Flynn's Criteria Research Articles

Temporary Use of Skeletal Traction in Management of Pediatric Supracondylar Humeral Fractures

The paper presents a treatment algorithm for supracondylar humeral fractures in children, involving temporary use of skeletal traction following failure of primary closed reduction and percutaneous fixation (CRPF) and introducing closed reduction after management by skeletal traction. The aim of this study was to assess the outcomes of supracondylar humerus fracture treatment performed according to the algorithm. The treatment was performed in 149 children (70 girls, 79 boys) with extension-type supracondylar humeral fractures. The study group was assessed with regard to a modified Gartland classification, neurological complications (12 children, 8%) and vascular complications (8 children, 5.4%). A total of 124 (83.2%) patients underwent emergency CRPF and 24 children (16.1%) received skeletal traction after a failed CRPF. After 2-6 days, an elective repeat CRPF procedure was attempted, which was successful in 17 children. The attempt failed in the other 7 children, who received traction and underwent open reduction under a single anesthesia. One child (0.7%) with a white and pulseless hand was treated by emergency open reduction and percutaneous fixation. The study used the Flynn criteria modified by the author. After 6 months, the results in the group treated with CRPF (both primary and following skeletal traction) were good in 90.8% of patients, satisfactory in 8.5%, and poor in 0.7%, whereas in the open reduction and percutaneous fixation group, the results were good in 87.5% of cases and satisfactory in 12.5%. 1. X-ray-guided closed reduction and percutaneous K wire fixation is a method of choice in the treatment of displaced supracondylar humeral fractures in children. If closed reduction fails, the surgeon is faced with a choice between primary open reduction and the use of direct traction through the olecranon. 2. The use of skeletal traction following failure of primary emergency CRPF results in local improvement in the fracture region and allows for scheduling an elective repeat delayed closed reduction and percutaneous K wire fixation procedure. 3. The algorithm used in clinical practice, based on literature reports and the author's experience, helps achieve good treatment outcomes.

Type-III supracondylar humerus fracture: functional outcome of open reduction and internal fixation after failed closed reduction

<p><strong>Background: </strong>To evaluate results of open reduction and internal fixation with Criss cross k-wires after failed closed reduction in Gartland type III Supracondylar fracture of humerus in our institution.<strong></strong></p><p><strong>Methods:</strong> This prospective study was conducted at the Krishna Rajendra hospital affiliated to the orthopaedic department of Mysore medical college and research institute from December 2018 to December 2019. Twenty-five patients of type-III fracture of supracondylar humerus were included within the study. Consent was obtained from all patients. Under anaesthesia, closed reduction was attempted first. When 2-3 attempts of closed reduction failed, an open reduction and internal fixation with cross k-wires was performed. Fortnightly follow up was applied for the first 8 weeks then monthly for the next 4 months. The clinical outcome was evaluated using Flynn criteria.</p><p><strong>Results:</strong> Out of 25 patients, 16 were male and 9 were female. Left side was involved in 17 patients and right side in 8. Mean age was 6.9 years with age range from 3 to 12 years. Excellent or good results were obtained in 23 (92%) patients and fair or poor in 2 (8%). </p><p><strong>Conclusions:</strong> We conclude that these fractures must be managed aggressively, by a specialised surgeon. Open reduction and internal fixation of severely displaced supracondylar fractures of the humerus is a safe and effective method when a satisfactory reduction can't be obtained by 2-3 attempts on closed method.</p>

The outcome of loose bone fragments in pediatric supracondylar humerus fractures: a retrospective study.

We evaluated the clinical and imaging outcomes of loose bone fragments in children with supracondylar humerus fractures after closed reduction with percutaneous pin (CRPP) fixation. A retrospective review was conducted on 12 children with fragments on imaging after closed reduction of displaced humeral supracondylar fractures (Gartland III). Primary radiographic assessment included fragment outcome, postoperative Baumann angle, carrying angle and loss of reduction. Clinical outcome included the elbow range of motion (ROM), Flynn grade and other complications. Between January 2015 and January 2018, 460 children (2–14 years old) with supracondylar humerus fractures were treated at our center, including 12 (2.6%) with loose bone fragments on postoperative X-ray. Union or absorption of fragments was noted in all 12 patients at 1 year postoperatively, with good radiographic and clinical outcomes. The mean Baumann angle was 15.5° ± 4.3° and the mean carrying angle was 11.2° ± 2.8°. All patients had a normal elbow ROM. Ten patients achieved an excellent and two a good result according to the Flynn criteria. Good results were achieved after CRPP fixation in 12 children with supracondylar humerus fractures and loose bone fragments. The fragments were mainly absorbed or achieved union to the humerus within 1 year.

Ultrasound-guided reduction and percutaneous crossed pin fixation for the treatment of displaced supracondylar fracture of the humerus in children

To investigate the effect of ultrasound guided reduction and exploration of ulnar nerve position and percutaneous crossed pin fixation for the treatment of displaced supracondylar fracture of the humerus in children. The clinical data of 45 patients with displaced supracondylar fracture of humerus from December 2017 to December 2018 were analyzed retrospectively, including 26 boys and 19 girls, ranging in age from 1 year and 3 months to 11 years and 4 months, with an average of 7.6 years old;44 cases of crashing injury, 1 case of falling injury;29 cases on the left side, 16 cases on the right side;12 patients classified to Gartland typeⅡand 33 patients classified to Gartlandtype Ⅲ. The operation was performed from 4 h to 7 d after injury, with an average of 2.5 d. There were no neurological and vascular injuries occurred in the children. Ultrasound was used to guide the fracture reduction of the child, and the cross-needle was fixed. In the medial needle insertion, the ulnar nerve position was detected by ultrasound to avoid damage to the ulnar nerve. The ulnar nerve state was observed during operation. The clinical function evaluation criteria of Flynn was used at the latest follow-up. The evaluation criteria was used to evaluate the functional and aesthetic characteristics of the elbow joints of the children, and to observe the complications such as ulnar nerve injury after operation. Ultrasound was used to detect the fracture from the medial side of the elbow, the lateral aspect of the elbow and the sagittal plane of the elbow. The position of the ulnar nerve could be clearly explored to avoid ulnar nerve injury when the needle was inserted inside. All children were followed up, and the duration ranged from 6 to 12 months, with an average of 9 months. None of the patients had a loss of repositioning and the fractures healed. The healing time ranged from 4 to 6 weeks, with an average of 5 weeks. At the latest follow-up, according to Flynn's evaluation criteria:compared with the healthy side, 41 patients with flexion and extension limitation were 0° to 5°, clinically evaluated as excellent;3 patients with flexion and extension limitation were 6° to 10°, clinically evaluated as good;1 patient with flexion and extension limitation was 11° to 15°, clinically evaluated as acceptable. Compared with the healthy side, 40 patients lost 0° to 5°of the angle, and 5 patients lost 6° to 10°of the angle. There were no complications such as ulnar nerve injury and cubitus varus. Although ultrasound-guided treatment of displaced supracondylar fracture of the humerus in children has higher requirements for the operator at present, because of its advantages of clear development, portability, effectiveness and no impact on health, it could clearly explorethe fracture situation during the operation, guide the reduction of the fracture, and accurately show the position of the ulnar nerve, effectively improve the safety of the medial puncture, so as to minimize the complications The occurrence of the disease. Therefore, the treatment of displaced supracondylar fracture of humerus with ultrasound-guided manual reduction and percutaneous cross needle fixation is effective and worthy of further promotion.

Crossed versus lateral K-wire fixation of supracondylar fractures of the humerus in children: a meta-analysis of randomized controlled trials

Supracondylar fractures of the humerus are common in children. Whether fixation should be performed with crossed or lateral wires remains controversial. We performed a meta-analysis of randomized controlled trials to evaluate both techniques in terms of the function of the elbow and the risk of neurologic injury and loss of reduction. We also assessed the quality of the evidence currently available. The MEDLINE, Embase, Cochrane Library, and LILACS (Latin American and Caribbean Health Sciences Literature) databases, as well as ongoing clinical trial databases, were searched until March 2020. The main outcomes were function, measured by the Flynn criteria, and complications (neurologic lesions and loss of reduction). A meta-analysis was conducted using relative risk (RR) analysis for dichotomous variables and difference in means for continuous variables. Heterogeneity was tested using the I2 statistic. Twelve trials, with a total of 930 patients, met the inclusion criteria. Both groups (crossed-wire and lateral-wire fixation) presented satisfactory functional results, with no difference between them (RR, 0.99; 95% confidence interval [CI], 0.96-1.02; P = .44). Patients undergoing crossed-wire fixation had a higher risk of iatrogenic neurologic injury (RR, 0.45; 95% CI, 0.21-0.99; P = .05). The crossed group showed greater fixation stability, with a lower incidence of loss of fracture reduction (RR, 1.39; 95% CI, 1.04-1.85; P = .03). The GRADEpro GDT (Guideline Development Tool) showed that the quality of evidence of the evaluated outcomes was low or very low. There is evidence of very low quality that fixation with lateral wires is safer regarding iatrogenic nerve lesions whereas fixation with crossed wires is more effective at maintaining fracture reduction.

A study on outcome of various K-wire fixations in paediatric supracondylar humerus fractures

<p class="abstract"><strong>Background:</strong> The ideal pin geometry for treatment of paediatric supracondylar humerus fracture is still debated. Various studies have been carried out comparing medial-lateral pinning (MLP) and lateral only pinning (LOP), but none have compared all three individually i.e. MLP, lateral divergent pinning and Lateral Trans olecranon fossa four cortex purchase pinning (TOF-FCP). This study aims to compare the cosmetic and functional outcome of these three pinning methods.</p><p class="abstract"><strong>Methods:</strong> 54 children with supracondylar humerus (Gartland type 2 or 3) meeting inclusion criteria were treated operatively and followed up till 6 months postoperatively. At 6 months the cosmetic and functional outcomes were assessed using the modified Flynn criteria.<strong></strong></p><p class="abstract"><strong>Results:</strong> All fractures united within 3 to 6 weeks duration. The mean duration of fracture union was 4.05 weeks. Functional outcome was satisfactory (i.e. excellent or good) at 6 months according to Flynn criteria in 95% of cases in cross pinning, 100% cases in TOF-FCP construct and 89% cases in lateral entry divergent pinning. cosmetic outcome was satisfactory (i.e. excellent or good) at 6 months according to Flynn criteria in 95% of cases in cross pinning, 100% cases in TOF-FCP construct and 89% cases in lateral entry divergent.</p><p class="abstract"><strong>Conclusions:</strong> Functional and cosmetic outcome of all three pinning geometries after operative intervention of paediatric supracondylar humerus fracture is similar in expert hands. The incidence of complications with TOF-FCP construct is less amongst the lateral only pinning.</p>

Clinical and functional outcome of elastic stable intramedullary nailing in pediatric femoral fractures in the age group of 5-16 years

<p class="abstract"><strong>Background:</strong> Fractures of the femur are the most incapacitating fractures. The best treatment for children between five to sixteen years of age is still debated. The ESIN has the benefits of early immediate stability to the involved bone segment, permitting early mobilization and return to the normal activities of the patients, respect for the physes, minimal scarring with lower complications. The purpose of this study was to present this study results following fixation of femoral shaft fractures with titanium elastic nails between the age 5-16 years of age.</p><p class="abstract"><strong>Methods:</strong> A total 52 patients in the age group of 5-16 years with femoral shaft fractures were stabilized using flexible nailing. Clinical and radiological follow-up was for a minimum period of 24 months. The final results were analysed using Flynn’s criteria.<strong></strong></p><p class="abstract"><strong>Results:</strong> Mean age at surgery was 7.4 years (range 5.6-14.3 years). The average duration of surgery was 65.3 (45-95) minutes and the mean duration of hospital stay was 8 (5-14) days. Skin irritation due to nail ends was the most common complication followed by significant lengthening (n=6), infection (n=2), significant shortening (n=2), varus angulation (n=2) and delayed union (n=2). The final outcome was excellent in 65.4% cases, satisfactory in 30.8% cases and three patients had poor outcomes as per Flynn's scoring criteria.</p><p class="abstract"><strong>Conclusions:</strong> In this study, ESIN showed good clinical and radiographic results in the age group 5 to 16 years, with minimal complications and high parent satisfaction consistent with previous studies but lesser number of mid adolescent age groups in the present study is a limitation.</p>

Pediatric Floating Elbow Injuries Are Not as Problematic as They Were Once Thought to Be: A Systematic Review

Pediatric ipsilateral supracondylar humerus and forearm fractures (floating elbow), are historically reported to have a high rate of complications, including pediatric acute compartment syndrome (PACS). As a result, treatment paradigms for these types of injuries differ in the urgency, extent of fixation, and type of immobilization than if each fracture were treated in isolation. We aimed to systematically review the literature on pediatric floating elbow injuries and assess the reported risk of PACS along with risk factors for poor outcomes. A systematic review was performed in November 2019 in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. An exhaustive search of the PubMed and Embase databases was conducted for peer-reviewed literature between 1999 and 2019. Two reviewers filtered the results, looking for articles in English that reported >10 pediatric floating elbow cases. Primary outcomes were the rate and risk factors for developing PACS. Secondary outcomes included patient and injury characteristics, treatment strategies, other complications (eg, neurovascular injuries), and final outcomes. The initial search yielded a total of 150 studies. Following review, 11 studies were included, with 433 patients available for review. The mechanism of injury was a fall in 96% of cases. Closed reduction and percutaneous pinning was the most common treatment performed for both fractures. Only 8/433 patients (2%) developed PACS. The incidence of a pulseless limb at presentation was 4%, and all patients regained a pulse following reduction. Three cases of iatrogenic ulnar nerve injury were reported in the setting of medial pin placement. Good to excellent results were reported in 83% to 100% of patients, based on the modified Flynn criteria. Despite being limited to heterogenous and retrospective case series, the evidence reviewed in this study contradicts the current belief of a high risk of PACS or other complications in pediatric floating elbows. PACS is much more common with displaced fractures in the setting of delayed treatment. The rate of other complications is comparable to isolated supracondylar humerus fractures. Evidence supports treating these injuries in an urgent fashion in the setting of a displaced fracture, although fixation of both distal and proximal fractures is not supported by evidence. The outcomes of pediatric floating elbows are generally good and do not reflect the poor prognosis that adult floating elbows represent. Level IV-systematic review of level IV studies.

Outcome of Percutaneous pinning among Children with displaced Supracondylar Fracture of the Humerus

Background: Percutaneous pining among children with displaced supracondylar fracture of the humerus, may offer additional benefits to patients in terms of outcome. Objective: To determine the union of fracture and range of motion at elbow, in supracondylar fracture, among children, with closed reduction and percutaneous pinning. Methodology: A cross-sectional study was conducted, from 19th December 2016 to 19 May 2018, at Ortho Unit 2, Nishtar Hospital, Multan, patients of both sex, having supracondylar fracture (Gartland type II and III) diagnosed radiographically, and presenting within 1st week of injury, were included, and patients with a history of previous surgery or trauma over the arm, compound fracture and neurovascular compromise, were excluded. All patients were operated for the fracture (closed reduction and pinning under image intensifier). The patients were discharged the next day after the procedure. The follow up completed at 6 weeks postoperatively by Flynn's criteria. Results: Out of 254, 202 (79.5%) patients were fulfilling the satisfactory level of outcome, 52 (20.5%) patient showed an unsatisfactory level of outcome according to operational definition In this study, 96 (37.8%) males and 106 (41.2%) females patients shows satisfactory outcome whereas 23 (9.1%) males and 29 (11.4%) females patients showed unsatisfactory level of outcome (p= 0.04). Out of 254 patients 59 (23.2%) showed excellent, 94 (37%) good, 49 (19.3%) fair and 52 (20.4%) poor outcome based on Flynn’s criteria. Conclusion: From our study, the percutaneous pinning of displaced supracondylar fracture of humerus among children under image intensifier is the effective method of treatment in our study setting.

Supracondylar humerus fractures in low- and lower middle-income countries: a scoping review of the current epidemiology, treatment modalities, and outcomes.

The purpose of this scoping review was to examine the nature and quality of research regarding paediatric supracondylar humerus (SCH) fractures in low and lower middle-income countries (LICs). We searched PubMed, Embase, Web of Science, and African Journals Online on January 9, 2018, for studies of SCH fractures in LICs. Studies were categorized by geographic region, Gartland classification of included patients, and study design. We evaluated each study's methodology and conclusions. Out of 1805 results, we analyzed 105 studies, most of which included type 3 fractures only (66%). Many were conducted in South Asia (58%) and assessed treatment outcomes (78%). Most of the studies had level IV evidence (67%). Common limitations of research were small sample size (12%) and inadequate follow-up (6%). Epidemiological studies concluded that SCH fractures are more common among male children, are usually secondary to falls, and rarely present with nerve injuries. Most therapeutic studies reported outcomes of surgery (91%). Thirteen studies concluded that all-lateral versus cross-pinning techniques have similar outcomes. Seven studies reported preference for closed reduction over open reduction, when intra-operative fluoroscopy was available. Most common outcome measures were Flynn criteria (77%) and range of motion (53%). None of the papers looked at treatment costs. Our data show a predominance of small level IV studies from LICs, with few studies of higher level of evidence. Many studies examined controversies with surgical technique, similar to studies performed in high-income countries. Few studies examined non-operative treatment, which is commonly the predominant treatment available for patients in LICs. Further investigation of common treatment modalities and outcomes for SCH fractures in LICs is needed.

Are Modified Gartland Type IV Supracondylar Humerus Fractures Different From Type III Fractures? A Retrospective Clinical Study

Aim: The present study investigates whether surgical treatment of modified Gartland Type IV supracondylar humerus fracture is radiologically and clinically different from the treatment of Type III fractures. Methods: The medical charts of 197 patients who underwent surgical treatment for pediatric supracondylar humerus fracture in our clinic between 2012 and 2015 were retrospectively reviewed, and 76 patients humerus Gartland Type III and unstable Type IV fractures regardless of neurovascular injury (49 males, 27 females) were included in the study as randomize. The patients were divided into two groups as patients with modified Gartland Type III (n=36) and patients with Type IV fractures (n=40). The mean age of the patients was 5.88±3.29 (1-15) years, and the mean duration of follow-up was 19.80±4.83 (12-29) months. All patients underwent surgery within the first 24 hours and closed reduction was first attempted. Posterior open reduction was performed in patients with failed attempts of closed reduction. The functional and cosmetic outcomes of the patients were evaluated according to the Flynn criteria. The Baumann’s angle was measured on the X-rays obtained in the last control visit.Results: The comparison of functional outcomes between the two groups revealed that satisfactory outcomes were obtained in 97.3% of patients in the Type III fracture group and 87.5% of patients in the Type IV fracture group; however, the difference was not statistically significant (p=0.509). The comparison of cosmetic outcomes showed that satisfactory outcomes have been obtained in 100% and 97.5% of the patients, and no significant difference was found between the two groups (p=0.495). There was no statistically significant difference between the two groups in terms of the need for open surgery, nerve injury, and Baumann’s angle (p=0.776, p=0.108, p=0.069, respectively).Conclusion: Modified Gartland Type IV pediatric supracondylar humerus fractures can be treated successfully just like Type III fractures with anatomical reduction, stable fixation and early initiation of joint movements.

A comparative study of percutaneous pinning techniques (Cross K wire vs lateral K wire) for Gartland type III pediatric supracondylar fracture of the humerus

Background: Supracondylar fractures of Humerus are one of the most common fractures in the children. Closed reduction and percutaneous k wire fixation are one of the most commonly used and widely accepted treatment modality in Gartland type 3 fracture, but controversy continues regarding the ideal pin fixation techniques. This study was conducted to compare lateral divergent k wires versus cross k wire (medial and lateral) in terms of the stability, functional outcome and iatrogenic ulnar nerve injury. Material and Method: This was a retrospective record based study. Total 30 patients of displaced supracondylar fracture of the humerus of age 3-12 years were divided into 2 groups which were evaluated from post-surgery. In group one crossed pinning was done for type 3 supracondylar fractures and other group was treated with lateral pinning and outcome of these patients record was assessed on basis of pain, motion, stability and function according to Flynn’s criteria and follow-up record of 2 year was studied. Data was analysed with the help of SPSS 20.0 version.Results: According to Flynn criteria, the final result was excellent in 90 %and good in 10 % of cases with 0% fair and 0% poor results. There was no statistically significant difference between medial-lateral entry group and lateral entry group.Conclusions: Lateral pinning is an equally good as compared to crossed pinning treatment of choice in terms of terms of the stability and functional outcome. The risk of ulnar nerve injury was zero in lateral divergent k wires. Both these methods give comparable functional and cosmetic results.

Comparison of Three Different Approaches in Pediatric Gartland Type 3 Supracondylar Humerus Fractures Treated With Cross-Pinning.

IntroductionAlthough closed reduction and percutaneous pinning are the accepted treatment approaches in pediatric humerus supracondylar fractures, the treatment approach in fractures without closed reduction remains unclear. This study compared the results of three different cross-pinning treatment methods.Materials and methodsA total of 62 patients (1-13 years old) who were operated for Gartland type 3 humerus supracondylar fractures between 2007 and 2016 were evaluated retrospectively. Of the patients evaluated, 24 patients had closed reduction, 25 patients had direct reduction from the medial, and 13 patients had direct reduction from the lateral and cross-pinning. The functional and cosmetic results of the patients were evaluated according to Flynn's criteria. In addition, the Baumann angle, lateral capitellohumeral angle (LCHA), and postoperative complications were compared among groups.ResultsBoth functional and cosmetic results and the Bauman and LCHA angles were similar in all three groups. In patients with open reduction, the control duration was significantly longer than that in patients with closed reduction, and this difference was due to a recent increase in the surgeons' preference for closed surgery. Two patients underwent pin site infection and two patients developed nerve palsy. Only the first patient who developed ulnar nerve palsy recovered during follow-up. Secondary surgery was applied to the other patient who developed brachial artery occlusion with ulnar and median nerve paralysis, and they recovered during follow-up. Three patients who underwent open surgery from the medial, along with the two patients who had undergone open surgery, developed pinhole infection. These patients were subsequently recovered with antibiotherapy without further complications. A patient who underwent open lateral surgery developed compartment syndrome and fasciotomy was performed.ConclusionClosed reduction and percutaneous pinning are generally accepted approaches in the treatment of pediatric humerus supracondylar type 3 fractures. However, in cases where closed reduction cannot be achieved, pinning with the medial approach and taking the ulnar nerve and medial colon is a reliable method to avoid both ulnar nerve injury and cubitus varus.

Comparison of internal fixation vs. external fixation after corrective osteotomy in children with cubitus varus

Cubitus varus deformity is a well-known late complication of supracondylar fractures in children. In this retrospective study, the primary objective was to compare clinical and radiologicoutcomes of lateral closing-wedge osteotomy with either internal fixation or external fixation in pediatric patients with cubitus varus deformities. From 2010 to 2017, 35 consecutive patients with cubitus varus deformities secondary to supracondylar fractures were included in this study. After corrective osteotomy was performed via a limited lateral approach, the method of definitive fixation was chosen between internal and external. Retrospectively, patientswho underwent external fixation on the lateral aspect of the elbow were defined as group I (n = 16) whereas patientswith unilateral single-plate fixation were defined as group II (n = 19). The functional outcome was evaluated using the Mayo Elbow Performance Score and Flynn criteria. No significant difference in age was found between the 2 groups (P = .15). Significantly lower costs, a shorter operation duration, smaller scars, and a shorter time for plaster cast use postoperatively were found in group I (P < .001). No nonunion or failure of fixation was found. No significant difference was noted in postoperative elbow range of motion or Mayo Elbow Performance Score (P = .64). Both groups achieved satisfactory functional and cosmetic results. In pediatric patients with cubitus varus, both methods of fixation after lateral closing-wedge corrective osteotomy are reliable, with a low rate of complications and satisfactory functional results. External fixation is more advantageous in terms of easier preoperative planning, shorter operative times, lower costs, and easier postoperative fixation removal.

Comparison of closed reduction and percutaneous cross verses parallel k wire fixation in supracondylar fractures of the humerus in children.

Around the elbow, supracondylar injury of humerus is one of the conventional fractures which usually occurs at the age of 7 to 8 years. Various conservative techniques have been used for the management, which comprises of the splintage, tractions, open or closed reduction with k wire fixation. However, closed reduction and percutaneous pinning remains the mainstay of surgical management, for they have shown splendid outcomes according to many authors. Objectives: The aim of this study is to summarise and compare the radiological and functional results of two ways of fixation (cross and parallel closed K wires) of supracondylar fractures in children. Study Design: Randomized controlled trial. Setting: Department of Orthopaedics Surgery, Services Hospital, Lahore. Period: 1st January 2018 to 31st June 2018. Material &amp; Methods: We included 180 patients (90 in each group). Results: The mean age was 6.45±2.34 years with 115(63.9%) male and 65(36.1%) female. Among the children who underwent fixation with cross k-wires, ulnar nerve injury was seen in 2(2.2%) cases and none were seen in the other group post operatively. Group A attained higher union rate at last follow up. 4(4.4%) cases in Cross K-wires and 19(21.1%) in two lateral k-wires gave outstanding outcome. In a nutshell, 60 in group A and 45 in group B showed excellent outcomes based on Flynn's criteria, p-value &lt; 0.05. Conclusion: According to Flynn’s criteria, closed percutaneous cross K-wire fixation of supracondylar fracture of humerus is an effective management option in terms of finer functional results as compared to Parallel k-wires. Although, the rate of radiological union is higher in cross k-wire fixation, there are 2.2% chances of ulnar nerve injury.

Functional and radiographic outcomes of Gartland type II supracondylar humerus fractures managed by closed reduction under nitrous oxide as conscious sedation.

The management of Gartland type II supracondylar fractures remains controversial. This study aimed to evaluate the clinical, functional, and radiographic outcomes of Gartland type II supracondylar fractures treated by immediate closed reduction and casting in the emergency department using equimolar nitrous oxide as conscious sedation. All patients were treated non-operatively using equimolar nitrous oxide as conscious sedation during closed reduction and cast immobilization. Three out of 34 patients (three elbows; 8.8%) were lost during follow-up. The mean follow-up time was 26.4 months (range: 6-48). The mean Quick DASH score at cast removal was 22.4 (range: 19-40) and 2.3 (range: 0-9) at the last follow-up visit in patients without secondary displacement (n = 26; 76.5%). The mean Quick-DASH score of patients (n = 5; 16.1%) requiring closed reduction and percutaneous pinning under general anesthesia because of secondary displacement was 21.4 (range: 19-25) at cast removal and 0.9 (range: 0-2.3) at the last follow-up visit. No significant differences between the two groups were found at any time (P = 0.38 and P = 0.48, respectively). The two groups also showed a comparable radiographic outcome and similar Flynn's criteria. The mean Numeric Pain Intensity was three (range: 0-6). No complications related to the administration of equimolar nitrous oxide were recorded. The use of equimolar nitrous oxide as conscious sedation for closed reduction and casting appears to be a safe, inexpensive, and appropriate conservative method of treatment for displaced Gartland type II supracondylar fractures in children. A regular follow-up is mandatory to detect early secondary displacement, as 16.1% of fractures required additional closed reduction and percutaneous pinning under general anesthesia. Level IV, retrospective study.

Open Reduction of Neglected Supracondylar Humeral Fractures With Callus Formation in Children.

The standard treatment for supracondylar humeral fractures (SHFs) in children is closed reduction and percutaneous Kirschner (K)-wire fixation. In patients who present >14 days after injury and show callus formation, this procedure cannot be performed. There are 2 options in these cases: functional exercises with osteotomy performed at a later stage if cubitus varus is present, or immediate open reduction and percutaneous K-wire fixation. This study aimed to evaluate the outcomes of K-wire fixation through an anterior approach in children with neglected SHF and identify factors predicting the outcomes. This retrospective study assessed the files of 32 children treated for neglected SHF at our hospital between June 2015 and May 2018. An incision was made along the anterior transverse groove of the elbow. The callus was removed, the fracture was reduced, and K-wire fixation was performed. The outcome evaluation included the radiological Baumann angle, pin fixation construct, carrying angles, and the functional outcome was Mayo Elbow Performance Score and Flynn criteria. Binary regression analysis compared the functional outcome as the dependent variable with age, time from injury to operation, operation time, and the amount of callus. The interval between injury and operation was 14 to 40 days (average, 22.4 d). Patients were followed for 12 to 36 months (average, 21.5 mo). Fracture healing took 5 to 8 weeks (average, 6.6 wk). No patient had a vascular injury or compartment syndrome. Twelve patients were intraoperatively assessed for radial and median nerve injury. No nerve repair was required. All nerve injuries recovered within 3 months. No iatrogenic ulnar nerve injury occurred. One patient had an infected incision. Binary regression analysis showed that the time elapsed between injury and operation (P=0.033) and Gartland type (P=0.008) were inversely correlated with outcomes; the longer the duration, the poorer the outcomes. The functional outcomes after open reduction and K-wire fixation through an anterior approach were poorer with longer time to surgery and Gartland type. Level III.

Effect of fracture location on rate of conversion to open reduction and clinical outcomes in pediatric Gartland type III supracondylar humerus fractures.

Supracondylar humerus fractures are the most common form of elbow fracture in children and adolescents. At present, treatment planning is based on the Gartland classification. Reduction and percutaneous pinning are done for Gartland type III fractures. In cases where closed reduction is unsuccessful, the procedure is converted to open reduction. However, there is no consensus on which patients are more likely to require conversion to open reduction. The aim of this study was to investigate the effect of fracture location on the rate of conversion to open reduction and clinical outcomes. A total of 112 patients who underwent early surgery for Gartland type III supracondylar humerus fracture between August 2011 and August 2017 were evaluated. The patients' age, sex, facture location, post-operative loss of reduction, and complications were noted. The fractures were classified according to fracture level relative to isthmus (high level) or at/below the isthmus (low level). Closed reduction was initially preferred. Open reduction with percutaneous pinning was performed, when necessary. Flynn's criteria were used to evaluate elbow motion after treatment. Mean follow-up time was 39 months (16-62 months). The mean age of the patients was 6.4±2 years (1.4-12 years). Thirty-nine of the patients were female, 73 were male; 32 fractures were in the dominant arm, 80 were in the non-dominant arm. Ninety of the fractures were classified as high level (proximal) and 22 as low level (distal). Patients with low-level fractures were significantly younger (p<0.01). Patients with low-level fractures also showed a significantly higher rate of conversion to open reduction compared to those with high-level fractures (p<0.01). Clinical outcomes evaluated with Flynn's criteria were statistically equivalent between the high and low fracture groups (p>0.05). The Gartland classification provides important guidance for the treatment of supracondylar humerus fractures, but may have limitations. Our results suggest that revising the classification by incorporating fracture location may be more beneficial for pre-operative planning.

The surgery outcomes of pediatric femoral shaft fractures and comparision of radiation risks.

Introduction:To show midterm results and compare the two methods utilized in pediatric femoral diaphysis fractures fixation and the risks of radiation.Methods:We conducted retrospective studies of 60 children and adolescent between the age of 6 to 16 years who were exposed to traumatic femoral shaft fractures and treated with methods of fixation titanyum elastic nail (EN), submuscular bridge plating (SBP) Twenty eight (18 males and 10 females) were treated with SBP (group 1), and 32 patients (18 males and 14 females) were treated with EN (group 2).Results:The mean age of the patients was 10,3 years. Duration of follow-up was 29.8 months. Mean union time was 7,4 weeks (range, 6-10 weeks). Operative time was on average 60.6 minutes. Considering Flynn’s criteria, the results of treatment was excellent in 50, good in 4 and poor in 6 cases.Conclusions:In the surgical treatment of pediatric femoral shaft fractures, fixation techniques such as submuscular bridge platingand elastic nails were found to have similar fracture healing and complication rates. An orthopaedic surgeon must protect himself, his personnel and the patient from radiation exposure. Open reduction internal plate fixation can be chosen as an alternative treatment for children who do not cause radiation exposure to the femoral fracture. (www.actabiomedica.it)

Analysis of radiological alignment and functional outcomes of pediatric patients after surgery with displaced supracondylar humerus fracture: A cross-sectional study

IntroductionSupracondylar humerus (SCH) fracture is the most common type of elbow joint fracture (50–70%) in children aged 3–10 years. Treatment of displaced SCH fracture are surgery using Kirschner wire. The outcome of SCH fracture in pediatric population can be assessed clinically and radiologically. MethodsThis study aims to analyze the correlation between radiological alignment and functional outcome in displaced SCH fracture in children under internal fixation. Study design was cross sectional with analytical approach. Medical records of children with displaced SCH fracture from January 2016 to December 2018 were taken for the study. The data included in this study were at six weeks after removal of implant. The parameter of radiological alignment used in this study was Baumann's angle and the functional outcome based on Flynn's criteria. Data were analyzed using the Pearson Correlation test. ResultsOf the thirty samples enrolled in this study, 63.3% were boys. The mean age was 6.4 ± 2.0 years with peak incidence 5–6 years. Left side and non-dominant arm were more commonly injured with percentage of 63.3% and 70%. The mean of Baumann's angle and functional outcome were 73.5 ± 7.18 and 6.44 ± 4.7 degrees, respectively. There was a significant positive Pearson correlation (r = 0.491) between radiological alignment and functional outcome (p value = 0.006). ConclusionRadiological alignment had a significant positive correlation with functional outcome after surgery in displaced SCH patients.