Was tun bei postoperativem Ulnarisschaden nach Kirschner-Draht-Osteosynthese der suprakondylären Humerusfraktur im Kindesalter?

[Nerve injuries due to fractures in childhood : Primarily and secondarily on the upper extremity]

The approach for nerve injuries in children in the context of fractures of the upper extremities is inconsistent in the literature. The underlying mostly retrospective studies do not usually consider the potential diagnostics. The frequency of nerve injuries with a clear need for reconstructive surgery is sometimes estimated so differently that precedent-setting errors in these studies must be assumed; however, as 10-20% of pediatric fractures near the elbow show primary or secondary nerve lesions, timely and appropriate further treatment is necessary. An overview concerning diagnostic tools with an explanation of potential results and an algorithm with a timeline for diagnostic and therapeutic management are presented. Good results after nerve lesions can only be achieved when timely diagnostics without delay and correct detection of axonal lesions which benefit from surgical treatment are carried out.

Retrospective Mid-Term Follow-Up of Posttraumatic and Iatrogenic Neurovascular Complications in Surgically Treated Paediatric Patients with Distal Humerus Fracture

BACKGROUND

The purpose of the study was to investigate and describe neurovascular complications and mid-term clinical outcomes of operatively managed fractures of the distal humerus in a paediatric population. Neurovascular injuries are common in these fractures, but reports about their implications for mid-term clinical outcomes is sparse.

METHODS

A single-centre retrospective study was conducted at a university teaching hospital investigating paediatric patients who underwent operative management of a distal humerus fracture between 2014 and 2018. Patient demographics, fracture classification, pre-, peri- and postoperative neurovascular complications were investigated. Mid-term follow up clinical examination and functional scoring using QuickDASH, the Broberg and Morrey Score (BMS), the Mayo Elbow Performance Score (MEPS) and the Numeric Rating Scale were performed.

RESULTS

A total of 84 patients were identified, of which 34 met the inclusion criteria and were available for follow-up clinical examination. The average time to follow-up was 150 weeks (1049.44 days ± 448.54). Ten primary traumatic neurovascular complications were identified, the majority of which involved the median nerve. Primary traumatic dissection of the brachial artery was recorded in three patients. Secondary iatrogenic nerve injury was documented in five patients after previously normal clinical examination. At follow-up, the average QuickDASH score was 3.0 ± 4.3, BMS was 98.6 ± 3.4 and MEPS was 97.1 ± 3.3 points.

CONCLUSIONS

The mid-term clinical outcome following surgical management of distal humerus fractures is excellent. There is, however, a considerable frequency of both primary and secondary neurovascular complications, which must be considered when opting to treat these injuries surgically.

[Supracondylar humeral fractures in childhood]

The classification of supracondylar humeral fractures in German-speaking areas is carried out according to von Laer, which has been appropriated from the AO system and has the advantage that it can be used to derive the treatment. When indicated immediate surgery is given preference over a delayed treatment. The result is controlled by functional tests directly during the operation. Instability of the fracture and correct placement of the Kirschner (K) wires are challenging. Alternatives are an external fixator and elastically stable intramedullary nailing (ESIN). Concomitant injuries initially affect the median nerve and the brachial artery and secondarily the radial nerve. Lesions of the ulnar nerve are mostly a postoperative complication. The bony consolidation is achieved after 3-4 weeks and afterwards implant removal can be safely carried out. Embedded K‑wires and ESIN are removed after 3-6 months, depending on the surgical capacity and complaints of the patient.