Fractures Of Humerus In Children Research Articles

Risk Factors for Vascular Repair and Compartment Syndrome in the Pulseless Supracondylar Humerus Fracture in Children

The aims of this study were to determine how often fracture reduction alone restored pulses and vascular perfusion in displaced supracondylar humerus fractures with absent distal pulses on presentation, and whether any preoperative factors were associated with the need for vascular repair and vascular complications. We reviewed 1255 supracondylar humerus fractures in children treated operatively over 12 years at one institution. We identified 33 patients who presented with displaced supracondylar humerus fractures and absent distal pulses. We reviewed the management and outcome of these injuries. Thirty-three (of 1255) patients presented with a pulseless supracondylar humerus fracture (2.6%). The patients were divided into 2 groups: those at presentation whose hand was well perfused (n=24) or poorly perfused (9). None (0 of 24) of the well-perfused patients underwent vascular repair; 3 had open reduction. Of the 21 well-perfused patients undergoing closed reduction and pinning, 11 (of 21) had a palpable pulse after surgery and 10 (of 21) remained pulseless but well perfused; all did well clinically. Of the 9 patients in the poorly perfused group, 4 underwent vascular repair, and compartment syndrome developed in 2 during the postoperative period. In just over half of patients with a poorly perfused hand (5 of 9), fracture reduction alone was the definitive treatment. In the largest series of children with pulseless displaced supracondylar humerus fractures in the literature, we identify 2 distinct populations, with the perfusion status of the hand at time of presentation correlating significantly with the ultimate need for vascular repair. In patients presenting with a well-perfused hand, fracture reduction alone was sufficient treatment in all 24 (of 24) cases, and no patients developed compartment syndrome. Nearly half of these patients still had an absent palpable pulse but well-perfused hand after closed reduction, yet did well clinically. Patients presenting with a poorly perfused hand are at high risk for vascular repair and compartment syndrome.

Proximal Humeral Fractures in Children and Adolescents

The purpose of the study was to investigate possible reasons for the failure of closed reduction of proximal humerus fractures in children and adolescents. We assessed the rate of soft tissue entrapment, and we also investigated the long-term clinical and radiological results after an age- and deformity-focused treatment regimen according to national guidelines. Forty-three patients were included in the study. Ten (mean age, 12.4 years; range, 6-16 years) of the patients were treated conservatively. The remaining 33 patients (mean age, 14 years; range, 6-18 years) were treated surgically (n = 2 Neer grade 2, n = 16 Neer grade 3, and n = 15 Neer grade 4) with either closed (n = 16) or open reduction with internal fixation. In 17 fractures, closed anatomical reduction of the fracture under general anesthesia was not possible. Subsequent open reduction and Kirschner wire or screw fixation (n = 12) or plate fixation (n = 5) was necessary. In 9 of these 17 fractures (5 fractures were totally displaced fractures), closed reduction was impossible because of the entrapment of periost (n = 2) or the biceps tendon with parts of the periost (n = 7). At follow-up, the clinical assessment included a structured interview, a detailed physical examination, and the assessment of overall shoulder function with the Constant score. Operative and postoperative complications did not occur. All surgically treated fractures anatomically reduced and healed without loss of reduction. At a mean follow-up of 39 months (range, 12-118 months), all patients who were evaluated had excellent results according to the Constant score and had a normal range of motion and excellent strength of the shoulder joint. A failed closed reduction should be interpreted as a possible soft tissue entrapment most likely because of the long biceps tendon. Those cases should be addressed with open reduction and removal of the entrapped structures. If anatomical reduction is achieved and maintained until fracture healing, excellent functional and radiological results can be expected from an age- and deformity-focused treatment regimen for children and adolescents with proximal humeral fractures. Level 4 (Therapeutic study).

Prospective, surgeon-randomized evaluation of crossed pins versus lateral pins for unstable supracondylar humerus fractures in children

Controversy exists concerning pin placement for supracondylar humerus fractures in children. Both crossed pin and lateral only pin configurations have shown good results; however, prospective studies are lacking. We present a prospective, surgeon-randomized study comparing crossed pin (group A, n = 20) versus preferential lateral only pin (group B, n = 20) fixation for displaced supracondylar humerus fractures. There was no difference in Baumann's angle (P>0.75), the humerotrochlear angle (P>0.85), or final elbow range of motion (P>0.25). Both groups had stable reductions and clinically normal alignment. The only complication in both groups was a transient ulnar nerve irritation, despite no intraoperative evidence of nerve violation with a nerve stimulator. One patient in each group required modification of the operative plan. In group B, one patient had a medial pin inserted because of medial comminution extending proximally limiting available lateral pin placement. In group A, the surgeon elected to use lateral pins only because of an obviously subluxating ulnar nerve. In conclusion, we recommend orthopedic surgeons treating unstable pediatric supracondylar humerus fractures be facile with both medial and lateral pin placement.

Open reduction via posterior triceps sparing approach in comparison with closed treatment of posteromedial displaced Gartland type III supracondylar humerus fractures

The results of closed and open reduction via posterior approach with percutaneous pinning of posteromedial displaced supracondylar humerus fractures in children were evaluated. Fifty-five consecutive patients with Gartland type III fractures were reviewed. The mean follow-up period was 22 months (12-48 months). The closed reduction group consisted of 32 patients and the open reduction group with the posterior approach using the triceps-sparing method consisted of 23 patients. Both groups were stabilized with cross Kirschner wire fixation and followed the same protocol. In comparison with closed reduction, despite the fact that better bone alignment was obtained with open reduction, longer union time (7 vs. 5.8 weeks), significantly reduced range of motion of the elbow (12.3 degrees vs. 3.8 degrees), poorer functional outcomes and bad cosmetics because of hypertrophic scar tissue of the skin were found. The patients were analyzed according to their Bauman angle and Flynn criteria: good or excellent functional and cosmetic results were 91% in the closed reduction group but 52% in the open reduction group. On the basis of results of this study, closed reduction and percutaneous fixation of the posteromedial totally displaced fractures are preferable to open reduction with posterior approach.

Outcome of Supracondylar Fractures of the Humerus in Children Treated by Closed Reduction and Percutaneous Pinning

Supracondylar fractures of humerus in children are common injuries. Displaced fractures are inherently unstable. Conservative treatment results in malunion. Open reduction and internal fixation (ORIF) is more invasive and recovery is prolonged. From September 2004 to September 2005, 102 displaced supracondylar fractures of humerus, aged between one and half year to 13 years, were treated using close reduction and percutaneous Kirschner (K) wire fixation under c-arm fluoroscopy. Seventy nine patients were treated by cross K-wires and in twenty three cases lateral two K-wires were put. Above elbow plaster of paris back slab was applied in all cases for at least four weeks. Back slab, K-wires were removed after four weeks and elbow range of motion exercise was started. Results were analyzed using Flynn's criteria. All patients were followed up to 14th week postoperatively. In cross K-wire group(N=79) 70.8% had excellent, 22.7% good, 3.8% fair and 2.5% had poor results at eight weeks follow up which was improved to 91.1% excellent, 6.3 good, 1.2% fair and 1.26% poor results at 14 weeks follow up. In lateral K-wire group (N=23) 70% had excellent, 21.7% good, 4.3% fair and 4.3% had poor result at eighth week which was improved to 91.3% excellent, 4.3% good, 4.3% fair and no poor result at 14th week follow up. Eight patients got superficial pin tract infection and seven patients sustained ulnar nerve injury post operatively. We recommend this procedure for displaced supracondylar fractures in children as it is safe and cost effective procedure with acceptable complication rates.

How Safe Is the Operative Treatment of Gartland Type 2 Supracondylar Humerus Fractures in Children?

Whereas operative treatment of supracondylar fractures is now standard of care for Gartland type 3 supracondylar humerus fractures in children, the treatment of type 2 fractures remains somewhat controversial. The purpose of this article was to examine the safety and efficacy of closed reduction and pinning of type 2 supracondylar humerus fractures in children. We performed a retrospective review of 189 type 2 supracondylar humerus fractures operatively treated at one tertiary care children's hospital from 2000 to 2006. Data were acquired from a review of radiographs and clinical notes. We found no intraoperative surgical or anesthetic complications in our series. None of our cases lost reduction after closed reduction and percutaneous pinning. There were 4 pin tract infections (2.1%) in our series: 3 were treated with antibiotics, and 1 needed irrigation and debridement in the operating room. This was the only patient who required reoperation for any reason. In this study, the largest reported series of type 2 supracondylar humerus fractures in children, we found an extremely low rate of complications after closed reduction and percutaneous pinning; secondary operations were also uncommon (0.5%). Our series demonstrates a high probability of satisfactory outcome after operative treatment of type 2 supracondylar fractures compared with previous studies of children treated by closed reduction without pinning. Therapeutic study, level 4 (case series [no or historical control group]).

Delayed surgical treatment of supracondylar humerus fractures in children using a medial approach

The appropriate management of supracondylar humerus fractures in children is frequently delayed due to various factors, and there is still no agreement on the treatment of choice. The purpose of this study was to evaluate the effects of delayed treatment of displaced supracondylar humerus fractures on the treatment results and complication rate. A total of 31 children with supracondylar humerus fractures who had not received adequate treatment for their displaced fractures were included in this study. The conditions leading to delayed treatment mainly included severe swelling or skin problems around the elbow and the health facility problems unique to our district. The mean delaying time was 6 days (range 2-19 days). There were 24 males and 7 females with a mean age of 7 years (range 1-13 years). The fractures were classified as type III-A (n = 15; 48%) and type III-B (n = 16; 52%) according to Gartland. Surgical treatment consisting of sentiment manual reduction through a medial approach and percutaneous cross-pinning was applied to all. No image intensifier was used during the procedures. A long-arm splint was used for post-operative immobilization. The average hospital stay was 2 days (range 1-3 day) and the patients were followed clinically and radiographically for an average of 4 years (range 2-11 years). Pins were removed at the end of the third week post-operatively, at which time the range of motion exercises were begun. None of the patients required physical therapy and full functional recovery was achieved within 3 months in 29 (93.5%) patients and within 5 months in the remaining 2 (6.5%). Two (6.5%) pre-operative nerve injuries (1 interosseous, 1 ulnar) were resolved spontaneously within 3 months post-operatively. At the final follow-up, 7 (22.5%) patients had cubitus varus deformity. Except for 2 (6.5%) pin-tract infections, which were resolved by oral antibiotics and pin removal, none of the patients had early or late complications, not even neurological deficit or myositis ossificans. Delayed presentation of displaced supracondylar humerus fractures in children did not increase complication rates or unsatisfactory results following an open reduction. Medial approach and cross-pinning is an effective and reliable treatment method for these fractures.

Management of Supracondylar Fractures of the Humerus in Children

Background : Supracondylar fractures are the most common elbow fractures in children and account for 3 to 7% of all fractures.. Objectives : The purpose of the study was to review and analyze the treatment pattern of supracondylar humerus fractures in children. Methods : 112 children with supracondylar fractures were treated in the orthopaedic department of Rustaq Hospital, Oman between February 1998 and September 2003. 110 fractures were extension type while two were flexion type injuries and were not included in our study. Fractures were classified according to Gartland classification. Results : Type I fractures were seen in 25 patients, Type II fractures in 50 patients and 35 patients had type III fractures. Indications for treatment were determined according to fracture type. Patients were divided into two groups Group A patients (Type I) were treated by external immobolisation with posterior cast slab application. Group B (Type II / III) patients underwent closed reduction with percutaneous Kirschner wire fixation. Two patients in group B where closed reduction was unsatisfactory underwent open reduction and internal fixation. In group A patients, 4 (16%) had neurapraxias whereas in group B patients transient neurologic complications were seen in 20% cases and iatrogenic nerve injury in 1.1% cases. All neurologic complications in group A and B resolved over a period of 4 months. Vascular compromise was noted in three cases in group B patients. Two cases recovered and one patient had Volkmann's Ischemia with subsequent sequelae. None of the patients in group A had any vascular injuries. 90% of operated patients had good functional outcome. Conclusion : From our study we concluded that all manipulations should be performed immediately in order to avoid severe swelling, neurological or vascular complications. Indication for open reduction and internal fixation includes open fractures, unsatisfactory closed reduction and fractures associated with vascular injury. Keywords: Humerus, Supracondylar Fracture, Vascular CompromiseNigerian Journal of Orthopaedics and Trauma Vol. 6 (2) 2007: pp. 58-60

Osteosynthesis of supracondylar humerus fractures in children: A biomechanical comparison of four techniques

Crossed k-wire osteosynthesis is a widely used procedure for displaced supracondylar humerus fractures in children, but the rate of secondary displacements is up to 31%. Alternative techniques including casts, elastic stable intramedullary nailing, and the fixateur extern, have been used, but there are no biomechanical data comparing these methods. We developed a biomechanical model to compare four osteosynthesis techniques for stabilizing supracondylar humerus fractures in children. An osteotomy to simulate a fracture was made in a total of 32 adult cadaver humeri. The pseudofractures were then stabilized by crossed k-wires, elastic nailing, a fixateur extern with either k-wires, or Schanz screws. We measured the stiffness values in flexion and extension and torsion with static loading. The movements in cyclic loading were chosen to resemble the mechanism described in the development of a clinical cubitus varus. No significant differences were found with static loading. With cyclic loading all methods showed an irreversible torsional deformation less than 20 degrees . Crossed k-wires and elastic nailing showed significantly lower reversible torsional deformation than the external fixateurs. Our biomechanical data reveal that the crossed k-wires have the highest stiffness and lowest loss of reduction under cyclic loading. The external fixators proved to be good alternatives.

완전 전위된 소아 상완골 과상부 골절의 치료 방법 비교 -관혈 정복 후 내고정술과 도수 정복 후 경피적 핀 고정술의 결과 비교-

Purpose: To evaluate and compare the results of children with displaced supracondylar fractures of humerus treated with open reduction and pinning with closed reduction and pinning. Materials and Methods: From March 2002, we treated 17 patients with completely displaced supracondylar fractures under the age of 7 with a minimal follow up period of 6 months. 9 patients were treated with closed reduction and pinning and 8 patients were treated with open reduction and pinning. The clinical results were evaluated with Flynn`s criteria. Time to bone union was also analyzed for these two set of patients. Results: The group treated with open reduction had 6 excellent and 2 good results for change in carrying angles, 5 excellent, 2 good and 1 fair results for motion loss evaluated by Flynn`s criteria. The average time to bony union for this group was 5.8 weeks. The group treated with closed reduction had 6 excellent, 2 good, and 1 fair results for change in carrying angles and 7 excellent, 1 good and 1 fair results for motion loss. The average time to bony uinon for this group was 3.7 weeks. Conclusion: In treating completely displaced supracondylar fractures of humerus in children, the closed reduction method and open reduction method all showed good results. But the operation time, duration of hospital stay and time to union was somewhat shorter for the patients treated with closed redution and pinning.

SUPRACONDYLAR FRACTURES

Objective:- To determine the surgical approach most suited in our setup and evaluate the results based on the functional and cosmetic outcome especially in the range of motion,the subsequent defromity, if any, and the carrying angle. Setting Orthopaedic surgery, Nishtar Hospital, Multan. Duration Two years, Study design Quasi experimental type of study. Material & Methods Thirty patients. Sampling technique Non-probability technique. Results The age of the patients included in our study ranged from 4-10 years with a mean age of 5.93 years in group A and 6.66 years in group B. Out of 30 patients in group-A and 11 (73.3%) males and 4(26.6%) in group B had fracture on right side where as 12(80%) in group-A and 11(73.3%) in group-B got injured due to fall from height. One (6.66%) patients from group-A and B had superficial wound infection. Pin tract infection was found in 1(6.66%) in group A and 2(13.33%) patients in group-B. Conclusion: This technique was easy to perform and proved to be safe, although hospitalization time was minimum in both groups. So we recommend medial approach for open reduction and internal fixation of all displaced supra-condylar fractures of humerus in children with appropriate indications.

Neurovascular complications and severe displacement in supracondylar humerus fractures in children: defensive or offensive strategy?

Out of 210 children suffering from severely displaced supracondylar fractures, 76 (36%) presented with immediate neurovascular complications: 47 (22%) were neurological, 16 (8%) vascular and 13 (6%) both. Injury to two nerves simultaneously was observed in six patients. The median nerve was affected in 28 cases, the ulnar nerve in 25 and the radial nerve in 13. Posterolateral displacement was associated with 86% of damage to the median nerve and 56% of damage to the ulnar nerve. Posteromedial displacement was associated with all incidents of injury to the radial nerve with one exception. Each patient made full neurological recovery, spontaneously and following primary or secondary neurolysis performed on nerve injuries in continuity. Two situations of primary abolition of the radial pulse were encountered, one involving a pink hand in 12.5% of cases and the other involving a white hand in 1.5% of cases. There was posterolateral displacement in three out of four patients. Postoperative vascularization was revealed by immediate return of the radial pulse in 26 patients and delayed return in three others. Urgent anatomical reduction of the fracture and its early fixation are crucial. A conservative therapeutic approach is customary in the majority of neurovascular complications. Prognosis is generally excellent. Ischaemia of the limb and total ruptures of the nerve are very rare.

Management of Supracondylar Fractures of Humerus With Condylar Involvement in Children

The intent of this study was to heighten awareness and to present the authors' experience of an uncommon supracondylar humerus fracture in children. Twenty-two children were studied over a period of 18 years. The average age was 7 years, and oldest child was 11 years at time of injury. The fracture subtypes with medial condyle, lateral condyle, and intercondylar extensions were classified based on radiographs. The patients were followed for an average of 6.5 years. Eighteen injuries (82%) were graded excellent or good, and there were two each with fair or poor outcomes. The most common complication was loss of carrying angle of more than 10 degrees, which occurred in three children. The best results were seen in cases where three or four cross-fixing wires were used across the fractures. The authors recommend closed reduction techniques and percutaneous multiple cross-pin fixation for the displaced fracture. The fracture is unique and distinctive enough to warrant a designation as supracondylar fracture type IV with subtypes in the younger child.

Minimally Invasive Anterior Approach in Open Reduction of Displaced Supracondylar Fractures of Humerus in Children

Minimally Invasive Anterior Approach in Open Reduction of Displaced Supracondylar Fractures of Humerus in Children

Effect of Surgical Delay on Perioperative Complications and Need for Open Reduction in Supracondylar Humerus Fractures in Children

This retrospective study examined whether a delay of greater than 12 hours is associated with an increased risk of perioperative complications in the operative treatment of supracondylar humerus fractures in children. Of 150 consecutive children with supracondylar fractures, 50 underwent surgery in less than 12 hours and 100 underwent surgery greater than 12 hours after injury. There was no significant difference between groups in rate of open reduction (P = 0.55), pin tract infection (P = 1.0), iatrogenic nerve injury (P = 1.0), vascular complication (P = 0.33), or compartment syndrome (P = 1.0), including when Gartland type III fractures were analyzed independently. There was no iatrogenic nerve injury, no compartment syndrome, and one pin tract infection in 150 patients. The study confirms previous retrospective studies finding no significant difference in perioperative complications or rate of open reduction in children undergoing early versus delayed surgical treatment of supracondylar humerus fractures.

The Location of the Biceps Tendon in Completely Displaced Proximal Humerus Fractures in Children

The Location of the Biceps Tendon in Completely Displaced Proximal Humerus Fractures in Children

The Location of the Biceps Tendon in Completely Displaced Proximal Humerus Fractures in Children

The location of the biceps tendon is a matter of concern for clinicians treating completely displaced proximal humeral fractures in children. This article describes four patients (one 12-year-old boy, two 12-year-old girls, and one 14-year-old girl) who underwent magnetic resonance imaging evaluation of their fractures to discern the location of the biceps tendon. In no case did the tendon become entrapped in the fracture site. At latest follow-up (1.5, 2, 1, and 2 years, respectively), full pain-free shoulder function and only mild radiographic abnormality were documented. Further investigation of proximal humeral fracture displacement using an adult cadaver model revealed that even extreme fracture displacement did not result in biceps tendon entrapment. The only displacement pattern that resulted even in fracture fragment contact with the biceps tendon was one where the shaft fragment was displaced 100% anteriorly.

Severely Displaced and Rotated Lateral Condylar Fracture of Humerus in Children

Eight children between 4 and 10 years old with displaced and rotated fractures of the lateral humeral condyle were treated by open reduction and internal fixation. In all cases union occurred. There were no complications apart from one case developed stiff elbow which need manipulation under anaesthesia later on.

Completely displaced supracondylar humerus fractures in children:results of open reduction versus closed reduction

AbstractThis retrospective study was performed to under¬stand the clinical results after closed reduction and open reduction in 35 children (mean age 6.4 years) with completely displaced supracondylar fractures of the distal humerus between 1996 and 2000. Closed reduction (21 cases) was attempted, with open reduction (14 cases) indicated in irreducible cases with or without severe swelling. After an average follow-up of 22 months, according to Flynn’s criteria, the results were excellent in 18, good in 12, fair in 2, and poor in 3. The satisfactory results rates were similar for closed and open reduction. The unsatisfactory results were related to the poor initial reduction and redisplacement after operation. The mean Baumann’s angle was 8.7° in the closed reduction group and 6.6° in the open reduction group. None of the patients showed restricted elbow motion of more than 10°, even in two cases of hypertrophic scar in the open reduction group. Selective open reduction for displaced supracondylar fractures of the distal humerus produced as good results as closed reduction.

Treatment of Completely Displaced Supracondylar Fracture of Humerus in Children

Treatment of Completely Displaced Supracondylar Fracture of Humerus in Children