Close reduction and percutaneous pinning in displaced supracondylar humerus fractures in children

BackgroundDisplaced supracondylar fractures of the humerus in children are common pediatric injuries treated by orthopedic surgeons. They also have a high rate of complications if not reduced and stabilized in optimal position which may lead to serious neurovascular injuries and residual deformity. Amongst the various methods used for treating these fractures, closed reduction and percutaneous pinning has shown improved results.MethodBetween March 2005 and April 2010, 277 cases of supracondylar humeral fractures (Gartland grade II and III) with less then 1 week old were included in this study. They were treated with closed reduction and percutaneous pinning with crossed Kirschner wires under image intensifier control. Clinical outcome were assessed according to Flynn's criteria.ResultsThe mean age at the time of operation was 6 years (range 2–10 years) and the average duration of follow-up was 4.6 years (range 2.1–7.2 years). The Flynn's criteria were excellent in 202, good in 68, fair in 5 and only 2 with poor results.ConclusionClosed reduction and percutaneous pinning is a sound and effective treatment for displaced supracondylar fractures.     

经皮穿针固定治疗肱骨近端骨折

肱骨近端骨折是一种临床常见的骨折类型,占全身骨折的2％～4％,其中15％为不稳定骨折,肱骨近端骨折可发生于任何年龄,常见于老年患者,和骨质疏松有关;在青少年中,由于活动能力增加,骺板相对薄弱,发生率有所增加,多为Salter—HarrisⅡ型骺损伤。对于存在移位或移位倾向的肱骨近端不稳定性骨折,应手术治疗。现将我院自2003年2月至2006年1月对33例得到随访的肱骨近端骨折经皮穿针固定手术治疗的结果分析研究如下。     

肱骨近端支架治疗肱骨近端骨折研究进展

肱骨近端骨折是肩部常见骨折之一,随着发病率的增加,手术干预比例不断加大,本文对肱骨近端骨折治疗传统和新出现的治疗手段进行分析探究。锁定钢板技术是临床使用最多的方式,但是其螺钉切出、再手术并发症发生率过高。腓骨移植技术可以弥补钢板无法有效支撑等不足,但也存在手术创伤大、潜在血管破坏发生率高等不足。关节置换是复杂肱骨近端骨折的治疗方式之一,学习曲线长、花费高等是其固有缺点。近年出现了肱骨近端支架干预方式,此技术具备固有3D立体结构优势,可以为肱骨头提供有效承重支持,能够为螺钉提供灵活的置入角度。为减少术后并发症,提高患者康复安全性提供技术选择。全面把握肱骨近端骨折的治疗手段,合理选择干预措施将会给患者带来更多的收益。     

Effect of tuberosity repair on functional outcome of reverse shoulder arthroplasty in proximal humerus fractures

PurposeUnsatisfactory results of hemiarthroplasty in Neer's 3- and 4-part proximal humerus fractures in elderly, have led to the shift towards reverse shoulder arthroplasty (RSA). The objective of our study was to repair the tuberosities that are generally overlooked during RSA and observe its impact on the functional outcome and shoulder scores.MethodsWe include elderly patients with acutely displaced or dislocated 3- or 4-part proximal humerus fractures from July 2013 to November 2019 who were treated with RSA along with tuberosity repair by non-absorbable sutures and bone grafting harvested from the humeral head. Open injuries and cases with neuro-muscular involvement of the deltoid muscle were excluded. According to the tuberosity healing on radiographs of the shoulder at 9th postoperative month, the patients were divided into 2 groups, as the group with successful tuberosity repair and the other with failed tuberosity repair. Statistical analysis of the functional outcome and shoulder scores between the 2 groups were done by independent t-test for normally distributed parameters and Mann-Whitney test for the parameters, where data was not normally distributed.ResultsOf 41 patients, tuberosity healing was achieved in 28 (68.3%) and failed in 13 (31.7%) cases. Lysis of the tuberosity occurred in 5 patients, tuberosity displacement in 2, and nonunion in 2. Mean age was 70.4 years (range 65 – 79 years) and mean follow-up was 58.7 months (range 18 – 93 months). There were no major complications. Group with successful tuberosity repair showed improvement in mean active range of movements, like anterior elevation (165.1° ± 4.9° vs. 144.6° ± 9.4°, p < 0.000), lateral elevation (158.9° ± 7.2° vs. 138.4° ± 9.6°, p < 0.000), external rotation (30.5° ± 6.9° vs. 35.0° ± 6.3°, p = 0.367), internal rotation (33.7° ± 7.5° vs. 32.6° ± 6.9°, p = 0.671) and in mean shoulder scores including Constant score (70.7 ± 4.1 vs. 55.5 ± 5.7, p < 0.000), American shoulder and elbow surgeons score (90.3 ± 2.4 vs. 69.0 ± 5.7, p < 0.000), disability of arm shoulder and hand score (22.1 ± 2.3 vs. 37.6 ± 2.6, p < 0.000).ConclusionSuccessful repair and tuberosity healing around the RSA prosthesis is associated with statistically significant improvement in postoperative range of motion, strength and shoulder scores. Standardized repair technique and interposition of cancellous bone grafts, harvested from the humeral head can improve the rate of tuberosity healing.     

PHN for treatment of proximal humerus fractures: evaluation of 80 cases

This paper analyses 80 cases of displaced proximal humerus fractures, with two or three fragments, treated by PHN nailing. The hold of the spiral blade was effective, and is particularly recommended for fractures with two fragments according to Neer’s classification. The results, analysed with Constant’s score and radiographic checkups, were satisfactory. Nearly all our patients (76 out of 80) had a mean age of 75 years and a total Constant score of 78.48. Only four (mean age 42.5 years) had a Constant score of 86. Shoulder articulation was good and only a few complications occurred.     

应用肱骨近端锁定钢板治疗肱骨近端骨折

目的观察、评价肱骨近端锁定钢板（LPHP）治疗肱骨近端骨折的疗效。方法通过分析自2008—01—2012—10收治并随访的52例肱骨近端二部分以上骨折。采用有限切开、透视复位、肱骨近端锁定钢板内固定的方法治疗,骨缺损患者采用自体髂骨及人工骨植骨。结果本组获得随访8—25个月（平均15个月）,肱骨近端骨折均得到了愈合,按Neer肩关节功能评分标准：优25例,良18例,可6例,差3例,优良率82．7％。未发生断板、断钉,无肱骨头缺血坏死及肩峰撞击综合征。结论应用肱骨近端锁定钢板治疗肱骨近端骨折,骨缺损者取髂骨、人工骨植骨,根据骨折类型及稳定性等指导功能锻炼,骨折愈合良好、并发症少、关节功能恢复好。     

Comparison of clinic-radiological outcome of cross pinning versus lateral pinning for displaced supracondylar fracture of humerus in children: A randomized controlled trial

IntroductionSupracondylar fracture of humerus (SFH) is frequently encountered in the immature skeleton, [1] predominantly in the non-dominant extremity.AimThis study compared the clinic-radiological outcome between cross pinning with lateral pinning for fixation of displaced supracondylar fracture of humerus in children.Materials and methodsAll eligible patients were randomized into two groups, group I for lateral pinning and group II for cross pinning. Before passing medial pin in group II a stab incision was given to visualise the medial epicondyle. Patients were followed up on 3 weeks, 6 weeks and 3 months. Final outcome was measured in terms of clinic-radiological union, Baumann angle, loss of reduction, stability of fracture fixation, incidence of iatrogenic nerve injury and Flynn's score. Results: There were 37 patients in group I and 40 in group II. Both groups were comparable in terms of demographic details. At the final outcome there were no difference in between the groups in terms of all radiological and clinical outcome. Two patients of group I developed delay ulnar neuritis, which resolve completely in subsequent follow-up.ConclusionBoth techniques provide stable fixation, union and good functional outcome without iatrogenic ulnar nerve injury provided that small incision sufficient enough to identify the medial epicondyle is given with passing of medial pin.     

Mid term results of PlantTan plate in the treatment of proximal humerus fractures

This prospective study evaluates the clinical efficacy of a special implant, PlantTan plate used for fixation of displaced proximal humerus fractures. The PlantTan plate was used for internal fixation of closed displaced proximal humeral fractures in 68 patients from September 1999 to June 2002, in a University Hospital. One of the surgeries was for a non-union, and five patients were lost to follow-up. The patients' ages ranged from 19 to 76 years (mean 61 years and median 66 years). Of the remaining 62 patients, 42 were female and 20 were male. As defined using the Neer classification 19 patients had two part, 37 three part and 6 had four part fractures. Median follow-up was 19 months (11-38). The outcome was assessed using radiographs, American Shoulder and Elbow Surgeons (ASES) score and Hospital for Special Surgery (HSS) scoring system. Fifty-two patients achieved union in a median of 8 weeks. The median cumulative score of activities of daily living of ASES was 20.4/30 (13-27). According to HSS, 11 scored excellent, 26 good, 14 fair and 11 scored poor. Eight patients had fixation failure and two developed avascular necrosis. Eleven patients developed an infection. Six patients developed an infection resulting in implant removal. One had a transient and one permanent axillary nerve palsy. Since the PlantTan plate provides stability, early active rehabilitation can be instituted. The implant is distally placed reducing impingement symptoms. However, the implant requires wide surgical exposure, is bulky and has an unacceptable infection rate. The fixation failure is high in patients with osteoporosis. In view of the above encountered problems, the implant has been discontinued in our hospital.     

Early results of displaced supracondylar fractures of humerus in children treated by closed reduction and percutaneous pinning

Background:

Displaced supracondylar fractures are notorious for difficulty in reduction, maintenance of reduction and frequent involvement of neurovascular structures. No general agreement on the treatment is evident with controversy prevailing regarding the ideal timing of surgery, method of maintenance of reduction and configuration of the pin fixation. A crossed pin configuration, though believed by some to be mechanically more stable than the lateral pins alone, has the risk of ulnar nerve injury due to the medial pin. Lateral pins alone impart less rotational stability to the fracture although it has been attributed mainly to technical errors of pin placement. The aim of this study was to assess the efficacy of treatment of this fracture using one lateral and one trans-olecranon K-wires or lateral entry K-wires alone.

Materials and Methods:

Ninety cases of displaced supracondylar humerus fractures were included in the study. The mean age of the patients was 6.7 years (range 3–12 years). The male/female ratio was 5:1 and left side was involved in 70% whereas 30% had right sided injuries. The most common mode of trauma was fall from height with elbow in extension. All the 90 consecutively admitted patients had extension type injury with 73.3% fractures being Gartland type III and 26.7% were type II. Posteromedial displacement was noted in 70% whereas 30% fractures were posterolaterally displaced. In 60 cases, lateral entry wires alone were used whereas, in 30 cases, one lateral and another transolecranon transarticular K-wire was used. K-wires were removed at 3 weeks postoperatively and followup was done at 6 weeks and 12 weeks when they were evaluated according to the criteria described by Flynn. Chi-square test was used as a statistical test of significance to compare results among different variables.

Results:

Results were graded according to Flynn''s criteria. Excellent results were achieved in 12 (13.3%), good in 54 (60%), fair in 15 (16.7%) while in nine patients (10%) poor results were obtained.

Conclusions:

Both lateral entry K-wires and lateral-trans-olecranon wire techniques provide stable fixation when observing the guidelines for wire placement and consistently satisfactory results can be obtained, both cosmetically and functionally with both the techniques.     

锁定接骨板治疗肱骨近端复杂骨折

目的探讨肱骨近端锁定接骨板（LPHP）治疗肱骨近端复杂骨折的临床疗效。方法回顾分析本院2003年1月至2005年10月采取LPHP治疗31例肱骨近端复杂骨折。按Neer分型，3部分骨折22例；4部分骨折9例。结果31例经5～13月随访．无1例发生内固定松动、断裂，全部骨折均愈合。肩关节功能按照Constant评分标准，功能优9例，良18例，中4例，优良率87．1％。结论LPHP治疗肱骨近端复杂骨折固定可靠、骨折愈合率高、可行早期功能锻炼，功能恢复好。     

经皮穿针和逆行髓内针固定治疗肱骨近端骨折

目的探讨经皮穿针和逆行髓内针固定治疗肱骨近端骨折的临床效果。方法1999年6月-2003年12月对29例肱骨近端骨折分别采用经皮穿针内固定21例，逆行髓内针固定5例，经皮穿针和逆行髓内针固定3例。结果术后无针眼感染、血管损伤、医源性桡神经损伤、螺纹针折断，未出现肱骨头坏死的征象。1例行经皮穿针内固定出现腋神经损伤症状，经治疗2个月后症状消失。29例术后8—12周骨折全部骨性愈合，无延迟愈合。术后3个月参照Neer肩关节百分评分标准，优10例，良15例，可3例，差1例，优良率为86．2％（25／29）。结论经皮穿针和逆行髓内针固定治疗效果满意，并发症发生率低，是治疗肱骨近端骨折的理想办法。     

Predictors of outcomes of proximal humerus fractures in children and adolescents: A systematic review

Purpose:Minimally displaced pediatric proximal humerus fractures can be reliably managed non-operatively; however, there is considerable debate regarding the appropriate management of severely displaced proximal humerus fractures, particularly in older children and adolescents with limited remodeling potential. The purpose of this study was to perform a systematic review to answer the questions: “What are the functional and quality-of-life outcomes of pediatric proximal humerus fractures?” and “What factors have been associated with a poorer outcome?”Methods:A review of Medline and Embase was performed on 4 July 2021 using search terms relevant to proximal humerus fractures, surgery, non-operative management, pediatrics, and outcomes. Studies including ≥10 pediatric patients with proximal humerus fractures, which assessed clinical outcomes by use of an established outcome measure, were selected. The following clinical information was collected: participant characteristics, treatment, complications, and outcomes.Results:Twelve articles were selected, including four prospective cohort studies and eight retrospective cohort studies. Favorable outcome scores were found for patients with minimally displaced fractures, and for children aged less than 10 years, irrespective of treatment methodology or grade of fracture displacement. Older age at injury and higher grade of fracture displacement were reported as risk factors for a poorer patient-reported outcome score.Conclusion:An excellent functional outcome can be expected following non-operative management for minimally displaced pediatric proximal humerus fractures. Prospective trials are required to establish a guideline for the management of severely displaced proximal humerus fractures in children and adolescents according to fracture displacement and the degree of skeletal maturity.Level of evidence:level V.     

Proximal humerus fractures: a comparative biomechanical analysis of intra and extramedullary implants

Introduction The biomechanical stability of a newly developed humerus nail (Sirus™) for the treatment of fractures of the proximal humerus was analyzed in comparison to established systems. In total, three randomized groups were formed (n = 4 pairs) from 12 matched pairs of human cadaver humeri. Materials and methods All intact bones were mechanically characterized by five subsequent load cycles under bending and torsional loading. The bending moment at the osteotomy was 7.5 N m the torsional moment was 8.3 N m over the hole specimen length. Loading was consistently initiated at the distal epiphysis and the deformation at the distal epiphysis was continuously recorded. Prior to implant reinforcement, a defect of 5 mm was created to simulate an unstable subcapital humerus fracture. For paired comparison, one humerus of each pair was stabilized with the Sirus proximal humerus nail while the counterpart was stabilized by a reference implant. In detail, the following groups were created: Sirus versus Proximal humerus nail (PHN) with spiral blade (group I); Sirus versus PHILOS plate (group II); Sirus versus 4.5 mm AO T-plate (group III). Results The Sirus nail demonstrated significantly higher stiffness values compared to the reference implants for both bending and torsional loading. The following distal epiphyseal displacements were recorded for a bending moment of 7.5 N m at the osteotomy: Sirus I: 8.8 mm, II: 8.4 mm, III: 7.7 mm (range 6.9–10.9), PHN 21.1 mm (range 15.7–25.2) (P = 0.005), PHILOS plate 27.5 mm (range 21.6–35.8) (P < 0.001), 4.5 AO T-plate 26.3 mm (range 24.3–33.9) (P = 0.01). The rotations corresponding to 8.3 N m torsional moment were: Sirus I: 9.1°, II: 9.3°, III: 10.6° (range 7.5–12.2), PHN 13.5° (range 10.3–15.6) (P = 0.158), PHILOS plate 15.6° (range 13.7–20.8) (P = 0.007), 4.5 AO T-Platte 14.1° (range 11.5–19.7) (P = 0.158). Conclusion The intramedullary load carriers were biomechanically superior when compared to the plating systems in the fracture model presented here. Supplementary, the Sirus Nail showed higher stiffness values than the PHN. However, the latter are gaining in importance due to the possibility of minimal invasive implantation. Whether this will be associated with functional advantages requires further clinical investigation.     

Plates with angular stability: our personal experience in surgical treatment of fractures of the proximal extremity of the humerus

We here report our experience in the use of locking proximal humerus plates that, compared to the old-generation ones, have shown a reduced incidence of complications, more manageability and higher preservation of soft tissues. Thirty-two patients underwent surgical treatment with plates with angular stability: 20 women and 12 men, with an average age of 52 years; in 6 cases they were fractures with 2 fragments, in 20 cases they were with 3 fragments and in 6 cases with 4 fragments. Results, evaluated according to the Constant Score, with a minimum follow-up of 6 months and the longest of 2 years, have revealed a 79-point Constant Score one year after surgery (min 42, max 94). In 2 cases we have observed necrosis of the epiphysis while there have not been any cases of secondary mobilisation of the synthesis equipment. Our findings, if we consider the low necrosis percentage, show the good adaptability and the preservation of the soft tissues as guaranteed by the synthesis equipment and by the surgery performed.     

Surgical approaches for open reduction and pinning in severely displaced supracondylar humerus fractures in children: a systematic review

Purpose  

There is no clear evidence in the actual literature regarding which of the surgical approaches could bring about the best functional, cosmetic, and radiological outcomes, as well as fewer complications, when an open reduction and pinning of a severely displaced supracondylar humerus fracture is performed. We, therefore, performed a systematic review of the English literature to investigate the existing evidence regarding this issue.     

Iatrogenic brachial artery injury during pinning of supracondylar fracture of humerus: A rare injury

Complications following supracondylar fracture of humerus are well-known. Pre- and post-operative complications have been documented in the literature. Neurovascular injury due to fracture fragments following this type of fracture is described. Iatrogenic brachial artery during surgical treatment of this fracture is unknown to the literature. So we report a rare case of iatrogenic brachial artery injury during pinning of supracondylar fracture of humerus and try to create awareness to the surgeons that such injuries can occur with improper operative techniques.     

肱骨近端骨折切开复位内固定术后撞击征原因分析

目的评价切开复位内固定治疗肱骨近端骨折临床治疗结果及术后撞击并发症发生率。方法2008年1月至2009年12月期间55例有移位的肱骨近端骨折患者在我科接受锁定钢板治疗,平均随访时间17.2个月。随访时采用Constant-Murley评分评价患肢术后功能;经术后X线片评估肱骨大结节顶端高度和钢板高度,同时以撞击试验检查术后撞击并发症发病率。结果 55例患者平均Constant-Murley评分为79.3分,其中撞击征阳性者7例(12.7%),平均Constant-Murley评分为55.9分(P=0.007),低于样本均数。撞击试验阳性所涉及7例中有5例术后影像学资料显示大结节位置过高,1例钢板位置过高。结论本研究中有临床症状的撞击大多由过高的肱骨大结节引起。肱骨大结节复位不良可能影响治疗效果。     

闭合复位经皮克氏针内固定治疗儿童不稳定肱骨髁上骨折

目的探讨C臂X线机透视下闭合复位经皮克氏针内固定治疗不稳定儿童肱骨髁上骨折的疗效。方法C臂X线机透视下闭合复位经皮克氏针内固定术治疗儿童不稳定肱骨髁上骨折35例。结果35例均获随访,时间7～13个月。术后无缺血性挛缩,3例出现针孔渗出较多,经加强换药后痊愈。无一例出现肘内翻、尺神经损伤。按Flynn标准评价：优20例,良15例,无一般及差病例。结论C臂X线机透视下闭合复位经皮克氏针内固定治疗儿童不稳定肱骨髁上骨折手术创伤小,固定可靠,可以获得良好的肘关节功能和外形。     

A new osteosynthesis device for the treatment of proximal humerus fractures. Description of the technique and preliminary results

The treatment of third proximal humerus complex fractures represents a challenge and osteosynthesis techniques are still controversial. The Authors report a new device that has been planned and used to treat this type of fracture, suitable for both young and elderly patients. The device consists of a perforated prismatic-triangular titanium cage (PTTC), available in different sizes so that it can be inserted in the bone cavity as a bridge. Thus, it supports the cephalic cap and, resting on the metaepiphyseal walls, allows greater and lesser tuberosities to be restored using osteosutures or minimal osteosynthesis devices. Furthermore, bone chips or bone substitutes can be inserted as filling in the perforated parts. From June 2005 to February 2006 we used this osteosynthesis surgical technique to treat 10 patients, 4 females and 6 males, all affected by proximal humerus complex fractures. No specific complications during and after surgery were noticed. The reported results are still to be considered as preliminary, but they are very encouraging. In all the cases the effective internal stabilisation allowed anatomical reduction of fragments, their stable fixation, reconstruction close to standard anatomy and early rehabilitation.