The recovery of elbow range of motion after treatment of supracondylar and lateral condylar fractures of the distal humerus in children

Risk Factors for Stiffness After Surgical Treatment of Pediatric Humeral Lateral Condyle Fractures: Results of a Multicenter Study

INTRODUCTION

Pediatric humeral lateral condyle fractures are the second most common elbow fractures. Their treatment presents challenges due to physeal and intra-articular involvement. Postoperative stiffness is a common concern that can limit limb functionality. This study aims to identify risk factors for postoperative stiffness in a large cohort of these fractures across multiple institutions.

METHODS

A large, multicenter retrospective review of medical records from 6 level I trauma centers was conducted. Data from children aged 1 to 12 years with lateral condyle fractures treated between 2005 and 2019 were collected. Elbow stiffness was defined in the present study as having a limited elbow ROM that led to requiring a physical or occupational therapy referral or needing surgical treatment to address stiffness. Relevant patient demographics, fracture characteristics, treatment approaches, and complications were analyzed.

RESULTS

Six hundred sixty-five fractures were analyzed. The average patient age was 8.8 years with 21% experiencing stiffness. The stiffness group had older patients, a higher incidence of elbow dislocations, a higher rate of open reduction, and more severe fracture patterns. Multivariate regression analysis identified open reduction, increased age, and concurrent elbow dislocation as significant risk factors for stiffness. Patients with stiffness commonly utilized only physical or occupational therapy (96%), while a small percentage (4%) required surgical interventions.

CONCLUSIONS

This study highlights the risk factors for postoperative stiffness in pediatric humeral lateral condyle fractures, namely increased age, concomitant elbow dislocation, and treatment with open reduction. Families of older patients or severe fracture patterns requiring open reduction and those with concurrent elbow instability should be counseled about their increased risk of stiffness. The authors recommend initially attempting a closed reduction in high-risk patients to help mitigate the risk of postoperative stiffness. Early initiation of range of motion exercises may also be beneficial for at-risk patients.

LEVEL OF EVIDENCE

Level III: Therapeutic studies-Investigating the results of treatment.

A systematic review of Clinical Practice Guidelines for the management of fractures in children to develop the WHO's Package of Interventions for Rehabilitation

INTRODUCTION

Fractures have been identified as one of the 20 major health conditions for the World Health Organization's (WHO) Package of Interventions for Rehabilitation (PIR) - that includes also the needs of children and youth. The identification of existing interventions for rehabilitation and related evidence is a crucial step along the development of the PIR. The methods for the identification have been developed by WHO Rehabilitation Program and Cochrane Rehabilitation under the guidance of WHO's Guideline Review Committee Secretariat.

EVIDENCE ACQUISITION

This paper is part of the "Best Evidence for Rehabilitation" (be4rehab) series, developed according to the methodology presented in the PIR introductory paper. It is a systematic review of the existing Clinical Practice Guidelines (CPGs) on fractures in pediatric population published between 2009 to 2019.

EVIDENCE SYNTHESIS

We identified seven relevant CPGs after title and abstract screening. According to inclusion/exclusion criteria and after checking for quality, publication time, multidisciplinarity and comprehensiveness, we have been able to include two CPGs: one addresses the treatment of supracondylar humerus fractures and the other provides recommendations on the treatment of diaphyseal femur fractures.

CONCLUSIONS

The selected CPGs on the management of supracondylar humerus and diaphyseal femur fractures in pediatric population include few recommendations considered as interventions for rehabilitation, of low quality of evidence and weak strength. We found several gaps in specific rehabilitative topics. High quality studies are absolutely needed to upgrade the quality of available evidence to inform future development of guidelines.

Combined Supracondylar Humerus Fracture, Monteggia Injury, and Radial/Ulnar Shaft Fractures in a 3-Year-Old Child

Ipsilateral pediatric elbow and forearm injuries are uncommon, particularly those comprising a supracondylar humerus fracture, radiocapitellar joint dislocation, proximal ulna fracture, and distal forearm fracture. We present the case of a boy who was 3 years, 6 months old and sustained this constellation of injuries. He underwent urgent treatment with closed reduction and percutaneous fixation of the humerus and flexible intramedullary nail fixation of the ulna. He presented with an ulnar sensory and motor neuropraxia that resolved, and he had full radiographic union and upper extremity range of motion by 3 months postoperatively. [Orthopedics. 2022;45(2):e107-e109.].

What is the minimum torque required to obtain passive elbow end range of motion?

BACKGROUND

Passive range of motion is a common clinical assessment. The point at which passive end range of motion is measured is typically described by the 'end-feel'of the joint.

RESEARCH QUESTION

What is the minimum amount of torque required to obtain passive elbow flexion and extension in children?

METHODS

Twenty-five children (age, 7.5 ± 1.6 years-old), who had previously sustained unilateral distal humeral fractures, participated in this prospective study.Passive elbow flexion and extension was measured at least 8 weeks and up to one year out of cast. Motion capture cameras were used to track twenty-one reflective markers placed on subjects and two markers attached to the pad of a force transducer.Five trials of passive range of motion (flexion and extension) were performed on both arms. Elbow joint moments were calculated as products of the forces applied and lengths to the elbow centers. A one way ANOVA was used to determine differences in moments for flexion and extension for both involved and uninvolved limbs. Pairedsamples t-tests were used to determine differences between the involved and the uninvolved limbs for both maximum flexion and extension.

RESULTS

There was no difference in the minimum mean joint moment (2.7 ± 1.1 Nm) at end range of motion. However, differences in passive range of motion was found between involved and uninvolved elbows (flexion p < .001; extension p = .001).

SIGNIFICANCE

The results demonstrate therapists obtained end range of passive elbow flexion and extension applying the same amount of minimum torque. A small torque is sufficient to achieve end range of elbow motion for children. This torque can be used in guiding clinical practice for assessing passive range of elbow motion in pediatric population. Because of a paucity of data for any joint, future research developing force data for other joints should be conducted.

Standardizing a Postoperative Protocol for Supracondylar Humerus Fractures

BACKGROUND

Supracondylar humerus fractures are the most commonly operated upper extremity fracture in pediatric orthopaedics, yet there does not currently exist a standardized recommendation for a postoperative protocol. As advanced practice providers take on larger roles in the care of fracture patients, it may alleviate confusion to standardize postoperative protocols. The aim of this study was to compare outcomes between three different postoperative management protocols following operative fixation of supracondylar humerus fractures.

METHODS

This is a retrospective study of all patients who underwent operative fixation of a supracondylar humerus fracture during the 2014 to 2015 academic year. Postoperative protocols were classified as either "liberal," "intermediate," or "conservative," based on how quickly the surgeon allowed unrestricted motion of the elbow postoperatively. Patients were evaluated for range of motion, functional elbow motion, and elbow clinical function, as well for postoperative complications. Univariate analysis was conducted to detect the differences in outcomes between protocol groups with P<0.01 considered significant.

RESULTS

One hundred patients were included in the final analysis, with 17 patients in the liberal group, 50 in the intermediate group, and 33 in the conservative group. There were no differences in patient population (age, sex, fracture type, concomitant nerve palsy, ipsilateral injuries, or physical therapy referrals) between the groups (P>0.01). There were no differences in range of motion, functional motion, or elbow clinical function (P>0.01) between the postoperative protocol groups. There were no postoperative complications (unplanned return to operating room, refracture, need for fixation revision, or infection) in any patient.

CONCLUSIONS

There were no differences in postoperative complications or outcomes between the patients in the liberal, intermediate, or conservative protocol groups. In an efficiency-focused era, we conclude that a standardized liberal protocol be considered at a busy orthopaedic center.

LEVEL OF EVIDENCE

This study is a level III therapeutic study. It is a retrospective study that compares the outcomes after following 1 of 3 different postoperative protocols.

Spontaneous humeral torsion deformity correction after displaced supracondylar fractures in children

BACKGROUND

After displaced supracondylar humerus fractures (SCHF) in children, residual deformities are common with cubitus varus (CV) being the clinically most visible. Distal fragment malrotation may lead to instability, fragment tilt and subsequent CV. Detection and assessment of malrotation is difficult and the fate of post-traumatic humeral torsion deformity is unknown. The aim of this study was to evaluate the incidence of humeral torsion differences in children with surgically treated SCHF and to observe spontaneous changes over time.

METHODS

A cohort of 27 children with displaced and surgically treated SCHF were followed prospectively from the diagnosis until twelve months after trauma. Clinical, photographic, sonographic and radiological data were obtained regularly. Differences in shoulder and elbow motion, elbow axis, sonographic humeral torsion measurement and radiological evaluation focusing on rotational spur were administered.

RESULTS

Six weeks after trauma, 67% of SCHF children had a sonographically detected humeral torsion difference of > 5° (average 14.0 ± 7.6°). Of those, 44% showed a rotational spur, slight valgus or varus on radiographs. During follow-up, an average decrease of the difference from 14° (six weeks) to 7.8° (four months) to 6.5° (six months) and to 4.9° (twelve months) was observed. The most significant correction of posttraumatic humeral torsion occurred in children < 5 years and with internal malrotation > 20°.

CONCLUSION

After displaced and surgically treated SCHF, most children had humeral torsion differences of both arms. This difference decreased within one year after trauma due to changes on the healthy side or correction in younger children with severe deformity.

LEVEL OF EVIDENCE/CLINICAL RELEVANCE

Therapeutic Level IV.

Efficacy of ultra-early rehabilitation on elbow function after Slongo's external fixation for supracondylar humeral fractures in older children and adolescents

OBJECTIVE

To evaluate the efficacy of ultra-early rehabilitation on elbow function after Slongo's external fixation for supracondylar humeral fractures in older children and adolescents.

METHODS

We retrospectively analyzed clinical data from 49 older children (> 8 years) and adolescents with supracondylar humerus fracture who were treated with Slongo's external fixation in our hospital from January 2016 to August 2020. Twenty-three patients received ultra-early postoperative rehabilitation (rehabilitation group) and 26 patients were not subjected to postoperative rehabilitation (control group). Time to ROM required for functional activity of daily living(ROM-ADL) in both groups was recorded postoperatively. Patients were followed up at 3 and 6 months after surgery to compare the elbow range of motion (ROM) and carrying angle (CA). Postoperative complications were assessed in both groups. Flynn scores and modified Mayo Elbow Performance Scores were also performed.

RESULTS

The elbow function at 6 months after surgery was significantly better than that at 3 months in the control group (P = 0.32). Time to ROM-ADL in the rehabilitation group was significantly shorter than that of the control group (P = 0.028). The elbow function, Flynn scores, and modified Mayo scores in the rehabilitation group at 3 and 6 months after surgery were significantly better than that of the control group (P(ROM, 3 months and 6 months) = 0.012 vs 0.039; P(Flynn scores, ROM, 3 months and 6 months) = 0.028 vs 0.005; P(Flynn scores, CA, 3 months and 6 months) = 0.032 vs 0.026; P(Modified Mayo scores, 3 months and 6 months) = 0.039 vs 0.024; respectively). There were no iatrogenic injuries, secondary fracture displacements, myositis ossificans, elbow deformities, or other complications in either group. One case of nail tract infection occurred in the rehabilitation group and was cured.

CONCLUSION

Slongo's external fixation is a safe and effective surgical treatment for supracondylar humeral fractures in children over 8 years old and adolescents. Ultra-early rehabilitation treatment for postoperative children can significantly speed up the recovery after surgery.

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.

Lateral Condyle Fracture of the Humerus in Children: Kirschner Wire or Screw Fixation?

INTRODUCTION

 The treatment of the displaced fracture of the lateral condyle of the distal humerus in children aims not only to avoid nonunion, malalignment, and impairment of the range of motion of the elbow but also to prevent delayed healing and the development of any prearthrotic deformity. To date there is no agreement on what kind of osteosynthesis should be used. So far, the screw fixation and Kirschner wire fixation have both been applied. Therefore, the goal of this study was to compare the outcome of these two methods.

MATERIALS AND METHODS

 A retrospective cohort study was undertaken including 43 patients aged 2 to 13 years who underwent osteosynthesis for a condylar fracture of the humerus over a period of 10 years. The electronic archive, including the radiological diagnostics, was analyzed. Statistical analysis was performed using IBM SPSS Statistics 20.0. Statistical significance was set at an α level of p = 0.05.

RESULTS

 Kirschner wire fixation was performed in 48.9% of condylar fractures of the humerus while screw fixation (alone or in combination with a pin) was assessed with a percentage of 51.1% of the cases in this study. Screw fixation only was applied in 20.9% of fractures of the lateral condyle. The selection of the method was independent of the age of the patient (p = 0.2). The comparison of the rate of complications and an impaired range of motion after Kirschner wire osteosynthesis to the rate after screw osteosynthesis showed a significantly lower percentage for the Kirschner wire group (p = 0.046). No case of nonunion, nerve palsy, or pin migration was detected in any patient in this study.

CONCLUSION

 Kirschner wire fixation of condylar humeral fractures in children resulted in a lower rate of complications than screw fixation. No case of nonunion of the fracture was found in the patients that we investigated so that we conclude that Kirschner wires sufficiently adapt the fracture in these cases.

LEVEL OF EVIDENCE

 Level III.

Timing of osteosynthesis of fractures in children changes the outcome

PURPOSE

The search for optimal treatment strategies for fractures in children that require osteosynthesis is controversial and is still being debated. A major factor that has been under discussion is the impact of the timing of surgery: the time delay between the trauma and the operation, as well as the duration of the surgical procedure, and the time of day that the operation is performed are potential factors that might influence the outcome. Therefore, the aim of our study was to investigate the influence of these factors on the outcome after osteosynthesis of diverse fractures of the extremities in children.

METHODS

In a retrospective study, 387 patients aged 1-18 years who presented with fractures of the extremities that underwent surgery were included. Patient records including radiological studies were analyzed. The follow up period lasted at least 12 months or until recovery. Statistical significance was set at an alpha level of P ≤ 0.05.

RESULTS

Delayed surgery, as well as a prolonged duration of surgery, and the mode of transportation of the patient significantly were related to a higher rate of complications. However, in this study, the complication rate was not found to be influenced by the mode of reduction of the fracture, or the time of day or the day of the week. A further parameter that significantly changed the outcome was the mechanism of injury. However, the rate of complications was unchanged if a resident or a consulting was the performing surgeon so that a resident can safely perform the procedure in the presence of a consultant.

CONCLUSION

Timing of surgery for fractures of the extremities in children, including the time from trauma to surgery, the duration of the operation and the mode of transportation to the ER, were found to have a significant impact on the occurrence of complications in this study while the mode of reduction and the time of day did not change the outcome. Future studies with a focus on selected types of fractures are needed to further enlighten this topic.

LEVEL OF EVIDENCE

Retrospective comparative study, level III.

Pediatric Terrible Triad Injury of the Elbow: A Rare and Easily Missed Injury: A Case Report

CASE

We report the case of a pediatric terrible triad injury of the elbow consisting of an ulnohumeral dislocation, a radial neck fracture, and a coronoid chondral injury, which was diagnosed at 14 days following injury. We describe our surgical technique and provide details of the postoperative course, including the development of a rotational contracture following heterotopic ossification.

CONCLUSION

We describe a rare and challenging injury that should be recognized early and managed surgically to maintain acceptable elbow function.

Conservative management of displaced paediatric supracondylar fractures: a systematic review

In low-income countries, where surgical expertise and resources are limited, displaced supracondylar fractures of the distal humerus are routinely managed with traction or closed reduction and casting. This is in contrast to high-income nations, where percutaneous K-wire fixation forms the mainstay of treatment. The aim of our study is to present the published evidence regarding the outcome of conservatively managed displaced supracondylar fractures in children. A systematic review of the literature was performed identifying 46 studies evaluating the outcome of displaced supracondylar fractures managed non-operatively. Our results show management by traction is equivalent to percutaneous pinning, whereas outcomes following closed reduction and casting were inconsistent. Traction therefore remains a viable option in low- and middle-income countries (LMICs). However, at present there are few data from LMICs, limiting the transferability of our conclusions.

Paediatric lateral humeral condylar fracture outcomes at twelve years follow-up as compared with age and sex matched paired controls

INTRODUCTION

Lateral humeral condylar fractures are the second most common elbow fractures in children. We present the long-term clinical and radiographic results.

MATERIAL AND METHODS

All children (<16 years) in the geographic catchment area with lateral condylar fracture were asked to participate and 32 (76.2%) patients enrolled. Clinical and functional results are compared with randomly selected but age and sex matched normal controls at 12.4 years (range 10.6 to 16.0).

RESULTS

Unsatisfactory clinical outcomes were found in 40.6% of the fracture cases vs. 6.3% controls (P = 0.003), according to Flynn's criteria. Flexion-extension range of motion was decreased >5° in 13 cases (40.6%) and in four controls (12.5%, P = 0.013). One in four (N = 8, 25%) of the cases showed cubitus varus >5° and 15.7% (N = 5) had cubitus valgus >5°, compared to one cubitus valgus (3.1%) in controls (P = 0.002).

CONCLUSION

The majority of the adolescent and young adult patients (59.4%) with a previous paediatric lateral humeral condylar fracture had recovered well and showed good or excellent overall outcomes according to Flynn's criteria for elbow assessment after a mean of 12.4 years post-injury. Long-term sequelae was unchanged regardless of treatment.

The long-term outcome of childhood supracondylar humeral fractures: A population-based follow up study with a minimum follow up of ten years and normal matched comparisons

AIMS

We present the clinical and radiographic outcome of 81 children with Gartland type I to III supracondylar humeral fractures at a minimum follow-up of ten years (mean 12.1 years; 10.3 to 16.1) following injury.

PATIENTS AND METHODS

The clinical and functional outcomes are compared with normal age- and gender-matched individuals. The population-based study setting was first identified from the institutional registries; the rate of participation was 76%. Controls were randomly selected from Finnish National Population Registry.

RESULTS

According to Flynn's criteria, most fractures (75.3%) resulted in a satisfactory ("good or excellent") outcome. Satisfactory recovery was achieved in 75.0% of type I fractures treated by closed splinting (p = 0.013). Type II fractures were associated with both satisfactory (57.7%) and unsatisfactory (42.3%) results, regardless of the type of treatment, although the numbers were small in the sub groups. Most type III fractures were treated operatively, and most (76%) had a satisfactory outcome according to Flynn's criteria (p = 0.015). Compared with none among the normal subjects, flexion of the elbow was reduced by > 10° at long-term follow-up in 20 cases (24.7%, p < 0.001) and 9 (11.1%) had a reduced flexion of > 15° (p = 0.004). In patients who had sustained a type III fracture, the carrying angle was decreased by 35.7% (from 9.8° to 6.3°; p = 0.048). All patients achieved an excellent Mayo Elbow Performance Score (mean 96.4 points).

CONCLUSION

The long-term outcome of extension-type supracondylar humeral fractures is generally good, but not exclusively benign, with the potential for long-term pain and ulnar nerve sensitivity, and a decrease in grip strength and range of movement in type II and type III fractures. Bony remodelling cannot be relied upon to correct any residual deformity. In particular, type II fractures have impaired long-term recovery and justify individual consideration in their treatment. Cite this article: Bone Joint J 2016;98-B:1410-17.

Complications of Pediatric Elbow Fractures

Fractures about the elbow in children are common and varied. Both diagnosis and treatment can be challenging, and optimal treatment protocols continue to evolve with new research data. This article reviews common complications related to pediatric elbow fractures and presents recent literature to help guide treatment.

The prognostic value of the fracture level in the treatment of Gartland type III supracondylar humeral fracture in children

A small proportion of children with Gartland type III supracondylar humeral fracture (SCHF) experience troubling limited or delayed recovery after operative treatment. We hypothesised that the fracture level relative to the isthmus of the humerus would affect the outcome. We retrospectively reviewed 230 children who underwent closed reduction and percutaneous pinning (CRPP) for their Gartland type III SCHFs between March 2003 and December 2012. There were 144 boys and 86 girls, with the mean age of six years (1.1 to 15.2). The clinico-radiological characteristics and surgical outcomes (recovery of the elbow range of movement, post-operative angulation, and the final Flynn grade) were recorded. Multivariate analysis was employed to identify prognostic factors that influenced outcome, including fracture level. Multivariate analysis revealed that a fracture below the humeral isthmus was significantly associated with poor prognosis in terms of the range of elbow movement (p < 0.001), angulation (p = 0.001) and Flynn grade (p = 0.003). Age over ten years was also a poor prognostic factor for recovery of the range of elbow movement (p = 0.027). This is the first study demonstrating a subclassification system of Gartland III fractures with prognostic significance. This will guide surgeons in peri-operative planning and counselling as well as directing future research aimed at improving outcomes.

Lack of Benefit of Physical Therapy on Function Following Supracondylar Humeral Fracture: A Randomized Controlled Trial

BACKGROUND

The goal of the study was to evaluate the efficacy of physical therapy in restoring function and mobility after a pediatric supracondylar humeral fracture.

METHODS

The study included sixty-one patients from five to twelve years of age with a supracondylar humeral fracture that was treated with casting or with closed reduction and pinning followed by casting. Patients were randomized to receive either no further treatment (no-PT group) or six sessions of a standardized hospital-based physical therapy program (PT group). The ASK-p (Activities Scale for Kids-performance version) and self-assessments of activity were used to assess function at one, nine, fifteen, and twenty-seven weeks after injury. Motion was measured at nine and fifteen weeks after injury by a blinded therapist. Anxiety was measured at one and nine weeks after injury with a self-assessment. Differences in ASK-p scores and anxiety level were analyzed with use of multivariate generalized estimating equations.

RESULTS

ASK-p scores were significantly better in the no-PT group at nine and fifteen weeks after injury (p = 0.02 and 0.01, respectively) but the difference at twenty-seven weeks was not significant. There were no differences between groups with respect to performance of activities of daily living or time to return to sports. Anxiety at nine weeks was associated with worse ASK-p scores at nine and fifteen weeks in the PT group and with better ASK-p scores in the no-PT group at these time points (p = 0.01 and 0.02, respectively). There were no differences between the groups with respect to elbow motion in the injured arm at any time. Severity of injury had no impact on function or elbow motion in either the PT or the no-PT group.

CONCLUSIONS

Children undergoing closed treatment of a supracondylar humeral fracture that was limited to approximately three weeks of cast immobilization received no benefit involving either return of function or elbow motion from a short course of physical therapy.

LEVEL OF EVIDENCE

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

Obesity and its effects on pediatric supracondylar humeral fractures

BACKGROUND

This study evaluates the effects of childhood obesity on fracture complexity and associated injuries in pediatric supracondylar humeral fractures.

METHODS

A billing query identified all patients who were two to eleven years of age and had undergone operative treatment for extension-type supracondylar humeral fractures over a 12.5-year period. Records were reviewed for demographic data, body mass index percentile, and injury data. Complex fractures were defined as type-3 supracondylar humeral fractures, supracondylar humeral fractures with intercondylar extension, or supracondylar humeral fractures with ipsilateral upper-extremity fractures. Logistic regression analyses were used to test relationships among body mass index subgroups, fracture complexity, elbow motion, preoperative and postoperative neurovascular status, and complications.

RESULTS

Three hundred and fifty-four patients met our inclusion criteria. Forty-one children were underweight (BMI in the <5th percentile), 182 were normal weight (BMI in the 5th to 85th percentile), sixty-three were overweight (BMI in the >85th to 95th percentile), and sixty-eight were obese (BMI in the >95th percentile). There were 149 patients, eleven of whom were obese, with isolated type-2 fractures and 205 patients, fifty-seven of whom were obese, with complex fractures. Thirty-two patients had preoperative nerve palsies and twenty-eight patients had postoperative nerve palsies. Using logistic regression, obesity was associated with complex fractures (odds ratio, 9.19 [95% confidence interval, 4.25 to 19.92]; p < 0.001), preoperative nerve palsies (odds ratio, 2.69 [95% confidence interval, 1.15 to 6.29]; p = 0.02), postoperative nerve palsies (odds ratio, 7.69 [95% confidence interval, 2.66 to 22.31]; p < 0.001), and postoperative complications (odds ratio, 4.03 [95% confidence interval, 1.72 to 9.46]; p < 0.001). Additionally, obese patients were more likely to sustain complex fractures from a fall on an outstretched hand than normal-weight patients (odds ratio, 13.00 [95% confidence interval, 3.44 to 49.19]; p < 0.001).

CONCLUSIONS

Obesity is associated with more complex supracondylar humeral fractures, preoperative and postoperative nerve palsies, and postoperative complications. To our knowledge, this study is the first to assess the implications of obesity on supracondylar humeral fracture complexity and associated injuries and it validates public health efforts in combating childhood obesity.

Recovery of elbow motion following pediatric lateral condylar fractures of the humerus

BACKGROUND

Temporary elbow stiffness is often seen after a lateral condylar fracture of the distal end of the humerus in children. There are scant scientific data available to assess the expected time frame for return of elbow motion after these injuries. The purpose of this study is to provide a prospective, longitudinal evaluation of elbow motion in a large group of pediatric patients undergoing treatment for a lateral condylar fracture of the distal end of the humerus.

METHODS

We prospectively evaluated 141 patients with lateral humeral condylar fractures at a mean age of 5.2 years and with a mean follow-up of twenty-nine weeks. The patients were treated with cast immobilization, percutaneous pinning, or open reduction and internal fixation on the basis of the initial displacement. Elbow motion was followed longitudinally at clinic visits. Relative arc of motion was calculated as a percentage of the motion of the normal, contralateral elbow.

RESULTS

The mean relative arc of motion at the time of cast removal was 44%, reaching 84% by week 12. By weeks 18, 24, 36, and 48, the relative arc of motion reached 87%, 90%, 93%, and 97%, respectively. Compared with fractures treated without surgery, those treated surgically had a significantly lower absolute arc of motion from the time of cast removal (p = 0.018) and up to eighteen weeks after the injury (p < 0.001); however, no significant difference was observed at eighteen weeks or beyond. For patients treated surgically, no significant difference in relative arc of motion was observed between the patients with closed or open reductions. The age of the patient (hazard ratio = 0.87, p = 0.008), length of immobilization (hazard ratio = 0.79, p = 0.03), and severity of the fracture (hazard ratio = 0.40, p < 0.0001) were independent predictors of recovery of elbow motion after a lateral humeral condylar fracture in children.

CONCLUSIONS

An initial rapid recovery in elbow motion can be expected after a lateral humeral condylar fracture in a child, with progressive improvements for up to one year after the injury. This recovery is slower if the patient is older, has a longer period of immobilization, and has a more severe injury.

[Supracondylar fractures of the humerus in children]

BACKGROUND

Supracondylar humerus fractures are common in children. Severe complications are rare. We present an overview of treatment options and prognosis.

MATERIAL AND METHODS

The article is based on a non-systematic search in PubMed and experience from our own clinical research.

RESULTS

The injury is usually caused by falling from a height with the arm in extension. The mean age is about 6 years. Undisplaced fractures are treated conservatively with a cast. Displaced fractures should not be treated with a cast alone, as this may cause malunions and permanent neurovascular complications. The rate of complications after traction of displaced fractures is substantially lower than for immobilisation in cast alone. Traction and percutaneous pinning yield similar results, but percutaneous pinning is less expensive--mainly because it shortens the hospital stay. In addition, the risk of cubitus varus deformity seems to be reduced. Today the treatment of choice is closed reduction and percutaneous pinning. Choice of pin configuration is at the surgeon's discretion. Crossed pins are more common than two lateral pins, although medial pins can affect the ulnar nerve. However, the affection is almost always transient. Deep infection after percutaneous pinning is very rare.

INTERPRETATION

Percutaneous pinning of displaced supracondylar humerus fractures in children is cheap and the results are good.

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.

Prospective longitudinal evaluation of elbow motion following pediatric supracondylar humeral fractures

BACKGROUND

Temporary elbow stiffness after the treatment of a supracondylar humeral fracture in a child is often a concern of parents. However, little attention has been devoted to documenting, longitudinally, the time required for motion recovery. The purpose of the present study was to provide a prospective, longitudinal evaluation of elbow motion in a large population of pediatric patients undergoing treatment of a supracondylar humeral fracture.

METHODS

We prospectively examined 373 patients (375 fractures) who presented to our urgent care center between March 1, 2007, and September 30, 2008. On the basis of a standard protocol, patients were managed with either casting or surgery, depending on the severity of the injury, and then were followed for a minimum of seven weeks. Values of elbow flexion and extension were recorded, and the relative arc of motion was calculated as a percentage of the motion of the contralateral elbow.

RESULTS

In general, following a supracondylar humeral fracture, the greatest increases in flexion, extension, and the absolute and relative arcs of motion are observed within the first month after cast removal, with a progressive improvement for up to forty-eight weeks after the injury. Age had a significant effect on the recovery of elbow motion, with patients older than five years of age demonstrating a 3% to 9% lower relative arc of motion at the follow-up points in comparison with younger patients. Similarly, patients with more-severe fractures requiring surgical treatment demonstrated a decrease in relative elbow motion of 10% (with respect to the contralateral side) at the time of cast removal in comparison with those who were managed nonoperatively.

CONCLUSIONS

The present study demonstrates that an initial rapid recovery in elbow motion can be expected after a supracondylar humeral fracture in a child, followed by a progressive improvement for up to one year after the injury. This motion recovery is slower in older patients and in those with more severe injuries.

Defining safe rehabilitation for ulnar collateral ligament reconstruction of the elbow: a biomechanical study

BACKGROUND

Ulnar collateral ligament reconstruction of the elbow using a variety of techniques has been successful in enabling overhead athletes with ulnar collateral ligament insufficiency to return to competition. Most current postoperative rehabilitation programs begin with a period of motion restriction, including limiting elbow extension, that is followed by a transition from elbow strengthening to an interval throwing program, to competition. Motion restrictions early in the postoperative period may increase the risk for contractures. There is limited information to support current motion restrictions.

PURPOSE

(1) To determine strain on the reconstructed ulnar collateral ligament during a rehabilitation protocol that includes passive range of motion, isometric muscle contraction, and varus and valgus torques. (2) To develop guidelines for a safe initial rehabilitation protocol.

STUDY DESIGN

Controlled laboratory study.

METHODS

Eight cadaveric elbows underwent ulnar collateral ligament reconstruction with the docking technique using a gracilis tendon graft. Differential variable reluctance transducers on the anterior and posterior bands of the reconstructed anterior bundle of the ulnar collateral ligament were used to measure strain, while an optical motion tracking system monitored elbow motion. Strain was measured in the following 3 settings: passive range of motion, 22.2 N isometric flexion and extension contractions, and 3.34 N x m varus and valgus torques with the arm at 90 degrees of flexion.

RESULTS

Range of motion from maximum extension to 50 degrees of flexion produced 3% or less strain in both bands of the reconstructed ligament. Forearm rotation did not significantly affect strain in the anterior or posterior bands (P = .336 and P = .357). Strain at 90 degrees approached 7% in the posterior band (upper 95% confidence interval). Isometric muscle contractions had no measurable effect on strain. Varus torques decreased and valgus torques increased strain significantly (P < .05).

CONCLUSION

In the immediate postoperative period, full extension is safe, while flexion beyond 50 degrees may place deleterious strain on the reconstruction. Isometric flexion and extension exercises do not increase ligament strain but may be unsafe at 90 degrees of flexion, while valgus exercises (internal rotation at the shoulder) can increase strain in the reconstructed ligament.

CLINICAL RELEVANCE

The results have implications for the development of appropriate rehabilitation protocols after ulnar collateral ligament reconstructive surgery.