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Schippers P, Gercek E, Schneidmüller D, Strohm PC, Ruckes C, Wegner E, Baranowski A, Dietz SO. Proximal humeral fractures in children - controversies in decision making. Eur J Trauma Emerg Surg 2024:10.1007/s00068-024-02534-7. [PMID: 38689019 DOI: 10.1007/s00068-024-02534-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 04/20/2024] [Indexed: 05/02/2024]
Abstract
BACKGROUND Proximal humeral fractures in children are rare and usually treated non-operatively, especially in children younger than ten. The decision between operative and non-operative treatment is mostly based on age and fracture angulation. In the current literature, diverging recommendations regarding fracture angulation that is still tolerable for non-operative treatment can be found. Besides, there is no consensus on how fracture angulation should be determined. This study aimed to determine whether leading experts in pediatric trauma surgery in Germany showed agreement concerning the measurement of fracture angulation, deciding between operative and non-operative treatment, and choosing a treatment modality. METHODS Twenty radiographs showing a proximal humeral fracture and the patient's age were assessed twice by twenty-two senior members of the "Section of Pediatric Traumatology of the German Association for Trauma Surgery". Experts determined the fracture angulation and chose between several operative and non-operative treatment modalities. The mean of individual standard deviations was calculated to estimate the accuracy of single measurements for fracture angulation. Besides Intra-Class Correlation and Fleiss' Kappa coefficients were determined. RESULTS For fracture angulation, experts showed moderate (ICC = 0.60) interobserver and excellent (ICC = 0.90) intraobserver agreement. For the treatment decision, there was fair (Kappa = 0.38) interobserver and substantial (Kappa = 0.77) intraobserver agreement. Finally, experts preferred ESIN over K-wires for operative and a Gilchrist over a Cuff/Collar for non-operative treatment. CONCLUSIONS Firstly, there is a need for consensus among experts on how fracture angulation in PHFs in children should be reliably determined. Our data indicate that choosing one method everybody agrees to use could be more helpful than using the most sophisticated. However, the overall importance of fracture angulation should also be critically discussed. Finally, experts should agree on treatment algorithms that could translate into guidelines to standardize the care and perform reliable outcome studies. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Philipp Schippers
- Department of Orthopedics and Traumatology, University Medical Center of the Johannes Gutenberg University, Langenbeckstr. 1, 55131, Mainz, Germany.
| | - Erol Gercek
- Department of Orthopedics and Traumatology, University Medical Center of the Johannes Gutenberg University, Langenbeckstr. 1, 55131, Mainz, Germany
| | | | - Peter C Strohm
- Clinic of Orthopedics and Trauma Surgery, Sozialstiftung Bamberg, Bamberg, Germany
| | - Christian Ruckes
- Interdisciplinary Center for Clinical Trials Mainz, University Medical Center, Johannes Gutenberg University Mainz, 55131, Mainz, Germany
| | - Erik Wegner
- Department of Orthopedics and Traumatology, University Medical Center of the Johannes Gutenberg University, Langenbeckstr. 1, 55131, Mainz, Germany
| | - Andreas Baranowski
- Department of Orthopedics and Traumatology, University Medical Center of the Johannes Gutenberg University, Langenbeckstr. 1, 55131, Mainz, Germany
| | - Sven-Oliver Dietz
- Department of Orthopedics and Traumatology, University Medical Center of the Johannes Gutenberg University, Langenbeckstr. 1, 55131, Mainz, Germany
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Alqahtani YS, Alotaibi BN, Alqahtani LS, Aljaafri ZA. Management of 'floating arm': a case report of adolescent ipsilateral proximal humerus fracture with open distal complex intraarticular fracture. J Surg Case Rep 2024; 2024:rjad724. [PMID: 38250133 PMCID: PMC10799251 DOI: 10.1093/jscr/rjad724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Accepted: 12/11/2023] [Indexed: 01/23/2024] Open
Abstract
Simultaneous ipsilateral fractures of the proximal and distal humerus, known as 'floating arm', are rarely seen in adolescents and are considered challenging to manage. Most of the published cases have involved proximal humerus and distal supracondylar fractures. This paper presents a special case of floating arm injury in a 14-year-old boy following a motor vehicle accident that was managed in a well-established trauma center. The injury consisted of displaced proximal humerus and open distal T-condylar intraarticular fractures. The patient was discharged in good condition and regained functionality with no reported complications.
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Affiliation(s)
- Yousef S Alqahtani
- Department of Orthopedic Surgery, Ministry of the National Guard – Health Affairs, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Bader N Alotaibi
- Department of Orthopedic Surgery, Ministry of the National Guard – Health Affairs, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Lujane S Alqahtani
- Department of Orthopedic Surgery, Ministry of the National Guard – Health Affairs, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Ziad A Aljaafri
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
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Wang Y, Wang Q, Yao W, Zhao J, Zhao X, He M. Kirschner wire versus external fixation in the treatment of proximal humeral fractures in older children and adolescents: a comparative study. BMC Musculoskelet Disord 2023; 24:899. [PMID: 37980527 PMCID: PMC10656960 DOI: 10.1186/s12891-023-07037-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Accepted: 11/12/2023] [Indexed: 11/20/2023] Open
Abstract
OBJECTIVE The purpose of this study was to compare the therapeutic effects of Kirschner wire fixation and external fixation in the treatment of proximal humeral fractures in older children and adolescents. METHODS A retrospective analysis was performed on the clinical data of older children and adolescents who underwent surgery at our institution for proximal humeral fractures between April 2014 and May 2022. One group (n = 28) underwent fracture reduction and Kirschner wire fixation, and the other group (n = 23) underwent external fixation. During the follow-up, the differences in shoulder joint function between the two groups were compared by analysing Quick Disabilities of the Arm, Shoulder, and Hand (Quick DASH) and Constant-Murley scores. Postoperative complications were also recorded. RESULTS The operation time of the Kirschner wire group was shorter than that of the external fixation group (69.07 ± 11.34 min vs. 77.39 ± 15.74 min, P = 0.33). The time to remove the fixator in the external fixation group was shorter than that in the Kirschner wire group (6.74 ± 1.57 vs. 7.61 ± 1.22, P = 0.032). The Quick DASH score and Constant-Murley score of the patients in the external fixation group were significantly better than those in the Kirschner wire group at 3 months after surgery (5.63 ± 4.33 vs. 8.93 ± 6.40, P = 0.040; 93.78 ± 2.43 vs. 91.75 ± 2.15, P = 0.003). There was no significant difference in the Quick DASH score or Constant-Murley score between the patients in the external fixator group and those in the Kirschner wire group at 9 months after the operation (2.77 ± 3.14 vs. 3.17 ± 3.68, P = 0.683; 97.39 ± 1.80 vs. 96.57 ± 2.15, P = 0.152). The most common complication of the two groups was pin tract infection. The incidence rate of infection was higher in the external fixation group than that in the Kirschner wire group (9 vs. 4, P = 0.043). CONCLUSION Both Kirschner wire fixation and external fixation of N-H III and IV proximal humeral fractures in older children and adolescents produce good outcomes. External fixation is a preferred surgical treatment option for paediatric proximal humerus fractures because early mobilization of the affected limb can be realized.
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Affiliation(s)
- Yu Wang
- Department of Orthopedics, Affiliated Hospital of Chengde Medical University, Chengde, Hebei, 067000, PR China
| | - Qian Wang
- Department of Orthopedics, Affiliated Hospital of Chengde Medical University, Chengde, Hebei, 067000, PR China
| | - Wuyi Yao
- Department of Orthopedics, Affiliated Hospital of Chengde Medical University, Chengde, Hebei, 067000, PR China
| | - Jingxin Zhao
- Department of Orthopedics, Affiliated Hospital of Chengde Medical University, Chengde, Hebei, 067000, PR China
| | - Xiaobin Zhao
- Department of Radiology, Affiliated Hospital of Chengde Medical University, 36 Nanyingzi Street, Chengde, Shuangqiao District, Hebei, 067000, PR China
| | - Man He
- Department of Rehabilitation, Affiliated Hospital of Chengde Medical University, Chengde, Hebei, 067000, PR China.
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Kraal T, Struijs PAA, Langenberg LC, van Bergen CJA. Fractures around the shoulder in the skeletally immature: A scoping review. World J Orthop 2023; 14:604-611. [PMID: 37662664 PMCID: PMC10473910 DOI: 10.5312/wjo.v14.i8.604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 06/23/2023] [Accepted: 07/10/2023] [Indexed: 08/17/2023] Open
Abstract
Fractures around the shoulder girdle in children are mainly caused by sports accidents. The clavicle and the proximal humerus are most commonly involved. Both the clavicle and the proximal humerus have a remarkable potential for remodeling, which is why most of these fractures in children can be treated conservatively. However, the key is to understand when a child benefits from surgical management. Clear indications for surgery of these fractures are lacking. This review focuses on the available evidence on the management of clavicle and proximal humerus fractures in children. The only strict indications for surgery for diaphyseal clavicle fractures in children are open fractures, tenting of the skin with necrosis, associated neurovascular injury, or a floating shoulder. There is no evidence to argue for surgery of displaced clavicle fractures to prevent malunion since most malunions are asymptomatic. In the rare case of a symptomatic malunion of the clavicle in children, corrective osteosynthesis is a viable treatment option. For proximal humerus fractures in children, treatment is dictated by the patient's age (and thus remodeling potential) and the amount of fracture displacement. Under ten years of age, even severely displaced fractures can be treated conservatively. From the age of 13 and onwards, surgery has better outcomes for severely displaced (Neer types III and IV) fractures. Between 10 and 13 years of age, the indications for surgical treatment are less clear, with varying cut-off values of angulation (30-60 degrees) or displacement (1/3 - 2/3 shaft width) in the current literature.
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Affiliation(s)
- Tim Kraal
- Department of Orthopedic Surgery and Sports Medicine, Amsterdam University Medical Centers, Amsterdam 1105 AZ, Netherlands
| | - Peter AA Struijs
- Department of Orthopedic Surgery and Sports Medicine, Amsterdam University Medical Centers, Amsterdam 1105 AZ, Netherlands
| | - Lisette C Langenberg
- Department of Orthopedic Surgery, NoordWest Ziekenhuisgroep, Alkmaar 1815 JD, Netherlands
- Department of Orthopedic Surgery and Sports Medicine, Erasmus University Medical Center – Sophia Children’s Hospital, Rotterdam 3015 GD, Netherlands
| | - Christiaan JA van Bergen
- Department of Orthopedic Surgery and Sports Medicine, Erasmus University Medical Center – Sophia Children’s Hospital, Rotterdam 3015 GD, Netherlands
- Department of Orthopedic Surgery, Amphia, Breda 4818 CK, Netherlands
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Liu S, Zhang Y, Cao J, Fu S, Peng A. Bone cemented K-wire fixation versus elastic stable intramedullary nailing fixation of paediatric proximal humerus fractures: A prospective cohort study. Medicine (Baltimore) 2023; 102:e32959. [PMID: 36820597 PMCID: PMC9907912 DOI: 10.1097/md.0000000000032959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/12/2023] Open
Abstract
BACKGROUND The objective of this study is to compare the treatments of pediatric displaced proximal humerus fractures with external-fixation technique using the combination of K-wires and bone-cement versus close reduction and internal fixation technique using elastic stable intramedullary nail. METHODS From April 2016 to March 2020, 72 children with proximal humeral fractures were allocated to group A and 44 children with proximal humeral fractures were allocated to group B. Patients in group A were treated with bone-cemented K-wire fixation, and patients in group B were treated with elastic stable intramedullary nailing. The function of the upper limb was assessed using the Shortened Version of the Disabilities of the Arm, Shoulder and Hand questionnaire and Neer score. Patient satisfaction was assessed using the 10-cm visual analogue scale. RESULTS Bone healing was achieved in group A and B after a mean time of 6.1 ± 1.2 and 6.4 ± 1.1 weeks, respectively. The mean surgical time of groups was 33 ± 9 and 54 ± 12 minutes, respectively. The mean Quick Disabilities of the Arm, Shoulder and Hand questionnaire score of groups were 0.5 ± 1.4 and 0.7 ± 1.5, respectively. Based on Neer score, we obtained 69 excellent and 3 good results in group A, and 41 excellent and 3 good results in group B. There were significant differences regarding duration of operation, cost of treatment, and postoperative angle at bone healing (P < .05). CONCLUSIONS The external cemented K-wire fixation is a useful and reliable alternative technique for the treatment of severely displaced proximal humerus fractures in children. The technique is a minimally invasive procedure with minimal complications.
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Affiliation(s)
- Shibo Liu
- Department of Orthopedics Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, China
- Department of Hand and Foot Surgery, Affiliated Hospital of Chengde Medical University, Chengde, China
| | - Yanlong Zhang
- Department of Orthopedics Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, China
| | - Jinchao Cao
- Department of Orthopedics Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, China
| | - Shijie Fu
- Department of Hand and Foot Surgery, Affiliated Hospital of Chengde Medical University, Chengde, China
| | - Aqin Peng
- Department of Orthopedics Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, China
- * Correspondence: Aqin Peng, Department of Orthopedics Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, Hebei 050051, China (e-mail: )
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Lim JW, Campbell DM, Clift BA. Proximal humerus fractures in adolescents: Experience from East of Scotland. Surgeon 2023; 21:31-39. [PMID: 35292214 DOI: 10.1016/j.surge.2022.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 02/09/2022] [Accepted: 02/17/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND The management of proximal humerus fractures (PHF) in adolescent has not been agreed upon. We aim to investigate the outcomes of PHF managed conservatively in adolescents. METHODS All shoulder radiographs performed in patients aged from 10 to 18 years and from 2008 to 2015 were reviewed. The radiological parameters, including anatomical side, Neer and Horwitz displacement grade, angulation and any residual deformities were recorded. Mail questionnaires based on the modified 15-Upper Extremities Functional Index (15-UEFI), with a maximum of 59 points, were sent out. The return of the completed anonymized questionnaire was considered as implied consent. RESULTS 118 patients with a median age of 12 at the time of fracture were identified. The majority of the fractures were Neer and Horwitz grade I displacement and 3 children had Neer and Horwitz grade III and IV displacement. The median angulation was 25°. The median follow-up length was 26 days. 55 patients had residual angulation and 25 patients had worsened angulation. No non-union was identified. No patients underwent subsequent corrective surgeries. 35 patients responded to the questionnaire. The median 15-UEFI was 59 points. None of the patients have contacted the research or clinical team regarding any concerns. CONCLUSION The vast majority of non-displaced and minimally displaced PHF in adolescent were managed conservatively in our unit. The functional outcomes for this cohort remain excellent even for those with residual deformities in the follow-up radiographs. Further large prospective multicenter studies on adolescent cohort with significantly displaced PHF are warranted.
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Affiliation(s)
- Jun Wei Lim
- Department of Orthopaedics and Trauma, Aberdeen Royal Infirmary, Foresterhill Health Campus, Aberdeen, AB25 2ZN, UK.
| | - Donald M Campbell
- Department of Orthopaedics and Trauma, Ninewells Hospital, Dundee, DD1 9SY, UK
| | - Benedict A Clift
- Department of Orthopaedics and Trauma, Ninewells Hospital, Dundee, DD1 9SY, UK
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Kaya M, Karahan N. The effect of different pin configurations on cyclic stability in pediatric proximal humerus fracture fixation: A Sawbones model study. Injury 2022; 53:1824-1828. [PMID: 35221101 DOI: 10.1016/j.injury.2022.02.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 01/31/2022] [Accepted: 02/08/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND In sawbones with proximal humerus fracture model, three different fixation configurations, Parallel-Straight K-wires, Cross-Straight K-wires and Palm-Tree Method, were biomechanically compared. METHODS A total of 36 anatomical pediatric humerus sawbones models were used. They were divided into three equal groups; parallel fixation with straight K-wires (Group PS), cross fixation with straight K-wires (Group CS), and Palm-Tree Method (Group PT). Models were tested in abduction and torsional at a speed of 0.5 mm/s and a 0-5 mm displacement range. Loading (N) and Stiffness (N/mm) data were calculated and compared statistically. RESULTS Group PS was significantly higher than the other two groups in abduction bending cyclic load values (P<0.001). It was also significantly higher in Group CS than in Group PT (P < 0.001). No significant differences were detected between the three different fixation groups' cyclic torsional load values (p < 0.05). CONCLUSION The parallel configuration with straight K-wires will provide a more stable fixation than the cross configuration with straight or Palm-Tree Method in pediatric proximal humeral sawbones fracture modeling.
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Affiliation(s)
- Murat Kaya
- Department of Orthopedics and Traumatology, Marmara University Pendik Training and Research Hospital, Istanbul, Turkey.
| | - Nazım Karahan
- Department of Orthopedics and Traumatology, Corlu District State Hospital, Tekirdag, Turkey.
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