The outcome and parents-based cosmetic satisfaction following fixation of paediatric supracondylar humerus fractures treated by closed method with or without small medial incision

Beneficial Perioperative Aspects Favor the Use of Percutaneous Crossed Pinning over Antegrade Nailing in Pediatric Supracondylar Fractures-A Retrospective Comparative Study

(1) Background: Displaced supracondylar humeral fractures in pediatric patients can be treated by either antegrade nailing (AN) or percutaneous crossed pinning (PCP). The aim of this study was to compare the intra- and perioperative management, complications and outcome of AN and PCP. (2) Methods: This retrospective study enrolled 271 individuals (median age 5 years, IQR 4-7 years) who underwent AN (n = 173) or PCP (n = 98). Patient history was analyzed for incidence of nerve injuries, postoperative treatment, postoperative malrotation, time of hospital stay, time to implant removal and revision rate. Operative procedures were investigated for duration and radiation exposure. (3) Results: PCP was associated with a significantly lower radiation exposure (dose area product: PCP mean 20.1 cGycm² vs. AN mean 34.7 cGycm², p < 0.001; fluoroscopy time: PCP mean 1.1 min, range 0.1-8.1 min, vs. AN mean 1.5 min, range 0.1-7.1 min, p < 0.001), duration of surgery (PCP mean 32.2 min vs. AN mean 48.3 min, p < 0.001) and time to implant removal (PCP mean 37 days vs. AN mean 113 days, p < 0.001). Cast removal was performed earlier in the AN group (PCP mean 30.2 days vs. AN mean 20.4 days, p < 0.001) and there were fewer iatrogenic nerve lesions (PCP: 24% vs. AN: 8%, p < 0.001). (4) Conclusions: In the investigated study population, the analyzed parameters seem to favor the use of PCP. The advantages of AN should be weighed against its drawbacks. For special indications, AN remains a relevant technique in supracondylar fracture treatment, and surgeons should be familiar with this procedure.

Biomechanical analysis between Orthofix® external fixator and different K-wire configurations for pediatric supracondylar humerus fractures

Background

Closed reduction and percutaneous fixation are considered as the optional treatments for displaced supracondylar humerus fractures. However, there was no published report about the biomechanical analysis in Orthofix® external fixator. In this study, we developed a model of supracondylar humerus fractures and compared the biomechanical analysis of external fixator and different K-wires configurations in order to evaluate the stability of external fixator in supracondylar humerus fractures.

Methods

We developed an anatomic humerus model by third-generation synthetic composite, and 60 synthetic humeris were osteotomized to simulate the humeral transverse supracondylar fracture. Those fractures were reduced and fixed by external fixator or K-wires, and then biomechanical analysis was performed in extension, varus, valgus, and internal and external rotation loading. A paired-sample t test was used to evaluate the distance at the fracture site between the external fixator and K-wire configurations.

Results

During all direction loading, there was a significant statistical difference between external fixator and K-wires (P < 0.001 for all pairwise comparisons). In extension and internal rotation loading, the external fixator and three crossed K-wires had no comparable stiffness values (P = 0.572; P = 0.795), and both were significantly greater than two crossed and lateral K-wires (P < 0.05). In external rotation loading, there was no significance between the external fixator and K-wire configurations except two lateral K-wires (P > 0.05). In valgus loading, the stability of the external fixator was less than that of three crossed K-wires (P = 0.001) but was not significantly different with those of two crossed or three lateral K-wires (P = 0.126; P = 0.564). In varus loading, the stability of the external fixator was larger than those of two and three lateral K-wires (P = 0.000; P = 007).

Conclusions

External fixator could provide enough stability for pediatric supracondylar humerus fractures without the injury of the ulnar nerve. Besides, it could enhance the rotational stiffness of the construct in rotation loading to avoid the complication of cubitus varus.

Operative management of supracondylar humeral fractures in children: Comparison of five fixation methods

BACKGROUND

The best method for stabilising supracondylar humeral fractures (SHFs) in children remains unclear. The objective of this study was to compare the outcomes of five different fixation methods for SHFs in children.

HYPOTHESIS

Differences in intra-operative and short-term post-operative parameters can be demonstrated across different fixation methods for SHFs in children.

PATIENTS AND METHODS

We reviewed the medical files of paediatric patients managed at our centre between 2006 and 2016 for SHF with major displacement (type 3 or 4 in the Lagrange-Rigault classification). Clinical and radiological parameters collected post-operatively and at last follow-up included Baumann's angle, anteversion of the distal humeral epiphysis, and operative time. Over the 11-year study period, 251 patients were included; mean age was 6.4 years and mean follow-up 4.7 months. The five fixation methods used were elastic stable intra-medullary nailing (ESIN, n=16), two pins in an X configuration (n=33), two lateral pins and one medial pin (n=144), two lateral pins (n=33), and three lateral pins (n=25). A minimally invasive 2-cm approach was used to insert the medial pins. Immediate instability of the fixation was considered in patients with an at least 15° deficit in Baumann's angle or anteversion, or with rotational malalignment, on the radiographs taken on day 1. Outcomes were analysed in each of the five internal fixation groups.

RESULTS

Immediate instability showed no significant differences across the five groups. Operative time was significantly shorter with two lateral pins (33min, P=0.046). Time to hardware removal was longer in the ESIN group (54 days, P=0.03). Use of a medial pin was associated with a lower risk of secondary displacement (2.0% vs. 8.6%, P=0.04) but did not affect the risk of nerve injury (4% vs. 3%, P=0.86).

DISCUSSION

This is one of the largest retrospective cohort studies of outcomes according to the fixation technique used to treat SHFs in children. Adding a medial pin through a minimally invasive approach is associated with a longer operative time but limits the risk of secondary displacement without increasing the frequency of iatrogenic nerve injury and improves fracture site stability. Use of a medial pin therefore deserves to be considered in paediatric SHFs.

LEVEL OF EVIDENCE

IV, retrospective cohort study.