Complications and timing of follow-up after closed reduction and percutaneous pinning of supracondylar humerus fractures: follow-up after percutaneous pinning of supracondylar humerus fractures

Treatment and outcomes of pediatric supracondylar humeral fractures in Korle Bu Teaching Hospital

Objectives:

Supracondylar humeral fractures (SCHF) are the most common elbow injury in the pediatric population. The treatment, outcome, and health-related quality of life (HRQoL) following these injuries are described.

Methods:

Patients with SCHF who were treated depending on the fracture type were evaluated. Medical records stored in the REDCap database were reviewed to obtain information on demographics, mechanisms of injury, neurovascular status, infection rates, and postoperative complications. Outcomes were assessed using Flynn's criteria and Pediatric Quality of Life (PedsQL) version 4.0. Follow-up was for 6 months.

Results:

A total of 101 patients with a mean age of 5.2 years (SD ± 2.3) were seen. Most of the injuries occurred at home (64.3%). The left-arm (nondominant) was the most injured (62%), though 92% of patients were right hand dominant. Ninety-six percent of the fractures were the extension type. A total of 98% had satisfactory outcomes using Flynn's criteria and older patients were likely to sustain Gartland type III SCHF (P = .01). There was a significant difference in mean scores of PedsQL (all P values < .01) at 6 months.

Conclusions:

In this prospective study, the quality of life of patients following SCHF diminished at the time of the injury and returned to the population normal 6 months after. There was no significant difference in HRQoL scores between patients who presented early and those who presented late. The delayed presentation and management did not also affect the functional outcome and complications. Therefore, surgical management of these injuries after late presentation is still safe.

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.

The Safety and Benefits of the Semisterile Technique for Closed Reduction and Percutaneous Pinning of Pediatric Upper Extremity Fractures

Background: Closed reduction and percutaneous pinning (CRPP) is traditionally performed following full surgical prep and draping. The semisterile technique utilizes minimal prep and draping, which was proven to be a viable alternative when treating pediatric supracondylar humerus fractures. The purpose of this study was to investigate the safety and benefits of the semisterile technique for CRPP of pediatric upper extremity fractures. Methods: A retrospective cohort study was conducted of pediatric patients who underwent CRPP of an upper extremity fracture over a 4-year period. Demographic data, fracture type/location, and the type of prep technique (full-prep vs semisterile) were recorded. Qualities of intraoperative care were assessed, and postoperative care parameters were compared. Patient outcomes for the 2 techniques were compared using bivariate analyses. Results: In total, 219 patient records were reviewed including 160 in the semisterile group and 59 in the full-prep group. When comparing intraoperative parameters between the full-prep and semisterile techniques, the average room setup time was similar (20.6 vs 18.8 minutes, P = .52). However, the procedure times (32.1 vs 26.9 minutes, P = .04) were significantly shorter in the semisterile group. Nearly a 10-minute decrease in total time in the operating room was present while utilizing the semisterile technique (62.8 vs 53.6 minutes, P < .01). There were no statistical differences in complication rates between prep groups (P = .31), and there were no infections while utilizing the semisterile technique. Conclusions: The semisterile technique is a safe and efficient alternative that may be used when performing CRPP of pediatric upper extremity fractures.

Intra-Operative Bone Stability Test

Fractures of the supercondylar humerus are the most common elbow fracture in pediatrics. Management of this injury would be aided if surgeons could reliably test fracture stability intraoperatively after pinning. A transverse supracondylar humerus fracture model was created using 3 adult cadaver upper-extremity specimens with an intact soft tissue envelope. Using the lateral entry technique, three 2.0 mm pins were then drilled using lateral entry technique to create an “A” pinning. Pins were checked in anteroposterior and lateral views with the C-arm to confirm accurate placement in both planes. The pinning configuration was then tested by holding the proximal fragment steady with one hand and applying stress to the distal fragment with the other hand. The amount of movement of the distal fragment relative to the proximal fragment was recorded for each specimen. Distraction did not produce any substantial displacement of the osteotomy. The most valuable maneuvers were (in order of effectiveness): external rotation, lateral translation, posterior translation, valgus, and apex posterior. The results of this study indicate that external rotation, lateral translation, posterior translation, and valgus stresses created the most temporary deformity to the construct. A combination of these maneuvers should help the surgeon to decide if the fixation is stable. Our study demonstrates a possible technique to determining intraoperatively the stability of fixation of supracondylar humerus fractures, which could prevent the need for postoperative radiographs to assess stability.

Is less more? Assessing the utility of early clinical and radiographic follow-up for operative supracondylar humerus fractures

PURPOSE

Postoperative protocols following surgical management of supracondylar humerus fractures (SCFs) are often based upon surgeon preference rather than clinical merit. The purpose of this study is to determine the utility of early clinical and radiographic follow-up.

METHODS

A retrospective review of patients who underwent closed reduction and percutaneous pinning (CRPP) for SCF between 2009 and 2015 was performed using a database of prospectively-collected consecutive patient data. Previously undiagnosed neuropathies documented at the first postoperative visit were identified. Unscheduled visits and postoperative complications were compared between patients who were seen at one week and those with delayed first clinic visits.

RESULTS

Of 873 patients, 823 (94.3%) were seen within ten days of surgery (early follow-up) and 50 (5.7%) had a delayed first clinic appointment. Among patients seen for early follow-up, 12 (1.5%) had a previously undocumented neuropathy diagnosed but only eight (1%) had an alteration of management secondary to clinical findings. Greater than 90% of patients seen for early follow-up had radiographs performed, but only one had an alteration in management due to radiographic findings. Patients seen for early follow-up had the same rate of unscheduled visits (2.9% versus 4%, p = 0.66) and postoperative complications (1.6% versus 0%, p > 0.99) as those with delayed first appointments. Radiographic parameters were comparable at final follow-up (Baumann's angle 74.5° versus 73.7°, p = 0.40; lateral humeral condylar angle 40.2° versus 41.2°, p = 0.53).

CONCLUSION

The early follow-up visit after CRPP of SCF rarely leads to alterations in care and does not reduce unscheduled visits or late complications.

LEVEL OF EVIDENCE

Level IV.

Outcome after pin fixation of supracondylar humerus fractures in children: postoperative radiographic examinations are unnecessary

Background and purpose - The quality of pin fixation of displaced supracondylar humerus fractures in children has not been assessed, and the clinical value of radiographic examinations after pin fixation is unclear. We evaluated pin configuration, quality of osteosynthesis, and outcome in 264 supracondylar fractures. The clinical significance of postoperative radiographs was analyzed. Patients and methods - 252 Gartland-III and 12 flexion-type supracondylar humerus fractures were pin-fixed in the periods 2002-2006 and 2012-2014. During 2012-2014, staff were intructed that postoperative radiographs should not be taken. Quality of reduction was assessed by measuring Baumann and lateral capitellohumeral angles (LCHA) and also by recording the crossing point of the anterior humeral line (AHL) with bony capitellum. Rotatory alignment was registered as normal or abnormal. Pin configuration and quality of osteosynthesis were evaluated. The clinical significance of postoperative radiographs was analyzed. Results - Postoperatively, Baumann angle was normal in 66% of the fractures, AHL crossed the capitellum in 84%, and no malrotation was evident in 85% of the fractures. Crossed pins were used in 89% of the cases. 2 or more pins fixed both fracture fragments in 66%. Radiographic examinations were inadequate for assessment of LCHA in 13%, of Bauman angle in 8%, of AHL in 2%, of rotation in 1%, and of pin fixation in 2% of the cases. Postoperative radiographs did not give useful information except in 1 patient who had corrective osteotomy. All 94 patients with follow-up (97%) who were treated during 2012-2014 were satisfied with the outcome. Interpretation - Despite pin fixation being deemed unsatisfactory in one-third of the cases, significant malunion was rare. Postoperative radiography did not alter management or outcome.

Fracture Supracondylar Humerus: A Review

Fracture supracondylar humerus is one of the most common fractures encountered in pediatric age group at all levels (both rural and urban). Thus it needs a special review in its management protocol as per the changing trend. Modified Gartland classification is the most accepted classification and has its importance in decision making regarding management and prognosis. Neurovascular complications are mostly associated with Type III A, III B and Type IV variety and they most of the time need surgical intervention for stabilization, exploration of brachial artery, sometimes median nerve exploration and reduction of fracture. Cubitus varus is the most common associated deformity associated with this fracture (especially in Type III A). The aim of the review was to develop an insight for the understanding of variations in presentation and management of supracondylar fracture of the humerus (both simplicity and complexity) and the flowing trend in addition to the recent advances to deal with this particular pediatric orthopaedic entity which often presents as an emergency.

Routine radiographs at time of pin removal after closed reduction and percutaneous pinning for type 2 supracondylar humerus fractures do not change management: a retrospective cohort study

PURPOSE

Radiographs are usually taken on day of pin removal for children treated with closed reduction and percutaneous pinning (CRPP) of type 2 supracondylar humerus fractures. The purpose of this study was to determine whether radiographs taken at time of pin removal for patients recovering uneventfully alter management.

METHODS

After IRB approval, billing records identified 1213 patients aged 1-10 years who underwent elbow surgery between 2007 and 2013 at our institution for a supracondylar humerus fracture. Of these patients, 389 met inclusion criteria. Clinical charts were reviewed for demographics, operative details, and clinical follow-up, focusing on clinical symptoms present at pin removal. Radiographs taken at time of pin removal and subsequent visits were assessed for healing and fracture alignment.

RESULTS

In no case was pin removal delayed based on radiographs. One hundred and nineteen (31 %) patients had radiographs taken following pin removal; in no case was loss of reduction found among these patients. No cases of neurologic or vascular injury, re-fracture, or loss of reduction occurred. Infection occurred in 12 patients (3 %). Pins were kept in place for 23.8 ± 4.4 days. Eighty-six patients (22 %) had additional intervention after pin removal (cast application in all cases). Of 389 patients, 75 (19 %) had no documented reason for extended casting, four (1 %) were extended based on physician evaluation of radiographs, and seven (2 %) were extended for other reasons.

CONCLUSIONS

Elimination of radiographs at time of pin removal should be considered. If continuing to obtain radiographs at pin removal, we recommend removing pins before taking radiographs to reduce patient fear and anxiety from visualizing percutaneous pins.

The utility of radiographs prior to pin removal after operative treatment of supracondylar humerus fractures in children

PURPOSE

To determine the safety, utility, and efficacy of pin removal prior to radiographs during the postoperative care of surgically treated displaced pediatric supracondylar humerus fractures.

METHODS

Retrospective review of 532 children with supracondylar humerus fractures treated with closed reduction and pinning from 2007 to 2012. Group 1: children who had their splint/cast removed and radiographs prior to pin removal. Group 2: children with radiographs taken after removal. Data recorded and analyzed included: demographic and radiographic data at the time of surgery and at final follow-up, including the number of radiographs taken prior to pin removal and if pins were ever retained after radiographs were performed on the date of intended removal.

RESULTS

There was no difference between the groups' demographics. The number of postoperative radiographs taken prior to pin removal ranged from zero to two. No statistically significant change in Baumann's (p = 0.79) or lateral humeral capitellar angles (p = 0.19) was noted between the groups. No children in group 1 (0/438) had their pins retained after radiographs were taken on the date of intended removal.

CONCLUSION

Obtaining postoperative radiographs prior to pin removal, although commonplace, is not necessary. If fracture stability is noted intraoperatively, and there is an uneventful postoperative course, it is safe and effective to discontinue immobilization and remove pins prior to X-ray. This is safely done without change in alignment or clinical sequelae. Doing so can aid in clinic flow, may decrease child anxiety, and limit multiple cast room visits.

LEVEL OF EVIDENCE

Level III therapeutic study.

[Supracondylar fractures of the humerus in children]

BACKGROUND

Supracondylar humerus fractures are common in children. Severe complications are rare. We present an overview of treatment options and prognosis.

MATERIAL AND METHODS

The article is based on a non-systematic search in PubMed and experience from our own clinical research.

RESULTS

The injury is usually caused by falling from a height with the arm in extension. The mean age is about 6 years. Undisplaced fractures are treated conservatively with a cast. Displaced fractures should not be treated with a cast alone, as this may cause malunions and permanent neurovascular complications. The rate of complications after traction of displaced fractures is substantially lower than for immobilisation in cast alone. Traction and percutaneous pinning yield similar results, but percutaneous pinning is less expensive--mainly because it shortens the hospital stay. In addition, the risk of cubitus varus deformity seems to be reduced. Today the treatment of choice is closed reduction and percutaneous pinning. Choice of pin configuration is at the surgeon's discretion. Crossed pins are more common than two lateral pins, although medial pins can affect the ulnar nerve. However, the affection is almost always transient. Deep infection after percutaneous pinning is very rare.

INTERPRETATION

Percutaneous pinning of displaced supracondylar humerus fractures in children is cheap and the results are good.

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.