Neurovascular injury from supracondylar fractures in children: a 10-year experience of 762 cases

We evaluated the management of supracondylar paediatric fractures at our institution over a 10-year period in this retrospective cohort study. In total, 762 children with a supracondylar fracture were treated. The mean age of injury was 5.2 years. The incidence of documented nerve and/or vascular injury was 8.3%. A total of 26 patients had early plastic surgeon involvement; of these, 25 had an open exploration. Eight patients required vein grafting for brachial artery reconstruction for intimal tears. There was one nerve rupture requiring repair and 12 children underwent neurolysis. There were 17 late referrals to the plastic surgery service, of which three were explored (two neurolysis, one neuroma resection and sural nerve grafting). In all cases of nerve injury, the deficit took 7.9 months to recover, indicating a more significant injury than neurapraxia. Early exploration of supracondylar fractures allows direct visualization of the extent of neurovascular injury and immediate intervention.Level of evidence: IV.

Epidemiological characteristics and distribution of pediatric supracondylar fractures in South China: a retrospective analysis of 760 cases

To evaluate demographic characteristics and distribution of pediatric supracondylar fractures (SCFs) at a tertiary hospital in South China. A retrospective observational study was conducted on children aged 15 years or younger with a diagnosis of SCFs during the period from January 2016 to December 2018. Patients' medical records and radiographs were retrospectively analyzed for age at the time of injury, sex, site and mechanism of traumatic injury. A total of 760 patients with 761 SCFs were reviewed (453 males, 59.6%, and 307 females, 40.4%). There were 748 extension-type fractures (98.3%) and 13 flexion-type fractures (1.7%). Associated injuries were identified in 30/760 (3.9%) patients: associated fracture ( n  = 15; 2%), nerve injury ( n  = 12; 1.6%), open fracture ( n  = 2; 0.2%) and compartment syndrome ( n  = 1; 0.1%). Age at the time of fracture has a bimodal pattern with a first peak around the age of 1 year and a second peak around the age of 4-5 years. The fractures occurred mostly around 11 a.m. and between 4 and 9 p.m. in the evening. Most fractures occurred at home (50.7%), and falling down (62.2%) was the most frequent mechanism of injury. SCFs occurred most frequently in children aged 1 and 4-5 years, and during daylight hours. In about 96% of cases, these were isolated injuries, and falling down was found to be the most frequent traumatic mechanism. Based on our findings, targeted educational efforts and interventions can be set up in order to prevent the occurrence of SCFs in South China. Level of evidence: III.

Residual Deformity of the Trochlea After Non-displaced Supracondylar Fracture in a Child: A Case Report

Residual deformity of the trochlea after fractures of the distal end of the humerus in children is well known and is referred to as fishtail deformity. Despite numerous reports on this entity, the reason for various types of fractures with the same results remains unknown. Fishtail deformities after non-displaced supracondylar fractures are very rare. A 7-year-old boy with a non-displaced supracondylar fracture was treated conservatively. Three years later, the patient returned to our hospital complaining of mild elbow pain. Radiography revealed a fishtail deformity of the trochlea due to the premature fusion of the epiphysis. At the latest follow-up at the age of 17 years, only a marginal limitation at the excursion of the elbow was observed, and no additional treatment was needed. Fishtail deformities can occur even after a non-displaced supracondylar fracture. Long-term follow-ups are required in children with distal humeral fractures.

Persistent Ulnar Nerve Palsy with Cubitus Valgus Deformity Following a Surgically Treated Flexion-type Supracondylar Humeral Fracture - A Case Report

Introduction

Supracondylar humeral fractures (SHFs) in children are mostly extension-type. SHFs have a high risk of cubitus varus deformity, while valgus deformity is rarely described. Nerve palsy can also occur during or after the injury, with most cases recovering spontaneously. Here, we present a rare case of cubitus valgus deformity after a flexion-type SHF with ulnar nerve (UN) palsy, which was successfully treated by corrective osteotomy and anterior transposition of the UN.

Case Report

A 10-year-old girl had left-sided cubitus valgus deformity with persistent UN palsy 4 months after open reduction and internal fixation (ORIF) at another hospital. Half a year after the initial operation, corrective osteotomy of the distal humerus with neurolysis and subcutaneous anterior transposition of the UN were performed. She showed excellent recovery 14-month postoperatively and reported restored motor and sensory function with symmetrical elbow appearance.

Conclusion

Surgeons usually observe the elbow angle carefully to avoid cubitus varus deformity. However, when treating a case of flexion-type SHFs, ORIF should be conducted to avoid cubitus valgus deformity, which could potentially cause UN traction as well as cosmetic dissatisfaction.

A Modified Reverse Right-angled Triangle Osteotomy Using the Lateral Approach for the Treatment of Posttraumatic Cubitus Varus Deformity in Children

BACKGROUND

Cubitus varus deformity is a complex 3-dimensional deformity. Various osteotomies have been introduced to correct this deformity, however, there is no consensus on the best procedure to correct the deformity while avoiding complications. In this retrospective study, we used a modified inverse right-angled triangle osteotomy to treat 22 children with posttraumatic cubitus varus deformity. The primary objective was to evaluate this technique by presenting its clinical and radiologic results.

METHODS

Twenty-two consecutive patients with a cubitus varus deformity underwent a modified reverse right-angled triangle osteotomy between October 2017 and May 2020 and were then followed for a minimum of 24 months. We evaluated its clinical and radiologic results. Functional outcomes were assessed using Oppenheim criteria.

RESULTS

The average follow-up period was 34.6 months (range, 24.0 to 58.1 months). The mean range of motion was 4.32 degrees (range, 0 degrees to 15 degrees)/122.73 degrees (range, 115 degrees to 130 degrees) (hyperextension/flexion) before surgery and 2.05 degrees (range, 0 degrees to 10 degrees)/127.27 degrees (range, 120 degrees to 145 degrees) at the final follow-up. There were significant ( P < 0.05) differences between the flexion and hyperextension angles before surgery and at the final follow-up. Based on Oppenheim criteria, results were excellent for 20, good for 2, and none of the patients had poor results. The mean humerus-elbow-wrist angle improved from 18.23 degrees (range, 10 degrees to 25 degrees) varus preoperatively to 8.45 degrees (range, 5 degrees to 15 degrees) valgus postoperatively ( P < 0.05). The mean of the preoperative lateral condylar prominence index was 3.52 (range, 2.5 to 5.2) and the average postoperative lateral condylar prominence index was -3.28 (range, -1.3 to -6.0). All patients were pleased with the overall appearance of their elbows.

CONCLUSIONS

The modified reverse right-angled triangle osteotomy can precisely and stably correct the deformity in the coronal and sagittal planes, we recommend this technique as a simple, safe, and reliable correction of cubitus varus deformity.

LEVEL OF EVIDENCE

Level IV; case series; therapeutic studies-investigating the results of treatment.

Influence of Obesity in Children with Supracondylar Humeral Fractures Requiring Surgical Treatment at a Tertiary Pediatric Trauma Center

BACKGROUND

Almost everywhere in the world, childhood obesity is becoming a serious public health problem with negative effects on both children's health and society as a whole. The main objective of this study was to determine whether obesity has an effect on the severity of supracondylar humerus fracture in children, regardless of whether it is a low- or high-energy trauma.

METHODS

The electronic records of patients treated for the supracondylar fracture of the humerus in the ten-year period from 1 January 2013 to 1 January 2023 were reviewed retrospectively.

RESULTS

In the observed period, 618 children, including 365 (59.06%) boys and 253 (40.94%) girls, were hospitalized and treated surgically with the diagnosis of supracondylar fracture. The distributions according to the observed parameters were as follows: age (months) = 88.18 ± 32.64; height (cm) = 123.42 ± 16.83; weight (kg) = 27.18 ± 11.32; body mass index = 17.18 ± 3.06; body mass index-for-age percentile = 57.34 ± 32.11. Overall, 141 (22.82%) fractures were classified as Gartland II, while 477 (77.18%) were classified as Gartland III. A total of 66 (10.68%) fractures were flexion type, while 552 (89.32%) were extension type. The left elbow was affected in 401 (64.89%) children, while the right was affected in 217 (35.11%) children. The main mechanism of injury was a fall at ground level (33.33%). In relation to gender, a statistically significant difference was recorded in body mass index and percentile (p < 0.05). According to Gartland, the proportion of children below and above the 85th percentile in relation to the type of injury was statistically significant (p < 0.05). It was determined that the energy level does not significantly influence the injury's severity: p(GII) = 0.225; p(GIII) = 0.180.

CONCLUSIONS

In our study, we found that the proportion of overweight and obese children requiring surgical treatment was higher in Gartland type III injury, so there is no doubt that as a society we must prevent further increases in the prevalence of childhood obesity for this reason as well.

The Effect of Delayed Closed Reduction of Supracondylar Fracture on Perioperative Complications

Background Supracondylar fracture is one of the most frequent pediatric traumas and surgically managed fractures. Multiple factors can contribute to delaying surgical management of supracondylar fracture, which is thought to lead to difficult reduction and more complications. Surgical treatment during the nighttime shift (from 20:00-8:00) might increase the complication rate including vascular injury, nerve injury, and the need to convert closed reduction to open due to multiple reasons including nontrained staff, exhausted on-call team, and other reasons. Objectives We are looking into the effect of delaying surgical intervention 24 hours from the trauma to the surgical intervention and the impact of daytime or night-time surgeries on perioperative complications. Methods A retrospective cohort study was conducted on all patients who presented with supracondylar fracture Gartland type 2 or 3 who required surgical intervention (63 patients) from 2018-2021 in an academic institute. All patients presented with unilateral injury. Patients were divided into an early surgical group where the surgery was done within the first 24 hours from the trauma and a delayed surgical group if performed after 24 hours. Additionally, patients were classified based on the time of the day surgery was performed into daytime or nighttime surgeries. The complication rate was compared between the groups. Results Most of the patients were male, and the mean age was 4.52 ± 2.28 years. No significant difference was found between the early and delayed groups in the complication rate. Nerve and vascular injury were statistically higher for cases operated at nighttime. Conclusion Delayed surgical treatment of supracondylar fracture doesn't affect the complication rate, whereas closed reduction of supracondylar fractures that were performed during nighttime duty was shown to lead to a higher rate of vascular and nerve injuries.

Incidence of flexion-type supracondylar fractures at a single Australian level one Paediatric Trauma Centre

Background

Supracondylar fractures are the most common elbow fracture. There have been no studies published analysing flexion‐type fractures in the Australian paediatric population. This paper aims to investigate flexion‐type supracondylar fractures in an Australian paediatric population. Eight hundred and three paediatric supracondylar elbow fractures were retrospectively reviewed at one hospital over a 5 year time period. The focus was on flexion‐type fractures.

Methods

Supracondylar fractures that presented to the Women's and Children's Hospital Emergency Department between 2015 and 2020 were retrospectively reviewed. Fractures were classified on plain radiographs according to the Modified Gartland Classification System. Injury and treatment data were collected for flexion‐type fractures.

Results

Twenty‐one (2.6%) of fractures were flexion‐type. The average age of injury was 6.8 years old. Flexion‐type fractures were more common in females (62%) and with high energy mechanisms (81%). Ulnar nerve palsies occurred in five cases (24%). Two ulna nerve palsies did completely resolve at 3 months follow up. One open fracture occurred. No vascular injuries occurred. Ten of the 21 flexion‐type fractures (48%) were treated surgically.

Conclusions

The authors conclude that: flexion fractures are uncommon, they occur more often after high energy mechanisms such as falls from monkey bars, swings, or trampolines. Flexion‐type fractures occur more often in slightly older females. The ulnar nerve is most frequently injured and in the current study—exclusively injured. At 3 month follow up, spontaneous nerve recovery had occurred in three of the five cases (60%).

The outcome of loose bone fragments in pediatric supracondylar humerus fractures: a retrospective study

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.

Fifteen-minute consultation: Assessing the child with an elbow injury

This article aims to provide a concise summary of the key considerations when assessing a child with an elbow injury. Elbow injuries are common with acute elbow trauma, accounting for 2%-3% of all visits to the emergency department. This article will cover history, examination and key X-ray findings, along with a brief guide to management. It is hoped this article will help healthcare professionals who assess children with elbow injuries. Our work is applicable to those both in the hospital and community setting.

Prevalence and Treatment Outcome of Displaced High-Long Oblique Supracondylar Humeral Fractures in Children

Aim: The treatment protocol for supracondylar humeral fracture has mainly been based only on the severity of displacement and percutaneous pinning has been recommend as a first treatment. However, a long oblique fracture line is difficult to fix by the traditional cross pinning. The purpose of this study is to assess the prevalence of high-long oblique supracondylar humeral (HLO) fracture and evaluate the surgical outcome of percutaneous pin fixation. Methods: We reviewed 690 children who had undergone an operation for the displaced supracondylar humeral fracture. HLO fracture was defined as having a fracture line starting from either cortex above the metaphyseal-diaphyseal junction and finishing at the opposite cortex around or below the olecranon fossa. Clinical and radiographic parameter outcomes were assessed. Results: There were 14 patients diagnosed with the HLO fracture (14/690) and all the patients were treated by pin fixation. The median age was 5 years 1 month (range, 2-11 years). The common mode of injury was direct contact injury to the elbow. There were 6 patients with lateral HLO fracture, and 8 patients had medial HLO type. In medial HLO type, medial pinning only was done in 3 patients due to the difficulty in lateral pin insertion. In addition, the lateral pin was not a bicortical fixation through capitellum entry in 2 patients who had it fixed by cross pinning. The final Baumann angle and lateral humero-capitellar angle were 20.5 (5-67.6) degrees and 49.3 (23.3-71.9) degrees, respectively, without statistical significance compared to the normal side. Flynn's cosmetic grade showed satisfactory results in all patients. Conclusion: The prevalence of HLO fractures was 2% in the displaced supracondylar humeral fracture. The mechanism of injury of HLO fractures may be direct contact injury. In medial HLO fractures, medial pinning is important for stability, and sometimes lateral pinning was impossible. Contrarily, lateral HLO fracture could easily be fixed by lateral-only pinning, but the correct lateral pinning is necessary because medial pinning is difficult. The HLO fracture is a difficult pattern to treat by traditional percutaneous pinning and another surgical option should be considered.

Methodological Challenges in Investigating Supracondylar Fractures of the Humerus From a Child's Viewpoint: Evolution of Study Protocol

Background

Outdoor play and risk-taking behaviors, including play at heights, are important to children’s physical, social, and cognitive development. These aspects of play are important to consider when informing prevention policies for serious injuries that commonly occur on play structures. Supracondylar fractures of the humerus (SCH) are the most common type of elbow fractures that result from falls on an outstretched hand among healthy children. Despite being one of the leading causes of admission to the hospital and surgical intervention, the details surrounding the cause of these injuries are often not recorded. Previous research has correlated decreased overall playground safety with higher rates of SCH fractures. Play structure height and the type of undersurface have been identified as potential risk factors for severe injuries, including SCH fractures, in part due to low compliance with safety standards. This paper explores the challenges we encountered designing the study and the resulting insights and methodological modifications we made.

Objective

The aim of this paper is to discuss the challenges related specifically to clinical research in pediatrics and strategies developed to conduct a study that prioritizes the engagement and perspective of children and their families.

Methods

To explore the link between the severity of SCH fractures and children’s behavioral, environmental, and mechanistic factors, we conducted a mixed-methods study.

Results

During phase 1 (the original methodology) from April 2017 to July 2018, there were 58 eligible study participants and 17 were recruited. For phase 2 (the revised methodology) between October 2018 and October 2019, there were 116 eligible participants and 47 were recruited.

Conclusions

The changes in methodology made following the first phase of data collection were effective in our ability to recruit participants. By identifying and addressing challenges pertaining to recruitment and resource limitations, we were able to collect data in a concise manner while not compromising the quality of the data and make for an easily adoptable methodology for other sites interested in participating in the study. We hope that future studies that plan to employ a similar methodology can gain insight through the methodological challenges we have encountered and the way we adapted the methodology to build a more pragmatic approach.

International Registered Report Identifier (IRRID)

DERR1-10.2196/21816

Prognosis and risk factors of nerve injuries in displaced pediatric supracondylar humerus fractures

Background

Supracondylar humerus (SCH) fractures are serious injuries due to the neighborhood of critical neural and vascular structures. One of the most devastating complications of SCH fractures is neurological damage, since it may cause permanent disability. The aim of this study is to categorize neurological complications, to report long-term functional outcomes, and to determine risk factors associated with childhood SCH fractures.

Methods

The records of 375 children were reviewed retrospectively. Data about amount and direction of displacement, the shape of the fracture, age at the time of fracture, gender, time from impaction to surgery, time of surgery, type of neurological injury, and recovery time were recorded.

Results

Neurological complications were seen in 37 (9.85%) children. Thirteen (35.1%) of the children had an iatrogenic nerve injury. All iatrogenic injuries were fully recovered in this study. However, 2 children who had combined neurological injury of radial, ulnar, and median nerves did not recover. Nearly 95% of all children who had neurological injury recovered fully. An anterior long and sharp bone fragment (spike) was observed in most of the children with neurological injury, and this spike was seen in 14 (58.3%) patients who had a trauma-related injury (n = 24).

Conclusion

The prognosis of these nerve injuries is excellent, especially the iatrogenic ones. A long and sharp bone fragment (spike) may be responsible for nerve injuries in some children. Surgical exploration is not necessary after an iatrogenic nerve injury when there is no neurotmesis. Patience and care are utmost needed to handle neurological complications.

Comparison of internal fixation vs. external fixation after corrective osteotomy in children with cubitus varus

BACKGROUND

Cubitus varus deformity is a well-known late complication of supracondylar fractures in children. In this retrospective study, the primary objective was to compare clinical and radiologic outcomes of lateral closing-wedge osteotomy with either internal fixation or external fixation in pediatric patients with cubitus varus deformities.

MATERIALS AND METHODS

From 2010 to 2017, 35 consecutive patients with cubitus varus deformities secondary to supracondylar fractures were included in this study. After corrective osteotomy was performed via a limited lateral approach, the method of definitive fixation was chosen between internal and external. Retrospectively, patients who underwent external fixation on the lateral aspect of the elbow were defined as group I (n = 16) whereas patients with unilateral single-plate fixation were defined as group II (n = 19). The functional outcome was evaluated using the Mayo Elbow Performance Score and Flynn criteria.

RESULTS

No significant difference in age was found between the 2 groups (P = .15). Significantly lower costs, a shorter operation duration, smaller scars, and a shorter time for plaster cast use postoperatively were found in group I (P < .001). No nonunion or failure of fixation was found. No significant difference was noted in postoperative elbow range of motion or Mayo Elbow Performance Score (P = .64). Both groups achieved satisfactory functional and cosmetic results.

CONCLUSIONS

In pediatric patients with cubitus varus, both methods of fixation after lateral closing-wedge corrective osteotomy are reliable, with a low rate of complications and satisfactory functional results. External fixation is more advantageous in terms of easier preoperative planning, shorter operative times, lower costs, and easier postoperative fixation removal.

Emergency room closed reduction versus in situ splinting in the treatment of paediatric supracondylar humerus fractures

PURPOSE

Displaced supracondylar humerus fractures are treated with open or closed reduction and percutaneous pinning. In 2012, our management of patients with a displaced fracture changed from closed reduction in the emergency department (ED) to in situ splinting prior to closed reduction and pinning in the operating room (OR). The purpose of this study was to investigate if outcomes or complications differ between these two management methods.

METHODS

Patients less than ten years old with a Gartland type II or III supracondylar humerus fracture between 2008 and 2016 were included. Cases of polytrauma were excluded. Radiographic outcomes were assessed at follow-up. The Fisher's exact test was used for categorical variables and the Wilcoxon rank sums tests for continuous variables.

RESULTS

In all, 157 patients were included, 89 with reduction in the ED and 68 without. There was no significant difference between the groups related to demographic factors or fracture characteristics. Patients managed without reduction in the ED had a lower average delay from ED to OR compared with those treated with reduction (16 hours versus 22 hours, p < 0.005) and a shorter hospital length of stay (34 hours versus 40 hours, p < 0.005).

CONCLUSION

No difference in complications or outcomes was found between patients with Type II or III supracondylar fractures treated initially with or without closed reduction in the ED. Patients treated without ED reduction were taken to the OR sooner and remained in the hospital for a shorter period of time. Splinting in situ reduces anaesthesia exposure without increasing postoperative complications or suboptimal outcomes.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Fixator-Assisted Plating in Pediatric Supracondylar Femur Fractures

Purpose. Pediatric femoral supracondylar fractures are difficult to reduce by either closed or open reduction. The abnormal muscle forces around the knee tend to significantly displace the distal short metaphyseal fragment. We describe a novel technique utilizing the combination of a temporarily intraoperative external fixation in order to achieve and maintain the reduction followed by internal fixation. Method. Three male patients younger than 16 years of age were operated in our department. The fractures were defined as pathological in 2 patients. In order to facilitate and maintain fracture reduction, an external fixator was temporarily used intraoperatively; once the fractures were internally fixed, the fixator was removed. Results. Anatomical reduction was achieved in all patients. In an average follow-up of 2 years, all the fractures are solidly healed and the various bone lesions are healing. All patients have returned to regular physical activity. Conclusion. Difficult supracondylar femur fractures in children are easier to manipulate and reduce with the assistance of an intraoperative external fixator. Once the fracture is internally fixed and stable, the external fixator is removed.

School Nurses on the Front Lines of Medicine: Emergencies Associated With Sport and Physical Activities: Part 1

Illness and injury associated with sport and physical activities may occur in the school setting. Although most sport-related illness and injury in students are considered minor emergencies, life- and limb-threatening illnesses or injuries may occur, such as sudden cardiac arrest, heat stroke, status asthmaticus, catastrophic brain or cervical spine injuries, hypoglycemia, blunt chest/abdominal injuries, or extremity fractures requiring surgery. It is important for the school nurse to recognize potential life- and limb-threatening emergencies associated with sport and physical activity, to initiate stabilization of the student with life- and limb-threatening symptoms, and to triage these students to an appropriate level of care (back to the classroom, home with their guardian with follow up at their primary healthcare provider's office, or directly to the closest emergency department via emergency medical services). This article describes the initial assessment and management of three common emergencies associated with sport and physical activities.

A Case Report and Literature Analysis:A Supracondylar Femur Fracture in a Super-Obese Patient

INTRODUCTION

Rate of obese patients are on the rise and fractures on these patients are difficult to treat, risk of management failure is high as they are more prone to develop wound infection, hardware failure, malunion and prolonged procedure time.

CASE REPORT

In this report, we present a case on how we successfully managed a supracondylar femur fracture in a patient with a body mass index of 98.1 kg/m² with surgical site infection as the main complication. No literature reported such a case with an astonishing weight of 264 kg given the case uniqueness and importance.

CONCLUSION

A retrograde intramedullary nailing of the femur was performed under difficult circumstances, with a variety of modification to be considered pre-peri and post-operatively. It is advised based on the literature review and expert opinion to take the recommendations into consideration for better outcome.

Is less more? Assessing the utility of early clinical and radiographic follow-up for operative supracondylar humerus fractures

PURPOSE

Postoperative protocols following surgical management of supracondylar humerus fractures (SCFs) are often based upon surgeon preference rather than clinical merit. The purpose of this study is to determine the utility of early clinical and radiographic follow-up.

METHODS

A retrospective review of patients who underwent closed reduction and percutaneous pinning (CRPP) for SCF between 2009 and 2015 was performed using a database of prospectively-collected consecutive patient data. Previously undiagnosed neuropathies documented at the first postoperative visit were identified. Unscheduled visits and postoperative complications were compared between patients who were seen at one week and those with delayed first clinic visits.

RESULTS

Of 873 patients, 823 (94.3%) were seen within ten days of surgery (early follow-up) and 50 (5.7%) had a delayed first clinic appointment. Among patients seen for early follow-up, 12 (1.5%) had a previously undocumented neuropathy diagnosed but only eight (1%) had an alteration of management secondary to clinical findings. Greater than 90% of patients seen for early follow-up had radiographs performed, but only one had an alteration in management due to radiographic findings. Patients seen for early follow-up had the same rate of unscheduled visits (2.9% versus 4%, p = 0.66) and postoperative complications (1.6% versus 0%, p > 0.99) as those with delayed first appointments. Radiographic parameters were comparable at final follow-up (Baumann's angle 74.5° versus 73.7°, p = 0.40; lateral humeral condylar angle 40.2° versus 41.2°, p = 0.53).

CONCLUSION

The early follow-up visit after CRPP of SCF rarely leads to alterations in care and does not reduce unscheduled visits or late complications.

LEVEL OF EVIDENCE

Level IV.

Primary total knee arthroplasty for complex supracondylar femoral fractures in patients with knee arthritis: A retrospective study of a patient cohort

When elder arthritis patients suffered from complex supracondylar femoral fractures, their joints condition and general health condition elevate the difficulties in operation and post-surgical recovery.Here, we aimed to simplify the operation procedure by using one-step Total Knee Arthroplasty (TKA) with a stemmed femoral implant. We also investigated if this method could improve the patients' experience after the operation. The surgery including femoral osteotomy and implantation was performed on all fourteen patients by the same orthopedic specialist. The patients' hospitalization time was recorded. The recovery of knee function and patient satisfaction was evaluated by a systematic follow-up with average time 38 months, up to 5 5 years, using Hospital for Special Surgery (HSS) knee scores, the range of motion (ROM), anteroposterior and lateral radiography, and Visual Analog Scale (VAS) scores. The average of hospitalization days was 16 days. No angular deformity, malunion, or shortening were found at radiography.The average ROM was 105.2° at the end of the follow-up period. The knees in all the patients show adequate stability. All patients had returned to their former daily activities. Seventeen out of 24 patients were satisfied with the outcome of the surgery.The usage of TKA with a stemmed femoral implant is a reasonable method for elderly patients suffering from supracondylar femoral fractures and concomitant knee arthritis.

Can a linear external fixator stand as a surgical alternative to open reduction in treating a high-grade supracondylar humerus fracture?

OBJECTIVE

High-grade pediatric supracondylar humerus fractures are commonly treated with closed reduction and internal fixation with percutaneous pinning. When this fails, open reduction followed by internal fixation is the widely accepted procedure of choice. Use of a lateral external fixator was recently described as an optional procedure, but evidence is scarce.

METHODS

We investigated the outcomes of upper limbs treated by either open reduction with internal fixation or closed reduction and external fixation.

RESULTS

Twenty-one patients completed the long-term follow-up; 11 underwent open reduction, and 10 underwent external fixation. Most patients in both groups reported excellent satisfaction. In both groups, the modified Disabilities of the Arm, Shoulder, and Hand score was extremely low and the average elbow range of motion was almost identical. Radiographic analysis consisting of Baumann's angle and the carrying angle revealed no statistical difference between the two groups.

DISCUSSION

Optional treatment using a linear external fixator for complex nonreducible supracondylar humerus fractures yielded acceptable clinical and radiographic results, as with open reduction. Our sample size was small, but the promising results may assist in the implementation of an alternative surgical procedure, especially in more complicated cases involving flexion-type fractures or severe soft tissue damage and swelling.

Corrective osteotomy for hyperextended elbow with limited flexion due to supracondylar fracture malunion

BACKGROUND

Extension deformity of the distal humerus after a malunited supracondylar fracture can restrict elbow flexion. Here we report a computer-assisted operative procedure and review the results of clinical cases in which corrective surgery was performed.

METHODS

The medical records of the patients who underwent corrective osteotomy for hyperextended elbow malunion of the distal humerus with limited elbow flexion (flexion angle ≤100°) were reviewed retrospectively. Osteotomy was performed using patient-specific instruments designed based on preoperative 3-dimensional computer simulation.

RESULTS

Three patients, a 55-year-old woman and two 12-year-old boys, met the inclusion criteria. The angles of hyperextension of the affected distal humerus were 29°, 29°, and 25°, respectively. The range of flexion/extension of the elbow motion in the first patient improved from 95°/25° preoperatively to 140°/-10° postoperatively, in the second patient from 100°/20° to 145°/5°, and in the third patient from 80°/25° to 140°/10°. Bone union was achieved in all patients. There were no major complications. The corrective operations not only improved elbow flexion but also increased the total range of motion in the elbow by rebuilding the anterior curve of the distal humerus.

CONCLUSIONS

Correction of the extension deformity of the distal humerus after a malunited supracondylar fracture is a reasonable option for patients older than 10 years with restricted elbow flexion. Preoperative computer simulation and the use of patient-specific instruments can be a useful alternative that enables accurate deformity correction and improves the total range of motion.

Medial comminution as a risk factor for the stability after lateral-only pin fixation for pediatric supracondylar humerus fracture: an audit

Background and purpose

Closed reduction and lateral-only pin fixation is one of the common treatment methods for displaced supracondylar fracture in children. However, several risk factors related to the stability have been reported. The aim of this study was to evaluate the medial comminution as a potential risk factor related to the stability after appropriate lateral-only pin fixation for Gartland type III supracondylar humerus fracture.

Methods

Sixty-seven patients with type III supracondylar fractures who were under the age of 12 years were included. Immediate postoperative and final Baumann and humerocapitellar angles were measured. Pin separation at fracture site was evaluated to estimate the proper pin placement. Presence of the medial comminution was recorded when two pediatric orthopedic surgeons agreed to the loss of cortical contact at the medial column by the small butterfly fragment or comminuted fracture fragments. Factors including age, sex, body mass index, pin number, pin separation at fracture site, and medial comminution were analyzed.

Results

Medial comminution was noted in 20 patients (29.8%). The average pin separation at fracture site was significantly decreased in patients with medial comminution compared to patients without medial comminution (P=0.017). A presence of medial comminution was associated with a 4.151-fold increase in the log odds for the Baumann angle changes of more than average difference between immediate postoperative and final follow-up angle (P=0.020).

Conclusion

When lateral-only pin fixation is applied for Gartland type III supracondylar humerus fracture in children, the medial comminution may be a risk factor for the stability because of the narrow pin separation at fracture site. We recommend additional medial pin fixation for supracondylar humerus fracture with medial comminution.

The Influence of Resident Level of Training on Fluoroscopy Time in Pediatric Supracondylar Humeral Fractures Treated with Closed Reduction and Percutaneous Pinning

Objective The purpose of this study was to evaluate the effect of resident level of training on fluoroscopy duration in pediatric supracondylar humeral fractures treated with closed reduction and percutaneous pinning (CRPP). Methods After classifying the surgeons according to their seniorities, the duration of fluoroscopy time of 80 patients with extension type III supracondylar fractures during reduction and pinning was recorded. Results The time duration of reduction procedures was similar in all groups with respect to the surgical experience; however, time durations of percutaneous pinning procedures were found statistically different between groups (p=0.042). Conclusion Surgical experience is very important in the management of supracondylar humeral fractures in children, especially in percutaneous pinning rather than closed reduction.

Management of Arterial Injury in Children with Supracondylar Fracture of the Humerus and a Pulseless Hand

Objective: To share our experience regarding the management of arterial injuries in children with pulseless hand secondary to supracondylar fracture of the humerus (SFH). Patients and Methods: All consecutive children with pulseless hands after SFH who were being treated in the vascular surgery units of the Combined Military Hospital, Lahore and Peshawar between September 2011 and September 2016 were included. The type of fracture, mode and pattern of injury, time from injury to definitive treatment, operative treatment, and complications were recorded. Results: There were 55 [82% (n=45) male and 18% (n=10) female] patients with pulseless hand and SFH [Gartland type III: 18% (n=10) and IV: 82% (n=45)]. The hand was cold in 38.1% (n=21) patients and warm in 61.8% (n=34). The most common mode of injury was accidental fall [45% (n=25)], and the mean time from injury to presentation was 4±2.5 hours (mean±standard deviation). Overall, 71% (n=39) patients underwent vascular reconstruction: autologous interposition venous grafting was performed in 49% (n=19) and segmental resection and primary anastomosis in 25% (n=10) of the cases. There were no cases with amputation, fasciotomy, re-exploration, or long-term ischemic sequel. Conclusion: Immediate vascular exploration is the treatment of choice for cold, pulseless hand. A similar approach should be adopted for warm, pulseless hand if there is no immediate return of pulse.

Gartland types IIB and III supracondylar fractures of the humerus in children: is Blount's method effective and safe?

BACKGROUND

Blount's method is controversial for the treatment of Gartland types IIB and III supracondylar fracture of the humerus (SCFH) in children. The purpose of this study was to evaluate the clinical and radiologic outcomes and the failure and complication rates.

METHODS

All types IIB and III SCFH treated with Blount's method from 2003-2013 were included in this retrospective single-center study. Clinical assessment was performed according to Flynn criteria. Baumann angle, anteversion angle, anterior humeral line, and humeroulnar angle were measured for radiographic assessment.

RESULTS

Among 447 children with types IIB and III SCHF, 339 were treated according to Blount's method. There were 173 boys (51%), and the mean age was 6.3 years (1-14 years); 71% were type III. Mean time to surgery was 5.7 hours. According to Flynn criteria, results were satisfactory in 91% of cases. No compartment syndrome was encountered. There were 16 (4.7%) secondary displacements requiring surgical revision. Five (1.9%) children developed a cubitus varus deformity. At latest follow-up, the mean Baumann angle was 74.7° (95% confidence interval, 74.1-75.3), the mean anteversion angle was 39.9° (95% confidence interval, 39.5-40.3), the anterior humeral line was normal in 87.6% of cases, and the mean humeroulnar angle was 8.7°.

CONCLUSION

Blount's method is appropriate to manage types IIB and III SCFH, provided anatomic and stable reduction is obtained.

A Review of Epidemiological Distribution of Different Types of Fractures in Paediatric Age

Introduction

Treating paediatric patient fractures comprises a large part of any orthopaedic trauma service. The majority of fractures take place during sports and recreational activities. In this study, we examined the incidence of fractures and their distribution according to patient age.

Methods

We collected retrospective data from all the paediatric age group patients (under age 18) referred to our orthopaedic service from August 2015 to July 2016. We collected data for 1022 patients during one calendar year.

Results

We noted 1022 paediatric fracture presentations in one calendar year, with a 48.63% incidence in male patients and 51.36% in female patients. The age with the highest incidence was 16 years in boys and 11 years in girls. Upper limb fractures were more common than lower limb fractures in most of the subgroups.

Conclusions

These insights into paediatric fracture distribution provide an opportunity to evaluate the resources in hospitals allocated to emergency and orthopaedic departments regarding their capacity to treat fractures in paediatric patients.

Functional outcomes of Gartland III supracondylar humerus fractures with early neurovascular complications in children: A retrospective observational study

This was a retrospective observational study. The aim of this study was to evaluate functional outcomes in children treated for Gartland III supracondylar humerus (SCH) fracture with neurovascular (NV) injuries using validated outcome measures. A secondary goal was to determine whether clinical parameters such as age at injury, sex, weight, fracture site, and/or direction of displacement could predict NV injury at the time of fracture or long-term functional outcomes in these patients.One hundred fifty-four patients of Gartland III SCH fractures between March 2004 and May 2013 were studied retrospectively. The patients were divided into 2 groups according to the presence of NV injury. Medical records and radiographs were reviewed to assess several parameters, including age, sex, weight, treatment intervention, the extremity involved, direction of fracture displacement, and NV injury. Functional outcome was assessed on final follow-up using the Pediatric Outcomes Data Collection Instrument (PODCI) and Quick Disabilities of the Arm, Shoulder, and Hand (Quick DASH) outcome measures. Statistical analysis was used to determine the relationship between NV injury and functional outcomes.There were 33 cases with Gartland III SCH fracture associated with NV injuries (10 cases of vascular compromise, 14 cases of neural injury, and 9 cases involving both vascular compromise and neural injury). There were significant differences between the 2 groups in age (P  =  .048), weight (P  =  .009), and direction of displacement (P  =  .004). Vascular compromise and median nerve injury were most common in fractures with posterolateral displacement, and radial nerve injuries were common in fractures with posteromedial displacement. The mean global function score in the PODCI was 91.4 points, and the mean Quick DASH score was 11.7 points, with excellent functional outcomes. No differences in outcomes were identified based upon age, fracture site, sex, weight, direction of displacement, or operative technique in NV injury patients (P > .05).The majority of patients with Gartland III SCH fractures associated with NV injuries returned to a high functioning level after treatment of their injuries. NV injury does not appear to influence functional outcomes. Good functional results can be expected regardless of age, fracture site, sex, weight, direction of displacement, and operative technique.

Relationship of cubitus varus and ulnar varus deformity in supracondylar humeral fractures according to the age at injury

BACKGROUND

We investigated the relationships of ulnar varus deformity and the degree of cubitus varus according to the age at injury in patients with cubitus varus.

METHODS

Basic demographic factors were investigated in group 1 (injured at age younger than 5 years) and group 2 (injured at age 5-10 years). The uninjured side ulnar angle (UA) at the time of injury and final follow-up and the humeral-elbow-wrist angle (HEW-A) at final follow-up were measured. ΔUA (injured side - uninjured side UA at final follow-up) and ΔHEW-A (injured side - uninjured side HEW-A at final follow-up) were calculated and compared between the 2 groups. The correlation between ΔUA and ΔHEW-A was analyzed, and the degree of correlation was compared between the groups.

RESULTS

Final UA and HEW-A on the injured side were increased more in group 1. ΔUA and ΔHEW-A were also more definitive in group 1. Positive correlations were found in both groups between ΔUA and ΔHEW-A, and the degree of correlation was similar in both groups. Distinct negative correlations were observed in both groups between the uninjured side UA at the time of injury and the ΔUA, but the degree of correlation differed significantly.

CONCLUSIONS

The degree of ulnar varus correlated well with the degree of cubitus varus. A straighter ulna at the time of injury could become more bowed if cubitus varus deformity occurred and progressed. This may be evidence suggesting that the earlier correction of cubitus varus would be more effective under a less deformed varus of the ulna.

LEVEL OF EVIDENCE

Level III; Retrospective Cohort Design; Treatment Study.

[Classification of pediatric supracondylar fractures: Gartland, AO and Holmberg: Which has the best interobserver agreement?]

METHODS

Several classifications have been proposed for supracondylar fractures of the humerus. The purpose of this study was to assess the reproducibility and interobserver agreement of the Holmbert, Gartland and AO classifications. Retrospective study consisting of concurrent, blind and independent assessments of a consecutive sample of 42 elbow X-rays (AP and lateral) of pediatric patients with supracondylar fractures. Three observers, with similar degree of training, evaluated the X-rays independently and scored each one of them using the 3 scales compared herein. The interobserver agreement was assessed using Kendalls Tau-b ratio; the arithmetic mean was calculated and the ratios were compared with Fishers transformation. The interpretation was made using the standards proposed by Landis Koch.

RESULTS

The Holmberg and Gartland classifications had a mean correlation coefficient of 0.654 and 0.706, respectively (p 0.001). Holmbergs classification provides a better anatomical description. The mean correlation coefficient of the AO classification was 0.491 (p = 0.001).The difference between the correlation coefficients was 0.052 for Holmbert/Gartland; 0.163 for Holmberg/AO, and 0.215 for Gartland/AO. There were no statistically significant differences among these values, but there were epistemological differences. According to Landis and Koch, the Holmberg and Gartland classifications show a substantial agreement, while the AO classification showed a moder ate agreement.

CONCLUSION

Holmbergs classification is the most recommendable one.

Pin tract infection of operatively treated supracondylar fractures in children: long-term functional outcomes and anatomical study

PURPOSE

The purpose of our study was to determine the long-term functional outcomes of pin tract infection after percutaneous pinning of displaced supracondylar humeral fractures in children, and to evaluate the potential for intracapsular pin placement based on pin configuration in cadaveric elbows.

METHODS

We conducted a retrospective review of all patients requiring percutaneous pinning in a single institution over a 19-year period. The functional outcome assessment consisted of a telephone interview using the Disabilities of the Arm, Shoulder and Hand (DASH)] Outcome Measure and the Patient-Rated Elbow Evaluation (PREE) questionnaires. The risk of intracapsular pin placement was studied in cadaveric elbows for the three most common pin configurations: divergent lateral, parallel lateral, and medial and lateral crossed pins.

RESULTS

Of 490 children, 21 (4.3 %) developed pin tract infection. There were 15 (3.1 %) superficial and six (1.2 %) deep infections (osteomyelitis and septic arthritis). Both DASH and PREE scores were excellent at a mean of 18 years post-surgery. The risk of intracapsular pin placement using parallel lateral pins was found to be greater (p < 0.05) than either crossed or divergent lateral pinning configurations.

CONCLUSIONS

Most infections after pinning of supracondylar humerus fractures are superficial and can be managed with pin removal, oral antibiotics, and local wound care. Septic arthritis and osteomyelitis are rare complications; when they do occur, they seem to be associated with parallel lateral pin configuration, though a causal relationship could not be established from the current study. Satisfactory long-term outcomes of these deep infections can be expected when treated aggressively with surgical debridement and intravenous antibiotics.

Triple modified French osteotomy: a possible answer to cubitus varus deformity. A technical note

BACKGROUND

Cubitus varus is the most common delayed complication of pediatric supracondylar humerus fractures. We developed a new technique, the triple modified French osteotomy, that we believe may be the answer to this common but yet unsolved deformity.

MATERIALS AND METHODS

Ten patients aged between 6 and 12 years with post-traumatic cubitus varus deformity were operated on with the triple modified French technique. A varus angle of more than 10° measured on the radiograph was an indication for surgery.

RESULTS

The radiologic union at the osteotomy site took place in a mean period of 5.5 weeks (range, 4.5-7 weeks). The average correction achieved by the osteotomy was 27°. There were no cases with complications of radial or ulnar nerve palsy or joint stiffness.

CONCLUSION

The triple modified lateral closing wedge French osteotomy is a simple and cosmetically effective method of treating cubitus varus deformity in children. It may obviate the need for more complex procedures; at the same time, it also addresses the potential drawbacks of a simple closing wedge osteotomy.

Percutaneous K-wire fixation in paediatric Supracondylar fractures of humerus: A retrospective study

Background:

Supracondylar fractures are the commonest elbow injury in children. Most displaced Supracondylar fractures are manipulated and held with a medial/lateral entry or two lateral Kirschner wires. It was the purpose of this study to investigate the treatment of this injury in this unique patient population.

Materials and Methods:

This study was conducted in the Department of Orthopaedic surgery in M. M. Medical College from July 2005 to July 2010. One hundred seventy patients were recruited from Emergency and outpatient department having closed displaced Supracondylar fractures of humerus in children. They were treated either with medial-lateral pin fixation (n = 85) or with 2-lateral pin fixation (n = 85). All patients were operated under general anaesthesia. All patients were followed for 6 months. Results were analysed using Flynn's criteria.

Statistical Analysis Used:

Chi Square Test. Chi Square calculator was used as a software.

Results:

All children achieved union in a mean time of 4 weeks (range: 3-6 weeks). Post-operatively, eight patients (4.70%) got ulnar nerve injury and six (3.52%) patients got pin tract infection. Comparison between two groups such as cross K-wire group (85) and lateral K-wire group (n = 85) by using the Chi Square Test showed that in case of 8 weeks with (P-values = 0.89), in 16 weeks (P = 0.91) and 24 weeks (P = 0.85) with respective excellent, good, fair and poor categories were not found statistically significant.

Conclusion:

The lateral percutaneous pinning technique of displaced Supracondylar fractures of the humerus offers a viable alternative to the crossed pinning group as it offers the same stability without the incipient risk of iatrogenic ulnar nerve injury.

A retrospective analysis of loss of reduction in operated supracondylar humerus fractures

BACKGROUND

Loss of reduction following closed or open reduction of displaced supracondylar fractures of the humerus in children varies widely and is considered dependent on stability of the fracture pattern, Gartland type, number and configuration of pins for fixation, technical errors, adequacy of initial reduction, and timing of the surgery. This study was aimed to evaluate the factors responsible for failure of reduction in operated pediatric supracondylar fracture humerus.

MATERIALS AND METHODS

We retrospectively assessed loss of reduction by evaluating changes in Baumann's angle, change in lateral rotation percentage, and anterior humeral line in 77 consecutive children who were treated with multiple Kirschner wire fixation and were available for followup. The intraoperative radiographs were compared with those taken immediately after surgery and 3 weeks postoperatively. Multivariate logistic regression analysis was performed by STATA 10.

RESULTS

Reduction was lost in 18.2% of the patients. Technical errors were significantly higher in those who lost reduction (P = 0.001; Odds Ratio: 57.63). Lateral pins had a significantly higher risk of losing reduction than cross pins (P = 0.029; Odds Ratio: 7.73). Other factors including stability of fracture configuration were not significantly different in the two groups.

CONCLUSIONS

The stability of fracture fixation in supracondylar fractures in children is dependent on a technically good pinning. Cross pinning provides a more stable fixation than lateral entry pins. Fracture pattern and accuracy of reduction were not important factors in determining the stability of fixation.

Radial nerve entrapement in osseous tunnel without clinical symptoms

Entrapment of a nerve in the callus of a healing fracture is not a common entity, but it does exist. The entrapment usually presents without neurological deficit. It is difficult to suspect the radial nerve injury if we need to operate on the same site. We present a case of entrapment of radial nerve in the callus of a supracondylar humerus fracture with cubitus varus deformity. The surgery for correction of the deformity led to the damage of the nerve. In retrospect a careful assessment of the x-rays showed two 3-4 mm diameter holes. Awareness of this finding would have given us sufficient indication of nerve entrapment to prevent this mishap.

Management of "floating elbow" in children

BACKGROUND

Supracondylar fractures associated with ipsilateral forearm fractures, aptly termed as "floating elbow" is a rare injury in children after a fall from height. The various authors have reported their results with conservative treatment of one or both injuries to aggressive emergency operative fixation of both components.

MATERIALS AND METHODS

During a period of three years, the author managed four cases of floating elbow in children. All cases were managed by closed reduction and pinning of both components of the injury.

RESULTS

All patients recovered full elbow range of motion at three months followup and were rated as excellent as per modified Flynn's criteria. None of the patients developed cubitus varus deformity, complications related to the pins or delayed union.

CONCLUSIONS

Early closed reduction and K wire fixation of both components of this injury gives better stability and prevents development of complications like compartment syndrome and elbow deformities.