Pediatric Supracondylar Fractures Research Articles

The Effect of C-Arm Position on Radiation Exposure During Fixation of Pediatric Supracondylar Fractures of the Humerus.

Closed reduction and percutaneous pinning of a pediatric supracondylar fracture of the humerus requires operating directly next to the C-arm to hold reduction and perform fixation under direct imaging. This study was designed to compare radiation exposure from two C-arm configurations: with the image intensifier serving as the operating surface, and with a radiolucent hand table serving as the operating surface and the image intensifier positioned above the table. We used a cadaveric specimen in this study to determine radiation exposure to the operative elbow and to the surgeon at the waist and neck levels during simulated closed reduction and percutaneous pinning of a pediatric supracondylar fracture of the humerus. Radiation exposure measurements were made (1) with the C-arm image intensifier serving as the operating surface, with the emitter positioned above the operative elbow; and (2) with the image intensifier positioned above a hand table, with the emitter below the table. When the image intensifier was used as the operating surface, we noted 16% less scatter radiation at the waist level of the surgeon but 53% more neck-level scatter radiation compared with when the hand table was used as the operating surface and the image intensifier was positioned above the table. In terms of direct radiation exposure to the operative elbow, use of the image intensifier as the operating surface resulted in 21% more radiation exposure than from use of the other configuration. The direct radiation exposure was also more than two orders of magnitude greater than the neck and waist-level scatter radiation exposure. Traditionally, there has been concern over increased radiation exposure when the C-arm image intensifier is used as an operating surface, with the emitter above, compared with when the image intensifier is positioned above the operating surface, with the emitter below. We determined that, although there was a statistically significant difference in radiation exposure between the two configurations, neither was safer than the other at all tested levels. In contrast to traditional teaching regarding radiation exposure, neither C-arm configuration-with the image intensifier serving as the operating surface or with the image intensifier positioned above a radiolucent hand table-was shown to be clearly safer for pediatric supracondylar humeral fracture fixation.

Comparison of treatment outcomes between two surgical approaches for treating pediatric displaced supracondylar humeral fractures

Objective To compare the results between two surgical approaches for treating complex supracondylar humeral fractures in children.Methods Open reduction and internal fixation with Kirschner-wires were carried out through a posterior incision around the elbow to treat 34 cases of pediatric displaced supracondylar humeral fractures from July 2010 to December 2011.These cases were divided into two groups based on the way with which the triceps brachii was managed.In group A (triceps-splitting approach) the triceps was split in the midline to allow access,while in group B (paratricipital approach) access was gained via a lateral triceps approach.The patients were follow-up postoperatively for 16 to 32 months,with an average of 21.7 months.Objective and subjective functional results (elbow range of motion including flexion/extension and pronation/supination,the strength of triceps muscle,carrying angle,Mayo Elbow Performance Score) and radiographic data (Baumarm angle,humerocapitellar angle) were assessed.The last follow-up evaluations were compared between the two groups.Results Elbow range of motion,carying angle,Baumann angle and humerocapitellar angle were in the normal range for both groups.There was no difference between the two groups.No significant difference was found between the two groups in the percent strength of triceps muscle normalized against the healthy side.Both groups achieved 100 Mayo Elbow Score showing no differences between the groups.Conclusion The triceps-splitting approach and paratricipital approach have comparable clinical results when used to treat pediatric displaced supracondylar humeral fractures. Key words: Children; Fracture fixation, internal; Supracondylar humeral fracture; Functional assessment; Surgical approach

Paediatric supracondylar humeral fractures: Epidemiology, mechanisms and incidence during school holidays

PurposeThe purpose of this study was to investigate the epidemiology of paediatric patients sustaining supracondylar humeral fractures, to identify common mechanisms of injury and to corroborate the anecdotal evidence that fractures occur more frequently during school holidays.MethodsAll paediatric patients who presented to the accident and emergency department with a supracondylar distal humerus fracture over the 3-year period from 1 July 2008 to 30 June 2011 were included in the study. Data were collected from the electronic medical records and radiology picture archiving and communication system (PACS) regarding age at injury, sex, Gartland type, date of injury, mechanism and management. The dates of all school holidays during the study period were obtained from the local education authority website.ResultsA total of 159 patients were identified, with a median age of 6 years 1 month (range 1 year to 14 years 4 months); 53 % of patients were male. The 155 extension-type injuries comprised 46, 28 and 26 % Gartland I, II and III fractures, respectively. Sixty-five patients (41 %) were treated operatively. Six patients had either neurological and/or vascular complications; however, none had any long-term neurological compromise and none required vascular surgical intervention. The mechanism of injury was recorded in 118 cases, the majority (37 %) of which were sustained during falls from play equipment. Among the patients, 115 were of school age. The weekly incidence during school holidays was significantly higher than that during term-time (1.16 vs. 0.60, p = 0.0005).ConclusionsThis study demonstrates the epidemiology of paediatric supracondylar fractures managed at a district general hospital over a 3-year-period. This work supports the long-standing anecdotal evidence that play equipment carries a high risk of injury and that the incidence of supracondylar fractures is significantly higher during school holidays.

Near-infrared spectroscopy for detection of vascular compromise in paediatric supracondylar fractures

Children suffering supracondylar fractures of the humerus are at risk of vascular compromise, which is currently assessed clinically, although other modalities such as angiography, pulse oximetry, Doppler ultrasound and magnetic resonance angiography have been used. We sought to ascertain whether tissue haemoglobin oxygenation (StO2) measurement could distinguish between patients with and without clinical vascular compromise following supracondylar fractures of the humerus. We prospectively observed StO2 using near-infrared spectroscopy in 29 paediatric patients with supracondylar fractures requiring operative manipulation. The injured and uninjured volar forearm compartments were monitored immediately before and after fracture reduction. The relationship between StO2 in the injured and uninjured limb, and the presence of pre-operative vascular compromise was assessed. Seven out of 29 children presented with vascular compromise. Patients with clinical vascular compromise had significantly lower pre-reduction StO2 (63.5% ± 15%, mean ± standard deviation), compared to those without compromise (80.9% ± 10%). StO2 normalized following surgery in all children with vascular compromise. These improvements in muscle StO2 were associated, in all patients, with the clinical return of pulses and resolution of neurological symptoms if present. StO2 monitoring can identify patients with clinical vascular compromise, can identify the return of adequate perfusion following operative correction of supracondylar fractures, and may be a useful adjunct to clinical assessment.

The displaced supracondylar humerus fracture

Supracondylar humerus fractures are the most common elbow fractures in children. Choice of treatment may be guided by the Gartland classification. Recent studies recommend conservative management for non or minimally displaced fractures, whereas there seems to be a trend towards surgical intervention for all displaced fractures. The purpose of this review is to discuss the various treatment options for displaced supracondylar humerus fractures. Closed reduction and percutaneous pinning are the preferred treatment options for most displaced pediatric supracondylar fractures of the humerus. The ideal pin configuration has always been subject to great controversy. It is well known that placement of a medial pin carries the risk of iatrogenic ulnar nerve injury, whereas lateral pinning carries an increased risk of median neuropathy. Therefore, given the potential risk, it is recommended to avoid medial pinning to prevent damage to the ulnar nerve and stabilize the fracture with two or three lateral pins. Today, the preferred treatment of displaced supracondylar humerus fractures in children is immediate closed reduction and percutaneous fixation with two or three lateral pins. In case of instability of the medial column, a medial pin may be used, but possibility of iatrogenic ulnar nerve injury should be considered.

Children’s orthopaedics

The December 2013 Children’s orthopaedics Roundup360 looks at: Long term-changes in hip morphology following osteotomy; Arthrogrypotic wrist contractures are surgically amenable; Paediatric femoral lengthening over a nail; Current management of paediatric supracondylar fractures; MRI perfusion index predictive of Perthes’ progression; Abduction bracing effective in residual acetabular deformity; Hurler syndrome in the spotlight; and the Pavlik works for femoral fractures too!

Answer to first reply to “Delayed surgery in displaced paediatric supracondylar fractures: a safe approach? Results from a large UK tertiary paediatric trauma centre”

We thank Mr Huntley for his careful review of our paper and the associated literature. We acknowledge his concern regarding the low rates of well-documented pre-operative neurological examinations within this cohort, and too his concern regarding the high rate of iatrogenic nerve injury. We recognise that both of these factors are a cause for concern and that high iatrogenic injury may be erroneously attributed as a result of poor recognition of pre-operative nerve injury. The ‘test’ of neurological documentation was set deliberately high in the original paper investigating neurovascular documentation [1]—that is, we required documentation of individual nerves in terms of sensory and motor function, such as is required for medicolegal purposes. The reality is that most pre-operative documentation was probably of similar quality to other units (i.e. a mere statement of ‘neurovascualarly intact’). Indeed, we are aware that your group has demonstrated similar problems with neurovascular documentation, particularly with the anterior interosseous nerve (AIN) [2]. In our case series, 9.5 % (19/137) of patients had pre-operative neurovascular deficit identified at presentation. We acknowledge there were several cases with incomplete documentation preoperatively that may have contributed to the high iatrogenic nerve rates. We have now implemented an assessment proforma to help facilitate accurate and detailed pre-operative neurovascular assessment and documentation, and detailed documentation has now increased from 8.8 % (12/137) to 81.6 % (31/38). We also acknowledge your comment that an absence of evidence does not equate to evidence of absence. Retrospective observational data, such as this, has intrinsic error, which limits the utility and generalisability of the findings. We agree that definitive evidence to support delaying supracondylar surgery must come from either a welldesigned prospective observational cohort study, or an interventional study. We hope our paper adds to the growing discussion within the literature and encourages greater collaboration amongst children’s orthopaedic surgeons to address this, and other fundamental questions of paediatric orthopaedics.

First Reply to: Delayed surgery in displaced paediatric supracondylar fractures: a safe approach? Results from a large UK tertiary paediatric trauma centre

First Reply to: Delayed surgery in displaced paediatric supracondylar fractures: a safe approach? Results from a large UK tertiary paediatric trauma centre

The epidemiology of paediatric supracondylar fracture fixation: A population-based study

IntroductionThe epidemiology of paediatric supracondylar fracture (SCF) fixation has not been evaluated at a population level. The purpose of this study was to: (1) determine the incidence density rate (IDR) of SCF fixation and (2) determine the rate of and risk factors for re-operation. MethodsUsing administrative databases, all patients who underwent SCF fixation (closed reduction percutaneous pinning (CRPP) or open reduction (OR)) in Ontario between April 2002 and March 2010 were identified. Exclusion criteria included age (>12 years), a prior or concurrent non-SCF elbow fracture or previous humeral osteotomy. The overall IDR of SCF fixation and for subgroups of age, sex and season were calculated. A multivariate regression (immediate and short-term re-operation) and a Cox proportional hazards model (long-term re-operation) were used to identify patient, injury and provider factors that influenced re-operation risk and were reported as odds ratios or hazard ratios (HRs) with 95% confidence intervals (CIs), respectively. ResultsA total of 3235 patients with a median age of 6.0 years (interquartile range (IQR): 3.0) underwent SCF fixation. The median follow-up was 6.0 years (IQR: 3.7). The majority underwent a CRPP (78.7%) which were performed after hours (75.6%). The overall IDR was 20.7/100,000person-years (py), but it varied significantly by season and age. Re-operation was uncommon in the immediate (1.0%), short-term (1.4%) and long-term (0.3%) follow-up period. As compared to CRPP, patients who underwent OR were more likely to undergo early nerve exploration (odds ratio: 7.8 (CI: 3.0–20.6)) and re-operation in the long term (HR: 3.0 (CI: 1.0–8.7)). Increased surgeon volume of SCF fixation was protective against repeat fixation (odds ratio: 0.9 (CI: 0.9–1.0)) and re-operation in the long term (HR: 0.9 (CI: 0.8–1.0)). ConclusionsWhile SCF fixation is common, the rate of re-operation is low. No differences existed between the sexes and a higher volume of fixations occurred during the summer months.

Height, Age Identified as Greater Risk Factors in Pediatric Distal Humeral Supracondylar Fractures

Height, Age Identified as Greater Risk Factors in Pediatric Distal Humeral Supracondylar Fractures

Orthopaedic Resident Preparedness for Closed Reduction and Pinning of Pediatric Supracondylar Fractures Is Improved by e-Learning

There is a need to provide more efficient surgical training methods for orthopaedic residents. E-learning could possibly increase resident surgical preparedness, confidence, and comfort for surgery. Using closed reduction and pinning of pediatric supracondylar humeral fractures as the index case, we hypothesized that e-learning could increase resident knowledge acquisition for case preparation in the operating room. An e-learning surgical training module was created on the Computer Enhanced Visual Learning platform. The module provides a detailed and focused road map of the procedure utilizing a multimedia format. A multisite prospective randomized controlled study design compared residents who used a textbook for case preparation (control group) with residents who used the same textbook plus completed the e-learning module (test group). All subjects completed a sixty-question test on the theory and methods of the case. After completion of the test, the control group then completed the module as well. All subjects were surveyed on their opinion regarding the effectiveness of the module after performing an actual surgical case. Twenty-eight subjects with no previous experience in this surgery were enrolled at four academic centers. Subjects were randomized into two equal groups. The test group scored significantly better (p < 0.001) and demonstrated competence on the test compared with the control group; the mean correct test score (and standard deviation) was 90.9% ± 6.8% for the test group and 73.5% ± 6.4% for the control group. All residents surveyed (n = 27) agreed that the module is a useful supplement to traditional methods for case preparation and twenty-two of twenty-seven residents agreed that it reduced their anxiety during the case and improved their attention to surgical detail. E-learning using the Computer Enhanced Visual Learning platform significantly improved preparedness, confidence, and comfort with percutaneous closed reduction and pinning of a pediatric supracondylar humeral fracture. We believe that adapting such methods into residency training programs will improve efficiency in surgical training.

Delayed surgery in displaced paediatric supracondylar fractures: a safe approach? Results from a large UK tertiary paediatric trauma centre

Displaced paediatric supracondylar humeral fractures pose a significant risk of neurovascular injury and consequently have traditionally been treated as a surgical emergency. Recently, the need for emergency surgery has been questioned. We wished to analyse our experience at a large UK tertiary paediatric trauma centre. A retrospective case note review was performed on patients with Gartland Grades 2 and 3 supracondylar fractures observed in a 2-year period from July 2008 to July 2010. We divided children into those treated before 12 h (early surgery) and after 12 h (delayed surgery). Analysis was undertaken using Fisher's exact test. Of the 137 patients, 115 were included in the study; median time-to-surgery was 15:30 (range 2:45-62:50); thirty-nine children were treated before 12 h and 76 patients after. In the early surgery group, three children (7.7%) developed a superficial pin-site infection, four children (10.3%) required open reduction, five children (12.8%) sustained an iatrogenic nerve injury, and two children (5%) required reoperation. In the delayed surgery group, one child (1.3%) had a superficial pin-site infection, four children (5.3%) required open reduction, seven children (9.2%) sustained an iatrogenic nerve injury, and two children (2.6%) reoperation. Bivariate analysis of our data using Fisher's exact t test revealed no statistically significant difference between early and delayed surgery groups with regard to infection rates (p = 0.1), iatrogenic nerve injury (p = 0.53) or need for open reduction (p = 0.44). Our results indicate that delayed surgery appears to offer a safe management approach in the treatment of displaced supracondylar fractures, but it is important that cases are carefully evaluated on an individual basis. These results indicate that patient transfer to a specialist paediatric centre, often with consequent surgical delay, is a safe management option and also negates the obligation to carry out these procedures at night.

Does cubitus varus cause morphologic and alignment changes in the elbow joint?

In cubitus varus after pediatric supracondylar fracture, late development of trochlear deformity causing additional varus angulation and joint misalignment relating to late complications of the tardy ulnar nerve palsy or posterolateral rotatory instability have been suggested. However, it is unclear whether these morphologic and alignment changes of the elbow joint occur in cubitus varus. The object of this study was to investigate morphologic changes of the bones and alignment changes of the elbow joint in longstanding cubitus varus using 3-dimensional computer bone models created from computed tomography data. We studied 14 patients with longstanding cubitus varus after pediatric supracondylar fractures. Three-dimensional bone models of the bilateral humerus, radius, and ulna were created from computed tomography data. We compared the morphology and alignment of the elbow joint between the affected side and contralateral unaffected side. The posterior trochlea, distal part of the lateral capitellum, diameters of the radial head, and articular surface of the ulna in cubitus varus were larger than those of the contralateral elbow. In the ulna, the convex portion of the trochlear notch shifted laterally in cubitus varus. Joint alignment in cubitus varus was affected by a shift of the ulna to a more distal and medial position with external rotation and flexion. In longstanding cubitus varus, the morphology and alignment of the elbow joint are observed to differ from those of the normal side.

Surgical Outcomes of Pediatric Humeral Supracondylar Fractures Treated By Posterior Approach and Triceps Splitting

Background: A significant number of complications that maybe occur with surgical treatment of humeral supracondylar fractures in children are approach related. In this study we tried to compare the outcome of triceps splitting (posterior approach) with other approaches. Methods: Thirty six consecutive children with displaced Gartland Type III extension supracondylar fractures underwent open reduction and internal fixation in our university hospital from March 2005 to March 2011. They were divided into three groups on the basis of surgical approach; Group A (14 patients) posterior approach with triceps splitting, Group B (10patients) posterior approach with tongue shape flap, and Group C (12 patients) lateral, anterolateral, or medial approach. Results: In group A, range of motion was graded as excellent in 71.43%, good 21.43%, and fair 7.14%. In group B, the range of motion was excellent in 70%, good 20%, and fair 10%. Deformity was observed in one patient (10%). In group C the range of motion of the elbow was excellent in 66.6%, good 16.7%, and fair 16.7%. Deformity was seen in two (16.7%) patients. Pin tract infection was seen in one patient in each group. Conclusion: In surgical treatment of humeral supracondylar fracture with normal neurovascular state in children, due to its simplicity, greater exposure, lack of interference with vital structures, and better surgical outcome, the posterior approach particularly posterior triceps splitting method is advocated.

Osteoid Osteoma of the Distal Humerus Mimicking Sequela of Pediatric Supracondylar Fracture: Arthroscopic Resection—Case Report and A Literature Review

Osteoid osteoma (OO) is a small and painful benign osteoblastic tumour located preferentially in the shaft of long bones near the metaphyseal junctions, with a predilection for the lower limbs. Juxta- and intra-articular OOs are rare and even though hip, elbow, and talus are the most commonly reported locations, they may be found in any joint accounting for approximately 13% of all osteoid osteomas. There is usually a significant time delay between symptom initiation and diagnosis when the lesion is present in an uncommon location due to the diagnostic challenge it presents due to the lack of classical clinical signs and/or radiographic features found in the extra-articular lesions. A case of a distal humerus OO of a 15-year-old girl is presented to point out that a confounding factor, such as a previous paediatric supracondylar fracture, may further delay the already difficult diagnosis of a juxta- or intra-articular osteoid osteoma and also to emphasize the possibility of arthroscopic treatment of such lesions.

A simple tip to improve the accuracy of crossed K-wire placement in the management of displaced paediatric supracondylar fractures of the humerus

A simple tip to improve the accuracy of crossed K-wire placement in the management of displaced paediatric supracondylar fractures of the humerus

Compared outcomes after percutaneous pinning versus open reduction in paediatric supracondylar elbow fractures

Supracondylar fractures of the elbow are common in children. Their treatment is controversial when displacement has occurred, although percutaneous pinning is usually advocated. In paediatric extension-type supracondylar fractures of the elbow, percutaneous pinning and crossed K-wire fixation after open reduction via the medial approach produce similar functional outcomes and complication rates. We retrospectively reviewed the medical charts of 58 children aged 2 to 15 years who underwent surgery for extension-type supracondylar elbow fractures between 2004 and 2008. Closed reduction and percutaneous pinning was used in 33 patients with a mean age of 7 years and 11 months; open reduction with cross-wiring in 25 patients with a mean age of 7 years. Functional outcomes were assessed using Flynn's criteria. Baumann's angle was determined and postoperative complications and sequelae were recorded. Outcomes were satisfactory in 30 (90.9%) patients treated with percutaneous pinning and in 23 (92%) patients treated with open reduction and cross-wiring. Mean Baumann's angle at last follow-up was 73.9±5.74° after percutaneous pinning and 74.76±4.07° after open reduction and cross-wiring. Postoperative complications consisted of reoperation in six (10.3%) patients and iatrogenic nerve injury in two (3.4%) patients. Cubitus varus occurred in two (6.06%) patients after closed treatment and in one (4%) patient after open treatment. In each group, three (5.1%) patients had greater than 15° of motion range limitation. In children with extension-type supracondylar elbow fractures, outcomes are similar with percutaneous pinning and with open reduction via the medial approach followed by cross-wiring. Level IV, retrospective study.

The Treatment of Displaced Supracondylar Humerus Fractures

Supracondylar humerus fractures are widely considered the most common fracture of the elbow in children. Fractures can range from a less severe, nondisplaced type I fracture to a more severe, displaced type III fracture with no cortical contact. Type III fractures can lead to adverse physical, social, and emotional consequences if they are not treated effectively. The American Academy of Orthopaedic Surgeons recently carried out a systematic review of the literature to develop a clinical practice guideline. The guidelines provided answers for the following questions regarding the treatment for type III supracondylar fractures (1) which is the preferred treatment for displaced supracondylar fractures of the humerus: reduction and casting versus closed reduction and percutaneous pinning; (2) which is the preferred method for fixing displaced supracondylar fractures of the humerus: medial (crossed) versus lateral pinning; and lastly, (3) does open reduction cause increased stiffness or have a high rate of complication? The purpose of this paper is to summarize and highlight the major findings from this systematic review. PubMed, EMBASE, CINAHL, and The Cochrane Central Register of Controlled Trials were searched to locate 1726 relevant articles published from January 1966 to July 29, 2010. Of these, 44 met our criteria for inclusion and were reviewed systematically. On the basis of the results from the systematic review: (1) we suggest closed reduction with pin fixation for patients with displaced (eg, Wilkins type II and III and displaced flexion) pediatric supracondylar fractures of the humerus. (2) The practitioner might use 2 or 3 laterally introduced pins to stabilize the reduction of displaced pediatric supracondylar fractures of the humerus. Considerations of potential harm indicate that the physician might avoid the use of a medial pin. (3) The practitioner might perform open reduction for displaced pediatric supracondylar fractures of the humerus after closed reduction if varus or other malposition of the bone occurs. Clearly, controversy exists regarding the best treatments for pediatric supracondylar humerus fractures. Properly designed randomized controlled trials comparing treatment options are necessary to determine optimal treatments. Level II.

Delayed surgery in displaced paediatric supracondylar fractures; results from liverpool

Delayed surgery in displaced paediatric supracondylar fractures; results from liverpool

Delayed surgery in displaced paediatric supracondylar fractures: Results from liverpool

Delayed surgery in displaced paediatric supracondylar fractures: Results from liverpool