The outcome of early revision of malaligned pediatric supracondylar humerus fractures

[Incorrectly healed supracondylar humerus fracture : That will grow out later on?!]

The supracondylar humerus fracture is the most frequent fracture of the elbow region during the growth period. The peak age is around 5 years. Extension fractures predominate. The clinical diagnostics are supplemented by X‑ray images in two projections. Growth-associated spontaneous corrections of posttraumatic deformities rarely occur. The goal of treatment is therefore the active transformation of every displaced fracture into a nondisplaced stably fixed fracture.If this is not successful, the consequences of healing in a malalignment can be, e.g., restriction of elbow flexion due to remaining antecurvation or cubitus varus. Combinations are often present. The causes include technical problems with reduction and retention but also misjudgement of the X‑ray findings, ignorance of the growth prognosis or inadequate verification of whether the treatment goal has been achieved.Unsatisfactory treatment results should be corrected as early as possible. This can be done primarily before bony healing is completed or secondarily as a corrective osteotomy at any later point in time. The earlier the correction of the malalignment is performed, the greater the chances of a complete restoration to the original condition. Depending on the type and extent of the deformity various techniques for corrective osteotomy are suggested in the literature.

Delayed Revision Closed Reduction and Percutaneous Pinning of a Pediatric Supracondylar Humerus Fracture: A Case Report

Supracondylar humerus fractures (SCH) are the most prevalent elbow fractures in the pediatric age group. Delay in treatment poses challenges and an elevated risk of complications. We describe a case of revision for postoperative malalignment with closed reduction percutaneous pinning with good clinical outcomes. Malunion complications in SCH can be minimized with early intervention in cases of postoperative displacement. Careful use of technical skills can help with closed reduction in cases with delayed presentation.

Management of Pediatric Elbow Fractures and Dislocations

Pediatric elbow fractures and dislocations have always been a challenge from a diagnostic and therapeutic point of view, primarily due to the complex nature of the pediatric elbow, especially its developmental anatomy. They must be diagnosed and treated on time to prevent numerous complications with long-term consequences. With the development of radiology and pediatric surgery and orthopedics, as well as the development of modern osteosynthesis materials, concerning current scientific and professional knowledge, the outcomes are getting better, with fewer acute and chronic complications. This comprehensive review aims to provide clinicians current knowledge about pediatric elbow fractures and dislocations so that in daily practice they have as few doubts as possible with the best possible treatment outcomes.

Posttraumatic Cubitus Varus: Respect the Columns

Posttraumatic cubitus varus is a multiplanar deformity that results from an improperly reduced supracondylar humerus fracture. The prevention of posttraumatic cubitus varus hinges on the stable restoration of all 3 columns of the distal humerus while avoiding malrotation. The collapse of any column leads to varying degrees of deformity in the coronal, sagittal, and/or axial plane. The purpose of this article is to explain the pattern of the deformity and use this to summarize preventative tactics for avoiding its described sequelae. We also summarize, illustrate, and present case examples for the various osteotomies used to correct the deformity, and speculate future directions.

Distal humeral corrective osteotomy for treatment of supracondylar fracture malunions in children

Purpose

This study aimed to determine the functional and radiographic outcomes following corrective distal humeral osteotomies for the treatment of supracondylar fracture malunions in children. We hypothesized that such secondary reconstructive procedures could restore a reasonable and near-normal amount of functionality in a large patient cohort at a tertiary referral center.

Methods

We retrospectively reviewed the clinical and radiological records of 38 children who underwent corrective osteotomy for posttraumatic supracondylar humeral malunion using K-wire fixation. All clinical data were extracted after chart review, including age, sex, dominant side whenever available, follow-up duration, and elbow range of motion preoperatively and at the final visit. Radiographic parameters, including Baumann's angle, humeroulnar angle, humerocondylar angle, and elbow range of motion were evaluated preoperatively, postoperatively, and at the final visit to identify the surgical correction outcomes.

Results

The mean age of the patients at fracture was 5.6 (±2.7) years, and the mean age at surgical intervention was 8.6 (±2.6) years. The mean follow-up period of the current series was 28.2 (±31.1) months. Baumann's angle, humeroulnar angle, and humerocondylar angle were successfully restored to physiological ranges (72.6°, 5.4°, and 36.1°, respectively). Postoperatively, elbow extension improved from -22° (±5.7) to -2.7° (±7.2) versus flexion from 115° (±13.2) to 128.2° (±11.1). Three revision surgeries (8%) were encountered.

Conclusions

Corrective osteotomy of the distal humerus with K-wire fixation is a reliable method to efficiently correct malunion of the distal humerus in different planes, thereby improving elbow range of motion and appearance.

Level of evidence

level IV: Retrospective therapeutic study.

Correction of Cubitus Varus Using Computer-Assisted Hexapod Multiplanar External Fixators: A Report of 3 Cases

CASE

Three male patients, 8-, 13-, and 18-year-old, all developed posttraumatic cubitus varus elbow deformity after distal humerus supracondylar fractures. Each underwent a distal humerus osteotomy with application of a hexapod external fixator to gradually correct the deformity.

CONCLUSION

In patients with cubitus varus malunion, the stability of the hexapod external fixation, percutaneous nature of the osteotomy, and availability of running a residual computer-assisted program provides a consistent technique for deformity correction.

Pinning of supracondylar fractures in children - Strategies to avoid complications

In the pediatric population supracondylar humerus fracture (SHF) is one of the most common injuries. Diagnosis is based on inspection and conventional radiography. SHFs should be classified according to the modified Gartland classification, which guides treatment. Non-displaced or minimally displaced fractures (Gartland type-I) should be treated non-operatively, completely displaced type III fractures require closed reduction and K-wire fixation. In type-II fractures, important landmarks, such as the anterior humeral line (Roger´s line), the shaft-physeal angle (Baumann´s angle) and the shaft condylar angle should be considered to guide treatment. Special attention has to be paid for potential rotational dislocation, which is indicated by a ventral spur. In such cases surgery is necessary. The degree of acceptable extension malpositioning depends on patient´s age. In 10-year-old children fractures with a shaft condylar angle of more than 15° are still suitable for non-operative therapy. Timing for surgery is controversially discussed. Postponing surgery to the next day seems reasonable if absence of pain, intact soft tissue and normal neurovascular status are present. Neurovascular complications are not uncommon, especially in Gartland type-III fractures and in cases with additional forearm injuries. A white hand without palpable pulse needs emergency surgery, the management of the pulseless pink hand is still controversially discussed. Different operative techniques exist for surgical treatment. The golden standard is closed reduction and percutaneous K-wire pinning. Crossed pinning seems to achieve best biomechanical stability. Since ulnar nerve injuries are reported to occur in 6% after medially inserting K-wires, lateral divergent insertion of two K-wires has been compared to crossed pinning fixation in several randomized controlled trials. Meta-analyses demonstrated a higher risk for ulnar nerve injury for the crossed pinning technique while risk for loss of fixation was higher in lateral only pinning. In both cases, K-wires should be removed 3-6 weeks after surgery with consolidation of the fracture. Clinical and radiological follow-up should be carried out at 3 weeks post fracture fixation to rule out loss of reduction. If this should occur, early revision surgery has been demonstrated beneficial.

Use of external fixation for juxta-articular fractures in children

In this article, the use of external fixation in the management of juxta-articular fractures in paediatric patients is discussed. Basic principles of Ilizarov technique are described for distal radial, distal femoral, distal humeral and distal tibial fractures. Common indications for external fixation in pediatric fractures are comminuted, complicated, and/or open fractures, particularly at the distal humerus, distal radius, distal femur and distal tibia. There are several benefits of external frame fixation in these type of injuries in children. This method avoids additional injury to the growth plate as K-wires are not placed through it. It enables careful reduction without interfragmentary compression and correct anatomic alignment. There is no soft tissue dissection and periosteal blood supply is preserved. External fixation ensures primary fracture stability even in presence of comminution and high adjustment capability. Immediate joint motion and early weight-bearing are further advantages. Joint bridging is an option in severe bone loss or soft tissue injuries.

Optimal postoperative immobilisation for supracondylar humeral fractures

BACKGROUND

Supracondylar humeral fractures (SCHFs) are very common in paediatric patients. In France, percutaneous fixation with two lateral-entry pins is widely used after successful closed reduction. Postoperative immobilisation is typically with a long arm cast combined with a tubular-bandage sling that immobilises the shoulder and holds the arm in adduction and internal rotation to prevent external rotation of the shoulder, which might cause secondary displacement. The objective of this study was to compare this standard immobilisation technique to a posterior plaster splint with a simple sling.

HYPOTHESIS

Secondary displacement is not more common with a posterior plaster splint and sling than with a long arm cast.

MATERIAL AND METHODS

One hundred patients with extension Gartland type III SCHFs managed by closed reduction and percutaneous fixation with two lateral-entry pins between December 2011 and December 2015 were assessed retrospectively. Postoperative immobilisation was with a posterior plaster splint and a simple sling worn for 4 weeks. Radiographs were obtained on days 1, 45, and 90.

RESULTS

Secondary displacement occurred in 8% of patients. No patient required revision surgery.

DISCUSSION

The secondary displacement rate was comparable to earlier reports. Of the 8 secondary displacements, 5 were ascribable to technical errors. The remaining 3 were not caused by rotation of the arm and would probably not have been prevented by using the tubular-bandage sling.

CONCLUSION

A posterior plaster splint combined with a simple sling is a simple and effective immobilisation method for SCHFs provided internal fixation is technically optimal.

LEVEL OF EVIDENCE

IV retrospective observational study.

Distal humeral flexion osteotomy for the treatment of supracondylar extension-type malunions in children

Distal humeral extension-type malunions may occur as a complication following improper reduction of supracondylar humerus fractures. We evaluated results after distal humeral flexion osteotomies for sagittal realignment of the humeral condyle in children. Medical records and radiographs of all patients younger than 18 years of age, who underwent this procedure because of a clinically relevant lack of elbow flexion, were evaluated. In a cohort of 18 children with a mean age of 8 years at the time of surgery and a mean follow-up duration of 1 year, elbow flexion increased significantly from a mean of 101° preoperatively to 126° at the final follow-up; established radiographic parameters (e.g. anterior humeral line, humerocondylar angle) were normalized as well. The distal humeral flexion osteotomy is a reliable method to efficiently correct extension-type malunions and improve impaired elbow flexion in children.