Supracondylar Fractures of the Humerus in Children

The effects of surgical delay on the outcome of pediatric supracondylar humeral fractures

BACKGROUND

Occasionally, the treatment of a pediatric supracondylar humeral fracture is delayed owing to lack of an available treating physician, necessitating transfer of the child, or delay in availability of an operating room. The purpose of this study is to prospectively evaluate whether delayed pinning of these fractures affects the outcome or number of complications.

METHODS

We reviewed information that was prospectively collected on 145 pediatric supracondylar humeral fractures that were treated by closed reduction and percutaneous pinning, with a minimum follow-up of 8 weeks. To determine the effect of delayed treatment, we compared a group of fractures that was treated within the first 21 hours after their presentation to our urgent care center (Group A) with a group that was treated after more than 21 hours (Group B). We compared the following variables: need for open reduction, length of surgery, length of hospitalization, the presence of neurologic complications, vascular complications including compartment syndrome, pin tract infection, loss of fixation, final carrying angle, range of motion, and outcome.

RESULTS

Overall, the mean time from presentation to surgery for both groups was 52 hours. This interval was greater for Gartland type II fractures (65 h) than for Gartland type III fractures (19 h) (P=0.00001). There was no need for an open reduction in either group. There were no significant differences between the groups regarding iatrogenic nerve injuries, vascular complications, compartment syndromes, surgical time, final carrying angle, range of motion, and outcome.

CONCLUSIONS

The results of this prospective study found that a delay in pinning closed supracondylar humeral fractures in children did not lead to a higher incidence of open reduction or a greater number of complications. Although the urgency of treating any child with a supracondylar fracture should be individualized, our study suggests that most of these injuries can be managed safely in a delayed fashion without compromising the clinical outcome. We recommend careful monitoring of any patient with type 3 injury whose treatment is delayed.

LEVEL OF EVIDENCE

II.

Does open reduction and pinning affect outcome in severely displaced supracondylar humeral fractures in children? A systematic review

Supracondylar fracture of the humerus is the second most common fracture in children (16.6%) and the most common elbow fracture. These fractures are classified using the modified Gartland classification. Type III and type IV are considered to be totally displaced. A totally displaced fracture is one of the most difficult fractures to manage and may lead to proceeding to open procedures to achieve acceptable reductions. Many surgeons are concerned about its outcome compared to closed procedures. We therefore performed a systematic review of the literature to investigate the existing evidence regarding functional and radiological outcomes as well as postsurgical complications of primary open compared to primary closed reduction.

Pediatric supracondylar fractures of the distal humerus

Supracondylar fractures of the humerus are a common pediatric elbow injury that are historically associated with morbidity due to malunion, neurovascular complications, and compartment syndrome. True anteroposterior and lateral radiographs are essential not only for an accurate diagnosis, but also for creating a treatment plan for these injuries. A staging system (based on the lateral radiograph) for classifying the severity of the fracture helps guide definitive management. Nondisplaced fractures are treated initially with a posterior splint, followed by a long-arm casting. Closed reduction and percutaneous pinning is the preferred treatment for displaced or unstable fractures. If there is any question about fracture stability, patients should be seen within 5 days postoperatively for repeat radiographs to ensure that the reduction and pin fixation has been maintained. Understanding the anatomy, radiographic findings, management options, and complications associated with this fracture allow physicians to limit the morbidity associated with this relatively common pediatric injury.

Perfused, pulseless, and puzzling: a systematic review of vascular injuries in pediatric supracondylar humerus fractures and results of a POSNA questionnaire

BACKGROUND

Supracondylar humerus fractures that present with a perfused, viable hand yet no pulse continue to be a source of controversy. The purpose of this study was to conduct a systematic review of the literature and perform a Pediatric Orthopaedic Society of North America (POSNA) opinion poll regarding management of pulseless supracondylar humeral fractures in children.

METHODS

A systematic review of the literature was conducted for relevant observational studies concerning neurovascular injuries in supracondylar humerus fractures. Single case reports and non-English language studies were excluded. Data were pooled for defined subgroups and 95% confidence intervals were reported. The results from the literature were then compared to popular opinion via a POSNA-approved survey concerning management of pulseless supracondylar humerus fractures.

RESULTS

A total of 331 cases of pulseless supracondylar fractures were identified from the literature, irrespective of perfusion status. In all, 157 fractures remained pulseless after closed reduction and stabilization. Of the fractures that continued to be pulseless despite adequate reduction, 82% [95% confidence interval (CI)=0.82 (0.76-0.88)] were found to have a documented brachial artery injury. POSNA members presumed this number would be 28% [95% CI=0.28 (0.22-0.34)]. A total of 98 perfused (aka pink) supracondylar fractures were identified. Of these pulseless, perfused fractures, 70% [95% CI=0.70 (0.58-0.82)] had a documented brachial artery injury. POSNA members speculated that this number would be 17% [95% CI=0.17 (0.12-0.22). A total of 54 patients had minimum 1 year follow-up data after vascular revascularization, and 91% [95% CI=0.91 (0.83-0.99)] of these patients had a patent artery based on vascular studies. POSNA members believed this number would be 55% [95% CI=0.55 (0.48-0.62)].

CONCLUSIONS

Our study revealed that common dogma regarding watchful waiting of pulseless and perfused supracondylar fractures needs to be questioned. In the vast majority of published cases, an absence of pulse is an indicator of arterial injury, even if the hand appears pink and warm, suggesting the need for more aggressive vascular evalvation and vascular exploration and repair in selected cases. Moreover, patency rates for revascularization procedures appear sufficiently high, making this intervention worthwhile.

The need for better analysis of observational studies in orthopedics. A retrospective study of elbow fractures in children

BACKGROUND AND PURPOSE

The conventional statistical methods employed in observational studies in orthopedics require the fundamental assumption that the outcomes are independent. However, fractures treated by the same surgeon cannot be regarded as being independent of each other and should be nested in the statistical analysis. If the effect on outcome of early rather than delayed surgery depends on the severity of the fracture, we have a case of interaction. This is rarely considered in orthopedic research, but could affect the conclusions drawn. The aim of this paper is to describe the concepts of multilevel modeling and interaction in orthopedics.

PATIENTS AND METHODS

In a cohort of 112 patients with single supracondylar humerus fractures, 78 patients were examined clinically on average 4 years after surgery. The range of motion was measured and the global satisfaction was assessed. The results were used to compare traditional least-squares regression analysis with a 2-level model with interactions.

RESULTS

We found that 25% of the variance in outcome could be attributed to between-surgeon variance. We identified an interaction between the surgeons' experience and the severity of the fractures that influenced the conclusions. The variable "number of pins" was not significant in the 2-level model (p = 0.07), while the ordinary least-squares analysis gave a result that was statistically significant (p = 0.01).

INTERPRETATION

Researchers should consider the need for a 2-level model and the presence of interactions. Standard statistical methods might lead to wrong conclusions.

Dorgan's lateral cross-wiring of supracondylar fractures of the humerus in children: A retrospective review

INTRODUCTION

The currently accepted treatment for displaced supracondylar humeral fractures in children is closed reduction and fixation with percutaneous Kirschner wires. The purpose of this study was to retrospectively review a novel cross-wiring technique where the cross-wire configuration is achieved solely from the lateral side, thereby reducing the risk of ulnar nerve injury.

METHODS

We retrospectively reviewed all children who had undergone this procedure at our centre over a 10-year period. The primary end points were a major loss of reduction as determined by radiological alignment and iatrogenic ulnar nerve injury. Secondary end points included clinical alignment, elbow range of motion and complications.

RESULTS

A total of 43 patients, who underwent lateral cross-wiring for displaced supracondylar fractures (Gartland type II and type III) of the humerus were reviewed with a mean follow-up time of 36 months. No major loss of reduction occurred. The mean change in Baumann's angle (4.2+/-1.6 degrees) between intra-operative and follow-up radiographs was not significant (p>0.05). No iatrogenic case of ulnar nerve injury occurred. The 'carrying angle' and 'return to function' in all children had returned to normal relative to the other side. Postoperative complications consisted of three patients developing pin-site infections, which were successfully treated.

CONCLUSION

Dorgan's lateral cross-wiring technique is an effective option in treating displaced supracondylar fractures of the humerus in children. It is as effective as the traditional cross-wire technique in terms of fracture healing with a reduced risk of ulnar nerve injury.

Open reduction and bioabsorbable pin fixation for late presenting irreducible supracondylar humeral fracture in children

The objective was to evaluate the availability and efficacy of internal fixation with absorbable poly-D: ,L: -lactic acid (PDLLA) pins for the treatment of late presenting irreducible Gartland type III supracondylar fracture of the humerus in children. Fifty-six cases of late presenting irreducible Gartland type III supracondylar fracture of the humerus in children were treated by open reduction and bioabsorbable PDLLA pin fixation from March 2005 to March 2008. The outcome of treatment was evaluated by the Mayo Elbow Performance Score (MEPS) and the criteria of Flynn. Fifty-six patients were followed up from 24 to 36 months (mean: 22 months). No displacement of bone fracture occurred, and all fractures healed within a normal time without wound infection; there were no cases of Volkmann's ischaemic contracture, myositis ossificans or iatrogenic injury of the ulnar nerve. No residual vascular deficits or iatrogenic nerve injury were noted; cubitus varus deformity occurred in one case. There were 49 excellent, four good and three fair results according to the MEPS; the rate of excellent and good outcome was 94.6%. All children but one had excellent cosmetic results according to the criteria of Flynn. All of the children and their parents stated that they would choose this treatment again. Treatment of late presenting irreducible Gartland type III supracondylar fracture of the humerus in children with bioabsorbable PDLLA pins provides sufficient stability and satisfactory efficacy. The absorbable implant has become popular for its avoidance of a second operation to remove the internal fixation, and the degree of patient satisfaction is high.

Surgical approaches for open reduction and pinning in severely displaced supracondylar humerus fractures in children: a systematic review

PURPOSE

There is no clear evidence in the actual literature regarding which of the surgical approaches could bring about the best functional, cosmetic, and radiological outcomes, as well as fewer complications, when an open reduction and pinning of a severely displaced supracondylar humerus fracture is performed. We, therefore, performed a systematic review of the English literature to investigate the existing evidence regarding this issue.

METHODS

A MEDLINE and EMBASE databases search was performed to identify articles that focused on the functional, cosmetic, and radiological outcomes, as well as post-surgical complications, regarding different surgical approaches used for open reduction and pinning in severely displaced supracondylar humerus fractures in children. One hundred and ninety-four articles were identified, of which seven were included for review. Data analysis included weighted means for all contingency tables and the Chi-square test. Standardized residues were studied when the Chi-square test was statistically significant. Statistical analyses were conducted using Stata 9.1/SE (StataCorp., College Station, TX) and P-values lower than 0.05 were considered to be statistically significant for all analyses.

RESULTS

For functional outcome, a high frequency of excellent results was found within the lateral and medial approaches, and a high frequency of good results within the anterior approach. A high frequency of poor results was found within the posterior approach. For cosmetic outcome, there was a high frequency of fair results within the posterior and lateral approaches, and a high frequency of poor results within the posterior approach. No statistically significant difference regarding time to union, as well as complications, was found.

CONCLUSION

Our results suggest that a combined antero-medial approach could be the method which allows the achievement of better functional and cosmetic outcome according to Flynn's criteria. Time to union, as well as post-surgical complications, should not be an issue regarding surgical approaches used for open reduction and pinning in these fractures.

Composite playground safety measure to correlate the rate of supracondylar humerus fractures with safety: an ecologic study

BACKGROUND

More than 200,000 children are injured at playgrounds in the United States each year. Our goal was to introduce a composite measure of playground safety and use this instrument to correlate the incidence of supracondylar humerus fractures with playground safety in an ecologic study design.

METHODS

We used a novel "overall-safety rating," defined as a composite of 3 previously validated instruments (National Program for Playground Safety School score, surface depth compliance, and the use zone compliance) to measure the overall safety of all playgrounds within a region. The regions were rated from most to least safe based on average playground safety as measured by this new method. The incidence of supracondylar fractures was calculated using Hasbro Children's Hospital Emergency Department data and state of Rhode Island Census data from 1998 to 2006. The incidence was then correlated with playground safety as defined by our composite measure.

RESULTS

Compared with the neighborhood deemed the safest, the least safe district had 4.7 times greater odds of supracondylar humerus fracture. Overall composite safety score of the district was linearly correlated with the injury rate observed in the population at risk (R=0.98; P=0.04).

CONCLUSIONS

Using our novel composite playground safety score, we found that the incidence of supracondylar humerus fractures was increased in districts with playgrounds with lower scores, suggesting that improvements in playground infrastructure may potentially reduce the incidence of supracondylar humerus fractures, and other injuries, in children.

LEVEL OF EVIDENCE

Level IV.

Use of the Gartland classification system for treatment of pediatric supracondylar humerus fractures

The extension-type pediatric supracondylar humerus fracture accounts for nearly two-thirds of all pediatric hospitalizations due to elbow trauma. The Gartland classification guides the standard of care for treatment of this entity. Type I injuries are treated with cast immobilization while type II and III injuries are treated operatively. The reported interobserver reliability ranges from moderate to full agreement, which is on par with other frequently referenced classification systems such as Lauge-Hansen for adult ankle fractures. In this study, 4 fellowship-trained pediatric orthopedic surgeons reviewed radiographs of 72 pediatric supracondylar fractures and classified them based on Gartland's system. They recommended their preferred treatment of cast immobilization for type I fractures and of closed reduction and pinning in the operating room for type II and type III fractures. The interobserver and intraobserver reliability for each set of radiographs was then analyzed. There was moderate agreement comparing all fractures and comparing types I and II fractures, while there was full agreement for type III fractures. There was full agreement for the intraobserver reliability. The preferred treatment (casting vs operative intervention) differed in 35% of patients, if based on the fracture classification.

Outcome of Gartland type II and type III supracondylar fractures treated by Blount's technique

BACKGROUND

According to some orthopedic surgeons, almost all supracondylar humerus fractures should be treated operatively by reduction and pinning. While according to others, closed reduction and immobolization should be used for Gartland type II and some type III fractures. However, the limit of this technique remains unclear. We present 74 patients with displaced extension-type supracondylar fractures treated by closed reduction and immobilization with a collar sling fixed to a cast around the wrist. The purpose of the study is to give a more precise limitation of this technique.

MATERIALS AND METHODS

Retrospective data acquisition of 74 patients with a Gartland type II or type III fractures treated by closed reduction and immobilization (Blount's technique) between January 2004 and December 2007 was done. The mean age was 6.3 years (range, 2-11). The mean time of follow-up was 6.5 months (range, 3-25). All open injuries and complex elbow fracture dislocations or T-condylar fractures were excluded from the study. All patients were evaluated with standardized anteroposterior and true lateral x-rays of the elbow, and Flynn criteria were used for functional assessment.

RESULTS

Gartland type II fractures had 94% good or excellent final results. Gartland type III fractures had 73% good or excellent final result. The Gartland type III outcome depended on the displacement. The fractures remained stable in 88% for the posterior displacement, and 58% for the posteromedial displacement. These displacements were mild. However, for the posterolaterally displaced fractures, only 36% were stable; 36% had a mild displacement and 27% had a major displacement.

CONCLUSION

Pure posterior displacement is more stable than posteromedial displacement which is more stable than posterolaterally displaced fractures. This study suggests that Gartland type II and pure posterior or posteromedial displaced Gartland type III fractures can be treated by closed reduction and immobilization with success.

Prospective analysis of a new minimally invasive technique for paediatric Gartland type III supracondylar fracture of the humerus

OBJECTIVE

The purpose of this study was to introduce a minimally invasive surgery using mosquito forceps for achieving the reduction of severely displaced supracondylar fracture of the humerus in children and evaluate the clinical outcome.

MATERIALS AND METHODS

Gartland type III supracondylar fractures of the humerus in children under the age of 12 were analysed from January 2000 to January 2007 at our institute. The control group cases were selected by successful reduction using the standard technique described by Rockwood and Wilkins (2001). The others composed the study group. This study included chart reviews, radiographic images of both the antero-posterior and the lateral views, physical examination, and Mayo elbow performance index scores preoperative, postoperative, and final follow-up.

RESULTS

Evaluations were completed for 42 cases. The mean age was 6.9 years and the group consisted of 23 boys and 19 girls. The mean follow-up time was 34.5 months. Twenty-six cases were of injuries to the left side, and 16 were of injuries to the right. The Mayo elbow performance index score was excellent in both groups. Operation time in the control and study groups was 46 and 79min, respectively. There was one case of iatrogenic ulnar nerve injury each in the study and control group. One case of loss of reduction and another with a combination of ulnar nerve injury and loss of reduction were noted in the control group. All four cases had an excellent final outcome. No mosquito-forceps-related complication was found, and in the final follow-up, no cubitus varus was found.

CONCLUSION

Minimally invasive surgery with the assistance of mosquito forceps for the reduction of severely displaced supracondylar fracture of the humerus in children was shown to be a safe and effective alternative method. The final functional outcome was the same as that of the standard technique.

Time of return of elbow motion after percutaneous pinning of pediatric supracondylar humerus fractures

The most common treatment for displaced pediatric supracondylar humerus fractures is closed reduction and percutaneous pinning. However, the time for return of elbow motion after treatment of these injuries is not well documented. To describe the return of elbow motion after closed reduction and percutaneous pinning of these fractures we retrospectively reviewed 63 patients (age range, 1.6-13.8 years) with displaced supracondylar fractures of the humerus stabilized with either two or three lateral entry pins. Pins were removed by 3 to 4 weeks. No patient participated in formal physical therapy. At each followup, elbow range of motion (ROM) was recorded for the injured and uninjured extremities. Elbow ROM returned to 72% of contralateral elbow motion by 6 weeks after pinning and progressively increased to 86% by 12 weeks, 94% by 26 weeks, and 98% by 52 weeks. After closed reduction and percutaneous pinning of a displaced, uncomplicated, supracondylar humerus fracture, 94% of the child's normal elbow ROM should be expected by 6 months after pinning. Further improvement may occur up to 1 year postoperatively. This information may be helpful in advising parents what to expect after their child's injury.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Timing of surgical treatment for type III supracondylar humerus fractures in pediatric patients

BACKGROUND

Type III supracondylar humeral fracture is a common cause of emergency hospitalization among children requiring surgical treatment. The configuration of the internal fixation material, surgical technique, and optimal timing of surgery (TS) have always been popular topics of debate. The TS in uncomplicated cases is usually determined by surgeons.

METHODS

In this study, we prospectively followed children with type III supracondylar fractures. We aimed to clarify the effects of injury side, gender, and post-injury delay on switching to open surgery and the ease of the reduction.

RESULTS

Based on our results, the probability of switching to open surgery increased by a factor of 4 every 5 h beginning 15 h after injury. Open surgery was necessary after 32 h.

CONCLUSION

Reduction became technically more difficult as TS increased.

Inter- and intra-observer reliability of the Baumann angle of the humerus in children with supracondylar humeral fractures

The Baumann angle of the humerus has been commonly used as an outcome measure for supracondylar fractures in children. However, there is limited or no information about the reliability of this measurement. The purpose of this study was to determine the inter-observer reliability (IEOR) and intra-observer reliability (IAOR) of the Baumann angle of the humerus. The Baumann angle of the humerus was measured by five observers on the anteroposterior radiographs of 35 children’s elbows, all of which had sustained a nondisplaced supracondylar humeral fracture. The values of IEOR and IAOR were calculated using a Pearson coefficient of correlation. Ranges of differences in the measurement of the Baumann angle of the humerus were established, and the percentage of agreement between observers was then calculated using those ranges. The Baumann angle of the humerus is a simple, repeatable and reliable measurement that can be used for the determination of the outcome of supracondylar humeral fractures in the paediatric population. An excellent IEOR was found for the measurement of the Baumann angle (r = 0.78, p = 0.0001). When the difference between observers in the reported measurement of the Baumann’s angle was calculated to be within seven degrees of each other, at least four of the five observers agreed 100% of the time. Similarly, excellent values of IAOR were found for the measurement of the Baumann’s angle (r = 0.80, p = 0.0001). Level of evidence for this study was III.

A systematic review of early versus delayed treatment for type III supracondylar humeral fractures in children

We performed a systematic review of early versus delayed treatment for type III Gartland supracondylar humeral fractures in children. We identified five non-randomised retrospective studies that fulfilled our criteria. We performed the analysis on 396 patients who sustained a type III supracondylar humeral fracture of which 243 (61.4%) belonged to the early treatment group and 153 (38.6%) belonged to the delayed treatment group. The planned treatment was closed reduction and percutaneous pin fixation. We found that failure of closed reduction and conversion to open reduction was significantly higher in the delayed treatment group (22.9%) as compared with the early treatment group (11.1%). Our study provides evidence that type III supracondylar humeral fractures in children should be treated early within 12h of injury.

Accuracy of emergency room physicians' interpretation of elbow fractures in children

Elbow fractures in children can be difficult diagnoses for inexperienced physicians to make. The purpose of this prospective study was to determine the accuracy of radiograph interpretation of elbow fractures in children by emergency room (ER) physicians. Thirty fractures were analyzed. The ER physician's radiograph interpretation was compared to the final interpretation by the treating staff pediatric orthopedic surgeon. Accuracy rates were determined for overall agreement and by fracture subtype. Overall accuracy of ER physicians' interpretation was 53% (16/30). This study underscores the importance of educating ER physicians and residents in children's fracture interpretation to optimize patient outcomes. Orthopedists need to be vigilant when taking care of these patients to prevent unnecessary complications.

Treatment of supracondylar fractures of the humerus in children through an anterior approach is a safe and effective method

In this prospective case series we evaluated the effectiveness and safety of using an anterior approach to paediatric supracondylar humerus fractures. We gathered data on 46 children that had a displaced supracondylar fracture of the humerus. All the patients had sustained a Gartland type III extension fracture that could not be reduced by closed means. Open reduction through an anterior approach was performed and two Kirschner wires were used to fix the fracture to the medial and lateral sides. Patients were recalled for follow-up and were evaluated using Flynn's radiological and clinical criteria. Loss of extension and flexion was noted by clinical assessment and carrying angle measured on radiograms. A follow-up examination performed in the 24th postoperative week showed that all fractures had healed; the patients' outcomes were rated as excellent or good according to Flynn's criteria. As a result the anterior approach for open reduction of paediatric supracondylar humeral fractures is a safe and reliable method with very good results.

Delaying treatment of supracondylar fractures in children

The aim of this retrospective multicentre study was to report the continued occurrence of compartment syndrome secondary to paediatric supracondylar humeral fractures in the period 1995 to 2005. The inclusion criteria were children with a closed, low-energy supracondylar fracture with no associated fractures or vascular compromise, who subsequently developed compartment syndrome. There were 11 patients (seven girls and four boys) identified from eight hospitals in three countries. Ten patients with severe elbow swelling documented at presentation had a mean delay before surgery of 22 hours (6 to 64). One patient without severe swelling documented at presentation suffered arterial entrapment following reduction, with a subsequent compartment syndrome requiring fasciotomy 25 hours after the index procedure.

This series is noteworthy, as all patients had low-energy injuries and presented with an intact radial pulse. Significant swelling at presentation and delay in fracture reduction may be important warning signs for the development of a compartment syndrome in children with supracondylar fractures of the humerus.

Lateral external fixation--a new surgical technique for displaced unreducible supracondylar humeral fractures in children

BACKGROUND

Percutaneous Kirschner wire fixation represents the classic treatment for displaced supracondylar humeral fractures in childhood. This type of treatment first requires satisfactory reduction of the fracture. Failure to achieve a satisfactory reduction or inadequate stabilization can result in instability of the fracture fragments, which can result in either an unsatisfactory cosmetic or functional outcome. In our experience, these problems can be overcome with the use of a small lateral external fixator.

METHODS

Between 1999 and 2005, thirty-one of 170 Gartland type-III supracondylar humeral fractures were treated with a lateral external fixator. The outcome of treatment was analyzed with regard to limb alignment, elbow movement, cosmetic appearance, and patient satisfaction.

RESULTS

In twenty-eight of the thirty-one patients, a satisfactory reduction was achieved with closed methods. All children except one had a normal or good range of movement. The cosmetic result was excellent in all cases. All of the children and their parents stated that they would choose this treatment again.

CONCLUSIONS

The use of a small lateral external fixator seems to be a safe alternative for the treatment of displaced supracondylar fractures of the humerus when a closed reduction appears to be unattainable by means of manipulation alone or when sufficient stability is not achieved with standard methods of Kirschner wire fixation.

Sagittal plane analysis of the open and closed methods in children with displaced supracondylar fractures of the humerus (a radiological study)

OBJECTIVES

The aim of this study was to compare the radiological outcome of open and close reduction and osteosynthesis methods in the treatment of type II and III supracondylar humerus fractures in childhood with respect to the immediate post-operative reduction quality in sagittal plane.

METHOD

One hundred and forty four-pediatric patients with type IIb and III supracondylar humerus fractures treated at two centers between 1995 and 2005 were evaluated radiologically within a retrospective study. Seventy-six patients (54 boys, 22 girls, mean age 7.6, range 2-12) were treated by closed reduction and cross percutaneous pinning while 68 (49 boys, 19 girls, mean age 7.3, range 2-13) were treated by open reduction. The reduction quality of the open and closed groups was compared on immediate post-operative lateral radiographs by measuring of lateral humerocapitellar angle, anterior humeral line and anterior coronoid line criteria. The reduction quality was classified excellent, good, fair and poor according to the achievement of three, two, one or none of the criteria, respectively. Reductions classified as excellent and good were introduced as acceptable results.

RESULTS

At least one criterion was achieved in all the patients of both the groups. The mean humerocapitellar angle was 30.1 degrees in closed reduction group while the mean of it was 29.8 degrees in open reduced group. Radiograph of 48 (63.1%) patients with closed reduction were found to display the anterior humeral line intersecting the middle one-third of capitellum while this criteria was 45 (66%) in open reduction group. The anterior coronoid line was disturbed in three patients in each of both the groups. The reduction quality was evaluated to be excellent in 32 patients, good in 31, fair in 13 at the closed reduction group while these evaluations were 31, 20 and 17 in open reduction group, respectively. Successful reduction was achieved in 74.9% of the patients in closed reduction group and 75% of the patients in open reduction group.

CONCLUSION

It is concluded that there was no significant difference between closed and open reductions of pediatric displaced supracondylar fractures with regard to the radiological criteria of reduction quality in sagittal plane.

Open reduction via posterior triceps sparing approach in comparison with closed treatment of posteromedial displaced Gartland type III supracondylar humerus fractures

The results of closed and open reduction via posterior approach with percutaneous pinning of posteromedial displaced supracondylar humerus fractures in children were evaluated. Fifty-five consecutive patients with Gartland type III fractures were reviewed. The mean follow-up period was 22 months (12-48 months). The closed reduction group consisted of 32 patients and the open reduction group with the posterior approach using the triceps-sparing method consisted of 23 patients. Both groups were stabilized with cross Kirschner wire fixation and followed the same protocol. In comparison with closed reduction, despite the fact that better bone alignment was obtained with open reduction, longer union time (7 vs. 5.8 weeks), significantly reduced range of motion of the elbow (12.3 degrees vs. 3.8 degrees), poorer functional outcomes and bad cosmetics because of hypertrophic scar tissue of the skin were found. The patients were analyzed according to their Bauman angle and Flynn criteria: good or excellent functional and cosmetic results were 91% in the closed reduction group but 52% in the open reduction group. On the basis of results of this study, closed reduction and percutaneous fixation of the posteromedial totally displaced fractures are preferable to open reduction with posterior approach.

Three lateral divergent or parallel pin fixations for the treatment of displaced supracondylar humerus fractures in children

BACKGROUND

To evaluate the efficacy of lateral or parallel pin fixation using 3 smooth Kirschner wires (K-wires) or smooth Steinmann pins for the operative management of displaced supracondylar humeral fracture in a consecutive series of children.

METHODS

Sixty-one consecutive displaced or angled supracondylar humeral fractures (Gartland type II or III) in children (mean age, 5 years 6 months) treated by 2 orthopaedic surgeons between 2001 and 2004 according to the following protocol: close reduction under general anesthesia with fluoroscopic guidance and only lateral percutaneous pinning using 3 divergent or parallel Kirschner wires or Steinmann pins. Minimum 2 years' follow-up was done in all 61 patients (range, 2.0-3.3 years). Clinical assessment was obtained at final follow-up using Flynn criteria, and radiologic assessment was obtained using the Baumann and lateral humerocapitellar angles of both arms. Statistical analysis was performed by means of the Student t test (P < 0.05).

RESULTS

The study group consisted of 61 patients, of whom 24 (39%) presented with Gartland type II fractures, and the remaining 37 (61%) presented with a type III fracture. A comparison of perioperative and final radiographs shows no loss of reduction of any fracture. There was also no clinically evident cubitus varus, hyperextension, or loss of motion. Eight patients had preoperative nerve palsy. Five of these nerve injuries resolved immediately after surgery, and the other 3 resolved completely within 12 weeks of surgery. After an average of 28 months postoperation, 56 (91.8%) patients had achieved an excellent clinical result, and 5 (8.2%) achieved a good result. There were no iatrogenic nerve palsies, and no patient required additional surgery. One patient had a minor pin-track infection.

CONCLUSIONS

Our series demonstrates that only 3 lateral divergent or parallel pin fixations are effective and safe for avoiding iatrogenic ulnar nerve injury and are appropriate treatment options for displaced or angled supracondylar humeral fractures in children.

LEVEL OF EVIDENCE

Therapeutic study, level III.

Supracondylar humeral fractures in children

Operative fixation is indicated for most type-II and III supracondylar humeral fractures in order to prevent malunion. Medial comminution is a subtle finding that, if treated nonoperatively, is likely to lead to unacceptable varus malunion. Angiography is not indicated for a pulseless limb, as it delays fracture reduction, which usually corrects the vascular problem. A high index of suspicion is necessary to avoid missing an impending compartment syndrome, especially when there is a concomitant forearm fracture or when there is a median nerve injury, which may mask symptoms of compartment syndrome. Lateral entry pins have been shown, in biomechanical and clinical studies, to be as stable as cross pinning if they are well spaced at the fracture line, and they are not associated with the risk of iatrogenic ulnar nerve injury.

Brachial plexus palsy following proximal humerus fracture in patients who are skeletally immature

From 1998 to 2006, 578 patients who were skeletally immature with proximal humerus fractures were treated at our institution. During that time period, 4 patients (0.7%) had associated brachial plexus and major peripheral nerve palsies. Average age at the time of injury was 12.3 years (range 10-14 years). Two fractures were physeal and 2 were metaphyseal. In all patients, the distal fracture fragment was displaced into the axilla, with resultant adduction and valgus malalignment at the time of injury. Two patients were treated with closed reduction and sling and swathe immobilization. One patient was treated with closed reduction and percutaneous pinning of the fracture. One patient was treated with sling immobilization without fracture reduction. All went on to bony healing with acceptable bony alignment. All patients were evaluated with serial physical examinations and radiographs to assess for neurologic recovery and bony healing. Average clinical and radiographic follow-up was 7.1 months (5-9 months). All patients demonstrated complete neurologic recovery by 5-9 months postinjury. All had neuropathic pain for at least 6 months after injury. No persistent neuropathic pain or functional limitations were seen at follow-up. Although rare, brachial plexus injury may accompany displaced proximal humeral fractures in patients who are skeletally immature. With careful attention to principles of fracture care, complete neurologic recovery may be expected within 9 months.

Delayed surgical treatment of supracondylar humerus fractures in children using a medial approach

PURPOSE

The appropriate management of supracondylar humerus fractures in children is frequently delayed due to various factors, and there is still no agreement on the treatment of choice. The purpose of this study was to evaluate the effects of delayed treatment of displaced supracondylar humerus fractures on the treatment results and complication rate.

METHODS

A total of 31 children with supracondylar humerus fractures who had not received adequate treatment for their displaced fractures were included in this study. The conditions leading to delayed treatment mainly included severe swelling or skin problems around the elbow and the health facility problems unique to our district. The mean delaying time was 6 days (range 2-19 days). There were 24 males and 7 females with a mean age of 7 years (range 1-13 years). The fractures were classified as type III-A (n = 15; 48%) and type III-B (n = 16; 52%) according to Gartland. Surgical treatment consisting of sentiment manual reduction through a medial approach and percutaneous cross-pinning was applied to all. No image intensifier was used during the procedures. A long-arm splint was used for post-operative immobilization.

RESULTS

The average hospital stay was 2 days (range 1-3 day) and the patients were followed clinically and radiographically for an average of 4 years (range 2-11 years). Pins were removed at the end of the third week post-operatively, at which time the range of motion exercises were begun. None of the patients required physical therapy and full functional recovery was achieved within 3 months in 29 (93.5%) patients and within 5 months in the remaining 2 (6.5%). Two (6.5%) pre-operative nerve injuries (1 interosseous, 1 ulnar) were resolved spontaneously within 3 months post-operatively. At the final follow-up, 7 (22.5%) patients had cubitus varus deformity. Except for 2 (6.5%) pin-tract infections, which were resolved by oral antibiotics and pin removal, none of the patients had early or late complications, not even neurological deficit or myositis ossificans.

CONCLUSIONS

Delayed presentation of displaced supracondylar humerus fractures in children did not increase complication rates or unsatisfactory results following an open reduction. Medial approach and cross-pinning is an effective and reliable treatment method for these fractures.

Die elastisch-stabile intramedulläre Nagelung (ESIN) der suprakondylären Humerusfraktur im Kindesalter

Supracondylar fractures are the most common elbow lesions in children. The standard procedure for displaced fractures has up to now been crossed-wire osteosynthesis. A new option is elastic stable intramedullary nailing (ESIN). We retrospectively reviewed the results of all supracondylar fractures that were treated in our department from 2000 to 2005 by the ESIN technique with the aim to provide evidence of advantages and disadvantages of this method. The mean age of the 60 patients included in the study (27 female, 33 male) was 5.9 years (range 1-12 years). Most patients presented with type II fractures (85%), 10% sustained a type III fracture and 5% the most displaced type IV. All patients were treated with the ESIN technique and underwent clinical and radiological follow-up examinations during the next 3-5 months. Average duration to implant removal was 100 days. All patients achieved free range of movement of the affected elbow. No visible malpositions, pseudarthrosis or nerve lesions were observed, in comparison to the conventional surgical technique (crossed-wire osteosynthesis) with up to 19% for these complications. Furthermore, due to the excellent stability of ESIN, the patients do not need a cast and movement is encouraged immediately. Our good experiences encourage us to continue applying the ESIN technique.

Treatment of pediatric supracondylar humerus fractures in the community hospital

BACKGROUND

Supracondylar fractures of the humerus are among the most common elbow injuries in the pediatric population. Because of the significant morbidity associated with treating displaced pediatric supracondylar humerus fractures, most community-based orthopedic surgeons prefer to transfer these injuries to specialty children's hospitals. Our intention in writing this article was to document and evaluate the results we obtained using the lateral diverging pin technique to treat patients at our community hospital. In doing so, we set out to determine if our results were comparable to those of specialty hospitals, allowing us in the future to eliminate the inconvenience placed on patients and their families when being transferred to a specialty facility.

METHODS

We retrospectively reviewed the patients treated surgically at our institution for a closed Gartland type II or type III supracondylar distal humerus fracture during the months of September and October of 2005. The medical records and radiographs of all children who had been treated for a displaced extension-type supracondylar humerus fractures were evaluated. The data recorded from the chart review included the age and sex of the patients, preoperative and postoperative neurovascular status, operative techniques (2 vs 3 lateral entry point Kirschner wires), and the operative time (start to close). The radiographs were reviewed to determine the Gartland type of fracture and the Baumann angle on the anteroposterior film immediately postoperative and at the time of fracture union.

RESULTS

Four Gartland type II and 3 Gartland type III fractures were identified during the study period. There were 3 boys and 4 girls with a mean age of 6.29 years (range, 3.92-8.58 years). The mean immediate postoperative Baumann angle was 18.29 degrees (range, 10-25 degrees). At the time of fracture union, the mean Baumann angle was 19.0 degrees (range, 14-22 degrees). The mean range-of-motion loss as compared with the extension loss (range, 10-2 degrees) and 4.57 degrees of flexion loss (range, 10-2 degrees). The mean operative time was 20.43 minutes (range, 7-37 minutes).

CONCLUSIONS

Our results show the change in Baumann angle and loss of range of motion compare favorably with results of studies done at specialty hospitals. We believe that the divergent lateral pinning technique, in combination with postoperative splinting and a sling can provide excellent results while eliminating the risk of injury to the ulnar nerve. With this knowledge, we feel that the advantage to treating these fractures at a community hospital is the elimination of the anxiety, stress, and time spent waiting in the emergency department of multiple hospitals.

Percutaneous pinning of pediatric supracondylar humerus fractures with the semisterile technique: the Miami experience

Pediatric supracondylar humerus fractures are common injuries. The standard of care for management of displaced supracondylar fractures has become closed reduction and percutaneous pinning of the fracture in the operating room. We have been using a "semisterile" surgical technique, similar to what is used when placing a traction pin at the bedside. The purpose of this study was to evaluate our cases from 2000-2004 requiring closed reduction and percutaneous pinning to determine if this method had an infection rate comparable to what is reported in the literature. A total of 304 cases were identified. There were no superficial pin track infections or deep infections requiring treatment in any patient. A review of the literature regarding percutaneous pinning of supracondylar humerus fractures reveals an overall infection rate of 2.34% (45/1922) with a deep infection rate of 0.47% (9/1922). Consequently, the use of the semisterile technique is safe and an efficient way to handle these cases in saving time, cost, and materials. We also found that the administration of perioperative antibiotics may not be necessary as 68% of our patients did not receive any antibiotics during the perioperative or postoperative period. Finally, we found that 37% of our patients were discharged home the same day the surgery was performed, and there were no cases of compartment syndrome or Volkmann ischemic contracture. This indicates that observation overnight in the hospital may not be necessary for every patient.

A systematic review of medial and lateral entry pinning versus lateral entry pinning for supracondylar fractures of the humerus

The supracondylar fracture of the distal humerus is the most common pediatric fracture in the elbow. This systematic review summarizes the existing data about the effect of medial and lateral (medial/lateral) entry pins versus only lateral entry pin fixation on the risk of iatrogenic nerve injury and deformity or loss of reduction. A literature search identified clinical trials and observational studies presenting the probability of nerve injury and/or deformity or loss of reduction associated with closed reduction and either medial/lateral entry or lateral entry pinning of supracondylar fractures in pediatric patients. Data from 2054 children were identified from 35 studies; 2 randomized trials, 6 cohort studies, and 25 case series. For operative fixation with medial/lateral entry pins, the probability of ulnar nerve injury is 5.04 times higher than with lateral entry pins. When all documented operative nerve injuries are included, the probability of iatrogenic nerve injury is 1.84 times higher with medial/lateral entry pins than with isolated lateral pins. Medial/lateral pin entry provides a more stable configuration, and the probability of deformity or loss of reduction is 0.58 times lower than with isolated lateral pin entry. When the prospective studies alone were analyzed, there were no significant difference in the probability of iatrogenic nerve injury or deformity and displacement, although the confidence intervals were wide. This systematic review indicates that medial/lateral entry pinning, of pediatric supracondylar fractures, remains the most stable configuration and that care needs to be taken regardless of technique to avoid iatrogenic nerve injury and loss of reduction.

Biomechanical analysis of pinning techniques for pediatric supracondylar humerus fractures

BACKGROUND

Closed reduction and percutaneous pin fixation is the recommended treatment of displaced (Gartland types 2 and 3) supracondylar humerus fractures. The need for a medial pin for maximal stability remains controversial. The purpose of this study was to develop a model of supracondylar humerus fractures simulating medial column comminution and to evaluate the torsional stability of various pin configurations recommended in the current literature.

METHODS

Transverse cuts were made in synthetic humeri with a wedge taken from the medial aspect of the proximal fracture fragment in one half of the specimens to simulate medial column comminution. Each fracture was then reduced and fixed with 1 of 4 pin configurations using 0.062 in K-wires. The fixed specimens were then subjected to a torsional load producing internal rotation of the distal fragment. Rotation in degrees and the corresponding torque was recorded for statistical analysis.

RESULTS

Specimens with the medial wedge removed demonstrated less torsional stability than their identically fixed counterparts with the intact medial column. In specimens with the intact medial column, the greatest torsional stability was achieved with the 2 lateral divergent and medial cross pin configuration followed by 3 lateral pins, then standard crossed pins with 2 lateral divergent pins demonstrating the least torsional stability. For the medial comminution group the 2 lateral, 1 medial pin construct again had the greatest torsional stability and 2 lateral pins the least. The standard crossed pin and 3 lateral pin constructs were not significantly different in the presence of medial comminution.

CONCLUSIONS

In a synthetic humerus model of supracondylar humerus fractures, medial comminution was shown to reduce torsional stability significantly in all pin configurations. There was no statistical difference in torsional stability between 3 lateral pins and standard crossed pins in specimens with medial comminution.

Supracondylar humeral fractures in children

Although supracondylar fracture is a very common elbow injury in childhood, there is no consensus on the timing of surgery, approach for open reduction and positioning of fixation wires. We report our ten-year experience between 1993 and 2003 in 291 children.

Most fractures (285; 98%) were extension injuries, mainly Gartland types II (73; 25%) and III (163; 56%). Six (2%) were open fractures and a neurovascular deficit was seen in 12 (4%) patients. Of the 236 children (81%) who required an operation, 181 (77%) were taken to theatre on the day of admission. Most (177; 75%) of the operations were performed by specialist registrars. Fixation was by crossed Kirschner wires in 158 of 186 (85%) patients and open reduction was necessary in 52 (22%).

A post-operative neurological deficit was seen in nine patients (4%) and three (1%) required exploration of the ulnar nerve. Only 22 (4%) patients had a long-term deformity, nine (3%) from malreduction and three (1%) because of growth arrest, but corrective surgery for functional limitation was required in only three (1%) patients.

Nonoperative treatment of displaced supracondylar fractures in children: Rigault type 2 fractures

BACKGROUND

Current opinion in the medical literature concerning displaced supracondylar fractures of the distal humerus recommends pinning because with flexion braces there is a risk of both secondary displacement and Volkmann syndrome.

PATIENTS AND METHODS

We analyzed 84 children with displaced supracondylar fractures. According to Rigault's classification, 30 children had grade 2 fractures, 21 had grade 3, 28 had grade 4 and 5 had multiple fragments, which were thus outside this classification. Fractures that could be reduced to a stable position under general anesthesia were treated with a posterior long arm splint with an average elbow flexion of 113 degrees (90-140). This technique was applied in 28 of the grade 2 fractures and in 4 of the grade 3 fractures, but in none of the grade 4 fractures.

RESULTS

Of the 4 cases of Rigault grade 3 fractures treated nonoperatively, 3 had to be re-reduced and 1 needed an operation later on for varus correction. Of the 28 Rigault grade 2 fractures, 27 showed excellent results, and 1 had a good result. We advise nonoperative treatment in type 2 supracondylar fractures if stable reduction is achieved.

Location of treatment of supracondylar fractures of the humerus in children

A change in the locations where children are treated for supracondylar fractures of the humerus has occurred during the past 13 years. Pediatric orthopaedic surgeons at specialist centers are seeing an increased number of such fractures. In New England, the number of supracondylar fractures of the humerus treated by closed reduction and percutaneous pinning has remained relatively constant between 1991 and 1999 with a range of 276 to 346 fractures per year, averaging 320 per year. In 1991, 63% of patients were treated by general orthopaedic surgeons in a nonspecialist setting. By 1999, 68% of the fractures were treated at centers with pediatric orthopaedic specialists available whereas only 32% were treated in a general orthopaedic setting. Associated with this change is a decreased length of stay from 2.2 (+/- 0.6) days in nonspecialist centers to 1.4 (+/- 0.4) days average in specialist centers.

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.

Lateral-entry pin fixation in the management of supracondylar fractures in children

BACKGROUND

There has been controversy regarding the optimal pin configuration in the management of supracondylar humeral fractures in children. A crossed-pin configuration may be mechanically more stable than lateral pins in torsional loading, but it is associated with a risk of iatrogenic injury to the ulnar nerve. Previous clinical studies have suggested that lateral pins provide sufficient fixation of unstable supracondylar fractures. However, these studies were retrospective and subject to patient-selection bias.

METHODS

A displaced supracondylar humeral fracture was fixed with only lateral-entry pins in 124 consecutively managed children. Medical records and radiographs were reviewed to identify any complications, including loss of fracture reduction, iatrogenic ulnar nerve injury, infection, loss of motion of the elbow, and the need for additional surgery. In addition, eight displaced supracondylar humeral fractures that had been reduced and fixed with lateral pins at other institutions and had lost reduction were analyzed to determine the causes of the failures.

RESULTS

Sixty-nine children had a type-2 fracture, according to Wilkins's modification of Gartland's classification system; forty-three (62%) of those fractures were stabilized with two pins and twenty-six (38%), with three pins. Fifty-five children had a type-3 fracture; nineteen (35%) of those fractures were stabilized with two pins and thirty-six (65%), with three pins. A comparison of perioperative and final radiographs showed no loss of reduction of any fracture. There was also no clinically evident cubitus varus, hyperextension, or loss of motion. There were no iatrogenic nerve palsies, and no patient required additional surgery. One patient had a pin-track infection. Our analysis of the eight clinical and radiographic failures of lateral pin fixation that were not part of the consecutive series showed that the loss of fixation was due to fundamental technical errors.

CONCLUSIONS

In this large, consecutive series without selection bias, the use of lateral-entry pins alone was effective for even the most unstable supracondylar humeral fractures. There were no iatrogenic ulnar nerve injuries, and no reduction was lost. The important technical points for fixation with lateral-entry pins are (1) maximize separation of the pins at the fracture site, (2) engage the medial and lateral columns proximal to the fracture, (3) engage sufficient bone in both the proximal segment and the distal fragment, and (4) maintain a low threshold for use of a third lateral-entry pin if there is concern about fracture stability or the location of the first two pins.

Ipsilateral supracondylar humerus fracture and Monteggia lesion: a case report

Two to 13% of supracondylar humerus fractures in children are associated with an ipsilateral forearm fracture, most of which are distal radius fractures. We present an unusual case of a 2-year-old girl with an ipsilateral supracondylar humerus fracture and a Monteggia lesion. Our management consisted of percutaneous K-wire fixation of the supracondylar humerus fracture and percutaneous insertion of an intramedullary K-wire for stabilization of the ulna fracture. Our patient had an excellent result, and we would recommend this method of fixation for similar injuries.

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

BACKGROUND

The purpose of this study was to evaluate the perioperative complication rates associated with early surgical treatment (eight hours or less following injury) and delayed surgical treatment (more than eight hours following injury) of displaced supracondylar humeral fractures in children.

METHODS

Fifty-two patients had early surgical treatment and 146 patients had delayed surgical treatment of a displaced supracondylar humeral fracture. The perioperative complication rates of the two groups were compared with the use of bivariate and multivariate statistical methods.

RESULTS

There was no significant difference between the two groups with respect to the need for conversion to formal open reduction and internal fixation (p = 0.56), pin-track infection (p = 0.12), or iatrogenic nerve injury (p = 0.72). No compartment syndromes occurred in either group. Power analysis revealed that our study had an 86% power to detect a 20% difference between the two groups if one existed.

CONCLUSIONS

We were unable to identify any significant difference, with regard to perioperative complication rates, between early and delayed treatment of displaced supracondylar humeral fractures. Within the parameters outlined in our study, we think that the timing of surgical intervention can be either early or delayed as deemed appropriate by the surgeon.

Upper extremity injuries in the paediatric athlete

Injuries to the upper extremity in paediatric and adolescent athletes are increasingly being seen with expanded participation and higher competitive levels of youth sports. Injury patterns are unique to the growing musculoskeletal system and specific to the demands of the involved sport. Shoulder injuries include sternoclavicular joint injury, clavicle fracture, acromioclavicular joint injury, osteolysis of the distal clavicle, little league shoulder, proximal humerus fracture, glenohumeral instability and rotator cuff injury. Elbow injuries include supracondylar fracture, lateral condyle fracture, radial head/neck fracture, medial epicondyle avulsion, elbow dislocation and little league elbow. Wrist and hand injuries include distal radius fracture, distal radial physeal injury, triangular fibrocartilage tear, scaphoid fracture, wrist ligamentous injury thumb metacarpalphalangeal ulnar collateral ligament injury, proximal and distal interphalangeal joint injuries and finger fractures. Recognition of injury patterns with early activity modification and the initiation of efficacious treatment can prevent deformity/disability and return the youth athlete to sport.

Evaluation of the role of pin fixation versus collar and cuff immobilisation in supracondylar fractures of the humerus in children

Long term results of children with supracondylar humeral fractures treated with manipulation and strapping and manipulation followed by pin fixation were evaluated. Forty patients were regarded as Gartland type II injuries. 33 of these were treated with closed reduction and collar and cuff immobilisation and 7 with closed reduction and percutaneous pinning. Two cases of cubitus varus were reported one from each treatment modality. Forty-four patients were included as Gartland type III injuries. Of these 14 were treated with closed reduction and collar and cuff immobilisation, 25 with closed reduction and percutaneous pinning and five with open reduction and pinning. There were two cases of cubitus varus and one case of cubitus valgus following pin fixation. In addition one case of extension lag and one significant ulnar nerve neurapraxia was recorded following pin fixation. One case of cubitus varus was seen following manipulation and collar and cuff treatment. There was no statistical difference between either treatment modality in terms of predicting a better outcome (p0.05). We conclude that pin fixation has no advantages over simple immobilisation in certain Gartland II and III type injuries. Although pin fixation is beneficial in unstable injuries collar and cuff immobilisation continues to have an important role in the treatment of stable supracondylar fractures.

Elbow Fractures in Children: Diagnosis and Management

Fractures about the elbow are very common in children, but the anatomy of the child's elbow may make the diagnosis less obvious than in a mature skeleton. An understanding of the ossification and fusion of the secondary growth centers about the elbow is essential to avoid overlooking these injuries and to optimize treatment. If plain radiographs are equivocal, an arthrogram of the elbow may clarify the anatomy and diagnosis. Early neurologic and vascular complications are not uncommon and must be recognized before fracture reduction. Many late complications, such as malunion, osteonecrosis, and physeal bridging, are largely preventable by correct early diagnosis and treatment. Anatomic reduction of articular surfaces, restoration of physeal anatomy, and near-anatomic alignment of fracture fragments in the frontal plane are the corner-stones of successful treatment of pediatric elbow fractures.