Skeletal traction and delayed percutaneous fixation of complicated supracondylar humerus fractures due to delayed or unsuccessful reductions and extensive swelling in children

Open Reduction and Fixation of Late-Presenting Pediatric Supracondylar Humeral Fractures: A Prospective Study

Background

Supracondylar humeral fracture (SCHF) is a common injury in children, and early treatment provides excellent results and prevents disabilities. Delayed presentation is still prevalent, mainly in developing countries, because many factors hinder the opportunity to receive appropriate treatment. Currently, there are no standard treatment protocols, and there is insufficient published literature on this topic. This study aimed to evaluate the effectiveness and outcomes of open reduction and Kirschner wire fixation using a triceps-sparing posterior approach in neglected cases with complicated fractures.

Methods

This was a prospective multicenter clinical study conducted between July 2016 and June 2021, which included 28 pediatric patients with neglected SCHF who presented to the hospital for definitive treatment five days or more after initial trauma without previous surgical intervention. All the patients underwent open reduction and K-wire fixation using a posterior triceps-sparing approach. The final functional outcome was assessed using the Mayo Elbow Performance Index (MEPI) and Flynn criteria.

Results

All fractures (100%) united within 3-5.5 weeks (mean 4 ± 0.7 weeks). Excellent scores observed in 67.9% (n = 19), good in 21.4% (n = 6), fair in 7.1% (n=2), and poor in 3.6% (n = 1) patients according to MEPI. Correspondingly, Flynn's criteria showed 96.4% (n = 27) satisfactory and 3.6% (n = 1) unsatisfactory outcome.

Conclusion

Open reduction and fixation using Kirschner wires through the posterior triceps-sparing approach is an effective treatment method for late-presenting SCHF in children with consequent satisfactory results.

Is open reduction necessary for pediatric T-condylar fractures of the humerus?

The aim of this study was to investigate the outcomes of closed reduction and percutaneous pinning (Kirschner wire fixation) as a less invasive method for the treatment of pediatric T-condylar fractures of the humerus compared with open reduction and pinning. Among pediatric patients who were diagnosed with T-condylar fractures of the humerus between 2010 and 2017, those who underwent closed reduction and percutaneous pinning were retrospectively evaluated. The surgical technique used was to restore joint alignment through closed reduction and then to insert a pin parallel to the joint surface to stabilize the intercondylar fracture. Then, the supracondylar fracture was fixed with crossed pins. At 1-year follow-up, rotation, angulation, and joint range of motion were evaluated. Patient satisfaction was assessed subjectively using the visual analogue scale. Early and late postoperative Baumann angles were measured. All patients were male, and the mean age was 10.8 ± 4.6 years. The mean follow-up duration was 16.5 ± 7.2 months, and the mean union duration was 7.4 ± 2.3 weeks. None of the patients had any rotational deformities, but two had 5° of varus, one had 5° of valgus, two had a flexion contracture of 10°, and one had a flexion contracture of 40°. The only complication observed was a pin-tract infection, which developed in one patient. The mean visual analogue scale score was 9.25 ± 1. In pediatric patients with T-condylar humerus fractures, closed reduction and percutaneous pinning may be a good alternative to open reduction and pinning, because it is less invasive and does not cause additional complications.

Comparison of the lateral and posterior approaches in the treatment of pediatric supracondylar humeral fractures

This study explored the radiological, functional, and cosmetic results of treatment of supracondylar humeral fractures with open reduction and percutaneous pinning, comparing posterior triceps V-splitting (group I, n=22) and lateral (group II, n=25) approaches. The time to union, the functional and cosmetic results, and the flexor and extensor muscle strengths were measured and compared with the contralateral extremities. There were no statistical differences between the groups. The V-splitting posterior approach is as safe and effective as the lateral approach in the surgical treatment of pediatric supracondylar humeral fractures.

Are the Appropriate Use Criteria for the management of pediatric supracondylar humerus fractures useful in clinical practice?

The aim of this study was to evaluate our treatment modalities in pediatric supracondylar humerus fractures according to the recently published Appropriate Use Criteria (AUC) by the American Academy of Orthopaedic Surgeons. A total of 991 patients with supracondylar humerus fractures were included. After reviewing medical records, 38 different clinical scenarios described in the AUC were observed. Of the 991 patients, 127 were type I, 423 were type II, and 405 were type III fractures according to the Gartland classification. The AUC was appropriate for 100% of type I, only 25 (5.9%) of type II, and 389 (96.0%) of type III fractures. Overall, the total appropriateness rate was 54.5%. We concluded that application of the AUC is useful but burdensome and that AUC provides important guidance especially for rarely encountered urgent clinical scenarios.

Supracondylar humerus fractures in children: a comparison of experiences

The most common elbow lesions found in pediatric practice are supracondylar fractures. We compared two groups of 34 patients each with a supracondylar humerus fracture grade III (Gartland classification). The first group was treated with percutaneous pinning with Kirschner wires, with patients in a supine position, sometimes preceded by transkeletal traction. The second group was treated with percutaneous pinning with Kirschner wires, with patients in a prone position, within 6 h of the trauma. No statistically significant differences with regard to clinical outcomes and neurovascular complications were revealed in the comparison. Therefore, we can state that both treatment techniques used are valid.

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

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

Operative management of type III extension supracondylar fractures in children

The purpose of this study was to compare primarily open versus primarily closed surgical treatment of Gartland type III extension supracondylar fractures in children. Also the outcomes of different pinning techniques in open surgery were evaluated retrospectively. Eighty displaced type III extension supracondylar fractures treated consecutively at two different centres were included. The treatment protocol of one institute was primarily closed reduction and percutaneous cross-pinning (n = 43). The treatment protocol of the other institute was primarily open reduction and internal fixation (n = 37) with two lateral parallel pins (n = 11), cross pins (n = 11) and two lateral and one medial pin (n = 15) according to the stability and configuration of the fracture. According to Flynn's criteria the outcomes of the open and closed reduction groups were not statistically significant (P > 0.05). Although the outcomes of closed reduction showed no superiority over open reduction, it should be the first choice of treatment due to its low morbidity and short hospital stay.

The measurements and standardization of humerocondylar angle in children

BACKGROUND

Supracondylar fractures of the humerus in children are very common. However, the literature regarding measurements of normal anatomical relationships of the distal humerus in sagittal plane is sparse.

METHOD

We reviewed the radiographs of normal elbow joints in 142 children treated in our hospital over 2 years. No history of previous trauma of distal humerus was found. The children were separated into 3 age groups (<5, 5-10, and 10-15 years old), and measurement of the humerocondylar angle (HCA) in sagittal plane was performed.

RESULTS

The mean age of children in group 1 was 3 years 1 month; in group 2, 7 years 8 months; and in group 3, 12 years. There were 99 boys and 43 girls. The mean HCA was 41.6 degrees (range, 30-70 degrees). No statistically significant influence on HCA by age, sex, or side was found. We found a small number of extreme variants in HCA (down to 30 degrees and up to 70 degrees) in children without any history of previous trauma and having a normal range of elbow motion.

CONCLUSIONS

We found that HCA is close to the well-accepted figure of 40 degrees. Interestingly, this value remains the same in all age groups. That means that the geometry of the distal humerus in sagittal plane is established very early during the growth and remains constant. Due to significant individual variations of HCA, it alone cannot be sufficient for final decisions in evaluation and treatment of supracondylar fractures.

How should one treat iatrogenic ulnar injury after closed reduction and percutaneous pinning of paediatric supracondylar humeral fractures?

OBJECTIVE

The purpose of this study was to assess iatrogenic ulnar nerve injuries after supracondylar humeral fractures treated with closed reduction and percutaneous pinning.

METHODS

The series consisted of 473 children. All patients were treated with closed reduction and percutaneous pinning. Neurological examination performed immediately after the operation revealed 25 ulnar nerve injuries (5.2%) in patients who had completely normal neurological findings in the preoperative period. Electromyographic examinations were performed at 6 and 12 weeks postoperatively in patient with ulnar nerve lesions.

RESULTS

The mean age was 6 years (4-8 years). The mean hospitalisation time was 2 days and the mean follow-up time was 30.8 months (17-63 months). Twenty-two patients with electromyogram showed partial denervation and conduction blocks at the elbow at 6 weeks. Regenerative electromyogram findings were found at 12 weeks. Sensory function in all patients had returned at a mean of 2 months (1-4 months) while motor function had returned at a mean of 5.4 months (1-7 months). Unusually all patients had complete return of nerve function and full motion in their elbows.

CONCLUSION

We evaluated the results of 473 patients and to our knowledge this is the largest series in the literature. Although the rate of ulnar nerve injuries (5.2%) is comparable, the number of the patients (n: 22) is the largest in the literature and may allow us to draw stronger conclusions. In our opinion, if ulnar nerve injury is detected after the operation, patients should be followed up for 7 months without intervention.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Underreduced supracondylar fracture of the humerus in children: clinical significance at skeletal maturity

BACKGROUND

Although supracondylar fractures of the humerus in children are common, the literature is sparse regarding acceptable limits of reduction of these fractures in the sagittal plane.

METHODS

We retrospectively reviewed 223 pediatric cases of supracondylar fractures of the elbow treated in our hospital between the years 1996 and 2000.

RESULTS

In 30 patients, we found some degree of underreduction of the extension component of the fracture. Twenty-two of them were followed and evaluated at or close to skeletal maturity. The mean age at the time of fracture was 5.4 years, the mean follow-up was 8.2 years. Radiographic remodeling, range of elbow motion, and awareness of the patients to the functional limitation were evaluated. At final follow-up, 17 (77%) of the patients had radiographic abnormality of the humerocondylar angle (a difference of 5 degrees or more compared with the uninjured side). Eleven patients (50%) had limited elbow flexion, and 7 (31%) were aware of this deficit. Most of the underreductions occurred when reduction was attempted in the emergency department, when the angulation was not appreciated, and when the cast was applied without any reduction attempt. Patients who were left to heal with some degree of extension developed limited end-elbow flexion and were aware of it. Although only 3 patients felt minor subjective functional disability at the last follow-up, 10 patients had unsatisfactory results according to Flynn criteria for motion restriction.

CONCLUSIONS

The treating surgeon must be aware of this possible outcome and be more demanding in the reduction of the extension component of the fracture. Otherwise, clinically significant limitation in elbow flexion may occur. Although the reduction of moderately displaced fractures may seem simple, it should be performed under general anesthesia and with radiographic control of reduction and pin placement.