The diagnostic value of sonographic findings in pediatric elbow fractures: A systematic review and meta-analysis

BACKGROUND

Sonography is a beneficial imaging modality for detecting elbow fractures in children, considering the lack of radiation exposure and time efficiency. This systematic review aims to determine the diagnostic value and clinical applicability of sonography and each sonographic finding in detecting pediatric elbow fractures.

METHODS

Pubmed, Scopus, and WOS databases were searched for related original articles until February 25, 2023, and data related to diagnostic performance were extracted. We used the Bivariate model and hierarchic summary receiver operating characteristic (HSROC) approach to calculate pooled diagnostic values. Cochrane Q test and I-squared were performed to evaluate heterogeneity. We assessed heterogeneity with meta-regression.

RESULTS

Eight studies were included, which involved a total number of 880 patients. According to meta-analysis, sonography demonstrated a pooled sensitivity of 97% (91-99%) and specificity of 90% (80-95%), positive likelihood ratio(LR+) of 9.82 (4.59-20.97), and negative likelihood ratio (LR-) of 0.03 (0.01-0.10). For the sonographic posterior fat pad sign as a sole diagnostic sign, we calculated a Pooled Sensitivity of 80% (70-88%), Specificity of 97% (87-99%), LR+ of 28.8 (6-139.3), and LR- of 0.2 (0.13-0.31). Also, lipohemarthrosis demonstrated a pooled sensitivity of 80% (70-88%), specificity of 97% (87-99%), LR+ of 28.8 (6-139.3), and LR- of 0.2 (0.13-0.31). The sensitivity of detecting fractures with cortical line disruption was significantly higher in studies that utilized a comprehensive technique compared to a conventional technique.

CONCLUSIONS

Sonography is a valuable diagnostic tool for the assessment of pediatric elbow injuries, and it can be capable of confirmation or exclusion of the diagnosis.

Effectiveness of ultrasonography performed at the emergency department for pediatric elbow trauma cases

BACKGROUND

Two-way direct radiography is the first-choice imaging method for pediatric patients presenting to the emergency department with elbow trauma. Although, unlike radiography, ultrasonography (US) is not used routinely, studies show that US can be used in the diagnosis of fractures in pediatric patients.

METHODS

In this single-center prospective observational study, patients under the age of 18 who presented to the emergency department after sustaining elbow trauma constituted the population of the study. Findings of the posterior fat pad sign using bedside US and the result obtained by seven-point assessment of the bone cortex were compared with the final diagnosis.

RESULTS

Of the 128 patients enrolled in the study, 6 patients were excluded due to various reasons. Seventy (57.4%) patients were male, and median age was 7.7 years. On examining the final diagnosis of the patients at the emergency department, fracture diagnosis was observed in 39 patients (32%). It was determined that fracture diagnosis for 94.9% of the patients included in the study could be achieved using US (in the presence of at least the fat pad sign and/or direct findings of fracture based on the seven-point assessment).

CONCLUSION

US should be considered as a diagnostic tool in cases of pediatric elbow traumas owing to its high sensitivity and negative predictive value. US, which is reproducible, ionizing radiation-free, and can be performed at the bedside, can considerably reduce unnecessary radiography in low-risk patients when evaluated along with physical examination findings among patients in the pediatric age group presenting with elbow trauma. We believe that the result of our study will contribute to patient care practices.

Comparative analysis of pinning techniques for supracondylar humerus fractures in paediatrics: A systematic review and meta-analysis of randomized controlled trials

Purpose

Supracondylar humeral fractures (SCHFs) rank among the frequently observed fractures in children. Nonetheless, there exists a dearth of consensus regarding the optimal surgical approach. This meta-analysis aims to thoroughly evaluate and compare two distinct pinning techniques (cross pinning versus lateral pinning) for SCHFs, using data from Randomized controlled trials (RCTs).

Methods

Literature review was done using PubMed, CINAHL, Scopus, and The Cochrane Library for RCTs comparing the two pinning methods and providing information on at least one of the following: Loss of Baumann's angle, loss of carrying angle, elbow function assessed based on Flynn criteria, pin tract infection, and iatrogenic ulnar nerve injury. Random effect model was used to calculate standardized mean difference or Odds Ratio (OR) for the outcomes. Review Manager 5.4.1. was used to perform quality assessment and statistical analysis.

Results

A total of 22 RCTs were included. 20 studies reported data for iatrogenic ulnar nerve injury, the OR was calculated to be 3.76 (95% CI 1.75-8.06), showing a significantly lower risk of surgical ulnar nerve injury with the lateral technique. However, no significant difference was found between the pinning techniques in regard to the other outcomes.

Conclusion

In comparison to lateral pinning, the utilization of cross pinning technique exposes the patient to a heightened susceptibility of iatrogenic nerve injury. Therefore, it is recommended that surgeons prioritize the implementation of the lateral pinning technique whenever feasible, as it offers greater protection against iatrogenic ulnar nerve injury. For the other intraoperative and postoperative outcomes, both surgical techniques yield comparable results.

How high is the quality of the videos about children's elbow fractures on Youtube?

OBJECTIVE

Pediatric elbow fractures are children's most common fractures. People use the internet to get information about their illnesses and also to search for treatment options. Videos uploaded to Youtube do not go through the review process. The aim of our study is to determine the quality of videos related to child elbow fractures on Youtube.

MATERIAL METHOD

The study was carried out with the data obtained from the video-sharing site www.youtube.com on 01.12.2022. Pediatric elbow fractures are written in the search engine section. Information about the number of views of the videos, upload date, view rate (number of views per day), number of comments, number of likes and dislikes, duration, whether they contain animation and the publishing source were evaluated. The videos are divided into 5 groups according to their sources: medical society/non-profit organization, physician, healthrelated website, university/academic, and patient/independent user/other. The quality of the videos was evaluated using the Global Quality Scale (GQS). All videos have been evaluated by 2 researchers.

RESULTS

In the study, 50 videos were included. In the statistical evaluation, no significant correlation was found between the modified discern score and GQS found by both researchers, and the number of views, the rate of views, comments, likes and dislikes, video duration and VPI. In addition, when the GQS and modified discern scores were compared according to the source of the video, it was found that the patient/independent user/other group scores were lower numerically, but there was no statistically significant difference in comparison.

CONCLUSION

Most of the videos about child elbow fractures have been uploaded by healthcare professionals. Therefore, we concluded that the videos are quite informative in terms of accurate information and quality content.

Radial head replacement - A comprehensive review

Background

Radial head fractures represent 1-4% of all adult fractures and 1/3rd of elbow fractures (Kaas et al., 2010). Radial head is an important secondary stabilier of the elbow. The aim of the treatment of radial head fractures is to achieve stability and good functional outcome. Radial head replacement (RHR) is indicated when robust reconstruction and fixation of the fracture fragments is not possible.

Methods

This article explores history and evolution, anatomical considerations, biomechanics, implant designs, indications, surgical outcomes and controversies in radial head replacement based on current evidence.

Results

There is a wide range of RHR designs available without conclusive evidence to support the superiority of one design over the other. Ranges of motion, functional outcomes and complication were comparable among different designs with a high incidence of complications reported in many studies.

Conclusion

RHR remains a good option in unreconstructible radial head fractures, with potential to regain excellent function. It is imperative to continue with the quest to innovate and improve on current designs, to reduce complications in the long term.

Temporary spanning plate across the elbow for complex fractures of the distal humerus

BACKGROUND

Open reduction internal fixation (ORIF) is the gold standard management of fractures of the distal humerus. Stable fixation to allow early mobilization is not always possible in cases with comminuted fracture patterns and bone loss, with a high failure rate. We propose augmentation of internal fixation in these unstable situations with a spanning plate across the elbow to protect the fixation construct temporarily until bone union.

METHODS

Eighteen patients with complex distal humeral fractures were managed with standard ORIF technique augmented with a temporary plate spanning across the elbow as an internal fixator. Cases included were either very distal, comminuted (6 cases) or insufficiency fractures (4 cases) or revision fixation cases (8 cases). The temporary spanning plate was removed as soon as signs of early radiographic union were detected.

RESULTS

Seventeen patients were available for final follow up at a mean 28.3 months. The spanning plate was removed after 3.4 months on average. At the final follow-up, the mean elbow total arc of motion was 86.3°. The mean Mayo Elbow Performance Score (MEPS) was 80, and the mean Quick Disabilities of the Arm, Shoulder and Hand (Q-DASH) score was 27.

CONCLUSION

Spanning the elbow temporarily with a plate in adjunct to standard ORIF technique is both simple and effective in achieving fracture stability and union and minimizes failure rates after fixation of comminuted, very distal fractures, osteoporotic cases, or revision fixation cases with bone loss.

LEVEL OF EVIDENCE

Level IV, Therapeutic study.

[What do orthopedic and trauma surgeons expect from radiologists when interpreting imaging of the elbow?]

CLINICAL ISSUE

The elbow is a complex joint with a multitude of acute and chronic pathologies. In addition to the clinical examination, radiological diagnostics play a decisive role in the further therapeutic management.

DIAGNOSTIC WORK-UP/PERFORMANCE

While acute traumatic injuries often present with obvious structural changes and the need for rapid treatment decisions, chronic processes can present with less evident alterations. Especially in these cases there is a need for clear communication between the treating physician and the radiologist with respect to managing optimal imaging as the basis for a certain diagnosis and therefore optimal treatment. Basic prerequisites on both sides are detailed knowledge of all elbow pathologies, classifications and the spectrum of radiological diagnostic imaging.

ACHIEVEMENTS/PRACTICAL RECOMMENDATIONS

From the point of view of orthopedic surgeons the radiologist is responsible for the correct performance and interpretation of the necessary imaging procedures. The aim of this article is to give an overview of important aspects in the imaging of typical orthopedic/traumatic pathologies.

The Acutely Injured Elbow

The acutely injured elbow can present as a diagnostic challenge, encompassing a spectrum of conditions that involve the various osseous and soft tissue structures of this complex joint. Imaging plays a vital role in the management of these patients by providing an accurate interpretation of the underlying trauma sustained, which can have important implications on the preservation of joint function and stability. This article examines the mechanisms, patterns, classifications, and imaging findings of acute elbow injuries, providing key concepts for the radiologist in the interpretation of these injuries.

Conservative versus surgical treatment of Gartland type 2 supracondylar humeral fractures: What can help us choosing?

Background

Pediatric supracondylar humeral fractures (PSHF) are most common elbow fractures among children and adolescents. While there is substantial agreement on treating type 1 and type 3 fractures (conservatively and surgically, respectively), the debate on optimal treatment of Gartland type 2 fractures is still open.We wanted to review our cases, analyzing outcomes and seeking for parameters that could help surgeons treating these injuries.

Methods

We retrospectively reviewed 41 patients treated with reduction and casting (group A) and matched to 38 patients treated with closed reduction and percutaneous pining (CRPP, group B) for Gartland type 2 fractures between 2009 and 2013. At a mean follow-up of more than 6 years patients were analyzed by an accurate clinical exam and evaluation scales. Radiographic parameters at time of cast or pins removal were studied too.

Results

There were no statistically significant differences in clinical exam and evaluation scales between groups. Two patients in group A developed a cubitus varus deformity and one patient in group B had a superficial pin-tract infection. Baumann angle (BA) was out of normal range in two cases of conservative group and anterior humeral line (AHL) bisected capitellum in 42.1% of patients in group A and 73.2% in group B (p < .05).

Conclusion

It is reasonable to expect satisfactory outcomes both after conservative and surgical treatment of type 2 fractures, if cornerstones of both treatments are applied. Parameters that should be focused are probably two: complications (2 cases of cubitus varus in group A versus one superificial pin-tract infections in group B) and the better trend in surgical group in regards to loss of flexion and hyperextension of the affected elbow, likely related to the other notable datum, that is the percentage of cases in which AHL bisects capitellum. We think that, in absence of vascolonervous lesions and important swelling, BA and AHL are the most important parameters that can help us choosing the optimal treatment, as clarified in the algorithm we developed.

Level of evidence

Level III - retrospective comparative study.

The challenging surgical treatment of closed distal humerus fractures in elderly and octogenarian patients: radiographic and functional outcomes with a minimum follow-up of 24 months

INTRODUCTION

The main purpose of this retrospective, non-randomized, case series study was to evaluate the clinical and radiographic outcomes of distal humerus fractures (DHFs) in a consecutive series of elderly patients operatively treated by two surgeons, and second, to identify proper indications for two elderly age ranges and two fracture pattern groups.

MATERIALS AND METHODS

From January 2009 to June 2014, 51 patients (pts) underwent open reduction and internal fixation (ORIF) using the locking compression plate (LCP) distal humerus plate (DHP) system at our institution. Medical records and radiographs were retrospectively assessed. Patients were divided into 3 groups according to gender, age (pts <85 years, pts ≥85 years) and AO classification (13-B1-B2-C1-C2 or 13-C3). All subjects completed MEPS, Quick-DASH and SF-36 PCS/MCS scores at final follow-up, and statistical analysis was performed.

RESULTS

36 patients (20 women, 16 men), mean age 80.3 years, with AO type 13-B and 13-C DHFs were included with a mean follow-up of 56 months (range 24-92). The most common mechanism of trauma was a fall from ground level (55.6%). The mean MEPS was 78.9 points, Quick-DASH 28.4, SF-36 PCS 48.3 and MCS 48.9. There was statistically significant evidence that having a 13-C3 fracture leads to worse results in MEPS, Quick-DASH and SF-36. The female gender correlates with worse results in SF-36. The patients ≥85 years had a worse prognosis according to Quick-DASH and SF-36, while the AO 13-C3 pattern obtained the worst ROM outcomes versus AO 13 B1-B2-C1-C2 (normal ROM 0°-140°): mean ROM 24°-114° vs 10°-130°, mean flexion deficit 26° vs 10°, mean extension deficit 24° vs 10°, respectively). Complications were presents in 36.1% of patients, overall belonging to the AO type 13-C fracture pattern and to the group ≥85 years.

CONCLUSION

These study data seem to confirm our hypothesis that plate fixation for DHFs guarantees adequate fracture osteosynthesis and satisfactory functional outcomes at medium to long-term follow-up, not only in elderly patients, but also in octogenarian osteoporotic patients (≥85 years) with 13-C1 and 13-C2 fracture patterns, while an alternative solution should be considered for type C3 fractures, even in a primary trauma setting.