Comparison of Lateral Pinning and Cross Pinning Results in Pediatric Distal Humerus Supracondylar Gartland Type 3 Fracture

Objectives: To compare the complications and outcomes of lateral entry pin fixation with medial and lateral pin fixation for Gartland type III supracondylar fractures of humerus. Methodology: This prospective comparative study involving 190 patients of Gartland type III close supracondylar fractures were included. from March-2019 to Dec-2020. In all patients, initially the elbow was mobilized using the splint placed above the elbow joint at 30 to 45 degrees’ flexion. After closed reduction, lateral pinning was applied in group I and in group II lateral and medial cross pinning was applied using the standard protocol. Patients were followed for iatrogenic ulnar nerve injury, radiologic and function outcomes in-terms of loss of reduction, elbow range of motion, loss in carrying angle and functional outcomes. Results: The two groups were comparable for loss of elbow range of motion, loss of carrying angle and loss of Bauman's angle. On clinical examination, immediate post-operative ulnar nerve injury was diagnosed in 4 (4.2%) cases in group II and in no patient in group I (p-value 0.12). Satisfactory functional outcomes were achieved in 85 (89.5%) patients in group I and in 88 (92.6%) patients in group II (p-value 0.44). Conclusion: Lateral pinning provided stable fixation clinically and radiologically as compared to lateral and medial cross pinning. Keywords: Supracondylar fracture of Humerus, Iatrogenic ulnar nerve injury, Lateral pin entry, lateral and medial cross pin entry.

Background: Supracondylar injuries of the humerus are the most prevalent elbow injury among pediatric patients. The conventional treatment of displaced fractures involves closing the reduction as well as percutaneous Kirchner wire pinning, using either lateral pin fixation or cross pin fixation. The objective of the study is to evaluate and contrast the results of lateral vs bilateral percutaneous pinning in pediatric patients with supracondylar humeral injuries. Methods: A comparative cross-sectional study was conducted at the National Institute of Traumatology and Orthopaedic Rehabilitation (NITOR) between July 2017 to June 2019. Children were classified into two groups according to the percutaneous pinning technique: Lateral pinning (n=15) and Crossed pinning (n=15). Both groups were comparable in terms of age, gender, injury duration, along with degree of fracture displacement. The chi-square test and t-tests for independence were employed. The results were reported as mean, frequency, along with percentage, with P < 0.05 indicating statistical significance, using SPSS software. Result: The average age of patients was 6.86 ± 2.53 years for group I and 6.57 ± 2.41 years for group II overall. In the cohort with dual lateral K-wire fixation, 20% achieved exceptional outcomes, 66.67% obtained good outcomes, and 13.33% realized fair outcomes. In the medial-lateral K-wire fixation cohort, 20% achieved exceptional outcomes, 60% attained satisfactory results, and 20% exhibited acceptable results, with a P value of 0.881, signifying statistical insignificance. In the medial-lateral cross K-wire fixation group, the incidence of iatrogenic ulnar nerve injuries was 6.67%, while the two lateral K-wire fixation group reported no neurological injuries, yielding a P value of 0.664. Thus, the difference in the incidence of ulnar nerve injury between the two patient cohorts was not significant. Conclusion: Both fixation methods exhibit effectiveness; the application of two lateral K-wires offers stability akin to medial-lateral cross K-wire fixation while mitigating the danger of iatrogenic ulnar nerve injury. J Shaheed Suhrawardy Med Coll 2024; 16(1): 7-13

Aim : The aim of this study is to compare the commonly used cross pinning and lateral pinning techniques in the surgical treatment of pediatric supracondylar humerus fractures in terms of clinical and radiological outcomes. Material and Methods : The study included patients who underwent surgery for Gartland type 3 supracondylar humerus fractures between 2018 and 2024. Patients were divided into two groups based on the surgical technique: lateral pinning (Group 1) and cross pinning (Group 2). All patients were followed for a minimum of 6 months. Demographic data (age, sex, side, mechanism of trauma) were recorded. Clinical evaluation was performed using Flynn’s criteria. Radiological evaluation included assessment of fracture union, Baumann’s angle and its change from 0 to 6 months, carrying angle, lateral humerocapitellar angle (LHCA), and its 0 to 6-month change. Complications and additional procedures were also recorded. Results : There were 32 patients in Group 1 and 28 in Group 2. There were no significant differences between the groups in terms of demographic characteristics. According to Flynn’s criteria, in Group 1, 24 patients had excellent, 5 had good, 3 had fair, and none had poor outcomes. In Group 2, 20 patients had excellent, 7 had good, 1 had fair, and none had poor outcomes. There were no statistically significant differences between the groups in terms of Baumann’s angle and its change, carrying angle, LHCA and its change. Ulnar nerve injury developed in 2 patients in Group 2 and resolved with conservative follow-up. Conslusion : Both lateral pinning and cross pinning techniques provide similar clinical and radiological outcomes in the treatment of pediatric supracondylar humerus fractures. To prevent ulnar nerve palsy in the cross pinning technique, a mini medial incision can be used to protect the ulnar nerve.

Closed reduction and percutaneous pin fixation techniques have been proposed as treatment strategies for displaced supracondylar humeral fractures (SCHFs) in children. Commonly lateral pinning and cross pinning techniques are utilised for fixation. However, controversy exists regarding the selection of the appropriate procedure. A prospective study with 24 cases of displaced fracture supracondylar humerus, treated by lateral pinning and cross pinning, was conducted between August 2022 and May 2024 at Department of Orthopaedics at J.J.M. Medical College, Davangere. Patients were treated with either the lateral entry pin alone or the cross pinning with a combination of lateral entry pin and medial entry pin. Age, gender, fractured side, duration of surgery, postoperative complications, surgical approach, direction of pin application (lateral or cross), and Modified Flynn grading system grade was noted for study outcome. No difference was found between lateral pinning and crossed pinning groups in terms of the grade of the modified Flynn grading system and complications like iatrogenic ulnar nerve damage, loss of reduction. Pin tract infection was seen in one patient.

Introduction: Paediatric Supracondylar fractures are the commonest elbow injuries encountered in the emergency departments. Most commonly they are the result of a fall on an outstretched hand that causes hyperextension of the elbow. The extension-type supracondylar humeral fractures account for 95% to 98% of all supracondylar fractures. Displaced fractures are treated with closed reduction and percutaneous pinning. However the method of pinning has been a matter of debate (lateral entry vs cross pinning). The issue with the lateral entry pinning like loss of reduction and ulnar nerve injury with the cross pinning method has always kept a doubt in the surgeons mind regarding the method of pinning. The present study was aimed to see functional results of using three lateral pins in type II and III supracondylar fractures and to look for any complications occurring thereafter. Methods: Forty consecutive patients of type II and III SC fractures were taken up for the study. Three lateral pins were used for all fractures. Using the Flynn criteria, the results were graded as excellent, good, fair or poor by comparing the carrying angle and range of motion with the opposite side. Results: Among the cohort of forty patients we had 25 males and 15 females. The mean age group was 6.5 + 3.2. Sixteen patients had type II fracture while as 24 had type III Gartlands fracture. The union occurred in all cases. At the final follow up, 87.5% patients showed excellent results 10% showed good and 2.5% fair results. There was no case of poor results. There were no iatrogenic nerve palsies, and no patient required additional surgery. Conclusion: Lateral three pin fixation is a good method for displaced supracondylar fractures and has little or no chances for ulnar nerve injury. This method has an easy learning curve among orthopaedic residents. A randomised control trail comparing it with other methods involving a larger series is needed to look for the effectiveness of this technique.

BACKGROUND Supracondylar humerus fracture (SCHF) is common injury in children where displaced type 3 and 4 types require reduction and K wire fixation. But the use of lateral only or crossed pinning configuration is debatable. METHODS A prospective comparative study was conducted for a period of two year (2021 and 2022) at National Trauma Center, Nepal in patients less than 16 years presenting with closed Gartland type 3 and 4 supracondylar humeral fracture. Cases were randomly assigned to crossed pinning (CP) and lateral pinning (LP) with K wires after closed reduction of SCHF. Functional outcome, complications, loss of reduction and Baumann angle was assessed at 3 months follow up. RESULTS Total of 80 cases were enrolled. Lateral pinning and cross pinning had 32 and 48 assigned respectively. The groups were comparable in terms of age, gender, mechanism of injury, types and duration of injury. The mean age was 6.40 years (SD 1.36), ranging from 4 to 9 years. CP had longer surgery duration (p = 0.000). Ulnar neuropraxia was present in 3 cases (3.8%) of CP, whereas LP had none. The Flynn’s criteria, time to union, loss of Bauman angle and loss of elbow motion were comparable between groups. CONCLUSION The lateral or crossed pinning in type 3 and 4 SCHF have similar radiological and functional outcomes. The Ulnar neuropraxia was present in CP groups but overall complications were comparable between both groups. KEYWORDS closed fracture reduction; kirschner wires; nerve injury; supracondylar distal humerus fractures; ulnar nerve

Background: Supracondylar fracture of humerus is one of the most common fractures in children and the most frequent before the age of 7 years. The peak age incidence is in the first decade of life. It is common due to direct fall on ground and indirect fall on outstretched hands. In this study we have compared the functional outcome and complications associated with percutaneous and open medio- lateral cross k wire fixation of Gartland type- 3 displaced supracondylar humerus fractures in children. Material and methods: 87 patients were included in the study out of which 22 were lost during follow up. 65 patients were divided randomly into two groups - Group-A, close k wire fixation (32 patients) and Group-B, open k wire fixation (33 patients). This was a prospective study from June 2010 to December 2012. The average age of patients was 7 years (3-13 yrs). Patients were called for follow up at 2 wks, 3 wks, 4 wks & 3 months after the index procedure. Results: The results were assessed as per Flynn's criterion with reference to carrying angle and elbow range of movement at 3 months after the index procedure. The carrying angle was better in group B (no cubitus varus) as compared to group A (2 cases cubitus varus). Loss of motion was more in group B (>15 degrees in 12. 12% patients) than in group A (none). There was no deep infection but superficial pin tract infection in group B which resolved by oral antibiotics. There was one iatrogenic injury to the ulnar nerve in group A which recovered spontaneously. Conclusion: In our study we concluded that closed K wire fixation is associated with better functional outcomes and is the procedure of choice for fresh cases of fracture supracondylar humerus. Close K wire fixation being minimally invasive helps preserve fracture haematoma which aids in fracture healing. Complications associated with closed procedure being cosmetic (cubitus varus) and reversible (nerve injury) are well tolerated by patients than complications (stiffness) with open procedure.

Context: Supracondylar fractures of the humerus (SCFH) are the most common type of pediatric fracture and related to significant morbidity with the complication of nerve injury and loss of reduction. Closed reduction and percutaneous Kirchner wires pinning either by lateral pin fixation or cross pin fixation for the displaced fractures are the mainstay treatment. Aims: This study has purpose to compare the construct stability, functional, and radiological results between the two methods of fracture fixation. Subjects and Methods: A total of 61 children with Gartland III SCFH were placed randomly into two groups, Group A (n = 30) managed by lateral pinning technique and Group B (n = 31) were managed by cross pinning techniques. Both groups were quite comparable with regard to age, gender, duration of injury, and degree of displacement of the fracture. The results were analyzed in terms of clinical and radiological outcome, Flynn functional scoring system, and complications. Fisher's exact test and unpaired t-tests were used. The results were expressed as mean, and the P < 0.05 was considered statistically significant using the SPSS software (version 22). Results: Statistically, there was no significant difference in clinical or radiological results between the two groups at 6 months after operation (P > 0.05). There was no significant loss of reduction found in either of the groups. There was one (6.6%) case of the lateral pinning group that had a minimal loss of reduction and two (6.4%) cases of the iatrogenic ulnar nerve neuropraxia in the cross pinning group. Neuropraxia recovered fully. Superficial pin tract infection was seen in two (6.67%) cases of the lateral pinning group. Conclusions: Although it appears that cross spinning is a more stable construct, the lateral pin fixation provides the same result without risk of iatrogenic nerve injury with comparable results.

BackgroundWe aimed to determine the ideal surgical timing in the first 24 hours after admission to the hospital of pediatric supracondylar humerus fractures (SHF) that do not require emergent intervention.Materials and MethodsPatients who underwent surgery in our institution between January 2011 and January 2019 due to pediatric Gartland type 3 SHFs were evaluated retrospectively. Open fractures, fractures associated with vascular injury and compartment syndrome, flexion type fractures were excluded. A total of 150 Gartland type 3 were included. The effect of early (<12 hours) or late (>12 hours) surgical interventions, daytime or night-time surgeries, working or non-working hour surgeries on operative parameters (operative duration and open reduction rate, reduction quality on postoperative early radiographs) were evaluated in pediatric SHFs.ResultsEarly (<12 hours) or late (>12 hours), daytime or nighttime, working or non-working hour surgeries were found to be similar in Gartland type 3 patients regarding early postoperative reduction quality, duration of surgery, open reduction rate (p>0.05). Mean times passed from first admission to hospital until surgery were longer in working hour, late (>12 hours) and daytime surgery groups than non-working hour, early (<12 hours) and night-time surgery groups (p<0.001).ConclusionAlthough delaying the operation to the working hours seems to prolong the time until surgery in pediatric Gartland type 3 SHF patients who do not require emergent intervention such as open fractures, neurovascular impairment and compartment syndrome, there may not be a time interval that makes a difference for the patients if surgery is performed within the first 24 hours, thus the surgery could be scheduled according to the surgeons’ preference.Level of Evidence: Level 3, Retrospective cohort study

It is aimed to compare biomechanically the 3 different pin techniques and the lateral onset cross-pinning (LXP) technique in supracondylar humeral fractures. Biomechanical testing was performed on 52 synthetic humeriFour pin configurations techniques were tested: crossed pins (XP), 2 lateral pins (2LP), 3 lateral pins (3LP), and LXP technique. Biomechanical testing was performed on Shimadzu Autograph measuring machine. Each pin configuration was tested in a total of 13 humeri: 4 in varus bending, 4 in valgus bending, and 5 in flexion bending. Displacement (mm), and load (N) data were sampled at 10 Hz during each test. Varus values were statistically lower in 2 LP group comparing to XP, 3 LP, LXP groups (p=0.01, p=0.02, p=0.012, consequently). Flexion load values statistically lower in 2 LP group comparing to XP, 3 LP, LXP groups (p=0.03, p=0.001, p=0,031, consequently). There was no difference between the groups in terms of valgus values (p>0.05). LXP technique is biomechanically similar to the traditional XP technique. In situations where orthopedic surgeons choose to use medial pins in addition to lateral pins such as distal humerus fractures with medial-sided defects.

Background: The supracondylar humerus fractures are common elbow fracture for children. Management of these fractures is accompanied with many intra and post operative complications. Aim of study: To compare between percutaneous fixations of supracondylar fractures of humerus in children by lateral pinning or by cross pinning.Patients and methods: A clinical prospective follow up study carried out in Orthopedics Department of Al-Basrah Teaching Hospital in Basrah city during one year period from 1st of September, 2019 to 31st of August, 2020 on sample of 30 children with supracondylar fracture of the humerus were included in present study; 15 children treated with lateral pinning (unilateral) percutaneous fixation and 15 children by cross pinning (bilateral) percutaneous fixation. The decision of each approach unilateral or bilateral was approved by the supervisor depending on Gartland classification.Results: No significant differences between children with unilateral fixation and children with bilateral fixation regarding postoperative outcomes. Mean surgical operation time of patients treated with percutaneous bilateral fixation was significantly longer than operation time for patients treated with percutaneous unilateral fixation (p&lt;0.001). Mean diameter of k-wire for patients treated with percutaneous bilateral fixation was significantly lower than mean diameter of k-wire for patients treated with percutaneous unilateral fixation (p=0.007). The postoperative complications following both unilateral and bilateral percutaneous fixations are infrequent. Conclusions: The unilateral and bilateral percutaneous fixations have same efficacy and safety in management of supracondylar fracture of humerus in children.

Introduction: Supracondylar fracture of the humerus is the most common elbow injury in children and makes up approximately 60% of all elbow injuries. The purpose of the present study is to evaluate the functional outcome of the displaced supracondylar humerus fracture treated with closed reduction and k-wire fixation by lateral and cross pinning technique. Material and Method: 50 children with fractures of the supracondylar humerus out of which 30 were boys and 20 were girls taken for prospective study at C.U. Shah Medical College from May 2017 to August 2019 was analyzed clinically and radiologically using Flynn’s criteria. Out of 50 cases 28 patients treated with lateral pinning and 22 patients treated with cross pinning technique based on the surgeon’s preference. Result: among patients treated with lateral pinning technique 19(68%) had an excellent result, 9(32%) had a good result. Similarly in patients treated with cross pinning technique, 9(41%), 7(32%), 2(9%), 4(18%) had excellent, good, fair, and poor outcomes respectively. 9 patients developed iatrogenic ulnar nerve palsy in cross pinning technique whereas 2 patients developed cubitus varus following cross pinning technique. Conclusion: Thus it can be concluded that closed reduction and K-wire fixation is an excellent method for the treatment of supracondylar fracture of the humerus with the significant difference in functional outcome between lateral pinning and cross pinning technique. The chances of ulnar nerve palsy increase following cross pinning technique which is not so in the case of lateral pinning. Thus suggesting the use of lateral pinning technique for the treatment of displaced supracondylar fracture of the humerus.

Here is my view of the top-10 most potentially influential papers from the Journal of Pediatric Orthopaedics from 2007. Included are the papers that were thought to provide the most useful examinations of treatments and outcomes. A pilot study of delayed versus immediate serial casting after botulinum toxin injection for partially reducible spastic equinus. Newman CJ, Kennedy A, Walsh M, O'Brien T, Lynch B, Hensey O. J Pediatr Orthop. 2007;27:882–885 (Level II, randomized controlled trial). Context: Spastic equinus commonly afflicts patients with diplegic and hemiplegic cerebral palsy. Hypertonia of the triceps surae may lead to irreversible muscle shortening, requiring surgical lengthening to restore the natural range of motion of the ankle and a more normal gait. Botulinum toxin A is a paralytic agent that temporarily chemically denervates treated muscles through inhibition of the release of acetylcholine at the neuromuscular junction. It is a well-accepted treatment for muscle spasticity, although it has been questioned when the timing is best for botulinum toxin injection of the triceps surae for cases where serial manipulations and casting are planned components of equinus treatment. Study Design, Results, and Conclusions: This study is a randomized controlled trial of 12 children with spastic diplegia or hemiplegia and mild gastrocnemius and soleus contractures. The patients’ gastrocnemius and soleus muscles were injected with botulinum toxin and randomized to either an immediate casting group (weekly casting for 3 weeks) or a delayed casting group (casting 4 weeks after injection, with weekly casting for 3 weeks to follow the delay). Significantly greater mean values for maximum dorsiflexion were obtained in the delayed casting group at 3 and 6 six months after injection. Comments: These results are important as they support the counterintuitive notion that delay before casting optimizes the ability to stretch the triceps surae with serial manipulations and castings. Limitations of the study include its small sample size (17 limbs in 12 patients), the mixed diagnoses of the patients, and the equivocal results regarding the quality of gait. Pearls: Patients who were casted immediately had a greater frequency of pain episodes requiring removal of the cast. This study calls to mind the importance of considering the comfort of patients with cerebral palsy, a group with some members who may lack the ability to articulate their feelings. Does leg lengthening pose a threat to a child's mental health? An interim report one year after surgery. Niemela BJ, Tjernstrom B, Andersson G, Wahlsten VS. J Pediatr Orthop. 2007;27:611–617 (Level III, case-control study). Context: Limb lengthening has been associated with negative psychological reactions in children: a bulky external fixator, to use a child's term, looks “freaky”. Younger children, and those with prolonged treatments, inadequate counseling, or poor coping behavior have been noted to be at greater risk. Study Design, Results, and Conclusions: Twenty-seven patients 6 to 16 years of age with leg-length differences or limb deformity treated with the Ilizarov technique were age and gender matched with a control group and tested on various psychological assessments, including the Revised Children's Manifest Anxiety Scale, Children's Depression Inventory, Speedy Performance of IQ I and II, the Child Behavior Checklist, and the Youth Self-Report. No differences in preoperative depression scores existed when comparing groups. Leg lengthening typically resulted in lowering of anxiety and depression scores. No adverse psychological reactions could be identified using the psychological measures in this study. Comments: Although this study revealed higher anxiety and depression scores in the 10–12 year-old age group, other tests revealed no relationship between patient age and psychological states. Parents of children undergoing lengthening had significant decreases in state scores after the procedures, although otherwise no differences in parent scores and test were identified when comparing groups. Pearls: To an adult, the long-term benefit of restoring limb-length equality should clearly outweigh the immediate-term costs of treatment. Children, of course, are not characterized by focus on long-term perspectives and ability to defer gratification. Thus, parents may not choose the same course of treatment that their children would, especially in cases when the gains are not realized at once (for instance, surgical procedures that are done to defer or prevent arthritis, as opposed to treat immediate pain). In the case of limb lengthening, preoperative preparation through counseling with the surgeon, psychologists, nurses, and school workers may help a child understand and therefore cope with the treatment. Effects of early weight bearing on the functional recovery of ambulatory children with cerebral palsy after bilateral proximal femoral osteotomy. Schaefer MK, McCarthy JJ, Josephic K. J Pediatr Orthop. 2007;27:668–670 (Level III, retrospective comparative study). Context: Ambulatory children with cerebral palsy often undergo proximal femoral osteotomy as treatment of excessive femoral anteversion or hip subluxation. Typical postoperative rehabilitation protocols include prolonged immobilization and prohibited weightbearing—a regimen that may prevent immediate failure of fixation, but also may lead to muscle atrophy and generalized osteopenia, not to mention high demands on the patients’ caregivers. Early weightbearing without brace or cast immobilization may avoid many of these potential outcomes, although loss of fixation and greater postoperative pain may ensue. Study Design, Results, and Conclusions: Twelve patients treated between 1999 and 2001 with proximal femoral osteotomy were made nonweightbearing and thus restricted to a wheelchair for 3–8 weeks. Thirteen patients treated between 2001 and 2003 were allowed immediate weightbearing as tolerated. No spica casts were used in either group; one hip orthosis was used in the nonweightbearing group. Charts were reviewed and compared for complications, pain scores, date of standing, type of postoperative casting, and the use of antispasmodic medications. Eight days postoperatively, the early weightbearing group had significantly less pain. Children allowed weightbearing as tolerated also stood an average of 26 days earlier than patients in the delayed weightbearing group. By 13 months, all patients were back to baseline ambulation, although the early mobilization group returned to baseline walking 4 months earlier than patients in the delayed weightbearing group. No loss of fixation was recorded in either group. Comments: Small groups, a retrospective review, and sequential assignment of patients rather than a randomized protocol limit the interpretation of the data. However, as all procedures were done by one surgeon at one institution with a similar nursing staff and PT protocols, these results are still of great value. This study suggests that not only is cast or brace immobilization unnecessary to maintain postoperative fixation of a proximal femoral osteotomy held with a blade plate, but that early mobilization decreases early pain, inpatient physical therapy duration, and time to ambulation without incurring additional risks. Pearls: Even without weightbearing, the operative limb is subject to force-bearing (from muscular contracture). Thus, patients who are instructed to remain nonweightbearing may be needlessly restricted. In the adult hip fracture population, it has been suggested that patients can autoregulate the amount of weight to place on the limb and not routinely expose the bone to more force than it can withstand. This study suggests that a similar phenomenon may take place even among young patients with cerebral palsy. Juvenile osteochondritis dissecans of the talus. Perumal V, Wall E, Babekir N. J Pediatr Orthop. 2007;27:821–825 (Level IV, retrospective review). Context: There are few studies of osteochondritis dissecans of the talus in children. Long-term followup to radiographic healing rarely has been reported. The usual treatment for symptomatic patients is activity modification, with drilling of the lesion if healing is delayed. Time to healing with and without drilling in the skeletally immature has not been reported. Persistent osteochondritis dissecans lesions noted on radiographs in children may lead to overlying cartilage destruction and loose bodies in adults. The natural history of these unhealed lesions is not known. Study Design, Results, and Conclusions: The records of 31 patients with open physes and Bernt and Hardy Stages 1–3 osteochondritis dissecans of the talus (63% medial talar dome) followed for a minimum of 6 months were reviewed for resolution of symptoms and radiographic healing. By 6 months, only 16% had evidence of clinical resolution and complete radiographic healing, whereas 77% had persistent evidence of the lesion on radiographs. Six percent had persistent pain after cast removal and underwent surgery. By 1 year, only an additional 12% showed clinical and radiographic evidence of healing. Almost ½ (42%) underwent surgery for persistent pain and incomplete radiographic healing, whereas 46% had resolution of symptoms without radiographic healing. Surgery, including various treatments such as retrograde drilling, bone grafting, and bone marrow injection, was performed on patients with persistent pain after 6 months or a year of observation. Surgery resulted in an 85% healing rate at 1 year, although it is unclear which surgical techniques were successful and which did not lead to radiographic healing. Comments: Though there may be clinical resolution of symptoms with 1 year of rest in the presence of nondisplaced osteochondritis dissecans of the talus, radiographic healing occurs in less than 1/3 of patients through rest and activity modification. When considering the investment of time with such low healing rates, earlier surgery may be warranted in this condition. Limitations of this study include its retrospective nature and variety of surgical treatments used for various indications. Pearls: Arthroscopic treatment of osteochondritis dissecans of the talus is minimally invasive, allowing for retrograde or antegrade drilling of lesions. The opportunity costs of delayed treatment make early treatment of symptomatic lesions an attractive alternative and should be presented to those providing informed consent. Arthroscopic findings at the time of patellar realignment surgery in adolescents. Luhmann SJ, Schoenecker PL, Dobbs MB, Gordon JE. J Pediatr Orthop. 2007;27:493–498 (Level IV, retrospective review, case series). Context: Patella dislocations are common knee injuries in children and adolescents. Osteochondral fracture of the lateral femoral condyle, chondral injury to the patella, and loose bodies in the knee are common sequelae of patella dislocations. Treatment for the adolescent with recurrent patellar dislocation typically includes lateral release, medialization of the tibial tubercle, and also may include medial reefing or medial patellofemoral ligament repair or reconstruction. Arthroscopy is not commonly considered a part of patellar realignment surgery, but is a reasonable adjunct to the realignment procedure—especially to exclude concomitant diagnoses. Study Design, Results, and Conclusions: A retrospective review of all patellar realignment surgery including arthroscopy by one surgeon over a 4-year period revealed 38 patients with 41 operated knees. Osteochondral lesions of the patella were seen in 30 knees (73%); of the femur, in 11 knees (23%); and loose bodies were found in six knees (15%). Additional findings in eight patients (20%) included meniscal tears, a discoid meniscus, a partial anterior cruciate ligament disruption, and medial tibiofemoral arthrosis, leading to an additional five procedures in four patients. Comments: Arthroscopy is a minimally invasive technique for examining the articular surfaces of a joint, and in this case, a joint traumatized by a dislocation event. Patellar dislocations may be accompanied by cartilage damage to the patella or femur. It makes good sense when treating the proximal cause of the dislocation to understand the full extent of the injury, which arthroscopy can do more reliably than MRI or other imaging techniques. This review again is limited by its retrospective nature. Long-term followup with a comparison group not undergoing arthroscopy with patellar realignment surgery would be a better study, but perhaps not reasonable in this day and age. Pearls: Improved tracking of the patella may be monitored during the stages of patellar realignment surgery, allowing for fine-tuning in the degrees of medialization of the tibial tubercle or reefing/tensioning of medial structures. The operating surgeon must be mindful, however, that in the anesthetized patient, only static stability is assessed: the additional force of the vastus medialis obliquus is not provided by the sleeping patient. Perioperative complications after surgical correction in neuromuscular scoliosis. Mohamad F, Parent S, Pawelek J, Marks M, Bastrom T, Faro F, Newton P. J Pediatr Orthop. 2007;27:392–397 (Level IV, retrospective review, case series). Context: Scoliosis is prevalent in patients with neuromuscular disorders. Such patients frequently have poor pulmonary function, limited mobility, and osteopenia; all of which increase the risk of complications of scoliosis surgery. In this population, the literature suggests postoperative complication rates ranging from 24%-75% at 2 years. The early perioperative complication rates for scoliosis surgery in this patient population have not been reported previously. Study Design, Results, and Conclusions: A retrospective review of hospital charts of all patients with neuromuscular conditions undergoing scoliosis surgery in a 17-year period at one institution revealed 175 patients, 58 of whom had 96 complications within the first 3 months after surgery. Forty-five complications were pulmonary, 20 were infectious, seven were cardiovascular, and six were related to instrumentation failure. Four surgeries were unplanned staged procedures, one patient sustained a compartment syndrome without significant sequelae, and one patient had severe gastroesophageal reflux refractory to medical management that was treated with a laparoscopic Nissen fundoplication and gastrostomy 10 days after spinal surgery. Eight patients had somatosensory evoked potential monitoring changes intraoperatively, including one patient whose changes were followed by revision of instrumentation, although no patient had identifiable permanent neurologic changes thought to be a result of the surgery. Two patients had pseudarthroses and two patients has unlisted “miscellaneous” complications. Risk factors identified as associated with complications included a history of seizures, almost 2 L blood loss (vs. 1 L blood loss average for those without complications), and unplanned staged procedures. A longer operative time tended toward a greater complication rate, including a greater infection rate for posterior spinal instrumentation and fusions; fusion down to the sacrum also tended toward a greater complication rate, although none of these associations were statistically significant. Patients with gastrostomy tubes did not have a different complication rate than those without feeding tubes. Comments: This study reinforces previous reports of a high rate of complications associated with scoliosis surgery in the neuromuscular patient population. Infections were less common (8% overall, with a deep wound infection rate of 1%) than previously reported, although numerous similar studies include a minimum of 2 years followup, whereas this study only reported complications within 3 months of surgery. Intraoperative changes in somatosensory evoked potentials were noted in multiple patients in this review; the authors recommend monitoring despite the difficulty that may be encountered in performing reliable monitoring in this patient population, and the fact that subtle differences in neurologic function postoperatively are difficult to discern. Nonetheless, the authors argue that performing intraoperative monitoring may have avoided major neurologic injury, and they recommend its routine use. Pearls: Approximately one in three patients with neuromuscular conditions undergoing scoliosis surgery sustained a complication within 3 months of surgery, with an average of nearly two complications per patient. The decision to perform scoliosis surgery in patients with neuromuscular conditions must be deliberate, with clear consideration of the potential benefits, given the high costs of risk exposure alone. Treatment of open femur fractures in children: comparison between external fixator and intramedullary fixation. Ramseier LE, Bhaskar AR, Cole WG, Howard AW. J Pediatr Orthop. 2007;27:748–750 (Level III, comparative cohort study). Context: Open femur fractures are at increased rate of infection, compared with those where the skin and soft tissue envelope remain intact. As such, many practitioners avoid intramedullary fixation so as to decrease the risk of infecting hardware. External fixation of such fractures may allow stabilization without instrumenting in the region of the open fracture, although it may not reduce and hold the bone optimally (not to mention the risks of pin complications). A comparison between these two treatments will help establish the relative risks of each treatment in this patient population. Study Design, Results, and Conclusions: A retrospective chart review over 17 years at one institution identified 35 skeletally immature patients with open femur fractures treated with intramedullary fixation (12 patients) or external fixation (23 patients). All open fractures underwent irrigation and debridement, and IV antibiotics were continued until soft tissue closure was achieved. The choice of stabilization method was left to physician preference. Gustilo-Anderson grades were recorded, with no significant difference in the breakdown of grades by treatment group. Patient ages also were comparable between groups, as were levels of the fracture, mechanisms of injury, and fraction of patients with polytrauma. Time to union was significantly shorter in the intramedullary fixation group (10 weeks vs. 16 weeks; p = 0.02); overall complications were more common in the external fixator group (21 of 23 vs. three of 12; p = 0.04), although after excluding pin tract infections, there was not a significant difference in infection rates (16 of 23 vs. three of 12; p = 0.20.) There were six refractures in the external fixation group and none in the intramedullary group, although this did not reach statistical significance (p = 0.06). Comments: Although we now understand that IM nailing of open femur fractures in adults has comparable complication rates to other treatment methods, this is the first study in children to suggest flexible intramedullary nailing of open femur fractures has lower complication rates and faster healing than treatment by external fixation. Varus malunion may predispose a femur treated with external fixation to refracture. Careful establishment of alignment and protection during the first 6 weeks after fixator removal may be keys to avoid refracture. Pearls: Do not be a slave to the p = 0.05 criterion. Here, there were six refractures in the external fixation group and none in the intramedullary group. The p value was “only” 0.06. That should be good enough. A foolish consistency is the hobgoblin of small minds, as Emerson noted. Surgical treatment of unresolved Osgood-Schlatter disease: ossicle resection with tibial tubercleplasty. Weiss JM, Jordan SS, Andersen JS, Lee BM, Kocher M. J Pediatr Orthop. 2007;27:844–847 (Level IV, retrospective review, case series). Context: Osgood-Schlatter apophysitis is a painful condition typically affecting preteens but residua of the condition may produce symptoms in teenagers as well. In these patients, persistent tenderness from semimobile ossicles in the patellar ligament is found even after skeletal maturity. The mainstays of treatment are nonoperative, however surgical resection of prominent and painful ossicles may be necessary to alleviate symptoms. Patients also may dislike the tibial tubercle prominence that often remains at skeletal maturity; tibial tubercleplasty may improve with surgical Study Design, Results, and Conclusions: A retrospective review of all patients treated for Osgood-Schlatter at one institution during a period revealed patients, who had surgical of whom were included in the study. size was in 11 of 16 average pain scores were the on all three and 12 of patients returned to their preoperative activity Comments: It is that less than of patients seen for Osgood-Schlatter apophysitis in a underwent surgery for persistent symptoms. As the of patients with this condition are treated by this suggests an even fraction of all patients with the condition who would benefit from surgery. All patients in this study underwent ossicle resection and tibial tubercleplasty. A randomized study examining the of procedures to pain and to activity would be although the small of patients treated for the condition makes such a study As the surgery is performed through a in the patellar ligament that is the risks of performing ossicle resection and tibial tubercleplasty are No complications were reported in this study, however, one of patients reported a after the first surgery that was during A patient reported no in symptoms and size and additional surgery. Pearls: It is that the of this are by a especially the patient can a in the size of the That it may be and to perform this in comparison to many years of symptoms and of medical As noted early surgery for patients with chondral lesions in the ankle the high opportunity costs of delayed treatment. Nonetheless, until we can better the risk factors for Osgood-Schlatter apophysitis should be considered a as it was for of the patients in this study. A review of medial and lateral versus lateral for fractures of the Lee BM, Kocher J Pediatr Orthop. (Level III, review of the study). Context: than have been on fractures of the during the 10 years. This review the the results of reports of more than children regarding the comparing two techniques of and of these Study Design, Results, and Conclusions: All randomized and retrospective cohort studies between and of fractures treated with two medial and lateral or two lateral were compared for injury, deformity loss of The technique of medial and lateral pin had a statistically higher of injury vs. than pin and a five greater risk of injury vs. and lateral pin was found to have the risk of deformity or loss of significantly less than the lateral group. Comments: Although this review found a difference in with these two no randomized control trial to has identified a significant difference in of these That may be the randomized have small to a significant difference in outcomes, or that these randomized used greater in medial pin for or tests of stability of pin before these Pearls: are the between the results and those of the randomized the of Kocher of the was the first of a in which no injury from the of medial also the difference in relative versus for an increase from to one could that risks are nearly were increased only of fractures with the the M. J Pediatr Orthop. (Level IV, retrospective review of surgical Context: fractures are commonly treated with and Although many studies pin and the of the for open suggests the use of techniques of operative to limit of and Study Design, Results, and Conclusions: four patients with a fracture of the were treated with followed by and The is performed in the operating with the patient is performed using an the to maintain the the surgeon and the surgical the in the of pin and the fracture with No or deep pin tract were reported. Comments: As costs for medical to using clinical that decrease the use of and operative and hospital are This technique for the and treatment of patients with fractures will by the use of and for overall operative It is with and of and to the low infection Although the authors suggest that of patients no perioperative antibiotics and there were no in the group, perioperative antibiotics may not be necessary for this the of this of treatment low to its continued use. Pearls: It is difficult to even a risk of complication to the of a medical are their patients’ as the authors the technique may allow the case to be which in may the patient to the operating most of these cases are done as an a patient may do better with a performed technique as opposed to a case 10 if

ObjectiveThis study aimed to characterize the spatial distribution and imaging features of periosteal entrapment in pediatric distal tibial Salter-Harris (S-H) type II fractures using magnetic resonance imaging (MRI) and to evaluate its clinical outcomes.MethodsThis retrospective study analyzed 20 cases of distal tibial S-H type II fractures between 2015 and 2024. All patients underwent post-injury MRI examinations (including T1-weighted, T2-weighted, and proton density-weighted imaging sequences). The precise location of periosteal entrapment was recorded and mapped to the four quadrants of the epiphysis. All patients were divided into three groups according to the treatment method: the conservative treatment group, the closed reduction and percutaneous fixation (CR-PF) group, and the open reduction and internal fixation (ORIF) group. Outcomes evaluated included fracture healing, growth disturbances (including bone bridge formation, angular deformity, and limb-length discrepancy), and the American Orthopaedic Foot and Ankle Society (AOFAS) score at the final follow-up (≥6 months).ResultsA total of 20 patients (16 boys and 4 girls) with an average age of 10.65 ± 2.41 years (range: 2–13 years) were included in this study, and the mean follow-up period was 22.53 months. Post-injury MRI showed periosteal entrapment in all patients, with the anterolateral quadrant being the main entrapment site (15/20, 75%). During the follow-up period, 2 patients developed growth disturbances: one patient who underwent ORIF showed a bone bridge formation on imaging, while the other patient who received CR-PF presented with ankle varus deformity without evidence of bone bridge formation. At the final follow-up, the assessment of AOFAS scores revealed no significant difference in functional outcomes among the three groups (P = 0.951).ConclusionDistal tibial S-H type II physeal fractures are at high risk of concomitant periosteal entrapment, which is localized predominantly to the anterolateral corner of the distal tibial physis. Conservative management, CR-PF, and ORIF resulted in comparable functional outcomes without significantly increasing the risk of growth disturbances, indicating that residual entrapped periosteum may not adversely affect fracture healing or long-term prognosis.

Closed reduction and percutaneous pin fixation is the recommended treatment of displaced (Gartland types 2 and 3) supracondylar humerus fractures. The need for a medial pin for maximal stability remains controversial. The purpose of this study was to develop a model of supracondylar humerus fractures simulating medial column comminution and to evaluate the torsional stability of various pin configurations recommended in the current literature. Transverse cuts were made in synthetic humeri with a wedge taken from the medial aspect of the proximal fracture fragment in one half of the specimens to simulate medial column comminution. Each fracture was then reduced and fixed with 1 of 4 pin configurations using 0.062 in K-wires. The fixed specimens were then subjected to a torsional load producing internal rotation of the distal fragment. Rotation in degrees and the corresponding torque was recorded for statistical analysis. Specimens with the medial wedge removed demonstrated less torsional stability than their identically fixed counterparts with the intact medial column. In specimens with the intact medial column, the greatest torsional stability was achieved with the 2 lateral divergent and medial cross pin configuration followed by 3 lateral pins, then standard crossed pins with 2 lateral divergent pins demonstrating the least torsional stability. For the medial comminution group the 2 lateral, 1 medial pin construct again had the greatest torsional stability and 2 lateral pins the least. The standard crossed pin and 3 lateral pin constructs were not significantly different in the presence of medial comminution. In a synthetic humerus model of supracondylar humerus fractures, medial comminution was shown to reduce torsional stability significantly in all pin configurations. There was no statistical difference in torsional stability between 3 lateral pins and standard crossed pins in specimens with medial comminution.