Pediatric Supracondylar Humeral Fractures Research Articles

Clinical and radiographic outcomes after paediatric supracondylar humeral fractures treated with combined intramedullary and lateral wire fixation: our experience in fifty-one cases.

Displaced supracondylar humerus fractures in children are known for their high rate of complications and require urgent surgical treatment. Basically, there are two methods of fracture fixation: the lateral pin technique and the crossed pin technique. However, the best technique remains debated. The aim of this study was to evaluate the clinical and radiographic outcomes of our method of fixation using combined intramedullary and lateral wires for treatment of displaced supracondylar humeral fractures in paediatric patients. Fifty-one paediatric patients were treated for displaced supracondylar humeral fractures. The method of fracture fixation used consists of two Kirschner wires inserted one intramedullary and the other laterally. Clinical and radiographic outcomes were assessed at last follow-up. According to Gartland's classification, 17 fractures (33%) were type 2 and 34 (67%) were type 3. The mean follow-up period was 7.8months. Functional outcome according to Flynn's criteria was satisfactory in all cases with 92% graded as excellent or good. Cosmetic outcome according to Flynn's criteria was satisfactory in all cases. Radiologically, at last follow-up, the mean Baumann angle was 69° (63-82°) and the mean lateral capitellohumeral angle was 41° (32-50°). Patients managed with combined intramedullary and lateral wires experience satisfactory results. Moreover, this technique, without risk for the ulnar nerve, can be interesting in the treatment of infrafossal fractures and fractures with anterior displacement.

Incidence, risk factors, and consequences of radiographic pin migration after pinning of pediatric supracondylar humeral fractures.

Current literature on pin migration is inconsistent and its significance is not understood. We aimed to investigate the incidence, magnitude, predictors, and consequences of radiographic pin migration after pediatric supracondylar humeral fractures (SCHF). We retrospectively reviewed pediatric patients treated with reduction and pinning of SCHF at our institution. Baseline and clinical data were collected. Pin migration was assessed by measuring the change in distance between pin tip and humeral cortex on sequential radiographs. Factors associated with pin migration and loss of reduction (LOR) were assessed. Six hundred forty-eight patients and 1506 pins were included; 21%, 5%, and 1% of patients had pin migration ≥5 mm, ≥10 mm, and ≥20 mm respectively. Mean migration in symptomatic patients was 20 mm compared to a migration of 5 mm in all patients with non-negligible migration ( P < 0.001). Pin migration > 10 mm was strongly associated with LOR [odds ratio (OR) = 6.91; confidence interval (CI), 2.70-17.68]. Factors associated with increased migration included increased days to pin removal ( β = 0.022; CI, 0.002-0.043), migration outwards versus inwards ( = 1.02; CI, 0.21-1.80), and BMI > 95th percentile (OR = 1.63; [1.06-2.50]). Factors not associated with migration included cross-pinning, number of pins, and fracture grade. In summary, we identified a 5% incidence of radiographic pin migration ≥ 10 mm and determined the factors associated with it. Pin migration became radiographically significant at >10 mm where it was strongly associated with LOR. Our findings contribute to the understanding of pin migration and suggest that interventions targeting pin migration may decrease the risk of LOR. Level of Evidence: Level III - Retrospective Cohort Study.

PROTOCOL FOR EXAMINING TRANSFER VALIDITY OF A SUPRACONDYLAR HUMERAL FRACTURE PINNING AUGMENTED REALITY SIMULATOR

Augmented reality simulators offer opportunities for practice of orthopaedic procedures outside of theatre environments. We developed an augmented reality simulator that allows trainees to practice pinning of paediatric supracondylar humeral fractures (SCHF) in a radiation-free environment at no extra risk to patients. The simulator is composed of a tangible child's elbow model, and simulated fluoroscopy on a tablet device. The treatment of these fractures is likely one of the first procedures involving X-ray guided wire insertion that trainee orthopaedic surgeons will encounter. This study aims to examine the extent of improvement simulator training provides to real-world operating theatre performance.This multi-centre study will involve four cohorts of New Zealand orthopaedic trainees in their SET1 year. Trainees with no simulator exposure in 2019 - 2021 will form the comparator cohort. Trainees in 2022 will receive additional, regular simulator training as the intervention cohort. The comparator cohort's performance in paediatric SCHF surgery will be retrospectively audited using routinely collected operative outcomes and parameters over a six-month period. The performance of the intervention cohorts will be collected in the same way over a comparable period. The data collected for both groups will be used to examine whether additional training with an augmented reality simulator shows improved real-world surgical outcomes compared to traditional surgical training. This protocol has been approved by the University of Otago Health Ethics committee, and the study is due for completion in 2024.This study is the first nation-wide transfer validity study of a surgical simulator in New Zealand. As of September 2022, all trainees in the intervention cohort have been recruited along with eight retrospective trainees via email. We present this protocol to maintain transparency of the prespecified research plans and ensure robust scientific methods. This protocol may also assist other researchers conducting similar studies within small populations.

Does posterior approach always lead to poor functional and cosmetic outcomes in displaced pediatric supracondylar humeral fractures?

Supracondylar humerus fractures (SCHFs) are the most common types of elbow fractures in children. Closed reduction percutaneous pinning (CRPP) is the primary surgical treatment of SCHFs. In cases that cannot be managed with closed reduction, treatment with open reduction and internal fixation (ORIF) is necessary. We aimed to compare CRPP and ORIF through a posterior approach regarding clinical and functional outcomes in pediatric SCHF cases. Patients with Gartland type III SCHF who underwent CRPP or ORIF with posterior approach at our clinic between January 2013 and December 2016 were included in this retrospective study. A total of 60 patients who underwent surgical treatment and had available data on our hospital database and no additional injuries were included in the study. We analyzed their data concerning age, gender, fracture type, neurovascular damage, and surgical treatment. In addition, we inspected the patients' anteroposterior and lateral radiographs at 1-year follow-up visits for Baumann (humerocapitellar) angle (BA) and carrying angle (CA) and checked their go-niometer assessments of elbow range of motion (ROM). The cosmetic and functional outcomes were determined using Flynn's criteria. Demographic, preoperative, and post-operative data of 60 patients between the ages of 2-15 were analyzed. 46 of these patients had CRPP, and 14 had posterior ORIF. CA, Baumann angle, and lateral capitello-humeral angle were measured for fractured elbow and contralateral elbow and compared statistically. There was no statistically significant difference between the two surgical ap-proaches in terms of CA (p=0.288), Baumann's angle (p=0.951) and LHCA (p=0.578). At the end of 1-year follow-up, elbow ROM was measured, and there was no statistically significant difference between the two groups (p=0.190). Furthermore, there is no statistically significant difference between the two surgical approaches in terms of both cosmetic (p=0.814) and functional (p=0.319) outcomes. A comprehensive literature review of pediatric SCHF shows that surgeons do not frequently prefer posterior incisions in Gartland type III fracture that cannot be managed with closed reduction. However, posterior open reduction is a safe and effective method since it provides more control over the distal humerus, allows for a complete anatomical reduction involving both cortices, reduces the risk of ulnar nerve injury, thanks to the nerve exploration, and yields positive cosmetic and functional outcomes.

Comparative Outcome of Three Different Approaches for Supracondylar Humeral Fractures in Children in Khyber Pakhtunkhwa, Pakistan

Background: The closed reduction and percutaneous pinning are the min treatment approaches tested in pediatric humerus supracondylar fractures but the treatment approach preferred in fractures without closed reduction is remains unclear. Objectives: The purpose of this study was to compare three common orthopaedic procedures for treating children with supracondylar humerus fractures of the displaced extension type. Methods: The current retrospective analytical study was started in the Department of Orthopedic at Khyber Teaching Medical College from 2015 to 2020, with the approval of the clinical research ethics committee. This analysis was conducted on 64 patients between the ages of 1 and 12 years who underwent hospital surgery for Gartland IIb, Gartland IIb, and Gartland III supracondylar humerus fracture. Results: A total of 64, 22 patients were from group A, in which 18 (81.81%) were male and only 4 (18.18%) were female, while in group B and C were 21 (80.76%), 5 (19.23%) and 14 (87.5%), 2 (12.50%) male and female, respectively. The injury on left elbow and right elbow in group A was recorded 68.18 and 31.81%, respectively. Among the total injured children, the left elbow was fractured in 47 (73.43%) case and the right one in 7 (10.93%). Approximately the duration of injury to therapeutic procedure was recorded 7.53±3.03 hours in the study. When compared to the group of displaced supracondylar humeral fractures that were conservatively handled, the functional and aesthetic treatment outcomes between the closed and open reduction with K-wire fixation groups were significantly different. According to this system, excellent, fair, good and poor functional outcomes were recorded in 10 (45.45%), 6 (27.27%), 4 (18.18%) and 2 (9.09%) patients of A group, respectively, while 13 (50%), 5 (19.23%), 5 (19.235), and 3 (11.50%) patients in group B, respectively. The poor and fair functional outcome was noted in 1 (6.25%) and 3 (18.75%) patients, respectively in group C. Practical implication: This is a critical surgical condition in children and they should be provided with the appropriate treatment to acquire the child's ability of movement. According to our findings among three management techniques, the most favorable was open reduction with K-wire fixation, and therefore was recommended with good success rate. Conclusion: It was thus concluded that open reduction with K-wire fixation is a good alternative to closed reduction with percutaneous pinning for treating displaced pediatric supracondylar humeral fracture. Keywords: Children; Supracondylar humerus fracture; Surgical treatment; Pediatric fractures; Pakistan

Closed reduction with percutaneous Kirschner wire drill-and-pry for pediatric supracondylar humeral fractures with bony callus formation and delayed presentation

BackgroundSupracondylar humeral fractures are the most common type of pediatric elbow fractures, and are primarily treated using closed reduction and percutaneous pinning. For patients who are treated ≥14 days after the injury, after callus formation has occurred, closed reduction is usually not possible. The purpose of this study is to report the clinical outcomes of closed reduction with percutaneous Kirschner wire (K-wire) drill-and-pry for the delayed treatment of pediatric supracondylar humeral fractures with bony callus formation. MethodsWe retrospectively reviewed the data of 16 patients who underwent percutaneous K-wire drill-and-pry between November 2019 and August 2021 for the treatment of supracondylar humeral fractures with bony callus formation ≥14 days after the injury. Clinical outcomes were assessed using the Flynn criteria. The postoperative Baumann angle and pin configuration were evaluated using x-ray examinations. ResultsAll patients were followed up for 8–28 months (average, 16.63 months). The fractures healed in 4–6 weeks (average, 4.38 weeks). The operative time ranged from 10 to 124 min (average, 35.12 min). No iatrogenic vascular or nerve injury occurred. No patient developed cubitus varus. According to the Flynn criteria, 12 patients had excellent outcomes, 2 patients had good outcomes, 1 patient had a fair outcome and 1 patient had a poor outcome. ConclusionClosed reduction with percutaneous K-wire drill-and-pry is a mini invasive technique for supracondylar humeral fractures with bony callus formation in children. Most patients had a good clinical and cosmetic outcomes without scarring.

Forearm Compartment Pressure Change in Children Operated for Supracondylar Humerus Fracture.

The aim of this study is to examine the preoperative and postoperative forearm compartment pressures in patients treated operatively for Gartland type III extension type supracondyler humerus fractures and understand the course of these values over postoperative period. Deep volar compartment pressure of 31 patients were measured in the proximal one third of the forearm preoperatively, and measurements were continued every 4 hours for the first 24 hours after the operation with a catheter. Type of the reduction technique (open reduction vs. closed reduction), duration of surgery, the time from the injury to surgery were all evaluated. In the measurements made immediately after the operation (0 h), a sudden increase in the compartment pressure was detected in all patients (15.0±5.9 to 27.9±7.5mmHg) independent of the reduction technique and gradually decreased over time. The mean compartment pressure at the 12th hour postoperatively was higher in the open reduction group than in the CR group (24.5±3.4, 20.7±6.7mmHg, respectively) ( P =0.044). The mean preoperative compartment pressure was 17.7±5.8mmHg in patients with a time from injury to surgery longer than 12 hours, and 12.4±4.8mmHg in patients with 12 hours or less ( P =0.006). The postoperative 0-, 12-, and 20-hour pressure values were higher in the >1 hour operation time group than in the ≤1 hour group and the differences were statistically significant ( P =0.046, 0.016, and 0.032, respectively). In pediatric supracondylar humeral fractures, those who underwent open reduction had higher preoperative and postoperative compartment pressures. The reduction attempt was found to be a factor that increased the compartment pressure and after the operation, the compartment pressure values decrease gradually. Prolonged operative time (>1h) and increased time from injury to operative fixation (>12h) were associated with higher compartment pressures. Level II-prospective study.

Integrating Simulation for Developing Pediatric Supracondylar Humeral Fracture Reduction and Fixation Skills into an Orthopaedic Surgery Residency Program

Supracondylar humeral fractures are the most common fracture managed with surgical intervention in the pediatric population. Academic providers involved in orthopaedic resident education must have confidence in the resident teams who help to manage these injuries. Surgical simulation of pediatric supracondylar humeral fractures provides orthopaedic residents an ideal setting to develop and refine their surgical technique to a defined level of proficiency. Through refinement of surgical techniques developed on a pediatric supracondylar humeral fracture model, all residents trained in this manner would be expected to be proficient and safe when performing the basic principles of surgery prior to experiencing them in a live operating room on a real pediatric patient. Surgeon confidence and skill can be increased while simultaneously decreasing operating room time, radiation exposure, and potentially improving patient outcomes. Residents at our institution have found working with the pediatric supracondylar humeral fracture simulation model very positive and beneficial. Participants report that the simulator improves their performance and increases their confidence in the operating room, scoring 4.8 and 4.5 out of 5, respectively.

Standalone Axial Malrotation after Pediatric Supracondylar Fracture Does Not Seem to Be an Indication for Immediate Postoperative Revision Surgery.

Rotational spurs as evidence for post-surgical malrotation are frequently observed when treating pediatric supracondylar humeral fractures (SCHFs). This study aimed to investigate the long-term outcome of a pediatric cohort with unrevised axial malrotation and to discuss the indication for revision surgery. Postoperative radiographs of children treated for SCHFs over eight years were retrospectively analyzed. Children with radiological signs of malrotation (von Laer malrotation quotient) were invited for a follow-up clinical and radiological examination. Among 338 treated children, 39 (11.5%) with a mean age of 5.3 years (range 1.8–11.7 years) showed radiological signs for postoperative malrotation and were not revised and therefore invited to participate in the study. Twelve patients (31%) with a mean age of 11.3 years (range 8.8–13.8 years) took part in the follow-up examination after a mean of 7.1 years (range 5.4 to 11.3 years). The mean postoperative van Laer malrotation quotient was 0.15 (range 0.11–0.2). At follow-up, the range of motion of the elbow joint was not significantly different compared to the contralateral side. Apart from the humeral ulnar angle (p = 0.023), there were no significant differences in the radiological axes. The Flynn criteria were excellent and good in 90% of the cases. The mean was 1.7 points indicating excellent subjective results. Standalone postoperative malrotation did not lead to an adverse long-term outcome in a small cohort of pediatric patients with SCHFs and did not indicate immediate postoperative revision surgery. However, further investigations with larger cohorts should verify whether additional criteria such as stability of the osteosynthesis and signs for increasing valgus or varus displacement in the follow-up radiographs should get more importance in decision making.

Pediatric distal humeral supracondylar fracture - achievement of optimal pinning configuration.

Pediatric supracondylar humeral fracture is com- monly managed using closed reduction and per- cutaneous Kirschner wires pinning. However, there is no consensus on optimal pinning configuration in the literature. Our study aims to review the pinning configuration in our department, correlate our results with the available literature, and suggest the optimal configuration using basic biomechanics principles. We performed a retrospective review on children that were treated with K-wire pinning for supracondylar fracture at our institution between August 2017 and August 2019. Intra-operative antero-posterior view fluoroscopic images were used to measure the pin separation ratio (PSR), pin crossing angle (PCA), medial inclination angle (MIA) and lateral inclination angle (LIA). Pearson Correlation was used to identify the relationship between the variables. Ninety-one patients were included for analysis (39 male: 52 female), with a mean age of 6. Average PCA in the crossed pin and lateral-entry only technique CA was 75° and 12°, respectively. Mean crossed pin and lateral-entry only technique PSR is 0.54 and 0.17, respectively. There was a significant difference in both mean PSR and PCA between the configurations (p <0.01). In subgroup analysis, optimal PSR > 0.33 and PCA >90° were best achieved in crossed pinning using 1 medial and 2 lateral pins. Assessing the biomechanical characteristics of the different fixation techniques, we have found that 2 lateral divergent pins and 1 medial pin using the crossed pin technique optimized both the PSR and PCA. We would recommend this configuration to optimize the stability of the fixation construct.

Functional and radiological outcomes of different pin configuration for displaced pediatric supracondylar humeral fracture: A retrospective cohort study.

BACKGROUNDThe most widely accepted treatment for pediatric supracondylar humeral fracture is closed reduction and percutaneous pinning (CRPP). However, there is debate regarding the technique that is utilized, whether crossed or lateral pinning, and the number of pins used. AIMTo compare the functional and radiological outcomes of lateral and cross pinning in the management of humeral supracondylar fracture.METHODSA retrospective analysis was performed on 101 patients who were surgically managed by either one of the CRPP techniques from 2015 to 2019. Several clinical parameters were taken into account, including pre- and post-intervention Baumann angle, as well as scores for pain, range of motion, function, and stability. Statistical analysis was performed to study the outcomes of the utilized techniques. RESULTSAmongst our study sample, which included 63 males and 38 females with a mean age of 5.87 years, about one-third of the patients underwent crossed pinning fixation configuration and the remaining two-thirds were managed by lateral pinning configuration. Similar results were obtained in the two groups with no statistical difference regarding Mayo elbow performance scores (MEPS) and Baumann angle. The mean MEPS in the lateral and crossed pinning groups were 93.68 + 8.59 and 93.62 + 9.05, respectively. The mean Baumann angle was 72.5° + 6.46 in the lateral group and 72.3° + 4.70 in the crossed-pinning group (P = 0.878).CONCLUSIONBoth lateral pinning and crossed pinning fixation configuration for displaced pediatric supracondylar humeral fractures provide similar functional and radiological outcomes.

A Mini-Open Approach to Medial Pinning in Pediatric Supracondylar Humeral Fractures May Be Safer Than Previously Thought.

Displaced pediatric supracondylar humeral fractures (SCHFs) are stabilized after reduction by smooth pins. Although some SCHFs are biomechanically stable after lateral-only entry pinning (lateral pinning), an additional medial entry pin (cross-pinning) confers superior stabilization in some SCHFs. There is a recognized risk of iatrogenic ulnar nerve injury with medial entry pinning. The best existing evidence has estimated an iatrogenic ulnar nerve injury rate of approximately 3.4% in cross-pinning. In similar studies, the rate of iatrogenic nerve injury (all nerves) in lateral pinning is estimated at 1.9%. This study aimed to use a large, single-center, single-technique (mini-open) retrospective case series to determine the rate of iatrogenic ulnar nerve injury in cross-pinning. Patients undergoing percutaneous cross-pinning via the mini-open technique for SCHFs from 2007 to 2017 were retrospectively reviewed. Injury characteristics, operative variables, fixation technique, and complications, such as iatrogenic nerve injury, were recorded. Patients who underwent operative treatment at another hospital, had no postoperative follow-up, or died due to polytrauma were excluded. In this study, 698 patients undergoing cross-pinning during the study period were identified. Patients treated with cross-pinning had severe fractures, including a total of 198 preoperative neurovascular injuries (28.4%), 32 patients (4.6%) with skin tenting, and 19 patients (2.7%) with open fractures. Iatrogenic nerve injury was reported in 3 cases (0.43%), all of which affected the ulnar nerve. In 2 of 3 cases of iatrogenic nerve injury, the ulnar nerve symptoms resolved at a mean follow-up of 15 weeks. The mini-open approach for medial pin insertion is safer than previous estimates. Here, in the largest single-center study of cross-pinning for SCHFs, the iatrogenic ulnar nerve injury rate of 0.43% was nearly 10 times lower than estimated rates from recent meta-analyses. Considering all nerves, the iatrogenic injury rate for this cross-pinning cohort was also lower than the estimated iatrogenic nerve injury rate for lateral pinning. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Does the Surgical Approach Have an Impact on Treatment Outcomes and Complications in The Surgical Treatment of Pediatric Supracondylar Humeral Fractures?

Amaç: Suprakondiler humerus kırıklarının (SKHK) cerrahi tedavisinde farklı tedavi yöntemleri ve cerrahi kesiler, distal parçanın yer değiştirme yönüne ve cerrahın deneyimine bağlıdır. Bu çalışmanın amacı, SKHK tedavi sonuçlarını ve komplikasyonları kapalı redüksiyon perkütan çivileme (KRPÇ) ile açık cerrahide cerrahi insizyon tipine göre karşılaştırmak ve bu sayede ideal yaklaşımı belirlemektir. Gereç ve Yöntemler: 142 (% 63,4) erkek ve 82 (% 36,6) kadın, yaş ortalaması 5,95 ± 2,79 yıl (1-13 yaş) olan toplam 224 hasta retrospektif olarak incelendi. Gartland sınıflandırmasına göre 58'i (% 25,8) Tip 2, 166'sı (% 74,2) Tip 3 idi. Çalışmaya dahil edilen hastaları medial, lateral, posterior insizyon ve KRPÇ ile ameliyat edilenler olmak üzere dört gruba ayırdık. Bulgular: En sık görülen komplikasyonlar: nörolojik defisit (n: 34,% 15.1), skarlaşma (n: 32,% 14.2), subkutan iğne migrasyonu (n: 24,% 10.2), cubitus varus (n: 20,% 8.9) ), çivi dibi enfeksiyonu (n: 15,% 6,6), fleksiyon kısıtlaması (n: 13,% 5,8), ekstansiyon kısıtlaması (n: 12,% 5,3), miyozit ossifikans (n: 12,% 5,3) ve kübitus valgus (n: 5,% 2,29). Açık redüksiyon internal fiksasyon uygulanan grup ile kapalı redüksiyon perkütan çivileme grubu arasında komplikasyonlar açısından farklılıklar olduğu belirlendi. Sonuç: Kapalı redüksiyon perkütan çivileme ve açık cerrahi grupları arasında fonksiyonel sonuçlar arasında fark yoktur. Redüksiyon kapatılamayan hastalarda cerrahın tecrübesine ve tercihine bağlı olarak açık cerrahi kesiler tercih edilebilir.

Dose reduction for minimizing radiation in displaced paediatric supracondylar humerus fractures: single vs. automated pulse mode.

Conventional C-arm image intensifiers (CCA) are an essential and indispensable aid in modern orthopaedic surgery. CCAs are defaulted to auto-pulse mode which emit multiple pulses (or bursts) of radiation to obtain optimum image quality. The number of pulses per shot can be configured manually. The purpose of this study is to investigate the efficacy of the single pulse mode of CCA in reducing and fixing paediatric supracondylar humeral fractures (SCHF). A retrospective chart review of 99 paediatric patients who underwent closed reduction and percutaneous pinning of displaced SCHF was performed. Fifty-one consecutive cases operated with auto-pulse mode (group A). Another 48 consecutive cases were operated with the single-pulse mode (group B). Baumann's angle, operative duration and average radiation dose rate were recorded for comparison between both groups. Twenty postpinning images were randomly selected (10 from each group) to study intra- and interobserver reliability. Twelve doctors were recruited and tasked to identify if each X-ray was taken with the auto-pulse or single-pulse mode. This was repeated after 2 weeks. The patients in the auto-pulse mode group had a significantly higher mean radiation dose of 40.4 ± 32.51 cGycm2/min compared to that of 14.8 ± 3.24 cGycm2/min for the single-pulse group (P ≤ 0.001). All patients in both groups had Baumann's angle within normal range of 64-81°. No significant difference was noted in average intraoperative timings between both groups (P = 0.869). In the majority of cases, the doctors were unable to visually differentiate between the modes of CCA used. The single-pulse mode is an excellent alternative to the auto-pulse mode in fixing SCHF. It gives significantly lower radiation without compromising the surgical outcome. Level of evidence: Level III retrospective comparative study.

Internal Rotation Stress Test Reduces Cross-Pinning and Improves Outcomes in Displaced Pediatric Supracondylar Humeral Fractures.

Background:Stabilization of the medial column is vital in preventing the loss of fixation and malunion in displaced pediatric supracondylar humeral fractures (SCHFs). The preferred percutaneous pin configuration for medial column fixation remains controversial between medial pinning (cross-pinning) and additional lateral-based pinning. The intraoperative internal rotation stress test (IRST) has been proposed to reliably determine the optimal fixation strategy for each unique fracture. This study evaluated the impact of implementing the IRST on both the choice of pin configuration and institution-wide complications in pediatric patients treated operatively for SCHFs.Methods:Pediatric patients undergoing percutaneous pinning for SCHFs between 2007 and 2017 at a single center were retrospectively reviewed. The IRST was made a universal institutional practice in 2013. Patients were divided into 2 groups for analysis: (1) patients who underwent treatment before the IRST was implemented in 2013 (the pre-IRST group), and (2) patients who were treated after the IRST was implemented in 2013 (the IRST group). Subgroup analysis was completed for patients in the IRST group who were treated with cross-pinning or 3 lateral-based pins.Results:In this study, 820 patients in the pre-IRST group and 636 patients in the IRST group were included. After the IRST implementation, the rate of loss of fixation fell from 1.2% to 0% (p = 0.003), and the reoperation rate fell from 3.3% to 0.2% (p < 0.001). No cases resulted in a loss of fixation after the adoption of the IRST. The number of patients treated with cross-pinning decreased significantly from 53.2% to 31.6% (p < 0.001) after the IRST implementation, yet cross-pinning continued to be used for more severe fractures. Complication rates within the IRST group were not significantly different (p > 0.05) between cross-pinning and 3 lateral-based pins.Conclusions:In the largest cohort reported on to date, to our knowledge, institutional implementation of the IRST resulted in a significant reduction in the use of cross-pinning. Although the usage of cross-pinning decreased, cross-pinning was still used frequently in the most severe fractures. The IRST use also resulted in significantly fewer complications such as loss of fixation after institution-wide implementation of the IRST for treating pediatric SCHFs.Level of Evidence:Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Comparison of lateral entry and crossed entry pinning for pediatric supracondylar humeral fractures: a meta-analysis of randomized controlled trials

BackgroundClosed reduction and pinning entry fixation have been proposed as treatment strategies for displaced supracondylar humeral fractures (SCHFs) in children. However, controversy exists regarding the selection of the appropriate procedure. Hence, this meta-analysis was conducted to compare the effect of lateral and crossed pin fixation for pediatric SCHFs, providing a reference for clinical treatment.MethodsOnline databases were systematically searched for randomized controlled trials (RCTs) comparing lateral pinning entry and crossed pinning entry for children with SCHFs. The primary endpoints were iatrogenic ulnar nerve injuries, complications, and radiographic and functional outcomes.ResultsOur results showed that iatrogenic ulnar nerve injuries occurred more commonly in the crossed pinning entry group than in the lateral pinning entry group (RR = 4.41, 95% CI 1.97–9.86, P < 0.05). However, its risk between the crossed pinning with mini-open incisions group and the lateral pinning entry group was not significantly different (RR = 1.58, 95% CI 0.008–29.57, P = 0.76). The loss of reduction risk was higher in the lateral pinning entry group than in the crossed pinning entry group (RR = 0.66; 95% CI 0.49–0.89, P < 0.05). There were no significant differences in the carry angle, Baumann angle, Flynn scores, infections, and other complications between these two groups.ConclusionsThe crossed pinning entry with mini-open incision technique reduced the loss of reduction risk, and the risk of iatrogenic ulnar nerve injury was lower than in the lateral pinning entry group. The crossed pinning entry with mini-open incision technique is an effective therapeutic strategy for managing displaced supracondylar humeral fractures in children.

Treatment and outcomes of pediatric supracondylar humeral fractures in Korle Bu Teaching Hospital.

Objectives:Supracondylar humeral fractures (SCHF) are the most common elbow injury in the pediatric population. The treatment, outcome, and health-related quality of life (HRQoL) following these injuries are described.Methods:Patients with SCHF who were treated depending on the fracture type were evaluated. Medical records stored in the REDCap database were reviewed to obtain information on demographics, mechanisms of injury, neurovascular status, infection rates, and postoperative complications. Outcomes were assessed using Flynn's criteria and Pediatric Quality of Life (PedsQL) version 4.0. Follow-up was for 6 months.Results:A total of 101 patients with a mean age of 5.2 years (SD ± 2.3) were seen. Most of the injuries occurred at home (64.3%). The left-arm (nondominant) was the most injured (62%), though 92% of patients were right hand dominant. Ninety-six percent of the fractures were the extension type. A total of 98% had satisfactory outcomes using Flynn's criteria and older patients were likely to sustain Gartland type III SCHF (P = .01). There was a significant difference in mean scores of PedsQL (all P values < .01) at 6 months.Conclusions:In this prospective study, the quality of life of patients following SCHF diminished at the time of the injury and returned to the population normal 6 months after. There was no significant difference in HRQoL scores between patients who presented early and those who presented late. The delayed presentation and management did not also affect the functional outcome and complications. Therefore, surgical management of these injuries after late presentation is still safe.

Does a medial mini-incision decrease the risk of iatrogenic ulnar nerve injury in pediatric supracondylar humeral fractures treated with closed reduction and percutaneous pinning? A retrospective cohort study

Background: The authors compared two techniques for safe medial pin placement during fixation of supracondylar humeral fractures, namely closed pinning and mini-open pinning of medial wire insertion, and their effectiveness in protection against iatrogenic ulnar nerve injury. Methods: One hundred and nineteen patients with type 2 and 3 Gartland supracondylar humeral fractures (AO Foundation/Orthopaedic Trauma Association [AO/OTA] 13-M/3.1 II, III and IV) were included in this study after applying the exclusion criteria. All patients were managed with cross pinning with identification of two groups. The first group was for percutaneous pinning (N=63), and the second group for patients with medial open incision during medial wire insertion (N=56). All patients were evaluated for the incidence of nerve injury after surgery. Results: Nerve injury occurred in 12 of 119 patients. The estimated duration of follow-up was 43.6±10.2 wk. The results revealed nine patients who had ulnar nerve injury among both groups (group 1, N=8, group 2, N=1), with statistically better results in group 2 (P=0.02). The incidence of nerve injury was not found to be correlated with other variables, which included age, gender, type of fracture, number of Kirschner wires that were inserted, and the level of the surgeon. Conclusions: A medial mini-open incision decreased the risk of ulnar nerve injury during cross pin fixation in the treatment of displaced supracondylar humeral fractures, without additional morbidity. Level of Evidence: Level III.

Patient outcomes in Tropical North Queensland after implementation of a dedicated orthopaedic trauma list.

To assess patient outcomes after the introduction of a regular orthopaedic-specific trauma list (OTL). A retrospective analysis of 422 trauma cases was performed comparing patient outcomes after the introduction of the OTL. Four common traumatic injuries requiring operative intervention were considered; closed tibial fractures, intra-capsular neck of femur fractures, displaced paediatric supracondylar humeral fractures and hand tendon injuries. The outcomes assessed included time from patient referral to theatre, time from admission to theatre, operative times, time of day operation commenced, consultant involvement, hospital length of stay (LOS), returns to theatre and mortality. Tibial fractures had an increased time from admission to theatre (0.46 days pre-OTL versus 1.21 days post-OTL, P=0.01), hand tendons injuries had an increase in time from referral to theatre (1.06 days pre-OTL versus 2.82 days post-OTL, P=0.001). Consultant involvement increased for supracondylar procedures (27% pre-OTL versus 61% post-OTL, P < 0.001) and tendinous hand injury repairs (5% pre-OTL versus 37% post-OTL, P < 0.001). There was a decrease in cases starting after 17:00 hours; however, no group reached statistical significance. There was a reduction in complications and shorter inpatient LOS, however; these were not statistically significant. There was no difference in overall operative times after OTL implementation; however, individual group differences existed between registrars and consultants. Implementing regular orthopaedic trauma lists resulted in greater consultant involvement and was associated with decreased after-hours operating. Delays to theatre increased from both time of referral and admission; however, this was not correlated with increases in significant harm.

Treatment of pediatric supracondylar humerus fractures accompanied with pink pulseless hands

BackgroundThe optimal treatment for pediatric supracondylar humeral fractures accompanied with a pink pulseless hand is controversial. Some clinicians recommend close observation after closed reduction and percutaneous pinning of the fractures, while some recommend surgical exploration if the radial pulse is unpalpable. The present study aimed to analyze the benefits and outcomes of close observation for treating pediatric supracondylar humeral fractures with a pink pulseless hand.MethodsThirteen consecutive children presenting with a pink pulseless hand following supracondylar humeral fracture were enrolled in this study. Preoperative and postoperative color-flow Duplex ultrasound detection was used to assess brachial artery compromise in most cases. Urgent closed reduction and percutaneous pinning of the fractures were attempted first. Close observation was carried out when the hand was pink and pulseless with an absent radial pulse.ResultsPreoperative color-flow Duplex ultrasound showed no disruption of the brachial artery in cases detected. Compression of the artery by the proximal fragment was observed in most cases, with one case of entrapment of the artery between fragments, and thrombus considered in two cases. All cases underwent urgent surgery, after which nine experienced immediate return of the radial pulse. The remaining four without a palpable pulse were managed with close observation and no deterioration of the vascular status was observed; therefore, no surgical exploration was performed. Postoperative color-flow Duplex ultrasound revealed continuity of the artery and rich collateral circulation. Patients completed an average of 4.5 years of follow-up, during which no major complications occurred. All patients achieved excellent limb function.ConclusionsOur study demonstrates that close observation after urgent closed reduction and percutaneous pinning is a sufficient approach for the treatment of pediatric supracondylar humeral fractures accompanied with a pink pulseless hand. Surgical exploration is not necessary as long as the hand is warm and well perfused. Color-flow Duplex ultrasound is beneficial for assessing vascular compromise and determining treatment strategies.