A Mini-Open Approach to Medial Pinning in Pediatric Supracondylar Humeral Fractures May Be Safer Than Previously Thought

Comparative risk of ulnar nerve injury in pediatric supracondylar humeral fractures: a multicenter evaluation of Kirschner wire fixation techniques

PURPOSE

This multicenter, retrospective cohort study aimed to compare the risk of ulnar nerve injury in pediatric supracondylar humeral fractures treated with percutaneous lateral-pins, blinded-crossed-pins, and crossed-pins with a mini-incision.

METHODS

Data were collected from 1705 children treated between January 2010 and December 2023 at four orthopedic centers in Colombia. The incidence of postoperative ulnar nerve injury was compared among three fixation techniques: lateral-pin, blinded-crossed-pin, and crossed-pin with a mini-incision.

RESULTS

A statistically significant difference in nerve injury rates was observed between the lateral-pin and both blinded-crossed-pin and mini-incision crossed-pin techniques (p < 0.001), with the lateral-pin technique demonstrating a significantly lower risk of injury. No significant difference was found between the blinded-crossed-pin and mini-incision crossed-pin techniques (p = 0.67).

CONCLUSION

Crossed-pin fixation was associated with a higher incidence of ulnar nerve injury, regardless of the use of a mini-incision. The lateral-pin technique remains the safest option for minimizing iatrogenic nerve injury. There is insufficient evidence to support the mini-incision as a safer alternative to traditional crossed-pin fixation.

The anterior and medial open approaches yield superior outcomes compared to the lateral and posterior open approaches in supracondylar humerus fractures in children: a systematic review and network meta-analysis

This study aimed to perform a systematic review and network meta-analysis (NMA) to examine which open approach is superior in terms of outcomes and complications in the treatment of pediatric supracondylar humerus fractures. MEDLINE/PubMed, Embase, Web of Science, Clinicaltrials.gov, and Cochrane Library were searched from database inception to December 2022 and screened for relevant studies. Data were collected regarding patient demographics, Flynn's functional and cosmetic outcomes, and complications. Unsatisfactory Flynn's and complications were considered negative events. Comparisons of outcomes from aggregate data from each surgical approach using relative risk (RR) with a 95% confidence interval (95% CI) were performed. The NMA of overall negative events was conducted using a Bayesian hierarchical random-effects model analysis. A total of 26 studies involving 1461 patients were included; 459 (31.4%) patients underwent a closed reduction and percutaneous pinning (CRPP), 84 (5.7%) an anterior approach, 240 (16.4%) a medial, 220 (15%) a lateral, and 458 (31.3%) a posterior. The lateral and posterior approaches demonstrate a higher risk of negative event in the NMA compared to CRPP [RR = 2 (1.03, 3.85); RR = 2.63 (1.96, 3.57), respectively], anterior approach [RR = 3.33 (1.11, 10); RR = 4.35 (1.49, 12.5), respectively], and medial approach [RR = 1.82 (1.16, 2.86); RR = 2.38 (1.23, 4.76), respectively]. The medial approach resulted in a similar negative event rate compared to the anterior [RR = 1.82 (0.58, 5.88)]. The anterior and medial open approaches yield superior functional and cosmetic outcomes with fewer complications compared to the lateral and posterior.

Anterior approach for pediatric supracondylar humerus fractures: A systematic review

BACKGROUND AND PURPOSE

Open reduction is rarely performed in pediatric supracondylar humerus fractures. However, clear evidence is lacking regarding the optimal open approach to achieve satisfactory results. The anterior approach provides direct visualization of the fracture and excellent exposure to neurovascular structures, although its utilization is less common. The objective of this study was to review the indications, outcomes, and complications associated with the anterior approach for open reduction of these fractures.

METHODS

Our protocol was registered at PROSPERO: CRD42023446923. MEDLINE/PubMed, Embase, Web of Science, Clinicaltrials.gov, and Cochrane Library were searched from database inception to search date (December 2023) and screened in duplicate for relevant studies. Data were collected regarding patient demographics, indications for open reduction, Flynn's functional and cosmetic outcomes, and complications. Study quality was assessed using the Methodological Index for Non-Randomized Studies Criteria.

RESULTS

A total of 19 studies involving 483 patients were included. One study was classified as Level 2 evidence, ten as Level 3, and eight as Level 4. The mean MINORS score was 13.05±3.47. The primary indication for open reduction was failed closed reduction, observed in 46% of patients. 97.7% and 98.6% of patients achieved Flynn's functional and cosmetic satisfactory results, respectively. The postsurgical neurovascular injury rate was 1.4%. One patient required reintervention.

CONCLUSION

The anterior approach is safe and effective for managing pediatric supracondylar humerus fractures requiring open reduction.

LEVEL OF EVIDENCE

Systematic review of Level 2-4 evidence studies.

Anterior approach for pediatric supracondylar humerus fractures: A systematic review

BACKGROUND AND PURPOSE

Open reduction is rarely performed in pediatric supracondylar humerus fractures. However, clear evidence is lacking regarding the optimal open approach to achieve satisfactory results. The anterior approach provides direct visualization of the fracture and excellent exposure to neurovascular structures, although its utilization is less common. The objective of this study was to review the indications, outcomes, and complications associated with the anterior approach for open reduction of these fractures.

METHODS

Our protocol was registered at PROSPERO: CRD42023446923. MEDLINE/PubMed, Embase, Web of Science, Clinicaltrials.gov, and Cochrane Library were searched from database inception to search date (December 2023) and screened in duplicate for relevant studies. Data were collected regarding patient demographics, indications for open reduction, Flynn's functional and cosmetic outcomes, and complications. Study quality was assessed using the Methodological Index for Non-Randomized Studies Criteria.

RESULTS

A total of 19 studies involving 483 patients were included. One study was classified as Level 2 evidence, ten as Level 3, and eight as Level 4. The mean MINORS score was 13.05±3.47. The primary indication for open reduction was failed closed reduction, observed in 46% of patients. 97.7% and 98.6% of patients achieved Flynn's functional and cosmetic satisfactory results, respectively. The postsurgical neurovascular injury rate was 1.4%. One patient required reintervention.

CONCLUSION

The anterior approach is safe and effective for managing pediatric supracondylar humerus fractures requiring open reduction.

LEVEL OF EVIDENCE

Systematic review of Level 2-4 evidence studies.

Use of lateral-exit crossed-pin fixation for pediatric supracondylar humeral fractures: a retrospective case series

Surgeons have been reluctant to perform crossed-pin fixation for displaced pediatric supracondylar humeral (SCH) fractures because it carries a risk of iatrogenic ulnar nerve injury. This study aimed to introduce lateral-exit crossed-pin fixation for displaced pediatric SCH fractures and to evaluate its clinical and radiological outcomes, with a particular focus on iatrogenic ulnar nerve injuries. Children who underwent lateral-exit crossed-pin fixation for displaced SCH fractures between 2010 and 2015 were retrospectively reviewed. Lateral-exit crossed-pin fixation involved the introduction of a medial pin from the medial epicondyle, as in the conventional method, followed by pulling the pin through the lateral skin until the distal and medial aspects of the pin were just under the cortex of the medial epicondyle. The time to union and loss of fixation were assessed. Flynn's clinical criteria (cosmetic and functional factors) and complications including iatrogenic ulnar nerve injury were investigated. A total of 81 children with displaced SCH fractures were treated with lateral-exit crossed-pin fixation. All but one patient achieved union with good alignment, with an average time to union of 7.9 weeks (3.9-10.3 weeks). Only one patient exhibited cubitus varus deformity associated with loss of reduction. All patients recovered to almost their full range of motion. No case of iatrogenic ulnar nerve injury developed; however, iatrogenic radial nerve injury developed in one patient. Lateral-exit crossed-pin fixation provides sufficient stability with a lower risk of iatrogenic ulnar nerve injury in children with displaced SCH fractures. This method is an acceptable technique for crossed-pin fixation.

Research: Construction and validation of elbow function prediction model after supracondylar humerus fracture in children

This article's objectives are to develop a model to predict children's recovery of elbow function following supracondylar fracture, analyze the risk factors affecting those children's elbow function after surgery, and propose a individualized treatment strategy for elbow function in various children. We retrospectively analyzed clinical data from 410 children with supracondylar humerus fracture. A modeling set and a validation set of kids in the included studies were arbitrarily split into 2 groups on a 7:3 basis. To identify statistically significant risk factors, univariate logistic regression analysis was used. Then, multivariate logistic regression was used with the risk factors, and the best logistic regression model was chosen based on sensitivity and accuracy to create a nomogram; A total of 410 children were included in the study according to the inclusion criteria. Among them, there were 248 males and 162 females, and the fracture type: 147 cases of type IIb and 263 cases of type III. There were no significant changes in the afflicted limb's lateral difference, surgical method, onset season, and number of K-wires, according to univariate logistic regression analysis. Age (P < .001), weight (P < .001), height (P < .001), preoperative elbow soft tissue injury (OR = 1.724, 95% CI: 1.040-2.859, P = .035), sex (OR = 2.220, 95% CI: 1.299-3.794, P = .004), fracture classification (Gartland IIb) (OR = 0.252, 95% CI: 0.149-0.426, P < .001), no nerve injury before surgery (OR = 0.304, 95% CI: 0.155-0.596, P = .001), prying technique (OR = 0.464, 95% CI: 0.234-0.920, P = .028), postoperative daily light time > 2 hours (OR = 0.488, 95% CI: 0.249-0.955, P = .036) has a significant difference in univariate analysis; Multivariate regression analysis yielded independent risk factors: fracture classification; No nerve injury before surgery; The daily light duration after surgery was > 2 hours; soft tissue injury; Age, postoperative cast fixation time. The establishment of predictive model is of significance for pediatric orthopedic clinicians in the daily diagnosis and treatment of supracondylar humerus fracture.

Impact of Pediatric Orthopaedic Fellowship Training on Pediatric Supracondylar Humerus Fracture Treatment and Outcomes: A Meta-analysis

BACKGROUND

Supracondylar humerus (SCH) fractures are common pediatric injuries, typically requiring closed reduction and percutaneous pinning or open reduction. These injuries are managed frequently by both pediatric-trained (PTOS) and nonpediatric-trained (NTOS) orthopaedic surgeons. However, some literature suggests that complications for pediatric injuries are lower when managed by PTOS. Therefore, this meta-analysis sought to compile existing literature comparing patients treated by PTOS and NTOS to better understand differences in management and clinical outcomes.

METHODS

Using preferred reporting items for systematic reviews and meta-analyses (PRISMA) methodology, a systematic review was conducted for all articles comparing SCH fractures managed by PTOS and NTOS in 4 online databases (PubMed, Embase, CINAHL, Cochrane). Study quality was assessed through the use of the Newcastle-Ottawa Scale. Meta-analyses were then performed for postoperative outcomes using pooled data from the included studies. Statistics were reported as odds ratios and 95% CI.

RESULTS

This search strategy yielded 242 unique titles, of which 12 underwent full-text review and 7 met final inclusion. All studies were retrospective and evaluated patients treated in the United States. There were a total of 692 and 769 patients treated by PTOS and NTOS, respectively. PTOS had shorter operative times [mean difference, 13.6 min (CI, -23.9 to -3.4), P=0.01] and less frequently utilized a medial-entry pin [odds ratios, 0.36 (CI, 0.2 to 0.9), P=0.03]. There were no differences in time to treatment, the necessity of open reduction, postoperative Baumann angle, or complications including surgical site infection or iatrogenic nerve injury.

CONCLUSIONS

Despite shorter operative times and lower frequency of cross-pinning when treated by PTOS, pediatric SCH fracture outcomes are similar when treated by PTOS and NTOS. These findings demonstrate that these fractures may possibly be treated safely by both PTOS and experienced fellowship-trained academic NTOS who are comfortable managing these injuries in pediatric patients.

LEVEL OF EVIDENCE

Level III; Meta-analysis.

A less invasive operative method using a medial cannulated cancellous screw and single plate fixation for the treatment of transcondylar fracture of the humerus in elderly patients in multicenter (TRON group) study

BACKGROUND

Double plate fixation for transcondylar fracture (TCF) tends to be more invasive to the soft tissue, and often carries a higher risk of postoperative complications, including ulnar nerve neuropathy. This study presents the outcomes of TCF of the distal humerus between patients treated with a single plate and cannulated cancellous screw fixation and patients treated with double plate fixation.

METHODS

Between 2011 and 2021, 371 cases involving treatment of distal humeral fracture were recorded in our multicenter (named TRON group) database. Patients of ≥ 65 years of age with TCF treated with opeb n reduction and internal fixation were included. Clinical outcomes were assessed by the Mayo elbow performance score, range of motion, and total elbow arc joint. Complications included fracture-related infection (FRI) and ulnar neuropathy.

RESULTS

There were significant differences in the average operative time (CCS group vs. Plate group: 119.0 min vs. 186.5 min; p < 0.001) and average tourniquet time (CCS group vs. Plate group: 91.5 min vs. 121.0 min; p < 0.001). FRI occurred as a complication in the Plate group (n = 6). The rates of FRI did not differ to a statistically significant extent (CCS group vs. Plate group: 0% vs. 9.2%; p = 0.477). No patients underwent reoperation. The rate of sensory symptoms in the Plate group was higher than that in the CCS group (CCS group: none [n = 25], numbness [n = 1] vs. Plate group: none [n = 57], numbness [n = 15], sensory depression [n = 2]; p = 0.039).

DISCUSSION

Among patients of ≥ 65 years of age with TCF, the clinical outcomes of patients treated with medial CCS and lateral/posterolateral plate did not differ from those of patients who received double plate fixation, and the former treatment was associated with significantly fewer complications, including ulnar nerve palsy. In addition to double plate fixation, this less invasive method of medial CCS and single plate fixation should be considered as a treatment option for TCF in elderly patients.

Management of iatrogenic ulnar nerve palsies after cross pinning of pediatric supracondylar humerus fractures: A systematic review

PURPOSE

Up to 4% of patients who undergo cross pinning of a pediatric supracondylar humerus fracture sustain an iatrogenic ulnar nerve palsy (IUNP). This study aims to summarize the evidence regarding the management of IUNP in this setting, and to identify if early intervention (early wire removal or exploration) leads to faster and/or more complete recovery of the ulnar nerve.

METHODS

A formal systematic review was undertaken, with databases searched including Ovid Medline, Embase and Cochrane central. This was performed in accordance with JBI methodology and PRISMA guidelines.

RESULTS

In all, 26 articles were included in final evaluation, reporting a total of 179 IUNP. In all, 153 cases (85%) were managed expectantly, reporting full recovery at final follow-up (average 4.5 months) in 140 cases (91%). There were 26 cases of IUNP which were managed with early wire removal and/or exploration, of which 22 had full recovery (85%). There were 17 cases of 179 (9%) which did not have full recovery.

CONCLUSION

The majority of IUNP are managed expectantly, with approximately 90% achieving full recovery at final follow-up. The literature does not support early wire removal and/or exploration, possibly because the damage to the nerve is done at the time of wire placement.

The Frequency and Outcomes of Nerve Palsies in Operatively Treated Supracondylar Humerus Fractures

BACKGROUND

A high index of suspicion for nerve palsy is essential in the setting of a displaced supracondylar humerus fracture (SCHF) with careful attention to the examination. We hypothesize that nerve injuries are more prevalent in higher energy type III and flexion SCHFs compared with type II fractures.

METHODS

A retrospective review was performed of 1085 operatively treated SCHFs in pediatric patients, aged 0 to 14 years, between January 1, 2015 and December 31, 2018. There were 979 patients eligible for analysis. Exclusion criteria included follow-up <3 weeks, polytrauma, pathologic fracture, and prior fracture of the ipsilateral elbow.

RESULTS

The overall rate of nerve injury was 10.6% (104/979). A significant difference in the rate of nerve palsy was identified between fracture types: 0.9% type II, 19.3% type III, and 10.7% flexion type SCHFs ( P <0.001). Median nerve palsy was the most common (n=65). An increased rate of ulnar nerve palsy was observed in flexion type SCHFs. The rate of nerve palsy was higher in the medial pin group (14.9%, P =0.035) but no significant association with iatrogenic ulnar nerve palsy was present. In type III and flexion SCHFs, operative time >60 minutes ( P =0.023) and the need for open reduction ( P =0.012) were significantly associated with postoperative nerve palsy. Referral to therapy was required in 30.8% of patients with a nerve palsy compared with 7.9% of patients without ( P <0.001).

CONCLUSION

Longer operative times, need for open reduction, and significantly higher rates of nerve palsy among type III and flexion SCHFs are best explained by the unstable nature of the fracture and greater degree of soft tissue trauma. Given prolonged duration of follow-up and more frequent need for therapy demonstrated in patients with a nerve palsy, these data can be used to improve counseling for families and patients after displaced SCHF.

LEVEL OF EVIDENCE

Level III-retrospective comparative study.

Nonaccidental Trauma in Pediatric Elbow Fractures: When You Should Be Worried

BACKGROUND

Nonaccidental trauma (NAT) is a rising source of morbidity and mortality in the pediatric population. Fractures are often the first cause for presentation to health care providers in the case of NAT but can be misidentified as accidental. Given that elbow fractures are the most common accidental injuries among pediatric patients, they are not traditionally associated with NAT. This study aims to determine the prevalence of NAT among elbow fractures and identify common features in nonaccidental elbow fractures.

METHODS

Current Procedural Terminology (CPT) codes were used to retrospectively identify all pediatric (0 to 17) elbow fractures at a single, tertiary children's hospital between 2007 and 2017. Among these, all fractures for which an institutional child abuse evaluation team was consulted were identified. The medical record was then used to determine which of these fractures were due to NAT. Standard injury radiographs of all victims of NAT as well as all patients under 1 year of age were blinded and radiographically evaluated for fracture type by a pediatric orthopaedic surgeon.

RESULTS

The prevalence of nonaccidental elbow fractures across the 10-year study period was 0.4% (N=18). However, the prevalence of nonaccidental elbow fractures in those patients below 1 year of age was markedly higher at 30.3% (10/33). Among all elbow fractures in patients below 1 year of age, supracondylar humerus fractures were the most common fracture type (19/33, 57.6%), yet transphyseal fractures (6/33, 18.1%) were most commonly the result of NAT (5/6, 83.3%). In children over 1 year of age, fracture type was not an indicator of NAT.

CONCLUSIONS

The vast majority of pediatric elbow fractures (99.6%) are accidental. However, certain factors, namely age below 1 year and transphyseal fractures increase the likelihood that these fractures may be a result of NAT.

LEVEL OF EVIDENCE

Level IV: retrospective case series.