A Comparative Study on Closed Reduction vs. Open Reduction Techniques in the Surgical Treatment of Rotated Lateral Condyle Fractures of the Distal Humerus in Children

Closed Reduction Techniques Are Associated With Fewer Complications Than Open Reductions in Treating Moderately Displaced Pediatric Lateral Humeral Condyle Fractures: A Multicenter Study

INTRODUCTION

Lateral humeral condyle (LC) fractures are the second most common pediatric elbow fractures. Traditionally, displaced fractures have been treated with open reduction although recent studies have demonstrated successful outcomes of closed reduction for similar injuries. This study investigates the outcomes comparing open and closed reduction in a large cohort of children with moderately displaced (Song classification types 1 to 4) lateral humeral condyle fractures.

METHODS

Retrospective data from patients aged between 1 and 12 years treated for lateral condyle fractures was collected from 6 academic level 1 trauma centers between 2005 and 2019. Data was collected on patient demographics, radiographic parameters, reduction type, type of hardware fixation, and fracture patterns. Complications recorded include infections, reoperations for nonunion, osteonecrosis, and elbow stiffness.

RESULTS

An initial 762 fractures were identified. After excluding Song 5 cases, a total of 480 fractures met inclusion criteria, with 202 (42%) treated with closed reduction and 278 (58%) treated with open reduction. Demographics and injury characteristics were similar across the 2 reduction cohorts. After propensity score matching, delayed healing (52% vs. 28%; OR: 2.88, 95% CI: 1.97-4.22; P<0.0001) and stiffness (22% vs. 10%; OR 2.42, 95% CI: 1.42-4.13; P=0.0012) were significantly higher in the open reduction group. No differences in the rates of infection or nonunion (3% CR and 1% OR) were noted between the 2 groups.

CONCLUSION

This study demonstrates that moderately displaced lateral condyle fractures requiring open reduction are more likely to have elbow stiffness and delayed healing when compared with the ones treated with closed reduction. For these reasons, we propose attempting closed reduction techniques as the first line of treatment in moderately displaced lateral humeral condyle fractures (if anatomic articular reduction can be achieved) to attain better patient outcomes.

Comparison of ultrasound-guided closed reduction and percutaneous pinning fixation for unstable humeral lateral condylar fractures

Objective

Ultrasound-guided techniques have become popular in severe humeral lateral condylar fractures (HLCFs). This study compared the results of ultrasound-guided closed reduction and percutaneous pinning (UG-CRPP) for Song types 4 and 5 and dislocation type of HLCFs.

Methods

This retrospective study was conducted in patients with HLCFs treated between January 2021 and October 2022 at three hospitals. The patients were divided into three groups according to Song's classification and elbow dislocation. The surgical time, reduction failure rate, and outcomes of the three groups were compared.

Results

The mean surgical time of the 94 patients across the three groups (Song 4 group, 42 cases; Song 5 group, 38 cases; and dislocation group, 14 cases) was the longest for Song 4 (66.14 ± 23.05 min), followed by the dislocation group (59.71 ± 21.07 min) and Song 5 (52.16 ± 14.94 min) (for all, P = 0.009). The failure rate decreased in the following order: dislocation group (5/14), Song 4 group (7/42), and Song 5 group (2/38). The failure rate of closed reduction in Song 4 was 3.2-fold higher than that in Song 5, and for the dislocation group, it was 7.6-fold higher than that in Song 5. Significant differences were observed between the Song 4, Song 5, and dislocation groups in terms of shaft-condylar angle and supination (P = 0.015, P = 0.043). No significant differences (P > 0.05) were observed in the carry angle, flexion, extension, or pronation of the three groups. Two cases of delayed healing, four cases of superficial infection, one case of trochlear necrosis, and 39 cases of lateral spur in the Song 4 group were observed. In the Song 5 group, five had a superficial infection, one had re-displacement, and 26 had a lateral spur. In the dislocation group, there were two cases of superficial infection and 10 of lateral spurs.

Conclusions

Song 4 HLCFs require longer surgical time and present more postoperative complications than Song 5 and dislocation-type HLCFs and can easily lead to lateral spurs. The failure rates of closed reduction in Song 4 and the dislocation type were higher than those in Song 5. Thus, UG-CRPP can be used to treat patients with unstable HLCFs.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

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

[Effectiveness comparison of ultrasound-guided closed reduction and Kirschner wire fixation for different unstable humeral lateralcondylar fractures of children]

Objective

To compare the effectiveness of ultrasound-guided closed reduction and Kirschner wire fixation for different unstable humeral lateralcondylar fractures of children.

Methods

The clinical data of 94 children with unstable humeral lateralcondylar fractures admitted to three medical centers between January 2021 and October 2022 were retrospectively analyzed. The children were divided into three groups according to the Song classification and whether the elbow joint was dislocated or not, including 42 cases of Song 4 type (group A), 38 cases of Song 5 type (group B), and 14 cases of elbow joint dislocation (group C). There was no significant difference in gender, age, side, cause of injury, and time from injury to operation among the three groups ( P>0.05). All children were treated with ultrasound-guided closed reduction and Kirschner wire fixation. The operation time and complications of the three groups were recorded and compared, and the failure of closed reduction was evaluated by ultrasound. X-ray examination was performed at last follow-up to measure the Baumann angle, condylar angle, carrying angle, and lateral osteophyte of the affected side; the extension, flexion, pronation, and supination range of motion of the affected elbow joint were measured; the function of the elbow joint was evaluated by Mayo score.

Results

The operation time in group A was significantly longer than that in groups B and C ( P<0.05). There were 7, 2, and 5 cases of closed reduction failure in groups A, B, and C, respectively, and there was no significant difference in the incidence of the closed reduction failure ( P>0.05). All patients were followed up 6-28 months, with an average of 15.7 months. There was no significant difference in the follow-up time among the three groups ( P>0.05). Complications: in group A, there were 2 cases of delayed union, 4 cases of needle tract infection, 1 case of trochlear necrosis, and 39 cases of lateral osteophyte; in group B, there was 1 case of malunion, 5 cases of needle tract infection, 1 case of redisplacement, and 26 cases of lateral osteophyte; in group C, there were 2 cases of needle tract infection and 10 cases of lateral osteophyte. There was no significant difference in the incidence of complications among the three groups ( P>0.05). No cubitus varus or cubitus valgus deformity was found in all patients. At last follow-up, except that the condylar angle in group A was significantly greater than that in groups B and C ( P<0.05), there was no significant difference in other imaging indicators, elbow range of motion, or Mayo score between groups ( P>0.05).

Conclusion

The Song type 4 of humeral lateralcondylar fracture treated with ultrasound-guided closed reduction and Kirschner wire fixation has a longer operation time, more postoperative complications, and is more prone to lateral osteophyte.

Criteria of ultrasound-guided closed reduction with percutaneous pinning in unstable humeral lateral condylar fractures: a three-center retrospective cohort study

Background

Interventions using ultrasound-guided closed reduction and percutaneous pinning (UG-CRPP) of humeral lateral condylar fractures (HLCFs) have been increasingly applied; however, their effectiveness for unstable HLCFs and the criteria for ultrasound outcomes remain unclear. This study assessed the outcomes of UG-CRPP for HLCFs and evaluated the success criteria in children.

Methods

Data were retrospectively collected from 106 patients with unstable HLCFs admitted to three hospitals between January 2021 and August 2022. Fifty-five cases were left-sided and 51 cases were right-sided: 74 male patients and 32 female patients were included. Perioperative data, elbow function, complications, and criteria for UG-CRPP were analyzed.

Results

The mean rate of UG-CRPP was 88%. The mean surgical time was 54.56 ± 21.07 min, and the mean fluoroscopy frequency was 9.25 ± 2.93 times. At the last follow-up, there were significant differences in elbow flexion between the affected side (135.82° ± 6.92°) and the unaffected side (140.58° ± 5.85°) (p = 0.01). The Mayo score of the affected side was 90.28° ± 4.97°, the Baumann angle was 71.4° ± 5.4°, condylar shaft angle was 39.9° ± 6.4°, and the carrying angle was 8.4° ± 3.6°. Seventy patients presented mild lateral spurs and 16 patients exhibited moderate spurs. Fourteen patients presented with pin infection, and one patient exhibited postoperative re-displacement. There was no premature physeal closure, varus, or valgus elbow deformity, delayed union, or non-union. Successful ultrasound-based outcome criteria for UG-CRPP were defined as follows: (i) absent or less than a cartilage thickness step on the cartilage hinge on coronal plane parallel articular surface scanning, (ii) no lateral displacement and intact distal end of the condylar and capitellum on coronal plane vertical articular surface scanning, (iii) no anteroposterior displacement and absent or less than a cartilage thickness step on sagittal plane vertical articular surface scanning, and (iv) intact posterior fracture line or less than a cortex step on posterolateral sagittal plane vertical articular surface scanning.

Conclusion

UG-CRPP is a procedure with minimal blood loss, less invasive, cosmetic, and no radiation exposure. It yielded good outcomes in unstable HLCFs. The successful criteria make it suitable for clinical application.

Arthroscopically assisted closed reduction for displaced lateral humeral condyle fractures over 4 mm in children

INTRODUCTION

Lateral humeral condyle fractures (LHCFs) are the most common intra-articular fracture occurring at the elbow in children. Conventional treatment for displaced pediatric LHCFs is open reduction and percutaneous pinning, and few studies have regarded the efficacy of arthroscopic-assisted techniques. We aimed to evaluate the efficacy of anatomic reduction via elbow arthroscopy for pediatric humeral lateral condyle fractures with displacements >4 mm.

METHODS

A total of 32 children with LHCFs featuring displacements >4 mm were enrolled in this retrospective study. Arthroscopically assisted reduction was performed as the primary treatment approach. For simple displaced fractures, arthroscopically assisted reduction was directly employed with intermittent intra-articular irrigation. For fractures with distal fragment rotation, the rotated fragments were firstly realigned into a simple displaced position under fluoroscopy before proceeding with arthroscopy. The success rate of arthroscopically assisted reduction and clinical outcomes at the latest follow-up were assessed, and complications related to the procedure were monitored.

RESULTS

Twenty-nine of 32 (90.62 %) enrolled cases were successfully treated with arthroscopically assisted reduction. Failure cases were attributed to soft tissue swelling, which hindered the manipulation of the fracture fragments for reduction or fixation. We subsequently adapted the surgical procedure, resulting in a significant increase in the success of arthroscopically assisted reduction, rising from 71.43 % to 96 %. Among the 29 successfully treated cases, excellent functional outcomes were observed in 18 cases, and 11 cases showed good outcomes. Regarding the carrying angle outcomes, 28 patients achieved excellent results, with one patient having a good outcome. The most frequent radiographic finding after surgery was lateral spur formation without further negative effects. Only one case of superficial infection occurred, promptly healing with topical management. No significant complications such as neurovascular injury or compartment syndrome were observed.

CONCLUSION

Arthroscopically assisted anatomic reduction provides a promising alternative to open reduction for LHCFs with displacements exceeding 4 mm, offering direct visualization of the articular surface and minimizing soft tissue dissection.

A meta-analysis of closed reduction percutaneous pinning and open reduction with pin fixation of pediatric humeral lateral condylar fracture

Objective

To compare the effectiveness and safety of closed reduction percutaneous pinning vs. open reduction with pin fixation to treat the pediatric humeral lateral condylar fracture.

Methods

Studies comparing closed reduction percutaneous pinning vs. open reduction with pin fixation for treating pediatric lateral humeral condyle fractures were found by searching Pubmed, Embase, the Cochrane Library, and Web of Science databases, including randomized/non-randomized controlled, retrospective case-control, and prospective cohort studies. Furthermore, quality evaluation and data retrieval were conducted after the literature review. A meta-analysis was performed using RevMan 5.4 software to compare both groups' outcome measures.

Results

This Meta-analysis incorporated eight studies with 856 cases. The Meta-analysis found no significant difference in functional outcomes, superficial infection, deep infection, poor fracture union, avascular necrosis of the humeral capitulum, or lateral spur formation between groups. However, the status of unaesthetic scars in the closed reduction percutaneous pinning group was superior.

Conclusions

For pediatric humeral lateral condylar fracture surgical therapy, the efficacy and safety of closed reduction percutaneous pinning vs. open reduction with pin fixation were not significantly different; closed reduction percutaneous pinning offered the benefit of eliminating unaesthetic scar. However, further high-quality research is required to verify the conclusions of this Meta-analysis.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/#myprospero, identifier CRD42023392451.

Open versus closed reduction internal fixation for lateral condyle humeral fractures in children: a systematic review and meta-analysis

OBJECTIVE

The objective of this meta-analysis was to illustrate the clinical outcomes and safety of two different management options for Song stage 2-4 lateral condyle humeral fractures in children.

METHOD

In January 2023, a systematic computer-based search was conducted. Data were retrieved for patients with two different management options for lateral condyle humeral fractures in children. The primary endpoints were clinical outcomes based on infection, avascular necrosis, and nonunion. After testing for publication bias and heterogeneity between studies, the data was aggregated for stochastic effect models when necessary.

RESULTS

Eight clinical studies with 742 patients were eventually included in the meta-analysis. There was no significant difference between the closed reduction and percutaneous pinning, and open reduction and internal fixation in terms of the clinical outcomes based on infection, avascular necrosis, and nonunion (P > 0.05).

CONCLUSIONS

Closed reduction and percutaneous pinning, as well as open reduction and internal fixation of lateral condyle humeral fractures in children, resulted in similar structural stability and functional outcomes. More high-quality randomized controlled trials are needed to determine this conclusion.