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

Effect of Antibiotic Prophylaxis on Infection Rates in Pediatric Supracondylar Humerus Fractures Treated with Closed Reduction and Percutaneous Pinning: A Prospective Double-Blinded Randomized Controlled Trial

BACKGROUND

Supracondylar humerus fractures (SCHFs) are the most common elbow fracture in the pediatric population. In the case of displaced fractures, closed reduction and percutaneous Kirschner wire pinning (CRPP) is commonly performed. Infection rates are between 0 and 7%; however, retrospective studies have shown no benefit of preoperative antibiotics. There continues to be notable variability in antibiotic usage based on surgeon preference and local institutional policy. We conducted a double-blinded, randomized controlled trial to evaluate whether antibiotic prophylaxis reduces the risk of infection in pediatric SCHF patients treated with CRPP.

METHODS

Pediatric patients with displaced SCHF who presented to a pediatric hospital were enrolled and randomized into two groups. Group I received one dose of prophylactic antibiotics (25 mg/kg cefazolin IV up to 1g or clindamycin 10 mg/kg up to 600 mg/kg IV in the case of cefazolin allergy). Group II received placebo (10-mL prefilled syringe of normal saline). All patients underwent CRPP and casting followed by pin removal 3 to 6 weeks after the initial procedure. The presence of pin-site infection, erythema, drainage, septic arthritis, and osteomyelitis was recorded.

RESULTS

One hundred sixty patients were enrolled in the study. Eighty-two patients were randomized to receive antibiotics, and 78 patients were randomized to placebo. No difference was seen in the rate of infection between the treatment groups (1.2% in the antibiotic group versus 1.3% in the placebo group; P = 1.00). Presence of purulent drainage (0.0% versus 1.3%; P = 0.49), septic arthritis (0.0% versus 0.0%; P = 1.00), and osteomyelitis (1.2% versus 0.0%; P = 1.00) was similar in both groups. No difference in the need for additional antibiotics (1.2% versus 1.3%; P = 1.00) or additional surgery (1.2% versus 0.0%; P = 1.00) was found between groups.

DISCUSSION

The use of antibiotic prophylaxis did not affect the risk of infection in pediatric patients who underwent CRPP for displaced SCHF.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov: NCT03261830.

LEVEL OF EVIDENCE

Therapeutic Level I.

Minimally invasive surgical technique for unstable supracondylar humerus fractures in children (Gartland type III or IV)

Background

Achieving and maintaining anatomical reduction during the treatment of pediatric humerus fractures, classified as Gartland type III or IV, presents a clinical challenge. Herein, we present a minimally invasive surgical approach using a novel and simple K-wire push technique that aids in achieving and maintaining anatomical reduction.

Methods

We reviewed data of children receiving treatment for supracondylar fractures of the humerus at our hospital between January 2016 and December 2020. Patients were divided into two groups based on the method of treatment: Group 1 was treated with the K-wire push technique, and Group 2 was treated with the standard technique as described by Rockwood and Wilkins. The medical records and radiographic images were reviewed. In total, 91 patients with Gartland types III and IV fractures were included, with 37 and 54 patients in Groups 1 and 2, respectively.

Results

The postoperative reduction radiographic parameters and Flynn scores at final follow-up were not significantly different between the two groups.

Conclusion

The minimally invasive K-wire push technique for unstable supracondylar fractures in children is a safe and effective alternative for improving reduction. Using this technique, complications can be minimized, and the requirement for open reduction can be reduced.

Review of pediatric functional outcomes measures used to evaluate surgical management in pediatric patients with an upper extremity fracture

For two decades, many scores, questionnaires, and rating systems have been used to evaluate the functional outcome of children with an upper extremity fracture (UEF). However, only a few of these were created specifically for children, and many assess only elbow function. In the absence of any published review on this topic, we set out to identify and categorize different scores used to evaluate the clinical and functional outcomes of surgically treated pediatric UEFs. A literature search was performed, and 38 studies were identified. The scores used more often were the shortened version of the Disability of the Arm, Shoulder and Hand questionnaire and the Mayo Elbow Performance Score/Index. In a lower number of studies, authors used other scoring systems, including the Mayo Wrist Score, the Patient-Rated Wrist Evaluation, the Patient-Rated Elbow Evaluation, the Métaizeau functional scoring system, the Oxford Elbow Score, the Price and Flynn criteria, the Hardacre Functional Score, the Neer Shoulder Score, the Constant-Murley Shoulder Score, the Modified Orthopedic Trauma Association Score, the Medical Outcomes Study Short Form-36, and the Pediatric Outcomes Data Collection Instrument. Some specific pediatric scoring systems to evaluate the functional outcome of children with a UEF have been suggested, but a single tool that is valid and reliable for skeletally immature patients of all ages is not yet available. Further studies are needed to identify specific pediatric measurements to increase validity, responsiveness, sensitivity, and interpretability of upper limb functional outcome scores in common clinical practice.

Indications for and Risks Associated With Implant Removal After Pediatric Trauma

A wide range of implants are used in the treatment of pediatric fractures, including wires, plates, screws, flexible rods, rigid rods, and external fixation devices. Pediatric bones differ from adult bones both mechanically and biologically, including the potential for remodeling. Implants used in pediatric trauma patients present a unique set of circumstances regarding indications, risks, timing of implant removal, weight-bearing restrictions, and long-term sequelae. Indications for implant removal include wire/pin fixation, when substantial growth remains, and infection. When considering implant removal, the risks and benefits must be assessed. The primary risk of implant removal is refracture. The timing of implant removal varies widely from several weeks to a year or more with the option of retention depending on the fracture, type of implant, and skeletal maturity of the patient.

Efficacy of Antibiotics in Supracondylar Fractures

BACKGROUND

Controversy exists surrounding antibiotic use in the setting of pediatric supracondylar humerus fractures treated with closed reduction and percutaneous Kirschner wire (K-wire) fixation. While the reported incidence of infection in the literature is low, surgeons frequently administer preoperative antibiotics. The purpose of this study was to retrospectively review preoperative antibiotic use and incidence of infection in children with supracondylar humerus fractures treated with closed reduction and K-wire fixation. It was hypothesized that antibiotic administration will not affect the incidence of infection following this procedure.

METHODS

We performed a retrospective review of 1053 patients with supracondylar humerus fractures treated with closed reduction and K-wire fixation at 3 institutions between 2006 and 2016. Patient demographics, antibiotic administration and follow-up data were reviewed in 905 patients.

RESULTS

Of 905 patients, 755 patients received preoperative antibiotics and 150 patients did not. The incidence of infection was 2.5% (n=22) in the group that received preoperative antibiotics and 2.0% in the group that did not receive antibiotics with an overall incidence of infection of 2.4%. The difference between groups did not reach significance (P>0.5). The majority of infections were treated with oral antibiotics with or without early pin removal. Four patients, all in the preoperative antibiotic group, required surgical debridement and intravenous antibiotics.

CONCLUSIONS

Retrospective review of the incidence of infection in closed reduction and percutaneous pinning of supracondylar humerus fractures found no difference between patients who received preoperative antibiotics and those who did not receive preoperative antibiotics.

LEVEL OF EVIDENCE

Level III-therapeutic.

Long-Term Outcomes of Operatively Treated Medial Epicondyle Fractures in Pediatric and Adolescent Patients

Purpose

Medial epicondyle fractures are among the most common pediatric elbow injuries. The management of these fractures continues to be debated. To better understand patient results with operative fixation, we reviewed the outcomes of operatively treated medial epicondyle fractures.

Methods

A retrospective review was performed to identify all patients less than 18 years of age at the time of injury who were treated surgically for medial epicondyle fractures. Outcomes were assessed based on the Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity and Pain Interference domains, Visual Analog Scale for pain, subjective range of motion, ulnar nerve function, and requirement for secondary surgery.

Results

We identified a cohort of 95 patients treated for a medial epicondyle fracture with open reduction and screw fixation. Of these, 39 patients with a mean age of 12.2 years (SD, 2.2 years; range, 7.6–16.0 years) at surgery were assessed for an average follow-up of 6.3 years (SD, 3.2 years; range, 2.2–13.9 years). Outcome measures and pain scores were excellent. The mean PROMIS Upper Extremity score was 56.9, the mean Pain Interference score was 38.5, and the mean Visual Analog Scale score was 0.4.Sixteen patients (41%) required secondary surgery for symptomatic hardware removal. Seven patients (18%) developed sensory complaints and 2 (5%) developed motor complaints consistent with ulnar nerve irritability. Three patients (8%) reported dissatisfaction with elbow range of motion. Patients who required secondary surgeries had higher (worse) PROMIS Pain Interference scores.

Conclusions

At an average of 6.3 years after surgery, the clinical outcomes for medial epicondyle fracture were excellent. While operative treatment for medial epicondyle fractures in children leads to excellent clinical outcomes, patients and surgeons should be aware of high rates of hardware removal.

Type of study/level of evidence

Therapeutic IV

Supracondylar Fractures: A Retrospective Chart Review Comparing Infection Rate, Antibiotic Use, Surgical Time and Cost of Full Surgical Preparation and Draping vs "Semi-Sterile" Technique

Background

Semi-sterile and full preparation and draping techniques are commonly used in closed reduction percutaneous pinning (CRPP) of supracondylar fractures. Debate exists whether full preparation and draping is safer than semi-sterile technique in regards to infection risk and the utility of pre-operative antibiotics. This study is a comparison of infection rates, pre-operative antibiotic administration, cost and surgical time between techniques.

Methods

A retrospective chart review of 336 pediatric patients with supracondylar fractures repaired with CRPP at our institution was completed between January 2014 and April 2018, 168 per technique. Infection rates, pre-operative antibiotic administration, preparation-to-incision time and cost in semi-sterile draping versus full preparation and draping techniques were compared.

Results

Of the 336 patients, 1/168 (0.1%) in the full preparation and draping group developed an infection compared to 0/168 (0%) patients in the semi-sterile group. Pre-operative antibiotics (Cefazolin) were administered to 76/168 (23%) patients in the full preparation and draping group and 0/168 (0%) in the semi-sterile group. The infection found received pre-operative antibiotics. Mean preparation-to-incision time for the semi-sterile group was 2.4±2.0 minutes and the full preparation and draping group was 9.9 ±4.2 minutes (p <0.001). Surgical supply cost was $80.72 [CDN] and 108.24$ [CDN], respectively, for the semi-sterile and full preparation and draping groups.

Conclusion

Risk of infection using a semi-sterile draping technique was safe and comparable to a full preparation and draping technique when used in CRPP of supracondylar fractures. The administration of pre-operative antibiotics does not appear to make a difference in infection rates. Semi-sterile operative technique is cost effective and has decreased preparation-to-incision time.

Mid-term Patient-reported Outcomes After Lateral Versus Crossed Pinning of Pediatric Supracondylar Humerus Fractures

BACKGROUND

Closed reduction and percutaneous pinning in a crossed or lateral configuration is the standard treatment for supracondylar humerus (SCH) fractures. We compared mid-term patient-reported outcomes (PROs), radiographic outcomes, and complication rates between patients treated with crossed versus lateral pinning.

METHODS

We reviewed 508 pediatric patients treated surgically for Gartland type-III SCH fractures from 2008 to 2017. We included patients aged 5 to 17 years at the time of telephone interviews, who had available radiographs. We excluded those unable to be reached by telephone; those who declined to be surveyed; and those lost to follow-up. Our sample comprised 142 participants (28%) (mean±SD age at surgery, 5.2±2.0 y), 93 (65%) of whom were treated with lateral pinning and 49 (35%) with crossed pinning. Participants' parents completed the Quick Disabilities of the Arm, Shoulder, and Hand and the Patient-Reported Outcomes Measurement Information System Parent Proxy at a mean 4.4 years (range: 2 to 10 y) postoperatively. Postoperative radiographs were reviewed to assess reduction. Bivariate analysis was performed to determine whether outcomes differed by pinning technique (α=0.05).

RESULTS

The proportions of participants achieving complete reduction were not significantly different between pin configuration groups (P=0.71). At follow-up, the 2 groups did not differ significantly in any PRO scores (all, P>0.05).

CONCLUSION

We found no differences between crossed and lateral pinning of Gartland type-III SCH fractures in terms of radiographic reduction, PROs, or complication rates at mid-term follow-up.

LEVEL OF EVIDENCE

Level III.

Doing Our Part to Conserve Resources: Determining Whether All Personal Protective Equipment Is Mandatory for Closed Reduction and Percutaneous Pinning of Supracondylar Humeral Fractures

BACKGROUND

Closed reduction and percutaneous pinning (CRPP) of supracondylar humeral fractures is one of the most common procedures performed in pediatric orthopaedics. The use of full, standard preparation and draping with standard personal protective equipment (PPE) may not be necessary during this procedure. This is of particular interest in the current climate as we face unprecedented PPE shortages due to the current COVID-19 pandemic.

METHODS

This is a retrospective chart review of 1,270 patients treated with CRPP of a supracondylar humeral fracture at 2 metropolitan pediatric centers by 10 fellowship-trained pediatric orthopaedic surgeons. One surgeon in the group did not wear a mask when performing CRPP of supracondylar humeral fractures, and multiple surgeons in the group utilized a semisterile preparation technique (no sterile gown or drapes). Infectious outcomes were compared between 2 groups: full sterile preparation and semisterile preparation. We additionally analyzed a subgroup of patients who had semisterile preparation without surgeon mask use. Hospital cost data were used to estimate annual cost savings with the adoption of the semisterile technique.

RESULTS

In this study, 1,270 patients who underwent CRPP of a supracondylar humeral fracture and met inclusion criteria were identified. There were 3 deep infections (0.24%). These infections all occurred in the group using full sterile preparation and surgical masks. No clinically relevant pin-track infections were noted. There were no known surgeon occupational exposures to bodily fluid. It is estimated that national adoption of this technique in the United States could save between 18,612 and 22,162 gowns and masks with costs savings of $3.7 million to $4.4 million annually.

CONCLUSIONS

We currently face critical shortages of PPE due to the COVID-19 pandemic. Data from this large series suggest that a semisterile technique during CRPP of supracondylar humeral fractures is a safe practice. We anticipate that this could preserve approximately 20,000 gowns and masks in the United States over the next year. Physicians are encouraged to reevaluate their daily practice to identify safe opportunities for resource preservation.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Supracondylar Humeral Fractures: An Audit of the Frequency of Bi-columnar Fixation and Intra-articular Wire Placement

Introduction For supracondylar humeral (SCH) fractures, biomechanical studies suggest the most stable wire configuration achieves bi-columnar fixation. Achieving medial column fixation using lateral-entry-only wires may require an intracapsular entry point. The aim of this study was to identify the rate of bi-columnar fixation achieved in our department when treating SCH fractures with percutaneous wire fixation. A secondary aim was to identify the rate of placement of an intra-articular wire. Further aims were to examine if failure to achieve bi-columnar fixation was associated with an increased loss of fixation and whether the placement of an intra-articular wire resulted in any cases of deep infection or septic arthritis. Material and methods All Gartland type 3 supracondylar humeral fractures, June 2014 to December 2016, were retrospectively identified. Intra-operative films were reviewed to determine bi-columnar fixation and the presence/absence of an intra-articular wire. Loss of reduction requiring revision and post-operative infections were determined from the electronic patient record. Results Of 49 supracondylar fractures identified, 42 were fixed with lateral-entry only wires (24 with two wires and 18 with three wires), and seven were fixed with medial/lateral cross wires (four with one lateral wire, two with two wires, and one with three wires). Bi-columnar fixation was achieved in 41/49 cases (84%). All cases where bi-columnar fixation was not achieved were fixed with lateral-entry-only wires. One out of 49 fractures (2%) required the revision of fixation at 10 days due to loss of reduction. In this case, the initial fixation was with two lateral-entry-only wires, without bi-columnar fixation. An intra-articular wire was present in 44 out of 49 cases (90%). One out of 49 cases (2%) had a superficial wound infection. There were no cases of deep infection or septic arthritis. Conclusion In our department, the rate of bi-columnar fixation was high and, in this group, no cases required revision fixation. One of eight cases judged to not have bi-columnar fixation initially, required revision due to loss of fixation. We contend that bi-columnar fixation generally achieves a stable wire configuration even using lateral-entry-only wires for SCH fractures. The rate of intra-articular wire placement was high; however, infection rates were low with no cases of septic arthritis.

Age does not affect the outcome after digital nerve repair in children - A retrospective long term follow up

BACKGROUND

Digital nerve injuries in children are not common, but they are considered to have an excellent prognosis, compared to adults, after nerve injury and repair. In studies including both children and adults age have been found to have an effect on outcome after nerve repair.

METHODS

We investigated in a retrospective follow up study the long-time result after digital nerve injury and repair in children, 1-16 years of age (n = 38), and evaluate if age influences outcome. A group with young children, 1-10 years of age (n = 18), was compared with a group with older children, 11-16 years of age (n = 20). A clinical evaluation to evaluate sensation and grip strength was performed and questionnaires were used [Disability of the Arm, Shoulder and Hand (DASH), Cold Sensitivity Severity Scale (CISS), VAS-function and VAS-cosmetic] in median 40 months (range 12-131 months) after the injury and repair.

RESULTS

All patient regained normal sensation. No correlations between age and monofilaments were found. Twenty children (52%) reported some problems with cold intolerance (i.e. CISS), but no other abnormal disability was found (i.e. DASH, VAS); again with no differences between the two groups.

CONCLUSIONS

Children have an excellent long-term recovery after a digital nerve repair and without any influence of age.

Management of pin tract infection in pediatric supracondylar humerus fractures: a comparative study of three methods

The objective of this study was to prospectively compare the incidence of pin tract infection in pediatric supracondylar humerus fractures managed with pin care daily or every other day or weekly. We hypothesized that there were some differences between these three methods. From June 2012 to May 2015, 135 children with supracondylar humerus fractures were randomized to postoperative pin care by cleaning pin tracts daily (group A, 45 cases) or cleaning every 2 days (group B, 45 cases) or cleaning weekly (group C, 45 cases). The three groups were comparable with respect to age, gender, affected side, body mass index (BMI), fracture type, injury to surgery time, number of intraoperative percutaneous pinning, and follow-up time. We collected data on pin retention time, union time, and pin tract infection. The average follow-up time of group A was 4.5 ± 1.3 and 4.2 ± 1.6 months in group B and 4.3 ± 1.4 months in group C. The patient demographics and intraoperative variables of three groups were comparable. No significant difference between these three groups was found in union time and pin fixation time. Of the 135 children, 48 (35.6%) cases had pin tract infection. Grade I infections (Checketts-Otterburns classification) occurred around 28.9% of 270 pin and grade II around 6.7%. We found no differences between three groups as regards frequency and severity of pin tract infections (both P > 0.05). However, complain of pain was more frequent in group A than other two groups (P < 0.05).

CONCLUSIONS

All of the three methods were effective for the management of pin site infection in pediatric supracondylar humerus fractures. However, excessive frequent care as well as pin care daily had the disadvantages of child's fear and parental anxiety. What is Known: • Pin site infection is a common complication after fracture fixation and bone lengthening using percutaneous pins or wires. • Closed reduction and percutaneous K-wires fixation are the mainstay of treatment in pediatric supracondylar humeral fractures. What is New: • All of the three methods were effective for the management of pin site infection. • Excessive frequent care as well as pin care daily has the disadvantages of child's fear and parental anxiety.

Multicenter Study of Pin Site Infections and Skin Complications Following Pinning of Pediatric Supracondylar Humerus Fractures

Introduction: Pediatric supracondylar humerus fractures are the most common elbow fractures in pediatric patients. Surgical fixation using pins is the primary treatment for displaced fractures. Pin site infections may follow supracondylar humerus fracture fixation; the previously reported incidence rate in the literature is 2.34%, but there is significant variability in reported incidence rates of pin site infection. This study aims to define the incidence rate and determine pre-, peri-, and postoperative factors that may contribute to pin site infection following operative reduction, pinning, and casting.

Methods: A retrospective chart analysis was performed over a one-year period on patients that developed pin site infection. A cast care form was added to Nemours’ electronic medical records (EMR) system (Epic Systems Corp., Verona, WI) to identify pin site infections for retrospective review. The cast care form noted any inflamed or infected pins. Patients with inflamed or infected pin sites underwent a detailed chart review. Preoperative antibiotic use, number and size of pins used, method of postoperative immobilization, pin dressings, whether postoperative immobilization was changed prior to pin removal, and length of time pins were in place was recorded.

Results: A total of 369 patients underwent operative reduction, pinning, and casting. Three patients developed a pin site infection. The pin site infection incidence rate was 3/369=0.81%. Descriptive statistics were reported for the three patients that developed pin site infections and three patients that developed pin site complications.

Conclusion: Pin site infection development is low. Factors that may contribute to the development of pin site infection include preoperative antibiotic use, length of time pins are left in, and changing the cast prior to pin removal.