Rate of Open Reduction for Supracondylar Humerus Fractures Varies Across Pediatric Orthopaedic Surgeons: A Single-Institution Analysis

Analysis of risk factors for failed closed reduction in pediatric Gartland Type III supracondylar humerus fracture

BACKGROUND

Gartland Type III supracondylar humerus fractures (SCHFs) are commonly treated using closed reduction followed by percutaneous pin fixation. However, conversion to open reduction may be necessary if closed reduction fails. This study aimed to identify risk factors associated with failed closed reduction and provide a theoretical basis for clinical decision-making in the treatment of Gartland Type III fractures.

METHODS

A retrospective analysis was conducted on children with Gartland Type III SCHF who underwent surgical treatment between April 2017 and June 2018. Based on whether or not the closed reduction was successful, patients were split into the open reduction group and the closed reduction group. Within the closed reduction group, subgroup analysis based on surgery duration was carried out. Data were collected from medical records and X-ray images. Univariate and multivariate regression analyses were utilized to evaluate the relationship between variables and failed closed reduction.

RESULTS

The study included 36 patients in the open reduction group and 135 patients in the closed reduction group. Multivariate analysis revealed that the presence of angle (P = .024, OR = 3.199), rotation (P = .000, OR = 6.359), skin creases (P = .013, OR = 4.077), anterior-posterior displacement ratio (P = .011, OR = 4.337), fracture angle in the anteroposterior view (P = .014, OR = 0.939), and fracture distal displacement direction (P = .002, OR = 5.384) were independent risk factors for failed closed reduction. Subgroup analysis showed that fracture distal displacement direction (P = .013), skin folds (P = .013), lateral displacement ratio (P = .016), and anterior-posterior displacement value (P = .005) significantly influenced the duration of closed reduction surgery.

CONCLUSION

The presence of sharp angle or rotation at the fracture ends, skin folds on the anterior elbow, minor anterior-posterior displacement of the fracture, higher medial inclination of the fracture plane, and distal fracture displacement toward the radial side are independent risk factors for failed closed reduction in pediatric Gartland Type III SCHF.

Single-surgeon perspective: is there ever a need to open extension-type supracondylar fractures?

BACKGROUND

Supracondylar humerus fractures (SCHFs) represent the most common pediatric elbow fracture, constituting approximately 12-17% of all pediatric fractures. The vast majority of operative supracondylar humerus fractures are treated with closed reduction and percutaneous pinning (CRPP); however, the estimated rate of SCHFs requiring open reduction is approximately 12.7%.

AIM

This study aims to analyze the likelihood of open reduction in pediatric extension-type SCHFs and to reaffirm the traditional teaching of reduction techniques described by Smith and Rang.

METHODS

A single-surgeon retrospective analysis of 56 operative pediatric SCH cases (51 extension-type, 6 flexion-type) who underwent either CRPP or open reduction over a 16-year period was performed. All cases were performed using the aforementioned reduction technique. The Modified Gartland's classification was utilized in the analysis of extension-type SCHF radiographs.

RESULTS

Gartland IIA fractures constituted 38% of SCHFs, 9% of Gartland IIB, 43% of Gartland III, and 7% of flexion-type. The rate of open reduction in SCHFs was 1.8% (1 out of 56 cases), performed in a flexion-type injury. All extension-type fractures were successfully managed with either CRPP or manipulation and casting alone. Of the cases requiring CRPP, 45% were divergent lateral wires, and 55% were crossed wires.

CONCLUSIONS

In our series, a 1.8% rate of open reduction was indicated in flexion-type SCH fractures. All 52 cases of extension-type SCHFs were successfully managed with closed reduction with or without percutaneous pinning. Successful closed reduction using the concept of intact periosteal hinge to aid and maintain reduction is crucial.

Impact of Preoperative Neuropraxia on Surgical Duration Following Pediatric Supracondylar Fracture of the Humerus: A Retrospective Cohort Study

Background  Supracondylar fractures of the humerus (SCFHs) are the most common type of elbow fracture in children. Because of the influence on functional outcome, neuropraxia is one of the most common concerns at presentation. The impact of preoperative neuropraxia on surgery duration is not extensively probed. The clinical implications of several other risk factors associated with preoperative neuropraxia at presentation may contribute to longer surgical duration of SCFH. Hypothesis  Preoperative neuropraxia is likely to increase surgery duration in patients who sustained SCFH. Patients and Methods  This is a retrospective cohort analysis. Sixty-six patients who sustained surgical pediatric supracondylar humerus fracture were included in the study. Baseline characteristics including age, gender, the type of fracture according to Gartland classification, mechanism of injury, patient weight, side of injury, and associated nerve injury were included in the study. Logistic regression analysis was performed using mean surgery duration as the main dependent variable and age, gender, fracture type according to the mechanism of injury, Gartland classification, injured arm, vascular status, time from presentation to surgery, weight, type of surgery, medial K-wire use, and afterhours surgery as the independent variables. A follow-up of 1 year was implemented. Result  The overall preoperative neuropraxia rate was 9.1%. The mean surgery duration was 57.6 ± 5.6 minutes. The mean duration of closed reduction and percutaneous pinning surgeries was 48.5 ± 5.3 minutes, whereas the mean duration of open reduction and internal fixation (ORIF) surgeries was 129.3 ± 15.1 minutes. Preoperative neuropraxia was associated with an overall increase in the surgery duration ( p  < 0.017). Bivariate binary regression analysis showed a significant correlation between the increase of surgery duration and flexion-type fracture (odds ratio = 11, p  < 0.038) as well as ORIF (odds ratio = 26.2, p  < 0.001). Conclusion  Preoperative neuropraxia and flexion-type fractures convey a potential longer surgical duration in pediatric supracondylar fracture. Level of Evidence  Prognostic III.

Factors associated with conversion to open reduction of type 3 supracondylar humerus fractures in children

BACKGROUND

The US News and World report utilizes the number of supracondylar humerus fractures treated in an open procedure, excluding open fractures and vascular exploration, as a metric in assessing Pediatric Orthopedic trauma care. The purpose of this study was to identify factors that increase the likelihood of a patient needing open reduction for Gartland Type 3 SCH fractures.

METHODS

All pediatric patients who underwent surgical management of closed, Type 3 SCH fractures at our Pediatric Level 1 Trauma Center between 2011 and 2017 were considered for inclusion. Patient age greater than 16 years, patients with closed physes and open fractures were excluded. Electronic medical records and radiographic imaging were reviewed. Student's t- and chi-squared tests were used, and logistic regression was performed comparing closed v open reduction.

RESULTS

362 subjects were included in this study. 318/362 (87.8%) were treated with closed reduction. 44/362 (12.2%) required open reduction. There were no statistically significant differences in age, gender, BMI, concomitant ipsilateral extremity fractures, Type 4 unstable fracture or patients that underwent hospital transfer. The mechanisms of injury with the greatest percentage requiring open reduction were fall from furniture and trampoline. Of those patients that underwent open reduction, 65.9% had posterolateral displacement of the fracture. Those with displacement >4 mm had 3.14 higher odds of requiring an open reduction (p = 0.002). The anterior spike fracture pattern had the highest rate of failed closed reduction of 66.7%. Of those patients that had an open reduction, 13/44 (29.5%) had a neuropraxia and 5/44 (11.4%) had vascular compromise. Those with neuropraxia had 3.26 higher odds of requiring an open reduction (p = 0.005). Time to operating room was significantly shorter in patients that underwent open reduction (p < 0.001).

CONCLUSION

Our rate of open reduction for Type 3 SCH fractures, 12.2%, is consistent with previously described rates. Posterolateral displacement of fractures, displacement >4 mm, fractures with an anterior spike and fractures associated with neurovascular compromise are more likely to undergo open reduction. Transfer status, BMI and patient age were not associated with open reduction. Open reduction was associated with shorter time to the operating room, likely representing the urgent care of significantly displaced fractures associated with neurovascular compromise.

LEVEL OF EVIDENCE

Level III.

The outcome of loose bone fragments in pediatric supracondylar humerus fractures: a retrospective study

We evaluated the clinical and imaging outcomes of loose bone fragments in children with supracondylar humerus fractures after closed reduction with percutaneous pin (CRPP) fixation. A retrospective review was conducted on 12 children with fragments on imaging after closed reduction of displaced humeral supracondylar fractures (Gartland III). Primary radiographic assessment included fragment outcome, postoperative Baumann angle, carrying angle and loss of reduction. Clinical outcome included the elbow range of motion (ROM), Flynn grade and other complications. Between January 2015 and January 2018, 460 children (2-14 years old) with supracondylar humerus fractures were treated at our center, including 12 (2.6%) with loose bone fragments on postoperative X-ray. Union or absorption of fragments was noted in all 12 patients at 1 year postoperatively, with good radiographic and clinical outcomes. The mean Baumann angle was 15.5° ± 4.3° and the mean carrying angle was 11.2° ± 2.8°. All patients had a normal elbow ROM. Ten patients achieved an excellent and two a good result according to the Flynn criteria. Good results were achieved after CRPP fixation in 12 children with supracondylar humerus fractures and loose bone fragments. The fragments were mainly absorbed or achieved union to the humerus within 1 year.

Does Surgical Experience Decrease Radiation Exposure in the Operating Room?

BACKGROUND

Intraoperative fluoroscopy facilitates minimally invasive surgery, and although it is irreplaceable in terms of intraoperative guidance, it results in substantial radiation exposure to the patient and surgical team. Although the risk of radiation exposure because of equipment factors has been described, there is little known about the impact of surgeon experience on radiation exposure. The aim of this study was to determine whether there is a relationship between years of surgical experience and total dose of radiation used for an archetypal pediatric orthopaedic surgical procedure that requires intraoperative fluoroscopy.

METHODS

This was a retrospective cohort study of children undergoing closed reduction and percutaneous pinning for supracondylar humerus fractures at a level I pediatric trauma center. Information pertaining to radiation dosage was gathered including fluoroscopic time, total images acquired, magnification use, and dose area product (DAP). Regression analysis was used to evaluate the effect of surgeon experience on the outcome variables.

RESULTS

A total of 759 pediatric patients treated by 17 attending surgeons were included. The median surgeon experience was 8.94 years (interquartile range, 5.9 to 19.8). Increased number of pins was associated with increased DAP (P<0.001) and lower years of experience (P=0.025). There was significantly higher fluoroscopy time in seconds (56.9 vs. 42.1 s, P=0.001), DAP (179.9 vs. 110.3 mGy-cm2, P=0.001), use of magnification (39.5 vs. 31.9 s, P=0.043), and total number of images obtained (74.5 vs. 57.6, P=0.008) in attending surgeons with <1 year of experience compared with those with greater experience. An operator extremity was visible in at least 1 saved image in 263 of 759 (35%) cases.

CONCLUSION

Increased surgical experience was significantly associated with decreased fluoroscopy usage, including time, number of images, and dose. Surgeon inexperience increases radiation exposure for patients and staff by over 60% when treating supracondylar humerus fractures. This study clearly identifies methods to reduce radiation exposure, including use of pulsed fluoroscopy instead of continuous fluoroscopy, decreasing use of magnification, removing the operator's extremity from the field, and judicious use and placement of each additional pin.

LEVEL OF EVIDENCE

Level III.

The Pediatric Open Supracondylar Fracture: Associated Injuries and Surgical Management

BACKGROUND

While supracondylar (SC) fractures are relatively common in children, the incidence of open injuries is believed to be only 1%. Two prior studies on open SC fractures in children reported an increased incidence of vascular injuries. The purposes of our study were to clarify the incidence, associated conditions, and current treatment for open SC fractures.

METHODS

The Pennsylvania Trauma Outcome Study database was queried. Subjects age 25 to 156 months old admitted to trauma centers between January 2000 and December 2015 with a SC fracture were included. Controls were those with closed fractures and the study group, those with open injuries. Study variables were age, sex, weight, injury severity score, length of stay (LOS), nerve injury, ipsilateral forearm fracture, compartment syndrome/fasciotomy, requirement for a vascular procedure. Other variables were mode of treatment, provisional reduction, repeat reduction, time interval between referring facility admission and operation, and time from emergency department admission to operation.

RESULTS

A total of 4308 subjects were included, 104 (2.4%) of whom had an open SC fracture. LOS was 2 days for the study group versus 1 day for controls (P<0.001). Open SC fractures were more likely than closed to be associated with a nerve injury (13.5% vs. 3.7%), ipsilateral forearm fracture (18.3% vs. 6.4%) and/or a vascular procedure (6.7% vs. 0.3%) (P<0.001). 5.9% of those in the study group required repeat surgery compared with 0.4% for controls (P<0.001). Time from emergency department admission to operation was 3.2 versus 10.3 hours (P<0.001).

CONCLUSIONS

We report the largest series to date of open SC fractures in children. Surgeons caring for such patients should be aware of their increased risks for both associated injuries and potential requirement for vascular reconstruction. The majority of children with an open SC fracture are managed with 1 operation and in the absence of vascular injury, seldom require an extended LOS.

LEVEL OF EVIDENCE

Level III-retrospective cohort study.

Two-Stage Surgical Procedure in Intra-articular Distal Tibiofibular Fractures with Soft Tissue Injury: in Which Stage Should the Fibular Plate be Applied at Initial Surgery?

Introduction:

The selection of the stage where fibular plate was performed in two-stage surgery of the intra-articular distal tibiofibular fractures with soft tissue injury is still controversial. The aim of the study was to compare the complications, radiological and functional outcomes between the patients who had fibular plate at initial or second phase during surgical management of such fractures.

Materials and Methods:

In this study, medical records of 47 patients who underwent a two-stage surgical procedure for intra-articular distal tibia fractures accompanying soft tissue injury were retrospectively examined. Delta frame was applied in all cases within 24 hours following admission to the emergency department in accordance with AO principles. Those cases where fibular plate was applied during the initial stage and the second stage were classified as Group 1 and Group 2 in order to compare recorded data between the two groups.

Results:

According to the results of the study, there were 25 cases in Group 1 and 22 cases in Group 2 in which fibular plate was applied at the first stage and the second stage, respectively. The mean follow-up was found as 27.7±7.0 months in Group 1 and 28.2±6.2 months in Group 2 (p=0.778). No difference was found between the two groups in terms of the age, sex, hospital stay, the time between two surgical procedures, tibiofibular angle and AOFAS scoring (p>0.05).These two groups were also similar in mechanism of injury, Denise-Weber or AO classification, rates of tibiofibular malalignment on post-operative CT, fibular rotation, intra-articular tibial step-off, tibial varus-valgus duration of union, rate of infection, fibular angulation and the presence of the flap/graft/debridement (p>0.05).

Conclusion:

In conclusion, two-stage surgical procedure in intra-articular distal tibiofibular fractures may be an effective method decreasing soft tissue complications. The timing of the open reduction and internal fixation of the fibula at different stages may not necessarily have an impact on the success of the post-operative tibial reduction, the total duration of surgery, syndesmosis malalignment or soft tissue complications.