A novel approach for the treatment of Jacob II and III fractures of the lateral humeral condyle in children: Percutaneous Kirschner wire fixation with ultrasound localization

Comparison of ultrasound-guided closed reduction and percutaneous pinning fixation for unstable humeral lateral condylar fractures

Objective

Ultrasound-guided techniques have become popular in severe humeral lateral condylar fractures (HLCFs). This study compared the results of ultrasound-guided closed reduction and percutaneous pinning (UG-CRPP) for Song types 4 and 5 and dislocation type of HLCFs.

Methods

This retrospective study was conducted in patients with HLCFs treated between January 2021 and October 2022 at three hospitals. The patients were divided into three groups according to Song's classification and elbow dislocation. The surgical time, reduction failure rate, and outcomes of the three groups were compared.

Results

The mean surgical time of the 94 patients across the three groups (Song 4 group, 42 cases; Song 5 group, 38 cases; and dislocation group, 14 cases) was the longest for Song 4 (66.14 ± 23.05 min), followed by the dislocation group (59.71 ± 21.07 min) and Song 5 (52.16 ± 14.94 min) (for all, P = 0.009). The failure rate decreased in the following order: dislocation group (5/14), Song 4 group (7/42), and Song 5 group (2/38). The failure rate of closed reduction in Song 4 was 3.2-fold higher than that in Song 5, and for the dislocation group, it was 7.6-fold higher than that in Song 5. Significant differences were observed between the Song 4, Song 5, and dislocation groups in terms of shaft-condylar angle and supination (P = 0.015, P = 0.043). No significant differences (P > 0.05) were observed in the carry angle, flexion, extension, or pronation of the three groups. Two cases of delayed healing, four cases of superficial infection, one case of trochlear necrosis, and 39 cases of lateral spur in the Song 4 group were observed. In the Song 5 group, five had a superficial infection, one had re-displacement, and 26 had a lateral spur. In the dislocation group, there were two cases of superficial infection and 10 of lateral spurs.

Conclusions

Song 4 HLCFs require longer surgical time and present more postoperative complications than Song 5 and dislocation-type HLCFs and can easily lead to lateral spurs. The failure rates of closed reduction in Song 4 and the dislocation type were higher than those in Song 5. Thus, UG-CRPP can be used to treat patients with unstable HLCFs.

[Effectiveness comparison of ultrasound-guided closed reduction and Kirschner wire fixation for different unstable humeral lateralcondylar fractures of children]

Objective

To compare the effectiveness of ultrasound-guided closed reduction and Kirschner wire fixation for different unstable humeral lateralcondylar fractures of children.

Methods

The clinical data of 94 children with unstable humeral lateralcondylar fractures admitted to three medical centers between January 2021 and October 2022 were retrospectively analyzed. The children were divided into three groups according to the Song classification and whether the elbow joint was dislocated or not, including 42 cases of Song 4 type (group A), 38 cases of Song 5 type (group B), and 14 cases of elbow joint dislocation (group C). There was no significant difference in gender, age, side, cause of injury, and time from injury to operation among the three groups ( P>0.05). All children were treated with ultrasound-guided closed reduction and Kirschner wire fixation. The operation time and complications of the three groups were recorded and compared, and the failure of closed reduction was evaluated by ultrasound. X-ray examination was performed at last follow-up to measure the Baumann angle, condylar angle, carrying angle, and lateral osteophyte of the affected side; the extension, flexion, pronation, and supination range of motion of the affected elbow joint were measured; the function of the elbow joint was evaluated by Mayo score.

Results

The operation time in group A was significantly longer than that in groups B and C ( P<0.05). There were 7, 2, and 5 cases of closed reduction failure in groups A, B, and C, respectively, and there was no significant difference in the incidence of the closed reduction failure ( P>0.05). All patients were followed up 6-28 months, with an average of 15.7 months. There was no significant difference in the follow-up time among the three groups ( P>0.05). Complications: in group A, there were 2 cases of delayed union, 4 cases of needle tract infection, 1 case of trochlear necrosis, and 39 cases of lateral osteophyte; in group B, there was 1 case of malunion, 5 cases of needle tract infection, 1 case of redisplacement, and 26 cases of lateral osteophyte; in group C, there were 2 cases of needle tract infection and 10 cases of lateral osteophyte. There was no significant difference in the incidence of complications among the three groups ( P>0.05). No cubitus varus or cubitus valgus deformity was found in all patients. At last follow-up, except that the condylar angle in group A was significantly greater than that in groups B and C ( P<0.05), there was no significant difference in other imaging indicators, elbow range of motion, or Mayo score between groups ( P>0.05).

Conclusion

The Song type 4 of humeral lateralcondylar fracture treated with ultrasound-guided closed reduction and Kirschner wire fixation has a longer operation time, more postoperative complications, and is more prone to lateral osteophyte.

Criteria of ultrasound-guided closed reduction with percutaneous pinning in unstable humeral lateral condylar fractures: a three-center retrospective cohort study

Background

Interventions using ultrasound-guided closed reduction and percutaneous pinning (UG-CRPP) of humeral lateral condylar fractures (HLCFs) have been increasingly applied; however, their effectiveness for unstable HLCFs and the criteria for ultrasound outcomes remain unclear. This study assessed the outcomes of UG-CRPP for HLCFs and evaluated the success criteria in children.

Methods

Data were retrospectively collected from 106 patients with unstable HLCFs admitted to three hospitals between January 2021 and August 2022. Fifty-five cases were left-sided and 51 cases were right-sided: 74 male patients and 32 female patients were included. Perioperative data, elbow function, complications, and criteria for UG-CRPP were analyzed.

Results

The mean rate of UG-CRPP was 88%. The mean surgical time was 54.56 ± 21.07 min, and the mean fluoroscopy frequency was 9.25 ± 2.93 times. At the last follow-up, there were significant differences in elbow flexion between the affected side (135.82° ± 6.92°) and the unaffected side (140.58° ± 5.85°) (p = 0.01). The Mayo score of the affected side was 90.28° ± 4.97°, the Baumann angle was 71.4° ± 5.4°, condylar shaft angle was 39.9° ± 6.4°, and the carrying angle was 8.4° ± 3.6°. Seventy patients presented mild lateral spurs and 16 patients exhibited moderate spurs. Fourteen patients presented with pin infection, and one patient exhibited postoperative re-displacement. There was no premature physeal closure, varus, or valgus elbow deformity, delayed union, or non-union. Successful ultrasound-based outcome criteria for UG-CRPP were defined as follows: (i) absent or less than a cartilage thickness step on the cartilage hinge on coronal plane parallel articular surface scanning, (ii) no lateral displacement and intact distal end of the condylar and capitellum on coronal plane vertical articular surface scanning, (iii) no anteroposterior displacement and absent or less than a cartilage thickness step on sagittal plane vertical articular surface scanning, and (iv) intact posterior fracture line or less than a cortex step on posterolateral sagittal plane vertical articular surface scanning.

Conclusion

UG-CRPP is a procedure with minimal blood loss, less invasive, cosmetic, and no radiation exposure. It yielded good outcomes in unstable HLCFs. The successful criteria make it suitable for clinical application.

Application of ultrasound in the management of TRASH (the radiographic appearance seemed harmless) fractures in preschool children: A review

Elbow fracture is one of the most common fractures in preschool children, and the secondary ossification center appears regularly with age increasing. Transphyseal separation of the distal humerus, medial humeral condyle fracture, lateral humeral condyle fracture, radial head osteochondral separation, and Monteggia fracture (minimal ulnar bow type) are difficult to diagnose based on X-ray films alone because of the unossified secondary ossification center or a suspicious non-alignment of the anatomical cartilage of the elbow joint in preschool children. These 5 fractures above are defined as The Radiographic Appearance Seemed Harmless fractures in preschool children (TRASH-PS). The TRASH-PS fractures must be taken into consideration when there is swelling at the injured site without fracture feature on X-ray. Additionally, relevant misdiagnosis or unsuitable management can lead to elbow dysfunction and deformity. Therefore, this work reviews the application of ultrasound in the management of TRASH-PS fractures.

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.