Remodeling of Sagittal Plane Malunion After Pediatric Supracondylar Humerus Fractures

Comparative Outcomes of Treatment Strategies for Traumatic Distal Humerus Physeal Separation in Children: A Systematic Review

Background: Distal humerus physeal separation (DHPS) presents a rare injury type in young children often associated with misdiagnosis and delayed treatment. The aim of this study was to summarize all the available current evidence regarding the management and outcome of DHPS and determine the incidence of complications and particularly the cubitus varus deformity and avascular necrosis of the trochlea. Methods: A systematic review was conducted under the PRISMA guidelines. Medline/Pubmed, Scopus, Web of Science, and Cochrane were searched for studies dealing with children suffering from traumatic DHPS. Results: Twelve studies with a total of 257 children with DHPS were included for analysis. The mean age was 16.8 months (range: 0.1-46 months) with a mean follow-up of 37 months (range: 0.5-516 months). Non-accidental trauma was reported in 17.2% and misdiagnosis at initial assessment in 7.8%. Closed reduction and percutaneous pinning (CRPP) was the treatment of choice in 54.4%, open reduction and percutaneous pinning (ORPP) in 26.5%, closed reduction and cast immobilization (CR+cast) in 10.9%, and cast immobilization without reduction in 8.2%. The average range of extension-flexion arc was 2.1° to 127.8° (range: -10-140°). The mean Bauman's angle was 72.4° (range: 66-79°), the mean shaft-condylar angle was 43.8° (range: 25-59°), the mean humeral length was 21.9 cm (range: 15.5-25.8 cm), and the mean carrying angle was 5.1° (range: 16° varus-19° valgus). According to Flynn's criteria, 85.2% of cases were classified as excellent or good. The ORPP technique was associated with excellent results, while the CR+cast treatment combination was correlated with the poorest outcome (p = 0.001). Cubitus varus occurred in 18.9% (34 cases) and was highly correlated with CR+cast or cast immobilization alone without fracture reduction (p = 0.014). Avascular necrosis of the trochlea was found in 3.9% (7 cases) and was mainly apparent after cast immobilization without reduction (p < 0.001). Conclusions: Post-traumatic cubitus varus deformity may be encountered in approximately one-fifth of young children with DHPS. Surgical intervention with either CRPP or ORPP is the most effective treatment approach, leading to superior functional outcome and a lower complication rate.

Nonoperative Management of Gartland Type II Supracondylar Humeral Fractures: A Comprehensive Review

PURPOSE OF REVIEW

This review aims to provide a comprehensive analysis of the nonoperative management of Gartland Type II fractures in pediatric patients.

RECENT FINDINGS

Supracondylar humeral fractures (SCF) are one of the most common traumatic fractures in pediatric populations, characterized as transverse fractures at the distal humerus between the medial and lateral columns. Early studies strongly opposed closed reduction and casting as an acceptable treatment modality for Gartland type II fractures as an early case series showed high rates of complications; however, more recent studies have suggested better outcomes. The optimal management of Gartland Type II supracondylar fractures has yet to be fully elucidated. This review highlights the indications, complications, and outcomes of nonoperative Gartland Type II supracondylar humeral fracture management. Additionally, it demonstrates the need for further research to inform guidelines on managing this condition.

Elbow rotation affects the accuracy of rotational formulas: validation of a modified method

BACKGROUND

Supracondylar humerus fractures (SCHFs) are the most common elbow fractures in children and are typically treated with closed reduction and Kirschner pin fixation. However, varying degrees of residual rotational displacement may remain after closed reduction. Several methods exist to assess rotational displacement, but none account for the effect of elbow rotation on the results. We hypothesize that the accuracy of the primitive rotational calculation formula (PRCF) decreases as elbow rotation increases and propose a modified rotational calculation formula (MRCF). This study aims to investigate the impact of elbow rotation on PRCF and validate the reliability of MRCF.

METHODS

Mimics software was used to reconstruct the distal humerus in a child and create a transverse SCHF, which was then subjected to X-ray fluoroscopy simulation. Axial rotational displacement was simulated in 5° increments, from 0° to 45°. Internal and external elbow rotations were simulated by adjusting the "LAO" and "RAO" angles. Five physicians measured and calculated displacement using both the primitive and modified rotational calculation formulas.

RESULTS

The PRCF method showed an average error of 17.98° ± 12.31° with a maximum error of 46.46%. Additionally, 13% of measurements had an error under 3°, and 29% had an error under 10°. With MRCF, the mean error for internal rotation was 2.04° ± 1.67°, with a maximum of 6.09%; 68% of cases had an error under 3° and 94% under 5%. For external rotation, the mean error was 2.74° ± 2.66°, with a maximum of 8.29%; 57% of cases had an error under 3° and 98% under 8°. Intraclass correlation coefficients for the five physicians were 0.966 for internal rotation and 0.989 for external rotation.

CONCLUSIONS

This study demonstrates that the accuracy of PRCF decreases as elbow rotation increases, supporting our hypothesis. MRCF effectively addresses the limitations of PRCF and provides stable, accurate measurements of rotational displacement even with varying elbow rotations. Accurate assessment of rotational displacement in the horizontal plane is essential to understanding the relationship between residual rotational displacement and SCHF prognosis. MRCF will play a critical role in this process.

Age-dependent Sagittal Plane Remodeling of Pediatric Supracondylar Fractures

BACKGROUND

Current treatment guidelines for pediatric supracondylar fractures have not fully accounted for age-related variations in the remodeling potential. This study aimed to explore age-dependent sagittal plane remodeling in supracondylar fractures by assessing cases with residual deformities after treatment.

METHODS

This study included 62 patients under 16 years of age treated for supracondylar fractures at our institution from 2002 to 2022. The distance between the posterior and anterior aspects of the capitellar ossific nucleus (CON) was defined as the CON size, while the distance from the anterior humeral line to the posterior aspect of CON was termed DAP-CON. The value obtained by subtracting the DAP-CON on the unfractured side from the DAP-CON on the fractured side was divided by the CON size and multiplied by 100 and termed the displacement of CON (d-CON). The absolute value of the difference between d-CON after intervention and d-CON at the last follow-up was denoted as sagittal plane remodeling.

RESULTS

For this patient cohort, the mean age was 5.5 years (range, 1.4 to 14.6 years), and the mean follow-up period was 30.4 months (range, 12.0 to 137.1 months). Sagittal plane remodeling was more pronounced in children younger than 5 years (group I) compared with those older (group II) ( P <0.001). In multiple regression analysis, only age at the time of injury was found to be a significant variable ( P <0.001). The receiver operating characteristic curve analysis identified 4.2 years as the cutoff age for predicting >33% sagittal plane remodeling, with an area under the curve of 0.975.

CONCLUSIONS

Children below the age of 5 years exhibit sagittal plane remodeling, with a cutoff age identified at 4.2 years for achieving >33% of d-CON. This indicates that mild deformities (16.5%

LEVEL OF EVIDENCE

Level IV-retrospective study.

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MESH Headings

• Humans
• Child
• Child, Preschool
• Male
• Adolescent
• Female
• Age Factors
• Humeral Fractures/surgery
• Infant
• Retrospective Studies
• Bone Remodeling
• Follow-Up Studies
• Fracture Fixation, Internal/methods

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Affiliation(s)

Yun Ki Kim Department of Orthopedic Surgery, Regional Rheumatoid and Degenerative Arthritis Center, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, Korea
Seung Hoo Lee Department of Orthopedic Surgery, Chungnam National University Sejong Hospital, Chungnam National University College of Medicine, Sejong, South Korea

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Cubitus varus deformity following paediatric supracondylar humeral fracture remodelling predominantly in the sagittal direction: A three-dimensional analysis of eighty-six cases

PURPOSE

Three-dimensional (3D) capacity for remodelling in cubitus varus deformity (CVD) after paediatric supracondylar humeral fractures (PSHFs) remains unelucidated. This study investigated remodelling patterns after PSHFs by examining 3D deformity distribution over time after injury.

METHODS

Computed tomography (CT) data of 86 patients with CVD after PSHFs were analysed. The 3D deformity angles in the sagittal, coronal, and axial directions were assessed and correlated with the duration between the age at injury and CT evaluation. For the subgroup analysis, we performed the same correlation analysis in a younger (< 8 years old) and an older group (≥ 8 years old); we categorized the duration into early (< 2 years), middle (≥ 2 to < 5 years), and late periods (≥ 5 years) and compared the deformity angles of each direction among the three groups.

RESULTS

Sagittal deformity showed a moderate correlation with the duration of deformity (r = -0.54; P < 0.001), while coronal and axial deformities showed a negligible correlation. Sagittal deformity showed moderate correlations with the duration in the younger group (r = -0.62; P < 0.001) and weak correlations in the older group (r = -0.37; P = 0.091). In the sagittal direction, the deformity angle in the early period was significantly larger than those in the mid and late periods (P < 0.001). However, there were no significant differences among the three groups in the coronal and axial directions.

CONCLUSION

Sagittal deformities in CVDs are capable of remodelling, especially in the early period and at a younger age, whereas coronal and axial deformities are less likely to undergo remodelling.

Posttraumatic Cubitus Varus: Respect the Columns

Posttraumatic cubitus varus is a multiplanar deformity that results from an improperly reduced supracondylar humerus fracture. The prevention of posttraumatic cubitus varus hinges on the stable restoration of all 3 columns of the distal humerus while avoiding malrotation. The collapse of any column leads to varying degrees of deformity in the coronal, sagittal, and/or axial plane. The purpose of this article is to explain the pattern of the deformity and use this to summarize preventative tactics for avoiding its described sequelae. We also summarize, illustrate, and present case examples for the various osteotomies used to correct the deformity, and speculate future directions.

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.

The effects of postoperative malrotation alignment on outcomes of Gartland type III/IV paediatric supracondylar humeral fractures treated by close reduction and percutaneous K-wire fixation

PURPOSE

In this study, we aimed to investigate the effects of postoperative malrotation alignment on the outcomes of Gartland type III/IV paediatric supracondylar humeral fracture (SCHF) treated by close reduction and percutaneous K-wire fixation.

METHODS

Between January 2014 and December 2021, 295 Gartland type III/IV paediatric SCHFs treated by close reduction and percutaneous K-wire fixation were selected for this retrospective study. The demographic, clinical and radiographic parameters of all cases were collected. The lateral rotation percentage (LRP) was measured on X-rays to evaluate postoperative malrotation alignment of the fracture. All cases were categorized into 4 groups according to LRP: LRP ≤ 10% (210, 71.2%), 10% < LRP ≤ 20% (41, 13.9%), 20% < LRP ≤ 30% (26, 8.8%) and LRP > 30% (18, 6.1%). The carrying angle, ranges of multidirectional motions, Mayo Elbow Performance Score (MEPS) and Flynn's Standard Score (FSS) of the injured elbow were assessed 6 months postoperation and compared among different groups. ROC analysis based on LRP and the excellent/good rate of FSS was performed to determine the acceptable maximum degree of postoperative malrotation alignment.

RESULTS

There was no difference in the demographic characteristics (age, sex, injured side and fracture type), postoperative Baumann angle, carrying angle or range of forearm rotation among the 4 groups (P > 0.05). The operation time and time from operation to K-wire removal were longer in the 20% < LRP ≤ 30% and LRP > 30% groups than in the LRP < 10% and 10% < LRP ≤ 20% groups (P < 0.001). The shaft condylar angle, range of elbow flexion, MEPS and FSS of the injured elbow 6 months postoperatively were lower in the 20% < LRP ≤ 30% and LRP > 30% groups than in the LRP < 10% and 10% < LRP ≤ 20% groups (P < 0.001). ROC analysis based on LRP and the excellent/good rate of FSS showed an area under the curve of 0.959 (95% CI 0.936-0.983), with a cutoff value of 26.5%, sensitivity of 95.3% and specificity of 90.1%.

CONCLUSION

A certain degree of residual malrotation alignment deformity of the SCHF may reduce the shaft condylar angle and extend the time from operation to removing the K-wire and affect elbow function, especially the range of elbow flexion. The acceptable maximum degree of residual malrotation deformity expressed as the LRP value was 26.5%.

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

Supracondylar humerus fractures are common pediatric injuries encountered by orthopedic surgeons. Displaced fractures are treated operatively with closed reduction and percutaneous pinning or open reduction of injuries that cannot be adequately closed reduced. The purpose of this study is to identify preoperative injury characteristics associated with open reduction. Retrospective chart review was performed on all AO type 13A (Gartland type) supracondylar humerus fractures in patients 2-13 years old treated surgically at a single level 1 trauma center over 6 years. Preoperative demographics and radiographic parameters were obtained for all patients. Primary outcomes were closed reduction or conversion to open reduction of fractures prior to k-wire fixation. Initial bivariate analysis was done using Chi-square tests. Final multivariate analysis with Bonferonni correction was performed using a backward, stepwise regression model including potential predictor variables identified in the bivariate analysis. A total of 211 patients received surgical treatment and 18 of those patients (8.5%) failed closed reduction and underwent open reduction. Final multivariate analysis demonstrated that only flexion type [relative risk (RR), 10.2] and coronal displacement more than 7 mm (RR, 4.49) were significant preoperative factors for conversion to open reduction. Patients with significant coronal displacement and flexion-type injuries are markers of challenging reduction and are at high risk for conversion to open reduction.

Distal humeral corrective osteotomy for treatment of supracondylar fracture malunions in children

Purpose

This study aimed to determine the functional and radiographic outcomes following corrective distal humeral osteotomies for the treatment of supracondylar fracture malunions in children. We hypothesized that such secondary reconstructive procedures could restore a reasonable and near-normal amount of functionality in a large patient cohort at a tertiary referral center.

Methods

We retrospectively reviewed the clinical and radiological records of 38 children who underwent corrective osteotomy for posttraumatic supracondylar humeral malunion using K-wire fixation. All clinical data were extracted after chart review, including age, sex, dominant side whenever available, follow-up duration, and elbow range of motion preoperatively and at the final visit. Radiographic parameters, including Baumann's angle, humeroulnar angle, humerocondylar angle, and elbow range of motion were evaluated preoperatively, postoperatively, and at the final visit to identify the surgical correction outcomes.

Results

The mean age of the patients at fracture was 5.6 (±2.7) years, and the mean age at surgical intervention was 8.6 (±2.6) years. The mean follow-up period of the current series was 28.2 (±31.1) months. Baumann's angle, humeroulnar angle, and humerocondylar angle were successfully restored to physiological ranges (72.6°, 5.4°, and 36.1°, respectively). Postoperatively, elbow extension improved from -22° (±5.7) to -2.7° (±7.2) versus flexion from 115° (±13.2) to 128.2° (±11.1). Three revision surgeries (8%) were encountered.

Conclusions

Corrective osteotomy of the distal humerus with K-wire fixation is a reliable method to efficiently correct malunion of the distal humerus in different planes, thereby improving elbow range of motion and appearance.

Level of evidence

level IV: Retrospective therapeutic study.

Closed reduction with percutaneous Kirschner wire drill-and-pry for pediatric supracondylar humeral fractures with bony callus formation and delayed presentation

BACKGROUND

Supracondylar humeral fractures are the most common type of pediatric elbow fractures, and are primarily treated using closed reduction and percutaneous pinning. For patients who are treated ≥14 days after the injury, after callus formation has occurred, closed reduction is usually not possible. The purpose of this study is to report the clinical outcomes of closed reduction with percutaneous Kirschner wire (K-wire) drill-and-pry for the delayed treatment of pediatric supracondylar humeral fractures with bony callus formation.

METHODS

We retrospectively reviewed the data of 16 patients who underwent percutaneous K-wire drill-and-pry between November 2019 and August 2021 for the treatment of supracondylar humeral fractures with bony callus formation ≥14 days after the injury. Clinical outcomes were assessed using the Flynn criteria. The postoperative Baumann angle and pin configuration were evaluated using x-ray examinations.

RESULTS

All patients were followed up for 8-28 months (average, 16.63 months). The fractures healed in 4-6 weeks (average, 4.38 weeks). The operative time ranged from 10 to 124 min (average, 35.12 min). No iatrogenic vascular or nerve injury occurred. No patient developed cubitus varus. According to the Flynn criteria, 12 patients had excellent outcomes, 2 patients had good outcomes, 1 patient had a fair outcome and 1 patient had a poor outcome.

CONCLUSION

Closed reduction with percutaneous K-wire drill-and-pry is a mini invasive technique for supracondylar humeral fractures with bony callus formation in children. Most patients had a good clinical and cosmetic outcomes without scarring.

Sequelae of childhood elbow fracture

Elbow fracture is frequent in children, and often requires surgery. There are many potential sequelae: neurovascular, ligamentous and osseous. Some are liable to be overlooked, due to young age and the cartilaginous nature of the joint. There is little bone remodeling in the elbow and displacement fracture, and especially supracondylar or lateral condyle fracture, has to be corrected rigorously, notably in older children. In case of lateral tilt in fracture of the neck of the radial head, on the other hand, remodeling is effective. Deformity in cubitus varus and cubitus valgus leads to neurological lesions and instability. Treatment should be early, with adapted surgery in expert hands. Post-traumatic stiffness is rare. Early intensive physiotherapy is unsuited to children and could worsen the stiffness due to inflammation. Lateral condyle non-union is a classic complication of fracture. Simple percutaneous screwing is a useful option. The equivalent in the medial epicondyle is well-tolerated, and simple monitoring now suffices. Late posterolateral rotational instability is a poorly known complication. It should be considered in case of cubitus varus that becomes painful after a long asymptomatic course. Radiocapitellar subluxation is seen on X-ray. Residual radial head dislocation after primary treatment (Monteggia lesion) responds well to the Bouyala technique of ulnar flexion osteotomy associated to annular ligament repair, without requiring ligament reconstruction.

Gartland Type IIa Supracondylar Humerus Fractures: Outcomes of Attempted Nonoperative Management

BACKGROUND

The optimal treatment of Gartland type IIa supracondylar humerus fractures remains controversial. We report the results of a series of patients with type IIa fractures who underwent closed reduction and immobilization using conscious sedation in the emergency department. Our goal was to identify variables associated with fractures that were successfully managed nonoperatively.

METHODS

This was a retrospective cohort study of pediatric patients who underwent closed reduction of Gartland type IIa supracondylar humerus fractures with the use of conscious sedation in the emergency department. Prereduction and postreduction radiographs were reviewed to determine the degree of fracture extension, anterior humeral line index, Baumann angle, and splint flexion angle. The success of closed reduction was defined as a reduction that was maintained without the need for surgical intervention.

RESULTS

A total of 54 patients (54 elbows) were included in this study. The mean overall age was 5.2±2.5 years. Following the closed reduction in the emergency department, 38 (70%) patients were successfully managed nonoperatively with casting, and 16 (30%) patients required operative intervention. The degree of fracture extension on the injury radiograph was 13.2±8.4 degrees in the nonoperative group compared with 19.8±7.5 degrees in the operative group (P=0.008). The postreduction degree of fracture extension was 3.0±3.4 degrees in the nonoperative group and 10.0±7.2 degrees in the operative group (P<0.0001). The mean anterior humeral line index on the injury radiograph was 0.34 in the nonoperative group and 0.13 in the operative group (P=0.104). The mean anterior humeral line index on the postreduction radiograph was 1.2 in the nonoperative group and 0.38 in the operative group (P=0.0002). Patient age, prereduction and postreduction Baumann angle, and the postreduction splint flexion angle did not differ significantly between groups.

CONCLUSIONS

Closed reduction under conscious sedation in the emergency department is a viable treatment option for Gartland type IIa supracondylar humerus fractures. Increasing fracture extension on injury radiographs can help predict failure of nonoperative management following closed reduction.

LEVEL OF EVIDENCE

Level III-retrospective comparative study.

Rotation of both X- and Y-axes is a predictive confounder of ulnar nerve injury and open reduction in pediatric lateral flexion supracondylar humeral fractures: A retrospective cohort study

BACKGROUND

Rotation of the distal fragment often occurs in flexion-type supracondylar humerus fractures (SCHFs), potentially leading to ulnar nerve injury (UNI) and open reduction. We analyzed the correlation between the rotations and UNI or open reduction and then assessed the risk factors associated with these rotations.

METHODS

Data of Wilkins type III lateral flexion SCHFs were collected over a 10-year time period (1 January 2012 to 31 December 2021) in Children's Hospital of Fudan University Anhui Hospital. We defined the rotation of the distal fragment on the coordinate axis as two types, IIIA (X-axis rotation) and IIIB (the rotation of both X- and Y-axes) on X-ray radiography. Demographic data, the incidence of the two-type rotation, odds ratios (ORs) of UNI and open reduction, and risk factors of the rotation of both X- and Y-axes were analyzed.

RESULTS

Totally, 152 patients were found (50 with IIIA vs. 102 IIIB). The UNI rate was 13%, and the open reduction rate was 22%. The UNI rate of the IIIB was five-fold higher than that of the IIIA [OR, 5.143; 95% confidence interval (CI), 1.414-23.125; p = 0.019], and the open reduction rate of the IIIB was nearly five-fold higher than that of the IIIA (OR, 4.729, 95%CI, 1.584-14.495; p = 0.003). In these two types, patients with UNI had a higher risk of open reduction than those without UNI (OR, 9.816; 95%CI, 3.503-27.508; p = 0.001). In the multiple regression analysis, a high level of fracture was identified as a risk factor for the rotation of both X- and Y-axes.

CONCLUSION

Type IIIB lateral flexion-type SCHFs have higher rates of UNI and open reduction, and a high level of fracture is a risk factor associated with this type.