Which pediatric supracondylar humerus fractures are high risk for conversion to open reduction?

Identifying Risk Factors for Open Reduction in Pediatric Supracondylar Humerus Fractures

BACKGROUND

Supracondylar humerus fractures (SCHFs) are the most common injuires of the elbow in children, often categorized by the Gartland classification. While type 1 and 2 fractures commonly managed conservatively, type 3 and 4 fractures typically require surgical treatment. Although closed reduction and percutaneous pinning have shown success, open reduction may be required in cases where adequate reduction cannot be achieved. This study aims to identify radiological and clinical risk factors associated with transitioning from closed reduction to open reduction in Gartland type 3 and 4 SCHF in children.

STUDY DESIGN AND METHODS

We retrospectively analysed 159 patients operated on between 2014 and 2022 for Gartland type 3 and 4 SCHF. Parameters including age, gender, injury severity, time to surgery, neurovascular damage, medial spike angle, fracture-skin distance, medial-lateral deviation, rotation, fracture level, and Baumann angle were evaluated.

RESULTS

A total of 159 SCHF in children aged 3 to 12 years, classified as Gartland type 3 (106 patients, 66.6%) and type 4 (53 patients 33.4%), underwent surgical intervention. Notably, 46 patients (28.9%) initially managed with closed reduction exhibited failure, prompting the necessity for conversion to open reduction. Injury severity, lateral deviation, advanced age, low medial spike angle, and low fracture tip-to-skin distance were found to be factors that could potentially increase the need for open reduction ( P <0.05). Logistic regression analysis showed that the low medial spike angle, flexion type injury, and low fracture type increased the likelihood of open surgery ( P <0.05). Sex, side, duration to surgery, and Baumann angle showed no significant associations.

CONCLUSIONS

SCHF commonly necessitate surgical intervention in children. Although the risk factors for failed closed reduction and the need for open surgery have been discussed in the literature, there is no consensus. Preoperative planning, particularly for patients with specific factors like lateral deviation, advanced age, low medial spike angle, low fracture-to-skin distance and high injury severity, should consider potential open surgery requirements.

LEVEL OF EVIDENCE

Level III.

Intercondylar T-Type Distal Humerus Fracture in a 10-Year-Old: A Case Report

CASE

A 10-year-old, postmenarchal girl presented to the emergency department with a closed, displaced, intercondylar T-type distal humerus fracture. Open reduction and internal fixation was performed 3 days following initial presentation. The patient healed but experienced elbow stiffness in the 7 months following the procedure. Implant removal and capsular release were performed at that time. At the 31-month follow-up, the patient reported satisfactory elbow functionality.

CONCLUSION

There is limited literature available discussing optimal management and associated outcomes of intercondylar T-type distal humerus fractures in the young-adolescent population. This report presents a possible method for management of the initial injury and the most common associated complication.

Radiologic, clinical, and functional evaluation of children with displaced T-condylar fractures treated by closed reduction and percutaneous fixation using the Mayo Elbow Performance Score

PURPOSE

T-condylar (T-C) fractures of the distal humerus are rare in children. There is no accepted treatment for such an injury, and there is a lack of reports evaluating the outcome of T-C fractures treated by closed reduction and percutaneous fixation. The aim of this study was to evaluate the feasibility of closed reduction and percutaneous K-wire and screw (CRPKS) fixation in patients with type II and III T-C fractures according to the Toniolo-Wilkins classification modified by Canavese et al. (TWC classification).

METHODS

The clinical data of 12 consecutive patients (8 males, 4 females) who were younger than 14 years of age and who had a T-C fracture that was managed by CRPKS were retrospectively evaluated. Fractures were classified according to the TWC classification. The baseline information of the patients, carrying angle (CA) and Mayo Elbow Performance Score (MEPS) were used to evaluate clinical and functional outcomes; related complications were recorded. Statistical analysis was performed.

RESULTS

The mean age at the time of injury was 11.6 ± 1.8 years (range, 8-14). The time from injury to surgical treatment was 1.5 ± 1.0 days (range, 0-3), and the mean follow-up duration was 33.7 ± 12.3 months (range, 18-61). Surgery lasted 45.7 ± 7.6 min on average (range, 35-58). All fractures healed in 4.9 ± 1.0 weeks on average (range, 4-7). At the last follow-up visit, the CA was 12.6° ± 5.8° on the injured side and 13.8° ± 1.8° on the uninjured side (p=0.432). The MEPS was 100 (95, 100) on the injured side and 100 (100, 100) on the uninjured side (p=0.194). Three complications were recorded.

CONCLUSION

Good functional and radiological outcomes can be expected in pediatric patients with type II and III T-C fractures treated by CRPKS. The technique is relatively simple to perform and has a lower rate of complications.

Value-Driven Pediatric Supracondylar Humerus Fracture Care: Implementing Evidence-Based Practices

Supracondylar humerus fractures are high-volume injuries in children; therefore, value-driven treatment has far-reaching implications for patients and families as well as healthcare systems. Children younger than 5 years can remodel posterior angulation. Most Type IIa fractures will maintain alignment after closed reduction. Many patients with surgical fractures can safely wait for nonemergent fixation. Outpatient surgery is associated with shorter surgical time, lower costs, and fewer return visits to the emergency department with no increase in adverse events. Type III fractures treated the following day do not have higher rates of open reduction, and patients with associated nerve injuries have no difference in recovery time compared with those treated more urgently. Pediatric-trained surgeons generally provide more efficient care (shorter surgical time and less after-hours surgery); however, their outcomes are equivalent to non-pediatric orthopaedic surgeons. Community hospitals have lower costs compared with teaching hospitals; therefore, transferring patients should be avoided when feasible. Postoperative care can be streamlined in uncomplicated cases to minimize radiographs, therapy referrals, and multiple visits. Splinting offers safer, lower cost immobilization over casting. With staffing shortages and an increasingly burdened healthcare system, it is imperative to maximize nonsurgical care, use outpatient facilities, and minimize postoperative requirements without negatively affecting patient outcomes.

Sterile Silicone Ring Tourniquets in Limb Surgery: A Prospective Clinical Trial in Pediatric Patients Undergoing Orthopedic Surgery

Sterile silicone ring tourniquets (SSRTs) reduce intraoperative bleeding and provide a wide surgical view. Moreover, they reduce the risk of contamination and are cheaper than conventional pneumatic tourniquets. Our study describes the perioperative outcomes of sterile silicone ring tourniquet placement in pediatric patients undergoing orthopedic surgery. We prospectively recruited 27 pediatric patients aged < 18 years who underwent 30 orthopedic surgeries between March and September 2021. Following complete surgical draping, all operations were initiated by placing SSRTs. We investigated the demographic and clinical characteristics of these patients, details of the tourniquet used, and intra- and postoperative outcomes of tourniquet placement. Owing to the narrowness of tourniquet bands and tourniquet placement at the proximal ends of the extremities, wide surgical fields were achieved, without limiting joint range of motion. Bleeding control was effective. Tourniquets were applied and removed rapidly and safely, regardless of limb circumference. None of the patients experienced postoperative pain, paresthesia, skin problems at the application site, surgical site infections, ischemic problems, or deep vein thrombosis. SSRTs effectively reduced intraoperative blood loss and facilitated wide operative fields in pediatric patients with various limb sizes. These tourniquets allow quick, safe, and effective orthopedic surgery for pediatric patients.