Current trends in the treatment of supracondylar fractures of the humerus in children: Results of a survey of the members of European Paediatric Orthopaedic Society

Reliability of radiographic union score and correlation of clinical outcomes in children operated for supracondylar humerus fracture: A prospective study

Background

Supracondylar humerus fractures are common in childhood, and postoperative follow-up planning for surgically treated fractures is still controversial. This study aims to investigate the interobserver and intraobserver reliability of the Radiographic Union Score for Tibial Fracture in the postoperative radiological follow-up of pediatric supracondylar humerus fractures and to evaluate the clinical results with the scores obtained during follow-up.

Methods

In this prospective study, patients who were operated on for supracondylar humerus fractures were called for follow-up three times: postoperative splint removal, pin removal, and final control. A total of 58 patients, 34 boys and 24 girls, who provided regular follow-ups, were included in the study. During follow-ups, the Radiographic Union Score for Tibial Fracture was calculated by evaluating the patients' elbow anteroposterior and lateral radiographs, and the elbow joint range of motion was recorded with a goniometer. In two experiments, orthopedic surgeons evaluated intraobserver and interobserver reliability using the intraclass correlation coefficient at different times. The patients were evaluated at the last follow-up according to the Flynn criteria.

Results

The first follow-up Radiographic Union Score for Tibial Fracture (median (range) was 8 (7-10), the second follow-up was 11 (9-12), and the third follow-up was 12 (11-12). Range of motion was 40° at the first follow-up, 90° at the second follow-up, and 120° at the third follow-up. Radiographic Union Score for Tibial Fracture and range of motion increased significantly as the weeks progressed (p < 0.001). Interobserver intraclass correlation coefficient at first follow-up was 0.80 (95% confidence interval 0.69-0.87), second follow-up was 0.85 (0.77-0.91), and third follow-up was 0.79 (0.67-0.87). Intraobserver intraclass correlation coefficient was 0.92 (0.88-0.95) at the first follow-up, 0.93 (0.98-0.96) at the second follow-up, and 1.00 (1.00-1.00) at the third follow-up. Flynn score results are functional; the cosmetic results were excellent in 46 patients, good in 4 patients, fair in 5 patients, poor in 3 patients, and cosmetic results were excellent in 54 patients and good in 4 patients.

Conclusion

Our study determined that the radiographic union of fractures in pediatric supracondylar humerus fractures is reliably evaluated with the Radiographic Union Score for Tibial Fracture score. Radiographic Union Score for Tibial Fracture can be used to provide data-driven estimates of splint and pin removal.

Level of evidence

Level II, prospective study.

Emergency Department Visits Following Supracondylar Humerus Fractures

INTRODUCTION

Pediatric supracondylar humerus fractures are common and the most frequent pediatric fracture to require surgical intervention. After initial management, emergency department (ED) visits subsequent to this injury/surgery are not well characterized, but are of clinical interest.

METHODS

Pediatric patients (age >1 ​​​​​​y old and <13 y old) with supracondylar humerus fractures were identified from the 2010 to 2021 PearlDiver M157 administrative database. These patients were stratified based on whether they visited the emergency department at least once within 90 days after their initial injury diagnosis/management. The timing of visits and reasons were determined, and predictive factors were assessed with multivariate logistical regression.

RESULTS

A total of 92,994 fractures were identified for which post-injury/post-operative ED visits were noted for 10,325 patients (11.1%). Nearly half of all ED visits occurred within the 2 weeks immediately after the fracture (46.1%), of which 54.7% of visits were not directly related to the elbow. On multivariate analysis, patients who utilized the ED after initial management of pediatric supracondylar humerus fracture were of greater odds ratio (OR) in decreasing order to have: had a history of ED visits before their initial injury (OR: 2.69), be diabetic (OR: 1.81), had surgical intervention for their fracture (OR:1.58), be obese (OR: 1.57), have asthma (OR:1.55), have Medicaid insurance (OR: 1.29), and be younger (OR: 1.11 per year decrease) ( P <0.001 for all).

DISCUSSION

In the 90 days after pediatric supracondylar humerus fracture, more than 1 in 10 patients visited the ED. This data highlight the need for close following of such patients after their injury/surgery and suggests risk factors for which patients such quality improvement measures should be focused.

LEVEL OF EVIDENCE

III.

Pediatric Supracondylar Humerus Fracture: When Should We Surgically Treat? A Case-Series

Background/Objectives: Supracondylar humerus fractures (SCHFs) are the most common pediatric elbow injuries and often require surgical intervention. Despite guidelines, optimal timing for surgical management, particularly for cases without neurovascular compromise, remains unclear. This study evaluates the influence of surgical timing on short-term outcomes, focusing on fracture reduction quality and surgical parameters. Methods: In total, 62 pediatric patients who had been treated for Gartland type II and III SCHF between 2018 and 2023 were retrospectively assessed. Patients were grouped based on time of admission (morning, afternoon, early evening, and night shifts) and time to surgery (<12 h vs. >12 h). Primary outcomes included immediate radiological reduction, assessed via the Baumann's angle (BA) and shaft-condylar angle (SCA). Secondary outcomes encompassed surgery duration and radiation exposure. Statistical analyses used ANOVA and chi-square tests, with p < 0.05 considered significant. Results: No significant differences were observed in BA (p = 0.84) or SCA (p = 0.79) between early and delayed surgical groups. Similarly, surgical timing (shift or delay >12 h) did not significantly affect surgery duration (p = 0.92) or radiation exposure (p = 0.12). The complication rate was 6.45%. Conclusions: Surgical timing, including delays beyond 12 h, does not adversely affect short-term outcomes in SCHFs. However, after-hours procedures may pose practical challenges, emphasizing the importance of surgeon experience and institutional protocols. Larger prospective studies are warranted to validate these findings and examine them in the long term.

Examining Outcomes and Complications for Operative Versus Nonoperative Treatment of Pediatric Type II Supracondylar Humerus Fractures: A Systematic Review of Comparative Studies

OBJECTIVE

The optimal management of pediatric type II supracondylar humerus fractures (SCHFs) is debated. We conducted a systematic review comparing outcomes and complications of nonoperative versus operative management to aid decision-making and inform future research.

METHODS

We searched PubMed, Web of Science, MEDLINE, and CINAHL from their inception until February 7, 2024, including studies on pediatric patients (<18 y) with any type II SCHF, provided they compared operative to nonoperative care and were in English. The quality of articles was evaluated using the Methodological Index for Non-Randomized Studies Scale.

RESULTS

Out of 417 studies reviewed, 7 met the inclusion criteria. These studies involved 1446 patients (mean age: 4.9 y; mean follow-up: 5.0 mo), comparing operative (n = 427) and nonoperative (n = 1019) treatments. Functional outcomes such as carrying angle, Baumann angle, elbow range-of-motion, and patient satisfaction were similar across treatment groups. Nonoperative management showed a higher incidence of residual sagittal deformity (14.1% vs 0.0%; P < 0.0001) and a treatment failure rate of 8.9% to 20.6%, necessitating surgical intervention. Factors prompting operative care included rotational deformity, varus/valgus misalignment, and a shaft-condylar angle below 30 degrees.

CONCLUSION

Nonoperative treatment of type II SCHF is linked with higher rates of residual sagittal deformity and a notable failure rate requiring subsequent surgery. Both treatment strategies showed similar functional outcomes and patient satisfaction. Further research should focus on identifying anatomic criteria predictive of nonoperative treatment failure.

LEVEL OF EVIDENCE

Level III-systematic review.

Treatment and Outcome of Supracondylar Humeral Fractures in Children Over 10 Years of Age at the Time of Injury: A Review of 60 Cases

OBJECTIVES

To assess the treatment and outcomes of supracondylar humeral fractures (SHFs) in children older than 10 years of age at the time of injury.

METHODS

The study analyzed clinical data from 60 patients who sustained SHF, all over the age of 10 years, were analyzed. The patients included 49 males and 11 females with a mean age of 10.9 ± 0.9 years (range, 10 to 14.5). All patients underwent surgical treatment under general anesthesia. Closed reduction (CR) and percutaneous fixation were the primary treatment, with open reduction and internal fixation being employed only in cases CR was unsuccessful. The study assessed the healing of fractures by measuring the radiographic angles, including the carrying angle (RCA), Baumann's angle (BA), and metaphyseal-diaphyseal angle (MDA) on anteroposterior radiographs of the elbow joint. In addition, the study evaluated whether the anterior humeral line (AHL) appropriately passed through the middle third of the capitellum. The final follow-up visit used the Mayo Elbow Performance Index score (MEPI) and Flynn's criteria to analyze the recovery of elbow function.

RESULTS

There were 15 (25%) SHF type II, 17 (28.3%) type III and 28 (46.7%) type IV. Of the 60 patients, 56 (93.3%) underwent successful CR, whereas 4 (6.7%) required open reduction and internal fixation because of an unsuccessful CR. The final follow-up showed the average BA as 72° ± 5.3°, the average MDA as 88.3° ± 2.8°, and the average RCA as 9.6° ± 3.9°. The AHL bisected accurately the capitellum in 59 cases (98.3%). The average range of elbow flexion-extension was 146.6° ± 8.6°, whereas the average MEPI score was 99.9 ± 0.6; 98.3% (n=59) were rated as excellent and 1.7% (n=1) were rated as good. According to Flynn's criteria, 86.7% had an excellent outcome (n=52), 10% had a good outcome (n=6), and 3.3% had a poor outcome (n=2). Only 1 patient (1.7%) experienced redisplacement. Eight cases of nerve injury were reported, with 7 involving the radial nerve and 1 involving the ulnar nerve; all resolved spontaneously.

CONCLUSIONS

CR and percutaneous fixation have been shown to be effective in treating SHF in 93.3% of children aged 10 years old and older at the time of injury, with favorable radiographic and functional outcomes and a low risk of secondary displacement. Open reduction should only be considered when CR is ineffective.

Management of Pediatric Elbow Fractures and Dislocations

Pediatric elbow fractures and dislocations have always been a challenge from a diagnostic and therapeutic point of view, primarily due to the complex nature of the pediatric elbow, especially its developmental anatomy. They must be diagnosed and treated on time to prevent numerous complications with long-term consequences. With the development of radiology and pediatric surgery and orthopedics, as well as the development of modern osteosynthesis materials, concerning current scientific and professional knowledge, the outcomes are getting better, with fewer acute and chronic complications. This comprehensive review aims to provide clinicians current knowledge about pediatric elbow fractures and dislocations so that in daily practice they have as few doubts as possible with the best possible treatment outcomes.

Postoperative Immobilization Period for Pediatric Supracondylar Fractures: The Shorter the Better?

BACKGROUND

There are now recognized standards of care published by the British and American Orthopaedic Associations which detail key areas of evidence-based recommendations for the treatment of children with displaced supracondylar humerus fractures. Although many aspects of treatment are covered in these recommendations, both the American and British Orthopaedic Associations do not recommend the exact duration of immobilization postoperatively.

METHODS

This study retrospectively compared outcomes of operatively managed supracondylar fractures immobilized postoperatively for short immobilization (SI) defined as 28 days or less, with long immobilization (LI) defined as more than 28 days. The outcomes measured were clinical (deformity, range of motion, and pin site infection) and radiologic (loss of position after the removal of K-wires, Baumann's angle, anterior humeral line, refracture, and signs of osteomyelitis). Demographic data were recorded to evaluate and ensure satisfactory matching of the 2 groups for analysis.

RESULTS

The study included 193 pediatric supracondylar fractures over a 4-year period which were treated with manipulation under anesthetic and K-wire fixation. The difference in average time in plaster between the 2 groups was statistically significant (SI: n=27.5 d, SD 1.23; LI: n=43.9 d, SD 15.29, P =0.0001). Data for operative techniques-closed or open reduction (SI: n=66, LI: n=78, P =0.59), and crossed wires (SI: n=37, LI: n=50, P =0.57) between the two groups showed no statistical significance. There was no statistical difference between the groups for the average number of days postoperatively at which wires were taken out (SI: n=28.9 d, SD 5.95, LI: n=30.1 d, SD 5.57, P =0.15), number of pin site infections requiring antibiotic treatment (SI: n=3, LI: n=5, P =0.70), or children from each group who were recorded to have regained full range of motion symmetrical to their contralateral arm (SI: n=79, LI: n=99, P =0.74).

CONCLUSIONS

Our study therefore suggests that shorter immobilization of these patients (SI group) does not yield a higher rate of complications including refracture and malunion.

Anterior Versus Posterior Surgical Approaches to Pediatric Supracondylar Humerus Fracture

OBJECTIVES

Gartland type III supracondylar humerus fractures frequently occur as traumatic injuries in children and often require surgical intervention. This study aimed to compare the efficacy of anterior and posterior surgical approaches to treating these fractures.

METHODS

This retrospective study analyzed 48 patients under the age of 10 with Gartland type III fractures. These patients were treated with either the anterior (n=23) or the posterior approach (n=25). At three and six months post-surgery, elbow range of motion (ROM), complications, and functional/cosmetic outcomes were assessed using Flynn's criteria.

RESULTS

No significant differences were found between the groups regarding age or gender. At three months, the anterior group showed significantly better extension (-8.26° vs. -13.20°, P=0.032), but this difference was not significant at six months. No significant differences were observed in flexion, pronation, or supination at any time point. Both groups showed significant ROM improvements from three to six months (P<0.001); however, these improvements were slightly below the normative values (P<0.05). The overall complication rates were low and comparable between the two approaches (anterior: 8.70%; posterior: 12.00%; P=0.700), primarily comprising reversible ulnar nerve injuries and superficial infections. Furthermore, based on Flynn's criteria, there were no significant differences in functional or cosmetic outcomes, with most patients achieving excellent or good results in both groups.

CONCLUSION

Both anterior and posterior approaches for pediatric Gartland type III supracondylar humerus fractures resulted in satisfactory outcomes. Therefore, the choice of surgical approach will depend on patient-related factors and surgeons' preferences.

[Reconstruction of medial and lateral column periosteal hinge using Kirschner wire to assist in closed reduction of multi-directional unstable humeral supracondylar fractures in children]

Objective

To investigate the effectiveness of medial and lateral column periosteal hinge reconstruction using Kirschner wire in the closed reduction of multi-directional unstable humeral supracondylar fractures in children.

Methods

A clinical data of 43 children with multi-direction unstable humeral supracondylar fractures, who met the selection criteria and were admitted between August 2020 and August 2022, was retrospectively analyzed. Twenty-one cases of fractures were treated wuth closed reduction after medial and lateral column periosteal hinge reconstruction using Kirschner wire and percutaneous Kirschner wires fixation (study group), while 22 cases of fractures were treated by traditional closed reduction technique and percutaneous Kirschner wire fixation (control group). There was no significant difference in gender, age, cause of injury, fracture side, and interval from injury to operation between the two groups ( P>0.05). The operation time, intraoperative fluoroscopy times, the number of children who were changed to open reduction after closed reduction failure, fracture healing time, complications within 2 months after operation, and the Flynn score of elbow joint function at last follow-up were compared between the two groups.

Results

All the fractures in the study group were successfully closed reduction, and 4 cases in the control group were changed to open reduction and completed the operation, the difference between the two groups was significant ( P=0.040). The operation time and intraoperative fluoroscopy times of the study group were significantly less than those of the control group ( P<0.05). All children in both groups were followed up 6-18 months with an average of 9.0 months in the study group and 9.8 months in the control group. Imaging review showed that the fractures of both groups healed, and the difference in the healing time between the two groups was not significant ( P=0.373). According to Flynn score at last follow-up, the excellent and good rate of elbow joint function was 95.2% (20/21) in the study group and 86.4% (19/22) in the control group, with no significant difference ( P=0.317). There was no complication such as infection or irritation at the end of Kirchner wire within 2 months after operation.

Conclusion

For children with multi-directional unstable humeral supracondylar fractures, the use of Kirschner wires to reconstruct the medial and lateral column periosteal hinge to assist in closed reduction has the advantages of shortening operation time, reducing intraoperative fluoroscopy times, and effectively reducing the incidence of open reduction, and can achieve similar postoperative elbow joint function when compared with traditional closed reduction technique.

Does radiation exposure during pediatric supracondylar humeral fracture surgery change according to the C-arm position? A comparison of two different techniques

INTRODUCTION

In the surgical treatment of supracondylar humeral fractures (SHF), the surgeon has to stand right next to the fluoroscopy device, so it is very important to know how to use it in the most appropriate way to reduce radiation exposure. The aim of this study was to investigate the effect of using C-arm in uniplanar (inverted) and biplanar (standard-horizontal) configurations on (1) the radiation exposure to the surgeon, and (2) surgical time and fluoroscopy exposure time.

MATERIAL AND METHODS

This prospective randomised study was conducted on 20 patients who underwent fluoroscopy during closed reduction and percutaneous pinning for a SHF. In the first configuration, the C-arm was inverted and the image intensifier was used as a surgical table. In the second configuration, the C-arm was used biplanar. The operations were performed by 5 surgeons, with each surgeon using each method only twice. During the operation, to find a value closed to direct radiation exposure measurement was made by attaching a dosimeter to the wrist and scatter radiation exposure was measured by attaching a dosimeter to the neck and waist of the surgeons. The operation time and fluoroscopy exposure time were determined.

RESULTS

The duration of operations performed with the biplanar C-arm position and the fluoroscopy exposure time in operations performed with the uniplanar method were found to be statistically significantly longer (p = 0.001). The measurements on the dosimeter worn on the neck of surgeons were found to be statistically significantly higher while using the uniplanar C-arm configuration (p = 0.001). There was no statistically significant difference between the dosimeter measurements on the wrists and waists of the surgeons and the C-arm configurations (p = 0.820; p = 0.185).

CONCLUSIONS

Although the use of biplanar C-arm has no effect on radiation exposure to the surgeon's wrist, the most important advantages are that the neck area is exposed to less radiation and it shortens the fluoroscopy time so the use of a biplanar C-arm can be recommended.

LEVEL OF EVIDENCE

Level II.

The Effect of Fracture Patterns, Pinning Configuration, Surgeon Experience and Subspecialty on Short-Term Radiological Outcomes of Pediatric Supracondylar Humeral Fractures Treated in the Prone Position: A Case-Series

BACKGROUND

The most common treatment modality for supracondylar humerus fractures (SCHFs) in children is closed reduction and percutaneous pinning (CRPP). Nonetheless, debate persists regarding the optimal technique used. Therefore, the purpose of our study was to investigate the impact of surgeon experience, surgeon subspecialty and pin configuration on short-term radiological outcomes following CRPP of displaced SCHFs.

METHODS

Patients less than 14 years of age who underwent CRPP for displaced SCHFs in the prone position between January 2018 and December 2022 were analyzed. Patients were separated into subgroups based on fracture type (low vs. high sagittal), pin configuration (lateral, cross, other), number and configuration of K-wires and first operator surgical experience. The following outcome measurements were collected: postoperative Baumann angle (BA), Shaft-Condylar angle (SCA), surgical duration (SD), duration of radiation exposure (DRE) and number of clinical and radiological follow-ups (FU).

RESULTS

A total of 44 patients with a mean age of 6 ± 2.5 years were included in the final analysis. The mean post-operative BA and SCA were 74.8° ± 4.9° and 37.7° ± 10.2°, respectively. No significant differences were found in the post-operative Baumann's angle or SCA among the subgroups. Regarding secondary outcomes, no differences were found among each subgroup regarding SD, DRE and FUs.

CONCLUSION

Short-term radiological outcomes following the treatment of SCHFs treated in the prone position are not affected by fracture patterns and pinning configuration, regardless of the surgeon's years of experience or subspecialty.

Is subclassification of Gartland extension-type pediatric supracondylar fracture into types IIA and IIB necessary for treatment decision? A result of pediatric orthopedist's survey and review of literature

Extension-type pediatric supracondylar humeral fractures are very common. The Gartland classification is typically used to guide treatment. However, there is still no consensus on what factors should be used to subclassify the type II fractures and whether subclassification is needed to guide treatment. Therefore, we aim to explore the opinions of pediatric orthopedists on the treatment method of the Gartland type II supracondylar fracture. Specifically, we ask what factors are considered for their treatment decisions and whether subclassification is needed to guide treatment. An online questionnaire was developed and sent to the Thai Paediatric Orthopedics Society and Asia-Pacific Paediatric Orthopaedic Society members. The results were analyzed to explore the relationship between respondents' demographic factors and treatment decisions. Out of 113 participants reached, 57 (50.4%) responded to the questionnaire. Factors chosen by respondents are stability testing intraoperatively (73.7%), the relationship of the anterior humeral line and capitellum (66.7%), the presence of rotation (50.9%), the presence of translation (47.4%), the presence of medial comminution 42.1%), soft tissue condition(38.6%), the shaft - condylar angle (31.6%), and the Bauman angle (21.1%). Thirty-three of 57 respondents (57.9%) deemed subclassification for Gartland type II necessary for guiding treatment. About half of respondents in our study deemed the current Gartland type II subclassification necessary to guide treatment, which may indicate that the subclassification might not be sufficiently comprehensive and reliable. Therefore, better criteria for a subclassification and a prospective evaluating study might be needed.

Retrospective Mid-Term Follow-Up of Posttraumatic and Iatrogenic Neurovascular Complications in Surgically Treated Paediatric Patients with Distal Humerus Fracture

BACKGROUND

The purpose of the study was to investigate and describe neurovascular complications and mid-term clinical outcomes of operatively managed fractures of the distal humerus in a paediatric population. Neurovascular injuries are common in these fractures, but reports about their implications for mid-term clinical outcomes is sparse.

METHODS

A single-centre retrospective study was conducted at a university teaching hospital investigating paediatric patients who underwent operative management of a distal humerus fracture between 2014 and 2018. Patient demographics, fracture classification, pre-, peri- and postoperative neurovascular complications were investigated. Mid-term follow up clinical examination and functional scoring using QuickDASH, the Broberg and Morrey Score (BMS), the Mayo Elbow Performance Score (MEPS) and the Numeric Rating Scale were performed.

RESULTS

A total of 84 patients were identified, of which 34 met the inclusion criteria and were available for follow-up clinical examination. The average time to follow-up was 150 weeks (1049.44 days ± 448.54). Ten primary traumatic neurovascular complications were identified, the majority of which involved the median nerve. Primary traumatic dissection of the brachial artery was recorded in three patients. Secondary iatrogenic nerve injury was documented in five patients after previously normal clinical examination. At follow-up, the average QuickDASH score was 3.0 ± 4.3, BMS was 98.6 ± 3.4 and MEPS was 97.1 ± 3.3 points.

CONCLUSIONS

The mid-term clinical outcome following surgical management of distal humerus fractures is excellent. There is, however, a considerable frequency of both primary and secondary neurovascular complications, which must be considered when opting to treat these injuries surgically.