1
|
Qiao F, Guan X, Jiang F, Lv P. Closed reduction and percutaneous pinning for treatment of unstable lateral condyle fractures of the humerus in children. Front Pediatr 2023; 11:1223615. [PMID: 37681201 PMCID: PMC10481872 DOI: 10.3389/fped.2023.1223615] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 07/17/2023] [Indexed: 09/09/2023] Open
Abstract
Objective In the past, obviously displaced lateral condyle fractures of the humerus in children were treated satisfactorily with open reduction and internal fixation (ORIF). However, in recent years, more studies have mentioned closed reduction and percutaneous pinning (CRPP) of these fractures. Methods In this retrospective investigation, the radiographic and clinical results of patients with these fractures that were initially managed with CRPP were newly classified. We classified these fractures into three groups according to the degree and pattern of fracture displacement as identified on four radiographic images. In Type I, the fracture is unstable and displacement is ≥2 mm; In Type II degree I, the fracture is unstable and displacement is >2 mm, with single rotation of fragment; In Type II degree II, the fracture is unstable and displacement is >2 mm, with single rotation of fragment, with rotation of fragment and antero-proximal displacement; In Type III, the fracture is unstable and displacement is >2 mm, with posterior dislocation of elbow joint. We also designed an algorithm for closed reduction of these fractures according to this new classification. Results We retrospectively analyzed the radiographic and clinical results of 37 unstable fractures (in 22 boys and 15 girls) that were treated with closed reduction. Twenty-one of 25 (84.0%) type I fractures, which could have been reduced to within 2 mm of residual displacement, were treated with closed reduction and pinning with 2 or 3 Kirschner wires (K wires). Three of 5 (60.0%) type II degree I, 3 of 4 (75.0%) type II degree II, and 3 of 3 (100%) type III fractures were treated with CRPP. In 4 of 25 (16.0%) type I, 2 of 5 (40.0%) type II degree I and 1 of 4 (25.0%) type II degree II fractures, closed reduction failed, so ORIF was implemented. There were no complications, such as nonunion, osteonecrosis of the capitellum, superficial or deep infection, malunion, cubitus varus or valgus, or early physeal arrest. Conclusion Although the management of type III fractures may not be more difficult than type II fractures with a rotated fracture fragment, as elbow dislocations are usually easy reducible. This retrospective study showed that type III fractures should not be ignored as a lateral condyle fracture that can be cured with CRPP and that lateral humeral condyle fractures with obvious displacement and rotation can be initially treated with CRPP to achieve satisfactory recovery of the elbow. Kirschner wire (K wire) fixation is recommended to avoid reoperation or anesthesia for hardware removal.
Collapse
Affiliation(s)
- Fei Qiao
- Department of Pediatric Orthopaedic, Dalian Women and Children's Medical Group, Dalian, China
| | - Xiaohong Guan
- Department of Anesthesia, Dalian Women and Children's Medical Group, Dalian, China
| | - Fei Jiang
- Department of Pediatric Orthopaedic, Dalian Women and Children's Medical Group, Dalian, China
| | - Ping Lv
- Department of Otorhinolaryngology, Dalian Women and Children's Medical Group, Dalian, China
| |
Collapse
|
2
|
Cho YJ, Kang SH, Kang MH. K-wire versus screws in the fixation of lateral condyle fracture of humerus in pediatrics: a systematic review and meta-analysis. BMC Musculoskelet Disord 2023; 24:649. [PMID: 37573303 PMCID: PMC10423410 DOI: 10.1186/s12891-023-06780-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 08/04/2023] [Indexed: 08/14/2023] Open
Abstract
BACKGROUND Lateral condyle fracture of the humerus is the second most common elbow fracture in children. Non-displaced lateral condyle fractures can often be managed with cast and conservative care, while reduction and fixation are often used to treat displaced lateral condyle fractures. Traditionally, K-wire fixation has been used for displaced lateral condyle fractures, but recently fixation using screws has been advocated in some studies. Therefore, we performed a meta-analysis to determine the difference in outcomes and complications between the two different fixation methods for the treatment of displaced lateral condyle fractures of the humerus in pediatric patients. METHODS Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used for this review. PubMed, Embase, and Cochrane Library were used for study selection. Studies comparing K-wires and screw fixation in displaced lateral condyle fractures in pediatric patients were included. Clinical outcomes using the Hardacre criteria, infection, limitation of range of motion of the elbow, lateral condyle overgrowth, delayed union, nonunion, and avascular necrosis were compared. Data were analyzed using the meta package in R version 4.2.2, and random-effects or fixed-effects models were used according to heterogeneity. RESULTS One randomized controlled study and three retrospective cohort studies were included, with a total of 240 patients (K-wire:118, screw:122). The clinical outcome using the Hardacre criteria was not different between the groups (P = 0.54), but the risk of infection (risk ratio [RR] = 5.52, 95% CI: 1.42-21.48, P = 0.01) and limitation of range of motion (RR = 3.75, 95% CI: 1.54-9.18, P < 0.01) were significantly higher in the K-wire fixation group than in screw fixation group. CONCLUSIONS The use of screws for fixation after reduction in the treatment of lateral condyle fracture of the humerus in children decreases the risk of superficial infection and elbow stiffness compared with the use of K-wire. Although removal of the implant under general anesthesia is necessary, screw fixation can be considered in displaced lateral condyle fractures of the humerus in children. TRIAL REGISTRATION PROSPERO (CRD42023415643).
Collapse
Affiliation(s)
- Yoon Joo Cho
- Department of Orthopaedic Surgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, 222, Banpo-Daero, Seocho-Gu, 06591, Seoul, Korea.
| | - Se Hyun Kang
- Department of Orthopaedic Surgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, 222, Banpo-Daero, Seocho-Gu, 06591, Seoul, Korea
| | - Mu Hyun Kang
- Department of Orthopaedic Surgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, 222, Banpo-Daero, Seocho-Gu, 06591, Seoul, Korea
| |
Collapse
|
3
|
Meng C, Meng Z, Huang X, Zhao F, Yang Q. A meta-analysis of closed reduction percutaneous pinning and open reduction with pin fixation of pediatric humeral lateral condylar fracture. Front Pediatr 2023; 11:1205755. [PMID: 37456567 PMCID: PMC10347534 DOI: 10.3389/fped.2023.1205755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 06/21/2023] [Indexed: 07/18/2023] Open
Abstract
Objective To compare the effectiveness and safety of closed reduction percutaneous pinning vs. open reduction with pin fixation to treat the pediatric humeral lateral condylar fracture. Methods Studies comparing closed reduction percutaneous pinning vs. open reduction with pin fixation for treating pediatric lateral humeral condyle fractures were found by searching Pubmed, Embase, the Cochrane Library, and Web of Science databases, including randomized/non-randomized controlled, retrospective case-control, and prospective cohort studies. Furthermore, quality evaluation and data retrieval were conducted after the literature review. A meta-analysis was performed using RevMan 5.4 software to compare both groups' outcome measures. Results This Meta-analysis incorporated eight studies with 856 cases. The Meta-analysis found no significant difference in functional outcomes, superficial infection, deep infection, poor fracture union, avascular necrosis of the humeral capitulum, or lateral spur formation between groups. However, the status of unaesthetic scars in the closed reduction percutaneous pinning group was superior. Conclusions For pediatric humeral lateral condylar fracture surgical therapy, the efficacy and safety of closed reduction percutaneous pinning vs. open reduction with pin fixation were not significantly different; closed reduction percutaneous pinning offered the benefit of eliminating unaesthetic scar. However, further high-quality research is required to verify the conclusions of this Meta-analysis. Systematic Review Registration https://www.crd.york.ac.uk/prospero/#myprospero, identifier CRD42023392451.
Collapse
Affiliation(s)
- Chao Meng
- Department of Pediatric Surgery, The Affiliated Tengzhou Central People’s Hospital of Xuzhou Medical University, Tengzhou, China
| | - Zhen Meng
- Department of Quality Control, Tengzhou Hospital of Traditional Chinese Medicine, Tengzhou, China
| | - Xin Huang
- Department of Pediatric Surgery, The Affiliated Tengzhou Central People’s Hospital of Xuzhou Medical University, Tengzhou, China
| | - Fenghua Zhao
- Department of Pediatric Surgery, The Affiliated Tengzhou Central People’s Hospital of Xuzhou Medical University, Tengzhou, China
| | - Qun Yang
- Department of Infectious Diseases, The Affiliated Tengzhou Central People’s Hospital of Xuzhou Medical University, Tengzhou, China
| |
Collapse
|
4
|
Zhu T, Jia G, Jin B, Liu T, Ma S, Chen J, Wang E. The Integrity of Cartilage Hinge in Song 2/3 Lateral Humeral Condylar Fractures in Children: A Retrospective Radiological Study in Two Centers. Orthop Surg 2022; 14:1656-1662. [PMID: 35732433 PMCID: PMC9363712 DOI: 10.1111/os.13371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Revised: 05/22/2022] [Accepted: 05/23/2022] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE For pediatric lateral condylar fractures (LCFs) of the humerus, it is often hard to determine the stability of the fracture based on the Song classification, especially for those categorized as Song stages 2 and 3. This study aims to define the characteristics of cartilage injury and assess the stability of LCFs classified as Song stages 2 and 3 on post-traumatic magnetic resonance imaging (MRI). METHODS This was a retrospective study based on imaging data, conducted with a short follow-up period. From January 2016 to May 2019, data of all patients with Song 2 and Song 3 LCFs treated at two institutions were collected. Based on the inclusion criteria, a total of 62 patients with Song stage 2/3 LCF were included. All radiographs were selected for observation and classification for comparison by two observers, both experienced pediatric orthopedic surgeons. MRIs scans for comparison were analyzed in three consecutive coronal sections and cross-sections. Patients were treated conservatively with casting or surgically with closed reduction and percutaneous pinning (CRPP). RESULTS Altogether 62 cases between 1.5 to 9 years old were included. Reliability analysis revealed poor, moderate, or good agreement between the two observers (range, 0.149-0.633). Both observers showed moderate or good consistency (range, 0.413-0.611). Among the 62 patients diagnosed with Song stages 2 and 3 fractures on initial radiographs, only two patients (3%) had complete fractures with complete disruption of the cartilage hinge as seen on MRI. The hinge was generally located in the posterior-inferior region of the distal humeral cartilage as indicated on MRI. There was no significant difference between Song stages 2 and 3 with regard to ratio of hinge to total values in any cross-sections, nor was there any significant difference in the completeness of the coronal sections (P > 0.05). Of the 62 patients treated, 50 were managed conservatively with casting and 12 underwent CRPP. Forty-nine of the remaining 60 patients (97%) with incomplete fractures were managed conservatively, while the remaining 11 patients were managed with CRPP. All patients with incomplete fractures showed bone healing and no evidence of lateral condyle displacement on follow-up radiographs. CONCLUSIONS The Song stage 2 or 3 classification is not entirely accurate and is inadequate at guiding treatment outcomes. The cartilage hinge was most likely located posteroinferiorly within the distal humeral epiphysis. According to our findings, conservative treatment with an effective cast or splint may be sufficient for bone healing in case of incomplete cartilage fractures.
Collapse
Affiliation(s)
- Tong Zhu
- Department of Pediatric Orthopaedics, Shengjing Hospital of China Medical University, Shenyang, China
| | - Guoqiang Jia
- Department of Pediatric Orthopaedics, Shengjing Hospital of China Medical University, Shenyang, China.,Department of Pediatric Orthopaedics, Children's Hospital of Anhui Medical University, Hefei, China
| | - Bin Jin
- Department of Pediatric Orthopaedics, Children's Hospital of Anhui Medical University, Hefei, China
| | - Tianjing Liu
- Department of Pediatric Orthopaedics, Shengjing Hospital of China Medical University, Shenyang, China
| | - Shuyu Ma
- Department of Pediatric Orthopaedics, Shengjing Hospital of China Medical University, Shenyang, China
| | - Jiayuan Chen
- Department of Pediatric Orthopaedics, Shengjing Hospital of China Medical University, Shenyang, China
| | - Enbo Wang
- Department of Pediatric Orthopaedics, Shengjing Hospital of China Medical University, Shenyang, China
| |
Collapse
|
5
|
Weng L, Cao Y, Zhang G, Zhou H, Liu X, Zhang Y. A Comparative Study on Closed Reduction vs. Open Reduction Techniques in the Surgical Treatment of Rotated Lateral Condyle Fractures of the Distal Humerus in Children. Front Pediatr 2022; 10:891840. [PMID: 35722490 PMCID: PMC9201398 DOI: 10.3389/fped.2022.891840] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 05/04/2022] [Indexed: 12/13/2022] Open
Abstract
Objective The best approach between closed reduction and open reduction in the treatment of total displaced and rotated LCFs is still being debated. This study aimed to comparatively evaluate the clinical outcomes and complications of closed reduction vs. open reduction in the treatment of displaced and rotated lateral condyle fractures in children. Methods We retrospectively evaluated 46 children who underwent surgical treatment for totally displaced and rotated lateral condyle fractures. Thirty-one children underwent open reduction and percutaneous pinning (ORPP). Ten children underwent closed reduction and percutaneous pinning (CRPP). Five children were changed to ORPP procedures because of the failure of closed reduction attempts. Clinical outcomes and complications in the groups were compared. Results Among three groups, no significant differences were found in demographic variables, and no differences were detected in the incidence of postoperative complications and clinical parameters. The ORPP group had the shortest surgical duration of the three groups (p < 0.005). Patients in CRPP group had faster fracture healing than the patients who underwent open reduction procedures. However, the success of CRPP seemed to be dependent on the earlier surgical intervention. Conclusion ORPP is still the first-line treatment for the totally displaced and rotated lateral condyle fractures because of its direct visualization of the joint surface and easy-to-accomplish characteristics. In addition, CRPP may be a feasible option for the treatment of this type of fractures because of it is less invasive and potentially minimizes complications. However, the technical difficulties of CRPP must be taken into account.
Collapse
Affiliation(s)
- Liuqi Weng
- Department of Orthopaedics, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Children's Hospital of Chongqing Medical University, Chongqing, China
- Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Yujiang Cao
- Department of Orthopaedics, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Children's Hospital of Chongqing Medical University, Chongqing, China
- Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Ge Zhang
- Department of Orthopaedics, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Children's Hospital of Chongqing Medical University, Chongqing, China
- Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Hai Zhou
- Department of Orthopaedics, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Children's Hospital of Chongqing Medical University, Chongqing, China
- Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Xing Liu
- Department of Orthopaedics, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Children's Hospital of Chongqing Medical University, Chongqing, China
- Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Yuan Zhang
- Department of Orthopaedics, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Children's Hospital of Chongqing Medical University, Chongqing, China
- Chongqing Key Laboratory of Pediatrics, Chongqing, China
| |
Collapse
|
6
|
Sahoo MM, Sahoo US, Jena M. Exposed versus buried K-wire fixation in paediatric lateral condyle humerus fractures: preliminary communication of a prospective comparative study. J Pediatr Orthop B 2022; 31:281-288. [PMID: 34285164 DOI: 10.1097/bpb.0000000000000880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Buried Kirschner's wires (K-wires) following internal fixation of paediatric Lateral condyle fracture of humerus allow them to hold the bone until radiological consolidation but requires another surgical procedure for implant removal. Exposed wires need meticulous pin tract care, earlier implant removal and may carry a higher risk of infection. The objective of this study was to compare the outcomes of buried versus exposed K-wires for these fractures. This prospective comparative(nonrandomised) study was conducted from July 2016 to April 2020 at a tertiary care level I trauma centre on 80 children, <12 years of age, divided into group 1(n = 40), where K-wires were left exposed, and group 2 (n = 40), where K-wires were buried. Functional outcome and complications were compared between the two groups with at least 3 months follow-up. Infection rate was significantly lower in buried K-wire group with 7 patients (17.5%) compared to 15 (37.5%) in exposed group, P = 0.045. Four out of those 15 patients needed debridement suggesting that exposed K-wires carry a higher risk of bone infection and subsequent morbidities. There was no significant difference in union time, range of motion (mean flexion 135.3° in exposed vs. 132.5° in buried, P = 0.988), carrying angle (8.5° vs. 8.6°, P = 0.981), or lateral condyle hypertrophy; 12 (30%) vs. 9 (22.5%), P = 0.446. Skin pigmentation was more in the exposed group; 13 (32.5%) vs. 10 (25%), P = 0.459. We recommend that K-wires should be buried subcutaneously, particularly when meticulous pin tract care is doubtful.
Collapse
Affiliation(s)
| | | | - Manoranjan Jena
- Department of Community Medicine, SCB Medical College and Hospital, Cuttack, Odisha, India
| |
Collapse
|
7
|
Impacts of Fracture Types on Success Rate of Closed Reduction and Percutaneous Pinning in Pediatric Lateral Condyle Humerus Fractures Displaced >4 mm. J Pediatr Orthop 2022; 42:265-272. [PMID: 35180724 DOI: 10.1097/bpo.0000000000002093] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Closed reduction and percutaneous pinning (CRPP) is a promising treatment for pediatric lateral condyle humerus fractures (LCHFs) displaced >4 mm. However, few studies discussed roles of fracture types on success of CRPP in LCHFs. This study aimed to analyze the impacts of types of LCHFs displaced >4 mm on the success rate of CRPP. METHODS We retrospectively reviewed 66 consecutive pediatric LCHFs attempted CRPP at our center. Song, Milch, Jakob, and Weiss classification were used to classify LCHFs. The fracture gap ≤2 mm and step of articular surface ≤2 mm were deemed as a successful CRPP. Otherwise, open reduction and internal fixation (ORIF) would be performed. Different fracture types and preoperative displacement were analyzed for their roles on success rate of CRPP in treating LCHFs displaced >4 mm. RESULTS Fifty patients met the inclusion criteria were finally included in this study. Results showed that Milch type II LCHFs had a higher success rate of CRPP than type I LCHFs (P=0.03, <0.05). Correlation was found between Milch types and success rate of CRPP displaced >4 mm. No difference was found between Song stage 4 and 5 LCHFs displaced >4 mm in success rate of CRPP (P=0.90, >0.05), also no difference was found in pre-operative displacement between CRPP group and ORIF group. CONCLUSIONS Milch classification is more important than Song classification in the success rate of CRPP when treating LCHFs displaced >4 mm. Milch type II LCHFs are recommended to be treated with CRPP, while Milch type I LCHFs are recommended to be treated with ORIF. The current study confirm Song's initial report that closed reduction can be successful and should be attempted for fractures with such displacement rather than going directly to ORIF. LEVEL OF EVIDENCE Level III.
Collapse
|
8
|
Swarup I, Chan C, Mehta N, Lawrence JT. Does an elbow arthrogram change management after closed reduction of mildly displaced lateral condyle fractures in children? J Pediatr Orthop B 2022; 31:7-11. [PMID: 32991375 DOI: 10.1097/bpb.0000000000000811] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The purpose of this study was to investigate whether an elbow arthrogram after closed reduction and percutaneous fixation of lateral condyle fractures results in a change in surgical management. This is a retrospective review of lateral condyle fractures managed with closed reduction and percutaneous fixation followed by an elbow arthrogram at our institution between 2008 and 2019. Chart and radiographic review was performed and operative notes were reviewed to determine rates of subsequent intervention after arthrogram. Descriptive statistics were used to summarize the data. This study included 47 patients. The majority of patients were male (34 patients, 72%), and the mean age at time of injury was 5.5 ± 2.6 years. The mean radiographic displacement was 2.6 mm (range 0.8-6.9 mm). All fractures were managed by fellowship-trained pediatric orthopaedic surgeons with an average of 10.5 years of experience (range 0-32 years). Fractures were stabilized with percutaneous pins in 44 patients (94%) and percutaneous screws in three patients (6%). No patients had subsequent changes in management after an elbow arthrogram. There were no complications related to performance of the arthrogram. Closed reduction and percutaneous fixation is often indicated for mildly displaced lateral condyle fractures. Articular reduction after percutaneous fixation is commonly assessed using an elbow arthrogram; however, it did not change surgical management in any case reviewed over the 10-year study period. While there seems to be little risk of performing an arthrogram, the clinical utility should be further evaluated.
Collapse
Affiliation(s)
- Ishaan Swarup
- Division of Pediatric Orthopaedic Surgery, UCSF Benioff Children's Hospital Oakland, Oakland, California
- Division of Pediatric Orthopaedic Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Calvin Chan
- Division of Pediatric Orthopaedic Surgery, UCSF Benioff Children's Hospital Oakland, Oakland, California
- Division of Pediatric Orthopaedic Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Nishank Mehta
- Division of Pediatric Orthopaedic Surgery, UCSF Benioff Children's Hospital Oakland, Oakland, California
- Division of Pediatric Orthopaedic Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - John T Lawrence
- Division of Pediatric Orthopaedic Surgery, UCSF Benioff Children's Hospital Oakland, Oakland, California
- Division of Pediatric Orthopaedic Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| |
Collapse
|
9
|
Closed reduction and percutaneous pinning vs open reduction and internal fixation in pediatric lateral condylar humerus fractures displaced by > 4 mm: an observational cross-sectional study. BMC Musculoskelet Disord 2021; 22:985. [PMID: 34823533 PMCID: PMC8620550 DOI: 10.1186/s12891-021-04880-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 11/12/2021] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Although open reduction and internal fixation (ORIF) is recommended for lateral condylar humerus fractures (LCHFs) displaced by > 4 mm, several studies have reported the use of closed reduction and percutaneous pinning (CRPP) to treat LCHFs with significant displacement. However, little is known about the clinical differences between these two surgical techniques. This study aimed to compare the therapeutic effects of CRPP and ORIF in treating LCHFs displaced by > 4 mm. METHODS We retrospectively reviewed pediatric LCHFs displaced by > 4 mm treated with either CRPP or ORIF at our center from June 2019 to October 2020. Song and Milch fracture classifications were used. Variables such as age at injury, sex, side injured, fracture displacement, fracture type, operating time, postoperative treatment, and complications were compared between the two techniques. RESULTS One hundred twenty LCHFs met inclusion criteria. There were 36 Milch type I and 84 type II LCHFs, and 69 Song stage 4 and 51 stage 5 LCHFs. CRPP was performed in 45 cases and ORIF in 75 cases. No differences were found in age, sex, side injured, preoperative displacement, postoperative displacement, and length of immobilization between the CRPP and ORIF groups. There was a difference between operation time and pin duration. The CRPP group had shorter operation times and pin duration, and required no additional operations to remove internal pins. The average follow-up duration was 13.9 months. All patients achieved fracture union, and no complications such as infection, nonunion, delayed union, osteonecrosis, fishtail deformity, cubitus varus or valgus, or pain were recorded during follow-up. Bone spurs, lateral prominences, and decreased carrying angle were common complications in all groups. No obvious cubitus varus was observed. Unaesthetic scars were only observed in the ORIF groups. No differences in range of motion or elbow function was found among the different therapies. CONCLUSIONS Both CRPP and ORIF can achieve satisfactory clinical outcomes in treating LCHFs displaced by > 4 mm. No differences were found in complications or prognoses between the two groups. However, CRPP shows some advantages over ORIF, like less invasive surgery, no obvious scarring, and no need for secondary surgery with anesthesia for pin removal.
Collapse
|
10
|
Ikwuezunma IA, Suresh KV, Nhan DT, Bryant BR, Kotian RN, Lee RJ. Patient-reported outcomes after operative versus nonoperative treatment of pediatric lateral humeral condyle fractures. Medicine (Baltimore) 2021; 100:e27440. [PMID: 34731118 PMCID: PMC8519235 DOI: 10.1097/md.0000000000027440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 09/19/2021] [Indexed: 01/05/2023] Open
Abstract
Lateral humeral condyle fractures in children are treated with several approaches, yet it is unclear which has the best treatment outcomes. We hypothesized that functional outcomes would be equivalent between treatment types, reduction approaches, and fixation types. Our purpose was to assess patient-reported outcomes and complications by treatment type (operative versus nonoperative), reduction approach (open versus percutaneous), and fixation type (cannulated screws versus Kirschner wires).We retrospectively reviewed data from acute lateral humeral condyle fractures treated at our level-1 pediatric trauma center from 2008 to 2017. Patients were included if they were 8 years or older and had completed clinical follow-up. Fractures were categorized by fracture severity as mild (<2-mm displacement), moderate (isolated, 2- to 5-mm displacement), or severe (isolated, >5-mm displacement or >2-mm displacement with concomitant elbow dislocation or other elbow fracture). We extracted data on patient age, sex, treatment type, reduction approach, fixation type, patient-reported outcomes (shortened Disabilities of the Arm, Shoulder, and Hand and Patient Reported Outcome Measurement Information System upper extremity), treatment complications, and follow-up duration. Patients in the operative versus nonoperative group and across fracture severity subgroups did not differ significantly by age, sex, or follow-up duration. Bivariate analysis was performed to determine whether outcomes differed by intervention. Alpha = 0.05.No differences were observed in patient-reported outcomes between operative versus nonoperative groups for the mild and severe fracture subgroups. No differences were observed between approach (open versus percutaneous) or instrumentation (cannulated screw versus Kirschner wire fixation) for any outcome measure within the operative group. Patients whose fractures were stabilized with screws versus wires had significantly higher rates of return to the operating room (94% versus 8.3%, P < .001). The overall complication rate for our cohort was low, with no differences by treatment type or fracture severity.In our cohort, patient-reported outcomes were similar across fracture severity categories, irrespective of treatment or fixation type. Patients who underwent internal fixation with cannulated screws experienced significantly higher rates of return to the operating room compared with those treated with Kirschner wires but otherwise had similar complication rates and patient-reported outcomes.Level of Evidence: 3.
Collapse
|
11
|
Guo L, Li X, Wang Z, Zhu S. Accuracy of MRI and X-Ray Measurement of Displacement Distance of Humeral Lateral Condyle Fractures. Orthop Surg 2021; 13:2018-2026. [PMID: 34541820 PMCID: PMC8528974 DOI: 10.1111/os.13116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 05/26/2021] [Accepted: 05/26/2021] [Indexed: 11/26/2022] Open
Abstract
Objective To investigate the accuracy of X‐ray and magnetic resonance imaging (MRI) measurements in evaluating the displacement of humeral lateral condyle fracture (HLCF) in different positions of the forearm based on human cadaveric HLCF models. Methods Three human cadaveric elbow HLCF fracture models were successfully established. The wrist joint was fixed, and the forearm was rotated forward along the mid‐axis. The maximum distance between the two segments of the lateral fracture gap was defined as LFS (lateral fracture space) distance, and the maximum distance between the two segments of the fracture gap at the anterior and posterior margins of the fracture model was defined as PFS (posterior fracture space). The LFS and PFS distances of the human cadaveric elbow HLCF fracture models were measured during forearm rotation at 0º, 45º, 90º, and 135º rotation using a Capture Motion System (CMS), positive and lateral elbow X‐ray, coronal and sagittal MRI scans, respectively, and the CMS measurements were considered as the true fracture gap distances. The values obtained by CMS, X‐ray, and MRI measurements for both LPS and PFS distances in the HLCF fracture model at each position during rotation were recorded. The LFS and PFS distances were measured by two independent orthopaedic and joint imaging physicians. The data were measured three times by each physician, and the final values were the average of the two measurements. The outcomes were determined by whether a statistical difference exists in the LFS and PFS among the CMS, X‐ray, and MRI groups. Results The interobserver agreement tests between the two observers showed good agreement in the measurements. A multiple sample ANOVA showed statistical differences in the LFS distances of HLCF measured at 0º, 45º, 90º, and 135º rotated by three radiographic measurements (P < 0.05). The LFS distances obtained by MRI and CMS measurements were greater than those obtained by X‐ray measurement in all positions using the LSD test (P < 0.05), and no statistical difference was found between the CMS and MRI methods in each position (P > 0.05). The same results were observed in terms of PFS values obtained by CMS, X‐ray, and MRI measurements at 0º, 45º, 90º, and 135º pronation. It was statistically different among the three groups as shown by multiple sample ANOVA (P < 0.05). The CMS and MRI measurements were greater than the X‐ray measurements (P < 0.05), while no statistical difference was observed between the CMS and MRI measurements (P > 0.05). Conclusion X‐rays often underestimate the degree of displacement of HLCF fractures; MRI measurements are closer to the true values compared with X‐ray.
Collapse
Affiliation(s)
- Lin Guo
- Tianjin Hospital, Tianjin, China
| | | | - Zhi Wang
- Tianjin Hospital, Tianjin, China
| | - Shan Zhu
- Tianjin Hospital, Tianjin, China
| |
Collapse
|
12
|
Tomsan H, Grady MF, Ganley TJ, Nguyen JC. Pediatric Elbow: Development, Common Pathologies, and Imaging Considerations. Semin Roentgenol 2021; 56:245-265. [PMID: 34281678 DOI: 10.1053/j.ro.2021.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Hanna Tomsan
- Department of Radiology, Mercy Catholic Medical Center, Darby, PA
| | - Matthew F Grady
- Divison of Orthopedic Surgery, Children's Hospital of Philadelphia, Philadelphia, PA; University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Theodore J Ganley
- Divison of Orthopedic Surgery, Children's Hospital of Philadelphia, Philadelphia, PA; University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Jie C Nguyen
- University of Pennsylvania School of Medicine, Philadelphia, PA; Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA.
| |
Collapse
|
13
|
Comparison of closed and open reduction internal fixation of acutely displaced unstable lateral humeral condylar fractures in children: a prospective cohort study. CURRENT ORTHOPAEDIC PRACTICE 2021. [DOI: 10.1097/bco.0000000000000982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
14
|
Treatment of pediatric lateral condylar humerus fractures with closed reduction and percutaneous pinning. BMC Musculoskelet Disord 2020; 21:707. [PMID: 33109140 PMCID: PMC7592374 DOI: 10.1186/s12891-020-03738-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 10/23/2020] [Indexed: 11/16/2022] Open
Abstract
Background Lateral condylar humerus fractures (LCHFs) are the second most common pediatric distal humerus fractures. Open reduction and internal fixation is recommended for fractures displaced by more than 2 mm. Few studies described using closed reduction and percutaneous pinning (CRPP) for treating fractures with greater displacements. This study aims to explore the feasibility of CRPP in treating displaced LCHFs. Methods All patients underwent attempted CRPP first. Once a satisfying reduction was obtained, as determined using fluoroscopy based on the relative anatomical position of the fragments, an intraoperative arthrogram was performed to further confirm the congruence of the articular surface of the distal humerus. Open reduction is necessary to ensure adequate reduction if the fracture gap is more than 2.0 mm on either anteroposterior view or oblique internal rotational view by fluoroscopy after CRPP. All included fractures were treated by a single pediatric surgeon. Results Forty-six patients were included, 29 boys and 17 girls, with an average age of 5.2 years. Of these, 22/28 (78%) Jakob type II fractures and 14/18 (78%) Jakob type III fractures were treated with CRPP. All cases in Song stages II and III, 19/25 (76%) cases in Song stage IV, and 14/18 (78%) cases of Song stage V were treated with CRPP. The remaining converted to open reduction with internal fixation. Overall, 36 of the 46 patients (78%) were treated with CRPP. The average pre-op displacement was 7.2 mm, and the average post-op displacement was 1.1 mm on the anteroposterior or oblique internal rotational radiograph in cases treated with CRPP. CRPP was performed in an average of 37 min. The average casting period was 4 weeks and the average time of pin removal was 6 weeks postoperatively. The average time of follow-up was 4 months. All patients achieved union, regardless of closed or open reduction. No infection, delayed union, cubitus varus or valgus, osteonecrosis of the trochlea or capitellum, or pain were recorded during follow-up. Conclusions Closed reduction and percutaneous pinning effectively treats LCHFs with displacement more than 4 mm. More than 3/4 of Song stage V or Jakob type III patients can avoid an incision.
Collapse
|
15
|
Tomori Y, Nanno M, Takai S. Anterolateral Versus Posterolateral Approach for Lateral Condylar Fractures of the Humerus in Children. JB JS Open Access 2020; 5:e20.00035. [PMID: 33163842 PMCID: PMC7556363 DOI: 10.2106/jbjs.oa.20.00035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Two surgical approaches, an anterolateral and a posterolateral approach, have been advocated for lateral condylar fractures (LCFs) of the humerus in children. The purpose of this study was to evaluate the radiographic and clinical outcomes of the 2 surgical approaches. METHODS We retrospectively analyzed the data of consecutive patients <15 years of age with an LCF treated via open reduction and internal fixation through 1 of 2 surgical approaches during the period of April 2000 to March 2019. Patients were classified into the anterolateral (AL) and posterolateral (PL) groups, according to the surgical approach used. Postoperative complications and radiographic and clinical findings (including range of motion and findings on the basis of the Flynn criteria) were investigated. To investigate humeral deformity, the Baumann angle and the carrying angle were measured on anteroposterior radiographs. RESULTS Sixty-one of 82 patients met the inclusion criteria. The AL group included 17 patients (13 male, 4 female), and the PL group included 44 patients (28 male, 16 female). In the PL group, 7 patients had cubitus varus deformity, 3 had malunion due to unacceptable reduction of fracture fragments, and 6 had elbow joint contracture. In the AL group, the overall clinical results were excellent for 15 patients and good for 2. In the PL group, the clinical results were excellent for 12 patients, good for 14, fair for 6, and poor for 12. CONCLUSIONS An anterolateral approach would be the optimal approach for an LCF in pediatric patients. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Collapse
Affiliation(s)
- Yuji Tomori
- Department of Orthopaedic Surgery, Nippon Medical School, Tokyo, Japan
| | - Mitsuhiko Nanno
- Department of Orthopaedic Surgery, Nippon Medical School, Tokyo, Japan
| | - Shinro Takai
- Department of Orthopaedic Surgery, Nippon Medical School, Tokyo, Japan
| |
Collapse
|
16
|
Soldado F F, Domenech-Fernandez P, Barrera-Ochoa S, Bergua-Domingo JM, Diaz-Gallardo P, Hodgson F, Knorr J. Transverse Anterior Approach to the Elbow for Pediatric Displaced Lateral Humeral Condyle Fractures. THE ARCHIVES OF BONE AND JOINT SURGERY 2020; 8:142-146. [PMID: 32490043 DOI: 10.22038/abjs.2019.30756.1797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background The anterior approach to the elbow for pediatric lateral condyle fractures (LCF) would provide a better visualization of the articular fracture resulting in better functional results, less complications and a more cosmetically-appealing scar than usually seen with the lateral approach. Methods Retrospective study of children undergoing an open reduction and internal fixation of a displaced LCF via an anterior approach with a transverse incision. Bilateral elbow range of motion (ROM), upper limb alignment and complications were registered. A 4-point ordinal Likert-type scale was employed for parents to rate their level of satisfaction with the cosmetic appearance of the scar. Results Eighteen children of mean age 76 months (range 27 to 101 months) were included. Fractures were classified as Jackob's Type II in 14 cases and Milch's type II in all cases. Mean follow-up was 12 (range 4 to19) months.Successful condral fracture visualization and reduction was achieved in every case. No intra-operative or post-operative complications occurred. In all cases bone union was obtained 4 to 5 weeks after surgery and at final follow-up, active elbow ROM of at least 90%, was obtained. All parents claimed to be "very satisfied" with their child's scar. A lateral spur was identified in 66.7% o patients. Conclusion The anterior approach to the elbow was both a feasible and safe allowing full anatomical cartilage reduction. Complications after this technique might decrease compared to the lateral approach but need future comparative studies. The rate of lateral spur did not decreased. Cosmetic scar results seem to be a clear advantage of this approach compared to the classical lateral approach.
Collapse
Affiliation(s)
- Francisco Soldado F
- Pediatric Hand Surgery and Microsurgery, UCA Unit, Vithas San Jose, Barcelona, Spain
| | | | - Sergi Barrera-Ochoa
- icat MA Hand and Microsurgery Unit; ICATME, Hospital Universitari Quiron-Dexeus, Barcelona, Spain
| | | | - Paula Diaz-Gallardo
- Pediatric Hand Surgery and Microsurgery, UCA Unit, Vithas San Jose, Barcelona, Spain
| | - Felipe Hodgson
- Department of Orthopaedic Surgery, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Jorge Knorr
- Pediatric Hand Surgery and Microsurgery, UCA Unit, Vithas San Jose, Barcelona, Spain
| |
Collapse
|
17
|
Birkett N, Al-Tawil K, Montgomery A. Functional Outcomes Following Surgical Fixation of Paediatric Lateral Condyle Fractures of the Elbow - A Systematic Review. Orthop Res Rev 2020; 12:45-52. [PMID: 32273780 PMCID: PMC7107004 DOI: 10.2147/orr.s215742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Accepted: 02/11/2020] [Indexed: 11/23/2022] Open
Abstract
Objective Lateral humeral condyle fractures are the second most common elbow fractures in children. Both K-wire fixation and screw fixation have been advocated as suitable treatment options for displaced fractures. This study aimed to identify which fixation method was associated with the best functional outcomes. Methods A systematic review was conducted. Studies reporting functional outcomes following surgical fixation of lateral condyle fractures were included for review. The primary outcome measure was functional outcome. The secondary outcome measure was major complications. A narrative analysis was undertaken, as meta-analysis was felt to be inappropriate due to the differences between included studies. Results Ten retrospective non-randomised, comparative studies were eligible and included. No randomised-controlled trials were identified. The highest rate of excellent functional outcomes was seen with screw fixation (120/126 [95%]), compared with K-wire fixation (135/162 [86%]). The incidence of major complications was comparable, with complications in 6/95 (6%) of screw fixations and 6/141 (4%) K-wire fixations. A small sample of data on closed reduction demonstrated excellent functional results in 73 of 76 (96%) of patients. Closed reduction of displaced fractures is associated with a significant learning curve however. Conclusion The evidence was of poor quality and comprised of retrospective case series. This prevented meta-analysis and any firm conclusions being drawn from the available data. Screw fixation may be associated with improved functional outcomes. Complication rates between the two methods are comparable. Further prospective studies are recommended.
Collapse
|
18
|
Tomori Y, Nanno M, Takai S. Kirschner Wire Fixation with and without Tension Band Wiring for Treatment of Fracture of the Lateral Humeral Condyle in Children. J NIPPON MED SCH 2020; 87:17-23. [PMID: 31611504 DOI: 10.1272/jnms.jnms.2020_87-105] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Kirschner wires (K-wires) are commonly used to treat displaced lateral humeral condyle fracture in children. However, K-wire fixation alone is insufficient for early elbow range of motion (ROM) exercises. Fixation combined with tension band wiring (TBW) converts distraction forces into compression forces, which provides more rigid fixation than K-wire fixation alone. Here, we retrospectively evaluated clinical outcomes of patients with displaced lateral humeral condyle fracture treated with TBW or K-wires only. METHODS We identified children with lateral condyle fractures who had undergone surgery during the period from April 2000 through March 2014. Nineteen patients were classified into 2 groups according to treatment: 10 were allocated to the TBW group (TBW and K-wires) and 9 to the K-wires group. The mean interval from injury to surgery was 5.1 days in both groups. Fractures were classified by using the Jacob's and Milch's classifications. In addition, we collected and analyzed data on postoperative complications, radiological and clinical evaluations, ROM, and Flynn's criteria. RESULTS Mean duration of follow-up was 14.4 months in the TBW group and 5.9 months in the K-wires group. Mean bone union time was 38.6 days and 49.8 days, respectively. Mean duration of cast/splint use was significantly longer for K-wires patients (49.8 days) than for TBW patients (35.8 days). Range of flexion at the final follow-up was significantly lower in the K-wires group. CONCLUSIONS TBW fixation appears to be the optimal treatment for displaced lateral humeral condyle fracture in children, as it facilitates early active range of motion exercises.
Collapse
Affiliation(s)
- Yuji Tomori
- Departments of Orthopedic Surgery, Nippon Medical School Hospital
| | - Mitsuhiko Nanno
- Departments of Orthopedic Surgery, Nippon Medical School Hospital
| | - Shinro Takai
- Departments of Orthopedic Surgery, Nippon Medical School Hospital
| |
Collapse
|
19
|
The Song Classification Is Reliable and Guides Prognosis and Treatment for Pediatric Lateral Condyle Fractures: An Independent Validation Study With Treatment Algorithm. J Pediatr Orthop 2020; 40:e203-e209. [PMID: 31415016 DOI: 10.1097/bpo.0000000000001439] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Lateral condyle fractures account for 15% to 20% of pediatric elbow fractures. Among numerous proposed classification systems, the Song classification appears the most comprehensive. The utility of any classification system relies on its ability to be descriptive, reproducible, and to guide prognosis/treatment. We assessed the Song classification by applying it to 736 retrospectively treated patients. METHODS A total of 736 pediatric patients with lateral condyle fractures were identified between 2007 and 2014. In total, 60 patients were selected for a radiographic interclass and intraclass correlation study. Radiographs of the patients were reviewed by 6 observers, who independently measured radiographs for displacement on radiographs and assigned a Song classification. Treatment and outcomes were then reviewed on all 736 patients and evaluated as a successful outcome when achieving a healed fracture at discharge without significant complication or necessitating a change from initial treatment modality. RESULTS Weighted κ values for intrarater and interrater reliability to assign Song classification indicated excellent agreement. Intraclass correlation coefficients of 6 observers measuring displacement on radiographs in millimeters indicated good to excellent agreement. In total, 106 Song 1 fracture were primarily treated by casting alone and only 5.5% required conversion to operative intervention. Overall, 139 Song 2 fractures were treated by closed treatment (n=114, 82% successful nonoperatively, 16% converted to operative management) or surgical means (n=25, 100% success) without treatment superiority (P>0.999) and both modalities had high success rates. Song 3 fractures (n=17) demonstrated a failure rate of 80% with casting (n=10) and were better managed by closed reduction and percutaneous pinning (n=7, 100% success, P=0.002). Song 4 (n=325) fractures had low success rate (34%) with casting (n=35), but achieved higher success rates (P<0.001) when managed with either closed (n=57) or open reduction (n=233) and pin fixation (89.5% and 92.7% success, respectively, P=0.401). Song 5 fractures (n=149) generally required an open reduction in our series with good success rates (91.2%). CONCLUSION This study validates the Song classification with high interobserver and intraobserver reliability. The Song classification improves on existing classification systems by better distinguishing fractures at risk for failure of nonoperative treatment and guiding treatment outcomes. LEVEL OF EVIDENCE Level IV.
Collapse
|
20
|
Vorhies JS, Funk S, Elliott M, Riccio A, Ramo B. The Utility of Intraoperative Arthrogram in the Management of Pediatric Lateral Condyle Fractures of the Humerus. Orthopedics 2020; 43:30-35. [PMID: 31693741 DOI: 10.3928/01477447-20191031-01] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 09/09/2019] [Indexed: 02/03/2023]
Abstract
Intraoperative arthrograms are commonly used in conjunction with closed reduction and percutaneous pinning (CRPP) of pediatric lateral condyle fractures of the humerus. The authors sought to determine how arthrograms affect management of these fractures. They reviewed all lateral condyle fractures treated surgically at a pediatric level I trauma center from 2008 to 2014. They stratified patients managed with and without an arthrogram as well as by timing of arthrogram. The authors compared injury parameters, initial and postoperative fracture displacement, and complications between groups. They identified 107 patients who were taken to the operating room for attempted closed reduction, which they classified as either CRPP without arthrogram or arthrogram first and then a decision to treat open or with CRPP. Fifty-eight (54.21%) underwent CRPP without arthrogram and 49 (45.79%) underwent arthrogram. Of those who had arthrograms, 27 (25.23%) were prior to fixation and 22 (20.56%) were after fixation. There was no difference in age, weight, or preoperative displacement among the groups. Mean postoperative displacement was significantly lower in the no arthrogram group vs the arthrogram group (0.91 mm vs 1.68 mm; P<.0001), but it did not differ based on timing of arthrogram (P=.836). Arthrograms changed management in 4 (8%) of 49 patients who had them. There was no statistical difference in the rate of changed management by timing of arthrogram (before vs after fixation, 14.8% vs 0%; P=.060). The authors demonstrated that arthrograms may be useful for assessing final fracture alignment after CRPP, but are unlikely to result in a treatment change and are not associated with improved postoperative alignment. [Orthopedics. 2020; 43(1):30-35.].
Collapse
|
21
|
Hachri S, Abouljaoud H, Cherrabi H, Atarraf K, Chater L, Afifi MA. [Fracture of the medial and lateral epicondyle associated with elbow dislocation in children (about a case)]. Pan Afr Med J 2018; 30:87. [PMID: 30344871 PMCID: PMC6191257 DOI: 10.11604/pamj.2018.30.87.14722] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Accepted: 04/17/2018] [Indexed: 11/25/2022] Open
Abstract
La luxation du coude est une lésion relativement rare chez l’enfant. Elle représente 3 a 6% des traumatismes du coude, On constate souvent des fractures associées à cette luxation, ce sont le plus souvent des fractures de l’épicondyle médial, l’association d’une fracture de l’épicondyle latéral et médial à la fois à une luxation reste exceptionnelle. Nous rapportons le cas d’un enfant âgé de 13 ans victime d’un traumatisme du coude gauche par un mécanisme indirect. L’examen locomoteur a objectivé un coude gauche tuméfié, déformé avec une impotence fonctionnelle totale. La radiographie a mis en évidence une luxation posteroexterne du coude associée à une fracture de l’épicondyle latéral et de l’épicondyle médial qui se trouve incarcéré en intra articulaire. La prise en charge a consisté en une réduction de la luxation sous anesthésie, avec un contrôle scopique objectivant une bonne réduction, une fracture de l’épicondyle latéral jugée stade 1 selon la classification de Lagrange et Rigault après réduction et une fracture de l’épicondyle médial stade 2 selon la classification de Watson-Jones, d’où la décision d’opérer cette dernière, avec un abord postéromédial du coude. Le contrôle radiologique post opératoire immédiat et à distance jugé satisfaisant avec une ablation de l’attelle faite à 3 semaines, et une ablation de matériel d’ostéosynthèse faite à 6 semaines, une rééducation du coude était prescrite, avec un bon résultat clinique.
Collapse
Affiliation(s)
- Sara Hachri
- Service de Traumato-orthopédie Pédiatrique, CHU Hassan II, Fès, Maroc
| | - Hind Abouljaoud
- Service de Traumato-orthopédie Pédiatrique, CHU Hassan II, Fès, Maroc
| | - Hind Cherrabi
- Service de Traumato-orthopédie Pédiatrique, CHU Hassan II, Fès, Maroc
| | - Karima Atarraf
- Service de Traumato-orthopédie Pédiatrique, CHU Hassan II, Fès, Maroc
| | - Lamiae Chater
- Service de Traumato-orthopédie Pédiatrique, CHU Hassan II, Fès, Maroc
| | | |
Collapse
|
22
|
Abstract
INTRODUCTION Lateral condyle fractures are a common pediatric elbow injury. Nonunion is a known complication of this injury but its incidence and causative risk factors are unknown. Further, a clear and consistent definition of nonunion for pediatric lateral condyle fractures does not exist. The purpose of this study is to determine the rate of nonunion, the risk factors associated with it and to provide a clear definition. METHODS A retrospective chart review of all pediatric lateral condyle fractures treated at an urban, tertiary pediatric care center between 2001 and 2014. Data collected included demographics, Weiss classification, type of treatment, follow-up, time from injury to surgery and complications. For patients with nonunions, additional treatments and final range of motion were also recorded. A nonunion was defined as lack of callus with fragment migration by 8 weeks after initiation of treatment. RESULTS A total of 530 patients were identified of which 500 were available for review. There were 7/500 (1.4%) nonunions in the cohort. Nonunion occurred in 1.4% (2/140) of type I fractures, 0% (0 /178) of type II fractures, and 3% (5/168) of type III fractures. The only significant risk factor for nonunion was the presence of a type III fracture (P=0.05). Five patients with nonunion underwent revision surgery with a partially threaded cannulated cancellous screw. All of these patients went on to union. Four of the 5 patients had their screws removed after union. CONCLUSION Nonunion after pediatric lateral condyle fracture is rare and is defined by lack of any callus with fragment migration at 8 weeks. The only significant risk factor for nonunion development was the presence of a type III fracture. Revision surgery with a partially threaded screw achieved union in all cases. LEVEL OF EVIDENCE Level IV-retrospective case review.
Collapse
|
23
|
Shaerf DA, Vanhegan IS, Dattani R. Diagnosis, management and complications of distal humerus lateral condyle fractures in children. Shoulder Elbow 2018; 10:114-120. [PMID: 29560037 PMCID: PMC5851120 DOI: 10.1177/1758573217701107] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Accepted: 03/02/2017] [Indexed: 11/16/2022]
Abstract
We review the diagnosis, evaluation and management of paediatric lateral condylar fractures. The complications of these fractures are also discussed, including the management of fracture non-union.
Collapse
Affiliation(s)
- Daniel A Shaerf
- West Hertfordshire Hospitals NHS Trust, Hemel Hempstead, Hertfordshire, UK
| | - Ivor S Vanhegan
- Kingston Hospital NHS Foundation Trust, Kingston upon Thames, London, UK
| | - Rupen Dattani
- Chelsea & Westminster Hospital NHS Foundation Trust, Chelsea, London, UK
| |
Collapse
|
24
|
Prasad A, Mishra P, Aggarwal AN, Chadha M, Pandey R, Anshuman R. Exposed versus Buried Kirschner Wires Used in Displaced Pediatric Fractures of Lateral Condyle of Humerus. Indian J Orthop 2018; 52:548-553. [PMID: 30237613 PMCID: PMC6142795 DOI: 10.4103/ortho.ijortho_295_17] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Comparision of results and complications of exposed versus buried Kirschner wires (K-wires) after open reduction of lateral condyle fractures is scarce and mainly from western population; hence, we envisaged to study the safety and efficacy of exposed and buried K-wires used for fixation of displaced pediatric fracture of the lateral condyle of humerus in Indian setup. MATERIALS AND METHODS A prospective, nonrandomized, comparative study was conducted in 50 patients with age <12 years, presenting with displaced fracture of lateral condyle of humerus of <2 weeks duration, without associated ipsilateral upper limb injury, who were treated by open reduction and internal fixation with either exposed or buried K-wires (n = 25 in each group). At a minimum followup of 3 months, status of fracture reduction, union, evidence of osteomyelitis, carrying angle at the elbow, and elbow range of motion (ROM) were assessed clinicoradiologically. RESULTS Four (16%) patients in exposed group and 1 (4%) in buried group had superficial infection, while 3 (12%) patients in exposed group and 2 (8%) in buried group had deep infection. All the patients with infection responded well to oral antibiotics and regular dressings. Buried group had higher incidence of secondary skin and wire-related complications. CONCLUSION There was no statistical difference between the two groups but exposed K wires are easy to remove so are preferred over buried K wires.
Collapse
Affiliation(s)
- Avijeet Prasad
- Department of Orthopedics, UCMS and GTB Hospital, New Delhi, India,Address for correspondence: Dr. Avijeet Prasad, 726, D-Pocket, Dilshad Garden, New Delhi - 110 095, India. E-mail:
| | - Puneet Mishra
- Department of Orthopedics, UCMS and GTB Hospital, New Delhi, India
| | | | - Manish Chadha
- Department of Orthopedics, UCMS and GTB Hospital, New Delhi, India
| | - Rohit Pandey
- Department of Orthopedics, UCMS and GTB Hospital, New Delhi, India
| | - Rahul Anshuman
- Department of Orthopedics, UCMS and GTB Hospital, New Delhi, India
| |
Collapse
|
25
|
Sahu RL. Percutaneous K wire fixation in pediatric lateral condylar fractures of humerus: A prospective study. Rev Esp Cir Ortop Traumatol (Engl Ed) 2018. [DOI: 10.1016/j.recote.2017.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
|
26
|
Lal Sahu R. Percutaneous K wire fixation in pediatric lateral condylar fractures of humerus: A prospective study. Rev Esp Cir Ortop Traumatol (Engl Ed) 2017; 62:1-7. [PMID: 29157991 DOI: 10.1016/j.recot.2017.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Revised: 09/19/2017] [Accepted: 10/04/2017] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND We evaluated the radiographic and clinical functional results of K-wire fixation in the treatment of displaced lateral condyle fractures of the humerus. MATERIALS AND METHODS A prospective longitudinal study was undertaken in our hospital during the period December 2010-December 2014. A total number of 85 children (18 girls and 67 boys) mean age 7.76 years; range 2-13 years with displaced (>2mm) lateral condyle fractures of the humerus. All the patients were treated by close reduction and internal fixation with two K-wires for three weeks. The fractures were classified according to the criteria by Milch and Badelon and functional results were evaluated according to the criteria by Hardacre et al. The mean follow-up period was 24 months (range: 20-28 months). RESULTS All children achieved union in a mean time of 3 weeks (range: 2.5-6 weeks). Functional results were excellent in 91.75% children and good in 7.05% children. Full range of elbow motion was achieved in all the patients. None of the patients had instability postoperatively. Post-operatively, 5.88% children got pin tract infection, which was superficial and healed after removing pins and oral antibiotic administration. CONCLUSION Percutaneous K-wire fixation is an effective treatment for unstable displaced lateral condylar fractures of the humerus in children. If fracture displacement after closed reduction exceeds 2mm, open reduction and internal fixation is recommended.
Collapse
Affiliation(s)
- R Lal Sahu
- Department of Orthopedics, School of Medical Sciences & Research, Sharda University, Greater Noida, Uttar Pradesh, India.
| |
Collapse
|
27
|
A 3-Dimensional Analysis of the Fracture Planes in Pediatric Lateral Humeral Condyle Fractures for Image-Based Pin Positioning During Fixation. J Orthop Trauma 2017; 31:e340-e346. [PMID: 28538289 DOI: 10.1097/bot.0000000000000914] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To determine the 3-dimensional morphology of pediatric lateral condylar physeal fractures using 3-dimensional computed tomography (3D-CT) and to identify optimal pin positions for percutaneous pinning. DESIGN Prospective case series of consecutively treated patients. SETTING Tertiary university hospital setting. PATIENTS Preoperative 3D-CTs in pediatric surgical candidates diagnosed with lateral condylar physeal fractures. INTERVENTION Closed reduction and percutaneous pinning was performed. MAIN OUTCOME MEASURES Reconstructed images of the distal humerus were aligned accordingly to determine the coronal (α), sagittal (β), and axial tilt (γ) angles of the fracture plane. Both α and β were also measured on plain radiography. Image-based position of the 2 pins was calculated preoperatively using 3D-CT, based on anteroposterior and lateral views. Final angle of pins was measured on postoperative radiographs. RESULTS A total of 29 fractures were assessed. 3D-CT reconstruction images of fractures showed a posterolateral fracture fragment with reference to the long axis of the humerus. The mean α, β, and γ were 62 degrees [95% confidence interval (CI), 59-64], 69 degrees (95% CI, 65-72), and 36 degrees (95% CI, 34-38). Both α and β measured on plain radiography were not significantly different from 3D-CT measurements (P = 0.6712, 0.6218). Average postoperative pin angles were 144 degrees (95% CI, 140-147) and 161 degrees (95% CI, 158-165) for the proximal pin, and 118 degrees (95% CI, 114-122) and 115 degrees (95% CI, 110-120) for the distal pin, on anteroposterior and lateral views, respectively, resulting in similar trajectories to the preoperatively calculated pin positions. CONCLUSION Our study adds to the current knowledge by providing an image-based angular reference of the fracture configuration in pediatric lateral humeral condyle fractures, which may be used during percutaneous pinning. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Collapse
|
28
|
Qin YF, Li ZJ, Li CK, Bai SC, Li H. Unburied versus buried wires for fixation of pediatric lateral condyle distal humeral fractures: A meta-analysis. Medicine (Baltimore) 2017; 96:e7736. [PMID: 28834878 PMCID: PMC5572000 DOI: 10.1097/md.0000000000007736] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Open reduction and internal fixation with Kirschner (K) wires has been reported as an efficient and convenient technique for pediatric lateral condyle distal humeral fractures. However, no single study has been large enough to definitively determine whether the K-wires should be buried or unburied. Therefore, we performed a meta-analysis pooling the results from several clinical trials to compare the outcome of using buried versus unburied K-wires. Potential academic articles were identified from the Cochrane Library, Medline (1966-2017.3), PubMed (1966-2017.3), Embase (1980-2017.3), ScienceDirect (1985-2017.3), and other databases. Gray studies were identified from the references of included literature reports. RevMan 5.1 was used to analyze the pooling of data. Nonrandomized controlled trials were included in this meta-analysis. There was a significant difference in the duration of wires in situ (MD = -13.28, 95% confidence interval: -16.42 to -10.14, P < .00001). No significant differences were found regarding infection, superficial infection, total complications, delayed union, or reoperation. Unburied K-wire fixation for treatment of lateral condyle distal humeral fractures in children does not increase the total infection rate, superficial infection, reoperation rate, or complications. However, unburied K-wire fixation is of benefit for early extraction and impartial cost savings.
Collapse
|
29
|
Abstract
BACKGROUND The purpose of the present study was to evaluate the effects of surgical timing on the outcome of pediatric lateral condyle fractures (LCF). We hypothesize that performing open reduction and internal fixation (ORIF) for a displaced LCF between 7 and 14 days after the occurrence of injury does not result in significant changes in outcome, as compared with those treated within the first 7 days. METHODS A total of 181 pediatric LCFs treated with ORIF, with a mean follow-up of 38 weeks and a mean age of 5 years, were included. All information related to the patient's elbow injury was prospectively collected. We identified 2 specific groups: 133 LCFs that were treated within the first 7 days after injury (group 1), and 48 that were treated between 7 and 14 days after injury (group 2). A satisfactory outcome was one in which there was evidence of healing of the fracture, a range of motion of at least 85% of the normal, contralateral side at the latest follow-up, and no evidence of complications, loss of fixation, infection, or avascular necrosis of the lateral condyle. RESULTS Overall, the mean time from injury to surgery was 5 days (range, 0 to 14 d). Initial fracture displacement was slightly larger in group 1 versus group 2, by a mean of 2.6 mm (P=0.004). There were no iatrogenic nerve injuries or vascular complications in either group. There was no difference in the mean surgical time between groups (P=0.004). At the latest follow-up appointment, elbows in both groups had similar range of motion (P=0.5), a low and similar rate of complications, and comparable rates of satisfactory outcomes (88.0% vs. 87.5%; P=0.6). CONCLUSION Our study suggests that performing an ORIF for a displaced pediatric LCF up to 14 days after the original injury does not adversely affect the outcome of the procedure. LEVEL OF EVIDENCE Level II-comparative study.
Collapse
|
30
|
The Use of Magnetic Resonance Imaging in Management of Minimally Displaced or Nondisplaced Lateral Humeral Condyle Fractures in Children. Pediatr Emerg Care 2017; 33:21-25. [PMID: 28045839 DOI: 10.1097/pec.0000000000000996] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Fractures of the lateral humeral condyle are common in children. Nondisplaced fractures are managed with cast immobilization and frequent radiographic follow-up. Possibility of assessing the displacement and stability of such fractures may be helpful in planning the initial treatment and survey. Magnetic resonance imaging (MRI) could be a useful tool in determining the stability of lateral condyle in children. We propose to investigate the use of MRI in such indication. METHODS Fourteen patients presenting with a minimally displaced or nondisplaced fracture were initially treated with a long arm cast and had an MRI within 5 days of injury. RESULTS The MRI showed that 10 patients had an incomplete fracture without disruption of the cartilage hinge and 4 patients had a complete fracture with extension of the fracture through the cartilaginous epiphysis into the elbow joint. Three patients with such complete fracture had no evidence of lateral condyle displacement on MRI, and 1 patient had a displacement of the lateral condyle. The patients with incomplete fractures had a conservative treatment. The patient with a complete and displaced fracture had an open reduction and internal fixation. The 3 patients with a complete fracture and no evidence of lateral condyle displacement on MRI had a control MRI, 6 to 10 days after cast application, to detect a secondary displacement of the fracture. CONCLUSIONS Because it seems difficult in minimally displaced or nondisplaced fractures to detect further displacement with radiographs, MRI was found mandatory to improve complete fracture visualization during the first phase of conservative treatment. In incomplete fractures, initial MRI investigation was consistent with a stable fracture and avoided further early radiographs or clinical survey. In such cases, we recommend a conservative treatment with late radiographs after long arm cast removal. We propose MRI routine use in the early evaluation of minimally displaced or nondisplaced lateral condyle fractures in children.
Collapse
|
31
|
Cannulated Lag Screw Fixation of Displaced Lateral Humeral Condyle Fractures Is Associated With Lower Rates of Open Reduction and Infection Than Pin Fixation. J Pediatr Orthop 2017; 37:7-13. [PMID: 26192878 DOI: 10.1097/bpo.0000000000000579] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Open reduction/internal fixation remains the most common way to surgically stabilize displaced pediatric lateral humeral condyle fractures, but closed reduction and internal fixation is being increasingly used. Our goal was to compare the clinical and functional results of treating displaced pediatric lateral humeral condylar fractures with traditional smooth or threaded pin fixation versus single cannulated screw fixation. METHODS From 1998 through 2012, the lateral humeral condyle fractures of 48 patients were treated with pin fixation (22 patients, until 2006) or cannulated, partially threaded screw fixation (26 patients, from 2006 onward). In each, closed reduction with percutaneous fixation was attempted first, followed by open reduction if anatomic reduction was not achieved. For the pin and screw groups, preoperative maximum radiographic displacement averaged 8.4 mm (range, 3.8 to 18.4 mm) and 6.3 mm (range, 2.2 to 15.5 mm), respectively; follow-up averaged 4.3 months (range, 1.5 to 20 mo) and 10.3 months (range, 2 to 30 mo), respectively. We reviewed preoperative and postoperative images and all follow-up clinical examination findings; serially assessed initial displacement, Baumann and carrying angles, range of motion limitations, and clinical alignment; evaluated functional results via the system of Hardacre and colleagues; and investigated all complications. RESULTS Open reduction was required in 73% (16/22) and 15% (4/26) of the pin and screw groups, respectively (P<0.001). All fractures were reduced to <1 mm postoperative displacement. Postoperative immobilization averaged 5.9 weeks (range, 4 to 11 wk) and 4.5 weeks (range, 3 to 8 wk) for the pin and screw groups, respectively. The only significant difference in complications was the infection rate: 5 (1 deep) in the pin group and none in the screw group (P<0.05). CONCLUSIONS Closed reduction and percutaneous 4.5-mm lag screw fixation of displaced pediatric lateral humeral condyle fractures is safe and reliable, enabling a higher rate of closed reduction, significantly lower infection rate, and earlier mobilization than traditional pin fixation. LEVEL OF EVIDENCE Level III-Therapeutic.
Collapse
|
32
|
Grand JGR. Percutaneous Screw Fixation of Incomplete Ossification of the Humeral Condyle in Three Dogs (Four Elbows). J Am Anim Hosp Assoc 2017; 53:45-51. [DOI: 10.5326/jaaha-ms-6246] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
ABSTRACT
Transcondylar screw fixation was performed using a minimally invasive percutaneous technique on three dogs (four elbows) diagnosed with incomplete ossification of the humeral condyle. The technique was performed using an aiming device in all four elbow joints and assisted by intraoperative fluoroscopy in one. All screws were successfully placed on first attempt and no elbow joint required repositioning of the transcondylar screw. On immediate postoperative radiographs, median transcondylar screw angulation was 2.9° and median percentage of screw eccentricity relative to the theoretical center of the humeral condyle was 14%. No short-term postoperative complications (<1 mo) were observed. The surgical technique described is a feasible option for surgical management of incomplete ossification of the humeral condyle in dogs that allowed accurate transcondylar screw placement and orientation.
Collapse
Affiliation(s)
- Jean-Guillaume Robert Grand
- From the Section of Veterinary Clinical Sciences, University College Dublin, Belfield, Dublin, Ireland
- * J-G. R. Grand's present affiliation is Clinique vétérinaire Aquivet, 19 avenue de la Forêt, ZAC Mermoz, 33320 Eysines, France
| |
Collapse
|
33
|
Closed Reduction and Percutaneous Pinning Versus Open Reduction and Internal Fixation for Type II Lateral Condyle Humerus Fractures in Children Displaced >2 mm. J Pediatr Orthop 2016; 36:780-786. [PMID: 26090985 DOI: 10.1097/bpo.0000000000000570] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The optimal treatment for pediatric lateral condyle fractures displaced >2 mm, but with little joint displacement is unclear. The purpose of this study was to assess clinical and radiographic outcomes and complication rates of patients undergoing open reduction internal fixation (ORIF) versus closed reduction and percutaneous pin fixation (CRPP) of lateral condyle fractures with >2 mm of displacement and no obvious articular surface incongruity. METHODS A retrospective review of all children with acute lateral condyle fractures with 2.1 to 5.0 mm of displacement treated from 2006 to 2014 was performed. A total of 74 patients were treated who met inclusion criteria; 51 underwent ORIF and 23 underwent CRPP. No differences existed between the 2 groups with respect to age, sex, extremity, mechanism of injury, time to treatment, fracture displacement, or fracture classification. Charts and radiographs were reviewed and the following parameters were documented: operating room time, time to union, return to activities, magnitude of lateral spurring, and complications. Major complications were defined as those with presumptive long-term effects or requiring reoperation. RESULTS All fractures healed within 12 weeks of surgery, regardless of treatment type and no differences were observed in time to union between groups. OR time averaged 30 minutes faster for the CRPP group (P<0.001). Nearly 10% of patients in each group developed elbow stiffness, requiring formal therapy. The overall complication rates were 25% for the ORIF group and 13% for the CRPP group (P=0.36). No major complications were observed in the CRPP group, whereas 3 (6%) were observed in the ORIF group, including 1 case of avascular necrosis, 1 case of osteomyelitis with an associated premature physeal closure, and 1 refracture requiring surgery. CONCLUSIONS Surgical treatment of lateral condyle fractures displaced >2 mm, but with no significant articular surface incongruity has good outcomes with both CRPP and ORIF. CRPP, however, minimizes surgical time, avoids an incision and is thus our preferred treatment approach when joint congruity can be confirmed. LEVEL OF EVIDENCE Level III-therapeutic study.
Collapse
|
34
|
Margalit A, Stein BE, Hassanzadeh H, Ain MC, Sponseller PD. Percutaneous Screw Fixation of Lateral Condylar Humeral Fractures. JBJS Essent Surg Tech 2016; 6:e15. [PMID: 30237925 DOI: 10.2106/jbjs.st.15.00060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Lateral condylar humeral fractures are the second most common elbow injury in children and commonly occur between the ages of 5 and 10 years. There are several systems for classification of this fracture, including those of Milch (fracture line location) and Jakob et al. (displacement). Although nonoperative management is indicated for nondisplaced or minimally displaced fractures (<2 mm), operative fixation is indicated for greater displacement. Traditionally, open reduction and internal fixation has been the method used to ensure adequate reduction. However, closed reduction and internal fixation techniques for displaced fractures have been receiving increasing attention, with recent studies showing promising results. Several constructs (multiple smooth pins, a single lag screw, and threaded pins) for closed reduction and internal fixation have been described. Smooth-pin fixation has the advantage of a small diameter and easy removal, whereas threaded pins combine a small diameter with compressive properties. Compression of these small, articular fractures is important, and the optimal mode of fixation for maintaining fracture reduction is debated. Fixation with a partially threaded lag screw works by achieving metaphyseal compression, preventing loss of reduction of the distal fragment. In our experience, the compressive abilities of smooth and threaded pins are limited in the soft osteocartilaginous lateral condyle. Partially threaded lag screw fixation is indicated for pediatric patients with a substantially displaced (Jakob type-II or III) lateral condylar fracture. The major steps of the procedure are (1) preoperative planning with anteroposterior, lateral, and oblique radiographs; (2) supine positioning of the patient with the shoulder in abduction; (3) closed reduction with manual pressure; (4) guide-pin insertion through the lateral column of the distal part of the humerus; and (5) exchange of the guide pin with a lag screw. Postoperatively, the elbow is immobilized with a bivalved long-arm fiberglass cast or a posterior splint. The cast or splint is removed after interval healing is demonstrated on radiographs, and the lag screw is removed after complete fracture union is demonstrated. Complications are rare, and patients are expected to have decreased infection and open-reduction rates compared those treated with pin fixation.
Collapse
Affiliation(s)
- Adam Margalit
- Department of Orthopaedic Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Benjamin Eric Stein
- Department of Orthopaedic Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Hamid Hassanzadeh
- Department of Orthopaedic Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Michael C Ain
- Department of Orthopaedic Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Paul D Sponseller
- Department of Orthopaedic Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| |
Collapse
|
35
|
Shirley E, Anderson M, Neal K, Mazur J. Screw Fixation of Lateral Condyle Fractures: Results of Treatment. J Pediatr Orthop 2015; 35:821-4. [PMID: 25494024 DOI: 10.1097/bpo.0000000000000377] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Fixation of lateral condyle distal humeral fractures has traditionally been achieved with K-wires. Screw fixation provides the advantage of compression across the fracture site, but the results of screw fixation and risk of iatrogenic physeal damage are not well defined. This study was designed to evaluate the efficacy of screw fixation for lateral condyle fractures. METHODS A retrospective study of patients with lateral condyle elbow fractures treated using screw fixation at a single institution was undertaken. Patients 12 years and younger with isolated fractures were included. Clinical notes were examined for residual symptoms, alignment, range of motion, and complications. Radiographs were reviewed for healing and growth arrest. RESULTS Ninety-six patients who were treated over a 7-year period met inclusion criteria. Mean patient age was 5.8 years (range, 2 to 12 y). Fifty-four patients required open reduction; 42 patients underwent a closed reduction. Mean follow-up was 28.1 weeks (range, 4.9 to 417 wk). The overall complication rate was 19% and was 5% when lateral overgrowth was excluded as a complication. Initial fracture union was achieved in 99% of patients. One patient required revision fixation with a bone graft. Hardware was symptomatic with prominence or loss of flexion in 4% of patients. There were no cases of growth arrest or alterations of the carrying angle. For patients with final follow-up >12 months, the mean extension loss was 2 degrees (range, 0 to 25 degrees) and the mean loss of flexion was 8 degrees (range, 0 to 25 degrees). CONCLUSION Screw fixation of lateral condyle fractures results in satisfactory union with a low risk of complications at early follow-up.
Collapse
|
36
|
What's new in pediatric orthopaedics: hand and upper extremity update. J Pediatr Orthop 2015; 34 Suppl 1:S63-7. [PMID: 25207740 DOI: 10.1097/bpo.0000000000000289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
|
37
|
Abstract
Elbow fractures are common in pediatric patients. Most injuries to the pediatric elbow are stable and require simple immobilization; however, more severe fractures can occur, often requiring operative stabilization and/or close monitoring. This article highlights the common fractures and dislocations about the pediatric elbow and discusses the history, evaluation, and treatment options for specific injuries.
Collapse
Affiliation(s)
- Kevin J Little
- Division of Pediatric Orthopaedics, Hand and Upper Extremity Surgery, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, ML 2017, Cincinnati, OH 45229, USA; Department of Orthopaedic Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way, Cincinnati, OH 45229, USA.
| |
Collapse
|
38
|
Knutsen A, Avoian T, Borkowski SL, Ebramzadeh E, Zionts LE, Sangiorgio SN. Accuracy of radiographs in assessment of displacement in lateral humeral condyle fractures. J Child Orthop 2014; 8:83-9. [PMID: 24488177 PMCID: PMC3935020 DOI: 10.1007/s11832-014-0553-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2013] [Accepted: 01/07/2014] [Indexed: 02/03/2023] Open
Abstract
PURPOSE Determining the magnitude of displacement in pediatric lateral humeral condyle fractures can be difficult. The purpose of this study was to (1) assess the effect of forearm rotation on true fracture displacement using a cadaver model and to (2) determine the accuracy of radiographic measurements of the fracture gap. METHODS A non-displaced fracture was created in three human cadaveric arms. The specimens were mounted on a custom apparatus allowing forearm rotation with the humerus fixed. First, the effect of pure rotation on fracture displacement was simulated by rotating the forearm from supination to pronation about the central axis of the forearm, to isolate the effects of muscle pull. Then, the clinical condition of obtaining a lateral oblique radiograph was simulated by rotating the forearm about the medial aspect of the forearm. Fracture displacements were measured using a motion-capture system (true-displacement) and clinical radiographs (apparent-displacement). RESULTS During pure rotation of the forearm, there were no significant differences in fracture displacement between supination and pronation, with changes in displacement of <1.0 mm. During rotation about the medial aspect of the forearm, there was a significant difference in true displacements between supination and pronation at the posterior edge (p < 0.05). CONCLUSION Overall, true fracture displacement measurements were larger than apparent radiographic displacement measurements, with differences from 1.6 to 6.0 mm, suggesting that the current clinical methods may not be sensitive enough to detect a displacement of 2.0 mm, especially when positioning the upper extremity for an internal oblique lateral radiograph.
Collapse
Affiliation(s)
- Ashleen Knutsen
- The J. Vernon Luck Research Center, Orthopaedic Institute for Children, 403 W. Adams Blvd., Los Angeles, CA 90007 USA
| | - Tigran Avoian
- The J. Vernon Luck Research Center, Orthopaedic Institute for Children, 403 W. Adams Blvd., Los Angeles, CA 90007 USA
| | - Sean L. Borkowski
- The J. Vernon Luck Research Center, Orthopaedic Institute for Children, 403 W. Adams Blvd., Los Angeles, CA 90007 USA
| | - Edward Ebramzadeh
- The J. Vernon Luck Research Center, Orthopaedic Institute for Children, 403 W. Adams Blvd., Los Angeles, CA 90007 USA
- UCLA/Orthopaedic Hospital Department of Orthopaedics, David Geffen School of Medicine at UCLA, 10833 Le Conte Ave 16-155 CHS, Los Angeles, CA 90095 USA
| | - Lewis E. Zionts
- The J. Vernon Luck Research Center, Orthopaedic Institute for Children, 403 W. Adams Blvd., Los Angeles, CA 90007 USA
- UCLA/Orthopaedic Hospital Department of Orthopaedics, David Geffen School of Medicine at UCLA, 10833 Le Conte Ave 16-155 CHS, Los Angeles, CA 90095 USA
| | - Sophia N. Sangiorgio
- The J. Vernon Luck Research Center, Orthopaedic Institute for Children, 403 W. Adams Blvd., Los Angeles, CA 90007 USA
- UCLA/Orthopaedic Hospital Department of Orthopaedics, David Geffen School of Medicine at UCLA, 10833 Le Conte Ave 16-155 CHS, Los Angeles, CA 90095 USA
| |
Collapse
|
39
|
Pictorial Essay of Pediatric Upper Extremity Trauma: Normal Variants and Unique Injuries. Can Assoc Radiol J 2013; 64:101-7. [DOI: 10.1016/j.carj.2012.11.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2012] [Accepted: 11/22/2012] [Indexed: 11/21/2022] Open
|
40
|
Abstract
BACKGROUND Fractures of the lateral humeral condyle represent the second most common elbow fracture in children and the most common physeal fracture about the elbow. Growth disturbances after this fracture, including premature physeal arrest, are rare but important complications. Only 4 radiographically documented reports of premature physeal arrest exist to date with just 1 offering comparative views. No computed tomography (CT) evidence of this event has previously been reported in the literature. The purpose of this study is to provide well-documented radiographic evidence of premature capitellar growth arrest, substantiated by CT imaging. METHODS We reviewed the radiographic and clinical records of 3 patients (mean age, 6.9 y) that presented with Jakob type III fractures. All fractures were treated with open reduction and internal fixation. Follow-up ranged from 1.6 to 11.1 years (mean, 6.0 y). Radiographs were evaluated for any growth disturbances, including premature capitellar-metaphyseal fusion, lateral spur formation, changes in the humeral-ulnar angles, and fishtail deformities. Contralateral elbow radiographs were utilized for comparison when available. Clinical findings at last follow-up were provided for clinical correlation. RESULTS The mean time to arrest and age at arrest were 2.6 and 9.5 years, respectively. At last follow-up, patient 1 was functionally asymptomatic, showed a 6-degree increase in the humeral-ulnar angle, an increase in the carrying angle, and a fishtail deformity. Patient 2 was functionally asymptomatic, showed equal humeral-ulnar angles, and a small lateral spur formation on the injured side. Patient 3 was functionally symptomatic with pain and a 15-degree loss of extension on the injured side. There was also a 13-degree increase in the humeral-ulnar angle with an increase in carrying angle of approximately 8 degrees. CONCLUSIONS This is the first study to radiographically document premature physeal arrest after lateral condyle fractures using both comparative views and CT imaging. It is important for surgeons to be aware of this potential complication after lateral condyle fractures of the humerus and to diligently monitor patients annually for possible intervention until they have achieved skeletal maturity. LEVEL OF EVIDENCE Level IV--case series.
Collapse
|
41
|
Abstract
BACKGROUND Bony overgrowth over the lateral condyle, or "lateral spurring," is commonly identified after lateral condyle fractures of the humerus in children. Despite its frequent recognition, no prior study has defined the phenomenon, established an incidence rate, explored a correlation with any fracture or treatment characteristics, nor assessed whether it is of functional significance. METHODS We retrospectively analyzed information on 212 consecutive lateral condyle fractures in children. Spurring was defined as an overgrowth of bone over the lateral aspect of the lateral condyle resulting in an irregularity of the metaphyseal flare. The magnitude of the spurring was classified by measuring the increase in maximum interepicondylar width of the distal humerus on the latest follow-up radiograph. RESULTS Of the 212 fractures, 55% were treated with cast immobilization, 11% with closed reduction and percutaneous pinning, and 34% with open reduction and internal fixation. Of all fractures, 73% developed a lateral spur. Of those, 43% had a mild spur, 38% a moderate spur, and 19% a severe spur. Fractures that developed a spur had a mean initial displacement of 3.3 mm, as compared with 1.1 mm in those that did not develop spurring (P<0.0001). The amount of initial displacement was higher for fractures that developed mild (2.4 mm, P=0004), moderate (3.6 mm, P<0.00001), and severe (4.9 mm, P<0.00001) spurs, as compared with fractures with no spur. At the latest follow-up, patients that developed lateral spurring had a mean relative arc of motion of 93.7% of the normal contralateral elbow, whereas patients without a spur had a relative range of motion of 94.3% (P=0.4). CONCLUSIONS Lateral spurring is an extremely common sequela of lateral humeral condyle fractures in children. The development of a spur correlates with initial displacement and surgical treatment. The size of the spur is associated with the amount of initial fracture displacement. Despite concerns from patients, families, and physicians alike, neither the presence nor the size of the lateral spur seems to influence the final outcome. LEVEL OF EVIDENCE Level II--retrospective study.
Collapse
|
42
|
Abstract
UNLABELLED Lateral condyle fractures of the distal humerus are problematic whether displaced early or late. Operative intervention with closed reduction and percutaneous pinning or open reduction internal fixation are indicated for a malaligned articular surface and/or an unstable fracture. Intraoperative arthrograms can aid the surgeon in assessing joint reduction. LEVEL OF EVIDENCE Case report.
Collapse
|
43
|
Pediatric Bone Imaging: Imaging Elbow Trauma in Children???A Review of Acute and Chronic Injuries. AJR Am J Roentgenol 2012; 198:1053-68. [PMID: 22528894 DOI: 10.2214/ajr.10.7314] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
|
44
|
Chan LWM, Siow HM. Exposed versus buried wires for fixation of lateral humeral condyle fractures in children: a comparison of safety and efficacy. J Child Orthop 2011; 5:329-33. [PMID: 23024723 PMCID: PMC3179532 DOI: 10.1007/s11832-011-0358-y] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2011] [Accepted: 07/06/2011] [Indexed: 02/03/2023] Open
Abstract
INTRODUCTION Displaced fractures of the lateral condyle of the humerus are usually treated with open reduction and fixation with smooth Kirschner wires. These may be passed through the skin and left exposed or buried subcutaneously. Exposed wires may be removed in the outpatient clinic, whereas buried wires require a formal procedure under anaesthesia. This advantage may be offset if there is a higher rate of complications with exposed wires. The aim of this study was to compare the safety and efficacy of exposed and buried wires. STUDY DESIGN Retrospective cohort. METHODS AND MATERIALS Children with lateral condyle fractures of the humerus who had undergone surgery were identified from our departmental database. Case records and X-rays of 75 patients were reviewed. RESULTS Forty-two patients had buried wires and 33 had exposed wires. There were no serious complications in either group. In the exposed wires group, 1 patient had a superficial wound infection that was treated effectively with 1 week of oral antibiotics, while 2 patients had hypergranulation of pin tracts treated with topical silver nitrate. None of the patients showed loss of reduction, deep infection, or any other complications requiring additional procedures. DISCUSSION/CONCLUSIONS There was no statistically significant difference in the rate of complications between the buried and exposed groups. We conclude that open reduction and exposed wiring is a safe and effective option for lateral condyle fractures, and recommend a period of 4 weeks of K-wire fixation followed by 2 weeks of backslab immobilisation as adequate for union with minimal risk of infection.
Collapse
Affiliation(s)
- Lester Wai Mon Chan
- Department of Orthopaedics, KK Women’s and Children’s Hospital, Singapore, 229899 Singapore
| | - Hua Ming Siow
- Department of Orthopaedics, KK Women’s and Children’s Hospital, Singapore, 229899 Singapore
| |
Collapse
|
45
|
Abstract
Lateral condylar fractures constitute 12% to 20% of all pediatric distal humerus fractures. These fractures are easily missed and when not managed appropriately can displace. Missed fracture is a common cause of nonunion and deformity; thus, a high index of suspicion and adequate clinical and radiographic evaluation are required. Displaced fractures are associated with a high rate of nonunion. Nondisplaced fractures or those displaced ≤2 mm are managed with cast immobilization and frequent radiographic follow-up. Fractures displaced >2 mm are managed with surgical fixation. Successful outcomes have been reported with closed reduction, open reduction, and arthroscopically assisted techniques. Complications associated with pediatric lateral condylar fracture include cubitus varus, cubitus valgus, fishtail deformity, and tardy ulnar nerve palsy.
Collapse
|
46
|
Bernthal NM, Hoshino CM, Dichter D, Wong M, Silva M. Recovery of elbow motion following pediatric lateral condylar fractures of the humerus. J Bone Joint Surg Am 2011; 93:871-7. [PMID: 21543677 DOI: 10.2106/jbjs.j.00935] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Temporary elbow stiffness is often seen after a lateral condylar fracture of the distal end of the humerus in children. There are scant scientific data available to assess the expected time frame for return of elbow motion after these injuries. The purpose of this study is to provide a prospective, longitudinal evaluation of elbow motion in a large group of pediatric patients undergoing treatment for a lateral condylar fracture of the distal end of the humerus. METHODS We prospectively evaluated 141 patients with lateral humeral condylar fractures at a mean age of 5.2 years and with a mean follow-up of twenty-nine weeks. The patients were treated with cast immobilization, percutaneous pinning, or open reduction and internal fixation on the basis of the initial displacement. Elbow motion was followed longitudinally at clinic visits. Relative arc of motion was calculated as a percentage of the motion of the normal, contralateral elbow. RESULTS The mean relative arc of motion at the time of cast removal was 44%, reaching 84% by week 12. By weeks 18, 24, 36, and 48, the relative arc of motion reached 87%, 90%, 93%, and 97%, respectively. Compared with fractures treated without surgery, those treated surgically had a significantly lower absolute arc of motion from the time of cast removal (p = 0.018) and up to eighteen weeks after the injury (p < 0.001); however, no significant difference was observed at eighteen weeks or beyond. For patients treated surgically, no significant difference in relative arc of motion was observed between the patients with closed or open reductions. The age of the patient (hazard ratio = 0.87, p = 0.008), length of immobilization (hazard ratio = 0.79, p = 0.03), and severity of the fracture (hazard ratio = 0.40, p < 0.0001) were independent predictors of recovery of elbow motion after a lateral humeral condylar fracture in children. CONCLUSIONS An initial rapid recovery in elbow motion can be expected after a lateral humeral condylar fracture in a child, with progressive improvements for up to one year after the injury. This recovery is slower if the patient is older, has a longer period of immobilization, and has a more severe injury.
Collapse
Affiliation(s)
- Nicholas M Bernthal
- Department of Orthopaedics, UCLA Orthopaedic Hospital, David Geffen School of Medicine, University of California at Los Angeles, 10833 Le Conte Avenue, 16-155 CHS, Los Angeles, CA 90095
| | | | | | | | | |
Collapse
|
47
|
Closed reduction and internal fixation of completely displaced and rotated lateral condyle fractures of the humerus in children. J Orthop Trauma 2010; 24:434-8. [PMID: 20577074 DOI: 10.1097/bot.0b013e3181de014f] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To determine the usefulness of closed reduction and internal fixation as the initial treatment for completely displaced and rotated fractures of the lateral condyle of the humerus in children. DESIGN Prospective. SETTING Three Level I trauma centers. PATIENTS We prospectively studied 24 consecutive completely displaced and rotated lateral condylar fractures of the humerus in children (Jakob Stage 3, 20 boys and four girls) that were treated by three different surgeons working at different hospitals during the same period. INTERVENTION In 21 fractures, we initially attempted closed reduction and internal fixation; in three, we used open reduction and internal fixation and made no attempt at closed reduction. MAIN OUTCOME MEASUREMENT We assessed the preoperative degree of displacement and postoperative radiographic quality of closed reduction. Clinical results were graded using the criteria suggested by Hardacre et al. RESULTS Eighteen of 24 (75%) completely displaced and rotated fractures were reduced within 2 mm of residual displacement using the closed method. Three fractures were treated with open reduction and internal fixation initially and internal fixation because of one surgeon's lack of confidence in closed reduction, because of lack of experience with it, early in the study period. Closed reduction to within 2 mm failed in three fractures, so open reduction and internal fixation was then performed. There were no significant complications such as limited range of motion, pain, osteonecrosis of the trochlea or capitellum, nonunion, malunion, or early physeal arrest. CONCLUSION Closed reduction and internal fixation is an effective treatment for completely displaced and rotated lateral condyle fractures of the humerus in many children.
Collapse
|
48
|
Twenty-degree-tilt radiography for evaluation of lateral humeral condylar fracture in children. Skeletal Radiol 2010; 39:267-72. [PMID: 19434409 DOI: 10.1007/s00256-009-0708-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2008] [Revised: 03/09/2009] [Accepted: 04/20/2009] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To investigate the efficacy of '20 degrees -tilt anteroposterior (A-P) radiography' in the assessment of lateral condylar fractures of the distal humerus. MATERIALS AND METHODS Eighteen children with lateral humeral condylar fractures were studied. Every child underwent conventional A-P and lateral radiography, and six children underwent multi-detector computed tomography (MDCT). For the investigation of 20 degrees -tilt radiography, ten children with lateral humeral condylar fractures had conventional and 20 degrees -tilt A-P and lateral radiography both preoperatively and postoperatively. Fragment dislocation was measured at the lateral and medial margins of the fracture on both the conventional A-P and 20 degrees -tilt A-P radiographs. RESULTS The lateral condylar fragment was triangular and was most prominent posteriorly. The fracture line was typically tilted approximately 20 degrees to a reference line perpendicular to the long axis of the humerus in the lateral view. The extent of dislocation at the lateral and medial margins of the fracture site by 20 degrees -tilt A-P radiography (9.3 +/- 3.6 mm and 5.6 +/- 2.5 mm) was significantly wider than that measured by the conventional method (6.8 +/- 4.1 mm and 2.0 +/- 1.5 mm ), which may influence treatment. CONCLUSION Twenty-degree-tilt A-P radiography may more precisely demonstrate fragment dislocation than standard radiographs and may influence patient treatment.
Collapse
|
49
|
A new classification system predictive of complications in surgically treated pediatric humeral lateral condyle fractures. J Pediatr Orthop 2009; 29:602-5. [PMID: 19700990 DOI: 10.1097/bpo.0b013e3181b2842c] [Citation(s) in RCA: 89] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The most commonly cited classification system for lateral condyle fractures (Milch) has not been shown to be predictive of outcome or recommend treatment. PURPOSE To determine whether a classification system and treatment based on fracture displacement and articular congruity correlates with the complication rate after pediatric lateral humeral condyle fractures. METHODS A retrospective review of all children with lateral condyle fractures treated operatively at one institution from 1996 to 2003 was performed. All fractures were classified by the following system: A Type I fracture is displaced less than 2 mm. In a Type II fracture there is > or = 2 mm of displacement with intact articular cartilage, as demonstrated by arthrogram (65 patients). In a Type III fracture there is > or = 2 mm of displacement and the articular surface is not intact (93 patients). The 158 patients with types 2 and 3 fractures underwent surgery and are the focus of this study. Complication rates were compared between groups 2 and 3, and with regard to patient age, length of time between injury and surgery, and duration of casting. RESULTS The overall complication rate was 25% (39 of 158). The most common complications included radiographic and/or clinical bump (16 of 158 or 10%), and infection treated with oral antibiotics (4 of 158 or 2.5%). There were 6% major complications (10 of 158) defined as those with presumptive long-term effects or requiring reoperation, including 1 nonunion (0.6%). There were no acute complications at the time of injury or surgery. If lateral bump is excluded as a complication, then the overall complication rate is 14.6% (23 of 158). The overall complication rates for types 2 and 3 fractures were statistically significantly different (P<0.03): 11% (7 of 65) for type 2 and 34% (32 of 93) for type 3 fractures. Major complication rates were 1.5% (1 of 65) for type 2 fractures and 10% (9 of 93) for type 3 fractures, whereas minor complications occurred in 9% (6 of 65) of type 2 fractures, and 25% (23 of 93) of type 3 fractures (P=0.03). There was no correlation between complication rate and patient age, number of days between fracture and surgery (all patients were treated within 16 d of their fracture), or duration of casting. We found that all 65 patients with Type II fractures had <4 mm of fracture displacement on pre-operative radiographs, and all fractures Type III fractures had > or = 4 mm of displacement. This may aid in predicting which fractures can be treated with closed pinning prior to an operative arthrogram. CONCLUSIONS This is the largest series of operatively treated lateral condyle fractures reported in the literature. This classification system and treatment based on fracture displacement and articular congruity predicts the risk of complications, which were more than 3 times as likely to occur in type 3 fractures as type 2 fractures.
Collapse
|
50
|
Song KS, Kang CH, Min BW, Bae KC, Cho CH, Lee JH. Closed reduction and internal fixation of displaced unstable lateral condylar fractures of the humerus in children. J Bone Joint Surg Am 2008; 90:2673-81. [PMID: 19047713 DOI: 10.2106/jbjs.g.01227] [Citation(s) in RCA: 94] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Open reduction and internal fixation of a displaced unstable fracture of the lateral condyle of the humerus in a child usually produces a good result. Only a few reports have focused on closed reduction and internal fixation of these fractures. We prospectively studied closed reduction and internal fixation to determine its usefulness as the initial treatment for displaced unstable fractures of the lateral condyle of the humerus. METHODS We classified lateral condylar humeral fractures into five groups according to the degree of displacement and the fracture pattern as determined on four radiographic views and created an algorithm for the treatment of these fractures on the basis of this classification system. We prospectively treated sixty-three unstable fractures (in forty-two boys and twenty-one girls) and assessed the quality of closed reduction. RESULTS Thirteen of seventeen stage-3 fractures were reduced to < or =1 mm of residual displacement. Thirty of forty stage-4 fractures and three of six stage-5 fractures were reduced to < or =2 mm of displacement. In ten of forty stage-4 fractures and three of six stage-5 fractures, closed reduction to within 2 mm failed and open reduction and internal fixation was performed. There were no major complications such as osteonecrosis of the trochlea or capitellum, nonunion, malunion, or early physeal arrest. CONCLUSIONS Closed reduction and internal fixation is an effective treatment for unstable displaced lateral condylar fractures of the humerus in many children. If fracture displacement after closed reduction exceeds 2 mm, open reduction and internal fixation is recommended.
Collapse
Affiliation(s)
- Kwang Soon Song
- Department of Orthopedic Surgery, School of Medicine, Keimyung University, 194 Dong san dong, Daegu 700-712, South Korea.
| | | | | | | | | | | |
Collapse
|