The effect of surgical timing on the perioperative complications of treatment of supracondylar humeral fractures in children

Displaced supracondylar humeral fractures in children: open reduction vs. closed reduction and pinning

INTRODUCTION

In the literature the best results for pediatric supracondylar humerus fractures have been achieved by closed reduction and wire fixation. However, in these reports the patient group of open reduction and pinning contained the patients who had had previous ineffective closed reduction trials. This retrospective study compared open and closed reduction with pinning, in which the first group of patients was all consecutively treated with open reduction.

MATERIALS AND METHODS

The study included 99 children with displaced extension-type supracondylar fractures of humerus who had complete follow-up. Open reduction patients had not had a previous attempted closed reduction. Open reduction and pinning were performed through a posteromedial incision in the first 44 patients and closed reduction and pinning in the subsequent 55 patients. Mean duration surgery was 15 h with open reduction and 17 h with closed reduction. Mean follow up was 35 months with the open reduction and 21 months with closed reduction. Humeral-ulnar angle was compared to the contralateral elbow, clinical flexion deficiency and extension lag, and complications were evaluated.

RESULTS

At the latest follow-up the open group had an average of 5.1 degrees valgus change and the closed group 3.6 degrees valgus change in humeral-ulnar angle compared to their uninvolved elbow. Average flexion deficiency was 8.61 degrees in the open and 5.25 degrees in the closed group. Average extension lag was 6.23 degrees in the open and 0.6 degrees in the closed group. Functional results were satisfactory in 71% of patients in the open and 93% of those in the closed reduction group. Cosmetic results were satisfactory in 95% of both groups.

CONCLUSIONS

Closed reduction and pinning is superior to open reduction and pinning for the treatment of pediatric supracondylar humerus fractures. In the case of technical insufficiencies open reduction and pinning through a posteromedial incision is an alternative treatment for decreasing the surgical time and complications. Complications was not caused in either group by the delayed surgical timing compared to reports in the literature.

Effect of surgical delay on perioperative complications and need for open reduction in supracondylar humerus fractures in children

This retrospective study examined whether a delay of greater than 12 hours is associated with an increased risk of perioperative complications in the operative treatment of supracondylar humerus fractures in children. Of 150 consecutive children with supracondylar fractures, 50 underwent surgery in less than 12 hours and 100 underwent surgery greater than 12 hours after injury. There was no significant difference between groups in rate of open reduction (P = 0.55), pin tract infection (P = 1.0), iatrogenic nerve injury (P = 1.0), vascular complication (P = 0.33), or compartment syndrome (P = 1.0), including when Gartland type III fractures were analyzed independently. There was no iatrogenic nerve injury, no compartment syndrome, and one pin tract infection in 150 patients. The study confirms previous retrospective studies finding no significant difference in perioperative complications or rate of open reduction in children undergoing early versus delayed surgical treatment of supracondylar humerus fractures.

Surgical technique for supracondylar fracture of the humerus with percutaneous leverage pinning

Percutaneous pinning with a leverage technique for supracondylar fracture of the humerus was performed in 36 elbows in 35 children. The patient was placed in the lateral position with the forearm hanging. Under radiographic imaging, a Kirschner wire, as a reduction pin, was inserted into the fracture line from the dorsal side, passed through the posterior cortex of the proximal fragment, and turned distally. After reduction of the posterior displacement by the leverage technique, the reduction pin was driven into the anterior cortex of the proximal fragment. Subsequently, a Kirschner wire was inserted from the lateral condyle for fixation between the proximal and distal fragments. This percutaneous pinning technique was successfully performed in 32 of 36 elbows, with excellent functional results in 28 elbows and good results in 4, as well as excellent cosmetic results in 27 elbows and good results in 5, based on the evaluation criteria of Flynn et al.

Displaced supracondylar humeral fractures in children: results of a national survey of paediatric orthopaedic consultants

Several aspects of the management of displaced supracondylar fractures in children remain controversial. Displaced supracondylar humeral fractures (Type III) in children have traditionally been considered orthopaedic emergencies. Recent studies have suggested that closed Type III supracondylar fractures without vascular compromise may be treated in a delayed manner without compromise to functional and cosmetic outcome. Debate continues over the fixation method of choice in these difficult fractures. A postal questionnaire of 121 practising paediatric orthopaedic consultants in the UK was performed to explore these issues. Seventy-seven replies were obtained (63.6%). The 54.5% of the respondents managed displaced supracondylar fractures without vascular compromise in a delayed manner (more than 8h from presentation). The incidence, initial assessment and factors which influence the timing of surgery of these fractures are discussed. The fixation method of choice reported was closed reduction and the use of smooth Kirshner wires (93.4%). Of these, crossed pin fixation is used by 83.9% of respondents and 9.7% employed laterally placed wires. The majority of consultants (69.7%) considered the operative treatment of these fractures a consultant-led procedure. This survey has established an overview of the current practices of paediatric orthopaedic consultants in the UK in the management of these difficult fractures.

Pediatric orthopedic trauma: principles in management

Optimal management of pediatric orthopedic trauma requires understanding the unique characteristics of the immature musculoskeletal system. The principles of pediatric orthopedic trauma management include anticipating future growth and bone remodeling potential, minimizing physeal injury, and aggressive treatment of open fractures and compartment syndromes. This article discusses the fundamentals of the pediatric musculoskeletal system and pediatric orthopedic trauma management in general and as they apply to specific injuries.

Pediatric supracondylar humerus fractures: the anterior approach

OBJECTIVES

To evaluate the efficiency of the anterior approach for displaced supracondylar pediatric humeral fractures.

DESIGN

A retrospective analysis.

SETTING

Clinical and outpatient clinic care.

PATIENTS

The anterior approach group consisted of twenty-six patients. The historical group consisted of thirty-two patients. All had a completely displaced extension-type supracondylar humerus fracture (Gartland Type III). All were operated within six hours of admission. All patients were contacted; twenty-five of the twenty-six and twenty-nine of the thirty-two patients were re-examined at the outpatient clinic. The other patients were contacted by telephone.

INTERVENTION

All fractures in the anterior approach group were operated through a ventral approach: An incision was made in the cubital fossa of only the skin and subcutaneous tissue, and reduction was performed with the thumb and index finger. The fractures in the historical group were approached through a lateral or a combined lateral and medial approach. For each case in both groups fixation was done with crossed percutaneous K-wires followed by plaster of Paris splinting for two weeks. Radiographic and clinical results were evaluated in follow-up examinations.

MAIN OUTCOME MEASUREMENTS

Functional and anatomic measurements were obtained at follow-up.

RESULTS

In both groups no compartment syndrome or Volkmann's ischemic contracture was seen. Two in the anterior approach group and one in the historical group had an associated brachial artery injury. Early postoperative fracture displacement occurred in one of the twenty-six anteriorly approached and in four of the thirty-two historical group patients. One of the four patients in the historical group with early displacement had no cosmetic or functional loss during follow-up examinations. One patient in the anterior approach group and two patients in the historical group had a rotational deformity, one of whom also suffered a functional loss. The only other functional losses were found in two patients in the anteriorly approached group and in three patients in the historical group.

CONCLUSIONS

The results of this study show that the anterior approach is safe, simple, and easy to perform. The anterior approach has good and excellent results by Flynn's criteria in 84 percent versus 75 percent in the control group (p = 0.56).

Skeletal traction and delayed percutaneous fixation of complicated supracondylar humerus fractures due to delayed or unsuccessful reductions and extensive swelling in children

The functional and radiological results of 13 supracondylar humerus fractures of 13 children were evaluated to determine the efficiency of delayed percutaneous fixation of the fractures after a period of skeletal overhead traction. All the fractures were complicated by delayed reduction, extensive swelling or unsuccessful reduction manipulations. As the unfavourable preexisting factors subsided under skeletal traction, anatomical reduction and fixation of fractures by percutaneous pinning were performed under general anesthesia. The average follow-up period was 21 months. Bauman and lateral capitellohumeral angles were measured and statistically analyzed. Functional and cosmetic results were evaluated by physical examination of the elbows. There were 11 excellent and two fair functional results while all cosmetic results were excellent or good. As a result, skeletal traction and delayed percutaneous pinning is accepted as an alternative method of treatment for complicated supracondylar humerus fractures in children.