9 years’ follow-up of 168 pin-fixed supracondylar humerus fractures in children

Background and purpose — The long-term outcome of pin-fixed supracondylar humerus fractures (SCHF) in children is not well known. We assessed the 7- to 12-year outcome in 168 children.

Patients and methods — During 2002–2006, 210 domestic children (age 7 (1–14) years) with SCHF (Gartland III 79%, Gartland II 19%, and flexion type 2%) were pin fixed in Helsinki. 36 (17%) patients had a nerve palsy. Radiographic alignment was regarded as satisfactory in 81% of patients (Baumann angle (BA) within ±10? of normal range and whose anterior humeral line (AHL) crossed the capitulum). After a mean follow-up of 9 (7–12) years, 168 (80%) patients answered a questionnaire regarding elbow appearance (scale 0–10), function (scale 0–10), and pain (scale 0–10), and symmetry of range of motion (ROM) and carrying angle (CA). 65 (31%) patients also attended a clinical follow-up examination.

Results — Mean subjective score for appearance was 8.7 (2–10) and for function 9.0 (2–10) (n = 168). Elbow ROM asymmetry was experienced by 28% and elbow CA asymmetry by 17% of the patients. Elbow pain was reported by 14%, and was more common in children with nerve injuries. Long-term outcome was good or excellent in 60/65 and CA in 56/65 of the follow-up visit patients using Flynn’s criteria. BA exceeding normal values by 10? was associated with lower subjective outcome; AHL crossing point with the capitulum was not associated with outcome.

Interpretation — Long-term subjective outcome is satisfactory with few exceptions if elbow ROM and CA are restored within 10° of the uninjured elbow. Radiographs at fracture union have little prognostic value. Nerve injuries can cause long-term pain.     

How safe is the operative treatment of Gartland type 2 supracondylar humerus fractures in children?

Whereas operative treatment of supracondylar fractures is now standard of care for Gartland type 3 supracondylar humerus fractures in children, the treatment of type 2 fractures remains somewhat controversial. The purpose of this article was to examine the safety and efficacy of closed reduction and pinning of type 2 supracondylar humerus fractures in children. METHODS: We performed a retrospective review of 189 type 2 supracondylar humerus fractures operatively treated at one tertiary care children's hospital from 2000 to 2006. Data were acquired from a review of radiographs and clinical notes. RESULTS: We found no intraoperative surgical or anesthetic complications in our series. None of our cases lost reduction after closed reduction and percutaneous pinning. There were 4 pin tract infections (2.1%) in our series: 3 were treated with antibiotics, and 1 needed irrigation and debridement in the operating room. This was the only patient who required reoperation for any reason. CONCLUSIONS: In this study, the largest reported series of type 2 supracondylar humerus fractures in children, we found an extremely low rate of complications after closed reduction and percutaneous pinning; secondary operations were also uncommon (0.5%). Our series demonstrates a high probability of satisfactory outcome after operative treatment of type 2 supracondylar fractures compared with previous studies of children treated by closed reduction without pinning. LEVEL OF EVIDENCE: Therapeutic study, level 4 (case series [no or historical control group]).     

The anterior cubital approach for irreducible Gartland type Ⅲ supracondylar fractures of the humerus in children

Objective To assess the anterior cubital fossa approach in the treatment of irreducible Gartland type Ⅲ supracondylar fractures of the humerus in children. Methods Forty-four children (26 boys) with Gartland Ⅲ supracondylar fractures of the humerus were divided into 2 groups. Group A(19 cases) was treated with a minimal incision in the anterior cubital fossa, and Group B (25 cases) through anterolateral cubital fossa or combined median-lateral approach. The fractures were stabilized with 1.5 mm Kirschner wires and plaster slab after anatomical reduction, followed by functional exercise for 3 to 6 weeks. The clinical outcomes of the 2 groups were evaluated by the Flynn score system for the elbow joint. Results All patients were followed up for 1 to 4 years, with an average of 1.8 years. Group A needed significantly shorter operation time (37 vs. 59 minutes). The good to excellent rates were 89% for Group A and 83% for Group B. There was no significant difference in functional recovery between the 2 groups (P > 0.05). Conclusion Open reduction through the anterior cubital approach is a quick and safe alternative for pediatric Gartland Ⅲ supracondylar fractures of the humerus, because it allows good visualization of the median and ulnar nerves, the brachial artery and the fracture.     

Is the modified Gartland classification system important in deciding the need for operative management of supracondylar humerus fractures?

PurposeThis study examined levels of agreement between paediatric orthopaedic surgeons in the need for operative management of extension-type supracondylar humerus fractures.MethodsThis was the second phase of a two-part study. De-identified baseline anteroposterior and lateral elbow radiographs from 60 paediatric patients with extension-type supracondylar humerus fractures were compiled. After classifying each fracture according to Gartland classification guidelines, radiographs were randomized, and surgeons indicated whether they would use operative or non-operative management to treat each fracture. Kappa statistics using pairwise comparisons were calculated to determine agreement levels.ResultsIn total, 11 international surgeons participated, and 10/11 completed both survey rounds. The overall weighted interobserver agreement was moderate (0.530, 95%CI [0.215,0.854]) while overall weighted intraobserver agreement was substantial (0.740, 95%CI [0.513,0.963]). The largest variability in preferred treatment methods between surgeons was observed for type IIA fractures, with 6/11 preferring non-operative and 5/11 preferring operative management. The largest individual surgeon variability was observed for type IIA fractures, with 8/11 showing variability (defined by not having made the same decision for at least 90% of the cases) in choosing whether to operate.ConclusionsOur findings suggest moderate interobserver, and substantial intraobserver agreement in treatment decision making. The largest disagreements between surgeons were observed for type IIA and IIB fractures and treatment decisions did not follow expected trends based on surgeons’ preferred treatment methods for each fracture type. This suggests differences in treatment approaches between surgeons in the management of type IIA fractures and highlights the role of other variables that underlie differences between surgeons’ treatment preferences.Level of evidenceIII     

Neurovascular complications and severe displacement in supracondylar humerus fractures in children: defensive or offensive strategy?

Out of 210 children suffering from severely displaced supracondylar fractures, 76 (36%) presented with immediate neurovascular complications: 47 (22%) were neurological, 16 (8%) vascular and 13 (6%) both. Injury to two nerves simultaneously was observed in six patients. The median nerve was affected in 28 cases, the ulnar nerve in 25 and the radial nerve in 13. Posterolateral displacement was associated with 86% of damage to the median nerve and 56% of damage to the ulnar nerve. Posteromedial displacement was associated with all incidents of injury to the radial nerve with one exception. Each patient made full neurological recovery, spontaneously and following primary or secondary neurolysis performed on nerve injuries in continuity. Two situations of primary abolition of the radial pulse were encountered, one involving a pink hand in 12.5% of cases and the other involving a white hand in 1.5% of cases. There was posterolateral displacement in three out of four patients. Postoperative vascularization was revealed by immediate return of the radial pulse in 26 patients and delayed return in three others. Urgent anatomical reduction of the fracture and its early fixation are crucial. A conservative therapeutic approach is customary in the majority of neurovascular complications. Prognosis is generally excellent. Ischaemia of the limb and total ruptures of the nerve are very rare.     

Delaying treatment of supracondylar fractures in children: has the pendulum swung too far?

The aim of this retrospective multicentre study was to report the continued occurrence of compartment syndrome secondary to paediatric supracondylar humeral fractures in the period 1995 to 2005. The inclusion criteria were children with a closed, low-energy supracondylar fracture with no associated fractures or vascular compromise, who subsequently developed compartment syndrome. There were 11 patients (seven girls and four boys) identified from eight hospitals in three countries. Ten patients with severe elbow swelling documented at presentation had a mean delay before surgery of 22 hours (6 to 64). One patient without severe swelling documented at presentation suffered arterial entrapment following reduction, with a subsequent compartment syndrome requiring fasciotomy 25 hours after the index procedure. This series is noteworthy, as all patients had low-energy injuries and presented with an intact radial pulse. Significant swelling at presentation and delay in fracture reduction may be important warning signs for the development of a compartment syndrome in children with supracondylar fractures of the humerus.     

Reliable classification of children’s fractures according to the comprehensive classification of long bone fractures by Müller

Background and purpose Guidelines for fracture treatment and evaluation require a valid classification. Classifications especially designed for children are available, but they might lead to reduced accuracy, considering the relative infrequency of childhood fractures in a general orthopedic department. We tested the reliability and accuracy of the Müller classification when used for long bone fractures in children.

Methods We included all long bone fractures in children aged < 16 years who were treated in 2008 at the surgical ward of Stavanger University Hospital. 20 surgeons recorded 232 fractures. Datasets were generated for intra- and inter-rater analysis, as well as a reference dataset for accuracy calculations. We present proportion of agreement (PA) and kappa (K) statistics.

Results For intra-rater analysis, overall agreement (κ) was 0.75 (95% CI: 0.68–0.81) and PA was 79%. For inter-rater assessment, K was 0.71 (95% CI: 0.61–0.80) and PA was 77%. Accuracy was estimated: κ = 0.72 (95% CI: 0.64–0.79) and PA = 76%.

Interpretation The Müller classification (slightly adjusted for pediatric fractures) showed substantial to excellent accuracy among general orthopedic surgeons when applied to long bone fractures in children. However, separate knowledge about the child-specific fracture pattern, the maturity of the bone, and the degree of displacement must be considered when the treatment and the prognosis of the fractures are evaluated.     

T-condylar fractures of the distal humerus in children: does early motion affect final range of motion?

Purpose

T-condylar fractures of the distal humerus are infrequent injuries in children. There are little data regarding outcomes in this age group. The adult literature demonstrates a high rate of postinjury stiffness. We describe a large series of T-condylar fractures in children and set out to identify factors that influence the postoperative range of motion (ROM) in children. Our hypothesis was that starting motion early (<3 weeks) would favorably influence the postoperative ROM.

Methods

Patients were identified based on the Current Procedural Terminology (CPT) code for ORIF of supracondylar distal humerus fractures with intracondylar extension (24546). Patient records and radiographs were reviewed to determine the demographics, fracture characteristics, surgical approach and fixation, and postoperative immobilization time. Our outcome measure was ROM in flexion/extension at 3 months, 6 months, 1 year, and final follow-up. Patients were analyzed by Morrey’s criteria of −30° extension and 130° flexion to assess for postoperative elbow stiffness.

Results

Thirty-eight potential patients from 1992 to 2010 were identified with specific T-condylar patterns. Twelve patients were excluded due to insufficient follow-up or lack of final ROM data. Our cohort included 26 patients (average age 13.4 years). The average postoperative immobilization time was 3.4 weeks (range 0.9−12 weeks). At the final follow-up, patients had −12° average extension and 130° average flexion. Nine patients (35 %) were stiff and 17 patients (65 %) had functional motion postoperatively. At 3 and 6 months, starting motion early yielded better flexion and extension ROM. Late-motion patients obtained similar results at the 1-year follow-up. Open fractures, gender, and age were all not significantly associated with elbow stiffness in our series, given the limited numbers.

Conclusion

Early ROM was associated with an earlier gain of functional motion without clear adverse consequences. Despite similar findings at the final follow-up, practitioners should consider instituting early ROM protocols to decrease the duration of stiffness and potential disability for the child and the family.     

Pediatric supracondylar humerus fractures: effect of bone–implant interface conditions on fracture stability

Background

Closed reduction and percutaneous fixation with Kirschner wires (KWs) is the standard of care of pediatric supra-condylar humerus fractures (SCHFs). Failure modes leading to loss of reduction are not clear and have not been quantified. Multiple factors may weaken the KW–bone interface bonding conditions. To the best of our knowledge, the possible effect of this decrease on different KW configurations and fracture stability has never been studied.

Purpose

To investigate the effect of bone–KW friction conditions on SCHF post-operative mechanical stability and to formulate clinical guidelines for KW configuration under different conditions.

Methods

Finite element-based model of a fixated SCHF was used to simulate structure stability for two lateral divergent versus crossed lateral and medial KW configurations under varying KW–bone friction conditions.

Results

Finite element simulations demonstrated that crossed KWs provide superior stability compared with the divergent configuration when KW–bone bonding is compromised. When KW–bone bonding conditions are adequate, crossed and divergent KW configurations provide similar, sufficient fracture stability.

Conclusions

Under normal bone–implant interface conditions, the two diverging lateral KW configuration offers satisfactory mechanical stability and may be the preferred choice of SCHF fixation. When KW–bone bonding is suboptimal, as when one or more of the lateral KWs are re-drilled, addition of a medial KW should be considered in order to improve stability despite risk to ulnar nerve.     

“Sandwich technique” in the surgical treatment of primary complex fractures of the femur and humerus

In this prospective study, our aim was to determine the clinical and radiographic outcomes of the surgical treatment of primary complex problem femoral and humeral shaft fractures treated by a new technique called “sandwich technique.” A total of 45 patients with comminuted, complex and/or osteopoenic fractures of the femur or humerus (30 femoral and 15 humeral fractures) were treated using this technique. The patients were followed up for a mean of 25 months. In 24 (85.7%) of 28 patients with femoral fractures and in 14 (93.3%) of 15 patients with humeral fractures, union was achieved within 3–6 months of the operation (mean: 4.5 months). The total union rate was 88.4%. The pseudoarthrosis rate was 12%. There was no infection or implant failure seen during the follow-up period. The cortical allograft struts can be used to provide collateral support to weakened osteopoenic/osteoporotic bone. This technique provides a union rate of about 88% in osteoporotic and/or complex primary humerus or femur fractures.

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Résumé Etude prospective de l’évolution clinique et radiographique des fractures complexes de l’humérus et du fémur avec une technique appelée “sandwich technique”. 30 fractures du fémur et 15 de l’humérus avaient été traitées avec un suivi moyen de 25 mois. Pour 24 des 28 patients opérés du fémur et 14 des 15 opérés de l’humérus, la consolidation était obtenue en 3 à 6 mois après l’opération, en moyenne 4,5 mois. Le taux total de consolidation était de 88,4% et celui des pseudarthroses de 12%. Il n’y a pas eu d’infection ni d’échec d’implant durant ce suivi. Les baguettes d’allogreffes corticales peuvent être utilisés pour renforcer les os ostéopéniques ou ostéoporotiques. Cette technique permet 88% de consolidation pour les fractures primaires mais complexes de l’humérus et du fémur.

     

Distal humerus fractures in the elderly: osteosynthesis or endoprosthesis? Review of the literature

Fractures of the distal humerus in adults are rare but challenging for the orthopaedic trauma surgeon. The bimodal distribution reflects the trauma mechanism. While distal humerus fractures are caused by high-energy traumata in young male adults, a fall from a standing height is the most common reason for humerus fractures among elderly females. As a rule, fractures of the distal humerus are treated surgically. In young patients, open reduction and internal fixation (ORIF) with anatomic locking plates are the gold standard. In elderly patients, reconstruction is not always possible, and total elbow arthroplasty (TEA) becomes necessary. The present article provides an overview of the current diagnostic and treatment recommendations. The current literature is reviewed and the results discussed.     

Minimal invasive long PHILOS®-plate osteosynthesis in metadiaphyseal fractures of the proximal humerus

Minimal invasive plate osteosynthesis (MIPO) not only meets the criteria of a “biological” osteosynthesis by minimising invasivity as well as iatrogenic soft tissue damage, but can also provide adequate stability for fracture healing and early functional aftertreatment. Up to date, only few publications report on MIPO of humeral shaft fractures mainly using the anterolateral deltopectoral approach for proximal plate insertion. Objective of the present study was to assess the feasibility and clinical outcome of MIPO for metadiaphyseal fractures of the proximal humerus through a lateral approach using angular stable long PHILOS^®-plates.We retrospectively evaluated 29 patients (mean age 77 years, range 48–95 years) with displaced metadiaphyseal fractures of the proximal humerus treated with MIPO technique. For the first time, an angular stable long PHILOS^®-plate through a lateral deltoid-split approach proximally and a brachialis/brachioradialis intermuscular approach with exposure of the radial nerve distally, were used.There were no infections and no iatrogenic injuries to the axillary and radial nerve. One patient showed subacromial impingement and one patient had to be reoperated for redislocation of the distal fragment with screw breakage, which was most likely due to incorrect screw placement. This patient was successfully operated using the same method and implant. Besides one patient who refused further follow-up, 28 patients could be followed up to a mean of 8 months (range 3–12 months) each with an entirely healed fracture. Furthermore, patient's quality of life was documented using the SF-36 questionnaire. Comparison with published United States normative data showed no significant deficits in the physical as well as in the mental domains 8 months after MIPO.Minimal invasive long PHILOS^®-plate osteosynthesis using a combined lateral deltoid-split and brachialis/brachioradialis intermuscular approach proved to be a safe procedure for the treatment of metadiaphyseal fractures of the proximal humerus with low morbidity and full restoration of quality of life in these elderly patients.     

Locking plates in distal humerus fractures： study of 43 patients

Objective:The treatment of multifragmentary,intraarticular fractures of the distal humerus is difficult,even in young patients with bone of good quality.Small distal fragment,diminished bone mineral qu...     

An evaluation of supracondylar humerus fractures: is there a correlation between postponing treatment and the need for open surgical intervention?

Purpose

The goal of this study was to evaluate the treatment and recovery of patients treated for Gartland type III supracondylar humerus fractures in order to determine if postponing treatment leads to a higher rate of open surgical treatment or complications.

Methods

A retrospective study was conducted examining the medical records of children with Gartland type III supracondylar humerus fractures at our institution for a two-year period. The patients included in the study were treated with closed reduction and percutaneous pinning (CRPP) or open reduction and internal fixation (ORIF).

Results

After exclusions, 134 patients were included in the study, with an average age of 5.6 years. The patients were grouped according to whether their treatment was postponed (39.6 %) or immediate (60.4 %). The majority of all patients were treated using CRPP: 46 (86.8 %) of the postponed patients and 75 (92.6 %) of the immediate patients. Very few postsurgical complications occurred in the patients; there was only one (1.6 %) case of iatrogenic nerve injury in a postponed patient as well as four (3.8 %) cases of loss of carrying angle: one (2.3 %) in postponed patients and three (4.8 %) in immediate patients.

Conclusions

Postponing treatment of type III supracondylar humerus fractures in children did not lead to an increase in open surgical treatment; nor did it lead to an increase in complications.