Morphology and dynamics of the ulnar nerve in the cubital tunnel after percutaneous cross-pinning of supracondylar fractures in children's elbows: an ultrasonographic study

Application of ultrasound in the closed reduction and percutaneous pinning in supracondylar humeral fractures

BACKGROUND

Ultrasound examination can be applied to the diagnosis of pediatric elbow fracture. This study aims to analyze the application value of ultrasound in the surgical treatment of supracondylar humeral fractures.

METHODS

64 children with supracondylar humeral fractures were treated with ultrasound-guided closed reduction and percutaneous pinning (CRPP), 31 patients were treated with CRPP under radiography guidence. The reduction effect of supracondylar humeral fractures was determined through the perioperative ultrasound images of the lateral, medial and posterior aspects of the elbow. Percutaneous pinning was performed after supracondylar humeral fractures were well reduced. A follow-up examination was performed and all the patients were evaluated according to Flynn's criteria.

RESULTS

The mean duration of surgery was 58.3 min (42-108 min) in the ultrasound group and 41.5 min (24-63 min) in the radiography group (P < 0.05). The mean carrying angle was 8.2° (0°-15°) in the ultrasound group and 9.4°(3°-16°) in the radiography group; The mean Baumann's angle was 75.5°(60°-85°) in the ultrasound group and 73.4°(62°-82°) in the radiography group; The mean lateral humerocapitellar angle was 38.4° (26°-54°) in the ultrasound group and 41.6°(29°-52°) in the radiography group; No significant differences were observed between the two groups. According to the Flynn's criteria, 49 (76.6%) patients had excellent, 10 (15.6%) patients achieved good, 3 (4.7%) patients showed fair results and 2 (3.1%) patients achieved poor results in the ultrasound group; 22 (70.9%) patients had excellent, 6 (19.4%) patients achieved good, 2 (6.5%) patients showed fair results and 1 (3.2%) patients achieved poor results in the radiography group; No statistically significant difference was noted between the results of these two groups (P > 0.05). After surgery, three patients had pin tract infection. One patient had ulnar nerve neurapraxia in the radiography group. No cases with Volkmann's contracture were reported.

CONCLUSION

Ultrasound-guided CRPP is a safe and reliable surgical treatment of pediatric supracondylar humeral fractures. Trial registration Retrospectively registered.

Multicentre collaborative cohort study of the use of Kirschner wires for the management of supracondylar fractures in children

PURPOSE

Supracondylar fractures of the humerus cause significant morbidity in children. Nerve damage and loss of fracture reduction are common recognised complications in patients with this injury. Uncertainty surrounds the optimal Kirschner wire configuration and diameter for closed reduction and pinning of these fractures. This study describes current practice and examined the association between wire configuration or diameter and outcomes (clinical and radiological) in the operative management of paediatric supracondylar fractures.

METHODS

Children presenting with Gartland II or III supracondylar fractures at five hospitals in south-west England were eligible for inclusion. Collaborators scrutinised paper and electronic case notes. Outcome measures were maintenance of reduction and iatrogenic nerve injury.

RESULTS

Altogether 209 patients were eligible for inclusion: 15.7% had a documented neurological deficit at presentation; 3.9% who were neurologically intact at presentation sustained a new deficit caused by treatment and 13.4% experienced a clinically significant loss of reduction following fixation. Maintenance of reduction was significantly better in patients treated specifically with crossed ×3 Kirschner wire configuration compared to all other configurations. The incidence of iatrogenic nerve injury was not significantly different between groups treated with different wire configurations.

CONCLUSION

We present a large multicentre cohort study showing that crossed ×3 Kirschner wires are associated with better maintenance of reduction than crossed ×2 or lateral entry wires. Greater numbers would be required to properly investigate nerve injury relating to operative management of supracondylar fractures. We found significant variations in practice and compliance with the British Orthopaedic Association Standard for Trauma (BOAST) 11 guidelines.

Changing trends in the management of children's fractures

The management of children's fractures has evolved as a result of better health education, changes in lifestyle, improved implant technology and the changing expectations of society. This review focuses on the changes seen in paediatric fractures, including epidemiology, the increasing problems of obesity, the mechanisms of injury, non-accidental injuries and litigation. We also examine the changes in the management of fractures at three specific sites: the supracondylar humerus, femoral shaft and forearm. There has been an increasing trend towards surgical stabilisation of these fractures. The reasons for this are multifactorial, including societal expectations of a perfect result and reduced hospital stay. Reduced hospital stay is beneficial to the social, educational and psychological needs of the child and beneficial to society as a whole, due to reduced costs.

Ulnar nerve morbidity as a long-term complication of pediatric supracondylar humeral fracture

BACKGROUND

Supracondylar humeral fractures are common in children. We studied long-term ulnar nerve symptoms secondary to these fractures and analyzed the treatment for ulnar neuropathy.

MATERIALS AND METHODS

The cohort included 91 patients with a supracondylar humeral fracture in childhood, on average 12 years previously, in the geographic catchment area. All the cases were reexamined in regard to ulnar nerve morbidity. Cases with secondary ulnar neuropathy were treated nonoperatively and operatively.

RESULTS

Ulnar neuropathy was present in four cases (4.4 %). They all had suffered from a dislocated fracture, and they had been operated primarily. Another three patients had slight ulnar nerve symptoms. Hence, the total prevalence of secondary ulnar nerve morbidity was 7.7 %. A jumping nerve was seen in 9.9 %; 51.6 % had a diminished axial angle.

CONCLUSIONS

We report a defined pattern of long-term ulnar nerve morbidity after pediatric supracondylar humeral fracture. The prevalence of neuropathy is alarming in the young population (<25 years of age).

Ultrasonographic examination of the radial and ulnar nerves after percutaneous cross-wiring of supracondylar humerus fractures in children: a prospective, randomized controlled study

In this prospective study, we aimed to find out whether there is a change in the ultrasonographic features of the radial and ulnar nerves as well as clinical outcomes after traditional and lateral percutaneous cross-wiring of the supracondylar humerus fractures in children. Twenty-nine consecutive children with completely displaced Gartland type III supracondylar humerus fractures were treated with the traditional (group T) or lateral (group L) cross-wiring technique. Our findings showed that ultrasonographic features of the radial nerve were not changed in both groups but the ulnar nerve movement was reduced, and the diameter of major axis of the ulnar nerve during elbow flexion was larger (P=0.040) than in elbow extension in the traditional cross-wiring technique but not in the lateral cross-wiring technique. Lateral cross-wiring technique does not change the ultrasonographic features of the radial and ulnar nerves, and provides satisfactory results.

Dynamics of the ulnar nerve after percutaneous pinning of supracondylar humeral fractures in children

This prospective study was performed to evaluate and compare the morphological changes and dynamics of the ulnar nerve after percutaneous cross-pinning with Kirshner wire (group 1; 13, mean age 8.3 years, 10 male and three female children) and only lateral pinning (group 2; eight, mean age 7.6 years, six male and two female children) of displaced unilateral supracondylar fractures in children's elbows using ultrasonography in comparison with the contralateral healthy elbows. Postoperative evaluation revealed that ulnar nerve movement was reduced and the major axis diameter of elbow flexion and ulnar nerve was larger (P<0.05) than the major axis diameter in the elbow extension in group 1 than group 2. We think that the treatment of the displaced supracondylar fracture of the humerus in children with only a lateral Kirshner wire would be safer and more convenient.

Supracondylar humeral fractures in children

Operative fixation is indicated for most type-II and III supracondylar humeral fractures in order to prevent malunion. Medial comminution is a subtle finding that, if treated nonoperatively, is likely to lead to unacceptable varus malunion. Angiography is not indicated for a pulseless limb, as it delays fracture reduction, which usually corrects the vascular problem. A high index of suspicion is necessary to avoid missing an impending compartment syndrome, especially when there is a concomitant forearm fracture or when there is a median nerve injury, which may mask symptoms of compartment syndrome. Lateral entry pins have been shown, in biomechanical and clinical studies, to be as stable as cross pinning if they are well spaced at the fracture line, and they are not associated with the risk of iatrogenic ulnar nerve injury.

Prevention of ulnar nerve injury during fixation of supracondylar fractures in children by 'flexion-extension cross-pinning' technique

No consensus exists concerning the best pin configuration for displaced supracondylar fractures of the humerus in children. Although cross-pinning is the most stable biomechanically, this configuration may cause iatrogenic ulnar nerve palsy. For the last 7 years, we have been using a three-pin fixation technique with insertion of two K wires from the lateral side (elbow in full flexion) and the third wire through the medial side (elbow in full extension). We used this technique in 67 displaced supracondylar fractures without any complications related to the ulnar nerve. The technique provides excellent stability and eliminates the risk of iatrogenic ulnar nerve palsy.