Complications and timing of follow-up after closed reduction and percutaneous pinning of supracondylar humerus fractures: follow-up after percutaneous pinning of supracondylar humerus fractures

The purpose of this study was to evaluate the need for clinical evaluation with radiographs within 10 days of closed reduction and percutaneous pinning for the treatment of displaced supracondylar humerus fractures. Between May 1 and December 31, 2001, the authors evaluated the complications with closed reduction and percutaneous pinning of 104 displaced supracondylar humerus fractures. Fifty-two of the patients had the initial follow-up examination with radiographs 10 days or less after pinning; the other 52 patients had the initial follow-up examination with radiographs either after 10 days or on the day of pin removal. The overall complication rate for the series was 7.7% (8/104). All eight complications were in type III fractures. The early follow-up group had six complications; the late follow-up group had two complications. Baumann's angle, lateral humerocapitellar angle, and lateral rotational percentage were not significantly different between the two groups. The only variable tested that was associated with a complication was pin configuration. No association between late follow-up and complications was identified. The authors conclude that clinical and radiographic evaluation of routine displaced supracondylar humerus fractures requiring closed reduction and percutaneous pinning may be safely delayed until pin removal.     

Carpometacarpal Fracture-Dislocations: A Retrospective Review of Injury Characteristics and Radiographic Outcomes

Background: The purpose of this study was to evaluate the demographics and early radiographic treatment outcome of patients with carpometacarpal (CMC) injuries at our institution over a 10-year period. Methods: We conducted a retrospective review of all patients who sustained CMC injuries of the second to fifth digits between 2005 and 2015. We recorded demographic data, mechanisms of and associated injuries, treatment methods, and complications. Injury and intraoperative and postoperative radiographs were evaluated, and the adequacy of reduction was determined on lateral radiographs of the hand using a grading system that we developed. Results: Eighty patients were included in this study. Delivering a blow with a closed fist was the most common mechanism of injury; however, high-energy mechanisms also made up a large percentage of those included. Injuries to the fourth and fifth CMC joints were most common, and these were frequently associated with fractures of the metacarpal bases and distal carpal row. Closed reduction and percutaneous pinning offered a higher percentage of patients with concentric reduction at the time of pin removal. Time to surgery was significantly different between those with concentric reduction and those with residual subluxation. Conclusion: The most common mechanism of CMC injuries was blow with a closed fist; however, these injuries can be associated with high-energy mechanisms. Fractures of the metacarpal base and distal carpal row are commonly seen with these injuries. With early diagnosis, closed reduction and percutaneous pinning achieved concentric radiographic reduction. Delayed diagnosis makes closed reduction difficult and was associated with less favorable radiographic outcome.     

Traitement chirurgical par embrochage percutané des fractures articulaires de la base du cinquième métacarpien (étude descriptive à propos de 20 cas)

ObjectivesThe aim of this study is to show the benefits of surgical treatment of intra articular fractures of the base of the fifth metacarpal by intermetacarpal double pinning.Patients and methodsIt is a retrospective study of 20 cases of intra-articular fractures of the base of the fifth metacarpal treated by percutaneous pinning, between January 2004 and December 2010. All patients had a closed reduction and intermetacarpal double pinning.ResultsAfter a mean of 19 months, we could review only 18 patients. The overall results were satisfactory, except for two patients who reported intermittent pain with changing weather and intense use of the hand, and a case of reflex sympathetic dystrophy syndrome after surgery. The evaluation of results was based on clinical criteria related to pain, mobility and grip strength, and on radiological criteria after analysis of specific hemato-metacarpal radiographs.ConclusionIntermetacarpal double pinning is a technique of choice in surgical treatment of intra-articular fractures of the base of the fifth metacarpal. It ensures good closed reduction and a satisfactory functional result.     

Percutaneous stabilization of unstable fractures of the humerus.

Forty-eight of fifty-four patients who had had closed reduction and percutaneous pinning of an unstable fracture of the proximal end of the humerus were available for clinical and roentgenographic follow-up at an average of three years (range, two to seven years) after the operation. According to the point-scale of Saillant et al., the result was good or excellent in thirty-four patients, fair in ten, and poor in four. Four patients had loss of fixation and had repeat fixation with percutaneous pinning after a second closed reduction. Only one of them had a poor result because of malunion. Four patients had a superficial pin-track infection and loosening of pins, one patient had a deep infection, and two had a non-union. Complete avascular necrosis with collapse of the humeral head developed in only two patients. However, eight patients had localized avascular necrosis with transient cyst formation and sclerosis in the humeral head that resolved over one to two years; these were thought to represent subtotal avascular necrosis. Although closed reduction and percutaneous pinning is a technically demanding procedure, it offered results in our patients that were comparable with or superior to those after previously described operative methods for the treatment of unstable fractures of the proximal end of the humerus.     

Management of displaced supracondylar fractures of the humerus in children

A series of 33 children with displaced supracondylar fractures of the humerus (SFH) were all treated operatively by open reduction and internal fixation or by closed reduction and percutaneous pinning. A follow-up study was performed on average 29 months (range 3-63 months) after the injury. In 18 per cent of cases primary neurovascular injury was observed and confirmed at operation. Of these patients 32 had open reduction and internal fixation by K-wires; in only one case was closed reduction and percutaneous pinning attempted. If there was preoperative neurological deficit, the nerves were visualized; however nerve suture was not required in our series. In one case we had to reconstruct both the brachial and radial arteries because of intimal lesions totally occluding the vessels. The average hospital stay was 9 days, including pin removal, which was usually performed about 4-5 weeks later, at the time of plaster removal. By Innocenti's criteria, 27 of 30 patients reviewed had an excellent result; three had a good result and three patients were lost to follow-up. There were no complications due to the operation, such as wound healing problems, infections or nerve lesions. In the light of our experience and of the good results, we recommend that displaced SFH be managed by open reduction and internal K-wire fixation. Percutaneous pinning is a good alternative method when closed reduction is successful at the first attempt.     

Displaced supracondylar humeral fractures in children: open reduction vs. closed reduction and pinning

Introduction In the literature the best results for pediatric supracondylar humerus fractures have been achieved by closed reduction and wire fixation. However, in these reports the patient group of open reduction and pinning contained the patients who had had previous ineffective closed reduction trials. This retrospective study compared open and closed reduction with pinning, in which the first group of patients was all consecutively treated with open reduction.Materials and methods The study included 99 children with displaced extension-type supracondylar fractures of humerus who had complete follow-up. Open reduction patients had not had a previous attempted closed reduction. Open reduction and pinning were performed through a posteromedial incision in the first 44 patients and closed reduction and pinning in the subsequent 55 patients. Mean duration surgery was 15 h with open reduction and 17 h with closed reduction. Mean follow up was 35 months with the open reduction and 21 months with closed reduction. Humeral-ulnar angle was compared to the contralateral elbow, clinical flexion deficiency and extension lag, and complications were evaluated.Results At the latest follow-up the open group had an average of 5.1° valgus change and the closed group 3.6° valgus change in humeral-ulnar angle compared to their uninvolved elbow. Average flexion deficiency was 8.61° in the open and 5.25° in the closed group. Average extension lag was 6.23° in the open and 0.6° in the closed group. Functional results were satisfactory in 71% of patients in the open and 93% of those in the closed reduction group. Cosmetic results were satisfactory in 95% of both groups.Conclusions Closed reduction and pinning is superior to open reduction and pinning for the treatment of pediatric supracondylar humerus fractures. In the case of technical insufficiencies open reduction and pinning through a posteromedial incision is an alternative treatment for decreasing the surgical time and complications. Complications was not caused in either group by the delayed surgical timing compared to reports in the literature.     

Deformity and function in supracondylar fractures of the humerus in children variously treated by closed reduction and splinting, traction, and percutaneous pinning.

The radiographs of 137 patients with supracondylar fractures of the humerus treated by closed reduction and splinting, traction, and closed reduction and percutaneous pinning (CRPP) were reviewed to determine the adequacy of the initial reduction and the maintenance of the reduction. Eighty-four patients were examined for function and deformity. Initially, Baumann's angle was adequate and similar in all patients, but the humerocapitellar angle was better with CRPP. Maintenance of reduction in both planes was superior with CRPP, and significantly better clinical results were achieved by CRPP. Nevertheless, there was no functional loss in any patient, and no parent wanted correction of deformity.     

Vascularized iliac bone graft for displaced femoral neck fractures in young adults.

From November 1989 to September 1994, a total of 26 patients (18 men and 8 women) with acute displaced femoral neck fractures were treated with closed reduction and Knowles pinning combined with vascularized iliac bone grafting. Mean patient age was 37.5 years (range: 24-48 years). The mean time interval from injury to surgery was 3.6 days (range: 1-10 days). One patient experienced loss of the reduction at 6 weeks postoperatively and subsequently went on to hip replacement. Mean follow-up for the remaining 25 patients was 56.2 months (range: 20-78 months). All fractures united within 4 months. The average union time was 3.3 months. Plain radiographs confirmed the presence of avascular necrosis in 2 patients during the final follow-up; 1 of these patients developed systemic lupus erythematous 1 year after the fracture and had been treated with high doses of corticosteroid. Functional and radiographic results were satisfactory in the remaining patients.     

Comparison of closed reduction and percutaneous pinning versus open reduction and percutaneous pinning in displaced supracondylar fractures of the humerus in children.

A retrospective review of 29 children with displaced supracondylar humerus fractures was performed. Fifteen patients treated with closed reduction and percutaneous pinning and 14 patients treated with open reduction and percutaneous pinning were evaluated at a minimum of 18 months (range 18-80 months). Results were graded according to the criteria of Flynn et al. (Flynn JC, Matthews JG, Benoit RL: Blind pinning of displaced supracondylar fractures of the humerus in children. J Bone Joint Surg [Am] 56:263-272, 1974) using both cosmetic and functional evaluations. Excellent or good results were obtained in 14 of the 15 fractures treated with closed reduction and percutaneous pinning and in 12 of the 14 fractures treated with open reduction and percutaneous pinning. The three fair cosmetic results were associated with inadequate reduction and residual medial angulation. Ten to 15 degrees of motion loss occurred in three older patients. One patient in each group had a minor pintract infection. There were no cases of iatrogenic nerve injury or myositis ossificans. The treatment goal in displaced supracondylar humerus fractures in children is anatomic reduction. If an anatomic reduction cannot be achieved with closed reduction, open reduction is indicated. This can be done without an increased risk of complications.     

Displaced type II extension supracondylar humerus fractures: do they all need pinning?

The treatment of a displaced type II extension supracondylar humerus fracture is controversial. Many authors recommend that all displaced type II fractures be surgically pinned. The purpose of this study was to determine the success of reduction and casting (without pinning) in maintaining the alignment of type II fractures. Of the 25 elbows that underwent an initial reduction in the emergency room, 18 (72%) maintained alignment. Seven fractures lost position, and five of the seven patients underwent secondary reduction and pinning. Twenty-three of the 25 (92%) elbows had a satisfactory outcome and 2 of the 25 (8%) had an unsatisfactory outcome according to the Flynn criteria. All 24 patients were satisfied with the treatment on a satisfaction survey. An attempt at closed reduction and casting, with selective pinning of the fractures that lose position, appears justified if close follow-up can be maintained.     

Routine radiographs at time of pin removal after closed reduction and percutaneous pinning for type 2 supracondylar humerus fractures do not change management: a retrospective cohort study

Purpose

Radiographs are usually taken on day of pin removal for children treated with closed reduction and percutaneous pinning (CRPP) of type 2 supracondylar humerus fractures. The purpose of this study was to determine whether radiographs taken at time of pin removal for patients recovering uneventfully alter management.

Methods

After IRB approval, billing records identified 1213 patients aged 1–10 years who underwent elbow surgery between 2007 and 2013 at our institution for a supracondylar humerus fracture. Of these patients, 389 met inclusion criteria. Clinical charts were reviewed for demographics, operative details, and clinical follow-up, focusing on clinical symptoms present at pin removal. Radiographs taken at time of pin removal and subsequent visits were assessed for healing and fracture alignment.

Results

In no case was pin removal delayed based on radiographs. One hundred and nineteen (31 %) patients had radiographs taken following pin removal; in no case was loss of reduction found among these patients. No cases of neurologic or vascular injury, re-fracture, or loss of reduction occurred. Infection occurred in 12 patients (3 %). Pins were kept in place for 23.8 ± 4.4 days. Eighty-six patients (22 %) had additional intervention after pin removal (cast application in all cases). Of 389 patients, 75 (19 %) had no documented reason for extended casting, four (1 %) were extended based on physician evaluation of radiographs, and seven (2 %) were extended for other reasons.

Conclusions

Elimination of radiographs at time of pin removal should be considered. If continuing to obtain radiographs at pin removal, we recommend removing pins before taking radiographs to reduce patient fear and anxiety from visualizing percutaneous pins.

     

Brachial plexus palsy following proximal humerus fracture in patients who are skeletally immature

From 1998 to 2006, 578 patients who were skeletally immature with proximal humerus fractures were treated at our institution. During that time period, 4 patients (0.7%) had associated brachial plexus and major peripheral nerve palsies. Average age at the time of injury was 12.3 years (range 10-14 years). Two fractures were physeal and 2 were metaphyseal. In all patients, the distal fracture fragment was displaced into the axilla, with resultant adduction and valgus malalignment at the time of injury. Two patients were treated with closed reduction and sling and swathe immobilization. One patient was treated with closed reduction and percutaneous pinning of the fracture. One patient was treated with sling immobilization without fracture reduction. All went on to bony healing with acceptable bony alignment. All patients were evaluated with serial physical examinations and radiographs to assess for neurologic recovery and bony healing. Average clinical and radiographic follow-up was 7.1 months (5-9 months). All patients demonstrated complete neurologic recovery by 5-9 months postinjury. All had neuropathic pain for at least 6 months after injury. No persistent neuropathic pain or functional limitations were seen at follow-up. Although rare, brachial plexus injury may accompany displaced proximal humeral fractures in patients who are skeletally immature. With careful attention to principles of fracture care, complete neurologic recovery may be expected within 9 months.     

The unstable distal radial fracture one year post Kapandji intrafocal pinning.

Kapandji pinning has been proposed as the treatment of choice for unstable Colles' fractures. The aim of this paper is to evaluate our experience treating unstable Colles' type fractures using this technique. Over a nine month period, 36 patients with Colles' type fractures were treated operatively at St. Vincent's Hospital. 22 of these fractures were deemed unstable and were treated using percutaneous intrafocal Kapandji pinning. 20 of these patients were recalled for review at a mean of 11.3 month post injury. At this stage the wrist was examined clinically and radiologically. Initial satisfactory correction of deformity was achieved by this technique. Between the time of wire removal and final review, however, there was significant recurrence of dorsal angulation (P < 0.05), but no significant radial shortening on radiographs. The patients had a satisfactory clinical result in spite of these radiological parameters.     

Open reduction and internal fixation of unstable slipped capital femoral epiphysis by means of surgical dislocation does not decrease the rate of avascular necrosis: a preliminary study

Purpose

The treatment of unstable slipped capital femoral epiphysis (SCFE) remains controversial. Surgical dislocation and open reduction has the potential to significantly reduce the rate of avascular necrosis (AVN) by allowing direct preservation of the femoral head blood supply. The purpose of this study was to determine if open reduction of the unstable SCFE by means of surgical hip dislocation reduced the risk of AVN compared with closed reduction and percutaneous pinning.

Methods

We reviewed the medical records and radiographs of patients treated at our institution between the years 2000 and 2008. Sex, age, side of slip, precipitating event, pre- and post-operative anterior physeal separation (APS) and slip angle, slip severity, time between inciting event and surgical treatment, number of screws used, development of AVN, and need for subsequent surgery were evaluated. Statistical analysis was performed to compare risk factors and occurrence of AVN.

Results

From 2004 to 2008, we treated 12 patients with unstable SCFEs: six had closed reduction and percutaneous pinning and six underwent open reduction by means of surgical hip dislocation. There were no statistically significant differences between the two groups regarding sex, age, slip angle, APS, time to surgery, and AVN rate. At follow-up, 4 (66.7 %) patients had AVN in the group which had open reduction, while 2 (33.3 %) patients had AVN in the group which underwent closed reduction. (p = 0.57).

Conclusions

Open reduction of the unstable SCFE by means of surgical dislocation of the hip does not decrease the rate of AVN when compared to closed reduction.     

The intermetacarpal double pinning in the surgical treatment of Bennett fracture (report of 24 cases)

ObjectivesThe interest of this work is to show the benefits of surgical treatment of Bennett fractures by intermetacarpal double pinning.Patients and methodsIt is a retrospective study of 24 cases of Bennett fracture treated by intermetacarpal double pinning, between January 2005 and December 2009. The treatment was surgical for all patients. The intermetacarpal double pinning using the technique of Iselin has been reserved for fractures with small fragment found in the series in 18 cases (72% of operated patients), and by Tubiana in six cases (24%).ResultsAfter a mean of 36 months, we could follow only 21 patients, the evaluation of results was based on clinical criteria relevant to pain, mobility and the pinch grip, and on criteria after radiological analysis of radiographs specific trapezo-metacarpal. All fractures were consolidated. Two cases of moderate osteoarthritis were observed. Overall, the results were excellent in 15 patients (71%), good in four patients (19%) and poor in two patients (10%).ConclusionIntermetacarpal double pinning is a technique of choice in surgical treatment of Bennett fracture. It ensures a good closed reduction and a satisfactory functional result.     

Treatment of distal clavicle fracture using Kirschner wires and tension-band wires

BACKGROUND: Nonunion frequently follows distal clavicle fracture. Traditional pinning methods using the through acromioclavicular articulation may result in osteoarthritic changes or ankylosis. This study introduces a direct pinning technique in which the acromioclavicular joint is spared. METHODS: Twelve patients with displaced distal clavicle fractures received open reduction and fixation with Kirschner wires (K-wires) and tension-band wires, from May 1996 to March 1997. The indication for surgery was type IIa fracture or fracture with displacement. Unrestricted passive and active range of motion was performed as soon as possible after the operation. Stretching and exertional exercises were permitted after radiographs showed an osseous union and after the implants were removed. RESULTS: Eleven patients achieved osseous union with painless full motion. Union time ranged from 3 to 6 months. One patient suffered from more comminuted fracture because of a fall 2 months after operation. This patient received a revision surgery with distal clavicle resection and coracoclavicle reconstruction. Symptomless ossification around the coracoclavicle ligament was noted on radiographs in one patient. The ossification did not progress after the 9-month follow-up. CONCLUSION: Edwards reported a rate of 45% delayed union and 30% nonunion in type II fractures. Several techniques had been described in the relevant literature. In our practice, fixation with Kirschner wires and tension-band wires has been successful in the treatment for displaced distal clavicle fracture.     

Supracondylar fractures of the humerus in children. A modified technique for closed pinning

Complications in the treatment of displaced supracondylar fractures of the humerus (DSFH), particularly cubitus varus, are a persistent problem. A prospective study was conducted on 20 children with DSFH, using a modified technique to reduce and pin the fracture. All fractures were treated with closed reduction and percutaneous pinning. After the fracture was internally fixed, intraoperative anteroposterior roentgenograms of each distal humerus were compared, using Baumann's angle. The reduction was accepted if Baumann's angle on the fractured extremity was within 4 degrees of that on the normal side. If the angles were not within 4 degrees, the closed reduction and percutaneous pinning was repeated. In this prospective series, all patients had a reduction to within 4 degrees of the normal side before they left the operating room. Three weeks after percutaneous pinning, the pins were removed and range of motion was begun. All patients returned for clinical and roentgenographic examination. With an average follow-up period of 17.2 months, all patients had excellent or good results. No patient developed cubitus varus deformity. Strict adherence to the guidelines of the protocol prevented cubitus varus deformity in this series of children with DSFH.     

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]).     

In situ pinning of hip for stable slipped capital femoral epiphysis on a radiolucent operating table

Patients with stable slipped capital femoral epiphysis (SCFE) usually can ambulate at the time of diagnosis. Satisfactory results have been reported after percutaneous in situ pinning using a fracture table. The authors describe a technique to determine the skin-pin entry point for percutaneous pinning of the hip on a regular radiolucent operating table. The pin entry point determined by this modified method was reliable in 15 SCFEs in 13 patients. Pinning on a regular radiolucent table was much easier, without the need to transfer obese patients to a fracture table. It was also useful when a bilateral pinning procedure was performed using single draping. Obtaining modified frog-leg lateral radiographs in patients with a stable SCFE was not associated with avascular necrosis or chondrolysis.     

Dorsal fracture-dislocations of the proximal interphalangeal joint: evaluation of closed reduction and percutaneous Kirschner wire pinning

Background

The purpose of this study is to evaluate the outcome of closed reduction and percutaneous Kirschner wire pinning in acute dorsal fracture-dislocations of the proximal interphalangeal (PIP) joint.

Methods

Eight men and one woman were treated with closed reduction and percutaneous Kirschner wire pinning by one orthopaedic surgeon. The ring finger was injured in six patients, the small finger in two patients and the middle finger in one patient. The mean joint surface involvement was 36 % (range, 26–49 %). The Kirschner wires were removed after an average of 28 days (range, 24–37 days).

Results

All patients demonstrated a painless, but fusiform, swollen PIP joint after a mean follow-up of 6.5 months. The average flexion of the PIP joint was 106° (range, 80–110), and the average extension of the PIP joint was 4° short of full extension (range, 10 hyperextension–15 flexion contracture). All patients had a concentrically reduced PIP joint with a healed fracture on radiographs. Two patients had radiographic evidence of degenerative changes, but were asymptomatic. One patient developed a superficial pin track infection, which quickly resolved with a short course of antibiotics, and avascular necrosis affecting one of the condyles of the proximal phalanx.

Conclusions

In agreement with previous studies, closed reduction and percutaneous Kirschner wire pinning in dorsal fracture-dislocations of the PIP joint is a minimally invasive and simple technique which appears to give satisfactory outcomes in the short to intermediate term.