Comparative analysis of surgical outcomes in children with type 3 and type 4 lateral physeal condylar humerus fractures in China: Closed Reduction-PerCutaneous Pinning (CRPP) vs. Open Reduction-Internal Fixation (ORIF)

Background

Lateral physeal condylar humerus fractures in pediatric patients aged 1-13 rank as the second most common elbow injury, occurring with a frequency ranging from 5% to 16.8%. There exists an ongoing debate regarding the surgical management of these fractures. This study aims to evaluate the efficacy of Open Reduction and Internal Fixation (ORIF) and Closed Reduction and Percutaneous Pinning (CRPP) as suitable surgical treatments for displaced unstable fractures of the lateral condyle physeal humerus in children. The comparison encompasses the results of ORIF and CRPP, alongside clinical and radiographic outcomes and complication rates.

Method

A retrospective review was conducted at the Department of Orthopedic Surgery in the research hospital. A cohort of 27 patients treated between 2016 and 2023 were analyzed, 19 patients meeting inclusion criteria. The fracture pattern and degree of displacement were assessed, with specialized radiologists, doctors, and surgeons in agreement. Among the patients, 11 underwent CRPP 7 type 3and 4 type 2, while 16 received ORIF 12 type 4 and 4 type 5. Data collection included fracture type, surgical method, operation time, pre and post-operative displacement, casting period, bone union condition, follow-up records, range of motion, complications, delayed union, lateral spurring, and pin removal records.

Results

For CRPP, the mean time for pin removal was 5.42 weeks, with excellent bone union and an average operation time of 34.57 min. Criteria of Hardacre showed 28.57% of cases as good and 71.42% as excellent. Similarly, ORIF demonstrated a mean operation time of 42.5 min, with the fracture healing within 5.33 weeks and the pin being removed after 15 days on average. Criteria of Hardacre indicated 25% of cases as good and 75% as excellent. Both groups showed satisfactory outcomes, with no complications such as osteomyelitis, nonunion, malunion, delayed union, myositis ossificans, physeal growth arrest, tardy ulnar nerve palsy, cubitus valgus, or varus, and no cases requiring re-surgery.

Conclusion

Both CRPP and ORIF are effective surgical methods for treating lateral physeal condylar humeral fractures (types 3 and 4 according to the Song classification) in children, demonstrating satisfactory outcomes. Notably, regardless of displacement (2 mm and >2 mm), both methods yield similar results, albeit with CRPP offering the advantage of avoiding incisions. Overall, both procedures are safe, with favorable bone healing outcomes.

A meta-analysis of closed reduction percutaneous pinning and open reduction with pin fixation of pediatric humeral lateral condylar fracture

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.

Lateral Humeral Condyle Fractures in Pediatric Patients

Lateral humeral condyle fractures are frequently seen in pediatric patients and have a high risk of unfavorable outcomes. A fall on the outstretched arm with supination of the forearm is the most common trauma mechanism. A physical examination combined with additional imaging will confirm the diagnosis. Several classifications have been described to categorize these fractures based on location and comminution. Treatment options depend on the severity of the fracture and consist of immobilization in a cast, closed reduction with percutaneous fixation, and open reduction with fixation. These fractures can lead to notable complications such as lateral condyle overgrowth, surgical site infection, pin tract infections, stiffness resulting in decreased range of motion, cubitus valgus deformities, 'fishtail' deformities, malunion, non-union, avascular necrosis, and premature epiphyseal fusion. Adequate follow-up is therefore warranted.

Management of lateral condyle fractures of the humerus in children

Lateral condyle fracture of the humerus is the second most common paediatric elbow fracture and is often missed, which can result in severe consequences including malunion, growth arrest and tardy ulnar nerve palsy. The difficulty in managing this fracture stems from a lack of awareness and the often subtle findings on radiographs. Patients can also present with quite vague symptoms; clinicians who do not have a high index of suspicion may not investigate beyond the initial clinical assessment and could miss vital cues. This article provides a guide to managing this common paediatric fracture, from initial presentation to definitive treatment, and discusses the complications that can ensue if managed incorrectly.

Diagnosis, management and complications of distal humerus lateral condyle fractures in children

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.

Unburied versus buried wires for fixation of pediatric lateral condyle distal humeral fractures: A meta-analysis

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.