Orthopedic pitfalls in the ED: pediatric supracondylar humerus fractures

Outcomes of Nonoperatively Treated Pediatric Supracondylar Humeral Fractures at the Nkhotakota District Hospital, Malawi

Displaced supracondylar humeral fractures (SCHFs) benefit from closed reduction and percutaneous pinning. In Malawi, many SCHFs are treated nonoperatively because of limited surgical capacity. We sought to assess clinical and functional outcomes of nonoperatively treated SCHFs in a resource-limited setting.

Methods

We retrospectively reviewed all patients with SCHFs treated at Nkhotakota District Hospital (NKKDH) in Malawi between January 2014 and December 2016. Patients subsequently underwent clinical and functional follow-up assessment.

Results

We identified 182 children (54% male, mean age of 7 years) with an SCHF; 151 (83%) of the fractures were due to a fall, and 178 (98%) were extension-type (Gartland class distribution: 63 [35%] type I, 52 [29%] type II, and 63 [35%] type III). Four patients with type-I fractures were treated with an arm sling alone, and 59 were treated with straight-arm traction to reduce swelling and then splint immobilization until union. All 119 of the patients with Gartland type-II and III or flexion-type injuries were treated with straight-arm traction, manipulation under anesthesia without fluoroscopy, and then splint immobilization until union. A total of 137 (75%) of the patients were available for follow-up, at a mean of 3.9 years after injury. The Flynn functional outcome was excellent for 39 (95%) with a type-I fracture, 30 (70%) with type-II, and 14 (29%) with type-III. The Flynn cosmetic outcome was excellent for 40 (98%) with a type-I fracture, 42 (98%) with type-II, and 41 (84%) with type-III. Forty (98%) of the children with a type-I fracture, 41 (95%) with type-II, and 32 (65%) with type-III returned to school without limitation. Controlling for sex, delayed presentation, medical comorbidities, injury mechanism, and skin blistering/superinfection during traction, patients with type-II fractures were 5.82-times more likely (95% confidence interval [CI], 1.71 to 19.85) and those with type-III fractures were 9.81-times more likely (95% CI, 3.00 to 32.04), to have a clinical complication or functional limitation compared with patients with type-I fractures.

Conclusions

Nonoperative treatment of type-III SCHFs resulted in a high risk of clinical complications or functional impairment. These results illustrate the urgent need to increase surgical capacity in low-income countries like Malawi to improve pediatric fracture care.

Level of Evidence

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

The Emergency Evaluation and Management of Pediatric Extremity Fractures

Approximately one-third of children sustain a fracture before the age of 16 years; however, their unique anatomy and healing properties often result in a good outcome. This article focuses on the diagnosis and management of pediatric extremity injuries. The article describes the anatomic features and healing principles unique to children and discusses pediatric upper and lower extremity fractures and presents evidence-based and standard practice for their management. Finally, the article describes the conditions under which emergency physicians are likely to miss pediatric fractures by highlighting specific examples and discussing the general factors that lead to these errors.

Bilateral Supracondylar Humerus Fracture in Pediatric after a Fall on an Outstretched Hand

Background. Supracondylar humerus fracture (SCH) is common in the pediatric age group 5-7 years, mostly due to a fall on an outstretched hand. However, a bilateral SCH is rarely observed in this age group. Management of SCH is either surgical or conservative based on the following factors: patient age, fracture pattern and neurovascular involvement. Complications of a displaced SCH can be dramatically reduced by early surgical fixation. Acute complications include: neurovascular injury and compartment syndrome, and long term complications include: stiffness, infections and angular deformities. In this article, we present a rare case of bilateral supracondylar humerus fractures with a six-months follow-up.

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.

Detection of Traumatic Pediatric Elbow Joint Effusion Using a Deep Convolutional Neural Network

OBJECTIVE

The purpose of this study is to determine whether a deep convolutional neural network (DCNN) trained on a dataset of limited size can accurately diagnose traumatic pediatric elbow effusion on lateral radiographs.

MATERIALS AND METHODS

A total of 901 lateral elbow radiographs from 882 pediatric patients who presented to the emergency department with upper extremity trauma were divided into a training set (657 images), a validation set (115 images), and an independent test set (129 images). The training set was used to train DCNNs of varying depth, architecture, and parameter initialization, some trained from randomly initialized parameter weights and others trained using parameter weights derived from pretraining on an ImageNet dataset. Hyperparameters were optimized using the validation set, and the DCNN with the highest ROC AUC on the validation set was selected for further performance testing on the test set.

RESULTS

The final trained DCNN model had an ROC AUC of 0.985 (95% CI, 0.966-1.000) on the validation set and 0.943 (95% CI, 0.884-1.000) on the test set. On the test set, sensitivity was 0.909 (95% CI, 0.788-1.000), specificity was 0.906 (95% CI, 0.844-0.958), and accuracy was 0.907 (95% CI, 0.843-0.951).

CONCLUSION

Accurate diagnosis of traumatic pediatric elbow joint effusion can be achieved using a DCNN.

Temporal characteristics of paediatric supracondylar humerus fractures

Objective

Supracondylar humeral fractures are the most common elbow injury occurring in the paediatric population, accounting for 55–80% of all elbow fractures and 3–18% of all paediatric fractures. They occur most commonly due to a fall from play equipment or furniture. This study aims to determine if any relationship exists between supracondylar humeral fractures and any temporal or injury characteristics. It was hypothesised that an increased incidence of supracondylar fractures would be observed in summer months and on weekends.

Methods

All patients <18 years of age with an isolated distal humerus supracondylar fracture between 2004 and 2014 were included in this study ( n = 569). Patient demographics and fracture characteristic data were collected. Hypothesis testing was performed to assess for any statistically significant relationship between fracture incidence and temporal or injury characteristics. Patients were then divided based on their management (conservative vs. operative) and hypothesis testing was performed to determine whether any difference existed between the management groups with regards to temporal and injury characteristics.

Results

No statistically significant association was noted between fracture incidence and gender, laterality, or day/month/season of injury. Time of injury and presentation to the Emergency Department demonstrated significant results, with highest incidence in the afternoon hours (12:00–17:59).

Conclusions

Unlike previous international studies, no significant difference was noted between day/month/season of injury and incidence of supracondylar fracture. This is thought to be likely due to the difference in climate between Australia and other countries.

Fracture Supracondylar Humerus: A Review

Fracture supracondylar humerus is one of the most common fractures encountered in pediatric age group at all levels (both rural and urban). Thus it needs a special review in its management protocol as per the changing trend. Modified Gartland classification is the most accepted classification and has its importance in decision making regarding management and prognosis. Neurovascular complications are mostly associated with Type III A, III B and Type IV variety and they most of the time need surgical intervention for stabilization, exploration of brachial artery, sometimes median nerve exploration and reduction of fracture. Cubitus varus is the most common associated deformity associated with this fracture (especially in Type III A). The aim of the review was to develop an insight for the understanding of variations in presentation and management of supracondylar fracture of the humerus (both simplicity and complexity) and the flowing trend in addition to the recent advances to deal with this particular pediatric orthopaedic entity which often presents as an emergency.

Emergency department evaluation and treatment of pediatric orthopedic injuries

Orthopedic injuries in children are unique when compared to those of adults because of the physiologic differences, especially the growth plates, stronger periosteum, and dynamic state of growth. The approach to the orthopedically injured child requires a gentle yet thorough focus with consideration of the growth plates as a primary area of weakness and growth when the child sustains an injury. Understanding the developmental stages of bones is paramount to being able to manage any injuries. Finally, what appears to be a benign injury may portend more serious issues, because nonaccidental trauma must always be considered in the evaluation of the injured child.

Arterial damage accompanying supracondylar fractures of the humerus

BACKGROUND

Arterial damage is sometimes associated with supracondylar fractures of the humerus. Diagnosis and careful management of the fracture and arterial repair is crucial.

OBJECTIVES

The aim of this study was to determine the prevalence and outcome of supracondylar fractures of the humerus with signs and symptoms of limb ischemia, before and after arterial decompression or arterial reconstruction.

MATERIALS AND METHODS

From September 2004 to July 2010, 225 consecutive patients with supracondylar fracture of the humerus were prospectively recruited.

RESULTS

From among 75 cases with Gartland type III fractures, 22 were found to have vascular injury.. Of the 22 cases with vascular injury, 7 patients underwent arterial reconstruction. The other 15 received arterial decompression. All patients had a satisfactory outcome.

CONCLUSIONS

A high level of suspicion and careful clinical evaluation leading to an early diagnosis and management of vascular injury accompanying supracondylar fracture is very important to prevent unnecessary sequelae ranging from limb claudication, and compartment syndrome to more severe complications like Volkmann's contracture and even limb loss.

Review article: paediatric supracondylar humeral fractures: emergency assessment and management

Supracondylar humeral fractures in children are common presentations to the ED but might be challenging to both diagnose and assess clinically. The ED has a critical role in accurately assessing the child, the limb's neurovascular status and initiating treatment. A specific approach to the clinical assessment of such a child is required as failure to detect neurovascular compromise can delay appropriate treatment and result in serious consequences. Most children can be investigated with X-ray radiograph alone with further treatment directed by severity of the fracture, commonly described using the Gartland classification. Our review article provides an overview of supracondylar humeral fractures and a suggested clinical approach to leave the emergency physician better equipped to assess and manage these fractures.

Perfused, pulseless, and puzzling: a systematic review of vascular injuries in pediatric supracondylar humerus fractures and results of a POSNA questionnaire

BACKGROUND

Supracondylar humerus fractures that present with a perfused, viable hand yet no pulse continue to be a source of controversy. The purpose of this study was to conduct a systematic review of the literature and perform a Pediatric Orthopaedic Society of North America (POSNA) opinion poll regarding management of pulseless supracondylar humeral fractures in children.

METHODS

A systematic review of the literature was conducted for relevant observational studies concerning neurovascular injuries in supracondylar humerus fractures. Single case reports and non-English language studies were excluded. Data were pooled for defined subgroups and 95% confidence intervals were reported. The results from the literature were then compared to popular opinion via a POSNA-approved survey concerning management of pulseless supracondylar humerus fractures.

RESULTS

A total of 331 cases of pulseless supracondylar fractures were identified from the literature, irrespective of perfusion status. In all, 157 fractures remained pulseless after closed reduction and stabilization. Of the fractures that continued to be pulseless despite adequate reduction, 82% [95% confidence interval (CI)=0.82 (0.76-0.88)] were found to have a documented brachial artery injury. POSNA members presumed this number would be 28% [95% CI=0.28 (0.22-0.34)]. A total of 98 perfused (aka pink) supracondylar fractures were identified. Of these pulseless, perfused fractures, 70% [95% CI=0.70 (0.58-0.82)] had a documented brachial artery injury. POSNA members speculated that this number would be 17% [95% CI=0.17 (0.12-0.22). A total of 54 patients had minimum 1 year follow-up data after vascular revascularization, and 91% [95% CI=0.91 (0.83-0.99)] of these patients had a patent artery based on vascular studies. POSNA members believed this number would be 55% [95% CI=0.55 (0.48-0.62)].

CONCLUSIONS

Our study revealed that common dogma regarding watchful waiting of pulseless and perfused supracondylar fractures needs to be questioned. In the vast majority of published cases, an absence of pulse is an indicator of arterial injury, even if the hand appears pink and warm, suggesting the need for more aggressive vascular evalvation and vascular exploration and repair in selected cases. Moreover, patency rates for revascularization procedures appear sufficiently high, making this intervention worthwhile.

Orthopedic pitfalls in the ED: neurovascular injury associated with posterior elbow dislocations

Posterior elbow dislocations are the most common type of elbow dislocation and are usually caused by a fall on an outstretched hand. Although the incidence of elbow dislocation complications is rare, the emergency physician is responsible for evaluation and identification of concomitant neurovascular injuries. Failure to identify neurovascular compromise after elbow dislocation or reduction can potentially lead to severe morbidity with limb ischemia, neurologic changes, compartment syndrome, and potential loss of limb. Cyanosis, pallor, pulselessness, and marked pain should suggest vascular injury or compartment syndrome, both requiring immediate intervention. Patients in whom it is not clear if there is vascular injury should undergo further imaging with angiography, considered the gold standard for evaluation of arterial damage. It is important for the emergency physician to maintain a high level of suspicion and evaluate for neurovascular compromise on every patient with elbow dislocation despite the low overall incidence of severe injury.

High-risk chief complaints III: abdomen and extremities

Abdominal and extremity complaints are a frequent reason for presentation to the emergency department. Although these are common complaints, several abdominal and extremity disease entities may be missed or may be subject to delayed diagnosis. This article provides an overview of the diagnosis and management of several high-risk abdominal and extremity complaints, including appendicitis, abdominal aortic aneurysm, mesenteric ischemia, bowel obstruction, retained foreign body, hand and finger lacerations, fractures, and compartment syndrome. Each section focuses primarily on the pitfalls in diagnosis by highlighting the limitations of history, physical examination findings, and diagnostic testing and provides specific risk management strategies.

Accuracy of emergency room physicians' interpretation of elbow fractures in children

Elbow fractures in children can be difficult diagnoses for inexperienced physicians to make. The purpose of this prospective study was to determine the accuracy of radiograph interpretation of elbow fractures in children by emergency room (ER) physicians. Thirty fractures were analyzed. The ER physician's radiograph interpretation was compared to the final interpretation by the treating staff pediatric orthopedic surgeon. Accuracy rates were determined for overall agreement and by fracture subtype. Overall accuracy of ER physicians' interpretation was 53% (16/30). This study underscores the importance of educating ER physicians and residents in children's fracture interpretation to optimize patient outcomes. Orthopedists need to be vigilant when taking care of these patients to prevent unnecessary complications.

Lateral external fixation--a new surgical technique for displaced unreducible supracondylar humeral fractures in children

BACKGROUND

Percutaneous Kirschner wire fixation represents the classic treatment for displaced supracondylar humeral fractures in childhood. This type of treatment first requires satisfactory reduction of the fracture. Failure to achieve a satisfactory reduction or inadequate stabilization can result in instability of the fracture fragments, which can result in either an unsatisfactory cosmetic or functional outcome. In our experience, these problems can be overcome with the use of a small lateral external fixator.

METHODS

Between 1999 and 2005, thirty-one of 170 Gartland type-III supracondylar humeral fractures were treated with a lateral external fixator. The outcome of treatment was analyzed with regard to limb alignment, elbow movement, cosmetic appearance, and patient satisfaction.

RESULTS

In twenty-eight of the thirty-one patients, a satisfactory reduction was achieved with closed methods. All children except one had a normal or good range of movement. The cosmetic result was excellent in all cases. All of the children and their parents stated that they would choose this treatment again.

CONCLUSIONS

The use of a small lateral external fixator seems to be a safe alternative for the treatment of displaced supracondylar fractures of the humerus when a closed reduction appears to be unattainable by means of manipulation alone or when sufficient stability is not achieved with standard methods of Kirschner wire fixation.

Pediatric upper extremity injuries

The pediatric musculoskeletal system differs greatly from that of an adult. Although these differences diminish with age, they present unique injury patterns and challenges in the diagnosis and treatment of pediatric orthopedic problems.