Supracondylar Fractures Of The Humerus Research Articles

Comparison of Outcome of Lateral K-Wire Fixation Verses Medio-Lateral Crossed K-Wire Fixation for Displaced Extension Type of Supracondylar Humeral Fractures in Children

INTRODUCTION: Supracondylar humeral fractures are the most common elbow fractures seen in children. The purpose of this study was to compare the efficacy of lateral entry pin fixation with that of medial and lateral entry pin fixation for the operative treatment of displaced extension supracondylar fractures of the humerus in children. MATERIAL AND METHODS: Total of 50 cases of displaced supracondylar fracture humerus were enrolled in study, 25 cases in two equal groups, Group A and group B. Group A received treatment by closed reduction with lateral k-wire fixation and Group B received treatment by closed reduction and medio-lateral k-wire fixation. The cases were followed at 4 weeks when slab was removed and physiotherapy started, and at 12 weeks for final outcome. The outcome was measured as per Flynn's criteria.RESULTS: The mean age of patents in group A was 6.40 years and in group B was 6.44 years. At final follow up, in group A, 18 (72%) cases had excellent, 7 (28%) good result, in group B; 20 (80%) had excellent, and 5 (20%) had good result. The p- value (0.08) derived between them was statistically not significant. Three pateints got superficial pin tract infection in group A and two iatrogenic ulnar nerve injury and one pin had pintract infection in group B. There were also no significant differences (p value- 0.697) between groups with respect to the baumann angle. CONCLUSION: Both lateral entry pin fixation and medio- lateral entry pin fixation are effective in the treatment of completely displaced (type-III) extension supracondylar fractures of the humerus in children. Although there remains subtle risk of ulnar nerve injury in medio-lateral pin fixation.DOI: http://dx.doi.org/10.3126/jucms.v2i3.11823 Journal of Universal College of Medical Sciences Vol.2(3) 2014: 20-25

Clinical Outcome of Dome Osteotomy in Cubitus Varus

Introduction: Cubitus varus (Gunstock deformity), is the most common long term complication of childhood supracondylar fracture of the humerus. For correction of cubitus varus deformity many types of osteotomies and fixations methods have been described. The most commonly used is the Lateral closing wedge osteotomy, which provides good results but results in two fragments of unequal width for bony union and the lateral condyle becomes prominent leading to Lateral condyle prominence, an another cosmetic deformity. To overcome this problem, Dome osteotomy was done. Material and Methods: This prospective study included 15 cases of cubitus varus deformity of elbow over a period of 18 months. Mean age of the cases was 9.07±3.07 years. Dome osteotomy with paratriceps approach was used. Pre and post -operative carrying angle of elbow, range of motion and lateral prominence indices were compared. Results: The mean follow-up period was 13.33±1.84 months. Mean time between injury and surgery was 16.53±4.10 months. There was significant improvement in carrying angle and lateral condylar prominence indices. Two of the cases developed transient ulnar nerve neuropraxia and one patient had superficial skin infection. Conclusion: Dome osteotomy is relatively technically demanding technique for correction of cubitus varus deformity but with better functional outcome without associated with lateral condyle prominence.

Gartland type III supracondylar humerus fractures: outcome and complications as related to operative timing and pin configuration.

PurposeSupracondylar fractures of the humerus are the most common fracture of the elbow in children. The purpose of this study was to evaluate, in terms of outcomes and complications, Gartland type III pediatric supracondylar humerus fractures treated at a pediatric level-one trauma center over a 7-year period, specifically addressing the impact of time to surgery on the incidence of complications and conversion to open reduction.MethodsWe retrospectively reviewed 297 pediatric patients that sustained a closed Gartland type III supracondylar humerus fracture treated between December 2004 and December 2011. The time to the operating room was calculated from the medical records for each patient. The outcome measures evaluated were operative time, conversion to open procedure, and perioperative and postoperative complications.ResultsIn our study, there were 30 complications in 25 children (8.4%). Conversion to open reduction occurred in 28 children (9.4%). The time from the emergency department to the operating room was not significantly correlated with increased complications, increased operative time, or conversion to open reduction (p > 0.05). Crossed pinning resulted in an increased risk of overall complications [odds ratio (OR) = 2.6] and iatrogenic nerve injuries (OR = 9.3). Complications also occurred more commonly in boys (OR = 3.3) and in older patients (p = 0.0069)ConclusionsWe found no significant correlation between the time to surgery and complications, operative time, or need for open reduction. These findings support the trend of treating Gartland type III supracondylar humerus fractures in a less urgent manner. In addition, our study supports the concept that cross pinning leads to more complications than lateral pinning, including an 8-fold increase in iatrogenic nerve injury.

Mid-term results of pediatric vascular injured supracondylar humerus fractures and surgical approach.

The purpose of this study was to describe our experience with poorly perfused hands after supracondylar fracture of the humerus (SFH) in children and to present mid-term outcomes of a single trauma center. This is a retrospective analysis of SFH patients with vascular injuries, conducted from 2003 to 2012. Nine patients (2.1% of all SFH patients) underwent vascular reconstruction with no hand perfusion after adequate reduction and fixation at a mean age of 8.3 years (± 1.8, range 4-12 years). No amputation was needed, and satisfactory elbow and hand functions were obtained. Immediate close anatomic reduction and pinning with re-evaluation of hand perfusion is mandatory for SFH patients with suspected vascular injury before vascular exploration.

Postoperative accuracy analysis of three-dimensional corrective osteotomy for cubitus varus deformity with a custom-made surgical guide based on computer simulation

For correction of cubitus varus deformity resulting from supracondylar fracture of the humerus, we developed an operative method with use of a custom-made surgical guide, designed on the basis of 3-dimensional (3D) computer simulation with computed tomography data. The purpose of this study was to investigate the postoperative accuracy of this system in clinical cases. Subjects included 17 consecutive patients (13 males and 4 females) with cubitus varus deformity after supracondylar fracture. Patients underwent 3D corrective osteotomy with use of a custom-made surgical guide. Postoperative computed tomography scan was performed after bone union diagnosis on plain radiographs, and postoperative 3D bone models were compared with preoperative simulation by surface registration technique. In addition, we evaluated radiographic parameters (humerus-elbow-wrist angle and tilting angle) and range of elbow motion at the most recent follow-up. Mean errors in 3D corrective osteotomy were 0.6° ± 0.7° in varus-valgus rotation, 0.8° ± 1.3° in flexion-extension rotation, 2.9° ± 2.8° in internal-external rotation, 1.7 ± 1.8 mm in anterior-posterior translation, 1.3 ± 1.8 mm in lateral-medial translation, and 7.1 ± 6.3 mm in proximal-distal translation. The mean humerus-elbow-wrist angle on plain radiographs of the affected side was 15° in varus before surgery and improved to 6° in valgus after surgery. The mean tilting angle of the affected side was 31° before surgery and improved to 40° after surgery. The 3D correction of cubitus varus deformity was performed accurately within the allowable error limits.

A study of biplanar crossed pin construct in the management of displaced pediatric supracondylar humeral fractures.

PurposeStudy of a biplanar crossed pin construct by two crossed Kirschner wires in the management of displaced extension type supracondylar humeral fractures in children.MethodsSixty-four patients with such fractures were included and treated according to the study protocol: after achieving closed reduction under general anesthesia with fluoroscopic control, two crossed Kirschner wires of equal diameter were inserted percutaneously. The first lateral wire tracts from the posterolateral corner of the epicondyle to the anteromedial cortex proximally. Then, the medial wire is inserted from the anteromedial corner of the epicondyle to the posterolateral cortex proximally after crossing the fracture site. Thus, a biplanar crossed pin construct was achieved, as each wire had two separate fixation points and the crossed construct was achieved not only in the coronal plane but also in the sagittal plane. Every effort was made to get this construct right at the very first attempt without repetition.ResultsTwo patients were lost to follow-up during the first postoperative year. The mean follow-up for the remaining 62 patients was 14.5 months (range 6–24 months). At the final follow-up, using Flynn’s overall modified classification, the clinical result was considered to be satisfactory in 60 (96.8 %) patients and unsatisfactory with poor result in two (3.2 %) patients. Technical error was thought to be the cause of the poor results. There were no postoperative neural or vascular complications.ConclusionA biplanar crossed pin construct achieved by two Kirschner wires crossed in the coronal and sagittal planes is efficient to stabilize a displaced extension type supracondylar fracture of the humerus in children.

English

INTRODUCTION: The supracondylar fracture of the distal humerus is the most common pediatric fracture in the elbow. The purpose of this study was to compare the infection rate of lateral entry pin fixation with that of medial and lateral entry pin fixation for the operative treatment of completely displaced extension supracondylar fractures of the humerus in children. MATERIAL & METHODS: Only the 81 patients who were able to follow up to final examination were included in the assessment. The patients were allocated randomly into two groups according to the pin configuration used. Group 1 comprised 40 patients, 30 male and 10 female, with a mean age of 7.5 years (range, 1.5–14 years). After closed reduction, fixation was achieved with K-wires placed from the lateral condyle. Group 2 comprised 41 patients, 28 males and 13 females, with a mean age of 7.8 years (range, 2–13 years). After closed reduction, two cross-wires passed—one from medial and one from lateral. RESULTS & CONCLUSION: On statistical evaluation, no significant difference was seen between the two groups With use of the specific techniques employed in this study, both lateral entry pin fixation and medial and lateral entry pin fixation are effective in the treatment of completely displaced (type-III) extension supracondylar fractures of the humerus in children however percentage wise lateral entry group was associated with pin tract infection more as compared to lateral and medial entry group may be because of small sample size so further studies needed with large sample size.

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.

Two Cases of Total Elbow Arthroplasty for Nonunion of Supracondylar Fracture of the Humerus

Two Cases of Total Elbow Arthroplasty for Nonunion of Supracondylar Fracture of the Humerus

The evaluation of the results of surgical treatment of forearm shaft fractures in children using elastic intramedullary stabilization in our ward

Children supracndylar fractures are among the most common fractures of the elbows. The variety of methods of treatment indicates that there is no unified and effective surgical treatment for all types of fractures. The aim of the study was clinical and radiological evaluation of the comparative results of treatment of supracondylar fractures of the humerus in children by closed reduction method for stabilizing wires “K” and open method for setting the stabilization crossed wires. We analyzed 289 cases of spracondylar fractures of the humerus in children age from 2 to 17 years old. The classification of a division of fractures of Gartland with Wilkins modification was used. The evaluation of results of treatment is based on the modified rating scales given by Faflik and Jasinski. The good outcome was achieved at 81% of patients, who were operated with the method of closed reduction, and 80% of cases after open reduction. The largest percentage of unsatisfactory results was obtained when more than 2 or incomplete repositions - usually open ones - were performed.

Dislocated Extension – Type Supracondylar Humerus Fractures in Children: Single Centre Experience

Aim: The aim of this study is to show our experience in cases of dislocated extension type – supracondylar humeral fractures and evaluate the results of their treatment in the period from 2000 to 2010 with a follow up of a maximum six months.Material and Methods: A retrospective analysis of the clinical cases for the period 2000 – 2010 was done. Children from 4 to 14 years of age with supracondylar fractures of the humerus – extension type are included. The total number of patients treated at the Clinic for Pediatric Surgery was 230.Results: The results of the treatment were evaluated after the last control examination six months later. We noticed postoperative neurological damage in 10 cases (4.85%). In 14 patients (6.8%) we noticed long term deformities such as cubitus varus or cubitus valgus. Infection at the entering place of the needles occurred in 4 patients (1.94%), which did not indicate premature extraction of the needles and conversion of the treatment.Conclusion: As a conclusion, we can stress that our outcomes in treatment of dislocated suparacondylar fractures of the humerus in children meet the world standards.

Dislocated Extension – Type Supracondylar Humerus Fractures in Children: Single Centre Experience

Aim: The aim of this study is to show our experience in cases of dislocated extension type – supracondylar humeral fractures and evaluate the results of their treatment in the period from 2000 to 2010 with a follow up of a maximum six months.Material and Methods: A retrospective analysis of the clinical cases for the period 2000 – 2010 was done. Children from 4 to 14 years of age with supracondylar fractures of the humerus – extension type are included. The total number of patients treated at the Clinic for Pediatric Surgery was 230.Results: The results of the treatment were evaluated after the last control examination six months later. We noticed postoperative neurological damage in 10 cases (4.85%). In 14 patients (6.8%) we noticed long term deformities such as cubitus varus or cubitus valgus. Infection at the entering place of the needles occurred in 4 patients (1.94%), which did not indicate premature extraction of the needles and conversion of the treatment.Conclusion: As a conclusion, we can stress that our outcomes in treatment of dislocated suparacondylar fractures of the humerus in children meet the world standards.

Compartment Syndrome of the Upper Arm After Closed Reduction and Percutaneous Pinning of a Supracondylar Humerus Fracture

Supracondylar fractures of the humerus are the most frequently seen elbow fractures in children. One of the most feared complications of this fracture, that is, compartment syndrome of the forearm is seen rarely. Compartment syndrome of the upper arm is an even more rare occurrence and to date, has not been reported in association with an isolated supracondylar humerus fracture in a child. A 9-year-old boy was cared for at our facility for a severe (Gartland type III) supracondylar humerus fracture and developed a compartment syndrome in the perioperative period. A clinical, radiographic, and literature review of this case was undertaken to better define this occurrence. This patient sustained a closed supracondylar humerus fracture in association with a motor and sensory deficit of the radial nerve. Because of the severity of the deformity, a provisional reduction was performed in the emergency department. Eleven hours after the injury, a routine closed reduction and percutaneous pinning was performed. Although significant swelling was noted at that time, compartment syndrome was not clinically suspected. He was observed as an inpatient because of this persistent swelling. Over the next day, he developed considerable tenderness over the anterior arm and mobile wad musculature, hence, compartment pressure measurements were made. These confirmed a compartment syndrome in the anterior compartment of the arm and equivocally in the mobile wad. An urgent compartment release of the arm was done, which resulted in full recovery. This is the first report of a compartment syndrome of the arm after an isolated supracondylar humerus fracture in a child. The presence of the associated fracture made the classic signs of compartment syndrome difficult to assess. Ultimately, muscle tenderness and compartment pressure measurement were most helpful in making this diagnosis. A high index of suspicion should be maintained for compartment syndrome of the arm as well as the forearm when evaluating children with severe supracondylar humerus fractures. Level IV, case report.

Ulnar Nerve Monitoring During Percutaneous Pinning of Supracondylar Fractures in Children

Supracondylar fractures of the humerus in children are frequently managed by closed reduction and percutaneous pinning. Insertion of medial and lateral pins is more stable than lateral pinning alone, but carries an increased risk for ulnar nerve damage. This study describes the use of electrical stimulation concurrent with medial pin insertion as a monitoring technique for avoiding iatrogenic ulnar nerve injury. A retrospective review was conducted on 138 children, mean age 5.6 years (SD±2.5), who were admitted to the hospital between 2007 and 2010 with uncomplicated supracondylar fractures, Gartland type II and above, and intact neurovascular presentation. The location of the ulnar nerve was identified and marked preoperatively by observing twitch contractions in response to electrical stimulation. The medial pin served as an active electrode during pin insertion, and repeated stimulation throughout the insertion process ensured no contact with the response of the ulnar nerve. After pin insertion, ulnar nerve stimulation was used again to ensure nerve continuity viability. All fractures were stabilized with 2 to 4 cross K-wires (size 1.6 mm), with number depending on stability of the fracture. The children were discharged home 2 days after fracture fixation, with no iatrogenic ulnar nerve injury observed in any of the children. The only postoperative complication involved 2 cases of anterior interosseus nerve neuropraxia, which resolved spontaneously after 4 to 6 months. Primary fracture healing was achieved without nonunions or delayed unions in all cases. Ulnar nerve stimulation before and during the percutaneous pinning of supracondylar fractures in children is a simple, economical, and easy-to-implement technique that can prevent iatrogenic ulnar nerve injury. Level IV.

Type - III supracondylar fracture of humerus effectively managed by closed reduction and pop application: A Case Report

Supracondylar fracture of the humerus is a common entity in children occurring most often in the age between 5 to 7 years. These constitute around 60% of the elbow fractures. Displaced factures may be associated with various complications like neurovascular compromise, compartment syndrome, skin problems, volkmann ischaemia and cubitus varus. The treatment is technically challenging and controversial. Type II and III fractures are displaced and are ideally treated operatively by open reduction and internal fixation. Conservative treatment is usually not recommended for type III fractures. We report a case of a type III supracondylar fracture in a young girl managed effectively by closed reduction and plaster cast alone with good cosmetic and functional outcome without any complications. The purpose of this paper is to highlight the likelihood of effective treatment of type III supracondylar humeral fractures conservatively through proper alignment and more vigilant care, avoiding the need for the surgery.

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.

Ipsilateral fracture of the supracondylar humerus and forearm in children

Simultaneous ipsilateral fracture of the elbow and forearm (floating elbow) is an uncommon injury and treatment recommendations are controversial. The aim of our study was to evaluate the incidence of ipsilateral fractures of the upper limb and to present our experience in dealing with such injuries and to review the literature relating to this topic. The following variables were used: age, gender, side, mechanism of injury, type of fracture, classification, treatment methods, complications and outcome. We prospectively followed five children who presented with displaced supracondylar fractures of the humerus associated with a forearm fracture of the same limb. All patients underwent emergency procedures in the form of closed reduction and K-wire fixation/cast fixation. At a minimum follow up of 24 months, all patients were assessed clinically and radiologically and the results evaluated according to a conventional scoring system. Four patients had excellent or good outcomes, and there was one poor result. The floating elbow is an indicator of a high energy injury. The incidence of open fractures, compartment syndrome and nerve injury and the need to perform an open reduction were higher than those recorded for isolated supracondylar or forearm fractures. The existing controversies in the management of such a complex injury and associated problems are outlined. A pertinent literature review is also included.

Close Reduction and Percutaneous K-wire Fixation without Image Intensifier in Supracondylar Fracture of Humerus in Children

Introduction: Extension Type III supracondyla fractures of the humerus is most common fractures around the elbow in children. Closed reduction and percutaneous pinning under image intensifier guide has been the gold standard method of treatment. However, image intensifier is not readily available in most part of our country. Closed reduction and percutaneous pinning is possible even without image intensifier. we report our case series of 51 cases who underwent closed reduction and percutaneous pinning without image intensifier. Methods: Between November 2009 and April 2011 a total of 51 children with a displaced supracondylar fractures of the humerus were managed by close reduction and percuteneus k-wire fixation without using image intensifier. They were followed for a period of minimum 6 months up to one and a half years (average one year) and the final outcome was assessed using functional and cosmetic criteria used by Flynn and associates. Results: Of these 51 patients, 46 (90%) patients showed an excellent results. Satisfactory results were achieved in 4 (8%) patients, poor in 1(2%) patients. Conclusion: Close reduction and percutaneous K-wire fixation without using image intensifier is radiation free, cost effective and relatively safe method of management of displaced supracondylar fractures of humerus in children. It can be used in a remote hospital where the facilities of image intensifier or portable x-ray are not available. DOI: http://dx.doi.org/10.3126/noaj.v3i1.9321 Nepal Orthopedic Association Journal 2013 Vol.3(1): 19-22

Anterior Interosseous Nerve Palsy after Supracondylar Fracture of Humerus in Adult. Case report

We present a case of anterior interosseous nerve palsy after a supracondylar fracture of the humerus in a 24-year-old woman. The patient was diagnosed and treated in two hospitals where the impairment of function of the hand indicating nerve damage was not noticed during a standard examination. An open reduction of the fracture with internal fixation using LCP plates and additional screws was performed, ultimately producing a good therapeutic outcome. Anterior interosseous nerve palsy was detected after 14 days during the first follow-up visit. The decision was made to institute conservative treatment. Full functional recovery was achieved after approximately 8 months. We believe that injuries of this type are more common but can be easily overlooked in the course of an imprecise physical examination. The Introduction of improved algorithms for the clinical examination of patients with similar fractures should be considered for the patient's good and on account of possible legal aspects of a failure to establish a correct diagnosis.