant fractures impair the results of treatment of elbow dislocations in children?]

We present 33 children with 34 elbow dislocations. In 22 cases concomittant fractures around the elbowe were noted: 13 displaced medial epicondyle fractures, 5 radial neck fractures, 2 radial head fractures, 2 coronoid process fractures, 1 olecranon fracture, 1 lateral condyle fracture, 1 medial condyle fracture. In 5 children more than one concomittant fracture were noted. The mean age during dislocation was 11 years (from 4 to 15), the mean follow up period was 3.5 years (from 2 to 5). On follow up a clinical examination of the elbow was performed including axis assesment and elbow ROM. X-ray were taken in all children in AP and lateral view. All children had a satisfying function of the extremity and no pain was noted. No difference in ROM was noted in children with isolated elbow dislocation or with concomittant medial epicondyle fractures however in 3 of those children a persistent flexion contracture was observed. Among children with other fractures poorer results occured in 3 patients, specially after displaced radial neck fractures. In one of them there was slight supination and pronation restriction, in second a complete ankylosis of proximal radioulnar joint occured in neutral forearm position. In one child after elbow dislocation and medial condyle fracture a late radial dislocation occured. We think that concomitant medial epicondyle fracture does not impare good results of elbow dislocation treatment if well recognised and treated. Other fractures, specially radial neck fractures, increase the risk of complications.     

Screw osteosynthesis of displaced fractures of the radial condyle of the humerus in childhood. A long-term prospective study

Summary Pseudoarthrosis and cubitus valgus as main complications following displaced fractures of the radial condyle in children can be prevented by open reduction and fixation by K wires. However, delayed union and stimulation of the radial physis with condylar overgrowth and varisation of the elbow as well as fishtail deformities of the distal end of the humerus are reported nevertheless. To prevent those growth disturbances all primary and secondary (4-day X-ray control) displaced fractures of the radial condyle, i. e. those with a central gap of more than 2 mm, were prospectively treated by open reduction and osteosynthesis with a metaphyseal lag screw beginning 1974. Sixty-six patients (41 boys, 25 girls) with an average follow-up of 10 years (2–22 years) sustained 28 primary and 6 secondary displaced fractures. In 5 cases a K wire fixation was performed in view of the smallness of the fragment. Two children with conservative treatment following overlooked displaced fractures showed condylar overgrowth and varisation of the elbow. Screw osteosynthesis led to symmetric elbow angles and function in all cases, whereas fishtail deformities could be observed in 8 of 27 children, probably as a consequence of the remaining central fracture instability. Conclusion: Open reduction and osteosynthesis with a metaphyseal lag screw prevents condylar overgrowth in displaced fractures of the radial condyle by guaranteeing fracture healing in anatomic position within 3–4 weeks. However, fishtail deformity can not be prevented by metaphyseal compression only.      

Flexion supracondylar fractures of the humerus in children: treatment by manipulation and extension cast

We have reviewed, at an average of 7 years, 14 children with flexion supracondylar fractures of the humerus. These fractures accounted for 6 per cent of the 288 displaced supracondylar fractures treated from 1981 to 1985. A total of 12 patients had typical fractures that were treated by manipulation and immobilization in an extension cast. Two patients had atypical fractures with anterior displacement and posterior angulation of the distal fragment; they were treated by manipulation, but were more stable when immobilized with the elbow flexed with strapping and collar and cuff support. Overall, excellent or good results were achieved in 10 cases and poor results in four cases. Of the poor results, two were due to cubitus varus. These children were the only ones under 2 years of age, and in each the deformity was due to the persistence of an abnormally large Baumann angle. Plaster immobilization was inadequate at this stage. The other two poor results were due to mild stiffness of the elbow.

For typical fractures, we conclude that excellent results can be expected in most children over the age of 2 years when treated with manipulation and immobilization in extension for 3 weeks. For the rarer atypical fractures, we conclude that excellent results can be expected after manipulation and immobilization in flexion for 3 weeks.     

Three weeks of Kirschner wire fixation for displaced lateral condylar fractures of the humerus in children

The authors assessed whether a period of 3 weeks, rather than the commonly used 6 weeks, of smooth Kirschner wire fixation and cast immobilization of the elbow was sufficient to achieve union of displaced fractures of the lateral humeral condyle treated by open reduction. The authors found only one nonunion in a case series of 104 children treated with 3 weeks of fixation. Infections occurred in two children (2%). Late review of 63 children (61%) showed abnormalities of elbow shape in 28 (44%) and wide surgical scars in 43 (68%). The abnormalities of elbow shape were mainly due to overgrowth of the lateral humeral condyle, to the formation of excessive amounts of bone over the outer surface of the condyle, or both. The authors' findings indicate that a period of 3 weeks of smooth Kirschner wire fixation and elbow immobilization is sufficient to achieve healing in most displaced fractures of the lateral humeral condyle treated by open reduction. The findings also indicate that new strategies are needed to reduce the occurrence of overgrowth of the lateral condyle, excessive formation of bone over the condyle, and wide scars.     

Reduction of displaced supracondylar fracture of the humerus in children by manipulation in flexion

Sixty-one children with posteriourly displaced supracondylar fractures of the humerus were treated by minipulation with the elbow flexed 40 degrees-60 degrees. This method proved to be safe, easy to apply and was followed by a high rate of success. The elbow was immobilized using a collar-and-cuff or a broad sling and binding of the arm to the forearm with zinc oxide adhesive plaster. In difficult children, the limb was put under the child's clothing to avoid its being used. Redisplacement occurred in only 8.2 per cent of the patients and in none of these was it severe enough to justify remanipulation.     

The comparison of the results of treatment of displaced supracondylar humeral fractures by skeletal traction and percutaneous K-wire fixation in children]

The aim of the study was to compare of the results of treatment of displaced supracondylar humeral fractures by skeletal traction and percutaneous K-wire fixation in children. We assessed retrospectively the type and result of treatment of 23 children. We obtained very good results in all cases treated by closed reposition secured by percutaneous K-wire fixation. In the group treated by skeletal traction, in 5 cases reposition was inadequate with subsequent limitation of range of motion in the elbow joint. According to our results closed reposition and percutaneous fixation should be the method of choice in displaced supracondylar humeral fractures in children.     

Die elastisch-stabile intramedulläre Nagelung (ESIN) der suprakondylären Humerusfraktur im Kindesalter

Supracondylar fractures are the most common elbow lesions in children. The standard procedure for displaced fractures has up to now been crossed-wire osteosynthesis. A new option is elastic stable intramedullary nailing (ESIN).We retrospectively reviewed the results of all supracondylar fractures that were treated in our department from 2000 to 2005 by the ESIN technique with the aim to provide evidence of advantages and disadvantages of this method.The mean age of the 60 patients included in the study (27 female, 33 male) was 5.9 years (range 1-12 years). Most patients presented with type II fractures (85%), 10% sustained a type III fracture and 5% the most displaced type IV. All patients were treated with the ESIN technique and underwent clinical and radiological follow-up examinations during the next 3-5 months. Average duration to implant removal was 100 days. All patients achieved free range of movement of the affected elbow. No visible malpositions, pseudarthrosis or nerve lesions were observed, in comparison to the conventional surgical technique (crossed-wire osteosynthesis) with up to 19% for these complications. Furthermore, due to the excellent stability of ESIN, the patients do not need a cast and movement is encouraged immediately. Our good experiences encourage us to continue applying the ESIN technique.     

Reduction of Displaced Supracondylar Fracture of the Humerus in Children by Manipulation in Flexion

Sixty-one children with posteriorly displaced supracondylar fractures of the humerus were treated by manipulation with the elbow flexed 40°-60°. This method proved to be safe, easy to apply and was followed by a high rate of success. The elbow was immobilized using a collar-and-cuff or a broad sling and binding of the arm to the forearm with zinc oxide adhesive plaster. In difficult children, the limb was put under the child's clothing to avoid its being used. Redisplacement occurred in only 8.2 per cent of the patients and in none of these was it severe enough to justify remanipulation.     

三种固定方法治疗儿童肱骨髁上骨折的临床对照试验

目的:探讨不同固定方法治疗儿童移位肱骨髁上骨折临床疗效及其临床适应证。方法:137例儿童移位肱骨髁上骨折患者,男85例,女52例;年龄3~12岁。分别采用交叉克氏针内固定(A组)38例,小夹板外固定(B组)67例,石膏托外固定(C组)32例。观察3组骨折愈合时间、肘内翻的发生率及肘关节伸屈功能并进行比较。结果:本组随访6个月~5年,平均29个月,参照Flynn疗效评价标准:A组,优29例,良7例,差2例,优良率为94.74%;B组,优12例,良49例,差6例,优良率为91.04%;C组,优9例,良16例,差7例,优良率为78.13%。A组疗效分别与B、C组比较,差异有统计学意义(P<0.05);B组与C组疗效比较,差异无统计学意义(P>0.05)。结论:三种固定方法以闭合克氏针固定疗效最佳,但三种固定方法各有其适应证:对无移位或轻度移位的肱骨髁上骨折可采用石膏托固定或小夹板固定;对严重移位或旋转,极不稳定型骨折可采用闭合交叉克氏针穿针固定或小夹板固定。临床应根据骨折类型、皮肤条件以及是否合并有神经血管损伤来合理选择最佳治疗方案。     

Medial humeral epicondylar fracture in children and adolescents

PURPOSE: To assess treatment outcomes of young patients with medial epicondylar fracture of the elbow using standard operative protocols. METHODS: 24 consecutive patients with medial humeral epicondylar fracture underwent surgery by one of the 3 methods: (1) 2 parallel Kirschner wires, (2) 2 parallel Kirschner wires plus a tension-band wire, and (3) a screw plus an anti-rotation Kirschner wire. Fractures displaced less than 5 mm were treated conservatively (casting for 3 weeks). Outcome was assessed clinically and radiologically. The Mayo Clinic Elbow Performance Index was measured. RESULTS: The 3 patients with undisplaced fractures had good radiological results and scores. One patient with a displaced fracture refused surgery and subsequently developed pseudarthrosis and cubitus valgus. All operatively treated patients had good scores, but 2 treated with 2 parallel Kirschner wires alone developed pseudarthrosis. Patients in this group needed longer rehabilitation to attain a functional range of movement than those in other groups (treated together with a tension-band wire or screw). CONCLUSION: Surgery is recommended for children with displaced medial epicondylar fractures of more than 5 mm. The use of a tension-band wire, instead of a screw, together with Kirschner wires is the preferred treatment for younger children.     

Fracture of the humeral condyles in children:49 cases evaluated after 18—45 years

We evaluated 49 children with fracture of the humeral condyles 18-45 years after the injury. 20 fractures with a displacement of 2-10 mm with no tilting of the osteochondral fragment had been treated without reduction and with good results. 16 fractures with marked displacement and tilting of the osteochondral fragment had been treated surgically, with good results. 13 patients had been treated for old, displaced fractures both operatively and nonoperatively, with poor results. Nonunion developed in 4 cases and aseptic necrosis in 6. Arthrosis of the elbow was found in cases complicated by aseptic necrosis and nonunion or in old fractures when resection of the humeral condyle was done, but it was never observed in uncomplicated fractures.     

Posttraumatische Fehlstellungen am kindlichen Ellenbogen

In children, fractures of the elbow are common injuries. The bones near the elbow joint account for only 20% of growth in length. Therefore, displaced fractures of the elbow joint have limited potential for spontaneous correction. Thus, the consequences of an inadequately reduced elbow fracture may adversely affect a patient for a lifetime. Posttraumatic deformities of the elbow are usually the result of insufficient primary treatment and seldom the result of growth disturbances. Cubitus varus and valgus are amongst the most common deformities following insufficiently treated supracondylar humerus fractures, fractures of the radius or dislocations of the radial head. These sequelae of elbow fractures pose a challenge for the treating surgeon. This article gives an overview of the possibilities for correcting elbow joint deformities and describes the authors’ preferred methods.     

Stark dislozierte Radiushalsfrakturen nach minimal-invasiver Joystick-Reposition und Prévot-Nagelung

Significantly displaced radial neck fractures in children are at risk for functional problems due to malaligned healing or growth disturbances at the proximal growth plate. Anatomic reduction is needed, especially in older children (aged 10+ years). Elastic stable intramedullary nailing (ESIN) (1993 Metaizeau) is the preferred method. When closed reduction is not possible, we use a joystick technique to fully reduce the radial head. The aim of this study was to challenge the hypothesis that this manipulation leads to secondary complications by affecting blood flow. Also, we asked the question to which extent an additional injury to the growth plate leads to functional problems concerning range of motion in the elbow joint.We undertook a retrospective analysis of children with severely displaced radial head fractures that occurred as isolated incidents or in combination with complex elbow fractures who had been treated by us with this technique between 1998 and 2004. We collected data on the clinical and radiological healing process.     

Prognosis of fracture of the talus in children: 21 (7-34)-year follow-up of 14 cases

14 children suffering from a fracture of the talar neck or body were examined after 21 (7-34) years. The talar neck was fractured in 10 children and the talar body in 4. 3 fractures were displaced and primarily treated with reduction and immobilization. Nondisplaced fractures were treated conservatively. All fractures healed. All patients with displaced fractures had exercise-induced pain at follow-up. Of 11 patients with nondisplaced fractures only 1 had minor complaints.

CT and conventional radiographs showed arthrosis in the talocrural joint and normal subtalar joints in those with displaced fractures. The radio- graphic findings were normal after nondisplaced fractures.     

儿童移位型肱骨髁上骨折致神经损伤

目的:探讨儿童移位型肱骨髁上骨折致神经损伤类型、保守治疗时间和损伤机理。方法:对53例伴神经损伤的儿童移位型肱骨髁上骨折进行回顾性分析。结果:53例54条神经损伤涉及桡神经29条、骨间后神经13条、骨间前神经6条、正中神经4条、尺神经2条。46条神经保守治疗,8条神经手术探查连续性完整,呈牵拉和挤压伤,2条伴挫伤,伤后8～12周2条桡神经行松解术。伤后8～12周神经功能恢复48条,超过12周6条,最长时间24周。结论:儿童移位型肱骨髁上骨折所致的神经损伤,多数功能可自然恢复。伤后4～6周对神经恢复情况综合评定,肌电图神经传导速度测定功能无恢复及早手术,观察到伤后8～12周为宜。神经在肘部的临床解剖学特点是损伤的基础。     

Displaced Mason type I fractures of the radial head and neck in adults: a fifteen- to thirty-three-year follow-up study

Undisplaced radial head and neck fractures are consistently described with no long-term deficits. The aim of this study was to evaluate specifically the long-term outcome of displaced Mason type I fractures, which have not previously described. Twenty women and twelve men, with a mean age of 46 years (range, 22-69 years) when they sustained a displaced Mason type I fracture, were reexamined at a mean of 21 years (range, 15-33 years) after injury. All were treated nonoperatively. Twenty-nine individuals had no subjective complaints, whereas three had occasional elbow pain. There was no objective impairment, and none had elbow osteoarthritis, defined as reduced joint space, whereas there was more radiographic degeneration in the formerly fractured elbow than in the uninjured elbow (85% vs 4%, P < .001). We conclude that the long-term results of nonoperatively treated displaced Mason type I fractures of the radial head and neck are predominantly favorable.     

Nonoperative treatment of displaced supracondylar fractures in children: Rigault type 2 fractures

BACKGROUND: Current opinion in the medical literature concerning displaced supracondylar fractures of the distal humerus recommends pinning because with flexion braces there is a risk of both secondary displacement and Volkmann syndrome. PATIENTS AND METHODS: We analyzed 84 children with displaced supracondylar fractures. According to Rigault's classification, 30 children had grade 2 fractures, 21 had grade 3, 28 had grade 4 and 5 had multiple fragments, which were thus outside this classification. Fractures that could be reduced to a stable position under general anesthesia were treated with a posterior long arm splint with an average elbow flexion of 113 degrees (90-140). This technique was applied in 28 of the grade 2 fractures and in 4 of the grade 3 fractures, but in none of the grade 4 fractures. RESULTS: Of the 4 cases of Rigault grade 3 fractures treated nonoperatively, 3 had to be re-reduced and 1 needed an operation later on for varus correction. Of the 28 Rigault grade 2 fractures, 27 showed excellent results, and 1 had a good result. We advise nonoperative treatment in type 2 supracondylar fractures if stable reduction is achieved.     

Supracondylar fractures of the humerus in childhood: range of movement following the posterior approach to open reduction

The posterior approach for open reduction of supracondylar fractures of the humerus has been condemned for causing decreased elbow movement. This study investigates this by comparing the range of movement in children treated by posterior open reduction and Kirschner wiring with those treated by closed reduction and immobilization. A total of 65 children with severely displaced supracondylar humeral fractures have been reviewed.

There was some loss of movement in 66 per cent of the open reduction group and 42 per cent of the closed reduction group. The proportion losing more than 10 ° of movement was the same in both groups. The difference between the two groups was due to the increased numbers in the open reduction group who lost less than 10 ° of motion. Posterior open reduction of childhood supracondylar fractures is not associated with an important loss of elbow movement and need not be avoided on this account.     

儿童移位肱骨髁间骨折的手术治疗

目的：回顾性评估切开复位内固定术治疗儿童移位肱骨髁间骨折的临床效果。方法：自2007年3月至2009年2月,我科应用切开复位及内固定治疗了8例移位的肱骨髁间骨折患儿,其中男7例、女1例,平均年龄8．2岁（6-12岁）。按照Riseborough—Radin分型系统,其中Ⅲ型6例、Ⅳ型2例;受伤机制包括：5例滑板车摔伤、1例摩托车摔伤、1例高处坠落伤、1例自行车摔伤。方法为采用Bryan—Morrey后内侧手术入路切开复位内固定术,应用克氏针钢丝或钉板系统内固定治疗。结果：术后无一例伤口感染及尺神经损伤,骨折均解剖对位。7例应用克氏针钢丝固定,1例行钉板系统固定。8例患儿均获得随访,平均随访时间2．2年（1．5-3年）。肘关节X线片显示无一例出现骨折的延迟愈合、不愈合,无一例肱骨远端骨骺坏死发生,2例合并肘关节异位骨化,肘关节屈伸活动度平均-10．6°131．3°,日常生活无明显影响。结论：移位的肱骨髁间骨折患儿,应用Bryan—Morrey后内侧手术入路切开复位内固定术可获得较好的治疗效果。