Surgical treatment of pediatric supracondylar humerus fracture could be safely performed by general orthopedists

A new technique of intramedullary elastic reduction of the "de-sharpened" Kirschner wire for the treatment of Gartland type III posterolateral displaced supracondylar fracture of the humerus in children

OBJECTIVE

To compare the clinical effects of intramedullary elastic reduction of the "de-sharpened Kirschner wire and traditional three-dimensional manipulation in the treatment of Gartland type III posterolateral supracondylar fracture of the humerus in children.

METHODS

A retrospective cohort analysis was made on 106 cases of Gartland type III posterolateral supracondylar fracture of the humerus treated in the Department of Orthopaedics of a Children's Hospital from March 2020 to March 2022. According to different surgical technology, the patients were divided into two groups: intramedullary elastic reduction of the de-sharpened Kirschner wire group (experimental group, n = 50) and traditional three-dimensional manipulation group (control group, n = 56). The surgical operating time, intraoperative fluoroscopy times, postoperative Baumann angle changes, postoperative elbow function Flynn score, and complications were collected and compared between the two groups.

RESULTS

All the enrolled cases underwent surgery successfully and were followed-up at least 6 months. The surgical operating time of the experimental group was 32.88 ± 3.69 min and that of the control group was 45.56 ± 10.13 min, and the difference was statistically significant (P < 0.05). The intraoperative fluoroscopy times were 20.62 ± 5.41 times in the experimental group and 32.48 ± 8.20 times in the control group (P < 0.05). The change of Baumann angle in the experimental group after operation was 2.3 ± 1.3 and that in the control group was 6.0 ± 2.1 (P < 0.5). Elbow joint Flynn scoring standard to evaluate the curative effect: the excellent and good rate was 98.00% (49/50) in the experimental group and 92.86% (52/56) in the control group (P > 0.5). There were no complications such as osteomyelitis, compartment syndrome, iatrogenic vascular and nerve injury, and myositis ossificans in either group.

CONCLUSIONS

Good functional outcome can be obtained with both intramedullary elastic reduction of the de-sharpened Kirschner wire and traditional three-dimensional manipulation for Gartland type III posterolateral displaced supracondylar fracture of the humerus in children; however, the former does not need repeated manipulation, and the operation time is shorter, the number of intraoperative fluoroscopy is less, and the recovery of the Baumann angle is better.

Increasing Value in Subspecialty Training: A Comparison of Variation in Surgical Complications for Pediatric Versus Other Fellowship-trained American Board of Orthopaedic Surgery Candidates in the Treatment of Supracondylar Fractures

INTRODUCTION

The effect of orthopaedic fellowship subspecialization on surgical complications for patients with supracondylar fracture is unknown. This study seeks to compare the effect of subspecialty training on supracondylar fracture complications.

METHODS

The American Board of Orthopaedic Surgery Part II Examination Case List database was reviewed for all supracondylar fractures from 1999 to 2016. Procedures were divided by fellowship subspecialty (trauma, pediatric, or other) and case volume and assessed by surgeon-reported surgical complications. Predictive factors of complications were analyzed using a binary multivariate logistic regression.

RESULTS

Of 10,961 supracondylar fractures identified, 53.47% were done by pediatric fellowship-trained surgeons. Pediatric-trained surgeons had fewer surgical complications compared with their trauma or other trained peers (4.54%, 5.67%, and 6.24%; P = 0.001). Treatment by pediatric-trained surgeons reduced surgical complications (OR = 0.79, 95% CI: 0.66 to 0.94; P = 0.010), whereas increased case volume (31+ cases) showed no significant effect (OR = 0.79, 95% CI: 0.62 to 1.02; P = 0.068). Patient sex, age, and year of procedure did not affect complication rates, while those treated in the Southeast region of the United States and those with a complex fracture type were at increased odds.

DISCUSSION

Treatment of supracondylar fractures by pediatric-trained surgeons demonstrates reduced surgeon-reported complications compared with their other fellowship-trained counterparts, whereas case volume does not. This suggests the value of fellowship training beyond pertinent surgical caseload among pediatric-trained surgeons and may lie in targeted education efforts.

Time of surgery and surgeon level in supracondylar humerus fractures in pediatric patients: A retrospective study

BACKGROUND

Supracondylar humerus fractures account for more than 60% of all elbow fractures and about 1/5 of all pediatric fractures. Unfortunately, these fractures can be associated with risk of complications including neurovascular injuries, malunions and limb deformities. Controversy exists regarding the effect of time of surgical intervention and/or level of surgeon performing the surgery on outcome of these fractures.

AIM

To determine whether time of surgical intervention and/or surgeon level influence the outcomes of surgically managed pediatric supracondylar humerus fractures.

METHODS

We retrospectively studied 155 pediatric patients presenting with a supracondylar humerus fracture in a level 1 trauma center from January 2006 to December 2019. The data extracted included demographic data, fracture characteristics, surgical data, and follow-up outcomes. The collected data was analyzed and P values of < 0.05 were considered statistically significant.

RESULTS

Of the cohort, 11% of patients had documented post-operative complications, of which the majority occurred in surgeries performed after day time working hours and in fractures requiring open reduction. While the lowest complication rate was found in surgeries performed by pediatric orthopaedic surgeons, this did not reach statistical significance.

CONCLUSION

In pediatric patients undergoing surgery for supracondylar fractures, we found a higher complication rate when surgeries were not performed during working hours. Surgeon level and training had no significant effect on the risk of post-operative complications.

Reliability of Gordon Lateral Rotation Percentage and Prabhakar Percentage of Metaphyseal Overhang for Pediatric Supracondylar Humerus Fracture; Is it Clinically Reliable for John Hopkins Classification Coronal Fracture Subtypes?

BACKGROUND

Rotational malalignment is a common problem in pediatric supracondylar humerus fractures (SCHF). Several techniques have been described to evaluate the true rotation value. Although the Prabhakar and Gordon techniques are used frequently, their superiority to each other in terms of measurement quality is unknown.

QUESTIONS/PURPOSES

The aim of this study was to investigate the clinical compatibility of the 2 techniques and to evaluate whether they are suitable for all subtypes.

METHODS

This cross-sectional study included 40 patients with SCHF (including subtypes; Typical, Medial Oblique, Lateral Oblique, and High fracture pattern). The Gordon lateral rotation percentage and Prabhakar percentage of metaphyseal overhang were measured twice by 4 experienced Orthopedics and Traumatology surgeons at 8-week intervals. The interobserver and intraobserver reliability were examined using the intraclass correlation coefficient.

RESULTS

The interobserver reliability for Gordon and Prabhakar technique was 0.816 and 0.762 for the first measurement and 0.811 and 0.811 for the second measurement, respectively.The medial oblique fracture pattern was determined to have the best interobserver agreement among the subtypes. The result was excellent for the medial and lateral oblique subtypes, good for the typical fracture pattern, and fair for the high fracture pattern. The intraobserver reliability for Gordon and Prabhakar technique was excellent, 0.924 and 0.922, respectively.

CONCLUSION

The main finding of this study was that the Gordon and Prabhakar techniques have similar interobserver and intraobserver reliability. Although the Gordon technique tends to have higher interobserver reliability, the difference was clinically insignificant. These measurements should not be relied upon in cases of SCHF with a high fracture pattern because of the different anatomic features of that region.

LEVEL OF EVIDENCE

Level III.

Is radiological rotation measurement affected by the fracture pattern in pediatric supracondylar humeral fractures?

BACKGROUND

In supracondylar humerus fractures (SCHF), the most frequently used method to calculate rotation is the Gordon lateral rotation percentage (GLRP) defined by Gordon et al. However, this technique includes only typical fractures (49%-80% of all fractures) from the Johns Hopkins (J-H) fracture classification system.

PURPOSE

The aim of the study was to investigate (1) is Gordon criteria useful for John Hopkins subgroups of supracondylar fractures and (2) is Gordon criteria affected by internal and external rotation.

MATERIAL AND METHODS

This study was designed using four pediatric left humerus bones obtained from the Sawbone© company. For each bone, an osteotomy was made to mimic each of the J-H coronal fracture patterns. The cut bones were placed in a wooden rotation apparatus. The GLRP measurements were taken by five blinded observers.

RESULTS

In the repeated measurements of the observers, <20° rotation typical and <30° medial oblique and lateral oblique fracture pattern were measured as within the limits of an acceptable amount of rotation according to the Gordon criteria. However, for high fracture pattern (HFP), ≤30° internal rotation and <60° external rotation were determined to be within the acceptable rotation criteria according to the Gordon criteria.

CONCLUSIONS

All fracture patterns have different characteristics; however, based on the data of this study, the Gordon criteria can be used safely for typical, medial oblique, and lateral oblique fracture patterns but it is necessary to lower the acceptable rate of 50% for HFP.

Complications With Surgical Treatment of Pediatric Supracondylar Humerus Fractures: Does Surgeon Training Matter?

INTRODUCTION

National trends reveal increased transfers to referral hospitals for surgical management of pediatric supracondylar humerus (SCH) fractures. This is partly because of the belief that pediatric orthopaedic surgeons (POs) deliver improved outcomes compared with nonpediatric orthopaedic surgeons (NPOs). We compared early outcomes of surgically treated SCH fractures between POs and NPOs at a single center where both groups manage these fractures.

METHODS

Patients ages 3 to 10 undergoing surgery for SCH fractures from 2014 to 2020 were included. Patient demographics and perioperative details were recorded. Radiographs at surgery and short-term follow-up assessed reduction. Primary outcomes were major loss of reduction (MLOR) and iatrogenic nerve injury (INI). Complications were compared between PO-treated and NPO-treated cohorts.

RESULTS

Three hundred and eleven fractures were reviewed. POs managed 132 cases, and NPOs managed 179 cases. Rate of MLOR was 1.5% among POs and 2.2% among NPOs (P=1). Rate of INI was 0% among POs and 3.4% among NPOs (P=0.041). All nerve palsies resolved postoperatively by mean 13.1 weeks. Rates of reoperation, infection, readmission, and open reduction were not significantly different. Operative times were decreased among POs (38.1 vs. 44.6 min; P=0.030). Pin constructs were graded as higher quality in the PO group, with a higher mean pin spread ratio (P=0.029), lower rate of "C" constructs (only 1 "column" engaged; P=0.010) and less frequent crossed-pin technique (P<0.001). Multivariate analysis revealed minimal positive associations only for operative time with MLOR (odds ratio=1.021; P=0.005) and INI (odds ratio=1.048; P=0.009).

CONCLUSIONS

Postsurgical outcomes between POs and NPOs were similar. Rates of MLOR were not different between groups, despite differences in pin constructs. The NPO group experienced a marginally higher rate of INI, though all injuries resolved. Pediatric subspecialty training is not a prerequisite for successfully treating SCH fractures, and overall value of orthopaedic care may be improved by decreasing transfers for these common injuries.

LEVEL OF EVIDENCE

Level III-retrospective cohort study.

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.].

Does Surgeon Subspecialty Training Affect Outcomes in the Treatment of Displaced Supracondylar Humerus Fractures in Children?

INTRODUCTION

The effect of the treating surgeon's subspecialty training on the outcomes of managing displaced supracondylar humerus fractures in the pediatric cohort remains under debate. The objective of this study was to examine patient outcomes and treatment variables for these injuries based on the surgeon subspecialty training.

METHODS

A retrospective study of children who had undergone primary closed reduction and percutaneous fixation for displaced supracondylar humerus fractures was done from January 2012 through May 2019. The following four groups with differing orthopaedic subspecialty training were evaluated: (1) pediatric fellowship trained (2) trauma fellowship trained, (3) sports medicine fellowship trained, and (4) all others. Outcomes examined included time to surgery, surgical time, fluoroscopy usage, postoperative follow-up protocols, radiographic measurements of alignment, and complications between surgeon groups.

RESULTS

Two hundred thirty-one cases were included (mean age 6 ± 2 years). Pediatric fellowship-trained surgeons took patients to surgery in a more delayed fashion (>12 hours, P = 0.02). Surgical time and fluoroscopy usage were significantly shorter for pediatric fellowship-trained surgeons (P < 0.001). No statistical difference was noted in pin configuration constructs between the groups. Pediatric fellowship-trained surgeons, on average, saw patients two times postoperatively within a year with most patients being within 30 days. Complications were not statistically different between the groups.

CONCLUSIONS

Pediatric fellowship-trained orthopaedic surgeons provide more efficient care on a more delayed basis for displaced supracondylar humerus fractures than other subspecialty-trained orthopaedic surgeons. However, if barriers exist that limit the practicality or availability of these specialists, nonpediatric fellowship-trained surgeons achieve similar and satisfactory outcomes.

LEVEL OF EVIDENCE

Level III retrospective cohort study.