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Kolac UC, Oral M, Sili MV, Ibik S, Aydinoglu HS, Bakircioglu S, Yilmaz G. Identifying Risk Factors for Open Reduction in Pediatric Supracondylar Humerus Fractures. J Pediatr Orthop 2024:01241398-990000000-00627. [PMID: 39099078 DOI: 10.1097/bpo.0000000000002784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/06/2024]
Abstract
BACKGROUND Supracondylar humerus fractures (SCHFs) are the most common injuires of the elbow in children, often categorized by the Gartland classification. While type 1 and 2 fractures commonly managed conservatively, type 3 and 4 fractures typically require surgical treatment. Although closed reduction and percutaneous pinning have shown success, open reduction may be required in cases where adequate reduction cannot be achieved. This study aims to identify radiological and clinical risk factors associated with transitioning from closed reduction to open reduction in Gartland type 3 and 4 SCHF in children. STUDY DESIGN AND METHODS We retrospectively analysed 159 patients operated on between 2014 and 2022 for Gartland type 3 and 4 SCHF. Parameters including age, gender, injury severity, time to surgery, neurovascular damage, medial spike angle, fracture-skin distance, medial-lateral deviation, rotation, fracture level, and Baumann angle were evaluated. RESULTS A total of 159 SCHF in children aged 3 to 12 years, classified as Gartland type 3 (106 patients, 66.6%) and type 4 (53 patients 33.4%), underwent surgical intervention. Notably, 46 patients (28.9%) initially managed with closed reduction exhibited failure, prompting the necessity for conversion to open reduction. Injury severity, lateral deviation, advanced age, low medial spike angle, and low fracture tip-to-skin distance were found to be factors that could potentially increase the need for open reduction (P<0.05). Logistic regression analysis showed that the low medial spike angle, flexion type injury, and low fracture type increased the likelihood of open surgery (P<0.05). Sex, side, duration to surgery, and Baumann angle showed no significant associations. CONCLUSIONS SCHF commonly necessitate surgical intervention in children. Although the risk factors for failed closed reduction and the need for open surgery have been discussed in the literature, there is no consensus. Preoperative planning, particularly for patients with specific factors like lateral deviation, advanced age, low medial spike angle, low fracture-to-skin distance and high injury severity, should consider potential open surgery requirements. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Ulas Can Kolac
- Department of Orthopedics and Traumatology, Hacettepe University
| | - Melih Oral
- Department of Orthopedics and Traumatology, Hacettepe University
| | | | - Serkan Ibik
- Department of Orthopedics and Traumatology, Hacettepe University
| | | | - Sancar Bakircioglu
- Department of Orthopedics and Traumatology, TOBB Echonomy and Technology University Turkey, Ankara, Turkey
| | - Guney Yilmaz
- Department of Orthopedics and Traumatology, Hacettepe University
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Gupta K, Erdman MK, Siddiqui A, Schur M, Meisel E, Goldstein RY. Age is a predictor of elbow stiffness after type III or IV supracondylar humerus fractures. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024:10.1007/s00590-024-04031-4. [PMID: 38916802 DOI: 10.1007/s00590-024-04031-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Accepted: 06/14/2024] [Indexed: 06/26/2024]
Abstract
PURPOSE Supracondylar humerus (SCH) fractures account for approximately 30% of injuries for those younger than 7 years of age (Cheng et al. in J Pediatr Orthop 19:344-350, 1999). Recent studies examining the association of patient age and SCH fracture outcomes have provided conflicting findings. The purpose of this study is to investigate SCH fracture outcomes in children at different ages of skeletal development. METHODS Retrospective review of a Level I pediatric trauma center between 2010 and 2014 was conducted. 190 patients with SCH fractures, age < 14 years, fracture type Gartland III or IV (AO/OTA 13-M 3.1 III and IV) were included. Patients were sorted into age groups: < 2 years, 4-6 years, and > 8 years. Patients were treated with either a closed or open reduction with percutaneous fixation. Clinical outcomes including postoperative elbow range of motion, nerve palsy, compartment syndrome, infection, and cubitus varus were assessed. RESULTS Patients in younger age groups were more likely to obtain postoperative full elbow flexion (< 2 years = 77%; 4-6 years = 66%; > 8 years = 43%) and full elbow extension (< 2 years = 96%; 4-6 years = 88%; > 8 years = 64%). Age was a significant predictor of nerve palsy on admission, mean operative time (< 2 years = 21.8 min; 4-6 years = 43.0 min; > 8 years = 80.7 min), and mean fluoroscopy time (< 2 years = 22.9 s; 4-6 years = 59.5 s; > 8 years = 171.9 s). There were no differences in rates of open reduction, compartment syndrome, pin tract infection, cubitus varus, or reoperation among groups. CONCLUSION Increasing age is associated with increased elbow stiffness after percutaneous fixation of Gartland Type III and Type IV SCH fractures. Older patients with SCH fractures may benefit from formal rehabilitation. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Kavish Gupta
- Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Mary Kate Erdman
- Department of Orthopaedic Surgery and Rehabilitation Medicine, University of Chicago Medicine and Biological Sciences, Chicago, IL, USA
| | - Ali Siddiqui
- Department of Orthopaedic Surgery and Rehabilitation, University of Florida College of Medicine-Jacksonville, Jacksonville, FL, USA
| | - Mathew Schur
- Department of Orthopaedic Surgery, University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| | - Erin Meisel
- Children's Orthopaedic Center, Children's Hospital Los Angeles, 4650 Sunset Blvd, MS #69, Los Angeles, CA, 90027, USA
| | - Rachel Y Goldstein
- Children's Orthopaedic Center, Children's Hospital Los Angeles, 4650 Sunset Blvd, MS #69, Los Angeles, CA, 90027, USA.
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Ma HL, Sun XW, Liu F, Hua ZT, Sun J, Zhang SC. Kirschner wire reconstruction of medial and lateral column periosteal hinge in the treatment of multidirectionally unstable supracondylar fracture of the humerus in children. Eur J Med Res 2023; 28:585. [PMID: 38082369 PMCID: PMC10714489 DOI: 10.1186/s40001-023-01560-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 11/29/2023] [Indexed: 12/18/2023] Open
Abstract
AIM AND OBJECTIVE To compare the clinical effect of reconstruction of internal and lateral column periosteal hinge-assisted treatment with Kirschner wire and internal fixation with Kirschner wire in the treatment of multidirectional unstable supracondylar fractures of humerus in children. METHODS A retrospective cohort study was conducted to analyze the clinical data of 48 patients (31 male, 17 female; mean age: 6.7 ± 2.4 years old) with multidirectionally unstable supracondylar fractures of the humerus treated in our Hospital from August 2020 to August 2022. Twenty-five cases were treated with Kirschner wire reconstruction of the internal and lateral column periosteal hinge assisted by closed reduction and Kirschner wire internal fixation (study group). Twenty-three cases were treated with closed reduction and Kirschner wire internal fixation (control group). The operation time, intraoperative fluoroscopy times, percentage of patients who underwent open reduction after failure of closed reduction, fracture healing time, Baumann angle (BA), shaft-condylar angle (SCA), range of motion (ROM), and Flynn score of elbow at the last follow-up were compared between two groups. Complications such as infection and irritation of Kirschner wire tail were observed in two groups 2 months after the operation. RESULTS All patients were followed up for 10-22 months ([13.85 ± 2.89] months). The average operation time of the control group was 82.1 min, which was significantly longer than that of the study group 32.3 min (P < 0.05). The number of intraoperative fluoroscopy (29.4 ± 9.2) in the control group was significantly higher than that in the study group (15.2 ± 6.3) (P < 0.05). The incision rate of the control group was 17% while that of the study group was 0 (P < 0.05). According to Flynn score, the excellent and good rate of the elbow joint in the control group was 86.9% (20/23). The excellent and good rate of the elbow joint in the study group was 92.0% (23/25) (P > 0.05). There was no significant difference in fracture healing time, BA, SCA, and ROM between the two groups (P > 0.05). No infection or Kirschner wire tail irritation occurred in the two groups during the 2-month follow-up. CONCLUSION Reconstruction of internal and lateral periosteal hinges with Kirscher wire has similar effects to closed reduction and Kirschner wire fixation in the treatment of multidirectionally unstable supracondylar fractures of the humerus in children, but it can shorten the operation time and reduce intraoperative fluoroscopy times and incision rate.
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Affiliation(s)
- Hai-Long Ma
- Department of Pediatric Orthopedics, Anhui Provincial Children's Hospital (Children's Hospital of Anhui Medical University), No. 39 Wangjiang East Road, Hefei, 230051, Anhui, People's Republic of China
| | - Xi-Wei Sun
- Department of Pediatric Orthopedics, Anhui Provincial Children's Hospital (Children's Hospital of Anhui Medical University), No. 39 Wangjiang East Road, Hefei, 230051, Anhui, People's Republic of China
| | - Fang Liu
- Department of Pediatric Orthopedics, Anhui Provincial Children's Hospital (Children's Hospital of Anhui Medical University), No. 39 Wangjiang East Road, Hefei, 230051, Anhui, People's Republic of China
| | - Zhong Tuo Hua
- Department of Pediatric Orthopedics, Anhui Provincial Children's Hospital (Children's Hospital of Anhui Medical University), No. 39 Wangjiang East Road, Hefei, 230051, Anhui, People's Republic of China
| | - Jun Sun
- Department of Pediatric Orthopedics, Anhui Provincial Children's Hospital (Children's Hospital of Anhui Medical University), No. 39 Wangjiang East Road, Hefei, 230051, Anhui, People's Republic of China
| | - Si-Cheng Zhang
- Department of Pediatric Orthopedics, Anhui Provincial Children's Hospital (Children's Hospital of Anhui Medical University), No. 39 Wangjiang East Road, Hefei, 230051, Anhui, People's Republic of China.
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Mitchell BC, Fogleman SA, Carroll AN, Leek BT, Edmonds EW, Fronek J, Pennock AT. Management of Pediatric and Adolescent Sublime Tubercle Injuries: Isolated and Complex Patterns Demonstrate Distinct Etiologies and Radiographic Outcomes. J Pediatr Orthop 2023; 43:e777-e782. [PMID: 37702278 DOI: 10.1097/bpo.0000000000002515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/14/2023]
Abstract
BACKGROUND The aim of this study was to assess the patient demographics, epidemiology, mechanism of injury, and natural history of sublime tubercle avulsion injuries. METHODS A multicenter retrospective study was performed in which sublime tubercle avulsion injuries were identified by surgeon records and database query of radiology reports. Demographic data and imaging were reviewed for each case, and injuries were classified as type 1 (isolated injuries with a simple bony avulsion or periosteal stripping) or type 2 (complex injuries with an associated elbow fracture or dislocation). Treatment modality and evidence of radiographic healing at a minimum of 3 months were collected. RESULTS Forty patients (78% male) with a median age of 15 years (range, 8 to 19 years) were identified with sublime tubercle avulsion injuries. Sixty-eight percent of cases (n=27) were determined to be type 1 injuries, and 32% (n=13) were classified as type 2 injuries. The majority of type 1 injuries (59%) occurred via a noncontact mechanism in overhead-throwing athletes, whereas 100% of the type 2 injuries were sustained via a contact mechanism. Type 1 injuries presented in a delayed manner in 19% of cases, whereas no type 2 injuries (0%) were delayed in presentation. Type 1 injuries infrequently underwent surgical intervention (19%), whereas 54% of type 2 injuries required surgery. Of those that did not undergo initial surgical management at a minimum of 3-month radiographic follow-up, 9/11 (82%) of type 1 injuries and 0/4 (0%) of type 2 injuries demonstrated evidence of healing. Only 1 case required reoperation (type 2 injury). CONCLUSIONS This series of adolescents with sublime tubercle avulsion injuries expands our understanding of the epidemiology of this rare injury, which was previously only described as a noncontact injury in baseball players. Type 1 injuries are more likely to occur via a noncontact mechanism and generally demonstrate radiographic evidence of healing after a period of rigid immobilization. Conversely, type 2 injuries are more likely to undergo initial surgical intervention, and those managed nonoperatively are less likely to achieve radiographic healing. Further studies are needed to elucidate treatment protocols and long-term functional outcomes. LEVEL OF EVIDENCE Level IV-case series.
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Affiliation(s)
| | | | - Alyssa N Carroll
- Division of Orthopaedic Surgery, Rady Children's Hospital, San Diego
| | - Bryan T Leek
- Department of Orthopaedic Surgery, University of California San Diego
| | - Eric W Edmonds
- Division of Orthopaedic Surgery, Rady Children's Hospital, San Diego
| | - Jan Fronek
- Section of Sports Medicine, Orthopaedic Surgery, Scripps Clinic Medical Group, La Jolla, CA
| | - Andrew T Pennock
- Division of Orthopaedic Surgery, Rady Children's Hospital, San Diego
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Park MS, Kim JR, Sung KH, Moon YJ, Lee SC, Wang SI. Comparison of Functional and Cosmetic Outcomes According to Fracture Level in Gartland Type III Pediatric Supracondylar Humerus Fractures. Clin Orthop Surg 2023; 15:668-677. [PMID: 37529183 PMCID: PMC10375807 DOI: 10.4055/cios22220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 01/09/2023] [Accepted: 01/09/2023] [Indexed: 08/03/2023] Open
Abstract
Background Supracondylar humerus (SCH) fractures in children have been traditionally categorized according to the Wilkins-modified Gartland classification scheme, which is solely based on the degree of displacement. As this classification does not consider fracture patterns in the coronal or sagittal plane, the relationship between the fracture pattern and prognosis in SCH fractures remains unclear. Therefore, the purpose of this study was to evaluate the relationship between the fracture level and prognosis of pediatric SCH fractures. Methods Medical records and radiographs of 786 patients with SCH fractures who underwent surgical treatment between March 2004 and December 2017 were reviewed. A total of 192 patients were included in this study. Anteroposterior elbow radiographs taken at the time of injury were evaluated to obtain the level of fracture. Functional outcomes were evaluated based on modified Flynn grading at the last follow-up. Results Of 192 patients included in this study, 24 (12.1%), 148 (74.8%), and 20 (10.1%) had fractures in zone 1 (metaphyseal-diaphyseal area), zone 2 (between zones 1 and 3), and zone 3 (metaphyseal-epiphyseal area), respectively. There were significant differences in age at the time of injury (p = 0.011), direction of fracture displacement (p = 0.014), and loss of carrying angle (p < 0.001) between fractures in zone 3 and those in zone 1 or zone 2. Zone 3 fractures and classic zone 2 fractures also showed significant difference in outcomes, with zone 3 fractures having more unsatisfactory outcome than classic zone 2 fractures (p = 0.049). Conclusions For SCH fractures, varus deformity of the elbow was more common in zone 3 (metaphyseal-epiphyseal area) than in the other zones. Thus, pediatric orthopedic surgeons should be mindful of the possibility of cubitus varus deformity when treating SCH fractures in zone 3. A thorough postoperative follow-up is required.
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Affiliation(s)
- Moon Seok Park
- Department of Orthopedic Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jung Ryul Kim
- Department of Orthopedics Surgery, Jeonbuk National University Medical School, Research Institute of Clinical Medicine of Jeonbuk National University–Biomedical Research Institute of Jeonbuk National University Hospital and Research Institute for Endocrine Sciences, Jeonju, Korea
| | - Ki Hyuk Sung
- Department of Orthopedic Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Young Jae Moon
- Department of Biochemistry and Molecular Biology, Jeonbuk National University Medical School, Research Institute of Clinical Medicine of Jeonbuk National University–Biomedical Research Institute of Jeonbuk National University Hospital and Research Institute for Endocrine Sciences, Jeonju, Korea
| | - Seung Cheol Lee
- Department of Orthopedics Surgery, Jeonbuk National University Medical School, Research Institute of Clinical Medicine of Jeonbuk National University–Biomedical Research Institute of Jeonbuk National University Hospital and Research Institute for Endocrine Sciences, Jeonju, Korea
| | - Sung Il Wang
- Department of Orthopedics Surgery, Jeonbuk National University Medical School, Research Institute of Clinical Medicine of Jeonbuk National University–Biomedical Research Institute of Jeonbuk National University Hospital and Research Institute for Endocrine Sciences, Jeonju, Korea
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Abraham E, Ye L, Castillo Tafur J, Boroda N, Schwarzman G. The Ulnar Olecranon-coronoid Notch Angle Affects Terminal Elbow Extension in Children and Adolescents. J Pediatr Orthop 2023:01241398-990000000-00321. [PMID: 37400091 DOI: 10.1097/bpo.0000000000002470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/05/2023]
Affiliation(s)
- Edward Abraham
- Department of Orthopaedics, University of Illinois at Chicago, Chicago, IL
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The Ulnar Olecranon-Coronoid Notch Angle Affects Terminal Elbow Extension in Children and Adolescents. J Pediatr Orthop 2023; 43:e179-e187. [PMID: 36607931 DOI: 10.1097/bpo.0000000000002304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND Limitations to terminal elbow extension (TEE) in pediatric populations have been commonly associated with the degree of ligamentous laxity and not bony factors. Ligamentous laxity, quantified through the Beighton score, is criticized for unreliably assessing joint mobility. This study aims to show that the olecranon-coronoid notch angle (OCNA) affects TEE in healthy children and adolescents. METHODS A retrospective study of 711 pediatric patients treated for upper extremity and shoulder injuries was cross-sectionally studied at 2 tertiary centers from 2014 to 2021. Radiographs were used to measure the OCNA, humerocondylar angle, proximal anterior ulnar angle, and the presence of secondary centers of ossification. A 2-axis goniometer measured clinical TEE to a firm endpoint. The statistical analysis studied the relationships between OCNA and TEE and the effect that age and sex have on these measurements. RESULTS Increased TEE was associated with increased OCNA (P<0.001) when accounting for age and sex. The average OCNA was 30.0 degrees (7.5 degrees), and the average TEE was 5.6 degrees (8.0 degrees). There was a difference in OCNA between subjects who had elbow hypoextension, normal TEE, and elbow hyperextension (P<0.001). The most common injuries were distal radius fractures (182, 26%), elbow sprains and contusions (111, 16%), distal both bone forearm fractures (95, 14%), single or both bone shaft fractures (77, 11%), and supracondylar fractures (74, 11%). CONCLUSION These results show that the orientation of the opening of the olecranon-coronoid notch influences the arc of TEE motion in a healthy pediatric population. The notch restrains TEE by activating the bony block mechanism between the olecranon apophysis and the olecranon fossa. The measurement of the OCNA can serve as a reproducible and quantitative method to predict hypomobility to hypermobility of TEE motion. LEVEL OF EVIDENCE Prognostic study: Level II.
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Bayomy AF, Shim SS, Padaki AS, Redler LH. Combined Supracondylar Humerus Fracture, Monteggia Injury, and Radial/Ulnar Shaft Fractures in a 3-Year-Old Child. Orthopedics 2022; 45:e107-e109. [PMID: 34978508 DOI: 10.3928/01477447-20211227-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
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.].
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Eastman J, White H, Evans J, Augsburger S, Wallace J, Riley S, Iwinski H. What is the minimum torque required to obtain passive elbow end range of motion? Gait Posture 2022; 93:235-239. [PMID: 35190315 DOI: 10.1016/j.gaitpost.2022.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 01/26/2022] [Accepted: 02/12/2022] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- Joel Eastman
- Motion Analysis Center Shriners Hospitals for Children Medical Center, 110 Conn Terrace, Lexington, KY 40508, USA
| | - Hank White
- Motion Analysis Center Shriners Hospitals for Children Medical Center, 110 Conn Terrace, Lexington, KY 40508, USA.
| | - Jenn Evans
- Motion Analysis Center Shriners Hospitals for Children Medical Center, 110 Conn Terrace, Lexington, KY 40508, USA
| | - Sam Augsburger
- Motion Analysis Center Shriners Hospitals for Children Medical Center, 110 Conn Terrace, Lexington, KY 40508, USA
| | - Juanita Wallace
- Department of Health and Exercise Science, Transylvania University, 300 North Broadway, Lexington, KY 40508, USA
| | - Scott Riley
- Shriners Hospitals for Children Medical Center, 110 Conn Terrace, Lexington, KY 40508, USA; University of Kentucky Department of Orthopaedic Surgery and Sports Medicine, 740 S. Limestone Street, Lexington, KY 40536, USA
| | - Henry Iwinski
- Shriners Hospitals for Children Medical Center, 110 Conn Terrace, Lexington, KY 40508, USA; University of Kentucky Department of Orthopaedic Surgery and Sports Medicine, 740 S. Limestone Street, Lexington, KY 40536, USA
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Standardizing a Postoperative Protocol for Supracondylar Humerus Fractures. J Pediatr Orthop 2022; 42:e103-e108. [PMID: 34857722 DOI: 10.1097/bpo.0000000000002029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
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.
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Rivera LVS, Cazzulino A, Swarup I. Rate of utilization of physical therapy after common pediatric elbow fractures. J Pediatr Orthop B 2022; 31:e1-e6. [PMID: 34678855 DOI: 10.1097/bpb.0000000000000929] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Supracondylar, medial epicondyle and lateral condyle fractures are the three most common elbow fractures in pediatric patients. There is a paucity of literature discussing the utilization of physical therapy following these injuries. The purpose of the current study was to determine the rate of utilization of physical therapy after these injuries as well as determine factors that may affect the need for physical therapy after common elbow fractures in pediatric patients. We retrospectively chart reviewed all pediatric elbow fractures that were managed at a major pediatric health system from 2013 to 2020. This study included patients under the age of 18 years and utilized International Classification of Diseases (ICD)-9, ICD-10 and Current Procedural Terminology codes to identify patients. Descriptive statistics, chi-square test and multivariate analyses were performed to compare differences between groups. This study included 2037 patients. Overall, 90 patients (4.4%) received a physical therapy referral at an average time of 90.1 (± 54.6) days between discharge and referral. The rate of physical therapy was 2.7% after nonoperative and 6.3% after operative treatment (P < 0.01). Overall, patients that sustained medial epicondyle fractures were prescribed physical therapy at a higher rate (19.8%) than supracondylar (1.4%) or lateral condyle fractures (5.0%) (P < 0.01). For each fracture type, physical therapy utilization was higher among those treated operatively versus those treated nonoperatively (P < 0.01). Physical therapy is more commonly prescribed for patients with medial epicondyle fractures and patients that received operative management. Additional research is needed to determine clinical indications and efficacy of physical therapy after common elbow fractures in pediatric patients.
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Affiliation(s)
| | - Alejandro Cazzulino
- Department of Orthopaedic Surgery, University of California, San Francisco, USA
| | - Ishaan Swarup
- Department of Orthopaedic Surgery, University of California, San Francisco, USA
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Coupal S, Lukas K, Plint A, Bhatt M, Cheung K, Smit K, Carsen S. Management of Gartland Type 1 Supracondylar Fractures: A Systematic Review. Front Pediatr 2022; 10:863985. [PMID: 35664877 PMCID: PMC9160664 DOI: 10.3389/fped.2022.863985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 04/19/2022] [Indexed: 11/13/2022] Open
Abstract
PURPOSE Gartland Type 1 supracondylar humerus fractures are stable, non-displaced injuries treated with non-operative management. This systematic review was performed to gather evidence on the optimal form of immobilization to treat these fractures. METHODS The review process was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. An electronic search was performed in November 2020. Articles were eligible if they included children less than 18 years old, with non-displaced supracondylar fractures, treated non-operatively. Randomized trials, quasi-experimental trials, and prospective cohort studies were included. Outcomes of interest included fracture displacement, pain control, time to return to normal activities, return of range of motion (ROM), child/parent satisfaction, adverse events, and cost. Risk of bias was assessed using the Newcastle-Ottawa scale, Rob-2, and the ROBINS tools. RESULTS After duplicate records were removed, 525 records were evaluated with 9 studies meeting the inclusion criteria and 5 reporting clinical outcomes. The studies were heterogenous, in intervention and outcomes, and all at moderate risk of bias. Within the available evidence there were no cases of fracture displacement. Two small studies suggested that cuff and collar treatment provided inadequate pain control and delay in return to normal activities, compared to posterior splints. Two randomized control trials (RCTs) suggested that soft fiberglass casts reduced appointment time and increased parent satisfaction, compared to traditional casts. No studies directly compared posterior splints to circumferential casts. CONCLUSION There is insufficient high-quality evidence to determine the optimal conservative treatment for patients with Gartland type 1 supracondylar fractures. Level of Evidence Level II systematic review of Level II studies. SYSTEMATIC REVIEW REGISTRATION [PROSPERO], identifier [CRD42020144616].
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Affiliation(s)
- Stephanie Coupal
- Division of Orthopedic Surgery, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON, Canada
| | - Kenneth Lukas
- Division of Orthopedic Surgery, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON, Canada
| | - Amy Plint
- Division of Emergency Medicine, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON, Canada
| | - Maala Bhatt
- Division of Emergency Medicine, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON, Canada
| | - Kevin Cheung
- Division of Plastic Surgery, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON, Canada
| | - Kevin Smit
- Division of Orthopedic Surgery, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON, Canada
| | - Sasha Carsen
- Division of Orthopedic Surgery, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON, Canada
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Yang L, Yang P, Li L, Tang X. The outcome of loose bone fragments in pediatric supracondylar humerus fractures: a retrospective study. J Pediatr Orthop B 2022; 31:12-17. [PMID: 33230053 PMCID: PMC8614548 DOI: 10.1097/bpb.0000000000000837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Accepted: 11/07/2020] [Indexed: 02/05/2023]
Abstract
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.
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Affiliation(s)
- Lei Yang
- Department of Pediatric Surgery, West China Hospital, Sichuan University, Guo Xue Xiang, Chengdu, Sichuan, People’s Republic of China
| | - Panyi Yang
- Department of Pediatric Surgery, West China Hospital, Sichuan University, Guo Xue Xiang, Chengdu, Sichuan, People’s Republic of China
| | - Lang Li
- Department of Pediatric Surgery, West China Hospital, Sichuan University, Guo Xue Xiang, Chengdu, Sichuan, People’s Republic of China
| | - Xueyang Tang
- Department of Pediatric Surgery, West China Hospital, Sichuan University, Guo Xue Xiang, Chengdu, Sichuan, People’s Republic of China
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Schmittenbecher PP, Adrian M. [Typical liability damages of the upper extremities in childhood and their evaluation]. Unfallchirurg 2021; 124:877-884. [PMID: 34609542 DOI: 10.1007/s00113-021-01086-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/06/2021] [Indexed: 10/20/2022]
Abstract
Legal appraisals of possible treatment errors in childhood and adolescence are rare, often refer to the treatment of trauma of the upper limbs and are frequently recognized. From the activity of the first author as an expert witness 31 expert opinions (25%) referred to the upper limbs. Supracondylar humeral fractures, radius neck fractures, radial condyle fractures and distal radius fractures were predominant. A primary treatment error was determined in 14 patients and a secondary error in 7 patients. This corresponds to a recognition rate of 68%. The aim of this study was the reflection and the development of a prevention strategy. Insufficient recognition of instability (radial condyle), inadequate reduction and inadequate stabilization (radius neck, supracondylar) as well as untreated malalignments and secondary dislocations (wrist) were the main reproaches. Poor communication and deficient documentation often aggravate the situation. Working along clear algorithms can help to avoid legal proceedings and assignment of guilt.
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Affiliation(s)
- P P Schmittenbecher
- Kinderchirurgische Klinik, Städt. Klinikum Karlsruhe, Moltkestr. 90, 76133, Karlsruhe, Deutschland.
| | - M Adrian
- Kinderchirurgische Klinik, Universitätsmedizin Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland
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Patel HA, Chaudhry S, Lee MC, Solomito M. Streamlining Postoperative Care After Pediatric Supracondylar Humerus Fractures: Is Follow-up After Pin Removal Routinely Needed? J Pediatr Orthop 2021; 41:e464-e469. [PMID: 34096552 DOI: 10.1097/bpo.0000000000001815] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Closed reduction and percutaneous pinning is the standard of care for displaced supracondylar humerus fractures (SCHFs). Although the operative management of SCHFs has achieved good consensus with low complication rates, there remains a paucity of literature on postoperative management. We hypothesized that routine office visits after pin removal can safely be avoided in uncomplicated SCHFs without compromising patient care. METHOD A retrospective review was conducted to query the electronic medical record for SCHFs, treated with closed reduction and percutaneous pinning. Patients with complicated SCHFs were excluded. Patients were divided into 2 cohorts: follow-up (FU) and nonfollow-up (NFU), depending on the presence or absence of after-pin removal (APR) FU visits. Demographics, surgical variables, number of x-rays, referrals for physical therapy, total FU visits, complications, and clinical events after pin removal up to 3 months were compared. Subgroup analysis was performed according to Gartland fracture types. RESULTS A total of 179 patients were included in the study, 111 in the FU group and 68 in the NFU group. There were no significant differences found in demographics between the 2 groups. There were no significant differences in complications and APR clinical events between 2 groups (P>0.05). An average of 1.98 additional x-rays were taken APR in FU group. None of the NFU group patients required physical therapy. Excluding patients with pin site infections, 15/108 (13.9%) of FU group patients had >1 APR visits. SUMMARY For operatively managed uncomplicated SCHFs, patients who do not have routinely scheduled FU APR have no greater incidence of clinical events APR than patients with a scheduled FU. With a detailed discussion including expectations, timeframe for resuming activities, home exercises, and reassurance of the ease of FU if desired, routine FU APR can be safely eliminated after uncomplicated SCHFs in order to streamline postoperative care. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Harshadkumar A Patel
- Department of Orthopedic Surgery, University of Connecticut, Connecticut Children's Medical Center, Hartford, CT
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16
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He M, Wang Q, Zhao J, Jin Y, Wang Y. Lateral entry pins and Slongo's external fixation: which method is more ideal for older children with supracondylar humeral fractures? J Orthop Surg Res 2021; 16:396. [PMID: 34154623 PMCID: PMC8215768 DOI: 10.1186/s13018-021-02541-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 06/08/2021] [Indexed: 11/17/2022] Open
Abstract
Objective The standard surgical treatment for supracondylar humeral fractures in children is closed reduction and percutaneous pinning. Given the need for greater fixation strength and higher risk of joint stiffness for children older than 8 years, external fixation is often performed for treating supracondylar humeral fractures in older children. The aim of this study was to compare the efficacy of lateral entry pins and Slongo’s external fixation for treating supracondylar humeral fractures in older children. Methods Children older than 8 years who underwent surgery for supracondylar humeral fractures at our hospital for surgery from January 2016 to December 2020 are to be retrospectively assessed. One group (n = 36) underwent internal fixation and percutaneous pinning with three lateral Kirschner wires, and the other group (n = 32) underwent Slongo’s external fixator surgery. The demographic data, operation duration, number of fluoroscopies, and fracture healing time were compared between both groups. The elbow joint function was evaluated 6 months after the surgery on the basis of fracture healing time, lifting angle, elbow joint range of motion (ROM), and Flynn score. The incidence of postoperative complications was also recorded. Results There was no significant difference between the two patient groups in terms of the demographic parameters. Compared to external fixation surgery, Kirschner wire surgery required shorter duration and fewer fluoroscopies (P < 0.05). Nevertheless, the fracture healing time was significantly less (P < 0.05), and the elbow ROM and Flynn scores were higher in the external fixator group compared to the Kirschner wire fixation group (P < 0.05). There was one case of secondary fracture displacement in the Kirschner wire group and one of pin tract infection in the external fixator group. No other iatrogenic injuries or complications were observed. Conclusion Maybe Slongo’s external fixator is a suitable alternative treatment option for supracondylar humeral fractures in children older than 8 years since it can achieve better fixation strength and early restoration of elbow joint movement with a lower risk of joint stiffness. Supplementary Information The online version contains supplementary material available at 10.1186/s13018-021-02541-z.
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Affiliation(s)
- Man He
- Department of Rehabilitation, Affiliated Hospital of Chengde Medical College, Chengde, Hebei, 067000, People's Republic of China
| | - Qian Wang
- Department of Orthopedics, Affiliated Hospital of Chengde Medical College, 36 Nanyingzi Street, Shuangqiao District, Chengde, Hebei, 067000, People's Republic of China
| | - Jingxin Zhao
- Department of Orthopedics, Affiliated Hospital of Chengde Medical College, 36 Nanyingzi Street, Shuangqiao District, Chengde, Hebei, 067000, People's Republic of China
| | - Yu Jin
- Department of Orthopedics, Affiliated Hospital of Chengde Medical College, 36 Nanyingzi Street, Shuangqiao District, Chengde, Hebei, 067000, People's Republic of China
| | - Yu Wang
- Department of Orthopedics, Affiliated Hospital of Chengde Medical College, 36 Nanyingzi Street, Shuangqiao District, Chengde, Hebei, 067000, People's Republic of China.
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Ernat JJ, Wimberly RL, Ho CA, Riccio AI. Vascular examination predicts functional outcomes in supracondylar humerus fractures: a prospective study. J Child Orthop 2020; 14:495-501. [PMID: 33343743 PMCID: PMC7740678 DOI: 10.1302/1863-2548.14.200130] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
PURPOSE This article prospectively examines the functional outcome measures following management of vascular insult secondary to paediatric supracondylar humerus fractures (SCHFX) using validated outcome measures. METHODS The three-year, prospective, IRB-approved study consecutively enrolled operative SCHFX patients. Clinical data included presence and symmetry of the radial pulse in injured and uninjured extremities, Doppler examination of non-palpable (NP) pulses and perfusion status of the hand. Pediatric Outcomes Data Collection Instruments (PODCI) and the Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) Measures were used to assess functional outcome at final follow-up. Multiple regression analysis was used to determine the relationship between the presence of a vascular abnormality and functional outcome while controlling for other injury parameters. RESULTS A total of 146/752 enrolled patients (mean age 6.8 years; range 2 years to 13 years) completed functional outcome measures at final follow-up. Of these, 20 (14%) patients had abnormal vascular exams at presentation: nine (6%) with palpable asymmetric pulse and 11 (7.5%) with NP pulse. Of those with NP pulses, nine/11 (6%) were Dopplerable and two (1.5%) lacked identifiable Doppler signal. Patients with a symmetric, palpable pulse demonstrated better PODCI pain and comfort scores (95.2 versus 85.2) (p < 0.0001), and QuickDASH scores (10.9 versus 21.6) (p < 0.007) compared to those with any abnormal vascular examination. Patients with palpable pulses, regardless of symmetry, demonstrated significantly higher PODCI pain and comfort scores (94.6 versus 84.7) (p < 0.003) than NP pulses. CONCLUSIONS In children with operative SCHFX, an abnormal vascular examination at presentation is predictive of poorer outcomes in pain and upper extremity function. A palpable pulse, versus NP, is predictive of better pain and comfort at final follow-up. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Justin J. Ernat
- Blanchfield Army Community Hospital, Fort Campbell, Kentucky, USA
| | - Robert L. Wimberly
- Texas Scottish Rite Hospital for Children and Children’s Medical Center of Dallas, Department of Orthopaedic Surgery, Dallas, Texas, USA
| | - Christine A. Ho
- Texas Scottish Rite Hospital for Children and Children’s Medical Center of Dallas, Department of Orthopaedic Surgery, Dallas, Texas, USA
| | - Anthony I. Riccio
- Texas Scottish Rite Hospital for Children and Children’s Medical Center of Dallas, Department of Orthopaedic Surgery, Dallas, Texas, USA,Correspondence should be sent to Anthony I. Riccio, Texas Scottish Rite Hospital for Children, 2222 Welborn Street, Dallas, TX 75219, USA. E-mail:
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Short and long-arm fiberglass cast immobilization for displaced distal forearm fractures in children: a randomized controlled trial. INTERNATIONAL ORTHOPAEDICS 2020; 45:759-768. [PMID: 32940750 PMCID: PMC7892746 DOI: 10.1007/s00264-020-04800-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 09/04/2020] [Indexed: 11/14/2022]
Abstract
Purpose The aim of this study was to investigate whether short-arm fiberglass cast (SAC) immobilization provides fracture stabilization comparable to that of long-arm cast (LAC) treatment of displaced distal forearm fractures after closed reduction in paediatric patients. Methods A prospective, randomized, controlled trial of children aged four to 16 years (mean 9.9 years) was designed with a sample of 120 children, whose size was set a priori, with 60 treated with SAC and 60 with LAC. The primary outcome was fracture stability and rate of loss of reduction. The secondary outcome analysis evaluated duration of analgesic therapy, restriction in activities of daily life, and the duration until patients regained normal range of motion in the elbow. Results No statistically significant differences were found between the two groups in loss of reduction or duration of analgesic therapy. In contrast, the duration until normal range of motion in the elbow was regained was significantly longer in the LAC group (median 4.5 days, P < 0.001). Restriction in activities of daily life did not differ significantly between the two groups except for the item “help needed with showering in the first days after trauma” (SAC 60%, LAC 87%, P = 0.001). Conclusion Fracture immobilization with short-arm fiberglass cast in reduced distal forearm fractures is not inferior to long-arm casts in children four years and older, excluding completely displaced fractures. Furthermore, short-arm casting reduces the need for assistance during showering. Trial registration NCT03297047, September 29, 2017
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Abstract
INTRODUCTION The incidence of residual deformity in the sagittal plane of the humerus (RDSPH) after nonoperative management of type II supracondylar humerus fractures (SCHFs), and the effects of such deformity on the overall arc of motion (AOM) of the elbow, are unknown. Our purpose was to analyze data collected prospectively on a large cohort of type II SCHF's to establish the incidence and extent of RDSPH, and the effects of the deformity on the elbow function, to further support our previously published recommendations on the treatment of type II SCHF. METHODS The clinical data and radiographs of 1107 pediatric type II SCHFs enrolled in a prospective registry, and followed for a minimum of 8 weeks, were retrospectively reviewed. The radiographs obtained during the latest follow-up appointment were examined for the presence of RDSPH, as demonstrated by the anterior humeral line falling anterior or posterior relative to the center of the capitellum. The amount of RDSPH in the sagittal plane was then calculated. We compared the treatment outcome of elbows with and without RDSPH by assessing the patients' AOM, the arc of flexion (AOF), and relative arcs of motion (R-AOM) and relative arcs of flexion (R-AOF) (as compared with the unaffected, contralateral elbow). RESULTS Overall, 799 (72.2%) fractures were treated nonsurgically, and 308 (27.8%) fractures were treated surgically. The overall incidence of RDSPH was 10.2%. None of the fractures managed operatively demonstrated residual deformity. The RDSPH was classified as mild in 35 fractures (3.2%), moderate in 64 fractures (5.7%) and severe in 14 fractures (1.3%). Therefore, the incidence of RDSPH in fractures treated nonoperatively was 14.1%. In fractures treated nonoperatively, the difference in AOM between those without (n=686) and with (n=113) RDSPH was <4 degrees (149.1 vs. 145.8 degrees, P=0.02). Those with and without RDSPH had a clinically similar AOF, with a mean difference of<4 degrees (134.5 vs. 137.9 degrees, P<0.0001). The differences in R-AOM and R-AOF between those with and without RDSPH were minimal (97.3% vs. 95.6% and 96.6% vs. 95.3%, respectively). A satisfactory outcome, defined as an R-AOM of at least 85% when compared with the unaffected, contralateral side at the latest follow-up, was achieved in 91% of fractures with RDSPH, and 93% of fractures without RDSPH. DISCUSSION AND CONCLUSION The incidence of RDSPH in type II SCHF treated nonoperatively was 14%. In our cohort, nearly 99% of all RDSPH were mild to moderate. On the basis of the data presented in the current study, nonsurgical treatment of type II SCHF can provide a satisfactory recovery of AOM, AOF, R-AOM, and R-AOF, and a high rate of satisfactory outcomes, even in the presence of RDSPH.
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Poggiali P, Nogueira FCS, Nogueira MPDM. Manejo da fratura supracondiliana do úmero na criança. Rev Bras Ortop 2020; 57:23-32. [PMID: 35198105 PMCID: PMC8856849 DOI: 10.1055/s-0040-1709734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2019] [Accepted: 01/27/2020] [Indexed: 11/15/2022] Open
Abstract
Supracondylar humeral fracture represents ∼ 3 to 15% of all fractures in children. It is the fracture that most requires surgical treatment in the pediatric population. Advances in treatment and care have contributed to a reduction in the most dramatic complication: Volkmann ischemic contracture. Nevertheless, the risks inherent to the fracture remain. Absence of palpable pulse in type-III fractures is reported in up to 20% of the cases. Careful sensory, motor, and vascular evaluation of the affected limb is crucial in determining the urgency of treatment. Older children, male patients, floating elbow, and neurovascular injury are risk factors for compartment syndrome. Medial comminution can lead to varus malunion, even in apparently innocent cases. The recommended treatment of displaced fractures is closed reduction and percutaneous pinning. Technical errors in pin placement are the main cause of loss of reduction. There is enough evidence for the addition of a third lateral or medial Kirschner wire in unstable fractures (types III and IV). Medial comminution may lead to cubitus varus even in mild displaced fractures. Based on current concepts, a flowchart for the treatment of supracondylar humeral fracture in children is suggested by the authors.
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Affiliation(s)
- Pedro Poggiali
- Pediatric Orthopedic Surgery, Rede Mater Dei de Saúde, Belo Horizonte, Minas Gerais, Brazil
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Abstract
Telehealth has seldom been used in the field of pediatric orthopaedics. The purpose of this study is to assess the efficacy of telehealth as a tool for the follow-up of children with nondisplaced elbow fractures. We hypothesize that patients treated via telehealth will have comparable clinical outcomes as those treated at our institution, with increased patient satisfaction. We conducted a randomized trial, which included 52 children with type I supracondylar humeral fractures, or occult elbow injuries, divided in two groups, based on the type of care provided during the fourth-week follow-up appointment: cast removal at our institution (group A) or cast removal at home via telehealth appointment (group B). The time duration and professional fees for this week 4 follow-up were calculated. Patients in both groups returned to our institution for a final follow-up in week 8. We measured the amount of fracture displacement, range of motion, pain, and patient satisfaction. There was no statistically significant difference in fracture displacement, range of motion, or pain scores between groups. The mean length of the fourth-week clinical encounter was higher in group A than group B (47.2 vs. 17.6 min, respectively; P < 0.001). Initially, the mean patient satisfaction scores were nearly identical in both groups (97%) until patients in group A were made aware of this difference in time duration, at which their mean satisfaction score decreased to 76.4% (P = 0.05). The use of telehealth as a tool in the treatment of nondisplaced pediatric elbow fractures is appealing. Patients managed via telehealth had higher satisfaction rates and spent only a third of the time for their clinical encounter.
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Arrebola LS, Yi LC, de Oliveira VGC. The use of video games combined with conventional physical therapy in children with upper limb fractures: An exploratory study. J Pediatr Rehabil Med 2019; 12:65-70. [PMID: 30883369 DOI: 10.3233/prm-170529] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
PURPOSE To determine the effect of rehabilitation using video games combined with conventional therapy in children with loss of range of motion (ROM) after conservative or surgical treatment of upper limb fractures. METHODS This retrospective observational study included 12 children (9 boys, 3 girls; mean age: 6.75 ± 2.83 y) treated with combined video game and conventional physical therapy following upper limb fracture. Children completed 60 minutes of combined therapy (20 minutes of game therapy and 40 minutes of physical therapy) two times per week until therapy was no longer warranted. The flexion and extension ROM of the elbow and wrist, pronation and supination of the forearm, and pain during rest and effort were measured at the beginning and end of treatment. RESULTS Children experienced significantly increased extension (p< 0.001) and flexion (p< 0.01) ROM of the elbow, increased flexion ROM of the wrist (p< 0.05), and reduced pain during effort (p< 0.05) after an average of 6 weeks of combined treatment. CONCLUSION The use of video games with conventional therapy was effective in reducing pain and recovering ROM in children with upper limb fractures.
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Affiliation(s)
- Lucas Simões Arrebola
- Human Movement Sciences Department, Universidade Federal de São Paulo, Baixada Santista Campus, Santos, São Paulo, Brazil.,Physical Therapy Department, Institute of Medical Assistance to the State Public Servant, São Paulo, Brazil
| | - Liu Chiao Yi
- Human Movement Sciences Department, Universidade Federal de São Paulo, Baixada Santista Campus, Santos, São Paulo, Brazil
| | - Vanessa Gonçalves Coutinho de Oliveira
- Human Movement Sciences Department, Universidade Federal de São Paulo, Baixada Santista Campus, Santos, São Paulo, Brazil.,Physical Therapy Department, Institute of Medical Assistance to the State Public Servant, São Paulo, Brazil
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Abstract
OBJECTIVE To compare the outcomes of pediatric supracondylar humerus fractures treated during daytime hours to those treated after-hours. DESIGN Retrospective. SETTING Academic Level I trauma center. PATIENTS/PARTICIPANTS Two hundred ninety-eight pediatric patients treated with surgical reduction and fixation of closed supracondylar fractures were included. INTERVENTION Seventy-seven patients underwent surgery during daytime hours (06:00-15:59 on weekdays). One hundred eighty-six patients underwent surgery after-hours (16:00-05:59 on weekdays and any surgery on weekends or holidays). MAIN OUTCOME MEASURES Surgeon subspecialty, operative duration, and radiographic and clinical outcomes, including range of motion and carrying angle, were extracted from the patient medical records. RESULTS There were no patient-related demographic differences between the daytime hours and after-hours groups. Daytime surgery was more likely to be performed by a pediatric orthopaedic surgeon than after-hours surgery. Fractures treated after-hours had more severe injury patterns. After-hours surgery was not independently associated with rate of open reduction, operative times, complications, achievement of functional range of motion, or radiographic alignment. A late-night surgery subgroup analysis demonstrated an increased rate of malunion in patients undergoing surgery between the hours of 23:00 and 05:59. CONCLUSIONS There is no difference in the operative duration or outcomes after surgical treatment of pediatric supracondylar humerus fractures performed after-hours when compared with daytime surgery. However, late-night surgery performed between 23:00 and 05:59 may be associated with a higher rate of malunion. Surgeons can use these data to make better-informed decisions about the timing of surgery in this patient population. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Abstract
BACKGROUND The ideal type of immobilization for nondisplaced pediatric elbow fractures has not been established. We hypothesized that the use of a long-arm cylinder made of soft cast material will result in similar outcomes to those obtained with a traditional long-arm hard cast. METHODS We randomly assigned 100 consecutive children who presented with a closed, nondisplaced, type I supracondylar humeral fracture or an occult, closed, acute elbow injury, to 1 of 2 groups: group A (n=50) received a long-arm, traditional fiberglass (hard) cast. Group B (n=50) received a long-arm, soft fiberglass cast. After 4 weeks, the cast was removed in group A by a member of our staff using a cast saw, and in group B by one of the patient's parents by rolling back the soft fiberglass material. We compared the amount of fracture displacement and/or angulation, recovery of range of motion, elbow pain, and patient satisfaction. RESULTS There were no instances of unplanned removal of the cast by the patient or parent. No evidence of fracture displacement or angulation was seen in either group. The final carrying angle of the affected elbow was nearly identical of that of the normal, contralateral elbow in both groups (P=0.64). At the latest follow-up appointment, elbows in groups A and B had a similar mean arc of motion (156 vs. 154 degrees; P=0.45), and had achieved identical relative arc of motion of 99.6% and 99.5% of that of the normal, contralateral side, respectively (P=0.94). Main pain scores were low and comparable over the study period. All patients in both groups reported the highest rate of satisfaction at the eighth week of follow-up. CONCLUSIONS The results indicate that children with nondisplaced supracondylar humeral fractures can be successfully managed with the use of a removable long-arm soft cast, maintaining fracture alignment and resulting in comparable rates of range of motion, pain, and patient satisfaction. The use of a removable immobilization that can reliably maintain fracture alignment and result in similar outcomes, while minimizing the risk of noncompliance, could be advantageous. Although we elected to remove the soft cast during a scheduled follow-up, it appears that such immobilization could be removed easily and safely at home, potentially resulting in a lower number of patient visits, decreased health care costs, and higher patient/parent satisfaction. LEVEL OF EVIDENCE Level I.
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Ernat J, Ho C, Wimberly RL, Jo C, Riccio AI. Fracture Classification Does Not Predict Functional Outcomes in Supracondylar Humerus Fractures: A Prospective Study. J Pediatr Orthop 2017; 37:e233-e237. [PMID: 27776052 DOI: 10.1097/bpo.0000000000000889] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Few studies have prospectively assessed functional outcomes after the surgical management of supracondylar humerus fractures (SCHFXs) and the relationship between fracture pattern and ultimate patient outcome has never been prospectively evaluated. The purpose of this study was to prospectively evaluate fracture classification and functional outcome in children with extension SCHFXs using validated outcome measures. METHODS An Institutional Review Board-approved prospective enrollment of consecutive patients with operative SCHFX was performed over a 3-year period. Fractures were classified by the treating surgeon using the modified Gartland classification. Functional outcome was assessed at final follow-up using the Pediatric Outcomes Data Collection Instruments (PODCI) and the Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) outcome measure. Patients with flexion-type fractures, multidirectionally unstable fractures and those with <10 weeks follow-up were excluded from analysis. Statistical analysis was used to determine the relationship between fracture classification/pattern and functional outcome. RESULTS Seven hundred fifty-two patients were enrolled during the study period. One hundred thirty-two patients with extension-type injuries (average age 6.7 y) completed functional outcome measures at an average follow-up of 12.4 weeks. Forty-five (34%) were type II fractures and 87 (66%) were type III fractures. Forty-five (34%) of the fractures were posteromedially displaced, 43 (33%) were posterolaterally displaced, and 44 (33%) were posteriorly displaced without coronal plane deformity. The average PODCI global functioning scale score and QuickDASH scores for the entire cohort were 93.6 and 11.4, respectively, indicating excellent function. No differences in outcome scores were noted between patients with type II and III fractures. No difference in outcome was identified based upon direction of fracture displacement. CONCLUSIONS This is the first study to prospectively analyze fracture classification and functional outcome using validated outcome measures following the operative treatment of pediatric extension-type SCHFX. Children generally have excellent functional outcomes following the operative treatment of SCHFX. Garland classification and direction of displacement do not influence functional outcomes. LEVEL OF EVIDENCE Level II-therapeutic.
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Affiliation(s)
- Justin Ernat
- *Tripler Army Medical Center, Orthopedic Surgery Service, Honolulu, HI †Department of Orthopaedic Surgery, Texas Scottish Rite Hospital for Children and Children's Medical Center of Dallas, TX
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Dekker AE, Krijnen P, Schipper IB. Results of crossed versus lateral entry K-wire fixation of displaced pediatric supracondylar humeral fractures: A systematic review and meta-analysis. Injury 2016; 47:2391-2398. [PMID: 27596688 DOI: 10.1016/j.injury.2016.08.022] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Revised: 06/28/2016] [Accepted: 08/27/2016] [Indexed: 02/02/2023]
Abstract
PURPOSE Supracondylar humeral fractures (SCHF) are among the most common injuries in children. The aim of this systematic review was to investigate functional and radiographic outcome after crossed and lateral K-wire fixation for displaced extension-type SCHF, and complications related to the type of K-wire construction used. METHODS RCTs and prospective comparative cohorts on the functional outcome and complications after fracture reduction and K-wire fixation were identified in MEDLINE, Embase, Web of Science and the Cochrane Library. RESULTS Thirteen studies were identified, including 1158 patients in seven RCTs and six prospective comparative cohorts. According to the Flynn criteria, there was no difference in outcome between the K-wire configurations (Relative Risk 1.07). Loss of reduction occurred in 27 (11.6%) of 232 patients treated with crossed K-wires, and in 35 (12.4%) of 282 patients treated with lateral entry K-wires. Twenty (4.1%) of 493 patients in the crossed group were diagnosed with iatrogenic ulnar nerve injury, compared with 2 (0.3%) of 666 patients in the lateral entry group. The overall incidence of persistent ulnar nerve related complaints was 3.5/1000. CONCLUSIONS Crossed and lateral entry pin fixation of SCHF result in similar construct stability and functional outcome. Although ulnar nerve injury was three times more likely in the crossed K-wire group, the overall incidence of this complication was very low. The available evidence does not support the use of either approach for daily practice. If the surgeon wishes to avoid all potential risk of iatrogenic ulnar nerve injury, the lateral K-wire approach is safest.
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Affiliation(s)
- A E Dekker
- Department of Trauma Surgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands, The Netherlands.
| | - P Krijnen
- Department of Trauma Surgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands, The Netherlands.
| | - I B Schipper
- Department of Trauma Surgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands, The Netherlands.
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Abstract
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.
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Affiliation(s)
- Brad T Hyatt
- Department of Orthopaedics and Rehabilitation, San Antonio Military Medical Center, 3551 Roger Brooke Drive, Fort Sam Houston, TX 78234, USA
| | - Matthew R Schmitz
- Department of Orthopaedics and Rehabilitation, San Antonio Military Medical Center, 3551 Roger Brooke Drive, Fort Sam Houston, TX 78234, USA
| | - Jeremy K Rush
- Department of Orthopaedics and Rehabilitation, San Antonio Military Medical Center, 3551 Roger Brooke Drive, Fort Sam Houston, TX 78234, USA.
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To pin or not to pin? Sagittal alignment of type II supracondylar humeral fractures in children. CURRENT ORTHOPAEDIC PRACTICE 2016. [DOI: 10.1097/bco.0000000000000336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Nemati Z, Javanshir MA, Saeedi H, Farmani F, Aghajani Fesharaki S. The effect of new dynamic splint in pinch strength in De Quervain syndrome: a comparative study. Disabil Rehabil Assist Technol 2016; 12:457-461. [DOI: 10.3109/17483107.2016.1139635] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Zahra Nemati
- Department of Orthotics and Prosthetics, School of Rehabilitation Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Mohammad Ali Javanshir
- Department of Orthotics and Prosthetics, School of Rehabilitation Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Hassan Saeedi
- Department of Orthotics and Prosthetics, School of Rehabilitation Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Farzad Farmani
- Department of Orthotics and Prosthetics, School of Rehabilitation Sciences, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Siamak Aghajani Fesharaki
- Department of Orthotics and Prosthetics, School of Rehabilitation Sciences, Iran University of Medical Sciences, Tehran, Iran
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Zorrilla S. de Neira J, Prada-Cañizares A, Marti-Ciruelos R, Pretell-Mazzini J. Supracondylar humeral fractures in children: current concepts for management and prognosis. INTERNATIONAL ORTHOPAEDICS 2015; 39:2287-96. [DOI: 10.1007/s00264-015-2975-4] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Accepted: 08/08/2015] [Indexed: 10/23/2022]
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Gauthé R, Leroux J, Latrobe C, Thomas D, Moukoko D, Ould-Slimane M, Foulongne E, Abu-Amara S, Lechevallier J. [Fishtail deformity after a non-displaced supracondylar humeral fracture in childhood: A case report]. Arch Pediatr 2015; 22:621-5. [PMID: 25934605 DOI: 10.1016/j.arcped.2015.03.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2014] [Revised: 08/15/2014] [Accepted: 03/20/2015] [Indexed: 11/16/2022]
Abstract
We report the case of a 13-year-old boy presenting with stiffness and pain in the elbow, which had appeared a few years before consultation. He reported a history of a closed, nondisplaced supracondylar fracture of the humerus 7 years before. Progression was good after orthopedic treatment. X-rays and CT showed a distinctive deformation, called a fishtail deformity, associated with severe arthritic injuries. We recall here that supracondylar fractures of the humerus are common in children and that early reduction decreases the complication rate. However, this case shows that fishtail deformity is a late and serious complication, which may occur after a nondisplaced supracondylar fracture of the humerus, with no severity factors and with good early progression.
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Affiliation(s)
- R Gauthé
- Clinique chirurgicale infantile, CHU Charles-Nicolle, 1, rue de Germont, 76031 Rouen cedex, France.
| | - J Leroux
- Clinique chirurgicale infantile, CHU Charles-Nicolle, 1, rue de Germont, 76031 Rouen cedex, France
| | - C Latrobe
- Clinique chirurgicale infantile, CHU Charles-Nicolle, 1, rue de Germont, 76031 Rouen cedex, France
| | - D Thomas
- Clinique chirurgicale infantile, CHU Charles-Nicolle, 1, rue de Germont, 76031 Rouen cedex, France
| | - D Moukoko
- Chirurgie pédiatrique orthopédique, CHU d'Angers, 4, rue Larrey, 49933 Angers cedex, France
| | - M Ould-Slimane
- Département de chirurgie orthopédique et traumatologique, CHU Charles-Nicolle, 1, rue de Germont, 76031 Rouen cedex, France
| | - E Foulongne
- Département de chirurgie orthopédique et traumatologique, CHU Charles-Nicolle, 1, rue de Germont, 76031 Rouen cedex, France
| | - S Abu-Amara
- Clinique chirurgicale infantile, CHU Charles-Nicolle, 1, rue de Germont, 76031 Rouen cedex, France
| | - J Lechevallier
- Clinique chirurgicale infantile, CHU Charles-Nicolle, 1, rue de Germont, 76031 Rouen cedex, France
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Kang S, Kam M, Miraj F, Park SS. The prognostic value of the fracture level in the treatment of Gartland type III supracondylar humeral fracture in children. Bone Joint J 2015; 97-B:134-40. [PMID: 25568427 DOI: 10.1302/0301-620x.97b1.34492] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
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.
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Affiliation(s)
- S Kang
- Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, 88, Olympic-ro, 43-gil, Songpa-gu, Seoul 138-736, South Korea
| | - M Kam
- Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, 88, Olympic-ro, 43-gil, Songpa-gu, Seoul 138-736, South Korea
| | - F Miraj
- Department of Orthopaedics and Traumatology, Fatmawati General Hospital, Jakarta, Indonesia
| | - S-S Park
- Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, 88, Olympic-ro, 43-gil, Songpa-gu, Seoul 138-736, South Korea
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Schmale GA, Mazor S, Mercer LD, Bompadre V. Lack of Benefit of Physical Therapy on Function Following Supracondylar Humeral Fracture: A Randomized Controlled Trial. J Bone Joint Surg Am 2014; 96:944-950. [PMID: 24897743 PMCID: PMC4049240 DOI: 10.2106/jbjs.l.01696] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
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.
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Affiliation(s)
- Gregory A. Schmale
- Department of Orthopedics and Sports Medicine (G.A.S. and V.B.) and Department of Emergency Medicine (S.M.), Seattle Children’s Hospital, 4800 Sand Point Way, Seattle, WA 98105. E-mail address for G.A. Schmale:
| | - Suzan Mazor
- Department of Orthopedics and Sports Medicine (G.A.S. and V.B.) and Department of Emergency Medicine (S.M.), Seattle Children’s Hospital, 4800 Sand Point Way, Seattle, WA 98105. E-mail address for G.A. Schmale:
| | - Laina D. Mercer
- Children’s Core for Biomedical Statistics, Seattle Children’s Hospital, 2001 8th Avenue, CW8-5B, Seattle, WA 98121
| | - Viviana Bompadre
- Department of Orthopedics and Sports Medicine (G.A.S. and V.B.) and Department of Emergency Medicine (S.M.), Seattle Children’s Hospital, 4800 Sand Point Way, Seattle, WA 98105. E-mail address for G.A. Schmale:
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Seeley MA, Gagnier JJ, Srinivasan RC, Hensinger RN, VanderHave KL, Farley FA, Caird MS. Obesity and its effects on pediatric supracondylar humeral fractures. J Bone Joint Surg Am 2014; 96:e18. [PMID: 24500590 DOI: 10.2106/jbjs.l.01643] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
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.
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Affiliation(s)
- Mark A Seeley
- Department of Orthopaedic Surgery, University of Michigan, C.S. Mott Children's Hospital, SPC 4241, 1540 East Hospital Drive, Ann Arbor, MI 48109. E-mail address for M.S. Caird:
| | - Joel J Gagnier
- Department of Orthopaedic Surgery, University of Michigan, C.S. Mott Children's Hospital, SPC 4241, 1540 East Hospital Drive, Ann Arbor, MI 48109. E-mail address for M.S. Caird:
| | - Ramesh C Srinivasan
- The Hand Center of San Antonio, 21 Spurs Lane, Suite 310, San Antonio, TX 78240
| | - Robert N Hensinger
- Department of Orthopaedic Surgery, University of Michigan, C.S. Mott Children's Hospital, SPC 4241, 1540 East Hospital Drive, Ann Arbor, MI 48109. E-mail address for M.S. Caird:
| | - Kelly L VanderHave
- Department of Orthopaedic Surgery, University of Michigan, C.S. Mott Children's Hospital, SPC 4241, 1540 East Hospital Drive, Ann Arbor, MI 48109. E-mail address for M.S. Caird:
| | - Frances A Farley
- Department of Orthopaedic Surgery, University of Michigan, C.S. Mott Children's Hospital, SPC 4241, 1540 East Hospital Drive, Ann Arbor, MI 48109. E-mail address for M.S. Caird:
| | - Michelle S Caird
- Department of Orthopaedic Surgery, University of Michigan, C.S. Mott Children's Hospital, SPC 4241, 1540 East Hospital Drive, Ann Arbor, MI 48109. E-mail address for M.S. Caird:
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Factors predictive of early radiographic failure after closed reduction of Gartland type II supracondylar humeral fractures. J Orthop Trauma 2013. [PMID: 23187157 DOI: 10.1097/bot.0b013e31827aa78e] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Supracondylar humerus fractures are the most common elbow fractures seen in the pediatric population. The American Academy of Orthopedic Surgeons Board of Directors recently published clinical practice guidelines recommending surgical treatment for all displaced fractures. We sought to identify predictive factors to assist the orthopedic surgeon in identifying which type II fractures are more likely to fail closed reduction and immobilization without pinning. DESIGN This was a retrospective cohort study. SETTING This study was conducted at a pediatric medical center in the Midwestern United States. PATIENTS This study analyzed 29 patients who underwent closed reduction and immobilization for significantly displaced, type II supracondylar humerus fractures. MAIN OUTCOME MEASUREMENTS We compared the lateral capitellar humeral angle, Baumann angle, and anterior humeral line index at the time of presentation, postreduction, and at final follow-up. RESULTS Two statistically similar groups were identified based on the amount of initial displacement. Variables were examined between the 2 groups including age, gender, initial displacement, quality of initial reduction, treatment in cast or splint, and position of immobilization. Forty-eight percent of the patients failed closed reduction and immobilization, with an average 71% loss of initial reduction at final follow-up. None of the examined variables were statistically significant or had any predictive value for failure. CONCLUSIONS Our study suggests that type II fractures should be viewed as a spectrum of injury. Our data show that a significantly displaced type II fracture that requires a reduction to obtain satisfactory alignment has a 48% chance of losing that reduction without percutaneous pinning.
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Abstract
To evaluate normative data on elbow range of motion (ROM) in the pediatric population. The passive ROM of 1361 healthy pediatric elbows was measured using a small goniometer calibrated in 1° increments, and recorded. The mean amount of flexion, extension, and arc of motion was 142°, -11°, and 153°, respectively. Our data indicated no meaningful correlation between patient sex, age, or weight and the amount of flexion, extension, or the total arc of motion. It appears that elbow ROM in this population is not affected by sex, age, or weight. Normative data are critical when setting the goals of a particular therapeutic approach.
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Abstract
BACKGROUND Supracondylar humerus fractures are the most common operative fractures in children; however, no studies describe the older child with this injury. The purpose of this study was to compare Gartland type III supracondylar humerus fractures in children older than 8 years of age with those in younger children than age 8. We hypothesized that there would be more complications in older children, reflecting a higher-energy injury mechanism. METHODS A retrospective chart review of supracondylar humerus fractures managed at a single level I pediatric trauma institution from 2004 to 2007 was performed. Patients with type III fractures were divided into groups based on age at presentation greater or less than 8. Baseline demographics, fracture characteristics, mechanism of injury, operative technique, and complications were analyzed. RESULTS A consecutive series of 1297 pediatric patients with surgically treated supracondylar humerus fractures was retrospectively reviewed including 873 (67.3%) type III fractures. Of those, 160 (18.3%) patients were older than age 8 at time of injury. Older children were more likely to have fractures from high-energy mechanisms (45.1% vs. 28.7%, P<0.001) and more open fracture (3.8% vs. 1.3%, P=0.0097). There was no difference in preoperative or iatrogenic neuropraxias between groups. There was a shorter delay between presentation and surgery in older children (mean, 217 vs. 451 min, P<0.0001). Three or more pins were used more often in older patients (61.8% in older children vs. 43.6% in younger children, P<0.0001). Major complications including reoperation, loss of fixation, or compartment syndrome were rare in both groups (1.1% in younger group vs. 0.6% in older group, P=1.000). There was a trend toward more pin site infections in older children (3.75% vs. 1.56%, P=0.071). Physical therapy was required nearly 4 times more frequently in older children for management of residual stiffness (20.0% vs. 5.7%, P<0.0001). CONCLUSIONS Children older than 8 years of age have a higher rate of open supracondylar humerus fractures, although nerve injury rates are similar. Surgeons placed more pins for fixation of fractures in older patients and elbow stiffness requiring physical therapy occurred more commonly after surgical intervention. EVIDENCE III Retrospective cohort.
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Enhanced biomechanical stiffness with large pins in the operative treatment of pediatric supracondylar humerus fractures. J Pediatr Orthop 2012; 32:201-5. [PMID: 22327456 DOI: 10.1097/bpo.0b013e31824536c8] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Various pin configurations have been recommended for the treatment of supracondylar humerus fractures on the basis of the choice between stability versus the risk of iatrogenic nerve injury. However, little attention has been paid to pin size. The purpose of this study was to evaluate the stability of large (2.8 mm or 0.110 inch) and small (1.6 mm or 0.062 inch) pin constructs in 6 configurations. METHODS A transverse fracture pattern was created by sectioning synthetic humeri in the midolecranon fossa. The specimens were then reduced and pinned in one of 6 configurations: 2 small pins (Kirschner wires) placed crossed or lateral divergent, 2 large pins (Steinmann pins) placed crossed or lateral divergent, or 3 small pins placed crossed or lateral divergent. All specimens were then tested in sagittal extension bending. We investigated the effect of pin configuration and cycle on the sagittal stiffness using multiple linear regression. RESULTS The 2 small lateral divergent pin configuration was significantly less stable than small crossed pins and large pins in a crossed or a lateral configuration. The addition of a third (lateral) pin to the small crossed pin construct made it significantly less stable than 2 large crossed pins. Although the stability between the remaining configurations was not significantly different, the 2 large crossed pins required the greatest torque to rotate the fragment 20 degrees. There was a significant reduction in torque as a function of cycle, suggesting a loss of fixation during cycling (P<0.05). CONCLUSIONS Large pins (2.8 mm) in any configuration and the placement of small pins (1.6 mm) in a crossed configuration provided more stable reduction in sagittal extension bending than did the conventional 2 small pins in a lateral divergent pin configuration. The most stable configurations involve crossing the medial and lateral pins. CLINICAL RELEVANCE There are more stable options than the traditional 2 small lateral pin configuration for fixation of unstable supracondylar fractures. The addition of a third pin is not always advantageous.
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Bernthal NM, Hoshino CM, Dichter D, Wong M, Silva M. Recovery of elbow motion following pediatric lateral condylar fractures of the humerus. J Bone Joint Surg Am 2011; 93:871-7. [PMID: 21543677 DOI: 10.2106/jbjs.j.00935] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
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.
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Affiliation(s)
- Nicholas M Bernthal
- Department of Orthopaedics, UCLA Orthopaedic Hospital, David Geffen School of Medicine, University of California at Los Angeles, 10833 Le Conte Avenue, 16-155 CHS, Los Angeles, CA 90095
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Noonan KJ, Zaltz I, Wenger D. What's New in Pediatric Orthopaedics. J Bone Joint Surg Am 2011; 93:597-606. [PMID: 21411710 DOI: 10.2106/jbjs.j.01693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Kenneth J Noonan
- University of Wisconsin School of Medicine and Public Health, Health Sciences Learning Center, Madison, 53705, USA.
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