Treatment of ipsilateral supracondylar and forearm fractures in children.

The treatment of ipsilateral supracondylar fractures of the humerus and fractures of the forearm bones was evaluated in 11 children. After an average of 6 years, 10 children had excellent or good results and one had a poor result from Volkmann's ischaemic contracture. Displaced supracondylar fractures of the humerus associated with distal fractures of the forearm bones are best treated by closed reduction and percutaneous pin fixation of the humeral fracture and a below-elbow plaster backslab.     

Closed reduction and percutaneous fixation of supracondylar fracture of the humerus and ipsilateral fracture of the forearm in children

We treated 22 children with a supracondylar fracture of the humerus and an ipsilateral fracture of the forearm by closed reduction and percutaneous fixation. There were four Gartland type-II and 18 Gartland type-III supracondylar fractures of the humerus. There were fractures of both bones of the forearm in 16 and of the radius in six. Both the supracondylar and the distal forearm fractures were treated by closed reduction and percutaneous fixation. The mean follow-up time was 38.6 months. At the latest follow-up there were 21 excellent or good results and one fair result. There were no cases of delayed union, nonunion or malunion. Five nerve injuries were diagnosed on admission and all recovered spontaneously within eight weeks. No patient developed a compartment syndrome.     

Ipsilateral supracondylar humerus fracture and Monteggia lesion: a case report

Two to 13% of supracondylar humerus fractures in children are associated with an ipsilateral forearm fracture, most of which are distal radius fractures. We present an unusual case of a 2-year-old girl with an ipsilateral supracondylar humerus fracture and a Monteggia lesion. Our management consisted of percutaneous K-wire fixation of the supracondylar humerus fracture and percutaneous insertion of an intramedullary K-wire for stabilization of the ulna fracture. Our patient had an excellent result, and we would recommend this method of fixation for similar injuries.     

Compartment syndrome in ipsilateral humerus and forearm fractures in children

Ipsilateral fractures of the humerus and forearm are uncommon injuries in children. The incidence of compartment syndrome in association with these fractures is controversial. The authors reviewed 978 consecutive children admitted to the hospital with upper extremity long bone fractures during a 13-year period. Forty-three children with ipsilateral fractures of the humerus and forearm were identified. Of 33 children with a supracondylar humerus fracture and ipsilateral forearm fracture, three children (7%) had compartment syndrome develop and required forearm fasciotomies. All three cases of compartment syndrome occurred among nine children with ipsilateral displaced extension supracondylar humerus and displaced forearm fractures; the incidence of compartment syndrome was 33% in this group. These findings suggest that children who sustain a displaced extension supracondylar humerus fracture and displaced forearm fracture are at significant risk for compartment syndrome. These children should be monitored closely during the perioperative period for signs and symptoms of increasing intracompartmental pressures in the forearm.     

Techniques for direct radiographic visualization during closed pinning of supracondylar humerus fractures in children

After reduction of a displaced supracondylar humerus fracture, the distal humerus must be easy to visualize; radiographic techniques in which the forearm overlaps the distal humerus make interpretation of fracture reduction difficult. Eighteen patients with displaced supracondylar humerus fractures were treated with reduction that was maintained manually with a variant of Dunlop's extension traction. This allows direct fluoroscopic evaluation of Baumann's angle, the contour of the distal humerus, the pin insertion site, and the angle of pin insertion. In young patients with a thin distal humerus and swollen elbow, the easiest pin placement may be achieved by inserting the pin on the lateral view (after the anteroposterior view confirms a satisfactory reduction).     

Ipsilateral supracondylar fracture of humerus and forearm bones in children

A total of 34 children with ipsilateral supracondylar fractures of the humerus and forearm were studied over an 8-year period. Of these, 19 patients had fractures of the distal quarter of the forearm bones while eight patients had a distal radial epiphyseal injury. Five of the patients had undisplaced supracondylar fractures. One patient had an anterior supracondylar fracture. All forearm fractures were treated by closed reduction. Nine displaced supracondylar fractures which could not be reduced by closed manipulation were treated by olecranon pin traction in two cases and by percutaneous pinning in seven cases. Excellent or good results were found in 29 children after an average follow-up of 3.8 years.     

Operative treatment of supracondylar fractures of the humerus in children. The consequences of pin placement

BACKGROUND: The commonly accepted treatment of displaced supracondylar fractures of the humerus in children is fracture reduction and percutaneous pin fixation; however, there is controversy about the optimal placement of the pins. A crossed-pin configuration is believed to be mechanically more stable than lateral pins alone; however, the ulnar nerve can be injured with the use of a medial pin. It has not been proved that the added stability of a medial pin is clinically necessary since, in young children, pin fixation is always augmented with immobilization in a splint or cast. METHODS: We retrospectively reviewed the results of reduction and Kirschner wire fixation of 345 extension-type supracondylar fractures in children. Maintenance of fracture reduction and evidence of ulnar nerve injury were evaluated in relation to pin configuration and fracture pattern. Of 141 children who had a Gartland type-2 fracture (a partially intact posterior cortex), seventy-four were treated with lateral pins only and sixty-seven were treated with crossed pins. Of 204 children who had a Gartland type-3 (unstable) fracture, fifty-one were treated with lateral pins only and 153 were treated with crossed pins. RESULTS: There was no difference with regard to maintenance of fracture reduction, as seen on anteroposterior and lateral radiographs, between the crossed pins and the lateral pins. The configuration of the pins did not affect the maintenance of reduction of either the Gartland type-2 fractures or the Gartland type-3 fractures. Ulnar nerve injury was not seen in the 125 patients in whom only lateral pins were used. The use of a medial pin was associated with ulnar nerve injury in 4% (six) of 149 patients in whom the pin was applied without hyperflexion of the elbow and in 15% (eleven) of seventy-one in whom the medial pin was applied with the elbow hyperflexed. Two years after the pinning, one of the seventeen children with ulnar nerve injury had persistent motor weakness and a sensory deficit. CONCLUSIONS: Fixation with only lateral pins is safe and effective for both Gartland type-2 and Gartland type-3 (unstable) supracondylar fractures of the humerus in children. The use of only lateral pins prevents iatrogenic injury to the ulnar nerve. On the basis of our findings, we do not recommend the routine use of crossed pins in the treatment of supracondylar fractures of the humerus in children. If a medial pin is used, the elbow should not be hyperflexed during its insertion.     

Combination of ipsilateral supracondylar humeral- and forearm fractures in children

In an 11-year period, from 01. 08. 1987 to 31. 08. 1998, a total of 72 children (mean age 7.6 years, range 2-12 years) with dislocated supracondylar humeral fractures were treated surgically in the Department for Traumatology, University Hospital, Essen. The combination of supracondylar humeral fracture and ipsilateral forearm fracture occurred in 8 children (11.1 %). 4 revealed a complete forearm fracture in the distal third, 4 children a fracture of the distal physis (Salter-Harris type II). The supracondylar humeral fractures were reduced openly via a single lateral approach and stabilized by crossed K-wire fixation. The distal forearm fractures were treated by closed reduction and percutaneous pinning. Fractures of the distal physis were treated by closed reduction and application of an above elbow cast. Excellent results were achieved in all children with ipsilateral supracondylar and forearm fractures.     

Biomechanical analysis of pinning techniques for pediatric supracondylar humerus fractures

BACKGROUND: Closed reduction and percutaneous pin fixation is the recommended treatment of displaced (Gartland types 2 and 3) supracondylar humerus fractures. The need for a medial pin for maximal stability remains controversial. The purpose of this study was to develop a model of supracondylar humerus fractures simulating medial column comminution and to evaluate the torsional stability of various pin configurations recommended in the current literature. METHODS: Transverse cuts were made in synthetic humeri with a wedge taken from the medial aspect of the proximal fracture fragment in one half of the specimens to simulate medial column comminution. Each fracture was then reduced and fixed with 1 of 4 pin configurations using 0.062 in K-wires. The fixed specimens were then subjected to a torsional load producing internal rotation of the distal fragment. Rotation in degrees and the corresponding torque was recorded for statistical analysis. RESULTS: Specimens with the medial wedge removed demonstrated less torsional stability than their identically fixed counterparts with the intact medial column. In specimens with the intact medial column, the greatest torsional stability was achieved with the 2 lateral divergent and medial cross pin configuration followed by 3 lateral pins, then standard crossed pins with 2 lateral divergent pins demonstrating the least torsional stability. For the medial comminution group the 2 lateral, 1 medial pin construct again had the greatest torsional stability and 2 lateral pins the least. The standard crossed pin and 3 lateral pin constructs were not significantly different in the presence of medial comminution. CONCLUSIONS: In a synthetic humerus model of supracondylar humerus fractures, medial comminution was shown to reduce torsional stability significantly in all pin configurations. There was no statistical difference in torsional stability between 3 lateral pins and standard crossed pins in specimens with medial comminution.     

Fractures of the distal humeral metaphyseal-diaphyseal junction in children

BACKGROUND: To our knowledge, there is no report in the English-language literature of metaphyseal-diaphyseal junction fractures of the distal humerus in children. The purpose of this study was to review our experience with this uncommon fracture. METHODS: Between 1998 and 2004, 422 displaced supracondylar humerus fractures underwent operative reduction and fixation at our institution. A retrospective review of medical records and radiographs revealed that 14 (3.3%) of these fractures occurred at the metaphyseal-diaphyseal junction just proximal to the olecranon fossa. In 8 patients, the fracture line was oblique (group A), and in 6 patients, the fracture line was transverse (group B). RESULTS: Average age at the time of fracture was 4.9 years (range, 1.5-10 years). All patients were treated by closed reduction and Kirschner wire fixation and had at least 1-year follow-up. In group A, operative time for reduction and fixation was significantly increased in comparison to the 408 remaining supracondylar humerus fractures. However, the clinical course in group A was uncomplicated, and no loss of fixation at follow-up was noted. The operative time in group B was even longer. These fractures were more problematic as loss of fixation occurred in 5 of the 6 patients, 4 occurring in the sagittal plane. In addition, multiple complications arose in group B including reoperation, cubitus varus, pin migration, and prolonged loss of motion. CONCLUSION: Metaphyseal-diaphyseal junction fractures of the distal humerus in children are rare but can be problematic. The transverse fracture pattern requires additional attention in the operating room with optimal pin fixation. Close postoperative follow-up is necessary. The oblique fracture pattern, while requiring increased time in the operating room for reduction and fixation, is typically stable with the usual fixation used for supracondylar humerus fractures. In summary, metaphyseal-diaphyseal junction fractures of the distal humerus are uncommon elbow fractures in children that should be differentiated from the more common supracondylar humerus fracture for optimal outcomes. LEVEL OF EVIDENCE: Therapeutic level 4 (case series).     

Lateral-entry pin fixation in the management of supracondylar fractures in children

BACKGROUND: There has been controversy regarding the optimal pin configuration in the management of supracondylar humeral fractures in children. A crossed-pin configuration may be mechanically more stable than lateral pins in torsional loading, but it is associated with a risk of iatrogenic injury to the ulnar nerve. Previous clinical studies have suggested that lateral pins provide sufficient fixation of unstable supracondylar fractures. However, these studies were retrospective and subject to patient-selection bias. METHODS: A displaced supracondylar humeral fracture was fixed with only lateral-entry pins in 124 consecutively managed children. Medical records and radiographs were reviewed to identify any complications, including loss of fracture reduction, iatrogenic ulnar nerve injury, infection, loss of motion of the elbow, and the need for additional surgery. In addition, eight displaced supracondylar humeral fractures that had been reduced and fixed with lateral pins at other institutions and had lost reduction were analyzed to determine the causes of the failures. RESULTS: Sixty-nine children had a type-2 fracture, according to Wilkins's modification of Gartland's classification system; forty-three (62%) of those fractures were stabilized with two pins and twenty-six (38%), with three pins. Fifty-five children had a type-3 fracture; nineteen (35%) of those fractures were stabilized with two pins and thirty-six (65%), with three pins. A comparison of perioperative and final radiographs showed no loss of reduction of any fracture. There was also no clinically evident cubitus varus, hyperextension, or loss of motion. There were no iatrogenic nerve palsies, and no patient required additional surgery. One patient had a pin-track infection. Our analysis of the eight clinical and radiographic failures of lateral pin fixation that were not part of the consecutive series showed that the loss of fixation was due to fundamental technical errors. CONCLUSIONS: In this large, consecutive series without selection bias, the use of lateral-entry pins alone was effective for even the most unstable supracondylar humeral fractures. There were no iatrogenic ulnar nerve injuries, and no reduction was lost. The important technical points for fixation with lateral-entry pins are (1) maximize separation of the pins at the fracture site, (2) engage the medial and lateral columns proximal to the fracture, (3) engage sufficient bone in both the proximal segment and the distal fragment, and (4) maintain a low threshold for use of a third lateral-entry pin if there is concern about fracture stability or the location of the first two pins.     

Ipsilateral proximal metaphyseal and flexion supracondylar humerus fractures with an associated olecranon avulsion fracture

An ipsilateral proximal humerus fracture, "flexion" supracondylar humerus fracture, and olecranon fracture found together is a rare event. The supracondylar fracture should be reduced and percutaneously pinned before the ipsilateral upper extremity fractures are reduced. Displaced supracondylar fractures should be pinned with crossed smooth pins. Most pediatric proximal humerus and olecranon fractures can be treated closed.     

Low incidence of ulnar nerve injury with crossed pin placement for pediatric supracondylar humerus fractures using a mini-open technique

OBJECTIVES: Several recent studies have suggested that medial pinning in pediatric supracondylar humerus fractures leads to increased rates of ulnar nerve injury. The purpose of this study was to determine the risk of iatrogenic ulnar nerve injury in a consecutive series of supracondylar fractures treated using a standardized technique of crossed pin placement. DESIGN: Single cohort retrospective. SETTING: Metropolitan university tertiary care center. PATIENTS AND PARTICIPANTS: Seventy-one consecutive children with Gartland type II or type III supracondylar humerus were treated surgically by 2 pediatric orthopaedic surgeons at 1 institution between 1995 and 2000 using a medial mini-open and cross-pinning technique. Sixty-five patients were available for follow-up (92%). INTERVENTION: Patients were treated with a combination of medial and lateral pins using a mini-incision technique. MAIN OUTCOME MEASUREMENTS: Outcomes analyzed included ulnar nerve injury and clinical and radiographic evidence of healing. RESULTS: The study group consisted of 65 patients, of whom 29 (45%) presented with Gartland type III fractures, and the remaining 36 (55%) presented with a type II fracture. There were no ulnar nerve motor injuries. One patient was noted to have transient sensory changes in the ulnar nerve distribution postoperatively, which resolved by the 1-week follow-up visit. All patients were noted to have normal ulnar motor and sensory nerve function at final follow-up (average 4.5 months). No cases of nonunion, malunion, or infection were identified during the follow-up period. CONCLUSIONS: The rate of iatrogenic ulnar nerve injury with this specific technique of crossed pin placement for extension-type supracondylar humerus fractures was extremely low in this series. A single case of transient ulnar sensory neuropraxia occurred. Our series demonstrates that crossed pin fixation can be performed safely and reliably and is an appropriate treatment option for unstable supracondylar humerus fractures.     

A systematic review of medial and lateral entry pinning versus lateral entry pinning for supracondylar fractures of the humerus

The supracondylar fracture of the distal humerus is the most common pediatric fracture in the elbow. This systematic review summarizes the existing data about the effect of medial and lateral (medial/lateral) entry pins versus only lateral entry pin fixation on the risk of iatrogenic nerve injury and deformity or loss of reduction. A literature search identified clinical trials and observational studies presenting the probability of nerve injury and/or deformity or loss of reduction associated with closed reduction and either medial/lateral entry or lateral entry pinning of supracondylar fractures in pediatric patients. Data from 2054 children were identified from 35 studies; 2 randomized trials, 6 cohort studies, and 25 case series. For operative fixation with medial/lateral entry pins, the probability of ulnar nerve injury is 5.04 times higher than with lateral entry pins. When all documented operative nerve injuries are included, the probability of iatrogenic nerve injury is 1.84 times higher with medial/lateral entry pins than with isolated lateral pins. Medial/lateral pin entry provides a more stable configuration, and the probability of deformity or loss of reduction is 0.58 times lower than with isolated lateral pin entry. When the prospective studies alone were analyzed, there were no significant difference in the probability of iatrogenic nerve injury or deformity and displacement, although the confidence intervals were wide. This systematic review indicates that medial/lateral entry pinning, of pediatric supracondylar fractures, remains the most stable configuration and that care needs to be taken regardless of technique to avoid iatrogenic nerve injury and loss of reduction.     

Increased pin diameter improves torsional stability in supracondylar humerus fractures: an experimental study

Background

Pediatric supracondylar humerus fractures are the most common elbow fractures seen in children, and account for 16 % of all pediatric fractures. Closed reduction and percutaneous pin fixation is the current treatment technique of choice for displaced supracondylar fractures of the distal humerus in children. The purpose of this study was to determine whether pin diameter affects the torsional strength of supracondylar humerus fractures treated by closed reduction and pin fixation.

Methods

Pediatric sawbone humeri simulating a Gartland type III fracture were utilized. Four different pin configurations were compared. Specimens were subjected to a torsional load producing internal rotation of the distal fragment. The stability provided by 1.25- and 1.6-mm pins was compared.

Results

The amount of torque required to produce 15° and 25° of rotation was greater using larger diameter pins in all models tested. The two lateral and one medial large pin (1.6 mm) configuration required the highest amount of torque to produce both 15° and 25° of rotation.

Conclusions

In a synthetic pediatric humerus model of supracondylar humerus fractures, larger diameter pins (1.6 mm) provided increased stability compared with small diameter pins (1.25 mm). Fixation using larger diameter pins created a stronger construct and improved the strength of fixation.

     

儿童肱骨髁上骨折术后关节功能恢复临床评估

[目的]回顾性分析儿童肱骨髁上骨折术后关节活动度(range of motion,ROM)的恢复过程及相关影响因素.[方法] 2007年11月～2010年3月间收集71例儿童肱骨髁上骨折的手术病例,同时收集67例儿童前臂远端骨折采用闭合复位、长臂石膏外固定的患者作为对照组,均在1个月后拆除固定装置并进行患肢功能锻炼,系列观察随访至活动度恢复到健侧的90％为止.对儿童肱骨髁上骨折术后及前臂远端骨折外固定后肘关节活动度的恢复情况对比分析.[结果]术前评价两组患者一般资料差异无统计学意义,具有可比性.肱骨髁上骨折组分别需14.05,16.23,3.05,2.11周可恢复肘关节伸、屈及前臂旋前、旋后四个方向的90％活动度.前臂远端骨折组中,肘关节伸、屈及前臂旋前、旋后活动度要恢复到预期目标分别需2周和4～5周.两组患者在肘关节伸屈、前臂旋转功能恢复方面差异有统计学意义.[结论]伸直型儿童肱骨髁上骨折术后固定1个月,肘关节伸屈功能恢复至正常需3～4个月,前臂旋转功能恢复需2～3周,旋后较旋前功能更易于恢复,肘关节屈曲功能恢复最慢.长臂石膏外固定一个月对儿童肘关节功能恢复影响较小.     

Effect of deferred treatment of supracondylar humeral fractures

PurposeTiming of surgery remains a controversial topic in the treatment of the supracondylar humeral fracture. In our institution, patients are not brought to theatre after midnight, except in the ‘life or limb’ situation. We hypothesised that time to surgery has no significant influence on complication rate with supracondylar fracture of the humerus.MethodsA retrospective review was performed of all patients who required operative intervention for supracondylar fractures of humerus between 2004 and 2006. Patients' charts were assessed for demographic details, fracture type, time to theatre and complications. Statistical comparisons were performed between different fracture grades.ResultsWe identified 124 supracondylar fractures of humerus that required operative intervention between 2004 and 2006. Fractures were mainly treated with operative manipulation with medial and lateral crossed K-wire fixation. Gartland III and flexion type fractures had a significantly shorter time to surgery than Gartland II (p < 0.05). There was no significant difference in complication rate between fractures operated after midnight or deferred until the morning (p = 0.68). Most common complications identified were ulnar nerve palsy and AIN palsy.ConclusionsWe have found no difference in complication rates when treatment of supracondylar fractures is delayed. Supracondylar fractures which are not grossly displaced, have no neurovascular deficit or risk of skin compromise, can be safely deferred without an increased risk of complication. Operative treatment of supracondylar fractures can be delayed until the next morning, except in the ‘life or limb’ situation.     

Effect of surgical delay on perioperative complications and need for open reduction in supracondylar humerus fractures in children

This retrospective study examined whether a delay of greater than 12 hours is associated with an increased risk of perioperative complications in the operative treatment of supracondylar humerus fractures in children. Of 150 consecutive children with supracondylar fractures, 50 underwent surgery in less than 12 hours and 100 underwent surgery greater than 12 hours after injury. There was no significant difference between groups in rate of open reduction (P = 0.55), pin tract infection (P = 1.0), iatrogenic nerve injury (P = 1.0), vascular complication (P = 0.33), or compartment syndrome (P = 1.0), including when Gartland type III fractures were analyzed independently. There was no iatrogenic nerve injury, no compartment syndrome, and one pin tract infection in 150 patients. The study confirms previous retrospective studies finding no significant difference in perioperative complications or rate of open reduction in children undergoing early versus delayed surgical treatment of supracondylar humerus fractures.