1
|
Ciftci S, Safali S, Ergin M, Özdemir A, Acar MA. Is methyl methacrylate fixator reliable for the treatment of gartland type IV supracondylar fractures? Niger J Clin Pract 2023; 26:1463-1471. [PMID: 37929522 DOI: 10.4103/njcp.njcp_15_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2023]
Abstract
Background In childhood supracondylar fractures of the humerus, fixation with percutaneous Kirschner wire is the standard treatment. In the case of irreducible-unstable fractures, these can be defined as fractures in which reduction is not well-achieved or in which fixation cannot be achieved with the K-wire. Intraoperative management of these types of fractures may be difficult. Treatment with a methyl methacrylate fixator consisting of K-wire and methyl methacrylate cement, as defined by the senior author of the article, may be a good option for Gartland type IV supracondylar humeral fractures where the fracture is unstable in flexion and extension due to complete periosteal tearing. Materials and Methods The short-term and mid-term results of 27 patients between the ages of 4-12 with Gartland type IV supracondylar fracture of the humerus treated with methyl methacrylate fixation were reviewed. The patients were scored in terms of function and cosmetic satisfaction. Results A total of 19 of the 27 patients treated with the methyl methacrylate fixator had full elbow motion function and rated the outcome of the treatment as excellent, which was judged by orthopedic surgeons on the basis of Flynn's criteria. Six patients had nearly full elbow motion and evaluated their recovery outcome as good. Two patients reported nearly full range of motion (ROM) and evaluated the method as moderate in terms of treatment. Discussion Treatment with the methyl methacrylate fixation method is an inexpensive method that allows early joint mobilization, provides strong biomechanical stability, ensures good outcomes, and should be considered in the treatment of irreducible and unstable supracondylar fractures of the humerus.
Collapse
Affiliation(s)
- S Ciftci
- Department of Orthopedics and Traumatology, Selcuk University Medical Faculty, Konya, Turkey
| | - S Safali
- Department of Orthopedics and Traumatology, Selcuk University Medical Faculty, Konya, Turkey
| | - M Ergin
- Department of Orthopedics and Traumatology, Cihanbeyli State Hospital, Konya, Turkey
| | - A Özdemir
- Department of Orthopedics and Traumatology, Division of Hand Surgery, Selcuk University Medical Faculty, Konya, Turkey
| | - M A Acar
- Department of Orthopedics and Traumatology, Selcuk University Medical Faculty, Konya, Turkey
| |
Collapse
|
2
|
Xing B, Dong B, Che X. Medial-lateral versus lateral-only pinning fixation in children with displaced supracondylar humeral fractures: a meta-analysis of randomized controlled trials. J Orthop Surg Res 2023; 18:43. [PMID: 36647086 PMCID: PMC9841617 DOI: 10.1186/s13018-023-03528-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 01/10/2023] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Supracondylar humeral fractures (SCHFs) are frequent in children, and closed reduction with percutaneous pin fixation remains the standard surgical treatment for displaced SCHFs. Two pinning configurations, medial-lateral crossed entry pinning (MLP) and lateral-only entry pinning (LP), are widely used, but which one is superior to another one is still debatable. This meta-analysis aimed to compare the efficacy and safety of both pinning fixation methods. METHODS Randomized controlled trials (RCTs) were searched on PubMed, EMBASE, Web of Science, Cochrane library and Google Scholar. Relative risk (RR) and mean difference (MD) with corresponding 95% confidence interval (CI) were calculated for radiographical outcomes, functional outcomes and complications. RESULTS A total of 19 RCTs comprising 1297 Gartland type II and type III fractures were included. MLP had a decreased risk of loss of reduction (RR = 0.70, 95%CI 0.52-0.94, P = 0.018) but a higher risk of iatrogenic ulnar nerve injury (RR = 2.21, 95%CI 1.11-4.41, P = 0.024) than LP. However, no significant difference was observed for incidence of ulnar nerve injury if applying a mini-open technique in MLP group (RR = 1.73, 0.47-6.31, P = 0.407). There were no differences between both groups in loss of carrying angle (MD = - 0.12, 95%CI - 0.39 to 0.16), loss of Baumann angle (MD = 0.08, 95%CI - 0.15 to 0.30), excellent grading of Flynn criteria (RR = 1.06, 95%CI 0.99-1.14, P = 0.102) and pin tract infection (RR = 0.92, 95%CI 0.50-1.70). CONCLUSIONS MLP is more effective in maintaining fixation, while LP is safer with respect to ulnar nerve injury. MLP with a mini-open technique reduces the risk of ulnar nerve lesion and is an effective and safe choice.
Collapse
Affiliation(s)
- Binbin Xing
- grid.263452.40000 0004 1798 4018Department of Traumatic Orthopedics, Yuncheng Central Hospital, Shanxi Medical University, No. 3690, Hedong East Street, Yanhu District, Yuncheng, 044000 Shanxi Province China
| | - Bin Dong
- grid.263452.40000 0004 1798 4018Department of Traumatic Orthopedics, Yuncheng Central Hospital, Shanxi Medical University, No. 3690, Hedong East Street, Yanhu District, Yuncheng, 044000 Shanxi Province China
| | - Xiaoling Che
- grid.263452.40000 0004 1798 4018Department of Traumatic Orthopedics, Yuncheng Central Hospital, Shanxi Medical University, No. 3690, Hedong East Street, Yanhu District, Yuncheng, 044000 Shanxi Province China
| |
Collapse
|
3
|
Graff C, Dounas GD, Sung J, Kumawat M, Huang Y, Todd M. Management of iatrogenic ulnar nerve palsies after cross pinning of pediatric supracondylar humerus fractures: A systematic review. J Child Orthop 2022; 16:366-373. [PMID: 36238145 PMCID: PMC9551003 DOI: 10.1177/18632521221124632] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 08/21/2022] [Indexed: 02/03/2023] Open
Abstract
PURPOSE Up to 4% of patients who undergo cross pinning of a pediatric supracondylar humerus fracture sustain an iatrogenic ulnar nerve palsy (IUNP). This study aims to summarize the evidence regarding the management of IUNP in this setting, and to identify if early intervention (early wire removal or exploration) leads to faster and/or more complete recovery of the ulnar nerve. METHODS A formal systematic review was undertaken, with databases searched including Ovid Medline, Embase and Cochrane central. This was performed in accordance with JBI methodology and PRISMA guidelines. RESULTS In all, 26 articles were included in final evaluation, reporting a total of 179 IUNP. In all, 153 cases (85%) were managed expectantly, reporting full recovery at final follow-up (average 4.5 months) in 140 cases (91%). There were 26 cases of IUNP which were managed with early wire removal and/or exploration, of which 22 had full recovery (85%). There were 17 cases of 179 (9%) which did not have full recovery. CONCLUSION The majority of IUNP are managed expectantly, with approximately 90% achieving full recovery at final follow-up. The literature does not support early wire removal and/or exploration, possibly because the damage to the nerve is done at the time of wire placement.
Collapse
Affiliation(s)
- Christy Graff
- The University of Adelaide, Adelaide,
SA, Australia,Department of Orthopaedics, Women’s and
Children’s Hospital, North Adelaide, SA, Australia,Royal Adelaide Hospital, Adelaide, SA,
Australia,Christy Graff, Department of Orthopaedics,
Women’s and Children’s Hospital, North Adelaide, SA 5006, Australia.
| | - George Dennis Dounas
- The University of Adelaide, Adelaide,
SA, Australia,Department of Orthopaedics, Women’s and
Children’s Hospital, North Adelaide, SA, Australia,Royal Adelaide Hospital, Adelaide, SA,
Australia
| | - Jonghoo Sung
- The University of Adelaide, Adelaide,
SA, Australia
| | | | - Yue Huang
- The University of Adelaide, Adelaide,
SA, Australia
| | - Maya Todd
- The University of Adelaide, Adelaide,
SA, Australia,Royal Adelaide Hospital, Adelaide, SA,
Australia
| |
Collapse
|
4
|
The Frequency and Outcomes of Nerve Palsies in Operatively Treated Supracondylar Humerus Fractures. J Pediatr Orthop 2022; 42:408-412. [PMID: 35765866 DOI: 10.1097/bpo.0000000000002186] [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 A high index of suspicion for nerve palsy is essential in the setting of a displaced supracondylar humerus fracture (SCHF) with careful attention to the examination. We hypothesize that nerve injuries are more prevalent in higher energy type III and flexion SCHFs compared with type II fractures. METHODS A retrospective review was performed of 1085 operatively treated SCHFs in pediatric patients, aged 0 to 14 years, between January 1, 2015 and December 31, 2018. There were 979 patients eligible for analysis. Exclusion criteria included follow-up <3 weeks, polytrauma, pathologic fracture, and prior fracture of the ipsilateral elbow. RESULTS The overall rate of nerve injury was 10.6% (104/979). A significant difference in the rate of nerve palsy was identified between fracture types: 0.9% type II, 19.3% type III, and 10.7% flexion type SCHFs ( P <0.001). Median nerve palsy was the most common (n=65). An increased rate of ulnar nerve palsy was observed in flexion type SCHFs. The rate of nerve palsy was higher in the medial pin group (14.9%, P =0.035) but no significant association with iatrogenic ulnar nerve palsy was present. In type III and flexion SCHFs, operative time >60 minutes ( P =0.023) and the need for open reduction ( P =0.012) were significantly associated with postoperative nerve palsy. Referral to therapy was required in 30.8% of patients with a nerve palsy compared with 7.9% of patients without ( P <0.001). CONCLUSION Longer operative times, need for open reduction, and significantly higher rates of nerve palsy among type III and flexion SCHFs are best explained by the unstable nature of the fracture and greater degree of soft tissue trauma. Given prolonged duration of follow-up and more frequent need for therapy demonstrated in patients with a nerve palsy, these data can be used to improve counseling for families and patients after displaced SCHF. LEVEL OF EVIDENCE Level III-retrospective comparative study.
Collapse
|
5
|
Treatment of grossly dislocated supracondylar humerus fractures after failed closed reduction: a retrospective analysis of different surgical approaches. Arch Orthop Trauma Surg 2022; 142:1933-1940. [PMID: 33983529 DOI: 10.1007/s00402-021-03937-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 05/02/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION The supracondylar humerus fracture (SCHF) is one of the most common pediatric injuries. Highly displaced fractures can be very challenging. If closed reduction fails, the therapy algorithm remains controversial. MATERIALS AND METHODS In total, 41 patients (21 boys and 20 girls) with irreducible Gartland type III SCHF, treated with open reduction through three different approaches and cross-pin fixation, were retrospectively evaluated. The mean follow-up was 46 months (min.: 12, max.: 83, SD: 23.9). The Mayo elbow performance score (MEPS) as well as the quick disabilities of arm, shoulder and hand (qDASH) score were used to assess the functional outcome. Baumann's angle and the anterior humeral line (AHL, Roger's line) were obtained from follow-up radiographs. Time to surgery, postoperative nerve-palsy, rate of revision surgery, and complication rate were examined. RESULTS Two revision surgeries were reported. One due to inadequate reduction and one due to secondary loss of reduction. In this context, the AHL was a sufficient tool to detect unsatisfactory reduction. According to the MEPS the functional outcome was excellent (> 90) in 37/41 patients and good (75-89) in 4/41 at the final visit. Fair or poor results were not documented. The qDASH score was 1.8 (min.: 0, max.: 13.6, SD: 3.4). There were no significant differences between the utilized surgical approaches. An iatrogenic injury of the ulnar nerve was not reported in any case. Overall, one heterotopic ossification without impairment of the range of motion and one preliminary affection of the radial nerve were documented. CONCLUSION In the rare case of an irreducible SCHF, an anatomical reduction can be achieved by open approaches with excellent functional outcome and a high grade of patient satisfaction. All described open approaches can be utilized with a high safety-level.
Collapse
|
6
|
Lee HA, Buczek MJ, Talwar D, Horn BD, Davidson RS. Post-Operative Splinting Versus Casting of Pediatric Supracondylar Humerus Fractures. Cureus 2021; 13:e17635. [PMID: 34646683 PMCID: PMC8486368 DOI: 10.7759/cureus.17635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/31/2021] [Indexed: 11/05/2022] Open
Abstract
Background Supracondylar humerus fractures (SCH) are common upper extremity fractures in children and are usually treated by closed reduction and percutaneous pinning. Post-operative management may cause complications, but the difference between cast and splint has not been closely investigated. Purpose Our objective was to compare casting and splinting of SCH fractures with respect to post-operative complications. Patients and methods We reviewed 1,146 pediatric SCH fractures that were reduced, percutaneously pinned, and immobilized by cast or splint. Open fractures, openly reduced fractures, and pre-operative neurological injuries were excluded. Over the course of immobilization, we noted if the initial cast or splint was maintained and if the patient returned due to complications. Results Post-operative casting was performed on 1,091 (95.2%) fractures and 55 (4.8%) were splinted. Age was a significant factor, increasing the likelihood of splinting by 12% with each year of age (p = 0.023). A total of 28 patients (2.4%) returned for unscheduled visits due to immobilization complaints, infection, and pain, but the rate difference between cast and splint was negligible. Reoperation was required for five patients (0.4%), and more likely for splinted fractures (p = 0.021). After controlling for age, splinting was still associated with reoperation (OR: 15.1, p = 0.004). Conclusions Although complications inevitably exist, both casting and splinting are effective immobilization methods. Both resulted in few complications such as post-operative discomfort, pain, infection, loss of reduction, or damage. It was difficult to evaluate significance with few splinted cases, but considering no major differences between splinted and casted fractures, clinicians should consider splinting to reduce the cost associated with casting.
Collapse
Affiliation(s)
- Hannah A Lee
- Orthopaedics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - Matthew J Buczek
- Orthopaedics, Children's Hospital of Philadelphia, Philadelphia, USA
| | - Divya Talwar
- Orthopaedics, Children's Hospital of Philadelphia, Philadelphia, USA
| | - B David Horn
- Orthopaedics, Children's Hospital of Philadelphia, Philadelphia, USA
| | | |
Collapse
|
7
|
Mets EJ, Grauer JN, McLynn RP, Frumberg DB. Pediatric Supracondylar Humerus Fracture Outcomes by Pediatric and Nonpediatric Orthopedists. Orthopedics 2021; 44:e203-e210. [PMID: 33316820 DOI: 10.3928/01477447-20201210-03] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Pediatric supracondylar humerus fractures are common and often require surgical intervention by an orthopedic surgeon, who may or may not have pediatric subspecialty training. This study used a large national database to assess for potential differences in perioperative outcomes for pediatric supracondylar humerus fractures treated by pediatric and nonpediatric orthopedists. A retrospective comparative cohort analysis was performed using data from the National Surgical Quality Improvement Project-Pediatric (NSQIP-P) database 2012 to 2017. Patients 1 to 11 years old were assessed. Demographics, comorbidities, and the incidence of adverse outcomes were compared between pediatric and nonpediatric orthopedists using multivariate analysis controlling for patient characteristics. A total of 15,831 patients were included in the study. Of these, 85.2% were treated by pediatric orthopedists and 14.8% were treated by nonpediatric orthopedists. Demographics, comorbidity burden, operative time, and hospital length of stay were not significantly different between the study groups. With multivariate analysis controlling for patient factors, no differences were identified for 30-day adverse events, reoperation, or readmission whether surgery was performed by pediatric or nonpediatric orthopedists. Considering self-selection of surgeons who perform surgery for pediatric supracondylar humerus fractures, no differences in hospital or general outcome metrics were identified based on who performed these procedures. [Orthopedics. 2021;44(2):e203-e210.].
Collapse
|
8
|
Zhao H, Xu S, Liu G, Zhao J, Wu S, Peng L. Comparison of lateral entry and crossed entry pinning for pediatric supracondylar humeral fractures: a meta-analysis of randomized controlled trials. J Orthop Surg Res 2021; 16:366. [PMID: 34107972 PMCID: PMC8188794 DOI: 10.1186/s13018-021-02505-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Accepted: 05/23/2021] [Indexed: 11/30/2022] Open
Abstract
Background Closed reduction and pinning entry fixation have been proposed as treatment strategies for displaced supracondylar humeral fractures (SCHFs) in children. However, controversy exists regarding the selection of the appropriate procedure. Hence, this meta-analysis was conducted to compare the effect of lateral and crossed pin fixation for pediatric SCHFs, providing a reference for clinical treatment. Methods Online databases were systematically searched for randomized controlled trials (RCTs) comparing lateral pinning entry and crossed pinning entry for children with SCHFs. The primary endpoints were iatrogenic ulnar nerve injuries, complications, and radiographic and functional outcomes. Results Our results showed that iatrogenic ulnar nerve injuries occurred more commonly in the crossed pinning entry group than in the lateral pinning entry group (RR = 4.41, 95% CI 1.97–9.86, P < 0.05). However, its risk between the crossed pinning with mini-open incisions group and the lateral pinning entry group was not significantly different (RR = 1.58, 95% CI 0.008–29.57, P = 0.76). The loss of reduction risk was higher in the lateral pinning entry group than in the crossed pinning entry group (RR = 0.66; 95% CI 0.49–0.89, P < 0.05). There were no significant differences in the carry angle, Baumann angle, Flynn scores, infections, and other complications between these two groups. Conclusions The crossed pinning entry with mini-open incision technique reduced the loss of reduction risk, and the risk of iatrogenic ulnar nerve injury was lower than in the lateral pinning entry group. The crossed pinning entry with mini-open incision technique is an effective therapeutic strategy for managing displaced supracondylar humeral fractures in children.
Collapse
Affiliation(s)
- Huaguo Zhao
- Department of Orthopedics, Ningbo No. 6 Hospital, 1059 Zhongsandong Road, Ningbo, Zhejiang, 315040, People's Republic of China
| | - Song Xu
- Department of Hepatobiliary Surgery, Shangyu People's Hospital of Shaoxing, 517 Citizen's Avenue, Shangyu, Shaoxing, Zhejiang, 312300, People's Republic of China
| | - Guanyi Liu
- Department of Orthopedics, Ningbo No. 6 Hospital, 1059 Zhongsandong Road, Ningbo, Zhejiang, 315040, People's Republic of China
| | - Jingyu Zhao
- Department of Orthopedics, Ninghai Hospital of Traditional Chinese Medicine, 1299 Taoyuan North Road, Ninghai, Ningbo, Zhejiang, 315600, People's Republic of China
| | - Shandong Wu
- Department of Orthopedics, Ninghai Hospital of Traditional Chinese Medicine, 1299 Taoyuan North Road, Ninghai, Ningbo, Zhejiang, 315600, People's Republic of China
| | - Linrui Peng
- Department of Orthopedics, Ningbo No. 6 Hospital, 1059 Zhongsandong Road, Ningbo, Zhejiang, 315040, People's Republic of China.
| |
Collapse
|
9
|
Abstract
PURPOSE Supracondylar humerus (SCH) fractures are the most common elbow fracture in children; however, they rarely occur as open injuries. Open fractures are associated with higher rates of infection, neurovascular injury, compartment syndrome, and nonunion. The purpose of this study was to evaluate the treatment and outcomes of open SCH fractures in children. METHODS Between 2008 and 2015, four children (1%) had open injuries among 420 treated for SCH fractures at a single center. The mean patient age was six years (range, four to eight years). Two patients had Gustilo-Anderson grade 1 open fractures and two had grade 2 fractures. Tetanus immunization was up-to-date in all. First dose of intravenous antibiotics was given on average 3hr 7min after onset of injury (range, 1hr 38min to 8hr 15min). Time from injury to irrigation and debridement (I&D) and closed reduction and percutaneous pinning (CRPP) was on average 8hr 16min (range, 4hr 19min to 13hr 15min). All patients received 24-hour intravenous antibiotics. Pins were removed at four weeks and bony union occurred by six weeks. RESULTS After an average follow-up period of 12 months (range, 6 to 22 months), there were no infections, neurovascular deficits, compartment syndromes, cubitus varus deformities, or range of motion losses. All outcomes were excellent according to the Flynn criteria. Due to the unstable nature of open SCH fractures, a medial pin was used in all four cases. No loss of reduction or ulnar nerve injury occurred. CONCLUSION Open injuries occur in approximately 1% of all SCH fractures in children. The authors recommend urgent intravenous antibiotics, I&D, and CRPP involving a medial pin to treat open SCH fractures. Excellent outcomes based on the Flynn criteria were obtained in four cases.
Collapse
Affiliation(s)
- Tommy Pan
- Department of Orthopaedics and Rehabilitation, Penn State College of Medicine, Hershey, USA
| | - Matthew R Widner
- Department of Orthopaedics and Rehabilitation, Penn State College of Medicine, Hershey, USA
| | - Michael M Chau
- Department of Orthopaedic Surgery, University of Minnesota Twin Cities, Minneapolis, USA
| | - William L Hennrikus
- Department of Orthopaedics and Rehabilitation, Penn State Health Milton S. Hershey Medical Center, Hershey, USA
| |
Collapse
|
10
|
Inpatient Versus Outpatient Treatment of Gartland Type II Supracondylar Humerus Fractures: A Cost and Safety Comparison. J Pediatr Orthop 2020; 40:211-217. [PMID: 31415017 PMCID: PMC8722678 DOI: 10.1097/bpo.0000000000001442] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND In an effort to increase health care value, there has been a recent focus on the transition of traditionally inpatient procedures to an outpatient setting. We hypothesized that in the treatment of Gartland extension type II supracondylar humerus fractures (SCHF), outpatient surgery can be performed safely and with similar clinical and radiographic outcomes compared with urgent inpatient treatment with an overall reduction in cost. METHODS We compared a prospective cohort of Gartland type II SCHF treated primarily as outpatients (postprotocol) to a retrospective cohort treated primarily as urgent inpatients (preprotocol), excluding patients with preoperative neurovascular injury, open fracture, additional ipsilateral upper extremity fracture, and prior ipsilateral SCHF. Inpatient versus outpatient treatment was also compared. Outcomes including perioperative factors, complications, readmission, reoperation, postoperative radiographic measurements, and direct hospital costs underwent univariate and multivariate analyses. RESULTS A total of 220 patients in the postprotocol cohort (88 inpatients and 132 outpatients) and 129 in the preprotocol cohort (97 inpatients and 32 outpatients) were analyzed. There were no differences in operative times, number of pins, conversion to open reductions, readmissions, or reoperations between cohorts or groups, and no cases developed postoperative neurovascular injuries or compartment syndromes. Total complications did not differ between the preprotocol and postprotocol cohorts; however, were higher in the inpatient group (3.8% vs. 0%; P=0.016) in the univariate, but not multivariate analysis. There were no differences in Baumann angle or humerocondylar angle. Significantly more inpatients' anterior humeral line fell outside of the middle third of the capitellum in the univariate, but not multivariate analysis. There were significant reductions in total cost per patient between the preprotocol and postprotocol cohorts (marginal effect, -$215; P<0.0001) and between the inpatient and outpatient groups (marginal effect, -$444; P<0.0001). CONCLUSIONS Delayed treatment of Gartland type II SCHF in the outpatient setting can be performed safely and with similar clinical and radiographic outcomes to those treated urgently as inpatients with a significant cost reduction. LEVEL OF EVIDENCE Therapeutic level III-retrospective comparative study.
Collapse
|
11
|
Ho CA, Podeszwa DA, Riccio AI, Wimberly RL, Ramo BA. Soft Tissue Injury Severity is Associated With Neurovascular Injury in Pediatric Supracondylar Humerus Fractures. J Pediatr Orthop 2018; 38:443-449. [PMID: 27603197 DOI: 10.1097/bpo.0000000000000855] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Neurovascular injury in pediatric supracondylar fractures (SCHFx) has been associated with fracture classification but not with soft tissue injury. The purpose of this study is to correlate clinical soft tissue damage to neurovascular injuries in SCHFx. METHODS This is an institutional review board approved prospective study from January 2010 through December 2013 of 748 operatively treated pediatric SCHFx. Prospective data were gathered both preoperatively and intraoperatively regarding detailed neurovascular examination as well as soft tissue status, with qualitative descriptives for swelling (mild/moderate/severe), ecchymosis, abrasions, skin tenting, and skin puckering. RESULTS A total of 7.8% of patients (41/526) had a nonpalpable radial pulse preoperatively. Compared with those with a palpable pulse, a nonpalpable pulse was associated with severe elbow swelling (P<0.0001), tenting (P=0.0085), puckering (P=0.0011), ecchymoses (P<0.0001), and open fracture (P=0.044). Ten patients had a loss of a palpable pulse from initial orthopaedic consult to time of surgery, and when compared with the patients who did not have a loss of pulse, this was associated with swelling severity (P=0.0001) and ecchymosis (P=0.053). A total of 14% of patients (71/526) had a neurological injury preoperatively, and this was associated with severe elbow swelling (P<0.0001), tenting (P=0.0008), puckering (P=0.0077), and ecchymoses (P<0.0001) when compared with patients who did not have a neurological injury. In total, 17 patients had a decline in their neurological examination from the time of initial orthopaedic consult to the time of surgery, and this was associated with severe elbow swelling (P=0.0054) and ecchymoses (P=0.011). After multivariate logistic regression analysis, severe swelling and ecchymoses were significantly associated with a nonpalpable pulse as well as neurological injury (P<0.05). No patient had compartment syndrome. CONCLUSIONS Soft tissue injury, as measured by swelling, ecchymosis, puckering, and tenting, had a clinically significant association with neurovascular compromise in pediatric SCHFx, and assessment of soft tissue injury is as important as the radiographic appearance when examining these patients. The physical examination signs of soft tissue injury may play a factor in determining urgency of surgical treatment in these fractures. LEVEL OF EVIDENCE Level II-therapeutic.
Collapse
Affiliation(s)
- Christine A Ho
- Department of Orthopaedic Surgery, Texas Scottish Rite Hospital for Children and Children's Medical Center of Dallas, Dallas, TX
| | | | | | | | | |
Collapse
|
12
|
The Utility of Routine Postoperative Radiographs After Pinning of Pediatric Supracondylar Humerus Fractures. J Pediatr Orthop 2017; 37:e309-e312. [PMID: 28441278 DOI: 10.1097/bpo.0000000000001000] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The purpose of this study was to determine the frequency with which postoperative radiographs resulted in a change in management following closed reduction and percutaneous pinning of displaced pediatric supracondylar humerus fractures. We hypothesize that only the initial postoperative radiograph will lead to changes in management of operative supracondylar humerus fractures. METHODS A retrospective review was performed at 2 level I pediatric trauma centers. Inclusion criteria were patients below 18 years of age who sustained supracondylar humerus fractures (Gartland type II, III, IV) who were operatively treated from 2008 to 2013 with adequate radiographic follow-up. Patients with flexion type, intra-articular, transphyseal, and open fractures were excluded from the study. Routine radiographs were taken at initial follow-up (1 wk postoperatively) and at pin removal (3 to 4 wk postoperatively). RESULTS The final analysis included 572 patients. Initial postoperative radiographs changed treatment in 9 patients (1.6%), including revision surgeries, 2 pin adjustments, and 2 early pin removals. At the time of pin removal, 20 (3.5%) patients required further immobilization. There were no changes to the initial plan for continued nonoperative treatment at final follow-up (6 to 8 wk postoperatively). CONCLUSIONS In this large retrospective series of patients treated with closed reduction and percutaneous pinning of displaced supracondylar humerus fractures, radiographs at 3 weeks do not reveal a need to return to the operating room or other significant pathology. These findings suggest that radiographs should be obtained within 7 to 10 days postoperatively for type III fractures and may only need to be repeated if the clinical situation warrants it, such as severe fracture pattern, persistent pain, or clinical deformity. LEVEL OF EVIDENCE Level IV-case series.
Collapse
|
13
|
Leiblein M, Lustenberger T, Schulz AK, Schmitz-Rixen T, Marzi I. Neurovascular complications after supracondylar humerus fractures in children. Trauma Case Rep 2017; 8:16-19. [PMID: 29644308 PMCID: PMC5883211 DOI: 10.1016/j.tcr.2017.01.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/02/2017] [Indexed: 01/31/2023] Open
Abstract
Background Supracondylar fractures of the humerus are a common injury in pediatric traumatology. The most common operative therapy is closed reduction and percutaneous pinning using K-wires. Common complications associated with this entity are neurovascular lesions, especially of the brachial artery and the median nerve. Methods We report two cases of patients treated in our trauma-center with supracondylar fracture of the humerus (AO IV°) and neurovascular complications. Results Both patients underwent open revision and recovered completely in their further course. Conclusion We recommend detailed neurovascular examination initially and after reposition of the fracture. The threshold for open reduction in cases of irreducible fractures should be low. In the presence of neurovascular impairment an open revision is mandatory, even months after the initial Trauma.Level of evidence: Level V (case report).
Collapse
Affiliation(s)
- Maximilian Leiblein
- Department of Trauma, Hand and Reconstructive Surgery, Hospital of the Goethe University, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Thomas Lustenberger
- Department of Trauma, Hand and Reconstructive Surgery, Hospital of the Goethe University, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Anne-Kathrin Schulz
- Department of Paediatric Surgery and Paediatric Urology, University Hospital Frankfurt/M., Theodor-Stern-Kai 7, 60590 Frankfurt/M, Germany
| | - Thomas Schmitz-Rixen
- Department of Vascular and Endovascular Surgery, Hospital of the Goethe University, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Ingo Marzi
- Department of Trauma, Hand and Reconstructive Surgery, Hospital of the Goethe University, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| |
Collapse
|
14
|
Zhong W, Wang XW. Clinical study of emergency treatment and selective closed reduction for the treatment of supracondylar humerus fracture in children. JOURNAL OF ACUTE DISEASE 2016. [DOI: 10.1016/j.joad.2016.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
|