Diagnostic arthroscopy in the treatment of minimally displaced lateral humeral condyle fractures in children

Arthroscopically assisted closed reduction for displaced lateral humeral condyle fractures over 4 mm in children

INTRODUCTION

Lateral humeral condyle fractures (LHCFs) are the most common intra-articular fracture occurring at the elbow in children. Conventional treatment for displaced pediatric LHCFs is open reduction and percutaneous pinning, and few studies have regarded the efficacy of arthroscopic-assisted techniques. We aimed to evaluate the efficacy of anatomic reduction via elbow arthroscopy for pediatric humeral lateral condyle fractures with displacements >4 mm.

METHODS

A total of 32 children with LHCFs featuring displacements >4 mm were enrolled in this retrospective study. Arthroscopically assisted reduction was performed as the primary treatment approach. For simple displaced fractures, arthroscopically assisted reduction was directly employed with intermittent intra-articular irrigation. For fractures with distal fragment rotation, the rotated fragments were firstly realigned into a simple displaced position under fluoroscopy before proceeding with arthroscopy. The success rate of arthroscopically assisted reduction and clinical outcomes at the latest follow-up were assessed, and complications related to the procedure were monitored.

RESULTS

Twenty-nine of 32 (90.62 %) enrolled cases were successfully treated with arthroscopically assisted reduction. Failure cases were attributed to soft tissue swelling, which hindered the manipulation of the fracture fragments for reduction or fixation. We subsequently adapted the surgical procedure, resulting in a significant increase in the success of arthroscopically assisted reduction, rising from 71.43 % to 96 %. Among the 29 successfully treated cases, excellent functional outcomes were observed in 18 cases, and 11 cases showed good outcomes. Regarding the carrying angle outcomes, 28 patients achieved excellent results, with one patient having a good outcome. The most frequent radiographic finding after surgery was lateral spur formation without further negative effects. Only one case of superficial infection occurred, promptly healing with topical management. No significant complications such as neurovascular injury or compartment syndrome were observed.

CONCLUSION

Arthroscopically assisted anatomic reduction provides a promising alternative to open reduction for LHCFs with displacements exceeding 4 mm, offering direct visualization of the articular surface and minimizing soft tissue dissection.

Good outcomes of elbow arthroscopy-assisted absorbable screw fixation for capitellum fracture of the humerus in children: a case series

Background

Capitellum fractures are rare coronal fractures of the distal humerus which accounts for 6% of all distal humeral fractures and only 1% of all elbow fractures. The purpose of this study was to investigate the efficacy and complications of arthroscopically assisted reduction and fixation with absorbable screws for capitellar fracture of the humerus in children.

Methods

This was a retrospective case series study, which considered four patients (4 elbows), ranging from 10 to 15 years old, who were treated by arthroscopic-assisted percutaneous absorbable screw between 2018 and 2020. The elbow flexion-extension and forearm supination-pronation ranges of motion (ROM) were measured at the preoperative examination and last follow-up examination. Finally, the clinical and radiological results were assessed.

Results

The result of operations is satisfactory. The mean follow-up was 3.0 years (range 2-3.8 years). Average range of motion significantly improved from pre- to postoperation, with forearm supination from 60°(50°-60°) to 90°(90°) and pronation improved from 75°(70°-80°) to 90°(90°). The postoperative elbow flexion-extension range of motion was significantly higher compared with range of motion before surgery (P < 0.001; r = 0.949). At the final follow-up examination, the Mayo Elbow Performance Score was excellent. Satisfactory clinical results were achieved in all patients, and no postoperative complications were observed.

Conclusions

It is an effective and safe surgical option to use arthroscopic-assisted percutaneous absorbable screw fixation for treating capitellum fracture of the humerus without any complications in children.

Level of evidence

Level IV; case series.

Minimally Displaced Lateral Humeral Condyle Fractures: Optimizing Follow-up and Minimizing Cost

BACKGROUND

Minimally displaced fractures of the lateral humeral condyle (LHC) may be treated nonoperatively in a long arm cast, but there is not a standardized evidence-based protocol. The aim of this study was to evaluate our nonoperatively treated LHC fractures, determine the risk of subsequent displacement, analyze our practice variability, and develop an evidence-based protocol to safely manage children with LHC fractures and to evaluate potential savings related to this analysis.

METHODS

We retrospectively reviewed clinical and radiographic parameters of all patients with LHC fractures at our institution from 2009 to 2015. All patients treated nonoperatively initially were included. We recorded demographic data and calculated the number of visits, casts applied, and radiographs within the first 4 weeks. We also analyzed practice variation among 27 treating providers. The number of children with subsequent displacement needing operative fixation was determined. We also looked at the average duration for each follow-up visit and the charges/costs associated with casting and radiographs.

RESULTS

There were 271 children with LHC fractures treated nonoperatively. Twenty-one were excluded because of the lack of adequate radiographs. There were 157 boys and 93 girls (average age 6.7 y). According to the Jakob classification, fracture types were as follows: 1 (230), 2 (20), and 3 (0). Within the first 4 weeks, the average number of visits was 2.6 (range: 1 to 5), average number of casts was 2.4 (range: 1 to 4), and the average number of radiographs was 9.4 (range: 2 to 31). Only 3 patients with LHC fracture type Jakob 1 were taken to the operating room post injury (9, 12, and 15 d, respectively) for subsequent displacement.

CONCLUSION

Displacement in appropriately selected LHC fractures treated nonoperatively was rare (3/250, 1.2%) in this cohort, and the data question the need for multiple visits and radiographs in the first 4 weeks. Optimal follow-up (proposed follow-up at 10 to 15 d after injury and then 4 to 6 wk with radiographs, including an internal oblique view) would be safe, minimize waste, and result in better value-based care.

LEVEL OF EVIDENCE

Level IV.

Complications of Elbow Arthroscopic Surgery: A Systematic Review and Meta-analysis

BACKGROUND

Elbow arthroscopic surgery has been popularized and has made significant progress during the past 3 decades. The elbow joint is relatively small and is in close proximity to many neurovascular structures. These factors make elbow arthroscopic surgery technically demanding and liable to complications.

PURPOSE

To evaluate the rate of complications after elbow arthroscopic surgery.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed to perform this systematic review and meta-analysis. PubMed, Web of Science, and Embase were searched up to July 2021. All clinical studies that reported complications after elbow arthroscopic surgery were included; a total of 1208 articles were initially found. Case reports, reviews, abstracts, imaging studies, technique studies, nonclinical studies, and those not reporting postoperative complications were excluded. Complication rates were pooled across studies and reported as percentages. Complications were expressed as weighted proportions with 95% CIs.

RESULTS

A total of 95 studies (14,289 elbows) were included in the meta-analysis. The overall weighted complication rate was 11.0% (95% CI, 8.8%-13.5%), with postoperative stiffness being the most commonly encountered complication (4.5% [95% CI, 2.1%-7.6%]; 158/8818 procedures). The second most encountered complication was the need for subsequent surgery with a weighted proportion of 4.1% (95% CI, 2.9%-5.6%; 177/8853 procedures) followed by nerve injury with a weighted proportion of 3.4% (95% CI, 2.6%-4.3%; 267/13,725 procedures). The ulnar nerve was the most commonly injured nerve (2.6% [95% CI, 1.9%-3.4%]; 123/6290 procedures).

CONCLUSION

The results of this study showed that elbow arthroscopic surgery is a relatively safe procedure with low complication rates.

Clinical value of MRI in evaluating and diagnosing of humeral lateral condyle fracture in children

Background

Humeral lateral condyle fractures (HLCFs) are common paediatric fractures. Radiographs are hard to accurately evaluate and diagnose the damage of articular epiphyseal cartilage in HLCFs.

Methods

60 children who should be suspected to be HLCFs in clinical practice from Dec 2015 to Nov 2017 were continuously included as the first part patients. Subsequently, 35 HLCFs patients with complete follow-up information who had no obvious displacement on radiograph were the second part patients. The sensitivity and specificity of radiograph and MRI in diagnosing of HLCFs and their stability were calculated respectively. Calculated the sensitivity and specificity of each scan sequence of MRI in diagnosing of HLCFs osteochondral fractures. The degree of fracture displacement was measured respectively. Compared the ratio of surgical treatment, secondary fracture displacement and complications between the stable fracture group and the unstable fracture group on MRI in part 2 patients.

Results

Sensitivity of diagnosing HLCFs by MRI was significantly higher than radiograph (100.00% vs. 89.09%, P = 0.03). Sensitivity of diagnosing integrity of trochlear cartilage chain by MRI was 96.30%, which was significantly higher than that by radiograph (62.96%, P < 0.01). The sensitivity of cartilage sensitive sequence (3D-FS-FSPGR/3D-FSPGR) was different with FS-PDWI and FS-T2WI (P = 0.01 and P = 0.02, respectively). The degree of HLCFs displacement by MRI was higher than radiograph (P < 0.05). In the unstable fracture group, 5 cases (45.45%) had a fracture displacement of more than 2 mm on MRI, which was significantly higher than that in stable fracture group (0.00%, P < 0.01).

Conclusions

MRI is superior to the radiograph of elbow joint in evaluating and diagnosing children HLCFs and their stability. The coronal 3D-FS-FSPGR/3D-FSPGR sequence is a significant sequence for diagnosing osteochondral fractures in HLCFs. MRI can provide important clinical value for treatment decisions of HLCFs without significant displacement.

Arthroscopy of the Pediatric Elbow: Review of the Current Concepts

As surgeons have become more familiar with elbow arthroscopy, the indications for arthroscopy of the pediatric elbow have expanded to include contracture releases, fracture fixation, treatment of osteochondritis dissecans (OCD) lesions, correction of elbow deformity, and debridement of soft tissue and bony pathologies. The treatment of various pathologies via an arthroscopic approach demonstrates equal, if not better, efficacy and safety as open surgery for the pediatric elbow. Arthroscopy provides the unique advantage of enabling the performance of extensive surgeries through a minimally-invasive approach, and it facilitates staged interventions in cases of increased complexity. For fracture work, arthroscopy enables direct visualization to assess reduction for percutaneous fixations. While future research is warranted to better evaluate the indications and outcomes of pediatric elbow arthroscopy, this update article presents a review of the current literature, as well as several innovative cases highlighting the potential of arthroscopy.

Determining the stability of minimally displaced lateral humeral condyle fractures in children: ultrasound is better than arthrography

Background

Evaluating of the articular cartilage status of the distal humeral epiphysis is difficult. Ultrasound imaging of the elbow is increasingly being used to confirm the integrity of the articular cartilage of minimally displaced lateral humeral condyle fractures in children with minimally displaced fractures. The aims of this study were to assess the correlations between ultrasound and arthrography findings for predicting the integrity of the cartilage hinge and to describe the utility of ultrasound in determining the need for pre-treatment.

Methods

Thirty-nine patients with minimally displaced lateral humeral condyle fractures who underwent ultrasound and arthrography examinations before surgery from May 2018 to December 2019 were included in this study. Ultrasound and arthrography predictors of the cartilage hinge status were independently measured. The ultrasound and arthrography results were compared.

Results

The mean displacement of the fractures was 3.1 mm (range, 2.0~5.0 mm). Arthrography showed incomplete fractures in 24 patients (61.5%) and complete fractures in 15 patients (38.5%). Ultrasound showed incomplete fractures in 25 patients (64.1%) and complete fractures in 14 patients (35.9%). The ultrasound and arthrography results of the integrity of the articular surface were consistent in 92.3% of the cases, including 23 that were predicted to have an intact articular surface and 13 that were predicted to have an incongruity articular surface. There was no correlation between the displacement and the fracture appearing complete on the ultrasound scan. The Pearson coefficient between ultrasound and arthrography for assessing the integrity of the articular surface was 0.837.

Conclusions

Ultrasound and arthrography assessments of the integrity of the cartilage hinge status appear to be highly consistent. Ultrasound can be used as a complementary tool with arthrography to predict the integrity of the cartilage hinge status in children with minimally displaced lateral humeral condyle fractures.

Level of evidence

Prospective study; level II.

Current Concepts in the Treatment of Lateral Condyle Fractures in Children

Lateral condyle fractures of the humerus are the second most common fracture about the elbow in children. The injury typically occurs as a result of a varus- or valgus-applied force to the forearm with the elbow in extension. Plain radiographs are sufficient in making the diagnosis; however, an elbow arthrogram permits optimal visualization of the articular surface in minimally displaced fractures. Traditionally, nonsurgical management is indicated for fractures with ≤2 mm of displacement and a congruent articular surface. Closed reduction and percutaneous pinning is performed for fractures with >2 mm of displacement with an intact cartilaginous hinge at the articular surface. Open reduction and internal fixation is often necessary for fractures with ≥4 mm of displacement or if there is articular incongruity. Complications include malunion, delayed presentation, fishtail deformity, lateral spurring, and growth arrest. Evolving management concepts include relative indications for surgical management, the optimal pin configuration, and the use of cannulated screw and bioresorbable fixation.

Outcomes of Arthroscopy-assisted Closed Reduction and Percutaneous Pinning for a Displaced Pediatric Lateral Condylar Humeral Fracture

BACKGROUND

Since 2015, we have performed arthroscopy-assisted closed reduction and percutaneous pinning (A/S-CRPP) for children with a displaced lateral condylar humeral fracture (LCF). The purpose of this study is to introduce our A/S-CRPP method and present its outcomes.

METHODS

In total, 39 displaced (>2 mm) LCFs for which A/S-CRPP was initially attempted and with available follow-up data of >12 months were retrospectively reviewed. A/S-CRPP is performed in the following order: closed reduction, 1 provisional K-wire fixation, arthroscopic verification of the reduction status, rereduction if needed, and additional fixation. Our reduction technique using articulations of the ulnohumeral and radiohumeral joints and direct compression is introduced. For rereduction, modified reduction forces were applied based on the arthroscopic findings. To evaluate the learning curve effect, the initial 6 months after the first case of A/S-CRPP was regarded as the "initial period." There were 12 cases during this period.

RESULTS

Among the 39 cases, surgical method was intraoperatively converted to open reduction and percutaneous pinning in 9 and A/S-CRPP was completed in 30. Among the 9 open reduction and percutaneous pinning conversion cases, 7 conversions occurred in the initial period. Among the 30 patients who underwent A/S-CRPP alone, 10 needed rereduction after an arthroscopic examination. No patients presented with >10-degree angular deformity or elbow motion limited >20 degrees, compared with the contralateral elbow. Postoperative radial nerve palsy occurred in 2 patients, all in the initial period. Both were resolved within 5 months, postoperatively.

CONCLUSIONS

We suggested our A/S-CRPP surgical technique for displaced pediatric LCF. It may require a 6-month learning curve period. Although more studies are needed, it seems to be a safe and appropriate surgical technique for treatment.

LEVEL OF EVIDENCE

Level IV-therapeutic study.

A novel transverse ultrasonography technique for minimally displaced lateral humeral condyle fractures in children

INTRODUCTION

Management of minimally displaced lateral humeral condyle fractures in pediatric patients is controversial. This is primarily because with current imaging modalities it is difficult to accurately and conveniently determine the stability of the fractures by detecting the integrity of the cartilage hinge. Nevertheless, transverse ultrasonography has not been intensively reported in previous studies.

HYPOTHESIS

Transverse ultrasonography can determine the integrity of the cartilage hinge in minimally displaced lateral condyle fractures.

MATERIALS AND METHODS

We retrospectively reviewed the medical records of 39 pediatric patients with minimally displaced fractures of the lateral humeral condyle who underwent transverse ultrasonography between 2014 and 2017. Conservative treatment was given to pediatric patients with intact cartilage hinges that had been confirmed by transverse ultrasound images. Surgical treatment was recommended for pediatric patients with disrupted cartilage hinges. Data regarding healing of the lateral humeral condyle fractures were recorded and analyzed.

RESULTS

According to transverse ultrasonography, there were 14 children with intact cartilage hinges and 25 children with disrupted cartilage hinges. Fourteen children with intact cartilage hinges of the fracture were treated conservatively, and none of them showed secondary displacement. There were 16 children in whom there was surgical intervention, and 9 other children decided to have conservative treatment among the 25 children with disruption of the cartilage hinge. Five of these 9 children who underwent conservative treatment were found to have further displacement during an average of 12.6 days after the fracture event, and no other patient was found to have further displacement.

CONCLUSION

Transverse ultrasonography can simply and accurately determine the stability of minimally displaced lateral condyle fractures without sedation, ionizing radiation or invasive techniques. We recommend routine use of transverse ultrasonography to detect stability of the fractures, which can effectively avoid inadequate treatment and unnecessary surgery in pediatric patients with minimally displaced fractures of the lateral humeral condyle.

LEVEL OF EVIDENCE

IV, retrospective cohort study.

[Treatment principles and outcome after fractures of the lateral humeral condyle in children]

BACKGROUND

Fractures of the lateral humeral condyle with displacement (>2 mm; <2 mm articular gap) require open reduction and stabilization. Non-displaced fractures should be treated conservatively; however, there are difficulties in the differentiation of complete (potentially unstable) an incomplete (stable) articular fractures. The aim of this study was to analyze the frequency of conservative and operative treatment approaches as well as the accuracy of treatment decisions based on fracture stability displayed on repetitive X‑rays.

MATERIAL AND METHODS

A retrospective data analysis of all lateral humeral condyles in children <16 years old treated between 2005 and 2014 was carried out. The patients were classified according to the fracture stability at the time of the incident (primarily stable or unstable) and after 4 days (secondarily stable or unstable) using conventional X‑ray images.

RESULTS

A total of 89 fractures of the lateral humeral condyle were treated (mean age 6.4 years, range 0.9-14 years). Of the fractures 52 (58%) were initially not displaced and 37 (42%) were initially displaced. The latter underwent open reduction and stabilization by osteosynthesis (primarily stable). Of the 52 initially not displaced fractures 35 remained stable and conservative treatment in a plaster cast was performed (primarily and secondarily stable). In 8 out of 52 cases a secondary displacement (>2 mm articular gap) occurred after an average of 6 days (range 3-10 days) and operative treatment was initiated (primarily stable and secondarily unstable). No follow-up x‑ray could be performed in 2 of the 52 fractures and at the end of treatment the fractures healed with displacement (primarily stable and secondarily unstable). In 7 of the 52 fractures operative treatment was performed although no displacement (primarily stable) was initially documented (overtreatment). The outcome of the whole study cohort was comparable with that described in the literature.

CONCLUSION

Treatment decisions in pediatric lateral humeral condyle fractures are based on the primary and secondary fracture stability as observed in staged follow-up radiographs. Stable fractures, whether complete or incomplete, healed with good results after conservative treatment and overtreatment could be avoided. Unstable fractures, whether primary or secondary during the course, need to be recognized as such and operative treatment with a stable osteosynthesis must be initiated.

Arthroscopic Treatment of Pediatric Fractures

Management of pediatric articular fractures has evolved over the years with a growing interest in arthroscopic handling. Several factors account for this recent appeal among which are progress in technology with increased availability of diagnostic methods, rise in athletic activities responsible for these fractures, and pediatric orthopaedic surgeons getting familiar with arthroscopic techniques. In our institution, 9 of 100 arthroscopic procedures are performed as a consequence of an articular fracture. In total, 80% of the fractures concern the knee (56% of tibial eminence fracture, 24% osteochondral fracture). Most of the remaining 20% are located at the ankle joint. Given the thorough articular exploration that arthroscopy provides, any associated cartilaginous or meniscal lesions is identified and addressed in the same procedure as the fracture fixation. Being a less invasive surgery with low complication rate, arthroscopic management of pediatric articular fractures provides very satisfactory results with earlier recovery. Of note, it is technically demanding and requires constant training. The operative time should be monitored and alternative options considered for each surgery. In this regard, arthroscopy has to be viewed as a means not an end.

Relevance of MRI for management of non-displaced lateral humeral condyle fractures in children

INTRODUCTION

The treatment for non-displaced (<2 mm displacement) fractures of the lateral humeral condyle in children is controversial. Most studies recommend non-surgical treatment. However, plain radiographs are not sufficient to evaluate extension of the fracture line through the articular cartilage. This explains the high frequency of secondary displacements and non-unions, despite well-conducted conservative treatment. We hypothesized that MRI could be used to analyse whether the fracture is complete or incomplete. This could help to determine whether surgical or conservative treatment is indicated.

MATERIAL AND METHODS

This prospective study enrolled children being treated for a non-displaced (< 2 mm gap) fracture of the lateral humeral condyle. All patients were treated with a long-arm cast in the emergency room. An MRI was done later on without sedation. A specific protocol was used to reduce the duration of the examination. T2-weighted and proton density fat-saturated sequences were used.

RESULTS

Twenty-seven patients were enrolled: 16 boys and 11 girls with a mean age of 5 years (2-10). The MRI was performed an average of 7 days (1-23) after the fracture. The MRI could not be interpreted in two cases because the child had moved during the examination. In the other 25 patients, the fracture was incomplete in 17 patients and complete in 8 patients. Two children had secondary displacement diagnosed 7 and 11 days after the fracture event. These two patients underwent open reduction and internal fixation. There was no correlation between patient age and the fracture being complete or incomplete. There were no cases of non-union.

CONCLUSION

MRI appears to be a reliable method for determining whether the fracture line is complete or incomplete. It can be performed without sedation, even in children as young as 2 years of age. Use of an injury-specific MRI protocol reduces the length of the examination, thereby improving its performance. We recommend that it be used to analyse non-displaced fractures of the lateral humeral condyle in children.

LEVEL OF EVIDENCE

3 Prospective study.