Calculation of rotational deformity in pediatric supracondylar humerus fractures

The fate of the malrotated elbow supracondylar fractures in children: is varus really a problem?

PURPOSE

To evaluate the functional and cosmetic effects of elbow supracondylar fractures (SCF) in children with residual rotational deformity.

METHODS

Retrospective review cohort of patients with evidence of malrotation after treatment for SCF. An analysis of the postoperative X-ray of 305 consecutive SCF type 3 treated surgically during five years identified 46 elbows with rotational deformity that fulfilled the selection criteria and were recalled for review; only 27 patients agreed to participate. Patients were evaluated clinically and radiographically. Clinically, the elbow and shoulder ROM were assessed. The postoperative fracture rotation (PFR) was radiologically measured using the Berdis method. Results were categorized according to Flynn criteria, and functional outcomes were evaluated with the QuickDASH questionnaire. On final assessment, a radiograph of both elbows was obtained, and measures were compared. Descriptive analysis was made calculating median, range, proportions, and confidence intervals. Non-parametric tests were used to test the association between variables.

RESULTS

The group had a median age of four years and a median follow-up of 52 months. Shoulder rotation was asymmetrical in 13 patients; six patients presented a change on carrying angle > 5° (4 varus/2 valgus). The higher the residual rotation, the higher the chances of an altered shoulder rotation (for each degree of PFR, the shoulder rotation was changed to 0.4°). However, there was a low correlation between the amount of rotation and the final carrying angle (r = 0.37). According to Flynn's criteria, over 95% had excellent or good results.

CONCLUSION

There was a weak correlation between varus and rotational malalignment. Patients with moderate residual malrotation could be expected to have a good outcome even if some shoulder rotation changes persist.

Associated Factor and Long-Term Clinical Outcomes for Patients with Postoperative Rotational Malreduction in Pediatric Supracondylar Humeral Fractures

Background and Objectives: Long-term outcomes of immediately postoperative rotational malreduction in the axial plane after operative treatment of supracondylar humeral fractures (SCHF) are unknown. This study aimed to investigate the long-term clinical outcomes and associated factors for immediately postoperative rotational malreduction of SCHF. Materials and methods: In this retrospective case-control study, 88 patients who underwent surgery for Gratland type III SCHF were enrolled between January 2012 and January 2020. Among them, 49 patients had immediately postoperative malrotational reduction (rotational malreduction group) and 39 patients had no rotational deformity (control group). To evaluate the associated factors for immediately postoperative rotational malreduction, demographic data, fracture patterns, physical examination signs, and preoperative radiological parameters were analyzed. To compare the clinical outcomes, operation time, range of motion of the elbow, time from operation to full range of motion, and Flynn criteria were evaluated. The Oxford elbow score was used to investigate long-term clinical outcomes for patients five years after operation. Results: The mean age was 5.7 ± 2.3 years and mean follow-up period was 15.7 ± 4.0 months. The rotational malreduction group had significantly more patients with oblique fracture pattern (p = 0.031) and Pucker sign (p = 0.016) and showed a significantly longer operative time (p = 0.029) than the control group. Although there was no significant difference in the range of elbow motion and the Flynn criteria, the Kaplan-Meier survival curve showed a longer time to recover the full range of elbow motion in the rotational malreduction group (p = 0.040). There were no significant differences in the long-term clinical outcomes assessed using the Oxford elbow score (p = 0.684). Conclusions: Oblique fracture pattern and Pucker sign may be associated with immediately postoperative rotational malreduction in the axial plane. Although patients with immediately postoperative rotational malreduction showed favorable results of long-term clinical outcomes, they required more weeks to recover the full range of elbow motion.

Assessment of the Gordon lateral rotation index in postoperative rotational evaluation of supracondylar humerus fractures: a study on validity, reliability, and applicability

There are several methods for the assessment and follow-up of reduction of supracondylar humerus fractures, which offer the possibility of evaluation in different planes. The Gordon lateral rotation index (GLRI) is one of the methods used to assess the axial plane. This study aims to evaluate the validity, reliability, and applicability of the GLRI to assess rotational alignment. The study included 50 patients with Gartland type 3 supracondylar humerus fracture. After closed reduction, fixation with 2 lateral pins and 1 medial pin was applied to all patients. Eight observers made measurements using follow-up radiographs in the early postoperative period and at the 3rd week. Gordon lateral rotation percentage (GLRP) significantly decreased from baseline to week 3 in all participants (P < 0.01). When the intraclass correlation coefficient (ICC) between the GLRP measurements of the observers in the early postoperative period was examined, a moderate agreement of 0.453 was seen between measurements of the observers (ICC = 0.453; P = 0.001; P < 0.01). When the ICC between the 3rd week GLRP measurements of the observers was analyzed, poor agreement of 0.294 was seen (ICC = 0.294; P = 0.001; P < 0.01). The GLRI has moderate validity, applicability, and reliability in the early postoperative period, and low validity, applicability, and reliability in the follow-up period. Consequently, GLRI is an objective method that can be used to assess rotational alignment in the early postoperative period of supracondylar humerus fractures. It is, however, not recommended for follow-up periods.

The effects of postoperative malrotation alignment on outcomes of Gartland type III/IV paediatric supracondylar humeral fractures treated by close reduction and percutaneous K-wire fixation

PURPOSE

In this study, we aimed to investigate the effects of postoperative malrotation alignment on the outcomes of Gartland type III/IV paediatric supracondylar humeral fracture (SCHF) treated by close reduction and percutaneous K-wire fixation.

METHODS

Between January 2014 and December 2021, 295 Gartland type III/IV paediatric SCHFs treated by close reduction and percutaneous K-wire fixation were selected for this retrospective study. The demographic, clinical and radiographic parameters of all cases were collected. The lateral rotation percentage (LRP) was measured on X-rays to evaluate postoperative malrotation alignment of the fracture. All cases were categorized into 4 groups according to LRP: LRP ≤ 10% (210, 71.2%), 10% < LRP ≤ 20% (41, 13.9%), 20% < LRP ≤ 30% (26, 8.8%) and LRP > 30% (18, 6.1%). The carrying angle, ranges of multidirectional motions, Mayo Elbow Performance Score (MEPS) and Flynn's Standard Score (FSS) of the injured elbow were assessed 6 months postoperation and compared among different groups. ROC analysis based on LRP and the excellent/good rate of FSS was performed to determine the acceptable maximum degree of postoperative malrotation alignment.

RESULTS

There was no difference in the demographic characteristics (age, sex, injured side and fracture type), postoperative Baumann angle, carrying angle or range of forearm rotation among the 4 groups (P > 0.05). The operation time and time from operation to K-wire removal were longer in the 20% < LRP ≤ 30% and LRP > 30% groups than in the LRP < 10% and 10% < LRP ≤ 20% groups (P < 0.001). The shaft condylar angle, range of elbow flexion, MEPS and FSS of the injured elbow 6 months postoperatively were lower in the 20% < LRP ≤ 30% and LRP > 30% groups than in the LRP < 10% and 10% < LRP ≤ 20% groups (P < 0.001). ROC analysis based on LRP and the excellent/good rate of FSS showed an area under the curve of 0.959 (95% CI 0.936-0.983), with a cutoff value of 26.5%, sensitivity of 95.3% and specificity of 90.1%.

CONCLUSION

A certain degree of residual malrotation alignment deformity of the SCHF may reduce the shaft condylar angle and extend the time from operation to removing the K-wire and affect elbow function, especially the range of elbow flexion. The acceptable maximum degree of residual malrotation deformity expressed as the LRP value was 26.5%.

Reliability of Gordon Lateral Rotation Percentage and Prabhakar Percentage of Metaphyseal Overhang for Pediatric Supracondylar Humerus Fracture; Is it Clinically Reliable for John Hopkins Classification Coronal Fracture Subtypes?

BACKGROUND

Rotational malalignment is a common problem in pediatric supracondylar humerus fractures (SCHF). Several techniques have been described to evaluate the true rotation value. Although the Prabhakar and Gordon techniques are used frequently, their superiority to each other in terms of measurement quality is unknown.

QUESTIONS/PURPOSES

The aim of this study was to investigate the clinical compatibility of the 2 techniques and to evaluate whether they are suitable for all subtypes.

METHODS

This cross-sectional study included 40 patients with SCHF (including subtypes; Typical, Medial Oblique, Lateral Oblique, and High fracture pattern). The Gordon lateral rotation percentage and Prabhakar percentage of metaphyseal overhang were measured twice by 4 experienced Orthopedics and Traumatology surgeons at 8-week intervals. The interobserver and intraobserver reliability were examined using the intraclass correlation coefficient.

RESULTS

The interobserver reliability for Gordon and Prabhakar technique was 0.816 and 0.762 for the first measurement and 0.811 and 0.811 for the second measurement, respectively.The medial oblique fracture pattern was determined to have the best interobserver agreement among the subtypes. The result was excellent for the medial and lateral oblique subtypes, good for the typical fracture pattern, and fair for the high fracture pattern. The intraobserver reliability for Gordon and Prabhakar technique was excellent, 0.924 and 0.922, respectively.

CONCLUSION

The main finding of this study was that the Gordon and Prabhakar techniques have similar interobserver and intraobserver reliability. Although the Gordon technique tends to have higher interobserver reliability, the difference was clinically insignificant. These measurements should not be relied upon in cases of SCHF with a high fracture pattern because of the different anatomic features of that region.

LEVEL OF EVIDENCE

Level III.

Radiological and Clinical Outcomes of Pediatric Patients With a Supracondylar Humerus Fracture Surgically Treated With Closed Reduction and Percutaneous Pinning

OBJECTIVES

It was aimed to evaluate the clinical and radiological results of patients operated on with closed reduction and pinning due to pediatric supracondylar humerus fractures.

MATERIALS AND METHODS

The radiological and clinical results of 100 patients operated on with closed reduction and percutaneous pinning for pediatric supracondylar humerus fractures in the Department of Orthopedics and Traumatology were examined between January 2015 and February 2022. Clinical results were evaluated by performing cosmetic and functional scores defined by Flynn. Closed reduction and percutaneous pinning techniques were used in surgical treatment.

RESULTS

In our study, 59 patients were male (59%), and 41 were female (41%). The average age of all patients is 6.21 ± 2.85 years. According to the Gartland classification, 21 patients' fractures were type IIA (21%), 12 patients' fractures were type IIB (12%), 51 patients' fractures were type III (51%), and 16 patients' fractures were type IV (16%). The average number of pins used in the treatment is 2.55 ± 0.50. The elbow bearing angle of the operated side of the patients was an average of 6.53 ± 3.29 degrees, the humerocapitellar angle was an average of 41.97 ± 3.08 degrees, and the lateral humerocapitellar angle was an average of 50.17 ± 3.58 degrees. Fifty-one patients had stage 0 (51%), 23 patients had stage 1 (23%), 23 patients had stage 2 (23%), and three patients had stage 3 (3%) residual sagittal plane deformity. According to the Flynn criteria, 92 patients had excellent functional results (92%), seven patients had good results (7%), and one patient had fair results (1%). Regarding cosmetic results, 91 patients had excellent results (91%), six patients had good results (6%), and three patients had fair results (3%).

CONCLUSION

Supracondylar humerus fractures are common in children and can cause serious complications. Closed reduction and percutaneous pinning techniques are effective treatment methods in the treatment of displaced supracondylar humerus fractures.

Is radiological rotation measurement affected by the fracture pattern in pediatric supracondylar humeral fractures?

BACKGROUND

In supracondylar humerus fractures (SCHF), the most frequently used method to calculate rotation is the Gordon lateral rotation percentage (GLRP) defined by Gordon et al. However, this technique includes only typical fractures (49%-80% of all fractures) from the Johns Hopkins (J-H) fracture classification system.

PURPOSE

The aim of the study was to investigate (1) is Gordon criteria useful for John Hopkins subgroups of supracondylar fractures and (2) is Gordon criteria affected by internal and external rotation.

MATERIAL AND METHODS

This study was designed using four pediatric left humerus bones obtained from the Sawbone© company. For each bone, an osteotomy was made to mimic each of the J-H coronal fracture patterns. The cut bones were placed in a wooden rotation apparatus. The GLRP measurements were taken by five blinded observers.

RESULTS

In the repeated measurements of the observers, <20° rotation typical and <30° medial oblique and lateral oblique fracture pattern were measured as within the limits of an acceptable amount of rotation according to the Gordon criteria. However, for high fracture pattern (HFP), ≤30° internal rotation and <60° external rotation were determined to be within the acceptable rotation criteria according to the Gordon criteria.

CONCLUSIONS

All fracture patterns have different characteristics; however, based on the data of this study, the Gordon criteria can be used safely for typical, medial oblique, and lateral oblique fracture patterns but it is necessary to lower the acceptable rate of 50% for HFP.

Fully displaced pediatric supracondylar humerus fractures: Which ones need to go at night?

BACKGROUND

Challenges remain in determining which displaced supracondylar humerus fractures are safe to postpone surgical treatment until daylight hours. The purpose of this study is to determine which characteristics can be identified to guide the timing of treatment of supracondylar humerus fractures.

METHODS

225 completely displaced Gartland extension type 3/4 supracondylar humerus fractures in healthy patients that presented between 6 am and 7 am were identified. Data were collected retrospectively. Data analysis included univariate, multivariable logistic regression and classification and regression tree analysis.

RESULTS

5% (78/225) underwent surgical treatment the night they presented, while 65% (147/225) were treated the next day. Overall complication rate was 6%, with no difference based on timing of surgery. 12% (28/225) presented with a motor nerve injury, while 6% (14/225) a "pink pulseless" extremity. Statistical analysis found the most reliable radiographic predictor to be the maximum displacement on the anterior-posterior or lateral view. Classification and regression tree analysis developed a clinical algorithm; patients with a "pink pulseless" extremity or motor nerve injury were recommended for surgery overnight, while those with an anterior-posterior or lateral view < 25 mm were recommended for surgery the next day.

CONCLUSION

This study provides guidance on the timing of treatment for displaced supracondylar humerus fractures that present overnight. We provide a simple algorithm with three key clinical predictors for timing of treatment: presence of a "pink pulseless" arm, presence of a motor nerve injury, and displacement of any cortex by at least 25 mm (anterior-posterior or lateral view). This provides a step forward to help practitioners make safer evidenced-based timing decisions for their patients.

LEVEL OF EVIDENCE

Prognostic Study, Level II.

Standalone Axial Malrotation after Pediatric Supracondylar Fracture Does Not Seem to Be an Indication for Immediate Postoperative Revision Surgery

Rotational spurs as evidence for post-surgical malrotation are frequently observed when treating pediatric supracondylar humeral fractures (SCHFs). This study aimed to investigate the long-term outcome of a pediatric cohort with unrevised axial malrotation and to discuss the indication for revision surgery. Postoperative radiographs of children treated for SCHFs over eight years were retrospectively analyzed. Children with radiological signs of malrotation (von Laer malrotation quotient) were invited for a follow-up clinical and radiological examination. Among 338 treated children, 39 (11.5%) with a mean age of 5.3 years (range 1.8–11.7 years) showed radiological signs for postoperative malrotation and were not revised and therefore invited to participate in the study. Twelve patients (31%) with a mean age of 11.3 years (range 8.8–13.8 years) took part in the follow-up examination after a mean of 7.1 years (range 5.4 to 11.3 years). The mean postoperative van Laer malrotation quotient was 0.15 (range 0.11–0.2). At follow-up, the range of motion of the elbow joint was not significantly different compared to the contralateral side. Apart from the humeral ulnar angle (p = 0.023), there were no significant differences in the radiological axes. The Flynn criteria were excellent and good in 90% of the cases. The mean was 1.7 points indicating excellent subjective results. Standalone postoperative malrotation did not lead to an adverse long-term outcome in a small cohort of pediatric patients with SCHFs and did not indicate immediate postoperative revision surgery. However, further investigations with larger cohorts should verify whether additional criteria such as stability of the osteosynthesis and signs for increasing valgus or varus displacement in the follow-up radiographs should get more importance in decision making.

Effect of rotational deformities after pediatric femoral fracture on clinical outcome

Femoral shaft fractures are the most common pediatric injuries that require hospitalization. Early closed reduction and spica casting are one of the most popular treatment options. One of the significant complications of spica casting is rotational deformities of the fracture. The present study aimed to determine the potential effects of rotational deformities in pediatric patients who underwent early spica casting after a femoral shaft fracture. Pediatric patients who underwent early spica casting following femoral shaft fractures were screened retrospectively. Radiological measurements were made on the patients' initial postop radiographs who could be measured rotationally according to the defined radiological method. Twenty-three patients with more than 10° of rotation in their measurements were included in the study. Differences in leg length and rotation between both legs were calculated with clinical examination methods for all patients in the study. The gaits of the patients were observed; patient and family complaints were obtained. We found a strong and positive correlation between the rotational measurement made on the X-ray and the clinical measurement (R: 0.634, P: 0.001). For measurements made on X-ray, the mean rotational value was calculated as 27.2 ± 6.9 degrees. After the patients' clinical examination, an average of 3.0 ± 1.7 degrees rotational difference was found between the broken limb and the healthy limb. No patient or family complained of trauma. Early spica casting, according to the age of the patient, is an effective treatment method. There may still be certain degrees of deformity after treatment, but patients well tolerate them even at high degrees. Accordingly, it was concluded that the rotational deformities less than 30 degrees would not cause clinical problems on children under 4 years of age which may require postoperative revisions or the use of various costly imaging techniques and include radiation.

Range of motion following percutaneous fixation of pediatric supracondylar humerus fracture is independent of anterior osseous fragment resorption

The objective of this study was to understand postoperative resorption of the anterior osseous fragment following closed reduction and percutaneous pinning (CRPP) of pediatric supracondylar humerus fractures and its effect on final range of motion (ROM). Eighty-six patients that underwent CRPP had sagittal and or axial plane deformities resulting in an anterior fragment. Humerocapitellar angle (HCA), anterior humeral line (AHL) and angle of rotation (AoR) were measured. A total of 11 (12.8%) patients failed to resorb the anterior fragment, 10 (90.9%) had satisfactory ROM. HCA initially was acceptable in 40 (46.5%) patients, and 37 (92.5%) demonstrated acceptable ROM. Final HCA was acceptable in 44 (51.2%) patients and 42 (95.4%) had acceptable final ROM. AHL was in the anterior third of the capitellum in 35 (40.6%) patients and 33 (94.3%) had acceptable ROM. Final AHL was in the anterior third of the capitellum in 43 (50.0%) patients and 41 (95.3%) had acceptable final ROM. No difference was found between acceptable ROM and HCA or AHL at either follow-up. Sixty-five and 21 patients had an AoR of 0° and between 23 and 36°, respectively. A total of 59 (90.7%) patients with an AoR of 0°, and 18 (85.7%) patients with an AoR of 23-36° displayed acceptable ROM. A total of 57 (87.7%) patients with an AoR of 0° and 18 (85.7%) with an AoR of 23-36° resorbed the anterior fragment. No association was found between rotational deformity and postoperative ROM or fragment resorption. Postoperative sagittal and axial plane alignment, HCA, AHL, AoR and resorption of the anterior osseous fragment does not correlate with final ROM.

Spontaneous humeral torsion deformity correction after displaced supracondylar fractures in children

BACKGROUND

After displaced supracondylar humerus fractures (SCHF) in children, residual deformities are common with cubitus varus (CV) being the clinically most visible. Distal fragment malrotation may lead to instability, fragment tilt and subsequent CV. Detection and assessment of malrotation is difficult and the fate of post-traumatic humeral torsion deformity is unknown. The aim of this study was to evaluate the incidence of humeral torsion differences in children with surgically treated SCHF and to observe spontaneous changes over time.

METHODS

A cohort of 27 children with displaced and surgically treated SCHF were followed prospectively from the diagnosis until twelve months after trauma. Clinical, photographic, sonographic and radiological data were obtained regularly. Differences in shoulder and elbow motion, elbow axis, sonographic humeral torsion measurement and radiological evaluation focusing on rotational spur were administered.

RESULTS

Six weeks after trauma, 67% of SCHF children had a sonographically detected humeral torsion difference of > 5° (average 14.0 ± 7.6°). Of those, 44% showed a rotational spur, slight valgus or varus on radiographs. During follow-up, an average decrease of the difference from 14° (six weeks) to 7.8° (four months) to 6.5° (six months) and to 4.9° (twelve months) was observed. The most significant correction of posttraumatic humeral torsion occurred in children < 5 years and with internal malrotation > 20°.

CONCLUSION

After displaced and surgically treated SCHF, most children had humeral torsion differences of both arms. This difference decreased within one year after trauma due to changes on the healthy side or correction in younger children with severe deformity.

LEVEL OF EVIDENCE/CLINICAL RELEVANCE

Therapeutic Level IV.

Assessment of Lateral Rotation Percentage and Rotational Deformity of the Elbow in Type 3 Supracondylar Humerus Fractures: A Biomechanical Study

BACKGROUND

Supracondylar humerus (SCH) fractures are the most common elbow fractures in children. Historically, displaced (Gartland type 3) SCH fractures have been treated with closed reduction and percutaneous pinning. Fluoroscopic imaging is used intraoperatively in order to assess adequate reduction of the fracture fragments before pinning. On lateral fluoroscopic and radiographic images, a lateral rotation percentage (LRP) can be estimated in order to assess rotational deformity. The purpose of this study was to determine the true rotational deformity of distal humerus fracture fragments in SCH fractures based upon the LRP using a clinically relevant laterally based pinning technique.

METHODS

In this study, a sawbones model was used to examine the correlation between calculated LRP and the true degree of rotational deformity with 3 of the most common extension-type SCH fracture types (low transverse, high transverse, and lateral oblique). Because fracture stability was not the focus of this study, a single pin was used to hold the construct and allow for fragment rotation along a fixed axis. In this study, 2 of the authors independently measured rotational deformity and compared this with LRP on fluoroscopic lateral imaging of a sawbones model at 0 to 45 degrees of rotational deformity.

RESULTS

The LRP of all 3 patterns demonstrated a near linear increase from 0 to 45 degrees with maximum LRP measured at 45 degrees for each of the 3 patterns. Univariate linear regression demonstrated an increase in LRP for the low transverse pattern of 2.02% for every degree of rotation deformity (R2=0.97), 2.29% for the lateral oblique pattern (R2=0.986), and 1.17% for the high transverse pattern (R2=0.971). Maximum LRP was measured at 45 degrees for all 3 patterns with a mean of 53.5% for the high transverse pattern, 93.5% for the low transverse pattern, and 111.2% for the lateral oblique pattern. A higher LRP was measured with increasing degrees of rotational displacement in the low transverse and lateral oblique patterns for all degrees of rotational deformity compared to the high transverse pattern.

CONCLUSION

There is a near linear correlation between the degree of malrotation and the LRP with more superior metaphyseal fracture patterns demonstrating a lower LRP than inferior fracture patterns.

CLINICAL RELEVANCE

Using our data one can estimate the degree of malrotation based on the LRP on radiographs in the clinical setting.

LEVEL OF EVIDENCE

Not applicable (basic-science article).

Radiographic assessments of pediatric supracondylar fractures and mid-term patient-reported outcomes

Radiographic parameters are commonly used to determine the need for surgical supracondylar humeral (SCH) fracture reduction and the postoperative quality of reduction. We studied whether such parameters are correlated with mid-term patient-reported outcome (PRO) scores in pediatric patients.We retrospectively reviewed data from 213 patients (104 girls) treated surgically for Gartland type-II (n = 84) or type-III (n = 129) SCH fractures from 2008-2016. Mean (± standard deviation) age at surgery was 5.1 ± 2.1 years. Mean time from initial treatment to outcome survey completion was 5.0 ± 2.1 years (range, 2.0-10 years). We evaluated preoperative radiographs for coronal/sagittal fracture displacement, presence of impaction/comminution, Gartland classification, and rotation. Patients, parents were asked via telephone to complete the QuickDASH (Quick Disability of the Arm, Shoulder, and Hand) and PROMIS (Patient-Reported Outcomes Measurement Information System) Strength Impact, Upper Extremity, and Pain Interference questionnaires. Parents were also asked whether the previously fractured arm appeared normal or abnormal. We evaluated postoperative radiographs for coronal/sagittal deformity, Baumann angle, and rotation and classified reductions as near complete/complete or incomplete. Anterior humeral line through the capitellum, Baumann angle in the 7.5th to 92.5th percentile of the sample, or rotation ratio between 0.85 and 1.15 were considered near complete/complete reductions; all others were considered incomplete. Bivariate analysis was used to determine whether radiographic parameters and arm appearance were associated with QuickDASH and PROMIS scores.Patients with Gartland type-III fractures had significantly greater disability on the QuickDASH at follow-up compared with those with Gartland type-II fractures (P < .01). It is unknown if this statistical difference translates to clinical relevance. No other preoperative or postoperative radiographic parameter was significantly associated with PRO scores. There was no association between fractured arm appearance at follow-up and PRO scores.Radiographic parameters that are used to evaluate the need for and quality of pediatric SCH fracture reduction are not significantly associated with mid-term PROMIS and QuickDASH scores.LOE: Prognostic Level III.

Can We Estimate the Amount of Malrotation in Supracondylar Humerus Fractures After CRPP?

BACKGROUND

Acceptable amounts of malrotation after CRPP for pediatric supracondylar humerus fracture (SCHFx) have yet to be defined. This is an attempt to correlate radiographic parameters of a malrotated SCHFx with degrees of rotational malalignment to assist intraoperative assessment of reduction.

METHODS

3D models of a left distal humerus were printed, simulating a transverse SCHFx with 5, 10, 15, 20, 25, and 30 degrees of malrotation. Four different scenarios were developed: (1) lateral cortical axis of rotation, (2) medial cortical axis of rotation, (3) centroid of the humerus longitudinal axis with the medial condyle rotated posteriorly, and (4) centroid of the humerus longitudinal axis with the medial condyle rotated anteriorly. Anteroposterior and lateral fluoroscopic views were taken with a consistent image profile. Five observers measured the amount of metaphyseal overhang on the lateral view and the width of the distal humerus just proximal to the fracture to establish amount of overhang as a percentage of distal humerus width. Regression analysis established "best fit" lines for the 4 scenarios. Ten observers used the observed characteristics of each type of malrotation and "best fit" lines to estimate axis and degrees of malrotation using the same fluoroscopy of the 24 models.

RESULTS

The intraclass correlation coefficient of reliability for percentage of metaphyseal overhang ranged from 0.775 to 0.987. Observers correctly predicted axis of malrotation in 76% and correctly predicted amount of malrotation in 75% of models.

CONCLUSIONS

Estimation of axis of malrotation and degrees of malrotation within 5 degrees in SCHFx can be predicted in 75% of our 3D printed models.

Does the Modified Gartland Classification Clarify Decision Making?

HYPOTHESIS

The modified Gartland classification system for pediatric supracondylar fractures is often utilized as a communication tool to aid in determining whether or not a fracture warrants operative intervention. This study sought to determine the interobserver and intraobserver reliability of the Gartland classification system, as well as to determine whether there was agreement that a fracture warranted operative intervention regardless of the classification system.

METHODS

A total of 200 anteroposterior and lateral radiographs of pediatric supracondylar humerus fractures were retrospectively reviewed by 3 fellowship-trained pediatric orthopaedic surgeons and 2 orthopaedic residents and then classified as type I, IIa, IIb, or III. The surgeons then recorded whether they would treat the fracture nonoperatively or operatively. The κ coefficients were calculated to determine interobserver and intraobserver reliability.

RESULTS

Overall, the Wilkins-modified Gartland classification has low-moderate interobserver reliability (κ=0.475) and high intraobserver reliability (κ=0.777). A low interobserver reliability was found when differentiating between type IIa and IIb (κ=0.240) among attendings. There was moderate-high interobserver reliability for the decision to operate (κ=0.691) and high intraobserver reliability (κ=0.760). Decreased interobserver reliability was present for decision to operate among residents. For fractures classified as type I, the decision to operate was made 3% of the time and 27% for type IIa. The decision was made to operate 99% of the time for type IIb and 100% for type III.

SUMMARY

There is almost full agreement for the nonoperative treatment of Type I fractures and operative treatment for type III fractures. There is agreement that type IIb fractures should be treated operatively and that the majority of type IIa fractures should be treated nonoperatively. However, the interobserver reliability for differentiating between type IIa and IIb fractures is low. Our results validate the Gartland classfication system as a method to help direct treatment of pediatric supracondylar humerus fractures, although the modification of the system, IIa versus IIb, seems to have limited reliability and utility. Terminology based on decision to treat may lead to a more clinically useful classification system in the evaluation and treatment of pediatric supracondylar humerus fractures.

LEVEL OF EVIDENCE

Level III-diagnostic studies.

Measurement of Malrotation on Direct Radiography in Pediatric Distal Radius Fractures: Prospective Observational Study

The aim of this prospective study was to test a mathematical method of measuring the malrotation of pediatric distal radius fractures (PDRFs) from direct radiographs. A total of 70 pediatric patients who presented at the Emergency Department with a distal radius fracture were evaluated. For 38 selected patients conservative treatment for PDRF was planned. Anteroposterior and lateral radiographs were taken of all of the patients for comparison before and after reduction. Radius bone diameters were measured in the coronal and sagittal planes on the healthy and fractured sides. Using the diameter values on the healthy side and the new diameter values on the fractured side in the rotation formula, the degree of malrotation between the fracture ends was calculated. The mean follow-up period was 13.5 months. Patients' mean age was 10.00 ± 3.19 years (range, 4-12 years). The rotation degree in the sagittal plane significantly differed between the proximal (26.52°±2.84°) and distal fracture ends (20.96°±2.73°) (P = 0.001). The rotation degree in the coronal plane significantly differed between the proximal (26.70°±2.38°) and distal fracture ends (20.26°±2.86°) (P = 0.001). The net rotation deformity of the fracture line was determined to be 5.55°± 3.54° on lateral radiographs and 5.44°± 3.35° on anteroposterior radiographs, no significant difference was observed between measurements (P >0.05). The malrotation deformity in PDRF occurs with greater rotation in the proximal fragment than in the distal fragment. The net rotation deformity created between the fracture ends can be calculated on direct radiographs.

LEVEL OF EVIDENCE

Diagnostic, Level II.

Calculation of pediatric femoral fracture rotation from direct roentgenograms

Background

Radiologic determination of pediatric femoral fracture rotation has been debated. Measuring the antetorsion angle of the fractured femur by computed tomography and comparing it with the opposite side has been the method of choice for this purpose. However, no simple method for direct measurement of femoral fracture rotation exists in the literature. In this study, our aim was to test a mathematical method of measuring the axial plane malrotation from direct roentgenograms.

Materials and methods

A pediatric femoral shaft fracture model was produced. The bone was secured to a wooden frame that allowed the distal part of the fracture to rotate around an axis. Radiographs were taken at known intervals of rotation ranging from the neutral position to 60° external rotation and to 60° internal rotation in 5° increments of rotation. Five independent, blinded observers measured the radiographs and calculated the fracture rotation according to a standard formula. Calculated rotation values were compared with known rotation values.

Results

Calculated rotation values were close to actual rotation values throughout the arc of rotation. The mean absolute error of five observers for all measurements of external and internal rotation was 3.97° (±0.83). The correlation coefficient between calculated and actual rotation values was 0.9927. The interobserver intraclass correlation coefficient for calculated rotation was 0.997.

Conclusions

Absolute error and correlation coefficient values indicate that this method is accurate and reliable in determining the fracture rotation.

Adequacy of treatment, bone remodeling, and clinical outcome in pediatric supracondylar humeral fractures

The aim of this study was to evaluate and compare, both clinically and roentgenographically, 62 extension-type supracondylar fractures on the basis of the synthesis method and severity of the fracture, with a mean follow-up of 4 years and 3 months. Range of motion, axial alignment of the elbow, muscle strength, and joint stability were estimated and the Mayo Elbow Performance Index and the Pediatric Orthopaedic Society of North America Pediatric Outcomes Data Collection Instrument questionnaire were used. Furthermore, we took radiographic measurements (Baumann's angle, humero-capitellar angle, and lateral rotational percentage). According to Flynn criteria, the clinical outcome of all our patients was satisfactory. According to the results of the questionnaires, no patients has reported any disabling limitation of the elbow function. Radiographic study proved a greater capacity of remodeling in the sagittal plane compared with the frontal one, irrespective of severity of fracture assessed by the Gartland classification. Statistical analysis stressed the validity of postoperative Baumann's angle as a predictor of final carrying angle. With regard to the synthesis method, the best way to approach Gartland II fractures proved to be by closed reduction and percutaneous pinning; the use of a third Kirschner wire in the treatment of Gartland III fractures did not lead to a better result. To conclude, remodeling positively influenced the clinical outcome, however, irrespective of synthesis method and severity of the fracture, we should pay more attention to the adequacy of reduction in frontal plane than in the sagittal one, for which a greater capacity of remodeling was proved.