Displaced humeral shaft fractures in children and adolescents: results and adverse effects in patients treated by elastic stable intramedullary nailing

Evaluation and Management of Pediatric Humeral Shaft Fractures

Diaphyseal humerus fractures in the pediatric population have dynamic treatment strategies that depend on injury pattern, mechanism, patient skeletal maturity, and size. Treatment strategies include closed reduction with various immobilization techniques, flexible nails, uniplanar or multiplanar external fixation, or plate osteosynthesis. Accepted parameters for sagittal and coronal alignment vary based on age and potential for remodeling, and the multiplanar motion of the shoulder joint can accommodate for greater variations in alignment than many other long bone fractures. Complications such as radial nerve palsy are possible with both open and closed injuries, and mal/nonunions, although rare, can occur. Overall, treatment should be predicated on a full evaluation of the patient, fracture, local soft tissues, and any concomitant injuries.

Review of pediatric functional outcomes measures used to evaluate surgical management in pediatric patients with an upper extremity fracture

For two decades, many scores, questionnaires, and rating systems have been used to evaluate the functional outcome of children with an upper extremity fracture (UEF). However, only a few of these were created specifically for children, and many assess only elbow function. In the absence of any published review on this topic, we set out to identify and categorize different scores used to evaluate the clinical and functional outcomes of surgically treated pediatric UEFs. A literature search was performed, and 38 studies were identified. The scores used more often were the shortened version of the Disability of the Arm, Shoulder and Hand questionnaire and the Mayo Elbow Performance Score/Index. In a lower number of studies, authors used other scoring systems, including the Mayo Wrist Score, the Patient-Rated Wrist Evaluation, the Patient-Rated Elbow Evaluation, the Métaizeau functional scoring system, the Oxford Elbow Score, the Price and Flynn criteria, the Hardacre Functional Score, the Neer Shoulder Score, the Constant-Murley Shoulder Score, the Modified Orthopedic Trauma Association Score, the Medical Outcomes Study Short Form-36, and the Pediatric Outcomes Data Collection Instrument. Some specific pediatric scoring systems to evaluate the functional outcome of children with a UEF have been suggested, but a single tool that is valid and reliable for skeletally immature patients of all ages is not yet available. Further studies are needed to identify specific pediatric measurements to increase validity, responsiveness, sensitivity, and interpretability of upper limb functional outcome scores in common clinical practice.

Elastic Stable Intramedullary Nailing for Pediatric Humeral Shaft Fractures Under Ultrasonographic Guidance: A Retrospective Study

OBJECTIVE

Fixation with an elastic stable intramedullary nail (ESIN) is a widely used technique for the treatment of humeral shaft fractures. Ultrasonography (US) is used as an auxiliary tool and alternative to radiography during surgery to reduce radiation damage, but whether it is effective in pediatric patients is not known. In this study we evaluated the utility of US in the treatment of pediatric humeral shaft fractures by closed reduction and fixation with an ESIN.

METHODS

Children who were admitted to our hospital with humeral shaft fractures were retrospectively examined from January 2016 to March 2019. The patients were divided into 2 groups, US (treated by US-guided closed reduction and ESIN fixation) and non-US (treated with the same technique but with intraoperative radiography instead of US). The postoperative functional recovery of the 2 groups was compared.

RESULTS

The study population comprised 28 boys and 17 girls (age range: 4-16 years) with humeral shaft fractures. US significantly reduced radiation exposure during the operation (P = 0.008), and intraoperative US facilitated the detection of nerve and vascular injury and aided surgical planning. There was no difference between the 2 groups in postoperative recovery based on the Constant-Murley shoulder score (CMS).

CONCLUSIONS

These results demonstrate that US-guided closed reduction and ESIN fixation for humeral shaft fractures can limit radiation exposure and help doctors to determine the optimal surgical strategy to avoid radial nerve injury.

A Shift From Non-operative Care to Surgical Fixation of Pediatric Humeral Shaft Fractures Even Though Their Severity Has Not Changed

Introduction: Humeral shaft fractures have traditionally been treated non-operatively due to their good union and low rate of functional impairment. In the recent years, upper extremity fractures and their operative treatment have increased in children. Nevertheless, the trends of humeral shaft fractures are not clear. Materials and Methods: All children aged <16 years, with a humeral shaft fracture in the geographical catchment area of Northern Finland Hospital District, with a yearly child population-at-risk of ~86 000 from the year 2001 until the end of 2015 were included. There were 88 cases, who comprised the study population. Radiographs were available of all. Injury, patient, and treatment characteristics were reviewed from hospital databases. Results: There was an increasing trend of surgical fixation of humeral shaft fractures during the 15 years' study period (β = 1.266, 95% CI 0.17 to 2.36, p = 0.035). However, we found no patient or fracture-related reasons that could have explained the increasing trend of surgical care. Comminuted fracture increased the risk of operative treatment 8-fold (Odds Ratio, OR 7.82, 95% CI 1.69 to 36.3, p = 0.009). Higher age, greater angular deformity or greater diameter of the humerus were not associated with the increased operation risk. Conclusions: The treatment philosophy concerning pediatric humeral shaft fractures has presented a shift from conservative care to surgical fixation. To authors' understanding there is not evidence supporting the increasing rate of osteosynthesis.

Functional outcome of displaced intercondylar fractures of the humerus in children and adolescents

The main aim of this study was to retrospectively evaluate the clinical, functional, and radiographic outcome of displaced intercondylar fractures of the humerus in children and adolescents, and evaluate upper-extremity function with the short version of the Disabilities of the Arm, Shoulder and Hand outcome questionnaire (Quick DASH), the hypothesis being that intercondylar fractures have poorer functional outcome than do other upper-limb fractures. The mean age at the time of injury was 11.9±2.5 years (range: 7.5-15.8 years). The male-female ratio was 3.5 : 1. Using the Toniolo & Wilkins classification, 13 (72%) fractures were classified as type II and five (28%) as type III. The overall complication rate was 50%. The mean Quick DASH score was 9±11 (range: 0-31.8). Displaced intercondylar fractures of the humerus, although uncommon in skeletally immature patients, are characterized by poorer clinical and functional outcome compared with other pediatric humerus and elbow fractures. Minimally displaced fractures with articular surface displacement of less than 2 mm can be safely managed with closed reduction and percutaneous fixation, but any greater intra-articular displacement requires open reduction and internal fixation, which means a higher complication rate and poorer functional outcome should be expected, especially in patients older than 10 years.

Flexible intramedullary nailing for treatment of proximal humeral and humeral shaft fractures in children: A retrospective series of 118 cases

BACKGROUND

The aim of this study was to analyze outcomes of treatment and complications in children treated with flexible intramedullary nailing (FIN) due to humeral fracture.

HYPOTHESIS

The FIN for treatment of humeral fractures in children would allow an early functional and cast-free follow-up with a quick pain reduction and low complication rate.

PATIENTS AND METHODS

From May 2002 until May 2016 case records of all children who underwent fixation with titanium intramedullary nails because of humeral fracture were retrospectively reviewed. The study included 118 patients treated with FIN for proximal humeral or humeral shaft fracture. The average age at the time of trauma was 12 years. Mean follow-up was 77 months. Left hand was affected in 51% of patients. The most common mechanism of injury was fall (n=58), followed by sports injuries, road traffic accidents, pathological fractures, motorbike accidents and bicycle riding.

RESULTS

There were no residual valgus/varum deformities. All patients achieved complete radiographic healing at a mean of 7.5 weeks. Nine complications were recorded: 1 humeral shaft fracture in patient with osteogenesis imperfecta, 4 entry site skin irritations, 2 skin infections and 2 radial nerve injuries. There were no cases of delayed union, nonunion or mal-union. After removal of the nails, all patients regained full function and all complications resolved.

DISCUSSION

The FIN for humeral fractures is a minimally invasive, simple and well reproducible technique with very low complication rate.

CONCLUSION

The FIN for treatment of humeral fractures shows very good functional and cosmetic results. It allows an early functional and cast-free follow-up with a quick pain reduction.

LEVEL OF EVIDENCE

Level IV - retrospective study.