Supracondylar Fractures Research Articles

Functional Outcome of K-Wire Fixation of Supracondylar Fracture of Humerus (Type-III) in the Children Following Six Months

Supracondylar fracture is an injury to the humerus or upper arm bone just above the elbow. It is most common type of upper arm injury in children. Mostly caused by fall on outstretched elbow or direct blow to the elbow and mostly treated by k-wire in the children due to good results post-operatively. The objective of my study was to assess the functional outcome of k -wire fixation after supracondylar fracture of humerus (type-III) following six months. A descriptive case-series, a total sample of 20 cases of k-wire fixation after supracondylar fracture of humerus following six months in the children were included in the study, whose functional range were within 90-120 children of both sex, between age under 12 years were included. Study results showed 40% children with no difficulty, 45% with mild difficulty, and 15% with moderate difficulty. Overall, there were good functional outcome. The Current study concluded that, there was good Functional outcome of supracondylar fracture of humerus (type-III) with k-wire fixation following six months in children.

Dorgan’s lateral cross pinning for displaced pediatric supracondylar fractures of the distal humerus

Background: Supracondylar humeral fractures are the most common elbow fracturesseen in children. Although closed reduction and percutaneous pin fixation is the treatment of choice for displaced supracondylar fractures of the humerus in children, controversy about which pin configuration is best in treating these fractures is ongoing. Some advocate lateral entry pins only while others advocate medial and lateral entry pins. In this study I utilized Dorgan’s cross lateral technique to fix such fractures which is believed to have the advantages of both the conventional pinning techniques. Objectives:To evaluate the functional and cosmetic outcome and complications of cross lateral pinning. Methods: Thirty cases of supracondylar humeral fractures were treated by closed or open reduction with cross lateral pin fixation under fluoroscopic guidance. The elbow was immobilized for a period of 4 weeks after which the pins were removed and physiotherapy initiated. At the end of 12 weeks the patients were evaluated clinically and radiologically and final results were assessed as per Flynn’s criteria. Results: According to Flynn’s criteria, the cosmetic result in my study was evaluated as excellent in 25 cases (83%) and good in 5 cases (17%) and functional result was evaluated as excellent cases in 23 (77%) and good in 7cases (23%). There were no cases of post operative loss of reduction of fractures. Six cases (20%) had pin tract infection while 24 patients (80%) had no complications at all. Conclusions: Cross lateral method of pinning for treating supracondylar fractures is a useful method of fixation as it gives stabilization like medio-lateral pinning and minimizes the risk of injuring the ulnar nerve like lateral pinning.

The Impact of a Resident, Fellow, or Physician Assistant on Operative Time and Complication Rate in Closed Reduction and Percutaneous Pin Fixation of Pediatric Distal Humerus Supracondylar Fractures

We sought to compare operative times and complications for attending surgeons operating alone or with an assistant including an orthopedic resident, fellow, or physician assistant (PA) for closed reduction and percutaneous pinning (CRPP) of pediatric supracondylar humerus fractures (SCH), an archetypal procedure integral to the education of orthopedic trainees. Using a retrospective database collected following institutional review board approval, a 1-way ANOVA (non-parametric) was used to assess the effect of assistant absence or presence by type of assistant on mean operative time. We analyzed the association between the attending surgeon assistant categories and the complication rate using Fisher's Exact Test. The study was performed at Gillette Children's Specialty Healthcare, St. Paul, Minnesota, and Children's Minnesota in St. Paul and Minneapolis. These three affiliated metropolitan hospitals, the last of which is a level 1 trauma facility, all share the same group of orthopedic surgeons, trainees, and physician assistants. All patients under 14 years of age treated with CRPP for Gartland type 2, 3, 4 and flexion type closed supracondylar fractures between April 2006 and September 2016 were analyzed. Of 1053 patients identified by Current Procedure Terminology code 24358, data was available for 888 patients. Out of the 888 patients, 44.1% were operated on by a surgeon alone, 48.4% with a resident, 4.8% with a fellow and 2.6% with a physician assistant. The ANOVA revealed a statistically significant increase (p < 0.001) in operative times when a resident participated compared to the other categories. The shortest mean surgery time (34.7 minutes) occurred when an attending surgeon and PA were present. The longest mean time (44.3 minutes) occurred with a surgeon and resident. This difference, at 9.6 minutes, constituted 28% more time. There were 40 patients with a complication, a rate of 4.5%. The rate for each of the assistant categories was surgeon alone 5.6%, with a resident 3.3%, with a fellow 4.7%, with a PA 8.7%. The Fisher's Exact Test results showed no statistically significant association between the type or absence of assistant and the complication rate. Differences in operative times were observed across assistant categories although the mean time difference was statistically insignificant between the surgeon unassisted versus assisted by the fellow or a PA. The finding of statistically increased operative times with resident participation in this study for this specific procedure is consistent with results for most other reported orthopedic surgeries. Complication rates did not vary based on the participating personnel.

Using large language models (ChatGPT, Copilot, PaLM, Bard, and Gemini) in Gross Anatomy course: Comparative analysis.

The increasing application of generative artificial intelligence large language models (LLMs) in various fields, including medical education, raises questions about their accuracy. The primary aim of our study was to undertake a detailed comparative analysis of the proficiencies and accuracies of six different LLMs (ChatGPT-4, ChatGPT-3.5-turbo, ChatGPT-3.5, Copilot, PaLM, Bard, and Gemini) in responding to medical multiple-choice questions (MCQs), and in generating clinical scenarios and MCQs for upper limb topics in a Gross Anatomy course for medical students. Selected chatbots were tested, answering 50 USMLE-style MCQs. The questions were randomly selected from the Gross Anatomy course exam database for medical students and reviewed by three independent experts. The results of five successive attempts to answer each set of questions by the chatbots were evaluated in terms of accuracy, relevance, and comprehensiveness. The best result was provided by ChatGPT-4, which answered 60.5% ± 1.9% of questions accurately, then Copilot (42.0% ± 0.0%) and ChatGPT-3.5 (41.0% ± 5.3%), followed by ChatGPT-3.5-turbo (38.5% ± 5.7%). Google PaLM 2 (34.5% ± 4.4%) and Bard (33.5% ± 3.0%) gave the poorest results. The overall performance of GPT-4 was statistically superior (p < 0.05) to those of Copilot, GPT-3.5, GPT-Turbo, PaLM2, and Bard by 18.6%, 19.5%, 22%, 26%, and 27%, respectively. Each chatbot was then asked to generate a clinical scenario for each of the three randomly selected topics-anatomical snuffbox, supracondylar fracture of the humerus, and the cubital fossa-and three related anatomical MCQs with five options each, and to indicate the correct answers. Two independent experts analyzed and graded 216 records received (0-5 scale). The best results were recorded for ChatGPT-4, then for Gemini, ChatGPT-3.5, and ChatGPT-3.5-turbo, Copilot, followed by Google PaLM 2; Copilot had the lowest grade. Technological progress notwithstanding, LLMs have yet to mature sufficiently to take over the role of teacher or facilitator completely within a Gross Anatomy course; however, they can be valuable tools for medical educators.

Emergency Department Visits Following Supracondylar Humerus Fractures

Introduction: Pediatric supracondylar humerus fractures are common and the most frequent pediatric fracture to require surgical intervention. After initial management, emergency department (ED) visits subsequent to this injury/surgery are not well characterized, but are of clinical interest. Methods: Pediatric patients (age &gt;1 ​​​​​​y old and &lt;13 y old) with supracondylar humerus fractures were identified from the 2010 to 2021 PearlDiver M157 administrative database. These patients were stratified based on whether they visited the emergency department at least once within 90 days after their initial injury diagnosis/management. The timing of visits and reasons were determined, and predictive factors were assessed with multivariate logistical regression. Results: A total of 92,994 fractures were identified for which post-injury/post-operative ED visits were noted for 10,325 patients (11.1%). Nearly half of all ED visits occurred within the 2 weeks immediately after the fracture (46.1%), of which 54.7% of visits were not directly related to the elbow. On multivariate analysis, patients who utilized the ED after initial management of pediatric supracondylar humerus fracture were of greater odds ratio (OR) in decreasing order to have: had a history of ED visits before their initial injury (OR: 2.69), be diabetic (OR: 1.81), had surgical intervention for their fracture (OR:1.58), be obese (OR: 1.57), have asthma (OR:1.55), have Medicaid insurance (OR: 1.29), and be younger (OR: 1.11 per year decrease) (P&lt;0.001 for all). Discussion: In the 90 days after pediatric supracondylar humerus fracture, more than 1 in 10 patients visited the ED. This data highlight the need for close following of such patients after their injury/surgery and suggests risk factors for which patients such quality improvement measures should be focused. Level of Evidence: III.

Failed ulnar nerve surgery due to persistent unrecognized snapping triceps from cubitus varus due to a distal humeral malunion in an adult: illustrative case.

Snapping triceps is a dynamic condition in which a portion of the medial head of the triceps dislocates over the medial epicondyle during flexion or extension. Pushed by the triceps, the ulnar nerve typically also dislocates over the medial epicondyle, causing neuropathy. Posttraumatic cubitus varus deformities resulting from pediatric supracondylar fractures have been associated with snapping triceps. This is the first case of snapping triceps associated with cubitus varus due to distal humeral malunion, which occurred in an adult. A 23-year-old man sustained a left distal humeral fracture from arm wrestling, which was treated nonoperatively, healing in a varus malunion. Within several months, he developed ulnar neuropathy and snapping at the medial elbow, which was diagnosed as a dislocating ulnar nerve and was treated with ulnar nerve transposition. He presented 8 years later with continued ulnar neuritis symptoms and snapping and was found to have snapping medial triceps. He chose nonoperative treatment. Snapping triceps, presenting as snapping at the elbow with ulnar nerve symptoms, can be incorrectly diagnosed as isolated ulnar nerve dislocation. Unrecognized snapping triceps leads to persistent symptoms after ulnar nerve transposition. The patient in this case demonstrated that an altered triceps line of pull can cause snapping triceps regardless of how the cubitus varus originated. https://thejns.org/doi/10.3171/CASE24596.

Treatment of Pink Pulseless Hand Following Supracondylar Fractures of the Humerus in Children.

Background: Supracondylar humerus fractures (SCHF) in children are common and can lead to serious complications, including neurovascular injury. The optimal management of children with a 'pink pulseless' hand following such a fracture is unclear. This study aimed to ascertain an appropriate therapeutic approach for children with SCHF and a pink pulseless hand. Methods: A retrospective analysis of medical records from paediatric patients under 16 years old with SCHF and clinically perfused but pulseless hands between 1 January 2016 and 30 June 2021 was conducted. Clinical characteristics, imaging, treatment processes and follow-up results were analysed to predict arterial injuries requiring vascular repair and determine the optimal timing for exploratory surgery. Results: The study included 88 patients, predominantly male (58%) with an average age of 6 years. Most fractures resulted from falls onto outstretched arms. Satisfactory outcomes, indicated by the return of the pulse following closed reduction and percutaneous pinning (CRPP) alone, were seen in 66% of patients, negating the necessity for vascular exploration. Amongst patients with a persistently absent radial pulse 72 hours after CRPP, 83% were diagnosed with brachial artery injuries, with all such patients experiencing recurrent pulse loss after surgery. Conclusions: Urgent reduction and CRPP are effective initial treatments for children with SCHF and a pink pulseless hand. Immediate vascular exploration is generally not necessary in these patients. Further research is needed to determine the optimal management for persistent pulselessness and recurrent pulse loss. Level of Evidence: Level IV (Therapeutic).

Displaced Pediatric Supracondylar Fracture (Gartland Type II and III): The Impact of Wire Fixation Type.

Introduction Supracondylar fractures are common in children. PercutaneousK-wire fixation is an accepted standard treatment for displaced supracondylar fractures in children, but the ideal wire configuration remains controversial. This study aimed to review the radiographic outcome and complications of Gartland type II and type III supracondylar fractures treated by the crossed and lateral K-wirefixation. Methods Seventy-five cases were retrospectively reviewed, 41 and34in crossed and lateral K-wire fixation groups, respectively. We studied patient demographics, fracture characteristics, different operative variables, and complications between the two groups. Results No significant difference was noted in patient demographics and the size of the wire used between the two groups. More type III fractures were fixed with crossed wires, 31 vs. 15 (75% vs. 44%, p = 0.019). Higher open reduction was also noted in the crossed-wire group. Loss of reduction between the crossed and the lateral groups was not significantly different, 15 vs. 13 (36.6% vs. 38.2%). The crossed-wire group had more iatrogenic nerve injury than the lateral wire group, 9 vs. 1 (22% vs. 3%, p = 0.0185). Higher complications were observed in the crossed-wire group than in the lateral-wire group, mainly due to iatrogenic nerve injury, 19 vs. 5 (46.3% vs.14.7%, p = 0.0052). Higher technical errors of wire fixation were noted with lateral wire fixation than with crossed-wire fixation, 28 vs. 12 (82% vs. 29%, p = 0.00001). Conclusions Higher complications were noted with crossed wires, primarily due to iatrogenic nerve injury. Between the crossed and lateral wire groups, there were no statistically significant differences in loss of reduction and other complications. We support lateral wiring with appropriate techniques in treating types II and III supracondylar fracturesto avoid iatrogenic nerve injury and other complications.

Common elbow injuries in children

Elbow injuries are one of the commonest paediatric musculoskeletal injuries. Their spectrum varies from pulled elbow to elbow dislocation. Supracondylar fractures are the most common type of paediatric elbow fractures accounting for 65–75 % of all paediatric elbow injuries. Other common paediatric elbow injuries include Lateral condyle fractures, Medial epicondyle fractures, Radial neck fractures, olecranon fractures, TRASH injuries and Elbow dislocations. Osteochondral fractures in kids can be missed due to their benign appearance or invisibility on x rays. TRASH stands for “The Radiological Appearance Seems Harmless”. In contrast to the full form, the abbreviation TRASH tells the harmful consequences of missing these injuries. This article will discuss the salient points regarding common elbow injuries, their diagnosis and best treatment practices. It will help the caregivers to be more prepared to deal with these situations and thus avoiding complications and getting better outcomes.

PREDICTORS OF ROTATIONAL FAILURE IN PAEDIATRIC SUPRACONDYLAR HUMERAL FRACTURES

Lateral-entry wiring (LEW) for displaced supracondylar humeral fractures (SHFs) has been popularised internationally. BOAST guidance suggests either LEW or crossed wires; the latter has reported lower risk of loss of fracture reduction –we explore technical reasons why.We reviewed 8 years of displaced SHFs in two regional centres. Injuries were grouped using the Gartland Classification, with posterolateral or posteromedial displacement assessment for Gartland 3 injuries. We identified any loss of fracture reduction, and reviewed intra-operative imaging to identify learning points that may contribute to early rotational displacement (ERD).345 SHFs were included, between 2012 and 2020. Gartland 2 (n=117) injuries had a 3.42% risk. ERD. Gartland 3 crossed wirings (n=114) had a 6.14% risk of ERD, with those moving all being posterolaterally displaced. Gartland 3, posterolaterally displaced LEW (n=56) had a 35.7% risk of ERD. Gartland 3, posteromedially displaced LEW (n=58) had a 22.4% risk of ERD. All injuries with ERD except 3 had identifiable learning points, the commonest being non-divergence of wires, or wires not passing through both fracture fragments.LEW requires divergent spread and bicolumnar fixation. Achieving a solid construct through this method appears more challenging than crossed wiring, with rates of ERD 3–5× higher. Low-volume surgeons should adhere to BOAST guidelines and choose a wiring construct that works best in their hands. They can also be reassured that should a loss of position occur, the risk of requirement for revision surgery is extremely low in our study (0.3%), and it is unlikely to affect long term outcomes.

In Supracondylar Humerus Fractures With Nerve Injury, Does Time to Surgery Impact Recovery?

Background: Supracondylar humerus (SCH) fractures are common and present with associated nerve injuries in 11% to 42% of cases. Historically, SCH fractures with neurological compromise warranted urgent surgical intervention. A recent study showed that treatment delay is acceptable in patients with isolated anterior interosseous nerve (AIN) injury. Though indications for urgent treatment are relaxing, no studies have evaluated the need for urgent surgical treatment for other nerve injuries associated with SCH fractures. The aim of this study was to determine if the timing of surgical intervention is related to the timing of neurological recovery in SCH fractures associated with any nerve injury. Methods: A retrospective review of 64 patients with surgically managed SCH fractures and concomitant neurological deficit on presentation was conducted at a single level 1 pediatric trauma hospital from 1997 to 2022. The relationship between the time to surgical intervention and the time to partial and complete nerve recovery was analyzed using linear regression. Results: Sixty-four patients with an average age of 6.9±2.0 years and an average time to surgery of 9.8±5.6 hours were analyzed. Sixty-two patients (97%) were followed to partial neurological recovery and 36 (56%) were followed to full neurological recovery. Neurological deficit included median [n=41 (64%)], radial [n=22 (34%)], and ulnar [n=15 (23%)]. Ten patients (16%) had isolated AIN injury. The average time to partial neurological recovery was 20±23 days and the time to full recovery was 93±83 days. There was a statistically significant relationship between time to partial neurological recovery and time to surgical intervention (P=0.02). There was no relationship between time to full neurological recovery and time to surgery (P=0.8). Conclusion: Earlier time to surgical intervention in pediatric SCH fractures with isolated nerve injury was associated with earlier partial recovery but not full neurological recovery. Prioritizing urgent surgery in these patients did not improve their ultimate neurological recovery. Level of Evidence: Therapeutic level III.

METHODS OF PERCUTANEOUSFIXATION OF FRAGMENTS IN SUPRACONDYLAR HUMERUS FRACTURES IN CHILDREN AND ADOLESCENTS

The aim of this study is to conduct a meta-analysis and evaluate the clinical efficacy and safety of crossed and lateral fixation of fragments in supracondylar humerus fractures in children and adolescents. Methods. A comprehensive literature search was conducted in the PubMed and EMBASE databases from 2015 to December 2023 using the following search terms: "supracondylar fractures of distal humerus in pediatric patients", "treatment", "methods of fixation", "pinning configuration", "biomechanical analysis of pin placement". According to the inclusion and exclusion criteria, the literature sources of anatomic-biomechanical and clinical studies related to the use of crossed and lateral fixation of fragments in the case of supracondylar fractures of the humerus in children and adolescents were selected and analyzed. The review was prepared in accordance with the recommendations of the "Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines." Results. A comparison of results from experimental studies investigating the degree of stabilization achieved in the crossed and lateral configurations of fixation structures reveals conflicting conclusions due to the heterogeneity of designs implemented. The principal limitation of lateral fixation is the increased risk of failure of fixation. The outcomes of clinical trials (Flynn criteria) demonstrate that both types of fracture fixation yield equivalent clinical outcomes. One disadvantage of crossed fixation is the risk of iatrogenic ulnar nerve damage, while another disadvantage is the increased complexity of the surgical technique. Conclusions. The results of anatomical and biomechanical studies indicate that cross-fixation provides more rigid fixation of fragments in supracondylar humerus fractures in children and adolescents. Nevertheless, clinical outcomes based on radiological and functional data (including Flynn's score) demonstrate no significant distinction between the two types of fixation configurations. However, they do indicate a notable risk of iatrogenic ulnar nerve damage in cross fixation, which justifies the necessity to utilise a mini-open technique in the medial fixation construct.

Our experience with a modified prying-up technique for closed reduction of irreducible supracondylar humeral fractures

Satisfactory reduction of some displaced pediatric supracondylar humerus fractures is not achievable via closed reduction, thus necessitating open procedure, which increases the incidence of complications. Using percutaneous prying-up technique to assist closed reduction may reduce the requirement for transform to an open operation. We retrospectively reviewed displaced pediatric supracondylar humerus fractures treated by the same surgeon from September 2021 to January 2024,with 134 subjects meeting criteria for inclusion. These children were divided into two groups. In Group A(n = 61),the prying-up technique was used to assist with closed reduction of fractures. Group B(n = 73) included fractures treated with conventional manual traction. To balance group size,12 fractures from group A were randomly removed, leaving a final 61 patients in each group. Demographics, operative time, the rate of failed closed reduction, complications and radiographic results were analyzed. The operative time was significantly less in Group A as compared with Group B(mean difference, − 7.22; [95% confidence interval (CI), − 8.49 to − 5.94]; p < 0.001). The rate of failed closed reduction were significantly lower in Group A as compared to Group B(2 of 61 vs. 10 of 61, p = 0.015).However, we found no difference in terms of the radiographic results and complications between the two groups(p > 0.05). percutaneous prying-up technique significantly improves the efficiency of surgery and reduces rate of failed closed reduction of supracondylar humeral fractures in pediatric patients. Level III, retrospective comparative study.See Guidelines for Authors for a complete description of levels of evidence.

Radiological and biomechanical evaluation of the ulnar nerve after the percutaneous application of the medial K-wire in the extended position on supracondylar humerus fractures: Does the postoperative long arm splint position matter?

Our study aimed to evaluate and compare the changes in ulnar nerve tension and strain at different elbow positions radiologically and mechanically before and after applying the medial K-wire on the supracondylar humerus fracture cadaver model. We used ten fresh frozen cadaver upper extremity specimens to measure strain and tension on the ulnar nerve in 3 different elbow positions: elbow full extension, elbow flexion-forearm supination, and elbow flexion-forearm pronation. We employed Shear wave elastography (Siemens Acuson S3000 USG, 9L4 linear probe) and a microstrain gauge (Microstrain, Inc., Burlington) to obtain our measurements. Minimum, maximum and mean stress and strain values on the nerve and its surroundings were measured and compared statistically. The mean values of elbows with full extension are statistically lower than those in elbows with 90° flexion-forearm supination and those with 90° flexion-forearm pronation positions. Statistical evaluations were performed between all of the groups. Elbow 90° flexion-forearm pronation, both minimum and maximum and mean values were statistically higher in the group, including the specimens with Kirschner applied. The mean values in the elbow full extension and elbow 90° flexion-forearm supination positions were statistically similar in the specimens with and without the K-wire applied. Despite the numerous techniques described in the literature, there is no absolute technical method to prevent ulnar nerve damage. K-wire application to the medial epicondyle with the elbow in a slightly extended position is a technique that can be applied to reduce the risk of ulnar nerve paralysis. However, it has been reported that ulnar nerve damage can be observed in cases where a splint is placed in the 90° flexion position. We hypothesize that the position of the elbow joint in the postoperative period may contribute to ulnar nerve paralysis due to soft tissue tension and strain and as a result of changing the balance of the surrounding tissues. Our findings suggest that the long arm splint applied in elbow 90° flexion and forearm pronation position should not be preferred in the postoperative period. The maximum strain values obtained in the elbow full extension were lower, suggesting that it would be appropriate to stabilize the elbow in the extension position as much as possible postoperatively. Level of evidence: Level V.

Pediatric orthopedic surgeons may perform better in terms of surgical outcomes in type 3 supracondylar humerus fractures: a comparative analysis

Supracondylar fractures of the humerus represent the most common surgical fractures in pediatric patients. There is a discourse regarding the influence of the surgeon training on treatment. Different studies show equivocal effect of subspecialty training. We conducted a single center case control study to evaluate the outcomes of type 3 fractures (fully displaced) comparing pediatric-trained orthopedic surgeons (PTOS) and non-pediatric trained orthopedic surgeons (NTOS). In this retrospective study, we investigated the surgical outcomes of type 3 supracondylar fractures of the humerus in children treated between the years 2012 and 2019, divided by surgeon type. During the research, a policy reform at our department was established and PTOS became the only surgeons for those injuries starting from September 2017. Patients’ demographics, perioperative details, and postoperative course were recorded. Primary outcome was reoperations, and secondary outcomes were open reductions, infections, length of surgery, and neurological deficits. 1175 patients were diagnosed with supracondylar fractures at our Level I trauma center, and 346 cases were diagnosed with radiologically confirmed type 3. Overall, 312 cases were analyzed; 113 cases were diagnosed before 1 September 2017 and treated by NTOS, and 199 cases were treated by PTOS until 31 December 2019; 7.1% (8) of the patients treated by NTOS had to be reoperated compared to 1.5% (3) of the patients treated by PTOS (P = 0.014). There was significant difference looking at postsurgical complications and surgery length. This study’s findings suggest that PTOS achieve superior outcomes when treating patients with type 3 supracondylar humerus fractures. Level of evidence: Level III.

Management of Pediatric Distal Humerus Metaphyseal Diaphyseal Junction Fracture; A Systematic Review and Meta-analysis

Abstract Background Fracture at the distal humerus metaphyseal diaphyseal junction (MDJ) in children is less frequently found in literature. Until this moment, there is no gold standard technique regarding its management and most surgeons treat it as a regular supracondylar humerus fracture by conventional pinning. This systematic review explores the relevant literature to assess the efficacy of different techniques. Methods Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used for this review. We searched online databases including PUBMED/MEDLINE, Scopus, Web of Science Core Collection, and Google Scholar. Data from papers that met our general inclusion criteria were extracted and categorized into treatment method groupings. Functional and cosmetic outcomes, demographic characteristics, and complications were the main parameters used to analyze the data. Results Ten (10) retrospective studies met our inclusion criteria with a total of 178 participants of unilateral pediatric distal humerus metaphyseal diaphyseal junction fractures. Most literature chose closed reduction and percutaneous pinning (CRPP) in 7 papers, followed by Elastic Stable Intra-medullary Nails (ESIN) used in 3 papers, then conservative treatment was chosen in 2 papers, while only one paper used lateral miniplate and assisted K-wire and another paper used combined CRPP and Intra- medullary (IM) K-wire. As regards the operation time; ESIN had the lowest time with a mean of 39.7 min (range: 37.5 – 41.9 min), while CRPP had the most prolonged time with a mean of 75.47 min (range: 55.9 – 92.1 min). The lowest healing time was observed in ESIN with a mean of 7.9 weeks (range: 6.8 – 9 weeks) while the most prolonged was in conservative management with a mean of 12 weeks and CRPP lies in between with a mean of 10 weeks. Regarding Flynn’s criteria, all participants received excellent and good except in CRPP; 13 cases were fair and 2 cases were poor. Regarding complications the most commonly observed complication after MDJ fracture was cubitus varus, the highest incidence was in conservative management 33% of cases, followed by CRPP 10.9% of cases, the least incidence was observed in ESIN 3.77% of cases, and none of the cases treated with mini plate developed this complication. Other complications were observed only with CRPP; 8.5% of cases developed fixation loss, 6.2% of cases had significantly reduced range of motion and one case refractured. Conclusion Pediatric distal humerus MDJ fracture should be differentiated from supracondylar fracture regarding management, as conventional pinning techniques are associated with a higher incidence of complications and increased both operative and healing times.

A Systematic Review and Meta-Analysis Study in Functional Outcome between Olecranon Osteotomy and Triceps Anconeous Pedicle Elevation in Intercondylar and Supracondylar Humerus Fracture

Abstract Background Approximately, 7% of all adult fractures involve the elbow, of these one third (2%) are distal humeral fractures. Articular fractures of elbow are the most difficult one to treat. Because of their complex anatomy, proximity to vital structures, injury patterns, associated osteoporosis in elderly patients and limited space for instrumentation. As far as we know, no previous meta-analysis study has investigated the privilege between olecranon osteotomy and triceps-reflacting anconeous pedicle (TRAP) regarding functional outcome and complications in the treatment of suprachondylar and interchondylar humerus fractures. Therefore, we performed this systematic review and meta-analysis study of this issue. Methods This meta-analysis study included all studies which comparing between TRAP and OO in the treatment of suprachondylar and interchondylar humerus fractures. The literature search was in the Web of Science, PubMed, Scopus, and Cochrane databases using advanced search strategy. The search results was screened using titles and abstracts then full paper. The following data were extracted: country, study design, sample size, baseline characters of included patients, intervention, outcomes, parameters measuring functional outcome as incidence of excellent and good elbow performance, Mayo elbow performance score, duration of operation, blood loss and, complications. The quality assessment was operated by ROBINS-I tool for assessment of risk of bias for non-randomized studies, cohort studies and the Cochrane RoB tool for randomized trials. Results This meta-analysis study included 10 studies. The result of meta-analysis study may be summarized as follow no statistically significant difference between operative time and blood loss during both approaches. No statistically significant difference between both approaches regarding MEPS score, DASH Score, incidence of excellent/good elbow function, supination and pronation. A significant increase in union time, extension deficit (degrees) and incidence of complications after OO approach comparing with TRAP approach. A significant decrease in ROM after OO approach comparing with TRAP approach. Conclusion TRAP approach is a better alternative to olecranon osteotomy approach in the treatment of inter-condylar and supracondylar humeral fracture. TRAP approach has privileges over olecranon osteotomy approach regarding post-operative union time, extension deficit, range of motion and incidence of complications.

Association of Clinical Findings With Complications in the Cubitus Varus Deformity After Supracondylar Fracture.

Cubitus varus deformity is primarily a cosmetic complaint that causes some early and late complications. However, no studies have reported the cubitus varus deformity regarding the frequency of complications, relationship to the degree of deformity, and period from the occurrence of the initial injury. Overall, 83 patients with cubitus varus deformity were examined. The differences in the humerus-elbow-wrist angle (∆HEW-A), tilting angle (∆TA), and internal rotation angle (∆IRA) between the affected and normal sides were measured to determine varus and extension and internal rotation deformity. The period from the occurrence of the initial injury to the evaluation date was also investigated. Multivariate logistic regression analysis was conducted to identify the explanatory variables (period, ∆HEW-A, ∆TA, and ∆IRA) independently associated with complication events. Receiver-operating characteristic curve analysis was also conducted to predict the risk of events. ∆HEW-A was independently associated with the risk of cosmetic complaint (odds ratio [OR], 1.171; 95% confidence interval [95% CI], 1.056 to 1.336) and instability (OR, 1.111; 95% CI, 1.028 to 1.200). ∆TA was independently associated with the risk of limited elbow motion (OR, 1.176; 95% CI, 1.077 to 1.285) and sports disability (OR, 0.892; 95% CI, 0.836 to 0.952). The period from the occurrence of the initial injury was independently associated with risk of pain (OR, 1.063; 95% CI, 1.019 to 1.108), ulnar nerve neuropathy (OR, 1.065; 95% CI, 1.011 to 1.125), and osteoarthritis (OR, 1.188; 95% CI, 1.098 to 1.286). The receiver-operating characteristic curve analysis revealed the optimal cutoffs of 20° and 27° for ∆HEW-A to predict cosmetic complaint and instability; of 25° for ∆TA to predict limited elbow motion; and of 8.8, 8.0, and 16.0 years for the period to predict pain, ulnar nerve neuropathy, and osteoarthritis, respectively. The treatment of cubitus varus deformity should be determined because a residual deformity >20° of varus and 25° of extension could develop risk of complications over time.

Clinical Efficacy of Medial and Lateral Plating in Distal Femur Fractures: Thesis Study

Abstract Background The problem of treating distal femoral fractures is complicated. The principles of the surgical management of supracondylar femur fractures have changed. Up until 1970, conservative management of these fractures was the recommended course of care. This was mostly caused by a lack of adequate implants and procedures. In modern times, locking compression plates offer the benefits of locking head screws, offering better fixation and absolute stability. This is significant in the treatment of fractures in osteoporotic bone because it enables the use of monocortical screws in the diaphyseal region, preserving the periosteum's blood supply and preventing structural bone loss to the opposite cortex. Varus collapse was the main complication, especially in osteoporotic bone. Therefore, anatomical reduction and rigid, stable fixation provided by double plating was considered the best option for treating this type of fracture. Patients and Methods This is a retrospective cohort study done in El Demerdash Hospital, Ain Shams University specialised hospitals, Air Force specialised hospital, and El Helmia military hospital through 20 cases of distal femur fractures of types 33-A3 to 33-C3, all of which were managed by dual plating and followed up for 6 months. People with open fractures, fracture type 33-A1, periprosthetic, and pathological fractures were excluded. Results In our study, through 20 cases with distal femur fractures between types 33-A3 and 33-C3, all managed by double plating, the mean age was 51.50, 6 of our patients had comorbidities (DM, HTN, or Both), the rest were medically free, the average operation time was 150 minutes, 2 of our patients needed a bone graft, the range of full union was from 3 to 6 months, the average AKSS among the 20 patients was 81.05, 14 of our cases achieved uneventful union, 2 cases had superficial wound infection, and 1 case had implant failure (screw cut out) and needed revision, so double plating is one of the better options to achieve bony union and a better functional outcome in severely comminuted distal femur fractures Conclusion Even though there were problems such as a lengthy operation and longer recovery period in our study, double plating is one of the best options for achieving bone union and a better functional outcome in severely comminuted distal femur fractures. Functional outcomes were excellent in 75% of cases and fair in 25% of cases, and the union rate was 100% with no Varus deformity or malunion.

Fix or Replace? Comparable Outcomes With Internal Fixation and Distal Femoral Replacement for Periprosthetic Fractures Above Total Knee Arthroplasty

BackgroundThe optimal treatment for periprosthetic fracture (PPfx) around total knee arthroplasty (TKA) remains a topic of debate. Due to its low incidence, comparative studies analyzing arthroplasty and fixation are lacking in the literature. The purpose of this study was to compare the outcomes of distal femoral replacement (DFR) and open reduction and internal fixation open reduction internal fixation (ORIF) for distal femur PPfx. MethodsWe reviewed a consecutive series of 99 patients who underwent DFR (n = 54) or ORIF (n = 45) for distal femur PPfx. The indications for DFR were reviewed. Fractures were classified based on their relation to the implant using the Su classification. The primary outcome was rerevision, while secondary endpoints included inpatient complications, mortality within the first year, and mechanical complications such as loosening and non-union. ResultsType 2 fractures were the most prevalent type in both groups (DFR 37 versus ORIF 48.9%), while Type 1 fractures were more commonly treated with ORIF (35.6 versus 16.7%) and Type 3 with DFR (46.3 versus 15.6%) (P = 0.003). The preferred techniques in the ORIF group were plate osteosynthesis (66.7%) and retrograde nailing (31.1%). At a mean follow-up of 4.2 years (range, one to 14.1), DFR and ORIF did not demonstrate any difference in revision rates (13 versus 24.4%, P = 0.140) or mortality (3.7 versus 4.4%, P = 0.887). However, more mechanical complications were noted in the ORIF group (22.2 versus 7.4%, P = 0.035). ConclusionsBoth DFR and open reduction and internal fixation have comparable revision rates, complications, and clinical outcomes when used in supracondylar periprosthetic distal femur fractures. Longer-term studies are needed to assess DFR survivorship as well as outcomes of newer trauma techniques such as nail-plate combinations.