Operative management of children's fractures of the shoulder region

Fractures about the shoulder in children rarely require operative treatment. Exceptions include open fractures and those associated with neurovascular compromise. Fractures of the proximal humerus in older children that cannot be adequately reduced and maintained should be treated with open reduction and internal fixation. Interposition of periosteum and biceps tendon can lead to difficulty in fracture reduction. Irreducible displaced fractures of the clavicular shaft, fractures that develop nonunion, and congenital pseudarthrosis of the clavicle can be treated by an intramedullary pin technique with bone grafting. Posterior displacement of fractures of the medical clavicle sometimes become an orthopedic emergency. Reduction by closed or open means should be accomplished to relieve compression of mediastinal structures. This injury does not require internal fixation. Types IV, V, and VI distal clavicle injuries require open reduction and reefing of the periosteal tube with occasional need for temporary lag-screw fixation. There is some debate about the type III injury. Large glenoid fractures involving the anterior rim that are associated with instability of the glenohumeral joint are best treated by open reduction and internal fixation.     

Metatarsal fractures

Metatarsal fractures are relatively common and if malunited, a frequent source of pain and disability. Nondisplaced fractures and fractures of the second to fourth metatarsal with displacement in the horizontal plane can be treated conservatively with protected weight bearing in a cast shoe for 4-6 weeks. In most displaced fractures, closed reduction can be achieved but maintenance of the reduction needs internal fixation. Percutaneous pinning is suitable for most fractures of the lesser metatarsals. Fractures with joint involvement and multiple fragments frequently require open reduction and plate fixation. Transverse fractures at the metaphyseal-diaphyseal junction of the fifth metatarsal ("Jones fractures") require an individualized approach tailored to the level of activity and time to union. Avulsion fractures of the fifth metatarsal bone are treated by open reduction and tension-band wiring or screw fixation if displaced more than 2 mm or with more that 30% of the joint involved. The metatarsals are the most common site of stress fractures, most of which are treated nonoperatively. Symptomatic posttraumatic deformities need adequate correction, in most cases by osteotomy across the former fracture site.     

Proximale Metakarpalfrakturen mit Gelenkbeteiligung

Intraarticular fractures of the base of the first metacarpal that have healed in displaced position quickly lead to posttraumatic arthritis. After satisfactory closed reduction a percutaneous pin fixation is sufficient, if necessary combined with fixation of the first metacarpal. If closed reduction cannot be obtained, open reduction with pin fixation, or rigid fixation with screws or plates, is advisable. Displaced fractures of the metacarpal base of the fingers also lead to posttraumatic arthritis with a weak grip. Displaced fractures and dislocated fractures require reduction and percutaneous or internal fixation with K-wires and possibly additional pin fixation of the carpometacarpal joints.     

Part II: Arthroscopic treatment of tibial plateau fractures: Intercondylar eminence avulsion fractures

Arthroscopic reduction and internal fixation (ARIF) of tibial intercondylar eminence fractures is the emerging state-of-the-art. ARIF is recommended for displaced type III fractures and should be considered for all cases of displaced type II fractures. Fractures without displacement after closed reduction require careful evaluation to rule out meniscal entrapment. Subjective results of ARIF are uniformly excellent, despite reports of objective anteroposterior laxity. Early range-of-motion exercises are essential to prevent loss of extension. Repair using nonabsorbable suture fixation, when of adequate strength to allow early range-of-motion, has the advantages of eliminating the risks of comminution of the fracture fragment, posterior neurovascular injury, and need for hardware removal, compared with ARIF using screws.     

Triplane fractures of the distal tibial epiphysis

Triplane distal tibial fractures can occur as two-, three-, or four-part fractures with or without a fibular fracture. Diagnosis of the particular anatomy of each fracture is ascertained by plain radiographs; if the fracture is displaced 2 mm or more on any view, anteroposterior and lateral tomograms and, if possible, a limited computerized tomography (CT) scan should be done. A plaster cast in situ for non-displaced fractures or closed reduction for displaced fractures should be attempted first by internal rotation and anterior movement of the fibular metaphyseal piece. Failure to obtain and/or maintain an adequate closed reduction (less than 2 mm displacement), determined by plain radiographs, is an indication for operative treatment. Operative treatment consists of screw fixation for the metaphyseal fragment alone in two-part fractures and both metaphyseal and epiphyseal screw fixation in three-part fractures. Associated fibular fractures may also require internal fixation. The prognosis is generally good if adequate reduction has been achieved by closed or open means.     

Lateral versus crossed wire fixation for displaced extension supracondylar humeral fractures in children

Reduction and percutaneous pin fixation is widely accepted treatment for displaced humeral supracondylar fractures in children, but the best pin configuration is still debatable. This study examined the outcome for crossed and lateral pins placement in type IIB and III supracondylar humeral fractures. Clinical notes and radiographs of 131 children with an average age of 6 years were retrospectively reviewed. Lateral pins fixation was used in 66 children and crossed wires in 65. The groups were similar with regard to gender, age, follow-up, severity of displacement and number of closed/open reductions. There was no statistical difference between the two groups either clinically or radiologically in the quality of outcome. However, postoperative ulnar nerve injuries occurred in 6% of patients treated with crossed wire fixation, whilst none of the group with pins inserted laterally suffered this complication. We recommend fixation of displaced humeral supracondylar fractures with two or three lateral pins inserted parallel or in a divergent fashion. This method of fixation gives similar results to crossed wires but prevents iatrogenic ulnar nerve injuries.     

Management of supracondylar humerus fractures in children: current concepts

Supracondylar humerus fractures are the most common elbow fractures in the pediatric population. Type I fractures are managed nonsurgically, but most displaced injuries (types II, III, and IV) require surgical intervention. Closed reduction and percutaneous pinning remains the mainstay of surgical management. Numerous studies have reported recent alterations in important aspects of managing these fractures. Currently, many surgeons wait until 12 to 18 hours after injury to perform surgery provided the child's neurovascular and soft-tissue statuses permit. Increasingly, type II fractures are managed surgically; cast management is reserved for fractures with extension displacement only. Two to three lateral pins are adequate for stabilizing most fractures. Evolving management concepts include those regarding pin placement, the problems of a pulseless hand, compartment syndrome, and posterolateral rotatory instability.     

Fractures of the neck of the talus

Talar neck fractures should be managed with meticulous attention to detail, and anatomical reduction is mandatory. Most type I fractures can be treated closed, unless there is loss of reduction, but type II, III, and IV, especially if displaced, usually require open reduction and internal fixation. Closed reduction may be attempted, but if the reduction is lost, or satisfactory reduction cannot be obtained, open reduction should be performed. Two incisions may be necessary to confirm accurate anatomical reduction. Poor results occur because of avascular necrosis, malunion, subtalar arthritis, and infection. Attention to detail can decrease the incidence of the latter three of these complications; the development of avascular necrosis does not seem to be related to the type of treatment. Though the most serious complication, avascular necrosis, may not require surgical intervention, many of the authors' patients have done well with conservative treatment.     

Evaluation of the role of pin fixation versus collar and cuff immobilisation in supracondylar fractures of the humerus in children

Long term results of children with supracondylar humeral fractures treated with manipulation and strapping and manipulation followed by pin fixation were evaluated. Forty patients were regarded as Gartland type II injuries. 33 of these were treated with closed reduction and collar and cuff immobilisation and 7 with closed reduction and percutaneous pinning. Two cases of cubitus varus were reported one from each treatment modality. Forty-four patients were included as Gartland type III injuries. Of these 14 were treated with closed reduction and collar and cuff immobilisation, 25 with closed reduction and percutaneous pinning and five with open reduction and pinning. There were two cases of cubitus varus and one case of cubitus valgus following pin fixation. In addition one case of extension lag and one significant ulnar nerve neurapraxia was recorded following pin fixation. One case of cubitus varus was seen following manipulation and collar and cuff treatment. There was no statistical difference between either treatment modality in terms of predicting a better outcome (p0.05).We conclude that pin fixation has no advantages over simple immobilisation in certain Gartland II and III type injuries. Although pin fixation is beneficial in unstable injuries collar and cuff immobilisation continues to have an important role in the treatment of stable supracondylar fractures.     

Treatment of displaced supracondylar humeral fractures among children: Crossed versus lateral pinning

This retrospective study evaluated different pinning configurations used in the treatment of displaced supracondylar humeral fractures among children, mainly regarding maintenance of fracture reduction and avoidance of complications. The fractures (41 type II and 67 type III) of 108 children (mean age 6.48 years) were treated by closed reduction and percutaneous pinning: 37 with crossed pins, 37 with two lateral pins and 34 with two lateral and one medial pin. Mean follow-up period was 7.4 months. Type III fractures fixed by two lateral pins were found significantly prone to postoperative instability, late complications and need for medial pin fixation. There was a significant relation between either delay to surgery or postoperative instability and occurrence of complications. Final outcome was significantly poorer in type III than in type II fractures. Fixation by two lateral pins only is not recommended for treating type III supracondylar humeral fractures, but could be used initially to fix severely unstable fractures to allow extension of the elbow before inserting a medial pin. Every effort should be made to avoid iatrogenic ulnar nerve injury while inserting the medial pin.     

Fractures of the olecranon and radial neck in children

Over one half of radial neck fractures are associated with other injuries about the elbow. Most radial neck fractures can be treated with closed reduction or with percutaneous probing, even if the other associated injuries require open reduction. The results are good, although radiologic imperfections may be seen after healing. In the older child, olecranon fractures that have significant displacement usually require open reduction with internal fixation.     

Severely displaced proximal humeral epiphyseal fractures

The purpose of this study was to document the late outcome of a group of patients with Neer grade III/IV proximal humeral physeal fractures who were treated with reduction of the fracture and maintenance of reduction until fracture consolidation. A total of 28 patients treated between 1984 and 1999 at a large children's hospital were included in this study. Nineteen of the 28 patients were 15 years or older (range 5-16 y). All patients were treated in the operating room with closed reduction followed by immobilization (n = 3), closed reduction and pin fixation (n = 20), open reduction and screw fixation (n = 3), or open reduction and pin fixation (n = 2). Postoperatively, all had Neer grade I or II displacement, which was maintained until fracture union. No operative or postoperative complications occurred. At an average follow-up of 4 years, all patients had near-normal glenohumeral motion and excellent strength and uniformly reported regaining full preinjury functional use of the involved extremity. Achieving and maintaining reduction in Neer grade III/IV proximal humeral epiphyseal fractures can be safely performed and results in excellent long-term shoulder function. This is of particular significance in the older adolescent who has minimal remodeling potential.     

The treatment of pediatric supracondylar humerus fractures

Based on the best current evidence and a systematic review of published studies, 14 recommendations have been created to guide clinical practice and management of supracondylar fractures of the humerus in children. Two each of these recommendations are graded Weak and Consensus; eight are graded Inconclusive. The two Moderate recommendations include nonsurgical immobilization for acute or nondisplaced fractures of the humerus or posterior fat pad sign, and closed reduction with pin fixation for displaced type II and III and displaced flexion fractures.     

Displaced hip fractures in children and adolescents

The results of ten acute, displaced proximal femoral fractures in patients 14 years and under are reported. These high-risk fractures were managed with urgent open reduction and pin or screw fixation with supplemental spica casting. The exception to this protocol was in two Delbet's type IV (intertrochanteric) fractures which were managed by closed reduction and spica casting. There was a case of partial avascular necrosis of the femoral head in a type I transepiphyseal fracture. At a minimum followup of 2 years the patients were asymptomatic with no significant limitation of hip motion.     

Open reduction and internal fixation of displaced intra-articular fractures of the calcaneus

BACKGROUND: Thirty-two displaced intra-articular fractures of the calcaneus in 30 patients were treated with open reduction and internal fixation. Fracture classification was based on Sanders computed tomographic classification. There were 18 type II fractures, 10 type III fractures, and 4 type IV fractures. METHODS: The operations were performed using a standard extended lateral approach, and the fractures were fixed with small-fragment AO T-plates without bone grafting. Average follow-up was 35.4 months (range, 24-53 months). The Creighton-Nebraska Health Foundation Assessment score for fractures of the calcaneus was used for evaluation. RESULTS: The average score was 86.7 for type II, 82.3 for type III, and 59.2 for type IV fractures. There was a clear statistically significant superiority with type II and type III fractures treated with open reduction when compared with type IV fractures (p < 0.0001). CONCLUSION: On the basis of our result, we recommend that type II and type III fractures be treated with open reduction and internal fixation. Despite the results of type IV fractures being significantly worse than that of type II and type III fractures, we recommend open reduction and internal fixation for type IV fractures to restore the hindfoot architecture and the subtalar joint, if possible. When the disrupted subtalar joint is so comminuted that it is beyond the surgeon's ability to reconstruct, primary subtalar arthrodesis should be performed in addition to open reduction and internal fixation.     

Percutaneous pin fixation of intercondylar fractures in young children

T-condylar fractures of the distal humerus are very rare in children. When they do occur they tend to affect those approaching skeletal maturity. Most agree that the undisplaced fracture can be managed conservatively. With increasing displacement and comminution the opinions tend to differ. As an alternative to open reduction and internal fixation we report the use of closed reduction and percutaneous pin fixation for displaced and comminuted T-condylar fractures in a series of three young children. In addition to the classical medial and lateral column fixation we report the use of a transcondylar wire to stabilise the distal fragments and discuss the use of intra-operative arthrography in low supracondylar fractures to exclude a missed intercondylar extension on plain xrays. Although small this series represents the largest series of children less than eight years of age.     

Traumatologie des Unterkiefergelenkfortsatzes

The indications for closed or open treatment of fractures of the mandibular condylar process are a controversial subject. Closed treatment is currently predominant for pediatric fractures and for adults with minimally or non-displaced fractures. In contrast closed treatment in adults with displaced and dislocated fractures will usually show less favorable results. Currently, there is an increasing agreement that the indications for open reduction are displaced fractures and particularly in cases of dislocated and bilateral fractures. Open reduction and internal fixation are aimed at restoring correct anatomy and thus physiological joint function. At present surgeons should be able to use safe operative approaches for the different fracture levels (base, neck and condylar head), which allow the application of stable osteosynthesis methods especially designed for the individual fracture patterns. The challenge is therefore to choose the optimum treatment for the individual case, i.e. an efficient quick and as least traumatic as possible recovery of function.     

Outcome of Gartland type II and type III supracondylar fractures treated by Blount's technique

Background:

According to some orthopedic surgeons, almost all supracondylar humerus fractures should be treated operatively by reduction and pinning. While according to others, closed reduction and immobolization should be used for Gartland type II and some type III fractures. However, the limit of this technique remains unclear. We present 74 patients with displaced extension-type supracondylar fractures treated by closed reduction and immobilization with a collar sling fixed to a cast around the wrist. The purpose of the study is to give a more precise limitation of this technique.

Materials and Methods:

Retrospective data acquisition of 74 patients with a Gartland type II or type III fractures treated by closed reduction and immobilization (Blount''s technique) between January 2004 and December 2007 was done. The mean age was 6.3 years (range, 2–11). The mean time of follow-up was 6.5 months (range, 3–25). All open injuries and complex elbow fracture dislocations or T-condylar fractures were excluded from the study. All patients were evaluated with standardized anteroposterior and true lateral x-rays of the elbow, and Flynn criteria were used for functional assessment.

Results:

Gartland type II fractures had 94% good or excellent final results. Gartland type III fractures had 73% good or excellent final result. The Gartland type III outcome depended on the displacement. The fractures remained stable in 88% for the posterior displacement, and 58% for the posteromedial displacement. These displacements were mild. However, for the posterolaterally displaced fractures, only 36% were stable; 36% had a mild displacement and 27% had a major displacement.

Conclusion:

Pure posterior displacement is more stable than posteromedial displacement which is more stable than posterolaterally displaced fractures. This study suggests that Gartland type II and pure posterior or posteromedial displaced Gartland type III fractures can be treated by closed reduction and immobilization with success.