Immobilization after pinning of supracondylar distal humerus fractures in children: use of the A-frame cast

Do K-wire Configurations and Numbers Have Effects on Gartland Type 3 Pediatric Supracondylar Humeral Fractures?

Purpose: The purpose of this study was to compare pin configuration effects on early secondary displacement in the surgical treatment of pediatric supracondylar humeral fractures (SCHF). Methods: The study consisted of 100 (68M, 32F) children who underwent surgery between 2010 and 2013 for Gartland Type 3 (SCHF). The patients were divided into five groups according to the top configurations. The average age at the time of injury was 7.34 (between 2 and 14 years). Bauman angle (BA), Humerocapital angle (HCA), Anterior humeral line (AHL), flexion range, extension range, and Carrying angle (CA) were compared at preoperative, postoperative 1st-day, postoperative last control, and non-operated side. Results: There was no statistical difference between all five subgroups in terms of BA, AHL, HCA, and CA were the same on postoperative 1st-day and postoperative last control. Also, there was no statistically significant difference was observed between age, sex, and type of fracture. Five of the cases have pin site infection and in three patients occurred ulnar nerve injury due to initial trauma. Conclusion: After a good and gentle reduction and early treatment of pediatric SCHF, all pin configurations maintain alignment. All pin configurations can be used for stabilization.

A novel retractor-assisted closed reduction combined with percutaneous pinning fixation for the treatment of elderly distal radius fractures: a retrospective cohort study

Background

Percutaneous pinning fixation (PCP) has been used for the treatment of distal radius fractures for decades, especially in the elderly with fragile soft tissue. However, achieving and maintaining a sound anatomic reduction before PCP is difficult if we use the manipulative reduction method alone. Our study innovatively applied the Steinmann pin retractor for closed reduction combined with PCP, to provide a new protocol for the treatment of distal radius fractures.

Methods

From March 2017 to July 2018, 49 patients out of 57 that met the inclusion criteria but not the exclusion criteria were included in our retrospective cohort study. Sixteen patients were treated with Steinmann pin retractor-assisted closed reduction combined with PCP (S-PCP), and 19 patients were treated with the manipulative reduction combined with PCP (M-PCP), and 14 patients were treated with the manipulative reduction combined with cast splint (M-C). All these patients received a positive postoperative radiological and clinical evaluation.

Results

All the patients were followed up for a minimum of 2 years. The radiological parameters in each group improved significantly postoperative (posttreatment). In the S-PCP group, the values of radial height (postoperative, 13.33±1.74 mm; the first follow-up, 13.27±1.81mm; last follow-up, 13.16±1.76mm) and ulnar variance (postoperative, −0.10±1.29mm; the first follow-up, −0.05±1.27mm; last follow-up, −0.12±1.09mm) significantly improved as compared to the M-PCP and M-C groups. While the patients in the M-C group experienced significant re-displacement at the first and last follow-ups, in the S-PCP group, the range of wrist motion including extension (89.94±5.21%), radial deviation (90.69±6.01%), and supination (90.25±5.87%); ulnar deviation (89.81±5.82%) and QuickDASH score (2.70±3.64); and grip strength (92.50±5.59%), pronation (90.50±6.04%), and modified Mayo wrist score (90.94±4.17, the excellent rate reached up to 75%) also improved as compared to the M-PCP group, M-C group, or both groups at the last follow-up.

Conclusion

S-PCP improves fracture reduction and wrist function and can serve as an effective method for A₂(AO/OTA) and A₃ type of distal radius fractures in the elderly with limited dorsal comminution, including intra-articular fractures with displacement less than 2mm.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13018-021-02556-6.

Stiffness of various pin configurations for pediatric supracondylar humeral fracture: a systematic review on biomechanical studies

To compare the biomechanical stability of various pin configurations for pediatric supracondylar humeral fractures under varus, internal rotation, and extension conditions. After electronic retrieval, 11 biomechanical studies were included. Stiffness values of pin configurations under different loading conditions were extracted and pooled. There were no statistically significant differences between two cross pins and two divergent lateral pins on the basis of the 'Hamdi method' (P=0.249-0.737). An additional pin did not strengthen two-pin construct (P=0.124-0.367), but better stabilized fractures with medial comminution (P<0.01). Isolated lateral pins are preferable because of a better balance of a lower risk of nerve injury and comparable fixation strength. Limitations such as differences in experimental setup among recruited studies and small sample size may compromise the methodologic power of this study.

Foam padding in casts accommodates soft tissue swelling and provides circumferential strength after fixation of supracondylar humerus fractures

BACKGROUND

Varying casting techniques are used after surgical treatment of pediatric supracondylar humerus fractures. The goals are to maintain fracture reduction, while accommodating soft tissue swelling and minimizing the risk of compartment syndrome.

METHODS

A retrospective chart review of consecutive patients aged 0 to 14 years who underwent surgical treatment of supracondylar humerus fractures over a 9½-year period at a pediatric trauma center was performed. A new method of casting, in which one half inch sterile foam is applied directly to the skin and overwrapped by circumferential fiberglass, is presented and compared with traditional casts.

RESULTS

A total of 541 consecutive patients were included. Foam had been used in 35% (190/541) of patients. Foam was used significantly more frequently in Gartland type 3 fractures (133/314 patients, 42%) than in type 2 fractures (57/227 patients, 25%) (P<0.001). Foam was also used more often in patients with preoperative neurovascular deficits (34/57, 60%) than in those without (156/484, 32%) (P<0.001). No patient in either group developed compartment syndrome postoperatively. Both patients in the study who required revision closed reduction and pinning were casted without foam, and one of these casts had been split. Reoperation was not associated with cast splitting (P=0.216) or foam use (P=0.543).

CONCLUSIONS

For postoperative immobilization of supracondylar humerus fractures we present a new method of placing foam directly on the skin, followed by circumferential fiberglass casting. This method offers the theoretical advantage of the strength of a circumferential cast, plus the benefit of allowing for swelling. Although the novel foam and cast combination was used in more severe fractures, results were comparable to traditional casts and may reduce the need for cast splitting.

LEVEL OF EVIDENCE

Therapeutic-Level III.

Pediatric supracondylar humerus fractures: effect of bone-implant interface conditions on fracture stability

BACKGROUND

Closed reduction and percutaneous fixation with Kirschner wires (KWs) is the standard of care of pediatric supra-condylar humerus fractures (SCHFs). Failure modes leading to loss of reduction are not clear and have not been quantified. Multiple factors may weaken the KW-bone interface bonding conditions. To the best of our knowledge, the possible effect of this decrease on different KW configurations and fracture stability has never been studied.

PURPOSE

To investigate the effect of bone-KW friction conditions on SCHF post-operative mechanical stability and to formulate clinical guidelines for KW configuration under different conditions.

METHODS

Finite element-based model of a fixated SCHF was used to simulate structure stability for two lateral divergent versus crossed lateral and medial KW configurations under varying KW-bone friction conditions.

RESULTS

Finite element simulations demonstrated that crossed KWs provide superior stability compared with the divergent configuration when KW-bone bonding is compromised. When KW-bone bonding conditions are adequate, crossed and divergent KW configurations provide similar, sufficient fracture stability.

CONCLUSIONS

Under normal bone-implant interface conditions, the two diverging lateral KW configuration offers satisfactory mechanical stability and may be the preferred choice of SCHF fixation. When KW-bone bonding is suboptimal, as when one or more of the lateral KWs are re-drilled, addition of a medial KW should be considered in order to improve stability despite risk to ulnar nerve.