Paediatric supracondylar humeral fractures: epidemiology, mechanisms and incidence during school holidays

Radiographic Evaluation of the Surgical Treatment of Pediatric Supracondylar Humeral Fractures

Objective  To perform a radiographic assessment of the quality of supracondylar fracture fixation by identifying the factors that have contributed to inadequate reduction and increased the chance of reduction loss during outpatient follow-up. The variables analyzed were as follows: fracture line, initial displacement, time of day the surgery was performed, and chosen fixation technique. Methods  Review of electronic medical records and radiographic evaluation of supracondylar fractures operated from January 2017 to December 2022. The radiograph assessment was based on the Baumann angle and the anterior humeral line. Determination of fixation quality was based on the number of cortices, crossing site, and wire divergence. Results  We evaluated 194 cases, and postoperative reduction was poor in 17% of the subjects. Reduction loss occurred in 39 cases (20.10%), and 19 (48.7%) of these patients presented insufficient fixation ( p  = 0.002). Among the cases operated during the day, 12.5% lost the reduction compared with 32% of the patients who underwent surgery at night and early in the morning ( p  = 0.001). Conclusion  Reduction quality and postoperative fixation loss were closely related to technical errors and the time of day the surgery was performed.

Application of Kirschner wire placement guided technology in paediatric supracondylar humerus fractures

BACKGROUND

To analyze the clinical efficacy of K-wire placement guided technology in paediatric supracondylar humerus fractures.

METHODS

A retrospective study was conducted in 105 patients who underwent closed reduction and percutaneous pinning surgeries in our hospital from June 2019 to August 2022. 54 patients treated with a assisted reduction fixation device to assist in closed reduction and percutaneous K-wire cross-fixation were allocated into the Non-guided group, and 51 patients with K-wire placement guided technology to guide K-wire placement were assigned into the Guided group. The operation duration, number of disposable K-wire placement, intraoperative fluoroscopy frequency, Baumann angle, carrying angle, fracture healing time and Flynn score of elbow joint function at the final follow-up were compared between two groups. The postoperative complications of two groups were recorded.

RESULTS

There were significant differences between two groups in terms of operation duration, intraoperative fluoroscopy frequency, and disposable K-wire placement rate (p < 0. 05), while no significant differences of Baumann angle, carrying angle and the fracture healing time between two groups were observed (p > 0. 05). In the control group, ulnar nerve injury in 2 case, pin site infection in 4 cases, mild cubitus varus in 2 cases and loss of reduction in 4 cases were detected. In the study group, ulnar nerve injury in 1 case, pin site infection in 2 cases and loss of reduction in 1 case was observed. There was no significant difference in Flynn scores between two groups.

CONCLUSION

K-wire placement guided technology is simple and convenient. The application of K-wire placement guided technology could relatively improved disposable K-wire placement rate, shorten the intraoperative fluoroscopy frequencies and reduce complication rates.

Epidemiological Characteristics of Pediatric Supracondylar of Humerus Fractures in a Tertiary Hospital in Iran

Objectives

Supracondylar humerus fracture (SHF) is the most common fracture observed in children. The present study aimed to assess the characteristic parameters in one of the most extensive available pediatric SHF series referred to a tertiary hospital in Iran.

Methods

The medical profiles of the SHF patients who were referred to our tertiary hospital between January 2017 and January 2022 were retrospectively reviewed. The inclusion criteria entailed age < 14 years and a radiographically confirmed diagnosis of SHF. The collected data included age, gender, side of injury, mechanism of injury, season of the injury, concurrent complications, type of fracture, and treatment.

Results

A total of 1,309 patients with a mean age of 7.7±2.7 years were included in this study. The incidence of SHF was 1.8-fold higher in males, while the mean age of incidence was significantly lower in female patients (7.2 vs. 8 years; P<0.001). Falling was the most frequent mechanism of injury (97%). Gartland type I was the most prevalent type of injury (n=482; 36.8%). Moreover, the majority of fractures were extension-type (n=1,249; 95.4%). Most patients were managed conservatively (n=785; 60%). Concurrent fractures as well as neuralgic, vascular, and muscular complications were present in 3%, 1.45%, 1.22%, and 0.5% of patients, respectively.

Conclusion

As evidenced by the results of this study, SHF is prevalent among the Iranian pediatric population. Therefore, greater awareness is required regarding the high incidence of this fracture in this population and its adequate management with respect to concurrent complications, particularly neurovascular compromise.

Management of 'floating arm': a case report of adolescent ipsilateral proximal humerus fracture with open distal complex intraarticular fracture

Simultaneous ipsilateral fractures of the proximal and distal humerus, known as 'floating arm', are rarely seen in adolescents and are considered challenging to manage. Most of the published cases have involved proximal humerus and distal supracondylar fractures. This paper presents a special case of floating arm injury in a 14-year-old boy following a motor vehicle accident that was managed in a well-established trauma center. The injury consisted of displaced proximal humerus and open distal T-condylar intraarticular fractures. The patient was discharged in good condition and regained functionality with no reported complications.

Evaluation of Gartland Classification, Baumann Angle and Anterior Humeral Line in Paediatrics Supracondylar Fractures: An Inter and Intra-Observer Reliability Study

Supracondylar fractures of the humerus are frequent paediatric injuries. The aims of this study were to evaluate the applicability and reproducibility of the Gartland and Wilkins classification, the Baumann angle (BA) and the Anterior Humeral Line (AHL). This retrospective monocentric observational study was conducted on 217 patients. Four observers assessed the pre-operative radiographs by applying the Gartland and Wilkins classification and the post-operative X-rays by measuring the BA and AHL. The kappa coefficient (K) and the Cohen's kappa were used for the reliability of the Gartland classification; the Intraclass Correlation Coefficient (ICC) for that of the BA. The AHL was evaluated in a double manner by using first the K and the Cohen's kappa and then the ICC. A total of 186 patients were eligible. Inter-observer reliability for the Gartland classification was K = 0.73-0.61 for type III, 0.65-0.61 for type Ia and 0.43-0.26 for type IIb. The Baumann angle mean value in the first data collection was 73.5 ± 6.85 (inter-observer ICC 0.74) and 72.9 ± 6.83 (inter-observer ICC 0.77) for the second data collection; AHL: inter-observer ICC 0.87 for the first evaluation and 0.80 for the second one. Gartland's classification modified by Wilkins has a high degree of reliability. BA and AHL appear reproducible and reliable.

Radial Nerve Palsy Associated with Humeral Shaft Fractures in Children

Background

This is the first systematic review of the relationship between humeral shaft fractures and radial nerve palsy in children. The present comprehensive review is aimed at identifying important clinical findings between humeral diaphysis fractures and radial nerve injuries and assessing the effects of treatment.

Methods

We searched electronic bibliographic databases, including PubMed, the Cochrane Library, Scopus, and Web of Knowledge, until March 2022. This systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses and the patients, interventions, comparisons, outcomes guidelines.

Results

We identified 23 original papers, of which 10 were eligible for further analysis. Cases of 32 young patients with radial nerve palsy were identified and analyzed. The prevalence of radial nerve palsy was 4.34% (eight cases out of 184 patients with humeral shaft fractures). The radial nerve was most often associated with a simple transverse fracture (12A3, 17 cases (65.4%)).

Conclusions

Radial nerve injury in humeral shaft fractures in children is rare, with a frequency of 4.34%. We highly recommend early surgical nerve exploration with transverse fractures in the distal third segment combined with primary radial palsy. Furthermore, we recommend making thoughtful decisions regarding early nerve exploration in the Holstein-Lewis fractures. In addition, consideration of early surgical nerve exploration in fractures resulting from high-energy trauma and open fractures despite their morphology is recommended.

Arm ischemia in a 4-year-old boy with supracondylar fracture of the humerus due to constraining bands over the brachial artery

Supracondylar humerus fractures are common in children and can compromise the brachial artery in 5% to 15% of cases. A 4-year-old boy with a left supracondylar fracture developed upper extremity ischemia after pinning of the fracture. Computed tomography angiography revealed cutoff of flow in the brachial artery. Intraoperatively, he was found to have bands tethering the artery into the fracture, obstructing the blood flow. The orthopedic pins were removed, and the constraining bands were lysed to free the artery, with reconstitution of flow confirmed by intraoperative angiography. The fracture was reduced and stabilized, and the patient recovered well with normal arterial flow on follow-up ultrasound after 3 months.

Anterior approach versus posterior approach for the open reduction of displaced pediatric supracondylar humerus fracture

Background

This study's objective was to compare the results and adverse outcomes of the anterior approach and posterior approach in patients with a type 3 Gartland pediatric supracondylar fracture who failed close treatment and indicated open reduction.

Methods

in this retrospective study patients with Gartland type 3 fracture who failed close reduction and required open reduction were enrolled in the study. Eligible patients underwent open reduction via anterior and posterior triceps sparing approaches. Patients were followed up 3, 6, and 12 months after the surgery. Study variables included age, sex, Bauman's angle, pin site infection, nerve injury, osteonecrosis, and elbow arc of motion.

Results

The study included a total of 83 patients. Surgery was performed on 49 patients using the posterior technique and 34 patients using the anterior approach. The mean age of patients was 6.78 ± 1.40 years. The mean age and the relative frequency of sex didn't differ significantly between study groups (P > 0.05). Two-way repeated measures ANOVA test showed that there was a statistically significant difference in elbow arc of motion in the anterior approach in comparison with the posterior approach, however, this increase was not clinically significant. In terms of adverse events including pin site infection, nerve injury, osteonecrosis, and cubitus varus, there was no statistically significant difference between the two approaches.

Conclusion

There was no clinically significant difference in elbow arc of motion and adverse events between the anterior approach and the posterior approach. Therefore, surgeons should choose the approach with which they are more familiar and comfortable.

Management of Pediatric Humeral Supracondylar Fractures in a Referral Center From a Developing Country: A Comparison With American Academy of Orthopaedic Surgeons (AAOS) Guidelines

Introduction Supracondylar fractures are the predominant type of pediatric elbow fractures. The usual mechanism of injury is falling over the hand with the elbow extended and the hand open. The management of these fractures encompasses a range of treatment options, and their goal is to recover the anatomy and achieve a stable contact area between them. There are some controversies on the management of these injuries mainly focused on those that present some degree of displacement. A review and analysis of the current treatment at our institution and a comparison with the guidelines suggested by the American Academy of Orthopaedic Surgeons (AAOS) for the treatment of these fractures in the pediatric population were performed. Materials and methods This was an observational, analytical, retrospective study of consecutive pediatric patients with displaced supracondylar humeral fracture treated at Hospital de Trauma "Manuel Giagni" in Asunción, Paraguay, from January 2016 to December 2021. Demographic and clinical data were assessed, and patients were clinically and radiologically followed for at least 12 months. The management of supracondylar humeral fractures at our hospital was compared with the guidelines suggested by the American Academy of Orthopaedic Surgeons (AAOS) by analyzing whether these guidelines were applied in each case. The mechanism of injury was divided into three groups, initial X-rays were measured, extension-type fractures were categorized into three groups, and the type of treatment was divided into two groups: non-operative and operative. Furthermore, trauma-related preoperative complications and postoperative complications were reported. Outpatient follow-up was performed for at least 12 months in all cases. Results Of the 843 patients analyzed, 71.5% were male, with a mean age of 5.6 years. It was observed that 57.5% of injuries were caused by falls on the same level. The most frequent type of injury was Gartland type III, accounting for 55% of the cases, and associated injuries were found in 4% of the cases. With regard to the type of treatment, 91.8% of patients were treated with closed reduction and percutaneous pin fixation. Complications on admission were found in 12% of the cases and late complications in 12% of the cases. Most patients (82%) had excellent Mayo Elbow Performance Score. Conclusion Supracondylar fractures were more frequent in males and in schoolchildren. Garland type III fractures were the most common type of injury. The treatment of choice was predominantly closed reduction and percutaneous pin fixation. The Mayo Elbow Performance Score was excellent in most patients. Our service, a referral center of a public hospital in a developing country, complies with the guidelines recommended by the AAOS.

Correlation of Fall Height, Fracture Severity and Clinical Outcome in Pediatric Supracondylar Fractures—A Retrospective Analysis with an Observation Period of 20 Years

The most common cause leading to supracondylar humerus fractures in children is falling onto an outstretched arm. A correlation between fall height and fracture severity may be assumed but has not yet been described. The aim of this study was to show that fracture severity increases with fall height. Furthermore, the correlation between fracture severity and outcome was examined. A total of 971 children with supracondylar humerus fractures between January 2000 and December 2019 were included in this study. The correlations between fall height and fracture severity and between fracture severity and outcome were assessed. Increasing fall height correlates with fracture severity (p < 0.001; r = 0.24). Furthermore, the incidence of complications increases with fracture severity and a correlation was present accordingly (p < 0.001; r = 0.28). A total of 30 (3.1%) patients showed limitations in range of motion and/or persistent neurologic deficits at the latest follow-up. Type I fractures rarely lead to subsequent limitations. The correlation between increasing fall height and fracture severity was significant. Furthermore, children with type III and IV supracondylar fractures are more likely to develop complications or restrictions in movement than children with type I and II fractures. Hence, the initial fall height may be an indirect indicator of a more or less favorable outcome.

The Effect of COVID-19 Pandemic on the Characteristics of Pediatric Supracondylar Fracture: A Retrospective Cohort Study

Background

Environmental factors play a key role in the occurrence of pediatric supracondylar humerus (SH) fracture which has been widely affected by the COVID-19 pandemic and the measures taken to curb its spread. In this study, we aim to investigate the ultimate impact coronavirus pandemic has had on SH fractures in children.

Materials and Methods

This retrospective cohort study compares SH fractures which occurred during the pandemic with their prepandemic counterpart in a pediatric trauma public hospital. Patient's data, submitted from February to July 2020 and 2019, were collected and divided into two groups based on fractures' time of occurrence, i.e., during or before the pandemic.

Results

There was no significant difference in terms of gender, type of fracture, injury location, and time of admission during a day between the aforementioned groups. However, in the pandemic group, patients were transferred to the operating room significantly quicker (odds ratio; 2.13 vs. 0.607, P = 0.01) and the surgery duration was shorter (40.17 ± 12.28 min vs. 49.11 ± 15.48 min, P = 0.011). It was found that the location of injury (home, school, etc.) varied between the two groups (P = 0.01) and the proportion of domestic injuries during the pandemic grew significantly (53.6% vs. 19.8%).

Conclusion

Although the incidence of pediatric SH fractures has decreased due to the closure of schools and sports clubs during the pandemic, domestic occurrence of the same fracture type has grown disproportionately. To prevent this trend, pediatric centers should educate parents on child safety measures and fracture risks during the lockdown.

Treatment of Radial Nerve Palsy in Paediatric Humeral Shaft Fractures. STROBE-Compliant Investigation

Background and Objectives:Due to the rarity of radial nerve palsy in humeral shaft fractures in the paediatric population and the lack of data in the literature, the purpose of our study was to report the treatment results of six children who sustained a radial nerve injury following a humeral shaft fracture. Materials and Methods: We treated six paediatric patients with radial nerve palsy caused by a humeral shaft fracture in our department from January 2011 to June 2022. The study group consisted of four boys and one girl aged 8.6 to 17.2 (average 13.6). The mean follow-up was 18.4 months. To present our results, we have used the STROBE protocol designed for retrospective observational studies. Results:We diagnosed two open and four closed humeral shaft fractures. Two simple transverse AO 12A3c; one simple oblique AO 12A2c; two simple spiral AO 12A1b/AO 12A1c and one intact wedge AO 12B2c were recognized. The humeral shaft was affected in the distal third five times and in the middle third one time. In our study group, we found two cases of neurotmesis; two entrapped nerves within the fracture; one stretched nerve over the bone fragments and one case of neuropraxia. We found restitution of the motor function in all cases. For all patients, extensor muscle strength was assessed on the grade M4 according to the BMRC scale (except for a patient with neuropraxia-M5). The differences in patients concerned the incomplete extension at the radiocarpal and metacarpophalangeal (MCP) joints. Conclusions: In our small case series, humeral shaft fractures complicated with radial nerve palsy are always challenging medical issues. In paediatric patients, we highly recommend an US examination where it is possible to be carried out to improve the system of decision making. Expectant observation with no nerve exploration is reasonable only in close fractures caused by low-energy trauma. Early surgical nerve exploration related with fracture stabilisation is highly recommended in fractures after high-energy trauma, especially in open fractures and where symptoms of nerve palsy appear at any stage of conservative treatment.

Analysis of the location and trajectory of the Kirschner wires in the fixation of extension-type supracondylar fracture of the humerus by 3D computational simulation

BACKGROUND

Closed reduction and percutaneous pinning is still a preference for the treatment of supracondylar humerus fractures in children. However, no reports have shown the pin trajectory and the characteristics of the entry point so far. So we established a computational simulation model of the elbow to observe the trajectory of pinning for supracondylar humerus fractures.

METHODS

We reconstructed an adult elbow computationally and simulated pin placement through lateral and medial pinning. Pin trajectories were traced after placement and after the addition of the skin profile; the relative entry points of the pins were determined. We used the center of the dorsal olecranon inflection as an anatomic reference for the entry points of lateral pinning. Four quadrants were established based on the center of the dorsal olecranon inflection: upper medial quadrant, upper lateral quadrant, lower medial quadrant, and lower lateral quadrant (LLQ).

RESULTS

The maximum angle of pinning through the lateral column was 64° ± 3°. The minimum angles of pinning through the lateral column and middle column were 37° ± 3° and 20° ± 2°, respectively. The range of safe angle pinning through the medial column was between 18° ± 2° and 57° ± 3° to avoid penetration of the olecranon fossa and the cortex of the medial column. The entry points of lateral pinning were within the lateral half of the LLQ, and the lateral one-third of the LLQ contained all entry points of the pins through the lateral column and minor points of the pins through the middle column. The exit points of the medial pinning were within the lateral fringe of the metaphyseal-diaphyseal junction region; entering from the inferior two-thirds of the medial epicondyle could lead to the exit points in the proximal half of the metaphyseal-diaphyseal junction region laterally.

DISCUSSION

For lateral pinning, the entry points would be within the lateral half of the LLQ. For the pins through the lateral column, the entry points should be within the lateral one-third of the LLQ. For medial pinning, entering from the inferior two-thirds of the medial epicondyle would lead to a more proximal exit.

Analysis of Physeal Fractures from the United States National Trauma Data Bank

Background: Pediatric long-bone physeal fractures can lead to growth deformities. Previous studies have reported that physeal fractures make up 18–30% of total fractures. This study aimed to characterize physeal fractures with respect to sex, age, anatomic location, and Salter–Harris (SH) classification from a current multicenter national database. Methods: A retrospective cohort study was performed using the 2016 United States National Trauma Data Bank (NTDB). Patients ≤ 18 years of age with a fracture of the humerus, radius, ulna, femur, tibia, or fibula were included. Results: The NTDB captured 132,018 patients and 58,015 total fractures. Physeal fractures made up 5.7% (3291) of all long-bone fractures, with males accounting for 71.0% (2338). Lower extremity physeal injuries comprised 58.6% (1929) of all physeal fractures. The most common site of physeal injury was the tibia comprising 31.8% (1047), 73.9% (774) of which were distal tibia fractures. Physeal fractures were greatest at 11 years of age for females and 14 years of age for males. Most fractures were SH Type II fractures. Discussion and Conclusions: Our analysis indicates that 5.7% of pediatric long-bone fractures involved the physis, with the distal tibia being the most common. These findings suggest a lower incidence of physeal fractures than previous studies and warrant further investigation.

Interventions for treating supracondylar elbow fractures in children

BACKGROUND

Elbow supracondylar fractures are common, with treatment decisions based on fracture displacement. However, there remains controversy regarding the best treatments for this injury.

OBJECTIVES

To assess the effects (benefits and harms) of interventions for treating supracondylar elbow fractures in children.

SEARCH METHODS

We searched CENTRAL, MEDLINE, and Embase in March 2021. We also searched trial registers and reference lists. We applied no language or publication restrictions.

SELECTION CRITERIA

We included randomised and quasi-randomised controlled trials comparing different interventions for the treatment of supracondylar elbow fractures in children. We included studies investigating surgical interventions (different fixation techniques and different reduction techniques), surgical versus non-surgical treatment, traction types, methods of non-surgical intervention, and timing and location of treatment.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. We collected data and conducted GRADE assessment for five critical outcomes: functional outcomes, treatment failure (requiring re-intervention), nerve injury, major complications (pin site infection in most studies), and cosmetic deformity (cubitus varus).  MAIN RESULTS: We included 52 trials with 3594 children who had supracondylar elbow fractures; most were Gartland 2 and 3 fractures. The mean ages of children ranged from 4.9 to 8.4 years and the majority of participants were boys. Most studies (33) were conducted in countries in South-East Asia. We identified 12 different comparisons of interventions: retrograde lateral wires versus retrograde crossed wires; lateral crossed (Dorgan) wires versus retrograde crossed wires; retrograde lateral wires versus lateral crossed (Dorgan) wires; retrograde crossed wires versus posterior intrafocal wires; retrograde lateral wires in a parallel versus divergent configuration; retrograde crossed wires using a mini-open technique or inserted percutaneously; buried versus non-buried wires; external versus internal fixation; open versus closed reduction; surgical fixation versus non-surgical immobilisation; skeletal versus skin traction; and collar and cuff versus backslab. We report here the findings of four comparisons that represent the most substantial body of evidence for the most clinically relevant comparisons.  All studies in these four comparisons had unclear risks of bias in at least one domain. We downgraded the certainty of all outcomes for serious risks of bias, for imprecision when evidence was derived from a small sample size or had a wide confidence interval (CI) that included the possibility of benefits or harms for both treatments, and when we detected the possibility of publication bias.  Retrograde lateral wires versus retrograde crossed wires (29 studies, 2068 children) There was low-certainty evidence of less nerve injury with retrograde lateral wires (RR 0.65, 95% CI 0.46 to 0.90; 28 studies, 1653 children). In a post hoc subgroup analysis, we noted a greater difference in the number of children with nerve injuries when lateral wires were compared to crossed wires inserted with a  percutaneous medial wire technique (RR 0.41, 95% CI 0.20 to 0.81, favours lateral wires; 10 studies, 552 children), but little difference when an open technique was used (RR 0.91, 95% CI 0.59 to 1.40, favours lateral wires; 11 studies, 656 children). Although we noted a statistically significant difference between these subgroups from the interaction test (P = 0.05), we could not rule out the possibility that other factors could account for this difference. We found little or no difference between the interventions in major complications, which were described as pin site infections in all studies (RR 1.08, 95% CI 0.65 to 1.79; 19 studies, 1126 children; low-certainty evidence). For functional status (1 study, 35 children), treatment failure requiring re-intervention (1 study, 60 children), and cosmetic deformity (2 studies, 95 children), there was very low-certainty evidence showing no evidence of a difference between interventions. Open reduction versus closed reduction (4 studies, 295 children) Type of reduction method may make little or no difference to nerve injuries (RR 0.30, 95% CI 0.09 to 1.01, favours open reduction; 3 studies, 163 children). However, there may be fewer major complications (pin site infections) when closed reduction is used (RR 4.15, 95% CI 1.07 to 16.20; 4 studies, 253 children). The certainty of the evidence for these outcomes is low. No studies reported functional outcome, treatment failure requiring re-intervention, or cosmetic deformity. The four studies in this comparison used direct visualisation during surgery. One additional study used a joystick technique for reduction, and we did not combine data from this study in analyses. Surgical fixation using wires versus non-surgical immobilisation using a cast (3 studies, 140 children) There was very low-certainty evidence showing little or no difference between interventions for treatment failure requiring re-intervention (1 study, 60 children), nerve injury (3 studies, 140 children), major complications (3 studies, 126 children), and cosmetic deformity (2 studies, 80 children). No studies reported functional outcome. Backslab versus sling (1 study, 50 children) No nerve injuries or major complications were experienced by children in either group; this evidence is of very low certainty. Functional outcome, treatment failure, and cosmetic deformity were not reported.  AUTHORS' CONCLUSIONS: We found insufficient evidence for many treatments of supracondylar fractures. Fixation of displaced supracondylar fractures with retrograde lateral wires compared with crossed wires provided the most substantial body of evidence in this review, and our findings indicate that there may be a lower risk of nerve injury with retrograde lateral wires. In future trials of treatments, we would encourage the adoption of a core outcome set, which includes patient-reported measures. Evaluation of the effectiveness of traction compared with surgical fixation would provide a valuable addition to this clinical field.

Evaluation of anterior approach in failed closed reduction and delayed presentation of supracondylar humerus fractures in children

BACKGROUND

The treatment of displaced paediatric supracondylar fracture is a challenging problem and requires strict vigilance and a proper management protocol. Prospective investigation of the treatment options for fractures that cannot be reduced by closed reduction is recommended in literature. Operative treatment is indicated for the fractures that cannot be reduced satisfactorily by closed methods. It is also considered the best option for late presenting fractures. The aim of this study was to assess and compare the clinical outcome using open reduction through anterior approach in delayed presentation and failed closed reduction of supracondylar fracture humerus in children.

MATERIALS AND METHODS

15 patients of failed closed reduction and 11 patients of delayed presentation of supracondylar humerus fractures were operated with anterior approach. The demographic data, time from injury to presentation and from admission to surgery, reasons for delayed presentation, type of fracture, operative findings and time, K-wire configuration, length of hospitalization, post operative complications were noted. The patients were followed up for a period of 12 months and final range of motion, Baumann's angle, and cosmetic, functional and overall outcome by Flynn's criteria were evaluated and analyzed.

RESULTS

The overall outcome was very satisfactory according to Flynn's criteria. 80.77% patients had excellent, 15.38% patients had good, and 3.85% patient had fair results with no poor results. Our results show distinct advantage of anterior approach which are on a par with or better than the previous studies using anterior approach, adding to their evidence.

CONCLUSION

Open reduction using anterior approach is a very safe, logical and effective technique of treating failed closed reduction or late presentation of supracondylar fractures humerus in children with excellent cosmetic and functional results, and offers distinctive advantage over other approaches.

Pediatric Supracondylar Humerus Fractures: Should We Avoid Surgery during After-Hours?

Pediatric supracondylar humerus fractures occur frequently. Often, the decision has to be made whether to operate immediately, e.g., during after-hours, or to postpone until office hours. However, the effect of timing of surgery on radiological and clinical outcomes is unclear. This literature review with the PICO methodology found six relevant articles that compared the results of office-hours and after-hours surgery for pediatric supracondylar humerus fractures. The surgical outcomes of both groups in these studies were assessed. One of the articles found a significantly higher "poor fixation rate" in the after-hours group, compared with office hours. Another article found more malunions in the "night" subgroup vs. the "all groups but night" group. A third article found a higher risk of postoperative paresthesia in the "late night" subgroup vs. the "day" group. Lastly, one article reported increased consultant attendance and decreased operative time when postponing to office hours more often. No differences were reported for functional outcomes in any of the articles. Consequently, no strong risks or benefits from surgical treatment during office hours vs. after-hours were found. It appears safe to postpone surgery to office hours if circumstances are not optimal for acute surgery, and if there is no medical contraindication. However, research with a higher level-of-evidence is needed make more definite recommendations.

Supracondylar fractures of the humerus in children: is departmental documentation hitting national standards?

BACKGROUND/AIMS

The British Orthopaedic Association's Standards for Trauma for the management of supracondylar humerus fractures in children specify that: 'A documented assessment of the limb, performed on presentation, must include the status of radial pulse, digital capillary refill time and the individual function of the radial, median (including anterior interosseous) and ulnar nerves.'

METHODS

The documentation of cases of supracondylar humerus fractures over 1 year was retrospectively analysed. An electronic pro forma for supracondylar humerus fractures was introduced, with prompts for the pieces of documentation required to meet national standards. The use of this pro forma was audited after 6 months and 12 months use.

RESULTS

Documentation ranged from 10% for anterior interosseous nerve to 53% for radial pulse. In the second reaudit, documentation ranged from 86% for anterior interosseous nerve to 95% for median nerve function. There were 17 patients for whom all documentation was present, and for these patients the pro forma had been used. Use of an electronic clerking pro forma improves adherence.

CONCLUSIONS

Full documentation of neurovascular status in paediatric supracondylar fractures is vital to allow for effective preoperative and postoperative further assessment. With the move into paperless documentation, online pro formas can help clinicians with effective assessment and documentation.

Treatment and outcomes of pediatric supracondylar humeral fractures in Korle Bu Teaching Hospital

Objectives:

Supracondylar humeral fractures (SCHF) are the most common elbow injury in the pediatric population. The treatment, outcome, and health-related quality of life (HRQoL) following these injuries are described.

Methods:

Patients with SCHF who were treated depending on the fracture type were evaluated. Medical records stored in the REDCap database were reviewed to obtain information on demographics, mechanisms of injury, neurovascular status, infection rates, and postoperative complications. Outcomes were assessed using Flynn's criteria and Pediatric Quality of Life (PedsQL) version 4.0. Follow-up was for 6 months.

Results:

A total of 101 patients with a mean age of 5.2 years (SD ± 2.3) were seen. Most of the injuries occurred at home (64.3%). The left-arm (nondominant) was the most injured (62%), though 92% of patients were right hand dominant. Ninety-six percent of the fractures were the extension type. A total of 98% had satisfactory outcomes using Flynn's criteria and older patients were likely to sustain Gartland type III SCHF (P = .01). There was a significant difference in mean scores of PedsQL (all P values < .01) at 6 months.

Conclusions:

In this prospective study, the quality of life of patients following SCHF diminished at the time of the injury and returned to the population normal 6 months after. There was no significant difference in HRQoL scores between patients who presented early and those who presented late. The delayed presentation and management did not also affect the functional outcome and complications. Therefore, surgical management of these injuries after late presentation is still safe.

A Standardized Order-Set Improves Variability in Opioid Discharge Prescribing Patterns After Surgical Fixation of Pediatric Supracondylar Humerus Fractures

OBJECTIVE

To evaluate institutional opioid prescribing patterns following percutaneous fixation of pediatric supracondylar humerus fractures before and after implementation of a standardized discharge order set.

DESIGN

A retrospective review of patients who underwent closed reduction and percutaneous skeletal fixation of a Type II or III supracondylar humerus fracture in 2017 (prior to pain protocol implementation) and again in 2019 (after pain protocol implementation) SETTING: Single Tertiary Care Children's Hospital PARTICIPANTS: In total, 106 patients met inclusion criteria between years 2017 (n = 49) and 2019 (n = 57). Exclusion criteria included miscoded patients, open fractures, patients who presented with vascular injury or nerve palsy, polytrauma patients with multiple fractures in the same upper extremity, and supracondylar humerus fractures that underwent an open procedure.

RESULTS

There were no significant differences between inpatient pain scores (p = 0.91) and MDE prescribed (p = 0.75) between the 2 cohorts. In 2017, large variability was noted in day supply of opioids (0-11.4 days) and MDE (0-8.45 mg/kg), with significant differences between prescribing patterns of junior and senior level residents (mean day supply of opioids (p = 0.045), mean MDE prescribed on discharge (p = 0.001)). After implementation of a standardized opioid discharge order set, there was a tenfold increase in the number of patients discharged without an opioid prescription (2017: 4%, 2019: 44%). Additionally, any discrepancies between prescribing practices of junior and senior level residents were eliminated (mean day supply of opioids (p = 0.65), mean MDE prescribed on discharge (p = 0.69)).

CONCLUSIONS

The introduction of a standardized post-operative opioid discharge order set led to a 10-fold increase in the number of patients discharged without an opioid prescription. Additionally, the order set decreased the variability in the prescribing patterns of discharge opioid medications without change in pain control. The resident prescribing variability based upon level of experience resolved with the use of the order set.

Pediatric Supracondylar Humerus Fracture Outcomes by Pediatric and Nonpediatric Orthopedists

Pediatric supracondylar humerus fractures are common and often require surgical intervention by an orthopedic surgeon, who may or may not have pediatric subspecialty training. This study used a large national database to assess for potential differences in perioperative outcomes for pediatric supracondylar humerus fractures treated by pediatric and nonpediatric orthopedists. A retrospective comparative cohort analysis was performed using data from the National Surgical Quality Improvement Project-Pediatric (NSQIP-P) database 2012 to 2017. Patients 1 to 11 years old were assessed. Demographics, comorbidities, and the incidence of adverse outcomes were compared between pediatric and nonpediatric orthopedists using multivariate analysis controlling for patient characteristics. A total of 15,831 patients were included in the study. Of these, 85.2% were treated by pediatric orthopedists and 14.8% were treated by nonpediatric orthopedists. Demographics, comorbidity burden, operative time, and hospital length of stay were not significantly different between the study groups. With multivariate analysis controlling for patient factors, no differences were identified for 30-day adverse events, reoperation, or readmission whether surgery was performed by pediatric or nonpediatric orthopedists. Considering self-selection of surgeons who perform surgery for pediatric supracondylar humerus fractures, no differences in hospital or general outcome metrics were identified based on who performed these procedures. [Orthopedics. 2021;44(2):e203-e210.].

Identifying Risk Factors for Elbow Injury in Children Presenting to the Emergency Department With Distal Forearm Fractures

BACKGROUND

Pediatric distal forearm fractures are one of the most common injuries seen in the emergency department. Orthopedic teaching instructs providers to radiograph the joint above and the joint below the fracture site for concurrent injury. Despite this teaching, there is little evidence to suggest that elbow injuries are common in children with distal forearm fractures. Similarly, there are few data that help the clinician predict which children are at higher risk for co-injury.

METHODS

We conducted a cross-sectional analysis of the 2011 National Emergency Department Sample data set. Children aged 2 to 17 years with an International Classification of Disease, Ninth Revision, code for a distal forearm fracture were included in the study. The primary outcome of interest was an "elbow" injury, defined as an International Classification of Disease, Ninth Revision, code for proximal radius, proximal ulna, or distal humeral fracture or dislocation. Multivariable logistic regression was performed using patient demographics, injury severity score, mechanism of injury, and underlying medical conditions.

RESULTS

A total of 54,262 children with a distal forearm fracture were identified. Of these children, only 0.8% (n = 463) had an elbow injury. Supracondylar fractures of the humerus were the most common elbow injury seen (48.2% of elbow injuries seen). Children were more likely to have a co-injury if they were younger (9.8 years vs 8.3 years, P < 0.01), female (36% vs 44%, P < 0.01), injured via fall (68% vs 76%, P < 0.01), had a higher injury severity score (4.1 vs 4.5, P < 0.01), or were admitted for their injuries (1.5% vs 15.7%, P < 0.01). In the adjusted model, only age and disposition were predictors of co-injury. Isolated buckle fracture of the radius and metaphyseal fracture of the radius with dorsal angulation were protective against elbow injury (odds ratio = 0.39 and 0.60, respectively).

CONCLUSIONS

Children with distal forearm fractures very rarely have concurrent elbow injuries. These injuries are more likely in younger female children.

Children with supracondylar humerus fractures have an increased risk of attention deficit hyperactivity disorder

Children with attention deficit hyperactivity disorder (ADHD) have an increased risk of sustaining fractures during their preschool years. Supracondylar humerus fractures (SHFs) comprise the majority of fracture surgeries in the pediatric age range. We hypothesized that ADHD symptoms would be present in children with SHFs, and this characteristic trauma may be associated with an ADHD diagnosis. Thus, we compared the ADHD symptoms of children with and without SHFs. Further, we compared the trauma characteristics, gender, proneness to injury, and presence of prior trauma history of children diagnosed with and without ADHD. We recruited 41 children who were admitted to emergency service with an SHF and 41 age- and gender-matched children without a fracture history. A semi-structured diagnostic inter- view and a Swanson Nolan Pelham questionnaire were used to obtain data about ADHD symptoms. A clinical intake form was utilized for further clinical data. ADHD symptoms were significantly higher in the fracture group ; male gender, parent- reported proneness to injury, and prior history of trauma were significantly associated with ADHD. Orthopedic surgeons may provide early detection of ADHD by using screening tools or asking questions to caregivers and making referrals when needed. This may lead to prevention of further injuries.

Overview of the contemporary management of supracondylar humeral fractures in children

PURPOSE

Supracondylar fractures are common injuries accounting for approximately 15% of all fractures in children with a large body of literature on this subject.

METHODS

 This article critically appraises the available evidence to provide an overview of the treatment options including the role and timing of surgery, the geometry of wire fixation and the management of nerve and arterial injury.

CONCLUSION

 Management decisions are based on a number of considerations particularly fracture stability. Closed reduction and percutaneous K-wire stabilisation are commonly recommended for an unstable displaced fracture. These techniques are however associated with the potential for iatrogenic neurological injury. Vascular injury is also rare but must be recognised and treated promptly to avoid significant permanent morbidity.

Management of acute paediatric fractures treated surgically in the UK: a cross-sectional study

INTRODUCTION

The epidemiology of acute paediatric orthopaedic trauma managed surgically across the NHS is poorly described. Compliance against national standards for the management of supracondylar humeral fractures is also unknown at a national level.

METHODS

Collaborators in 129 NHS hospitals prospectively collected data on surgically managed acute paediatric orthopaedic trauma cases. Data were collected over a seven-day period and included demographics, injury characteristics, operative details and timing of surgery. A national audit was also undertaken to evaluate compliance with the British Orthopaedic Association Standards for Trauma Guideline 11: Supracondylar Fractures of the Humerus in Children.

RESULTS

Data were captured on 770 surgically treated cases. The three most common injuries were forearm fractures of both bones (n = 235), distal radius fractures (n = 194) and supracondylar elbow fractures (n = 89). The mode day of injury was Friday (n = 136) and the mode day of surgery was Saturday (n = 138). 88% of supracondylar fractures received surgery on the day of presentation or the following day. Only 14% of supracondylar fractures were treated surgically after 8pm; 33/89 used 2.0mm Kirschner wires, 38/89 used 1.6mm wires and 2/89 used 1.2mm wires.

CONCLUSION

Forearm fractures of both bones, distal radius fractures and supracondylar humeral fractures were the three most common injuries treated surgically. There is wide variation in compliance against national standards in the management of supracondylar humeral fractures with 88% undertaking surgery on the day of or the day following presentation but only 37% using the recommended 2.0mm Kirschner wires.

Epidemiologic Study of Syrian Refugees Underwent Surgery Due to Fracture in a Tertiary Reference Hospital in Turkey

Aim This study aims to analyze the spectrum, management, and outcome of Syrian refugees' fracture over four-year period, highlighting challenges in management and follow-up. Methods This was a retrospective review of Syrian refugee patients operated for fractures at our centre from January 2015 to January 2019. The patients were evaluated for age, gender, mechanism of injury, location and type of fracture, presence of accompanying injuries, surgical technique, complications, mortality and morbidity. The comparison of complications and postop outpatient clinic controls between Turkish citizens and Syrian refugees were also evaluated. Results The study included a total of 455 patients comprising 281 adults (202 males, 79 females) with a mean (SD) age of 41.1 (19.3) years and 174 children with a mean age of 8.8 (4.9) years. The trauma mechanism was most commonly fall in both adult and pediatric patients (86.6% / 73.5%). Whilst lower limb fractures were more common in adults (73.7%), upper limb fractures were more common in children (63.4%). The presence of accompanying trauma was determined in 21 (7.5%) adults and 10 (5.7%) children. Multiple fractures were determined in 12 (4.3%) adults and eight (4.6%) children. Plate fixation (PF) was most used in 137 (48.8%) adult patients and K-wire augmentation was used in 75 (43.1%) pediatric patients. Out of the 455 patients, 41 (14.6%) adults and 13 (7.3%) children developed complications. Whilst three adult patients were died during follow-up, no deaths were recorded in the pediatric patients. Complication rate was 54/455 in Syrian refugees and 32/455 in citizens. It was observed that the complication was significantly higher in immigrants (p: 0.017). Sixty-five (14.2%) Syrian immigrants did not come to the outpatient clinic control at all or once, while this rate was 29/455 (6.3%) for Turkish citizens (p = 0.012). Conclusion Inadequate living conditions and lack of communication faced by refugees reduce the rate of patient follow-up and negatively affect the results of orthopedic trauma.

Are Postcast Removal X-rays and a Second Follow-up Necessary in the Treatment of Nondisplaced Supracondylar Humerus Fractures?

BACKGROUND

The utility of routine follow-up radiographs for the treatment of nondisplaced pediatric supracondylar humerus fractures has not been established. The purpose of this study is to (1) determine the frequency that postcast removal x-rays change patient management and (2) determine the role of routine follow-up for range of motion evaluation after cast removal in the treatment of nondisplaced supracondylar humerus fractures.

METHODS

We conducted a single center retrospective chart review of patients under the age of 18 years old that sustained nondisplaced supracondylar humerus fractures between January 1, 2010 and July 1, 2018. Demographic information, fracture characteristics, time to follow-up and each appointment outcome were recorded. A change in patient management after postcast removal x-ray was defined as a need for an additional period of immobilization, a delay in initiation of range of motion exercises, or need for operative intervention. In addition, the appointment for range of motion evaluation was considered to alter management if further activity restriction was required, a formal physical therapy program was recommended or an additional office visit required. Unscheduled appointments were also noted.

RESULTS

A total of 489 patients met inclusion criteria. The average age was 4.90±2.68 years and 51.8% were female. A total of 487 patients had routine follow-up x-rays after cast removal. No patient had a change of management based on postcast removal radiographs. In all, 290 patients returned for range of motion follow-up with 94.8% of patients being discharged from care. There were 14 patients whose management changed based on this evaluation (4.8%). The most common reason was an additional appointment for range of motion evaluation (12/14 patients, 86%). There were 13 patients with unscheduled evaluation after discharge from care, 77% were secondary to repeat injury.

CONCLUSION

This study suggests that postcast removal x-rays and routine follow-up after cast removal rarely change patient management and may not be necessary in the treatment of nondisplaced pediatric supracondylar humerus fractures.

LEVEL OF EVIDENCE

Level IV-case series.

The effect of the angle between fracture line and Kirschner wires on stability in supracondylar humerus fractures treated with Kirschner wire fixation: A finite element analysis

Objectives

This study aims to investigate the effects of the angles created by the Kirschner wires (K-wires), which are applied in the percutaneous fixation of supracondylar humerus fractures with cross K-wire, with the fracture line on fracture stabilization.

Patients and methods

The study was conducted on distal humerus fracture models. Medial and lateral K-wires were placed in the fracture models. The angle between the fracture line and the K-wire inserted from medial was represented by alpha (α), while the angle between the fracture line and the K-wires inserted from lateral was represented by beta (β). A combination of various angles (30°, 45°, and 60°) was used in each model, where no two models had the same combination of α and β, resulting in nine different wire configurations. The simulation program was used to simulate the effects of forces, which were applied on rotation, flexion and extension directions, on these models. We measured and compared the stress on the wires and the displacement of fractures under different force configurations.

Results

When the force was applied in the counterclockwise direction, the stresses were 58 megaPascal (MPa) on medial K-wire, 24 MPa on lower lateral K-wire, and 45 MPa on upper lateral K-wire in (45°, 45°) wire configuration. When the force was applied in the clockwise direction, the stresses were 57 MPa on medial K-wire, 23 MPa on lower lateral K-wire, and 45 MPa on upper lateral K-wire in (45°, 45°) wire configuration. In all models, the increased α and β angles were translated into the decreased stress on K-wires at the fracture level and decreased displacement under rotational deforming forces. Despite having generally lower fracture displacement, the increased α and β angles led to variable changes in the stress on K-wires against flexion and extension forces.

Conclusion

In supracondylar humerus fractures, increasing the insertion angle of both medial and lateral K-wires augments stabilization and reduces displacement, particularly against rotational deforming forces.

Methodological Challenges in Investigating Supracondylar Fractures of the Humerus From a Child's Viewpoint: Evolution of Study Protocol

Background

Outdoor play and risk-taking behaviors, including play at heights, are important to children’s physical, social, and cognitive development. These aspects of play are important to consider when informing prevention policies for serious injuries that commonly occur on play structures. Supracondylar fractures of the humerus (SCH) are the most common type of elbow fractures that result from falls on an outstretched hand among healthy children. Despite being one of the leading causes of admission to the hospital and surgical intervention, the details surrounding the cause of these injuries are often not recorded. Previous research has correlated decreased overall playground safety with higher rates of SCH fractures. Play structure height and the type of undersurface have been identified as potential risk factors for severe injuries, including SCH fractures, in part due to low compliance with safety standards. This paper explores the challenges we encountered designing the study and the resulting insights and methodological modifications we made.

Objective

The aim of this paper is to discuss the challenges related specifically to clinical research in pediatrics and strategies developed to conduct a study that prioritizes the engagement and perspective of children and their families.

Methods

To explore the link between the severity of SCH fractures and children’s behavioral, environmental, and mechanistic factors, we conducted a mixed-methods study.

Results

During phase 1 (the original methodology) from April 2017 to July 2018, there were 58 eligible study participants and 17 were recruited. For phase 2 (the revised methodology) between October 2018 and October 2019, there were 116 eligible participants and 47 were recruited.

Conclusions

The changes in methodology made following the first phase of data collection were effective in our ability to recruit participants. By identifying and addressing challenges pertaining to recruitment and resource limitations, we were able to collect data in a concise manner while not compromising the quality of the data and make for an easily adoptable methodology for other sites interested in participating in the study. We hope that future studies that plan to employ a similar methodology can gain insight through the methodological challenges we have encountered and the way we adapted the methodology to build a more pragmatic approach.

International Registered Report Identifier (IRRID)

DERR1-10.2196/21816

Comprehensive Analysis of Pediatric Supracondylar Fractures in the Emergency Department; A Single Center Experience

Objective:

To describe the demographic characteristics and to assess possible risk factors related to the moment of presentation at Emergency Department (ED) for pediatric humeral supracondylar fractures.

Methods:

This was cross-sectional study being conducted during 5-year period from 2013 to 2017 at ED of a regional hospital in Spain. We have included all the pediatric patients (<14 years) with supracondylar fractures referring to our center during the study period. The demographic, clinical and radiological characteristics of the patients were recorded. The outcome and treatment strategies were also recorded. The risk factors of the pediatric supracondylar fracture was also assessed in our series.

Results:

We have included 52 pediatric patients with supracondylar fractures in this series. The mean age was 7.48 ± 2.97 years with a minimum age of 2 years and a maximum of 14 years. Among the patients there were 32 (61.54%) male and 20 (38.46%) female. Age less than 7 years found to be a protective factor against unstable fractures [OR 0.33 (0.10 - 1.02)]. Fractures presented during daytime hours showed a greater instability [OR 3.49 (1.07-11.39)]. However, the risk of presentation at nighttime was higher during the summer months (June to September).

Conclusion:

The older is the child, the greater is the risk of suffering an unstable fracture, which increases the need for surgery. This risk is greater during the daytime. Otherwise, during the summer months, there is a higher risk of patient presentation at nighttime.

Effectiveness of operative versus expectant management on recovery of nerve palsies in pediatric supracondylar fractures: a systematic review protocol

OBJECTIVE

The objective of this review is to evaluate the effectiveness of operative versus expectant management on recovery of nerve palsies after pediatric supracondylar fracture of the humerus or after surgery for supracondylar fracture of the humerus.

INTRODUCTION

Supracondylar humerus fractures are the most common fracture of the elbow in children. These fractures have a high risk of complications from both the trauma itself and the treatment. Up to 12% of patients will have associated nerve injury, but there is insufficient information regarding the timing of investigation of and intervention in a persistent nerve palsy. This review aims to summarize the evidence and guide clinicians regarding the timing of investigation and/or surgical intervention for persistent nerve palsies after supracondylar humerus fractures in the pediatric population.

INCLUSION CRITERIA

This review will include pediatric patients with ipsilateral upper limb nerve palsy after supracondylar fracture of the humerus or after surgery for a supracondylar fracture of the humerus without preexisting nerve palsies.

METHODS

A comprehensive database search will be undertaken in MEDLINE, Embase, and Cochrane Central Register of Controlled Trials. The trial registers to be searched will include PROSPERO and AllTrials. The search strategy will include the keywords pediatric/paediatric, supracondylar, nerve injury/palsy/palsies, fracture, and humerus. Titles and abstracts will be screened by independent reviewers for suitability against the inclusion criteria, with accepted publications then being assessed in full with data extraction, synthesis, and assessment of methodological quality, using standardized critical appraisal tools from JBI.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42019121581.

Paediatric orthopaedics in lockdown: A study on the effect of the SARS-Cov-2 pandemic on acute paediatric orthopaedics and trauma

AIMS

To determine the impact of COVID-19 on orthopaediatric admissions and fracture clinics within a regional integrated care system (ICS).

METHODS

A retrospective review was performed for all paediatric orthopaedic patients admitted across the region during the recent lockdown period (24 March 2020 to 10 May 2020) and the same period in 2019. Age, sex, mechanism, anatomical region, and treatment modality were compared, as were fracture clinic attendances within the receiving regional major trauma centre (MTC) between the two periods.

RESULTS

Paediatric trauma admissions across the region fell by 33% (197 vs 132) with a proportional increase to 59% (n = 78) of admissions to the MTC during lockdown compared with 28.4% in 2019 (N = 56). There was a reduction in manipulation under anaesthetic (p = 0.015) and the use of Kirschner wires (K-wires) (p = 0.040) between the two time periods. The median time to surgery remained one day in both (2019 IQR 0 to 2; 2020 IQR 1 to 1). Supracondylar fractures were the most common reason for fracture clinic attendance (17.3%, n = 19) with a proportional increase of 108.4% vs 2019 (2019 n = 20; 2020 n = 19) (p = 0.007). While upper limb injuries and falls from play apparatus, equipment, or height remained the most common indications for admission, there was a reduction in sports injuries (p < 0.001) but an increase in lacerations (p = 0.031). Fracture clinic management changed with 67% (n = 40) of follow-up appointments via telephone and 69% (n = 65) of patients requiring cast immobilization treated with a 3M Soft Cast, enabling self-removal. The safeguarding team saw a 22% reduction in referrals (2019: n = 41, 2020: n = 32).

CONCLUSION

During this viral pandemic, the number of trauma cases decreased with a change in the mechanism of injury, median age of presentation, and an increase in referrals to the regional MTC. Adaptions in standard practice led to fewer MUA, and K-wire procedures being performed, more supracondylar fractures managed through clinic and an increase in the use of removable cast.Cite this article: Bone Joint Open 2020;1-7:424-430.

Sex-based differences in pediatric supracondylar humerus fractures

Supracondylar humerus (SCH) fractures are reported to be approximately twice as common among boys as among girls. Little is known about sex-associated differences in fracture patterns and complications. We compared the incidence of pediatric SCH fractures, injury mechanism (high-energy or low-energy), fracture subtypes, associated neurologic injuries, and treatment types by patient sex.We reviewed 1231 pediatric SCH fractures treated at 1 center from 2008 to 2017, analyzing sex distributions overall and by year and fracture subtype. We noted patient demographic characteristics, injury mechanisms, neurologic injuries, and treatments (nonoperative or operative). Binomial 2-tailed, chi-squared, and Student's t tests were used for analysis. Multiple logistic regression was performed to assess associations between sex, age, and injury mechanism. Alpha = 0.05.We found no significant difference in the distribution of girls (52%) vs boys (48%) in our sample compared with a binomial distribution (P = .11). Annual percentages of fractures occurring in girls ranged from 46% to 63%, and sex distribution did not change significantly over time. The mean (± standard deviation) age at injury was significantly younger for girls (5.5 ± 2.5 years) than for boys (6.1 ± 2.5 years) (P < .001). High-energy injury mechanism was associated with older age (odds ratio [OR], 1.05; 95% confidence interval [CI], 1.03-1.06) but not male sex (OR, 1.04; 95% CI, 0.98-1.1). The overall incidence of neurologic injury was 9.5% but boys did not have greater odds of sustaining neurologic injury (OR, 1.03; 95% CI, 1.0-1.1). We found no sex-associated differences in the distribution of Gartland fracture subtypes (P = .13) or treatment type (P = .39).Compared with boys, girls sustain SCH fractures at a younger age. SCH fractures were distributed equally among girls and boys in our sample. Patient sex was not associated with fracture subtype, injury mechanism, neurologic injury, or operative treatment. These findings challenge the perception that SCH fracture is more common in boys than girls.Level III, retrospective study.

Epidemiological Analysis of Displaced Supracondylar Fractures

INTRODUCTION

 Supracondylar fractures are one of the most common fracture patterns sustained by children, and one of the most common injuries requiring operative fixation. Understanding the complications associated with supracondylar fractures is vital for the practicing orthopedic surgeon. This analysis of supracondylar fractures examined the clinically important aspects including vascular injury, compartment syndrome, neurological injury, brachialis entrapment, associated injuries, and etiologies of injury. Recent advances in technology have resulted in a myriad of new forms of recreational equipment for children to play with. The purpose of this study is to compare the historical literature, the current literature, and a single surgeon's sample of supracondylar fractures. In addition, this study aims to evaluate if any changes in epidemiology or etiology have occurred due to the development of new recreational equipment.

OBJECTIVE

 The purpose of this study is to evaluate and provide a qualitative overview of the epidemiology of displaced supracondylar fractures, to compare historically reported numbers to more recent literature as well as a single surgeon sample, and to evaluate if changes in epidemiology or etiology have occurred due to the new recreational equipment that children use.

METHODS

Some 75 displaced supracondylar elbow fractures were reviewed. Data elements recorded from the electronic medical record (EMR) included patient age, gender, height, weight, handedness, date, time, location, mechanism, Gartland classification, concurrent injuries, and neurovascular status.  Results: In this study, there were 42 males and 33 females. The average age was six years. Some 70 of the 75 patients were older than the age three. One fracture was open, nine fractures had a pucker sign, seven presented with a nerve palsy, four presented without a pulse, and seven patients presented with an additional ipsilateral distal radius fracture. All fractures were the result of a fall. Falls from playground equipment resulted in 29 fractures. There were 10 from falls off of furniture, six from falls during sports, three from falls on the stairs, and three from fall off of bikes. The remaining fractures resulted from running, tripping, falling from a toy ball, sled, tree, wagon, fence, bounce house, van, deck, power wheels car, ATV, and a go-cart. Some 64 fractures were transferred from 27 different outside hospitals. Eleven fractures presented directly to the ED. Twenty-six fractures occurred during the summer, 20 occurred in the autumn, 6 occurred in the winter, and 23 occurred during the spring. Some 35 fractures occurred at home, 30 on the school grounds, four in a gymnasium, four in a park, one at a farm show, and one in a parking lot. Some 25 fractures were treated between midnight and 8 am, 16 were treated between 8 am and 5 pm, and 34 were treated between 5 pm and midnight.  Conclusion: Pediatric supracondylar fractures are common in children, and many of them require operative intervention. This study examined the most important aspects of supracondylar fractures. This update provides a look at the clinically important aspects of supracondylar fractures and compares them to previous teachings and canon. Despite the advancement and changes in recreational equipment that children are using, children are still sustaining supracondylar fractures in the most common ways including falls from playground equipment and falls from standing.

Flexion-Type Supracondylar Humeral Fracture with Ulnar Nerve Injury in Children: Two Case Reports and Review of the Literature

Case series

Patients: Female, 7-year-old • Male, 6-year-old

Final Diagnosis: Flexion-type supracondylar humeral fracture

Symptoms: Pain

Medication: —

Clinical Procedure: —

Specialty: Orthopedics and Traumatology

Epidemiological study on supracondylar fractures of distal humerus in pediatric patients

OBJECTIVE

The purpose of this work is to study the epidemiology of patients with distal humerus supracondylar fractures in pediatric age treated in a tertiary hospital.

METHOD

A descriptive study was conducted on the epidemiological characteristics of distal humerus supracondylar fractures in pediatric patients treated in a tertiary hospital from January 1, 2014 to June 30, 2018. The following variables were analyzed: age, side of lesion, sex, type of Gartland's classification, date of injury, mechanism, place and moment of trauma, therapeutic attitude, complications and associated fractures.

RESULTS

A total of 140 patients were included in the study, with an average age of 5 years and 3 months. According to Gartland's classification, 40% of patients with type I fractures were found, 20.7% with type II and 39.3% with type III. Of the total sample, 76 patients (54.3%) were treated surgically and 9 (6.4%) had neurological complications. Likewise, in 135 cases the place of the fall could be identified, most of them (52.1%) in the park with a significantly higher incidence from May to August (45.8%) and the weekends (70.71%).

CONCLUSIONS

The incidence of supracondylar humerus fractures seems to be greater associated with the activity in the parks and, above all, it would be greater during the summer period, in the afternoon and the weekends.

DISTAL HUMERAL FRACTURE: AN EPIDEMIOLOGICAL ANALYSIS OF ORTHOPEDIC PATIENTS FOR CHILDREN

Objective:

To analyze the epidemiological profiles of children with orthopedic distal humerus fractures.

Methods:

An analytical descriptive study was conducted with a retrospective approach using medical records of 665 orthopedic children who attended the Jesser Amarante Faria Children's Hospital, a reference hospital in the city of Joinville, Santa Catarina, between June 2012 and December 2016.

Results:

The results showed a predominance of male patients (64.2%), with a mean age of 7 years, and the age group of 6–10 years being the most frequent with 319 patients (48%). The main mechanism of trauma was fall of height in 59.7% of patients, Gartland type 1 fracture in 57.1%, and absence of vascular injury in 99.7%. Conservative management was implemented in 64.7% (95%) of patients. Absence of neurological lesion (95.6%) and closed lesion (99.4%) were the main epidemiological characteristics of patients in the study. A low complication rate was observed, with reduction losses in 1.7% of patients, followed by infections in 1.1%.

Conclusion:

We can conclude that the cases studied presented epidemiological characteristics similar to those described in the literature. Level of evidence IV, Description of a case series, with analysis of results, without a comparative study.

Emergency room closed reduction versus in situ splinting in the treatment of paediatric supracondylar humerus fractures

PURPOSE

Displaced supracondylar humerus fractures are treated with open or closed reduction and percutaneous pinning. In 2012, our management of patients with a displaced fracture changed from closed reduction in the emergency department (ED) to in situ splinting prior to closed reduction and pinning in the operating room (OR). The purpose of this study was to investigate if outcomes or complications differ between these two management methods.

METHODS

Patients less than ten years old with a Gartland type II or III supracondylar humerus fracture between 2008 and 2016 were included. Cases of polytrauma were excluded. Radiographic outcomes were assessed at follow-up. The Fisher's exact test was used for categorical variables and the Wilcoxon rank sums tests for continuous variables.

RESULTS

In all, 157 patients were included, 89 with reduction in the ED and 68 without. There was no significant difference between the groups related to demographic factors or fracture characteristics. Patients managed without reduction in the ED had a lower average delay from ED to OR compared with those treated with reduction (16 hours versus 22 hours, p < 0.005) and a shorter hospital length of stay (34 hours versus 40 hours, p < 0.005).

CONCLUSION

No difference in complications or outcomes was found between patients with Type II or III supracondylar fractures treated initially with or without closed reduction in the ED. Patients treated without ED reduction were taken to the OR sooner and remained in the hospital for a shorter period of time. Splinting in situ reduces anaesthesia exposure without increasing postoperative complications or suboptimal outcomes.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Infantile Supracondylar Humeral Fractures (Patients Less Than Two Years of Age): Twice as Common in Females and a High Rate of Malunion with Lateral Column-Only Fixation

BACKGROUND

The age range for supracondylar humeral fractures spans from 1 to 14 years of age; most published studies have analyzed patients as non-age-segregated cohorts. Some isolated studies focused on the upper age range, demonstrating a male predominance and more severe fractures. The purpose of the current study was to analyze a large cohort of patients with surgically treated supracondylar humeral fractures at the low end of the age range (<2 years of age).

METHODS

Patients <2 years of age were identified from surgical billing records. Pin constructs were categorized as lateral column-only fixation or medial and lateral column fixation. All patients were followed through fracture-healing. Substantial loss of reduction was defined as a Baumann angle that changed ≥10° between surgery and healing or as a lateral rotation percentage (i.e., Gordon index) of ≥50% at the time of healing. The Fisher exact test was used for statistical analysis.

RESULTS

One hundred and three patients met our inclusion criteria. There were 69 female and 34 male patients (a 2:1 female-to-male ratio). Two patients did not have adequate follow-up radiographs. Of the 46 patients with bicolumnar fixation, 5 (11%) demonstrated loss of reduction compared with 20 (36%) of 55 patients with lateral column-only fixation. This difference between the groups was significant (p = 0.005). The group with lateral column-only fixation had 4.7-times-higher odds of loss of reduction (95% confidence interval, 1.6 to 13.8). A subset of patients had in-cast imaging that allowed calculation of the posterior sagittal cast index (a measure of cast fit). Eight of 15 patients who had a posterior sagittal cast index of ≥0.20 experienced loss of reduction, while only 1 of 19 patients with a cast index value of <0.20 had loss of reduction (p = 0.004).

CONCLUSIONS

Supracondylar humeral fractures were twice as common in females in this very young cohort. We also found a nearly 5-times-higher odds of loss of reduction when fracture fixation was of the lateral column only.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Understanding the Epidemiology of Pediatric Supracondylar Humeral Fractures in the United States: Identifying Opportunities for Intervention

BACKGROUND

Supracondylar humeral fractures (SCHF) are the most common elbow fractures in children. The epidemiology of these injuries in the United States is described.

METHODS

The Nationwide Emergency Department Sample database was queried for all children (age, below 18 y) with SCHF treated in the emergency department (ED) from 2006 to 2011, and weighted estimates were extracted.

RESULTS

A total of 63,348 ED visits for SCHF were identified. The weighted estimate of ED visits remained stable over the study period, ranging from 60.3 to 71.8 per 100,000 children annually. There was no significant difference in fracture rate (52% male) by sex. The mean age of closed injury was 5.5±3.1 years, with 53.6% of fractures occurring in children 3 to 6 years. Open injuries accounted for 1.0% of fractures. Children with open injuries were significantly older (mean, 9.1±4.4 y; P<0.0001) and more often male (OR, 1.43; P<0.001). Neurovascular injury occurred in significantly older children (mean, 7.6±3.1 y; P<0.0001) and was documented in 11.4% of open fractures and 3.6% of operative fractures. Although the South had the greatest number of total SCHF-related ED visits, children in the West had significantly more SCHF-related ED visits per 100,000 children annually (77.9) than all other regions (P<0.05). Average fracture rates were approximately 60% higher in April to September than October to March (P<0.001). Mean total charges for patients treated and discharged from the ED were $2965, compared with $17,865 in children admitted for surgery (P<0.05). Mean charges were significantly higher in the West compared with all other regions (P<0.0001).

CONCLUSIONS

The incidence of pediatric SCHF-related ED visits remained stable from 2006 to 2011 and occurred most frequently in children aged 3 to 6 years. Open injuries are rare and are more likely to occur in older boys. There are significant differences in the injury rates and charges across geographic regions, identifying opportunities for injury prevention, cost reduction, and value improvement. The indications for operative management should be clearly delineated given the high cost of surgical treatment.

LEVEL OF EVIDENCE

Therapeutic Level IV.

Cross Pinning Versus Lateral Pinning in the Management of Type III Supracondylar Humerus Fractures in Children

INTRODUCTION

Closed reduction of supracondylar humerus fractures with K-wires has become the standard line of management with different opinions regarding the technique that is utilized.

AIM

To compare the functional and radiological outcomes of lateral and cross pinning technique in supracondylar fractures of humerus in children.

MATERIALS AND METHODS

A prospective study with 57 cases of displaced fracture supracondylar humerus, treated by lateral (Group A n=28) and cross pinning (Group B n=29), was conducted between May 2013 and May 2015. Independent sample student's t-test was done to assess the parameters like age, follow-up and duration of surgery. The results were expressed as mean with standard deviation and p<0.05 was considered as statistically significant.

RESULTS

As per the Gartland classification system, 46 (80.7%) patients had Type IIIA and 11 (19.2%) patients had Type IIIB fracture. The average surgical time was 28.3±1.6 minutes in Group A and 30±3.6 minutes in Group B (p=0.02). About, 3.5% patients in Group A had pin loosening. As per the Flynn criteria, 78.6% in Group A and 79.3% in Group B had excellent results.

CONCLUSION

No significant difference in terms of functional and radiological outcome was observed between both the techniques. Thus, both the techniques have equal results.

EPIDEMIOLOGY OF FRACTURES AND DISLOCATIONS IN CHILDREN

Fracture is quite a common occurrence in the age group of children, with a fairly wide variety of epidemiology throughout the world, hence it could be considered as a major health problem. A retrospective study of all pediatric fractures presenting to Dr. Soegiri General Hospital Lamongan, Indonesiain 2015 was undertaken. It showed that 79.5% of children’s fractures occurred in males and that 86.76% presented as a single fracture, whileelbow dislocation is the most prevalent dislocation in this study.Analysis of pediatric fractures shows that there is a trimodal distribution of single fracture with age, withdistal radius/ulna fracture as the most prevalent single fracture.The commonest cause of single fracture are road traffic accident, and the majority involve the upper limb. Those suggested that there should be more concern about road safety program in Indonesia.

Distance of translation as a predictor of failure of fixation in paediatric supracondylar fractures

Introduction This study investigates the influence of incomplete reduction of supracondylar fractures on the incidence of loss of reduction requiring reoperation Materials and methods A review of 107 consecutive patients presenting with supracondylar fractures treated with closed reduction and Kirschner wire stabilisation, between January 2011 and March 2013, was conducted. The mean age was 5 years (range 10 months to 12 years). Pre-, intra- and postoperative radiographs were reviewed. All patients who had failure of fixation requiring revision surgery were identified. Results Ninety-nine patients had an initial adequate radiographic reduction. Of these, one (1%) required revision surgery. Eight patients had an initial incomplete radiographic reduction and, of these, six (75%) required revision surgery (P < 0.0001). Discussion Supracondylar fractures treated with closed reduction and K wire stabilisation require adequate intraoperative reduction. Incomplete reduction should not be accepted, as despite the bones potential to remodel, the risk of further loss of reduction is high, requiring reoperation.