Pediatric fractures of the humerus

[Treatment of proximal humeral fractures in childhood and adolescence : Consensus report of the pediatric traumatology section of the German Society for Trauma Surgery]

BACKGROUND

Proximal humeral fractures are a relatively common injury in childhood and adolescence, accounting for 0.45-2% of all fractures [2, 18]. Treatment is usually conservative but is still the subject of a scientific debate [9, 12]. In addition to the S1-LL, there are different recommendations for the diagnostics and treatment of these fractures in the literature.

METHODOLOGY

As part of the 10th scientific meeting of the SKT of the DGU, the existing recommendations and the relevant or current literature were critically discussed by a panel of experts and a consensus was formulated. An algorithm for the diagnostics, therapy and treatment was integrated into this.

RESULTS

The measurement of axial deviation and tilt is not interobserver and intraobserver reliable [3]. The age limit for when complete correction is possible was set at an age of 10 years, as the correction potential changes around this age. For diagnostic purposes, well-centered X‑ray images in 2 planes (true AP and Y‑images without thoracic parts) is defined as the standard. At the age of less than 10 years, any malposition can be treated conservatively with Gilchrist bandaging for 2-3 weeks. Surgery can only be indicated in individual cases, e.g., in the event of severe pain or the need for rapid weight bearing. An ad latus displacement of more than half the shaft width should not be tolerated over the age of 10 years. Due to the variance in the measurement results, it is not possible to recommend surgical treatment depending on the extent of the ad axim dislocation. As a guideline, the greater the dislocation and the closer the child is to growth joint closure, the more likely surgical treatment is indicated. The development should be taken into account. The gold standard is retrograde, radial and unilateral ESIN osteosynthesis using two intramedullary nails. Osteosynthesis does not require immobilization. A follow-up X‑ray is planned for unstable fractures without osteosynthesis after 1 week, otherwise optional for documentation of consolidation after 4-6 weeks, e.g., if sports clearance is to be granted and before metal removal (12 weeks).

CONCLUSION

Recommendations for surgical indications based on the extent of tilt are not reproducible and seem difficult in view of the current literature [3, 9, 12]. A pragmatic approach is recommended. The prognosis of the fracture appears to be so good, taking the algorithm into account, that restitutio ad integrum can be expected in most cases.

Neonatal upper limb fractures - a narrative overview of the literature

The aim of this paper is to review the topic of neonatal fractures of the upper limb, describing the different types of fractures focusing on the etiology, epidemiology, risk factors, clinical approach, diagnosis, treatment and prognosis of these injuries. We included all types of research studies, both experimental and observational, published in English, French, Portuguese and Spanish. The information was obtained using the keywords neonatal upper limb fracture, clavicle fracture or humerus fracture from the following resources: MEDLINE database, Embase® database and LILACS database. Other resources such as hand searches of the references of retrieved literature and authoritative texts, personal and hospital libraries searching for texts on upper limb neonatal fractures, discussions with experts in the field of upper limb neonatal fractures and personal experience, were also considered for the completion of the article.Neonatal fractures of the upper limb are consensually considered to have a good prognosis and no long-term sequelae. Conservative treatment is the option in the vast majority of the fractures and is associated with excellent results, with good healing, full range of motion, adequate remodeling without obvious deformity, neurologic impairment or functional implications.

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.

Evaluation and Management of Pediatric Humeral Shaft Fractures

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

Novel Use of a Shoulder Spica: Treatment for Midshaft Humerus Fracture in the Presence of Limb Deficiency

Pediatric midshaft humerus fractures are typically managed with a hanging arm cast, Sarmiento bracing, coaptation splint, or a combination of these treatment options. Here we report a novel use of a shoulder spica cast in the treatment of a midshaft humerus fracture in the presence of limb deficiency. Current treatments proved unsuccessful in maintaining adequate alignment, specifically the varus deformity of the fracture. A shoulder spica was able to successfully maintain acceptable alignment throughout the duration of the patient's healing process. This nontraditional use of a shoulder spica cast shows the practicality of its ability to be utilized for the treatment of unique upper extremity orthopedic obstacles.

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.

The Holstein-Lewis humerus shaft fracture in children: are they different from adults?

Spiral fractures in the distal third humerus shaft (Holstein-Lewis fracture pattern) have been associated with high risk of radial nerve palsy in adults and surgical treatment is recommended as the treatment of choice to remove the entrapped nerve from the fracture site. But this association and treatment approach has not been evaluated in pediatric humerus shaft fractures. In a retrospective study, 38 pediatric patients with Holstein-Lewis fracture configuration were identified after a review of radiographs of 1609 patients with humerus shaft fracture. Age at initial presentation, sex, mechanism of injury, side involved, presence of any associated injuries, neurovascular status, radial nerve status, fracture management, and any complications were noted. Thiry-three (86.8%) patients with mean age 10.1 ± 3.7 years were successfully treated by closed methods. Five patients (13.2%) with mean age 15.2 ± 2.6 years underwent surgical treatment. Contrary to adults, no children/adolescents had radial nerve palsy at presentation. Radiographic healing was acceptable in all cases at latest follow-up. Holstein-Lewis fracture behaves differently in children with no increased risk of radial nerve palsy. Majority can be treated conservatively. The thick periosteum in children may offer protection to the radial nerve and may be responsible for the success of closed treatment.

Remodelling in Children's Fractures and Limits of Acceptability

Remodeling follows inflammatory and reparative phases of bone healing and is very pronounced in children. Unlike adults, in growing children, remodeling can restore the alignment of initially malunited fractures to a certain extent, making anatomic reduction less essential. Remodeling is not universal and ubiquitous. Animal experiments and clinical studies have proven that in a malunited fracture, the angulation corrects maximally by physeal realignment (75%) and partly by appositional remodeling of the diaphysis also known as the cortical drift (25%). Remodeling potential reduces with the increasing age of the child; lower extremities have higher remodeling potential compared to the upper extremity. Remodeling is most pronounced at the growing end of the bone and in the axis of the adjacent joint motion. Correction of a very small amount of rotational malalignment is possible, but it is clinically not relevant. Overgrowth of the bone after a fracture occurs due to hyperaemia of fracture healing. Overgrowth is the most common after paediatric femur fractures, though it is reported after fractures of the tibia and humerus as well. The orthopaedic surgeon treating children's fractures should be familiar with regional variations of remodeling and limits of acceptance of angulation in different regions. Acceptability criteria for different bones are though well defined, but serve best as guidelines only. For the final decision-making patient's functional capacity, parents' willingness to wait until the completion of the remodeling process, and the experience of treating doctor should be considered concurrently. In case of the slightest doubt, a more aggressive approach should be taken to achieve a satisfactory result.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Long bone fractures in neonatal intensive care units of Afyonkarahisar: Five-year's experience

Objective:

To determine the incidence of long bone fractures and the clinical features related with these fractures diagnosed in neonatal intensive care units (ICUs) within the province of Afyonkarahisar in Turkey.

Materials and Methods:

The incidence of clavicular fractures was 2.4 in 1000 live births, and the incidence of femoral fractures was 0.32 in 1000 live births at the neonatal ICUs of Afyonkarahisar.

Results:

The incidence of birth trauma-related femoral fracture was 0.16 in 1000 live births, and the incidence of femoral fractures related with osteopenia of prematurity was 1.08 in 1000 live births. The mean gestational age at delivery was 39 weeks, the mean birth weight was 3.308 grams, and the male/female ratio was 3:2 for newborns with birth trauma-related femoral fractures. The mean gestational age at delivery was 30.4 weeks, the mean birth weight was 1256 grams, and the male/female ratio was 2:3 for newborns who had femoral fractures related with osteopenia of prematurity. Breech presentation was present in three newborns (60%), and cesarean section was the type of delivery in all newborns with birth trauma-related femoral fractures.

Conclusion:

Cesarean delivery does not reduce the risk for birth trauma-associated femoral fractures, and there is a risk for femoral fracture in cases of emergency cesarean performed for malpresentation. In order to overcome osteopenia of prematurity, calcium, phosphorus, and vitamin D should be supplemented in premature newborns with intrauterine growth retardation and receive long-term total parenteral nutrition.

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

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

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.

Management of paediatric humeral shaft fractures and associated nerve palsy

PURPOSE

The aim of this study is to review the management of all paediatric humerus diaphyseal fractures treated at a single institution over a 20-year period.

METHODS

Retrospective review from between 1996 and 2016 identified 96 humerus shaft fractures in paediatric patients (0 to 17 years). After excluding those deceased from inciting trauma, pathological and perinatal fractures, 80 patients remained for analysis. Data collected included age, fracture type, displacement, nerve palsy, treatment, complications and time to union. Radiographs were reviewed at the time of injury and at latest follow-up.

RESULTS

Of 80 paediatric humeral diaphyseal fractures, 65 (81%) were treated with immobilization. In all, 15 (19%) fractures were treated with surgical stabilization. Most common indications were fracture displacement, open fractures and to improve mobilization in patients with multiple injuries. Fractures were stabilized with a plate (eight), flexible nails (five), external fixation (one) and percutaneous pinning (one). The operative group, compared with the nonoperative group, was older, had more high-energy mechanisms, more open fractures and increased fracture displacement. All patients in the nonoperative and operative groups went on to union with minimal complications. A nerve palsy was present in five patients (6%)with three of the five involving the radial nerve (4%). All nerve palsies were observed and had full neurological recovery.

CONCLUSION

Over a 20-year period nonoperative management of paediatric humerus shaft fractures was successful in the majority of patients. Operative stabilization, when rarely indicated, had a low complication rate and improved radiographic alignment. All nerve injuries fully recovered without surgical intervention.

LEVEL OF EVIDENCE

IV.

Occlusion Outside the Norm: A Unique Case of the Pulseless, Well-Perfused Hand Following Closed Humeral Shaft Fracture

Transient arterial injury is a common complication encountered in the management of pediatric supracondylar humerus fractures, often presenting as a pulseless hand that appears well perfused, also known as the "pink, pulseless hand." Arterial injuries in pediatric humeral shaft fractures, on the other hand, are exceedingly rare, especially in closed fractures. The authors report a rare case of a humeral shaft fracture presenting as a pink, pulseless hand. Although this complication was initially managed according to supracondylar protocol, the patient's neurologic status deteriorated. This prompted vascular assessment with computed tomography angiography, revealing a complete occlusion of the brachial artery. At this more proximal level, there is significant risk for compromise of the collateral circulation. The patient was eventually treated successfully with open reduction of the fracture followed by brachial artery repair. Although watchful waiting may be appropriate in the management of this entity for supracondylar fractures, more aggressive management was indicated for this patient because of the occlusion occurring prior to the bifurcation of the brachial artery. The lack of collateral circulation makes improvement in this injury pattern unlikely. This report emphasizes that suspected vascular injury following humeral shaft fractures should be evaluated with computed tomography angiography. If an occlusion is identified, it should be treated aggressively with immediate open fracture reduction and evaluation by a vascular team for possible repair vs grafting. [Orthopedics. 2019; 42(2):e279-e281.].

Spiral Fracture in Young Infant Causing a Diagnostic Dilemma: Nutritional Rickets versus Child Abuse

Fractures are uncommon in young, nonambulatory infants. The differential diagnosis includes nonaccidental injury (NAI) and metabolic bone disease, including rickets. While rickets typically present after six months of age, multiple cases have been reported in younger infants. We report a case of an 11-week-old male infant who presented with a spiral fracture of the humerus and no radiologic evidence of rickets. A detailed psychosocial assessment failed to reveal any risk factors for NAI. The patient had elevated alkaline phosphatase and PTH with low 25 hydroxyvitamin D and 1,25 dihydroxyvitamin D levels. Additionally, the mother was noncompliant with prenatal vitamins, exclusively breastfeeding without vitamin D supplementation, and had markedly low vitamin D levels 15 weeks postpartum. The biochemical data and history were consistent with rickets. Given the diagnostic dilemma, the working diagnosis was rickets and the patient was started on ergocalciferol with subsequent normalization of his laboratory values and healing of the fracture. These findings are consistent with nutritional rickets largely due to maternal-fetal hypovitaminosis D. This case highlights that in young infants rickets should be considered even in the absence of positive radiologic findings. Additionally, it illustrates the importance of maintaining adequate vitamin D supplementation during pregnancy and early infancy.

Age- and severity-adjusted treatment of proximal humerus fractures in children and adolescents-A systematical review and meta-analysis

BACKGROUND

Fractures of the proximal humerus in patients under the age of 18 years show a low incidence; existing clinical studies only comprise small patient numbers. Different treatment methods are mentioned in the literature but a comparison of the outcome of these methods is rarely made. Up to now, no evidence-based algorithm for conservative and operative treatment is available. The aim of this systematic review with meta-analysis was therefore to gather the best evidence of different treatment methods and their associated functional outcome, complication rates, rates of limb length discrepancies and radiological outcome.

METHODS AND FINDINGS

The OVID database was systematically searched on September 30th in 2016 in order to find all published clinical studies on the subject of proximal humerus fractures of patients ≤18 years. Exclusion criteria were previously defined. The Coleman Methodology Score was used to evaluate the quality of the single studies. 886 studies have been identified by the search strategy. 19 studies with a total of 643 children (mean age: 11.8 years) were included into the meta-analysis with a mean Coleman Methodology Score of 71 ± 7.4 points. 18 of the 19 studies eligible for inclusion were retrospective ones, of the best quality available (mean follow-up ≥ 1 year, mean follow-up rate ≥ 65%). 56% of the patients were male. Proximal humerus fractures were treated conservatively in 41% and surgically in 59% of the cases (Elastic Stable Intramedullary Nailing (ESIN): 31%; K-wires: 20%; 8% other methods, e.g. plate osteosynthesis, olecranon traction). The overall success rate (good/excellent outcome) for all treatment methods was 93%. The success rate of ESIN (98%) and of K- wire fixation (95%) was significantly higher (p = 0.01) than the success rate of conservative treatment options (91%). A subgroup analysis of severely displaced fractures (Neer grade III/IV, angulation ≥ 20°) resulted in a change of success rates, to the disadvantage of conservative treatment methods (conservative treatment 82%, ESIN 98%, K-wires 95%; p < 0.001). Complication rates did not differ to a significant extent. 9% of the complications occurred in the patients treated by K-wire fixation, 8% if a conservative treatment option was chosen and 7% in the fractures that were stabilized by ESIN. A change from a one-nail technique to a two-nail technique reduced the complication rate of ESIN significantly. Follow-up X- rays without residual deformity could be found in 96% of the patients treated by ESIN, a rate which was higher than in the patients treated conservatively (93%) or by K-wire fixation (88%). The rate of arm length discrepancies at final follow- up was lower if the fractures were stabilized by ESIN (4%) than if they were treated conservatively (9%) or by K-wires (19%). An evaluation of age-dependent treatment options was performed.

CONCLUSIONS

By performing this meta-analysis an evidence-based treatment algorithm could be introduced to treat the fractures according to the severity of displacement and according to the patient's age. For severely displaced fractures ESIN is the method of choice, with the best clinical and radiological outcome.

Outcome of Conservative Versus Surgical Treatment of Humeral Shaft Fracture in Children and Adolescents: Comparison Between Nonoperative Treatment (Desault's Bandage), External Fixation and Elastic Stable Intramedullary Nailing

BACKGROUND

The main objective of this study was to retrospectively evaluate the clinical and radiographic outcomes of displaced humeral shaft fractures in children treated by Desault's bandage (DB), external fixation (EF), and elastic stable intramedullary nailing (ESIN).

METHODS

During the study period, 36 consecutive children with displaced humeral shaft fracture were treated by DB (Group A), EF (Group B) or ESIN (Group C). All the patients underwent full-length preoperative and postoperative anteroposterior and lateral radiographs of the injured humerus. One year after the index surgery, patients were asked to answer the short version of the Disabilities of the Arm, Shoulder and Hand outcome questionnaire (Quick DASH).

RESULTS

Ten patients (27.8%) were in Group A, 11 (30%) in Group B, and 15 (41.7%) in Group C. Mean age at the time of injury was 10.8±2.3 years (range, 8 to 15.2 y), 11.7±2.5 years (range, 6.8 to 15.9 y), and 12.7±2.2 years (range, 6.9 to 15.3 y) in Groups A, B, and C, respectively (P=0.08). Groups A, B, and C did not differ significantly in their demographics (P>0.05).Surgical treatment (Groups B and C) provided a better radiologic outcome than nonoperative treatment (Group A) (P=0.05). No statistically significant differences were observed for preoperative, postoperative and at last follow-up mean displacement between Groups B and C (P>0.05).Overall, 9 of 36 patients developed a complication: 2 in Group A (20%), 4 in Group B (37%), and 3 in Group C (20.1) (P=0.92).Mean Quick DASH score was 3±8.6 (range, 0 to 27.3), 1.4±2.9 (range, 0 to 9), and 1.2±4.7 (range, 0 to 18.2) in Groups A, B, and C, respectively. All the patients were able to resume previous physical and sport activities 4 to 6 months after the last fracture reduction procedure.

CONCLUSIONS

Surgery is not contraindicated in children with displaced humeral shaft fractures. EF and ESIN provide a better radiologic outcome, less posttreatment pain and faster mobilization than DB. However, numerical differences, although statistically significant, were not clinically relevant for all variables but immobilization time. Nonoperative treatment was as efficacious as surgical treatment apart from the length of time for immobilization.

LEVEL OF EVIDENCE

Level III.

Evaluation of upper extremity function of displaced diaphyseal humeral fractures in children treated by elastic stable intramedullary nailing: preliminary results

The aim of this study was to retrospectively evaluate the outcome of displaced humeral shaft fractures in children and adolescents treated by elastic stable intramedullary nailing (ESIN) and to evaluate upper extremity function using the Quick-DASH questionnaire. Correction was maintained over time in 14 of 16 patients. All patients were pain free at last follow-up. Shoulder and elbow ranges of motion were comparable with the noninjured side. The mean Quick-DASH score was 1. This study reports good functional outcomes in children with displaced humeral shaft fractures surgically treated with ESIN, even in the presence of residual deformity. ESIN enables stable reduction, good rotational control, and good functional outcome.

Flexible Intramedullary Nailing of Pediatric Humeral Fractures: Indications, Techniques, and Tips

Most proximal and diaphyseal pediatric humeral fractures can be treated successfully by closed means; however, certain patient factors or fracture characteristics may make surgical stabilization with flexible intramedullary nails (FIN) a better choice. Common indications for FIN of pediatric humeral fractures include unstable proximal-third fractures in children nearing skeletal maturity, unstable distal metaphyseal-diaphyseal junction fractures, shaft fractures in polytraumatized patients or patients with ipsilateral both-bone forearm fractures (floating elbow), and prophylactic stabilization of benign diaphyseal bone cysts or surgical stabilization of pathologic fractures. FIN can be safely inserted in an antegrade or retrograde manner depending on the fracture location and configuration. Careful dissection at the location of rod insertion can prevent iatrogenic nerve injuries. Rapid fracture union and return to full function can be expected in most cases. Implant prominence is the most common complication.

Humerus Diaphysis Fracture in a Newborn during Vaginal Breech Delivery

While most obstetricians are familiar with fracture of the clavicle in newborns during birth, an unlucky minority of obstetricians has encountered long-bone fractures in newborns as well. This complication is traumatic not only for the neonate, but also for the family and the obstetrician; it is also difficult to explain. Fortunately, the long-term prognosis for fracture of the long bones is excellent. Both vaginal and cesarean breech deliveries and maneuvers can be responsible for birth traumas, including long-bone fractures. This case report presents a newborn with breech presentation delivered vaginally that resulted in humerus diaphysis fracture.

Evaluation and management of pediatric proximal humerus fractures

In the pediatric population, sports participation, falls, and motor vehicle accidents can result in proximal humerus fractures. Because the proximal humeral growth plate is responsible for up to 80% of the growth of the humerus, the remodeling of these fractures in children is tremendous. Most of these injuries can be treated with a sling or hanging arm cast, although older children with decreased remodeling capacity may require surgery. Special considerations should be taken for management of proximal humerus fractures that occur in the context of Little League shoulder, lesser tuerosity avulsion fractures, fracture-dislocations, birth fractures, and fractures associated with cysts. Most pediatric patients with proximal humerus fractures have favorable results, and complications are infrequent.

A mechanical Jack-like Mechanism drives spontaneous fracture healing in neonatal mice

Treatment of fractured bones involves correction of displacement or angulation, known as reduction. However, angulated long-bone fractures in infants often heal and regain proper morphology spontaneously, without reduction. To study the mechanism underlying spontaneous regeneration of fractured bones, we left humeral fractures induced in newborn mice unstabilized, and rapid realignment of initially angulated bones was seen. This realignment was surprisingly not mediated by bone remodeling, but instead involved substantial movement of the two fragments prior to callus ossification. Analysis of gene expression profiles, cell proliferation, and bone growth revealed the formation of a functional, bidirectional growth plate at the concave side of the fracture. This growth plate acts like a mechanical jack, generating opposing forces that straighten the two fragments. Finally, we show that muscle force is important in this process, as blocking muscle contraction disrupts growth plate formation, leading to premature callus ossification and failed reduction.

Stable incidence of surgical treatment and hospitalisation for humeral shaft fractures among 0- to 16-year-old patients in Finland from 1987 to 2010

BACKGROUND

Studies among children experiencing fractures report an increasing trend toward operative management. In the present study, we examined whether the same trend has occurred for humeral shaft fractures in accordance with increasing interest toward intramedullary nailing and other operative treatments. The number, incidence and treatment of all hospitalised 0- to 16-year-old patients with humeral shaft fractures in Finland was assessed over a recent 24-year period.

METHOD

The study included the entire adolescent (0-16 years) population in Finland during the 24-year period from January 1, 1987, to December 31, 2010. Data on hospitalised patients who sustained humeral shaft fractures were obtained from the nationwide National Hospital Discharge Register (NHDR) of Finland.

RESULTS

During the study period, there were a total of 1,165 hospitalisations with a main or secondary diagnosis of humeral shaft fracture. The incidence of hospitalisation due to humeral shaft fractures was 4.8 per 100,000 person-years. The incidence increased only slightly among girls from 3.3 per 100,000 person-years in 1987 to 5.3 per 100,000 person-years in 2010. The incidence of reposition and casting was 1.1 per 100,000 person-years and the incidence of reposition with osteosynthesis, including intramedullary nailing, was 1.4 per 100,000 person-years. The specific incidence of intramedullary nailing remained low with no signs of increased incidence, and the incidence was 0.3 per 100,000 person-years. There were no significant changes in the incidence of surgical treatment during the 24-year study period.

CONCLUSION

Despite an overall increasing trend toward operative management of fractures in children, conservative management remains the treatment of choice for humeral shaft fractures based on the low and steady incidence of surgical treatment during the 24-year study period. In addition, the incidence of hospitalisation for fractures remained low without a significant increase during the study period.

Treatment of unicameral bone cyst: systematic review and meta analysis

PURPOSE

Different treatment modalities have been utilized to treat unicameral bone cyst (UBC), but evidence has not been fully described to support one treatment over another and the optimal treatment is controversial. The aim of this quantitative systematic review was to assess the effectiveness of different UBC treatment modalities.

METHODS

We utilized Pubmed to isolate retrospective studies on patients with UBC who received any kind of treatment. The included studies needed to have a minimum sample size of 15 patients, and have provided data on radiographic healing outcome.

RESULTS

Sixty-two articles were selected for the meta-analysis from a total of 463 articles. The cumulative sample size was 3,211 patients with 3,217 UBC, and male to female ratio was 2.2:1. The summary or pool estimate of methylprednisolone acetate (MPA) injection resulted in a healing rate of (77.4 %) that was comparable to bone marrow injection (77.9 %). A higher healing rate was observed with MPA injection when inner wall disruption was performed. The pool estimate of bone marrow with demineralized bone matrix injection was high (98.7 %). UBC healing rate after surgical curettage was comparable whether autograft or allograft was utilized (90 %). UBC treatment with flexible intramedullary nails without curettage provided almost 100% healing rate, while continuous decompression with cannulated screws provided 89 % healing rate. Conservative treatment indicated a healing rate of 64.2, 95 % CI (26.7-101.8).

CONCLUSIONS

Active treatment for UBC provided variable healing rates and the outcomes were favorable relative to conservative treatment. Due to the heterogeneity of the studies and reporting bias, the interpretation of these findings should be handled with caution.

Birth-associated long-bone fractures

OBJECTIVE

To assess the incidence and outcome of neonatal long-bone fractures at a tertiary teaching hospital.

METHODS

A retrospective study of all neonates with long-bone fractures delivered at Jordan University Hospital between January 1, 2000, and December 31, 2010.

RESULTS

Among a total of 34 519 live births, 8 neonates had a long-bone fracture (incidence 0.23/1000 live births); of these, 6 had a femur fracture (0.17/1000 live births) and 2 had a humerus fracture (0.05/1000 live births). The route of delivery was emergency cesarean delivery for 6 infants, elective cesarean delivery for 1 infant, and the vaginal route for 1 infant. The mean birth weight was 2723g. All neonates weighed more than 2200g and their gestational age was more than 35weeks, with the exception of 1 neonate born at 31weeks weighing 1500g. The mean time interval from birth to fracture diagnosis was 1.5days. All fractures healed with no residual deformity.

CONCLUSION

Emergency cesarean delivery carries a higher risk of long-bone fracture than vaginal delivery. Prematurity, malpresentation, abnormal lie, and multiple pregnancies may predispose to long-bone fractures. The prognosis of birth-associated long-bone fractures is good.

Femur fractures in the pediatric population: abuse or accidental trauma?

BACKGROUND

Child abuse represents a serious threat to the health and well-being of the pediatric population. Orthopaedic specialists will often become involved when child abuse is suspected as a result of the presence of bony injury. Distinguishing abuse from accidental trauma can be difficult and is often based on clinical suspicion.

QUESTIONS/PURPOSES

We sought to determine whether accidental femur fractures in pediatric patients younger than age 4 could be distinguished from child abuse using a combination of presumed risk factors from the history, physical examination findings, radiographic findings, and age.

METHODS

We searched our institution's SCAN (Suspected Child Abuse and Neglect) and trauma databases. We identified 70 patients in whom the etiology of their femur fracture was abuse and compared that group with 139 patients who had a femur fracture in whom accidental trauma was the etiology.

RESULTS

A history suspicious for abuse, physical or radiographic evidence of prior injury, and age younger than 18 months were risk factors for abuse. Patients with no risk factors had a 4% chance, patients with one risk factor had a 29% chance, patients with two risk factors had an 87% chance, and patients with all three risk factors had a 92% chance of their femur fracture being a result of abuse.

CONCLUSIONS

Clinicians can use this predictive model to guide judgment and referral to social services when seeing femur fractures in very young children in the emergency room.

LEVEL OF EVIDENCE

Level III, diagnostic study. See Guidelines for Authors for a complete description of levels of evidence.

The treatment of upper limb fractures in children and adolescents

BACKGROUND

The treatment of fractures in children and adolescents must be based on an adequate knowledge of the physiology of the growing skeleton. Treatment failures usually do not result from technical deficiencies, but rather from a misunderstanding of the special considerations applying to the treatment of fractures in this age group.

METHODS

We selectively reviewed recent publications on the main types of long bone fracture occurring in the period of skeletal development.

RESULTS

Alleviating pain is the first step in fracture management, and due attention must be paid to any evidence of child abuse. The goals of treatment are to bring about healing of the fracture and to preserve the function of the wounded limb. The growth that has yet to take place over the remaining period of skeletal development also has to be considered. Predicting the growth pattern of fractured bones is a basic task of the pediatric traumatologist. During the period of skeletal development, conservative and surgical treatments are used in complementary fashion. Particular expertise is needed to deal with fractures around the elbow, especially supracondylar humeral fractures, displaced fractures of the radial condyle of the humerus, radial neck fractures, and radial head dislocations (Monteggia lesions). These problems account for a large fraction of the avoidable cases of faulty fracture healing leading to functional impairment in children and adolescents.

CONCLUSION

The main requirements for the proper treatment of fractures in children and adolescents are the immediate alleviation of pain and the provision of effective treatment (either in the hospital or on an outpatient basis) to ensure the best possible outcome, while the associated costs and effort is kept to a minimum. Further important goals are a rapid recovery of mobility and the avoidance of late complications, such as restriction of the range of motion or growth disorders of the fractured bone. To achieve these goals, the treating physician should have the necessary expertise in all of the applicable conservative and surgical treatment methods and should be able to apply them for the proper indications.

Case report: Longitudinal stress fracture of the humerus: imaging features and pitfalls

Longitudinal stress fractures are an uncommon injury in which a diaphyseal fracture line occurs parallel to the long axis of a bone in the absence of direct trauma. They have been described in the tibia and less commonly in the femur but apparently not in the upper limb. We report a longitudinal stress fracture occurring in the humerus of a 62-year-old woman who had a history of osteoporosis and had undergone recent surgery of the contralateral wrist. We present the radiographic, MRI, and CT features of the case and emphasize the difficulties in diagnosis caused by negative findings on early radiographs and by nonspecific bone marrow edema pattern on MRI. The risk of a contralateral upper extremity stress fracture from activities of daily living in a patient with osteoporosis whose other upper extremity is immobilized also is highlighted.

Bilateral humerus fracture in a neonate after cesarean delivery

Humerus fractures in neonates are rare, but can occur during cesarean section and bilateral humerus fracture has not been reported yet. This case represents a newborn delivered by cesarean section for breech presentation which resulted in bilateral humerus fracture.

Child abuse and orthopaedic injury patterns: analysis at a level I pediatric trauma center

BACKGROUND

Child abuse is a serious threat to the physical and psychosocial well-being of the pediatric population. Musculoskeletal injuries are common manifestations of child abuse. There have been multiple studies that have attempted to identify the factors associated with, and the specific injury patterns seen with musculoskeletal trauma from child abuse, yet there have been no large studies that have used prospectively collected data and controlled comparisons. The purpose of our study was to describe the patterns of orthopaedic injury for child abuse cases detected in the large urban area that our institution serves, and to compare the injury profiles of these victims of child abuse to that of general (accidental) trauma patients seen in the emergency room and/or hospitalized during the same time period.

METHODS

This study is a retrospective review of prospectively collected information from an urban level I pediatric trauma center. Five hundred cases of child abuse (age birth to 48 mo) were identified by membership in our institution's Suspected Child Abuse and Neglect database collected between 1998 and 2007. These cases were compared against 985 general trauma (accidental) control patients of the same age group from 2000 to 2003. Age, sex, and injury type were compared.

RESULTS

Victims of child abuse were on average younger than accidental trauma patients in the cohort of patients under 48 months of age. There was no difference in sex distribution between child abuse and accidental trauma patients. When the entire cohort of patients under 48 months were examined after adjusting for age and sex, the odds of rib (14.4 times), tibia/fibula (6.3 times), radius/ulna (5.8 times), and clavicle fractures (4.4 times) were significantly higher in child abuse versus accidental trauma patients. When regrouping the data based on age, in patients younger than 18 months of age, the odds of rib (23.7 times), tibia/fibula (12.8 times), humerus (2.3 times), and femur fractures (1.8 times) were found to be significantly higher in the child abuse group. Yet, in the more than 18 months age group, the risk of humerus (3.4 times) and femur fractures (3.3 times) was actually higher in the accidental trauma group than in the child abuse group.

CONCLUSIONS

Patients who present to an urban level I pediatric trauma center and are victims of abuse are generally younger, and have an equal propensity to be male or female. It is important for the clinician to recognize that the age of the patient (younger or older than 18 mo and/or walking age) is an important determinant in identifying injury patterns suspicious for abuse. Patients below the age of 18 months who present with rib, tibia/fibula, humerus, or femur fractures are more likely to be victims of abuse than accidental trauma patients. Yet, when patients advance in age beyond 18 months, their presentation with long bone fractures (ie, femur and humerus) is more likely to be related to accidental trauma than child abuse.

LEVEL OF EVIDENCE

level III, prognostic study.

Surgical treatment of traumatic pediatric humeral diaphyseal fractures with titanium elastic nails

BACKGROUND

Nearly all pediatric humeral shaft fractures can be successfully treated with closed methods. Some patients, however, require internal fixation either because of an inability to maintain an adequate reduction, significant soft tissue injury, or concomitant fractures.

METHODS

This is a retrospective review of all traumatic humeral shaft fractures treated at our hospitals between 1999 and 2006. Thirteen pediatric patients ranging in age from 4.8 to 16.7 years (mean age 12.0 years) were treated surgically with titanium elastic nails (TENs). Relative surgical indications included open fractures, inability to maintain an acceptable reduction, the presence of ipsilateral forearm fractures (floating elbow), concomitant lower extremity fractures, and closed head injury. Two patients had associated radial nerve injury at presentation.

RESULTS

The patients were followed for a mean of 29 months. All fractures healed in good alignment. There were no intraoperative complications, including neurologic or vascular injury, and no patient developed an infection postoperatively. Two patients had nail migration, one of whom developed nail protrusion through the skin. One patient with preoperative radial nerve injury ultimately underwent tendon transfer to restore wrist extension. Of the 13 patients, 12 reported a full return to sports and other activities with no limitations or discomfort.

CONCLUSIONS

When surgical stabilization of pediatric humeral shaft fractures is indicated, TEN fixation is effective and has a high rate of union and a low rate of complications. This technique is familiar to most orthopaedic surgeons treating pediatric fractures.

LEVEL OF EVIDENCE

Level of evidence: IV (case series).

Orthopaedic conditions in the newborn

The occasional consultation on a neonate can be unfamiliar territory for many orthopaedic surgeons. Just as children are not little adults, newborns are not just little children; rather, they have a unique physiology that affects the presentation of their orthopaedic concerns. Careful physical examination with appropriate understanding of neonatal development is essential to making the proper diagnosis. A flail extremity in the newborn is most commonly attributed to fracture or brachial plexus palsy; however, infection must also be considered and ruled out to prevent long-term morbidity. Metatarsus adductus is the most common foot abnormality, but clubfoot, calcaneovalgus deformity, and congenital vertical talus may also be encountered. Joint contractures that spontaneously improve are normal in the newborn, but it is important to identify and institute proper treatment for early developmental dysplasia of the hip, congenital knee dislocation, and torticollis. Clavicular pseudarthrosis and periosteal reactions may be discovered on radiographic examination. A basic understanding of the relevant conditions will help the orthopaedist with the initial diagnosis and management of orthopaedic issues in the newborn.

Remodeling of birth fractures of the humeral diaphysis

BACKGROUND

Birth fractures of the humeral diaphysis are encountered at most pediatric medical centers and pediatric orthopaedic practices. The treatment strategy of these fractures is uniformly nonoperative. However, we have not found sufficient studies in the literature demonstrating the extent to which remodeling is possible and therefore how much deformity is acceptable in the treatment of these fractures.

METHODS

We reviewed the records of our institution's Orthopaedic Surgery Clinic and identified all children seen for birth fractures of the humerus from 2001 to 2005. The angulation and displacement at presentation and at follow-up were measured.

RESULTS

All patients were treated nonoperatively, and most were managed by swaddling. In 9 patients with more than 4 months of radiographic follow-up, the mean initial angulation was 26 degrees in the coronal plane and 25 degrees in the sagittal plane. The mean angulation at final follow-up was 5 degrees in the coronal plane and 7 degrees in the sagittal plane. The maximum angulation at presentation was 66 degrees, which remodeled to 5 degrees at 7.3 months' follow-up.

CONCLUSIONS

Our findings suggest that attempts to obtain an anatomical reduction or the use of more than the simplest immobilization methods are not necessary given the tremendous capacity for remodeling of these fractures in infants.

[Bilateral proximal metaphyseal fracture of the humerus in a child. A case report]

A case of bilateral proximal metaphyseal fracture of the humerus in a 3 year-old child victim of a traffic road accident is presented. The fractures were managed conservatively under general anesthesia with an excellent remodeling at the fOllow-up of 2 years and 8 months.