|
1
|
Ito R, Tokutake K, Takegami Y, Okui N, Natsume T, Koh S, Tatebe M, Yamamoto M. Primary nerve exploration is required in more than 10% of complete motor nerve paralysis cases associated with Gartland type III paediatric supracondylar humerus fractures : a multicentre retrospective study. Bone Jt Open 2025; 6:609-617. [PMID: 40449937 DOI: 10.1302/2633-1462.66.bjo-2025-0020.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/03/2025] Open
Abstract
Aims This study aims to determine the prevalence, prognosis, and outcome of complete motor paralysis associated with Gartland type III paediatric supracondylar humerus fractures (SCHFs) and identify when primary nerve exploration is indicated. Methods In this multicentre retrospective study, we investigated complete motor paralysis associated with Gartland type III paediatric SCHFs. Iatrogenic paralysis was excluded. Radiographs were used to determine a fascial penetration sign. Findings from nerve explorations were recorded. Notable cases were defined as those with the following nerve conditions: 1) complete or partial laceration; 2) tethering/entrapment; 3) formation of a neuroma; or 4) entrapment at the fracture site or callus. The frequency with which ultrasound was used was documented and its findings were examined. Results Among 691 patients with Gartland type III SCHFs, 45 (7%) had complete motor paralysis. Of these, 20 (44%) were managed without primary nerve exploration. Overall, 18 (90%) spontaneously recovered and two (10%) required neurorrhaphy and nerve grafting during a secondary exploration. Of the other 25 (56%) who underwent primary nerve exploration, one had a complete radial nerve laceration, and five had tethered/entrapped nerves. The fascial penetration sign was positive in each of the eight notable cases (18%), a rate that was substantially higher than in the others (19 of 37; p = 0.014, sensitivity 100%, specificity 49%). Ultrasound was used preoperatively in 14 cases (31%) to investigate the condition of the nerve, possible contact with the proximal fragment, and its changes after traction. Conclusion For Gartland type III paediatric SCHF patients with complete motor paralysis, we estimate that more than 10% require primary nerve exploration due to tethered/entrapped or lacerated nerves. A positive fascial penetration sign on radiography provided early evidence that primary nerve exploration was warranted. In addition, preoperative ultrasound under general anaesthesia to assess the condition of the nerves can play a crucial role.
Collapse
Affiliation(s)
- Rina Ito
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Katsuhiro Tokutake
- Department of Human Enhancement and Hand Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yasuhiko Takegami
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Nobuyuki Okui
- Department of Orthopaedic Surgery, Yokkaichi Municipal Hospital, Yokkaichi, Japan
| | - Tadahiro Natsume
- Department of Orthopaedic Surgery, Kariya Toyota General Hospital, Kariya, Japan
| | - Shukuki Koh
- Department of Orthopaedic Surgery, Japanese Red Cross Aichi Medical Center Nagoya Daiichi Hospital, Nagoya, Japan
| | - Masahiro Tatebe
- Hand and Microsurgery Center, Anjo Kosei Hospital, Anjo-shi, Japan
| | - Michiro Yamamoto
- Department of Human Enhancement and Hand Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| |
Collapse
|
|
2
|
Sandbæk D, Wünsche L, Halvorsen V, Madsen JE, Brattgjerd JE. The Mini-invasive Medial Approach is Safe for Cross-pinning in Pediatric Supracondylar Humerus Fractures When Performed by Resident Surgeons-A Retrospective Cohort Study. J Pediatr Orthop 2025:01241398-990000000-00846. [PMID: 40420677 DOI: 10.1097/bpo.0000000000003011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/28/2025]
Abstract
BACKGROUND AND PURPOSE In the treatment of pediatric supracondylar humerus fractures (SCHF), cross-pinning increases the risk of ulnar nerve injuries due to a misplaced medial pin. However, the extent to which the use of a mini-invasive approach medially may lead to safe cross-pinning remains unclear. Accordingly, we evaluated the safety of a mini-invasive medial approach in the hands of resident surgeons, who most commonly perform surgery on these patients. METHODS We retrospectively analyzed iatrogenic injury rate to the ulnar nerve in children operated between 2017 and 2021. Patient, fracture, and treatment details were collected from medical records and followed a predefined protocol. 211 children with an extension-type SCHF, who were treated with an open or closed reduction before pinning, were identified. Patients with preoperative nerve injuries, concurrently operated fracture in the same arm, pin configurations other than 2 or 3 crossed pins, or surgeries conducted by an attending surgeon, were excluded. Our institutional practice of cross-pinning with a mini-invasive medial approach to a semiflexed elbow was performed by residents in orthopaedic surgery in 167 patients. RESULTS No iatrogenic ulnar nerve motor injuries were found. Three out of 167 patients experienced transient sensory changes to the ulnar nerve, all resolving within the first week. In every procedure, the lead surgeon was a resident. CONCLUSION Our results indicate that the mini-invasive medial approach is safe in the hands of resident surgeons for cross-pinning in pediatric SCHF. This finding suggests that iatrogenic ulnar nerve injuries may be prevented by performing mini-invasive medial pinning in a semiflexed elbow.
Collapse
Affiliation(s)
- Dan Sandbæk
- Institute for Clinical Medicine, University of Oslo
- Division of Orthopaedic Surgery, Oslo University Hospital
- Division of Orthopaedic Surgery, Østfold Hospital, Grålum, Norway
| | | | - Vera Halvorsen
- Division of Orthopaedic Surgery, Oslo University Hospital
| | - Jan Erik Madsen
- Institute for Clinical Medicine, University of Oslo
- Division of Orthopaedic Surgery, Oslo University Hospital
| | - Jan Egil Brattgjerd
- Division of Orthopaedic Surgery, Oslo University Hospital
- Institute of Rehabilitation Science and Health Technology, Oslo Metropolitan University, Oslo
| |
Collapse
|
|
3
|
Syed AN, Isaacs D, Ashebo L, Talwar D, Anari JB, Lawrence JTR. Nerve Recovery in Pediatric Supracondylar Humeral Fractures: Assessing the Impact of Time to Surgery. J Bone Joint Surg Am 2025; 107:687-693. [PMID: 39977536 DOI: 10.2106/jbjs.24.00371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/22/2025]
Abstract
BACKGROUND Nerve injuries in pediatric supracondylar humeral (SCH) fractures occur in 2% to 35% of patients. Previous research has suggested that isolated anterior interosseous nerve injuries are not influenced by the time to surgery; however, little is known about other nerve injuries or mixed, motor, and sensory injuries. With this study, we aimed to examine the impact of time to surgery on nerve recovery in patients with traumatic nerve injuries associated with SCH fractures. METHODS Patients <18 years of age with SCH fractures stabilized using percutaneous pins during the period of January 2009 to June 2022 were retrospectively reviewed. Patients presenting with any traumatic nerve injury noted preoperatively were included, while those with iatrogenic or postoperative nerve injuries and incomplete documentation were excluded. Demographic data, injury characteristics, time to surgery, and number of days to nerve recovery were collected. Comparisons of nerve recovery time by anatomic distribution and functional deficit using an 8-hour time-to-surgery cutoff were made in bivariate and multivariate analyses. RESULTS A total of 2,753 patients with SCH fractures were identified, with 214 of the patients having an associated nerve injury. Documentation of nerve recovery was available for 197 patients (180 patients with complete recovery) with an overall mean age of 6.8 ± 2.1 years. Time to recovery differed significantly when comparing the motor, sensory, and mixed-deficit cohorts (p < 0.001). Early surgery (≤8 hours from injury to surgery) was significantly associated with shorter overall time to nerve recovery (p = 0.002), recovery of multiple nerve distributions (p = 0.011), and recovery of mixed motor and sensory deficits (p = 0.007). On multivariable analysis, mixed nerve deficits (hazard ratio [HR], 0.537 [95% CI, 0.396 to 0.728]; p < 0.001) and time from injury to treatment of >8 hours (HR, 0.542 [95% CI, 0.373 to 0.786]; p = 0.001) were significantly associated with delayed nerve recovery. CONCLUSIONS Surgical timing impacts the time to recovery of complex nerve injuries. Early surgical management of patients with mixed motor-sensory deficits may help to reduce the time to complete nerve recovery. LEVEL OF EVIDENCE Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.
Collapse
Affiliation(s)
- Akbar N Syed
- Division of Orthopaedics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - David Isaacs
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Leta Ashebo
- Division of Orthopaedics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Divya Talwar
- Division of Orthopaedics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jason B Anari
- Division of Orthopaedics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - J Todd R Lawrence
- Division of Orthopaedics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| |
Collapse
|
|
4
|
Takagi T, Aibara N, Yamaguchi S, Seki A, Takayama S. The Initial Characteristics of Paediatric Supracondylar Humerus Fractures Led to Cubitus Varus Deformity and Delayed Displacement. J Hand Surg Asian Pac Vol 2025; 30:148-154. [PMID: 39773152 DOI: 10.1142/s2424835525500237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2025]
Abstract
Background: Supracondylar humerus fractures are the most common type of elbow fracture in children, with a variety of complications such as cubitus varus deformity. The most important goal of the initial treatment is to avoid complicated deformities. In the present study, we investigated cubitus varus deformity and discussed the ideal initial treatment for supracondylar humerus fractures. Methods: There were 58 conservative cases (26 girls and 32 boys) and 115 operative cases (40 girls and 75 boys) with supracondylar humerus fractures. We evaluated the correlation between the following factors on injury in the conservative cases: Gartland classification, presence of comminuted medial fractures, medial shift length, anterior spike length, age, sex, affected side (as explanatory variables) and the factors of cubitus varus deformity as response variables by using the linear regression model for multivariable analysis. Moreover, we evaluated the changes in displacement after the operation in the operative cases, adding the presence of medial pins and the number of pins as explanatory variables. Results: Injury severity (Gartland classification) was a significant factor for cubitus varus deformity. The presence of comminuted bone fragments on the medial side, anterior spike length, age, sex and affected side were not significant factors of cubitus varus deformity. However, medial displacement on injury was a significant factor of both cubitus varus deformity. In the operative case study, medial displacement was a significant factor in cubitus varus deformity. The presence of comminuted bone fragments on the medial side, number of pins and age were also significant factors for cubitus varus deformities. Conclusions: The present study concluded that it is important to perform accurate reduction and fixation, with special attention to medial shift and medial comminuted fragments to avoid cubitus varus deformity. Level of Evidence: Level IV (Therapeutic).
Collapse
Affiliation(s)
- Takehiko Takagi
- Division of Orthopaedic Surgery, Department of Surgical Specialties, National Center for Child Health and Development, Tokyo, Japan
| | - Noriyuki Aibara
- Division of Orthopaedic Surgery, Department of Surgical Specialties, National Center for Child Health and Development, Tokyo, Japan
| | - Sakura Yamaguchi
- Division of Orthopaedic Surgery, Department of Surgical Specialties, National Center for Child Health and Development, Tokyo, Japan
| | - Atsuhito Seki
- Division of Orthopaedic Surgery, Department of Surgical Specialties, National Center for Child Health and Development, Tokyo, Japan
| | - Shinichiro Takayama
- Division of Orthopaedic Surgery, Department of Surgical Specialties, National Center for Child Health and Development, Tokyo, Japan
| |
Collapse
|
|
5
|
Giray E, Keles A. Pediatric supracondylar humerus fracture with fascicular median nerve injury: The role of neuromuscular ultrasound in diagnosis and management - a case report. J Back Musculoskelet Rehabil 2025; 38:192-199. [PMID: 39970452 DOI: 10.1177/10538127241290931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/21/2025]
Abstract
BACKGROUND Supracondylar humerus fractures are the most common type of elbow fractures in children. Nerve injuries, primarily neuropraxia, are frequent complications and are often managed with a "wait-and-see" approach. Electroneuromyography (ENMG) is the standard method for evaluating peripheral nerve injuries, while ultrasound (US) is valuable for localizing lesions. OBJECTIVE This case report aims to highlight the beneficial role of US in the follow-up and rehabilitation of nerve injuries following pediatric supracondylar humerus fractures. CASE PRESENTATION A 4-year-old boy presented with a supracondylar humerus fracture that was treated with closed reduction and K-wire fixation. He exhibited weakness in the first two fingers of his left hand, difficulty grasping, and nail changes. Ultrasound revealed a median nerve lesion adjacent to the fracture site. ENMG indicated an acute severe axonal injury involving the branch innervating the flexor carpi radialis muscle. Following rehabilitation, there was improvement in hand grip strength, measured using a JAMAR hand dynamometer, and in health-related quality of life (QoL), assessed by the Pediatric Outcomes Data Collection Instrument (PODCI) score. Follow-up ENMG showed signs of mild reinnervation. CONCLUSION Pre-ENMG ultrasound provides crucial information regarding which nerve should be examined with a nerve conduction study and identifies the initial muscle to be evaluated during needle EMG. This aids in accurately localizing nerve damage and guiding effective treatment.
Collapse
Affiliation(s)
- Esra Giray
- Department of Physical Medicine and Rehabilitation, University of Health Sciences, Fatih Sultan Mehmet Training and Research Hospital, Istanbul, Turkey
| | - Aslinur Keles
- Department of Physical Medicine and Rehabilitation, University of Health Sciences, Fatih Sultan Mehmet Training and Research Hospital, Istanbul, Turkey
| |
Collapse
|
|
6
|
Erdoğan F, Öztürk Ö, Cengiz T, Şimşek ŞA, Coskun HS, Dabak N. The Impact of Surgical Timing on Complications and Clinical Outcomes in Surgery for Displaced Pediatric Supracondylar Humerus Fracture. Ortop Traumatol Rehabil 2024; 26:257-263. [PMID: 40136091 DOI: 10.5604/01.3001.0055.0633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/27/2025]
Abstract
BACKGROUND Pediatric supracondylar humerus fractures are common in children aged 5-7. The mechanism of injury, fracture type, and its relationship to the epiphysis significantly affect long-term outcomes. This study examines the impact of demographic data, fracture characteristics, and surgical timing and duration on postoperative results. MATERIAL AND METHODS Patients treated for supracondylar humerus fractures between February 2009 and January 2021 were included. Pre- and postoperative radiographs were analyzed, and surgical timing and duration were compared with fracture type and clinical outcomes. RESULTS A total of 121 patients (72 males, 49 females) at a mean age of 6.6 2.8 years were evaluated. The mean surgery duration was 50.1 29.2 minutes. Fractures were classified as Gartland type 2a (38 patients), type 2b (59 patients), and type 3 (24 patients). Closed reduction with percutaneous pinning was performed in 82 cases. Complications occurred in 7 patients with surgery delays of less than 8 hours and in 4 patients with delays over 8 hours. A significant correlation was found between surgical timing, hospital stay, and complications (p<0.05). The Flynn criteria indicated better outcomes in patients with surgery performed between midnight and 08 a.m. and within 8 hours of injury. CONCLUSIONS 1. Pediatric patients operated on during nighttime hours exhibited higher complication rates and longer hospital stays. 2. Outcomes assessed using the Flynn criteria were superior in patients operated on during daytime hours or with surgical waiting times of less than 8 hours. 3. These findings suggest that there is no universal definitive limit for optimal surgical timing. 4. Patient-specific conditions and clinical features should guide surgeons in determining the appropriate timing for surgery.
Collapse
Affiliation(s)
- Furkan Erdoğan
- Ondokuz Mayis University Faculty of Medicine, Department of Orthopedics and Traumatology, Samsun, Turkey
| | - Özkan Öztürk
- Amasya University Sabuncuoğlu Şerefeddin Training and Research Hospital, Department of Orthopedics and Traumatology, Amasya, Turkey
| | - Tolgahan Cengiz
- Inebolu State Hospital, Clinic of Orthopedics and Traumatology, Kastamonu, Turkey
| | - Şafak Aydın Şimşek
- Ondokuz Mayis University Faculty of Medicine, Department of Orthopedics and Traumatology, Samsun, Turkey
| | - Hüseyin Sina Coskun
- Ondokuz Mayis University Faculty of Medicine, Department of Orthopedics and Traumatology, Samsun, Turkey
| | - Nevzat Dabak
- Ondokuz Mayis University Faculty of Medicine, Department of Orthopedics and Traumatology, Samsun, Turkey
| |
Collapse
|
|
7
|
Vajda M, Lőrincz A, Szakó L, Szabó L, Kassai T, Zahár Á, Józsa G. The first analysis of a multicentre paediatric supracondylar humerus fracture (SCHF) registry by fracture type. Arch Orthop Trauma Surg 2024; 145:39. [PMID: 39666055 PMCID: PMC11638461 DOI: 10.1007/s00402-024-05644-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2024] [Accepted: 10/25/2024] [Indexed: 12/13/2024]
Abstract
INTRODUCTION Supracondylar humerus fractures (SCHFs) represent a significant segment of paediatric bone injuries, posing unique challenges due to their potential for severe complications. This study aims to provide a detailed analysis of the surgically treated SCHF cases recorded in our registry. MATERIALS AND METHODS Prospectively collected data from seven institutes were retrospectively analysed using the Hungarian SCHF Registry, with data about surgically treated paediatric patients with SCHFs. We created three groups based on fracture type (Gartland IIA, IIB and III), and compared their preoperative, operative, and postoperative data. We analysed differences between the groups using the Chi-Squared test or Fisher's Exact test for categorical variables. The Kruskal-Wallis rank sum test was performed for continuous variables. If there was a significant difference between the groups, we conducted Dunn's post-hoc analysis. RESULTS The fracture type was available for 214 patients (Gartland IIA group contained 31, IIB 121, and III 62 children). Our investigation highlighted notable patterns: lower oxygen saturation levels at initial assessment correlated with higher fracture severity (p = 0.0125); Body Mass Index (BMI) did not significantly influence the type of fracture (p = 0.2254); neither the mechanism of injury (flexion vs. extension) (p = 0.5606), nor the initial radial pulse (p = 0.0647) showed significant difference; the complexity of fractures was directly proportional to operative time (p < 0.01); less severe fractures required longer time to heal before pin removal (p = 0.0125); while severe fractures showed a tendency towards neurological complications, the overall complication rates did not vary significantly across different fracture types (p = 0.0988). CONCLUSIONS Our study emphasizes the significance of initial oxygen saturation levels as potential indicators of fracture severity. It also stresses the need for detailed attention to neurological complications and the prolonged use of pins, thereby highlighting the importance of customized treatment strategies in paediatric SCHFs. LEVEL OF EVIDENCE II.
Collapse
Affiliation(s)
- Mátyás Vajda
- Saint George University Teaching Hospital of County-Fejér, 3 Seregélyesi Street, Székesfehérvár, H8000, Hungary
- Institute for Translational Medicine, Medical School, University of Pécs, 12 Szigeti Street, Pécs, H7624, Hungary
| | - Aba Lőrincz
- Institute for Translational Medicine, Medical School, University of Pécs, 12 Szigeti Street, Pécs, H7624, Hungary
| | - Lajos Szakó
- Institute for Translational Medicine, Medical School, University of Pécs, 12 Szigeti Street, Pécs, H7624, Hungary
| | - László Szabó
- Institute for Translational Medicine, Medical School, University of Pécs, 12 Szigeti Street, Pécs, H7624, Hungary
| | - Tamás Kassai
- Department of Pediatric Traumatology, Péterfy Hospital, Manninger Jenő National Trauma Center, 17 Fiumei Street, Budapest, H1081, Hungary
| | - Ákos Zahár
- Saint George University Teaching Hospital of County-Fejér, 3 Seregélyesi Street, Székesfehérvár, H8000, Hungary
| | - Gergő Józsa
- Institute for Translational Medicine, Medical School, University of Pécs, 12 Szigeti Street, Pécs, H7624, Hungary.
- Division of Paediatric Surgery, Traumatology, Urology and Paediatric Otolaryngology, Department of Pediatrics, Medical School, University of Pécs, 7 József Attila Street, Pécs, H7623, Hungary.
| |
Collapse
|
|
8
|
Schädlich IS, Buschbaum S, Magnus T, Reinshagen K, Wintges K, Gelderblom M. Median nerve lesions in pediatric displaced supracondylar humerus fracture: A prospective neurological, electrodiagnostic and ultrasound characterization. Eur J Neurol 2024; 31:e16459. [PMID: 39230443 PMCID: PMC11555132 DOI: 10.1111/ene.16459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Revised: 08/12/2024] [Accepted: 08/18/2024] [Indexed: 09/05/2024]
Abstract
BACKGROUND AND PURPOSE Supracondylar humerus fractures (SCHFs) are the most common elbow fractures in children. Traumatic median nerve injury and isolated lesions of its pure forearm motor branch, anterior interosseus nerve (AIN), have both been independently reported as complications of displaced SCHFs. Our main objectives were to characterize the neurological syndrome to distinguish median nerve from AIN lesions and to determine the prognosis of median nerve lesions after displaced SCHFs. METHODS Ten children were prospectively followed for an average of 11.6 months. Patients received a standardized clinical examination and high-resolution ultrasound of the median nerve every 1-3 months starting 1-2 months after trauma. Electrodiagnostic studies were performed within the first 4 months and after complete clinical recovery. RESULTS All children shared a clinical syndrome with predominant but not exclusive affection of AIN innervated muscles. High-resolution ultrasound uniformly excluded persistent nerve entrapment and neurotmesis requiring revision surgery but visualized post-traumatic median nerve neuroma at the fracture site in all patients. Electrodiagnostic studies showed axonal motor and sensory median nerve neuropathy. All children achieved complete functional recovery under conservative management. Motor recovery required up to 11 months and differed between involved muscles. CONCLUSIONS It was shown that neurological deficits of the median nerve in displaced SCHFs exceeded an isolated AIN lesion. Notably, detailed neurological follow-up examinations and sonographic exclusion of persistent nerve compression were able to guide conservative therapy in affected children. Under these conditions the prognosis of median nerve lesions was excellent despite severe initial deficits, development of neuroma and axonal injury.
Collapse
Affiliation(s)
| | - Sabriena Buschbaum
- Department of NeurologyUniversity Medical Center Hamburg‐EppendorfHamburgGermany
| | - Tim Magnus
- Department of NeurologyUniversity Medical Center Hamburg‐EppendorfHamburgGermany
| | - Konrad Reinshagen
- Department of Pediatric SurgeryUniversity Medical Center Hamburg‐EppendorfHamburgGermany
| | - Kristofer Wintges
- Department of Pediatric SurgeryUniversity Medical Center Hamburg‐EppendorfHamburgGermany
| | - Mathias Gelderblom
- Department of NeurologyUniversity Medical Center Hamburg‐EppendorfHamburgGermany
| |
Collapse
|
|
9
|
Phan MDM, Tran QN, Vo NQD, Lam KT, Nguyen PD. Treatment of Pink Pulseless Hand Following Supracondylar Fractures of the Humerus in Children. J Hand Surg Asian Pac Vol 2024; 29:554-560. [PMID: 39544037 DOI: 10.1142/s2424835524500462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2024]
Abstract
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).
Collapse
Affiliation(s)
| | | | - Nam Quang Dinh Vo
- Hospital for Traumatology and Orthopaedics, Ho Chi Minh City, Vietnam
| | | | | |
Collapse
|
|
10
|
Zhu D, Wen Y, Wang Q, Son B, Feng W. Conservative versus surgical treatment of Gartland type II supracondylar humeral fractures in children. J Pediatr Orthop B 2024; 33:568-573. [PMID: 38375829 DOI: 10.1097/bpb.0000000000001170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/21/2024]
Abstract
The purpose of the study was to compare the efficacy of conservative and surgical treatments for Gartland type II supracondylar humerus fractures in children. We assessed 142 patients with type II supracondylar humerus fractures treated in our hospital from February 2018 to February 2019. The patients were divided into two groups: initial conservative treatment (Group A) and initial surgical treatment (Group B). Clinical outcomes were measured by the Flynn scoring system. Variables were analyzed using a statistical approach between those groups. All patients were followed up for 6-12 months. The rate of loss reduction was 19.8% in patients treated conservatively, and the incidence of pin infections was 7.1% in patients treated surgically. Although there were no statistical differences between the three groups in fracture healing time and Flynn score, the conservative treatment was superior to surgical treatment in functional recovery times. At the last follow-up, all fractures had healed without iatrogenic vascular or nerve injury, Volkmann's contracture, or cubit varus deformity. Conservative treatment is safe and effective for the treatment of Gartland type II supracondylar fracture and represents a faster recovery time of elbow range of motion as compared with surgical treatment. Type IIB had a 41.3% risk of secondary displacement versus 5.3% for IIA, but we still prefer closed reduction. However, closed reduction of Garland type II must be followed accurately in the first 2 weeks to identify patients with loss of reduction. The patients who loss reduction can be treated with percutaneous pinning, and the clinical effect was consistent with immediate surgical treatment. Level of evidence: level III.
Collapse
Affiliation(s)
- Danjiang Zhu
- Department of Orthopaedics, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, China
| | | | | | | | | |
Collapse
|
|
11
|
Wahlig BD, Sullivan MH, Broida SE, Larson AN, Shaughnessy WJ, Stans AA, Grigoriou E, Milbrandt TA. In Supracondylar Humerus Fractures With Nerve Injury, Does Time to Surgery Impact Recovery? J Pediatr Orthop 2024; 44:e871-e875. [PMID: 39466291 DOI: 10.1097/bpo.0000000000002793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/29/2024]
Abstract
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.
Collapse
Affiliation(s)
- Brian D Wahlig
- Mayo Clinic Department of Orthopedic Surgery, Rochester, MN
| | | | | | | | | | | | | | | |
Collapse
|
|
12
|
Chrenko R, Hanko M, Grega M, Sýkora Ľ, Jáger R. Peripheral nerve injuries associated with dislocated supracondylar fractures of distal humerus in children: incidence and need of surgical treatment. Childs Nerv Syst 2024; 40:3771-3776. [PMID: 38886222 DOI: 10.1007/s00381-024-06497-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Accepted: 06/08/2024] [Indexed: 06/20/2024]
Abstract
PURPOSE The objective of this study was to determine the incidence, necessity for neurosurgical intervention, and overall results of the treatment of pediatric peripheral nerve injuries associated with dislocated supracondylar fractures of the distal humerus. METHOD A retrospective analysis of pediatric patients with supracondylar fractures treated from April 2019 to April 2022 with a minimum follow-up of 3 months was conducted. RESULTS Of 453 included patients, there were 51 recorded peripheral nerve injuries. The ulnar nerve was the most frequently injured nerve. Nine patients required neurosurgical intervention, with the most common procedure being the release of entrapped nerves. The combination of a supracondylar fracture and arterial injury was identified as a significant risk factor for peripheral nerve injury (p < 0.001). Only one patient experienced an unsatisfactory outcome. CONCLUSION Although the prognosis for peripheral nerve injuries in children with supracondylar fractures is generally favorable, these injuries must be properly identified. We recommend an active neurosurgical approach in children with persisting neurological deficits to minimize the risk of permanent neurological impairment.
Collapse
Affiliation(s)
- Robert Chrenko
- Department of Pediatric Neurosurgery, National Institute of Children's Diseases, Bratislava, Slovakia
| | - Martin Hanko
- Department of Pediatric Neurosurgery, National Institute of Children's Diseases, Bratislava, Slovakia.
- Department of Neurological and Spinal Surgery, Penta Hospitals Bory, Ivana Kadlečíka 2, 841 03, Bratislava, Slovakia.
| | - Marek Grega
- Department of Pediatric Neurosurgery, National Institute of Children's Diseases, Bratislava, Slovakia
| | - Ľubomír Sýkora
- Trauma Center, Department of Pediatric Surgery, National Institute of Children's Diseases, Bratislava, Slovakia
| | - René Jáger
- Trauma Center, Department of Pediatric Surgery, National Institute of Children's Diseases, Bratislava, Slovakia
| |
Collapse
|
|
13
|
Chen JJ, Yang CY. Case Report: Supercharged end-to-side anterior interosseous to ulnar motor nerve transfer for ulnar nerve neuropathy after cross pinning of pediatric supracondylar humerus fracture. Front Pediatr 2024; 12:1398624. [PMID: 39318610 PMCID: PMC11420005 DOI: 10.3389/fped.2024.1398624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2024] [Accepted: 08/27/2024] [Indexed: 09/26/2024] Open
Abstract
Ulnar nerve neuropathy following pediatric supracondylar humerus fracture fixation with cross pinning poses challenges in management. Despite various treatment strategies, including conservative approaches and early intervention, achieving complete neural recovery remains elusive in some cases. This paper presents a novel approach utilizing supercharged end-to-side anterior interosseous nerve transfer for a 13-year-old patient who experienced persistent ulnar neuropathy after K-wire removal. The patient underwent neurolysis of the ulnar nerve followed by nerve transfer, resulting in significant improvement in function and strength. This case highlights the potential efficacy of combining neurolysis and supercharge techniques in pediatric ulnar neuropathy cases refractory to conservative treatment, offering a promising avenue for enhancing patient outcomes.
Collapse
Affiliation(s)
- Jian-Jiun Chen
- Department of Orthopedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Surgery, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chen-Yuan Yang
- Department of Orthopedic Surgery, Kuang Tien General Hospital, Taichung, Taiwan
- Department of Nursing, Hungkuang University, Taichung, Taiwan
| |
Collapse
|
|
14
|
Rigatti G, Danesi SRC, Barbosa RD, Schreiner DB. Radiographic Evaluation of the Surgical Treatment of Pediatric Supracondylar Humeral Fractures. Rev Bras Ortop 2024; 59:e607-e612. [PMID: 39239584 PMCID: PMC11374409 DOI: 10.1055/s-0044-1787765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 03/18/2024] [Indexed: 09/07/2024] Open
Abstract
Objective To perform a radiographic assessment of the quality of supracondylar fracture fixation by identifying the factors that have contributed to inadequate reduction and increased the chance of reduction loss during outpatient follow-up. The variables analyzed were as follows: fracture line, initial displacement, time of day the surgery was performed, and chosen fixation technique. Methods Review of electronic medical records and radiographic evaluation of supracondylar fractures operated from January 2017 to December 2022. The radiograph assessment was based on the Baumann angle and the anterior humeral line. Determination of fixation quality was based on the number of cortices, crossing site, and wire divergence. Results We evaluated 194 cases, and postoperative reduction was poor in 17% of the subjects. Reduction loss occurred in 39 cases (20.10%), and 19 (48.7%) of these patients presented insufficient fixation ( p = 0.002). Among the cases operated during the day, 12.5% lost the reduction compared with 32% of the patients who underwent surgery at night and early in the morning ( p = 0.001). Conclusion Reduction quality and postoperative fixation loss were closely related to technical errors and the time of day the surgery was performed.
Collapse
Affiliation(s)
- Gabriel Rigatti
- Departamento de Ortopedia e Traumatologia, Hospital Cristo Redentor, Grupo Hospitalar Conceição, Porto Alegre, RS, Brasil
| | | | - Rafaela Dias Barbosa
- Ortopedia Pediátrica, Hospital Cristo Redentor, Grupo Hospitalar Conceição, Porto Alegre, RS, Brasil
| | | |
Collapse
|
|
15
|
Schlechter JA, Tholcke LC, Lum TG, Thomas ES, Gornick BR, Ignacio GC, McMichael JC. Use of paralytic agents during the operative treatment of type III supracondylar humerus fractures in children: A single-center investigation and survey of Pediatric Orthopaedic Society of North America members. JOURNAL OF THE PEDIATRIC ORTHOPAEDIC SOCIETY OF NORTH AMERICA 2024; 7:100035. [PMID: 40433298 PMCID: PMC12088114 DOI: 10.1016/j.jposna.2024.100035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Accepted: 03/27/2024] [Indexed: 05/29/2025]
Abstract
Background Paralytic agents are occasionally used during the surgical treatment of type III (OTA 13A2) supracondylar humerus fractures (SCHFx) in children depending on surgeon preference. Paralytic agents create a neuromuscular blockade and therefore may potentially help with ease of fracture reduction. Controversy regarding the use of a paralytic agent as an adjunct to anesthesia exists due to potential associated adverse drug reactions, including prolonged paralysis, cardiovascular effects, or electrolyte abnormalities.The purpose of this study was to investigate intraoperative paralytic use in pediatric type III SCHFx and to report survey responses of members of the Pediatric Orthopaedic Society of North America (POSNA) on paralytic use in SCHFx management. Methods A retrospective chart review identified 319 type III SCHFx treated at our institution (January 2016-May 2019). Patients were assigned to 3 groups: group 1, surgical treatment without a paralytic agent (n = 240); group 2, treatment with rocuronium (n = 43); group 3, treatment with succinylcholine (n = 36). POSNA members were surveyed regarding paralytic use intraoperatively for type III SCHFx (November-December 2021) on paralytic use frequency, request for paralytics, reversal agent use, average time to surgery after injury and/or presentation, effect of time to surgery after injury and/or presentation on when to use a paralytic, annual number of SCHFx surgeries performed, awareness of paralytic complications, and years of surgeon experience. Statistical analysis was performed. Results Average patient age was 5.2 ± 2.2 years. Group 2 had significant increases in anesthesia duration, surgical duration, fluoroscopic time, and radiation exposure compared to group 1. Group 2 had a higher conversion rate to open reduction than other groups. No statistically significant difference was found among groups in terms of sex, body mass index (BMI), laterality, radiographic measurements, or rates of open procedures or complications. Survey results indicated 32% (24/76) routinely use paralytics during closed reduction maneuvers; 71% (17/24) request administering paralytics at the beginning/before the case; and 33% (8/24) use paralytics in all type III SCHFx. Conclusions Surgeons at our center reported paralytic use for closed reduction in 25% of patients; similarly, one-third of POSNA survey respondents reported paralytic use during operative management. Although paralytic agents are used during the treatment of supracondylar humerus fractures in children this study was unable to demonstrate an association of advantageous outcomes, such as shorter surgical times. Routine paralytic use to facilitate closed reduction of supracondylar humerus fractures in children warrants further study. Key Concepts (1)Paralytic agents may be utilized in pediatric supracondylar humerus fracture (SCHFx) surgeries, but their efficacy remains controversial due to associated adverse reactions.(2)Administration of rocuronium during surgery was associated with prolonged anesthesia and surgical durations, as well as increased fluoroscopic time and radiation exposure, suggesting potential drawbacks to its use.(3)Despite common use, the study found no significant correlation between paralytic agent administration and beneficial outcomes such as shorter surgical times.(4)Survey responses revealed varying practices among orthopaedic surgeons regarding paralytic agent use during closed reduction maneuvers for SCHFx.(5)Understanding variations in paralytic agent use among orthopaedic surgeons underscores the importance of future research to guide clinical decision-making.(6)The study highlights the need for standardized protocols and evidence-based practices in the use of paralytic agents for pediatric SCHFx.(7)The findings underscore the need for further research to establish the efficacy and safety of routine paralytic use in pediatric SCHFx surgeries and inform standardized protocols. Level of Evidence III, Retrospective chart review; Therapeutic study.
Collapse
Affiliation(s)
- John A. Schlechter
- Riverside University Health System – Medical Center, Department of Orthopaedic Surgery, Moreno Valley, CA, USA
- CHOC Children’s Hospital, Orange, CA, USA
- Pediatric Orthopaedic Specialists of Orange County, Orange, CA, USA
| | - Loren C. Tholcke
- Riverside University Health System – Medical Center, Department of Orthopaedic Surgery, Moreno Valley, CA, USA
- CHOC Children’s Hospital, Orange, CA, USA
| | | | - Evelyn S. Thomas
- CHOC Children’s Hospital, Orange, CA, USA
- Kettering Health Dayton, Dayton, OH, USA
| | - Bryn R. Gornick
- CHOC Children’s Hospital, Orange, CA, USA
- Pediatric Orthopaedic Specialists of Orange County, Orange, CA, USA
| | - Gian C. Ignacio
- The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Jessica C. McMichael
- CHOC Children’s Hospital, Orange, CA, USA
- Pediatric Orthopaedic Specialists of Orange County, Orange, CA, USA
| |
Collapse
|
|
16
|
Uslu M, Solmaz M, Daşcı MF, Beytemür O. Bilateral Flexion-Type Supracondylar Humerus Fracture. J Am Acad Orthop Surg Glob Res Rev 2024; 8:01979360-202404000-00006. [PMID: 38547051 PMCID: PMC10980408 DOI: 10.5435/jaaosglobal-d-23-00239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Revised: 02/08/2024] [Accepted: 02/14/2024] [Indexed: 04/01/2024]
Abstract
Supracondylar humerus fractures are common in the pediatric population, but flexion fractures are very rare in this population. The need for open reduction in these fractures is high and can be challenging for orthopaedic surgeons. In this article, we report a 9-year-old patient with bilateral flexion-type humeral fracture treated with closed reduction, which, to our knowledge, is the first report in the literature. We concluded that the first step in the treatment of flexion-type supracondylar fractures should be closed reduction with the help of an experienced assistant surgeon and that successful results can be obtained even in bilateral flexion-type fractures with appropriate treatment and follow-up.
Collapse
Affiliation(s)
- Muhammed Uslu
- From the Department of Orthopedics and Traumatology, University of Health Science, Bagcilar Training and Research Hospital, Istanbul, Turkey
| | - Mahsum Solmaz
- From the Department of Orthopedics and Traumatology, University of Health Science, Bagcilar Training and Research Hospital, Istanbul, Turkey
| | - Mustafa Fatih Daşcı
- From the Department of Orthopedics and Traumatology, University of Health Science, Bagcilar Training and Research Hospital, Istanbul, Turkey
| | - Ozan Beytemür
- From the Department of Orthopedics and Traumatology, University of Health Science, Bagcilar Training and Research Hospital, Istanbul, Turkey
| |
Collapse
|
|
17
|
Joyce KM, Dony A, Whitehouse H, Foster P, Bhat W, Bains R, Bourke G. Neurovascular injury from supracondylar fractures in children: a 10-year experience of 762 cases. J Hand Surg Eur Vol 2024; 49:483-489. [PMID: 37747700 DOI: 10.1177/17531934231201925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/26/2023]
Abstract
We evaluated the management of supracondylar paediatric fractures at our institution over a 10-year period in this retrospective cohort study. In total, 762 children with a supracondylar fracture were treated. The mean age of injury was 5.2 years. The incidence of documented nerve and/or vascular injury was 8.3%. A total of 26 patients had early plastic surgeon involvement; of these, 25 had an open exploration. Eight patients required vein grafting for brachial artery reconstruction for intimal tears. There was one nerve rupture requiring repair and 12 children underwent neurolysis. There were 17 late referrals to the plastic surgery service, of which three were explored (two neurolysis, one neuroma resection and sural nerve grafting). In all cases of nerve injury, the deficit took 7.9 months to recover, indicating a more significant injury than neurapraxia. Early exploration of supracondylar fractures allows direct visualization of the extent of neurovascular injury and immediate intervention.Level of evidence: IV.
Collapse
Affiliation(s)
- Kenneth M Joyce
- Department of Plastic Surgery, Leeds Children's Hospital, Leeds, UK
| | - Alna Dony
- School of Medicine, University of Leeds, Leeds, UK
| | - Harry Whitehouse
- Department of Plastic Surgery, Leeds Children's Hospital, Leeds, UK
| | - Patrick Foster
- Department of Trauma & Orthopaedic Surgery, Leeds Children's Hospital, Leeds, UK
| | - Waseem Bhat
- Department of Plastic Surgery, Leeds Children's Hospital, Leeds, UK
| | - Robert Bains
- Department of Plastic Surgery, Leeds Children's Hospital, Leeds, UK
| | - Grainne Bourke
- Department of Plastic Surgery, Leeds Children's Hospital, Leeds, UK
- Leeds Institute of Medical Research, Leeds, UK
| |
Collapse
|
|
18
|
Böttcher R, Dähne F, Böttcher S, Johl U, Tittel A, Schnick U. [Nerve injuries due to fractures in childhood : Primarily and secondarily on the upper extremity]. UNFALLCHIRURGIE (HEIDELBERG, GERMANY) 2024; 127:313-321. [PMID: 38443721 DOI: 10.1007/s00113-024-01423-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 02/13/2024] [Indexed: 03/07/2024]
Abstract
The approach for nerve injuries in children in the context of fractures of the upper extremities is inconsistent in the literature. The underlying mostly retrospective studies do not usually consider the potential diagnostics. The frequency of nerve injuries with a clear need for reconstructive surgery is sometimes estimated so differently that precedent-setting errors in these studies must be assumed; however, as 10-20% of pediatric fractures near the elbow show primary or secondary nerve lesions, timely and appropriate further treatment is necessary. An overview concerning diagnostic tools with an explanation of potential results and an algorithm with a timeline for diagnostic and therapeutic management are presented. Good results after nerve lesions can only be achieved when timely diagnostics without delay and correct detection of axonal lesions which benefit from surgical treatment are carried out.
Collapse
Affiliation(s)
- Richarda Böttcher
- Schwerpunkt für rekonstruktive Chirurgie bei Plexusparese, Tetraplegie und Cerebralparese, BG Klinikum Unfallkrankenhaus Berlin, Warener Straße 7, 12683, Berlin, Deutschland.
| | - Frank Dähne
- Klinik für Neurologie mit Stroke Unit und Frührehabilitation, BG Klinikum Unfallkrankenhaus Berlin, Warener Straße 7, 12683, Berlin, Deutschland
| | - Sebastian Böttcher
- Klinik für Neurologie mit Stroke Unit und Frührehabilitation, BG Klinikum Unfallkrankenhaus Berlin, Warener Straße 7, 12683, Berlin, Deutschland
| | - Ulrike Johl
- Klinik für Neurologie mit Stroke Unit und Frührehabilitation, BG Klinikum Unfallkrankenhaus Berlin, Warener Straße 7, 12683, Berlin, Deutschland
| | - Anja Tittel
- Institut für Radiologie und Neuroradiologie, BG Klinikum Unfallkrankenhaus Berlin, Warener Straße 7, 12683, Berlin, Deutschland
| | - Ulrike Schnick
- Schwerpunkt für rekonstruktive Chirurgie bei Plexusparese, Tetraplegie und Cerebralparese, BG Klinikum Unfallkrankenhaus Berlin, Warener Straße 7, 12683, Berlin, Deutschland
| |
Collapse
|
|
19
|
Rehm A, Elerian S, Shehata R, Clegg R, Ashby E. Use of lateral-exit crossed-pin fixation for pediatric supracondylar humeral fractures: a retrospective case series. J Pediatr Orthop B 2024; 33:202-203. [PMID: 38299643 DOI: 10.1097/bpb.0000000000001123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2024]
Affiliation(s)
- Andreas Rehm
- Paediatric Division, Cambridge University Hospitals NHS Foundation Trust
| | - Sherif Elerian
- Trauma & Orthopaedics, Cambridge University Hospitals NHS Foundation Trust
| | - Ramy Shehata
- Trauma & Orthopaedics, Cambridge University Hospitals NHS Foundation Trust
| | - Rachael Clegg
- Department of Paediatric Orthopaedics, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Elizabeth Ashby
- Department of Paediatric Orthopaedics, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| |
Collapse
|
|
20
|
Yun YH, Kang HW, Lim C, Lee KR, Song MH. Use of lateral-exit crossed-pin fixation for pediatric supracondylar humeral fractures: a retrospective case series. J Pediatr Orthop B 2024; 33:154-159. [PMID: 37040658 DOI: 10.1097/bpb.0000000000001087] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/13/2023]
Abstract
Surgeons have been reluctant to perform crossed-pin fixation for displaced pediatric supracondylar humeral (SCH) fractures because it carries a risk of iatrogenic ulnar nerve injury. This study aimed to introduce lateral-exit crossed-pin fixation for displaced pediatric SCH fractures and to evaluate its clinical and radiological outcomes, with a particular focus on iatrogenic ulnar nerve injuries. Children who underwent lateral-exit crossed-pin fixation for displaced SCH fractures between 2010 and 2015 were retrospectively reviewed. Lateral-exit crossed-pin fixation involved the introduction of a medial pin from the medial epicondyle, as in the conventional method, followed by pulling the pin through the lateral skin until the distal and medial aspects of the pin were just under the cortex of the medial epicondyle. The time to union and loss of fixation were assessed. Flynn's clinical criteria (cosmetic and functional factors) and complications including iatrogenic ulnar nerve injury were investigated. A total of 81 children with displaced SCH fractures were treated with lateral-exit crossed-pin fixation. All but one patient achieved union with good alignment, with an average time to union of 7.9 weeks (3.9-10.3 weeks). Only one patient exhibited cubitus varus deformity associated with loss of reduction. All patients recovered to almost their full range of motion. No case of iatrogenic ulnar nerve injury developed; however, iatrogenic radial nerve injury developed in one patient. Lateral-exit crossed-pin fixation provides sufficient stability with a lower risk of iatrogenic ulnar nerve injury in children with displaced SCH fractures. This method is an acceptable technique for crossed-pin fixation.
Collapse
Affiliation(s)
- Yeo-Hon Yun
- Department of Orthopaedic Surgery, Ewha Womans University Mokdong Hospital, Seoul
| | - Ho Won Kang
- Department of Orthopaedic Surgery, Ewha Womans University Mokdong Hospital, Seoul
| | - Chaemoon Lim
- Department of Orthopaedic Surgery, Jeju National University Hospital, Jeju
| | - Kwang Ryeol Lee
- Division of Pediatric Orthopaedics, Seoul National University Children's Hospital, Seoul
| | - Mi Hyun Song
- Division of Pediatric Orthopaedics, Seoul National University Children's Hospital, Seoul
- Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea
| |
Collapse
|
|
21
|
Deininger S, Antoniadis G, Pedro MT. [Functional Outcome of Peripheral Nerve Injury after Pediatric Supracondylar Humerus Fracture: Comparison of Surgical and Conservative Treatment]. HANDCHIR MIKROCHIR P 2024; 56:93-98. [PMID: 38508207 DOI: 10.1055/a-2254-2465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/22/2024] Open
Abstract
Supracondylar humerus fractures are the most common elbow fractures in children up to 10 years of age. The incidence of associated nerve injuries varies up to 15% depending on the data. Traumatic and iatrogenic lesions mainly affect the ulnar nerve. The regeneration of peripheral nerves is comparatively better in childhood. In the present study, the functional results after surgical and conservative treatment of nerve injuries in children after supracondylar fractures were compared and analyzed for influencing factors. In this retrospective comparative study, clinical data of pediatric nerve injuries following supracondylar humerus fractures treated over a period of 13 years (2008-2021) were analyzed. Children who were treated surgically (neurolysis, autologous reconstruction) due to insufficient clinical/neurophysiological improvement within 6 months after trauma or who were followed up conservatively in case of regression of symptoms within 6 months after trauma were included. All patients underwent multidisciplinary follow-up. 48 patients (26 female/22 male) with nerve injuries were included in this study. All patients had a history of surgical treatment with K- wire fixation due to severe dislocated fractures. The mean age was 7±2 years. The initial symptoms were severe motor deficits in all patients and sensory deficits in 87.5% (n=42). Isolated lesions of the ulnar nerve were most common (n=24, 50%). The nerve was neurolysed in 21 patients and additionally transferred to the volar side in 15. Nerve grafting was performed in 7 children and split repair in 2. Postoperatively, there was a significant improvement in motor function in all patients. Despite comparably severe motor deficits at initial presentation, further 20 children were treated conservatively due to the regression of neurological deficits. They showed comparably good functional results. No serious complications were recorded in either group. The average follow-up time was 377.25±524.87 days. The presented study shows excellent functional results after surgical treatment of pediatric nerve injuries without severe complications. Children with comparatively high-grade lesions at initial presentation have a good chance of complete spontaneous remission even without surgery. For this reason, the indication for surgery in children should be very carefully considered.
Collapse
Affiliation(s)
- Stefanie Deininger
- Klinik für Neurochirurgie, Bezirkskrankenhaus Günzburg, Günzburg, Germany
| | | | - Maria Teresa Pedro
- Klinik für Neurochirurgie, Bezirkskrankenhaus Günzburg, Günzburg, Germany
| |
Collapse
|
|
22
|
Ottesen TD, Amick M, Kirwin DS, Mercier MR, Brand J, Frumberg DB, Grauer JN, Rubin LE. Increasing Value in Subspecialty Training: A Comparison of Variation in Surgical Complications for Pediatric Versus Other Fellowship-trained American Board of Orthopaedic Surgery Candidates in the Treatment of Supracondylar Fractures. J Am Acad Orthop Surg Glob Res Rev 2024; 8:01979360-202401000-00006. [PMID: 38252550 PMCID: PMC10805463 DOI: 10.5435/jaaosglobal-d-22-00239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 11/27/2023] [Accepted: 12/07/2023] [Indexed: 01/24/2024]
Abstract
INTRODUCTION The effect of orthopaedic fellowship subspecialization on surgical complications for patients with supracondylar fracture is unknown. This study seeks to compare the effect of subspecialty training on supracondylar fracture complications. METHODS The American Board of Orthopaedic Surgery Part II Examination Case List database was reviewed for all supracondylar fractures from 1999 to 2016. Procedures were divided by fellowship subspecialty (trauma, pediatric, or other) and case volume and assessed by surgeon-reported surgical complications. Predictive factors of complications were analyzed using a binary multivariate logistic regression. RESULTS Of 10,961 supracondylar fractures identified, 53.47% were done by pediatric fellowship-trained surgeons. Pediatric-trained surgeons had fewer surgical complications compared with their trauma or other trained peers (4.54%, 5.67%, and 6.24%; P = 0.001). Treatment by pediatric-trained surgeons reduced surgical complications (OR = 0.79, 95% CI: 0.66 to 0.94; P = 0.010), whereas increased case volume (31+ cases) showed no significant effect (OR = 0.79, 95% CI: 0.62 to 1.02; P = 0.068). Patient sex, age, and year of procedure did not affect complication rates, while those treated in the Southeast region of the United States and those with a complex fracture type were at increased odds. DISCUSSION Treatment of supracondylar fractures by pediatric-trained surgeons demonstrates reduced surgeon-reported complications compared with their other fellowship-trained counterparts, whereas case volume does not. This suggests the value of fellowship training beyond pertinent surgical caseload among pediatric-trained surgeons and may lie in targeted education efforts.
Collapse
Affiliation(s)
- Taylor D Ottesen
- From the Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT (Dr. Ottesen, Dr. Amick, Dr. Kirwin, Dr. Mercier, Dr. Brand, Dr. Frumberg, Dr. Grauer, and Dr. Rubin), and the Harvard Combined Orthopaedic Residency Program, Boston, MA (Dr. Ottesen)
| | | | | | | | | | | | | | | |
Collapse
|
|
23
|
Hannaford A, Simon NG. Ulnar neuropathy. HANDBOOK OF CLINICAL NEUROLOGY 2024; 201:103-126. [PMID: 38697734 DOI: 10.1016/b978-0-323-90108-6.00006-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2024]
Abstract
Ulnar neuropathy at the elbow is the second most common compressive neuropathy. Less common, although similarly disabling, are ulnar neuropathies above the elbow, at the forearm, and the wrist, which can present with different combinations of intrinsic hand muscle weakness and sensory loss. Electrodiagnostic studies are moderately sensitive in diagnosing ulnar neuropathy, although their ability to localize the site of nerve injury is often limited. Nerve imaging with ultrasound can provide greater localization of ulnar injury and identification of specific anatomical pathology causing nerve entrapment. Specifically, imaging can now reliably distinguish ulnar nerve entrapment under the humero-ulnar arcade (cubital tunnel) from nerve injury at the retro-epicondylar groove. Both these pathologies have historically been diagnosed as either "ulnar neuropathy at the elbow," which is non-specific, or "cubital tunnel syndrome," which is often erroneous. Natural history studies are few and limited, although many cases of mild-moderate ulnar neuropathy at the elbow appear to remit spontaneously. Conservative management, perineural steroid injections, and surgical release have all been studied in treating ulnar neuropathy at the elbow. Despite this, questions remain about the most appropriate management for many patients, which is reflected in the absence of management guidelines.
Collapse
Affiliation(s)
- Andrew Hannaford
- Westmead Clinical School, Westmead Hospital, University of Sydney, Westmead, NSW, Australia
| | - Neil G Simon
- Northern Beaches Clinical School, Macquarie University, Sydney, NSW, Australia.
| |
Collapse
|
|
24
|
Shih CA, Huang MT, Chern TC, Shao CJ, Wu KC, Lin CJ, Jou IM, Wu PT. The use of ultrasound for monitoring reduction and ulnar nerve subluxation in pediatric humeral supracondylar fractures. Eur J Radiol 2024; 170:111201. [PMID: 38042022 DOI: 10.1016/j.ejrad.2023.111201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 11/04/2023] [Accepted: 11/13/2023] [Indexed: 12/04/2023]
Abstract
BACKGROUND Traditional treatment for displaced humeral supracondylar fractures (SCFs) in children involves closed reduction (CR) under fluoroscopic guidance, percutaneous pinning, and immobilization with a long-arm cast. This study aims to explore the viability of using radiation-free ultrasound (US) for guiding CR and tracking ulnar nerve dynamics during medial pinning, contrasting the US method with the conventional cross pinning technique. MATERIALS AND METHODS We assessed 70 children with acute displaced SCFs. The US group (n = 30) underwent US-guided reduction, whereas the traditional group (n = 40) underwent fluoroscopy-guided reduction. Both groups received percutaneous cross pinning and subsequent cast immobilization. Postoperative outcomes were compared between the two methods after a 6-month follow-up. In the US group, ultrasonography assessed fracture displacement distances before and after CR. The angle at which the ulnar nerve relocated to the cubital tunnel during elbow extension was documented using real-time US monitoring during medial pinning. RESULTS The US group demonstrated improved reduction accuracy, increased range of motion, superior restoration of both Baumann and Humeroulnar angles, and a decreased incidence of malunions compared to the traditional group (all p < 0.05). The ultrasonographic measurement of fracture displacement was comparable with that of fluoroscopy (intraclass correlation coefficient > 0.90). In the US group, no ulnar nerve injury was noted, compared to 2.5 % in the traditional group, and real-time US observations revealed ulnar nerve hypermobility, with 53.3 % of patients exhibiting anterior ulnar nerve subluxation at 120° elbow flexion, 40 % at 90°, 16.7 % at 60°, and none at 30° flexion. CONCLUSION Ultrasound is as reliable as fluoroscopy for evaluating fracture reductions. The use of intra-operative ultrasound significantly improves reduction accuracy and radiographic outcomes while reducing the risk of ulnar nerve injury.
Collapse
Affiliation(s)
- Chien-An Shih
- Department of Orthopedics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Ming-Tung Huang
- Department of Orthopedics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Great East Gate Orthopedic Clinic, Tainan, Taiwan
| | | | - Chung-Jung Shao
- Department of Orthopedic Surgery, Tainan Municipal Hospital, Tainan, Taiwan
| | - Kuo-Chen Wu
- Department of Orthopedic Surgery, Kuo General Hospital, Tainan, Taiwan
| | - Chii-Jeng Lin
- Department of Orthopedics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Orthopedics, College of Medicine, National Cheng Kung University, Tainan, Taiwan; President Office, Joint Commission of Taiwan, New Taipei City, Taiwan, ROC
| | - I-Ming Jou
- Great East Gate Orthopedic Clinic, Tainan, Taiwan; Department of Orthopedics, E-Da Hospital, Kaohsiung, Taiwan; School of Medicine, College of Medicine, I-Shou University, Kaohsiung, Taiwan.
| | - Po-Ting Wu
- Department of Orthopedics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Orthopedics, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Biomedical Engineering, National Cheng Kung University, Tainan, Taiwan; Department of Biochemistry and Molecular Biology, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Medical Device Innovation Center, National Cheng Kung University, Tainan, Taiwan.
| |
Collapse
|
|
25
|
Graff C, Dounas GD, Todd MRLC, Sung J, Kumawat M. Management of Traumatic Nerve Palsies in Paediatric Supracondylar Humerus Fractures: A Systematic Review. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1862. [PMID: 38136064 PMCID: PMC10741981 DOI: 10.3390/children10121862] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 11/20/2023] [Accepted: 11/22/2023] [Indexed: 12/24/2023]
Abstract
Purpose: Up to 12% of paediatric supracondylar humerus fractures (SCHFs) have an associated traumatic nerve injury. This review aims to summarize the evidence and guide clinicians regarding the timing of investigations and/or surgical interventions for traumatic nerve palsies after this injury. Methods: A formal systematic review was undertaken in accordance with the Joanna Briggs Institute (JBI) methodology for systematic reviews and PRISMA guidelines. Manuscripts were reviewed by independent reviewers against the inclusion and exclusion criteria, and data extraction, synthesis, and assessment for methodological quality were undertaken. Results: A total of 51 manuscripts were included in the final evaluation, reporting on a total of 510 traumatic nerve palsies in paediatric SCHFs. In this study, 376 nerve palsies recovered without any investigation or intervention over an average time of 19.5 weeks. Comparatively, 37 went back to theatre for exploration beyond the initial treatment due to persistent deficits, at an average time of 4 months. The most common finding at the time of exploration was entrapment of the nerve requiring neurolysis. A total of 27 cases did not achieve full recovery regardless of management. Of the 15 reports of nerve laceration secondary to paediatric SCHFs, 13 were the radial nerve. Conclusions: Most paediatric patients who sustain a SCHF with associated traumatic nerve injury will have full recovery. Delayed or no recovery of the nerve palsy should be considered for exploration within four months of the injury; earlier exploration should be considered for radial nerve palsies.
Collapse
Affiliation(s)
- Christy Graff
- The Women’s and Children’s Hospital, North Adelaide, SA 5006, Australia (J.S.)
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA 5005, Australia (M.K.)
- The Royal Adelaide Hospital, Adelaide, SA 5000, Australia
| | - George Dennis Dounas
- The Women’s and Children’s Hospital, North Adelaide, SA 5006, Australia (J.S.)
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA 5005, Australia (M.K.)
- The Royal Adelaide Hospital, Adelaide, SA 5000, Australia
| | - Maya Rani Louise Chandra Todd
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA 5005, Australia (M.K.)
- The Royal Adelaide Hospital, Adelaide, SA 5000, Australia
| | - Jonghoo Sung
- The Women’s and Children’s Hospital, North Adelaide, SA 5006, Australia (J.S.)
| | - Medhir Kumawat
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA 5005, Australia (M.K.)
| |
Collapse
|
|
26
|
Muslu O, Cengiz T, Aydın Şimşek Ş, Yurtbay A, Keskin D. Radiological and Clinical Outcomes of Pediatric Patients With a Supracondylar Humerus Fracture Surgically Treated With Closed Reduction and Percutaneous Pinning. Cureus 2023; 15:e49358. [PMID: 38146547 PMCID: PMC10749690 DOI: 10.7759/cureus.49358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/23/2023] [Indexed: 12/27/2023] Open
Abstract
OBJECTIVES It was aimed to evaluate the clinical and radiological results of patients operated on with closed reduction and pinning due to pediatric supracondylar humerus fractures. MATERIALS AND METHODS The radiological and clinical results of 100 patients operated on with closed reduction and percutaneous pinning for pediatric supracondylar humerus fractures in the Department of Orthopedics and Traumatology were examined between January 2015 and February 2022. Clinical results were evaluated by performing cosmetic and functional scores defined by Flynn. Closed reduction and percutaneous pinning techniques were used in surgical treatment. RESULTS In our study, 59 patients were male (59%), and 41 were female (41%). The average age of all patients is 6.21 ± 2.85 years. According to the Gartland classification, 21 patients' fractures were type IIA (21%), 12 patients' fractures were type IIB (12%), 51 patients' fractures were type III (51%), and 16 patients' fractures were type IV (16%). The average number of pins used in the treatment is 2.55 ± 0.50. The elbow bearing angle of the operated side of the patients was an average of 6.53 ± 3.29 degrees, the humerocapitellar angle was an average of 41.97 ± 3.08 degrees, and the lateral humerocapitellar angle was an average of 50.17 ± 3.58 degrees. Fifty-one patients had stage 0 (51%), 23 patients had stage 1 (23%), 23 patients had stage 2 (23%), and three patients had stage 3 (3%) residual sagittal plane deformity. According to the Flynn criteria, 92 patients had excellent functional results (92%), seven patients had good results (7%), and one patient had fair results (1%). Regarding cosmetic results, 91 patients had excellent results (91%), six patients had good results (6%), and three patients had fair results (3%). CONCLUSION Supracondylar humerus fractures are common in children and can cause serious complications. Closed reduction and percutaneous pinning techniques are effective treatment methods in the treatment of displaced supracondylar humerus fractures.
Collapse
Affiliation(s)
- Oğuzhan Muslu
- Orthopaedics and Traumatology, Hatay Training and Research Hospital, Hatay, TUR
| | - Tolgahan Cengiz
- Orthopaedics and Traumatology, Inebolu State Hospital, Kastamonu, TUR
| | - Şafak Aydın Şimşek
- Orthopaedics and Traumatology, Faculty of Medicine, Ondokuz Mayıs University, Samsun, TUR
| | - Alparslan Yurtbay
- Orthopaedics and Traumatology, Samsun Education and Research Hospital, Samsun, TUR
| | - Davut Keskin
- Orthopaedics and Traumatology, Faculty of Medicine, Ondokuz Mayıs University, Samsun, TUR
| |
Collapse
|
|
27
|
Jain S, Loganathan D, Ahmed A, Mohan R, Sheikh M. Management of displaced supracondylar fractures in children and adherence to the BOAST guideline- experience in a District General Hospital, UK. J Clin Orthop Trauma 2023; 45:102276. [PMID: 37994354 PMCID: PMC10661609 DOI: 10.1016/j.jcot.2023.102276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 09/29/2023] [Accepted: 11/03/2023] [Indexed: 11/24/2023] Open
Abstract
Background Supracondylar fracture is the most common elbow fracture in children. These fractures can be associated with significant complications, including nerve injury, vascular compromise, compartment syndrome and clinical deformity. The British Orthopaedic Association Standards for Trauma (BOAST) provide clear and comprehensive guidance for managing the supracondylar fracture. Aims We reviewed the management of displaced (Gartland type 2 and 3) supracondylar fractures and adherence to BOAST guidelines between 1st audit and re-audit following the introduction of supracondylar assessment proforma. Methods We retrospectively analysed the adherence to BOAST guidelines for 103 patients operated between 2014 and 2020. Documentation of vascular status and individual nerve functions were assessed during presentation to the emergency department, immediately before surgery, and postoperatively before discharge from the hospital. We also reviewed the documentation of the K-wire's size utilised for fixation, the medial wire fixation technique, and post-fixation stability during the operation. A new supracondylar fracture assessment proforma was designed and implemented after the 1st audit as part of the quality improvement measure. During the second stage of the audit cycle, we reviewed 22 patients and used the same methodology as the first audit to analyse the data. Results Results: We found significant improvements in the documentation of capillary refill time from 65 % to 95.5 % (p = 0.0038), radial pulse from 59.2 % to 95.5 % (p = 0.0009), and documentation of individual nerve function from 37.9 % to 72.7 % (p = 0.0040) in the emergency department during 2nd stage of the audit cycle. Individual nerve function documentation by the operating team immediately before surgery changed from 42.7 % to 50 %. The use of 2 mm K-wires improved from 53.3 % to 89.5 % (p = 0.0037) Documentation of medial wire fixation technique and post-fixation stability increased to 100 % from 82.9 % to 89.5 % from 42.7 % (p = 0.0002), respectively. Postoperatively, we noted improvement in both radial pulse and capillary refill time documentation from 27.2 % to 54.2 % (p = 0.0216) and the individual nerve function from 9.7 % to 50 % (p = 0.00005). Conclusion Poor adherence in stage 1 of the audit cycle to BOAST standards was significantly improved in stage 2 (Re-audit) after introducing a simple supracondylar fracture assessment proforma and focussed educational sessions.
Collapse
Affiliation(s)
- Sanjay Jain
- Department of Trauma and Orthopaedics, North Manchester General Hospital, Delaunays Road, Manchester, M8 5RB, UK
| | - Deeraj Loganathan
- Department of Trauma and Orthopaedics, North Manchester General Hospital, Delaunays Road, Manchester, M8 5RB, UK
| | - Azeem Ahmed
- Department of Trauma and Orthopaedics, North Manchester General Hospital, Delaunays Road, Manchester, M8 5RB, UK
| | - Rama Mohan
- Department of Trauma and Orthopaedics, North Manchester General Hospital, Delaunays Road, Manchester, M8 5RB, UK
| | - Manzoor Sheikh
- Department of Trauma and Orthopaedics, North Manchester General Hospital, Delaunays Road, Manchester, M8 5RB, UK
| |
Collapse
|
|
28
|
Navarro Vergara AD, Navarro Fretes A, Aníbal Arréllaga Alonso R, Medina Villate MM. Management of Pediatric Humeral Supracondylar Fractures in a Referral Center From a Developing Country: A Comparison With American Academy of Orthopaedic Surgeons (AAOS) Guidelines. Cureus 2023; 15:e44430. [PMID: 37791213 PMCID: PMC10543996 DOI: 10.7759/cureus.44430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/30/2023] [Indexed: 10/05/2023] Open
Abstract
Introduction Supracondylar fractures are the predominant type of pediatric elbow fractures. The usual mechanism of injury is falling over the hand with the elbow extended and the hand open. The management of these fractures encompasses a range of treatment options, and their goal is to recover the anatomy and achieve a stable contact area between them. There are some controversies on the management of these injuries mainly focused on those that present some degree of displacement. A review and analysis of the current treatment at our institution and a comparison with the guidelines suggested by the American Academy of Orthopaedic Surgeons (AAOS) for the treatment of these fractures in the pediatric population were performed. Materials and methods This was an observational, analytical, retrospective study of consecutive pediatric patients with displaced supracondylar humeral fracture treated at Hospital de Trauma "Manuel Giagni" in Asunción, Paraguay, from January 2016 to December 2021. Demographic and clinical data were assessed, and patients were clinically and radiologically followed for at least 12 months. The management of supracondylar humeral fractures at our hospital was compared with the guidelines suggested by the American Academy of Orthopaedic Surgeons (AAOS) by analyzing whether these guidelines were applied in each case. The mechanism of injury was divided into three groups, initial X-rays were measured, extension-type fractures were categorized into three groups, and the type of treatment was divided into two groups: non-operative and operative. Furthermore, trauma-related preoperative complications and postoperative complications were reported. Outpatient follow-up was performed for at least 12 months in all cases. Results Of the 843 patients analyzed, 71.5% were male, with a mean age of 5.6 years. It was observed that 57.5% of injuries were caused by falls on the same level. The most frequent type of injury was Gartland type III, accounting for 55% of the cases, and associated injuries were found in 4% of the cases. With regard to the type of treatment, 91.8% of patients were treated with closed reduction and percutaneous pin fixation. Complications on admission were found in 12% of the cases and late complications in 12% of the cases. Most patients (82%) had excellent Mayo Elbow Performance Score. Conclusion Supracondylar fractures were more frequent in males and in schoolchildren. Garland type III fractures were the most common type of injury. The treatment of choice was predominantly closed reduction and percutaneous pin fixation. The Mayo Elbow Performance Score was excellent in most patients. Our service, a referral center of a public hospital in a developing country, complies with the guidelines recommended by the AAOS.
Collapse
Affiliation(s)
- Alberto Daniel Navarro Vergara
- Orthopedics and Traumatology, Hospital de Trauma "Manuel Giagni", Asunción, PRY
- Orthopedics and Traumatology, Hospital de Especialidades Quirúrgicas Ingavi del Instituto de Previsión Social (IPS), Asunción, PRY
- Orthopedics and Traumatology, Universidad del Norte, Asunción, PRY
| | - Alberto Navarro Fretes
- Orthopedics and Traumatology, Universidad del Norte, Asunción, PRY
- Pediatric Orthopedics, Hospital de Especialidades Quirúrgicas Ingavi del Instituto de Previsión Social (IPS), Asunción, PRY
- Pediatrics Service, Hospital de Trauma "Manuel Giagni", Asunción, PRY
| | | | - Maria Mercedes Medina Villate
- Orthopedics and Traumatology, Hospital de Especialidades Quirúrgicas Ingavi del Instituto de Previsión Social (IPS), Asunción, PRY
| |
Collapse
|
|
29
|
Mubarak FS, Mohamed Anzar MA, Kanagratnam K. Descriptive Study on Epidemiology, Clinical Presentation, Treatment, and Outcome of Supracondylar Fractures Treated in a Base Hospital of Sri Lanka: A Single-Center Study. Cureus 2023; 15:e40494. [PMID: 37461766 PMCID: PMC10349923 DOI: 10.7759/cureus.40494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/15/2023] [Indexed: 07/20/2023] Open
Abstract
INTRODUCTION Supracondylar fractures are common pediatric elbow injuries, with management in developing countries presenting challenges due to limited resources, inadequate facilities, and a lack of trained personnel. METHOD This study aimed to describe the incidence, demographics, clinical presentation, treatment methods, and outcomes of supracondylar fractures treated at Ashraff Memorial Hospital (AMH)-Kalmunai, a base hospital in Sri Lanka. This is a retrospective descriptive study conducted between January 2019 and December 2020. RESULTS The study involved 79 children with supracondylar fractures. The majority of the children were male (70.9%) and their ages ranged from one to 15 years. The study identified falls as the most common presenting complaint (92.4%), followed by road traffic accidents (3.8%), native treatment (2.5%), and mismanagement (1.3%). The majority of fractures affected the right side (69.6%), while the remaining cases involved the left side (30.4%). Regarding the time duration from fracture to hospital presentation, a significant proportion of children sought medical attention on the same day (51.9%), followed by presentations within the first three days (38%), within a week (5.1%), or after a month (3.8%). Based on the Gartland classification, type I fractures accounted for 44.3% of cases, followed by type II fractures (29.1%) and type III fractures (26.6%). The most common treatment approach was closed reduction and percutaneous pinning (41.8%). Other treatment options included plaster of Paris (POP) cast without manipulation (36.7%), POP cast with manipulation (7.6%), analgesics alone (6.3%), and open reduction fixation (5.1%). Follow-up procedures varied, with routine cast removal (11.4%), routine cast and K-wire removal (45.6%), and re-do surgery with routine follow-up (1.3%). Among the type III fractures, two children presented with vascular compromise and anterior interosseous nerve (AIN) impairment, while another two children had AIN impairment only. Type I and type II fractures did not exhibit nerve involvement or vascular impairment. Only one out of the 79 children had an open fracture. CONCLUSION Supracondylar fracture is the most common orthopedic fracture in children. The study sheds light on the challenges and opportunities associated with treating pediatric supracondylar fractures in a resource-constrained context. The findings can help produce guidelines for the management of supracondylar fractures in underdeveloped nations, as well as contribute to global efforts to enhance the management of pediatric fractures.
Collapse
Affiliation(s)
- Fathima S Mubarak
- Cardiothoracic Surgery, Harefield Hospital, Harefield, GBR
- Orthopedic Surgery, Ashraff Memorial Hospital, Kalmunai, LKA
| | | | | |
Collapse
|
|
30
|
Ho CA, Gottschalk HP, Samora JB, Freese K, Chaudhry S. Diagnosis and Management of Nerve Injuries Caused by Pediatric Upper Extremity Fractures. JOURNAL OF THE PEDIATRIC ORTHOPAEDIC SOCIETY OF NORTH AMERICA 2023; 5:708. [PMID: 40433531 PMCID: PMC12088131 DOI: 10.55275/jposna-2023-708] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Indexed: 05/29/2025]
Abstract
Although nerve injuries occur commonly with pediatric upper extremity fractures, there is very little existing literature to guide the management of those nerve injuries that do not recover during routine fracture healing and follow-up, and even less guidance is available regarding the choice of diagnostic tests such as magnetic resonance imaging (MRI) with nerve sequences, electromyography (EMG), nerve conduction velocities, (NCV), ultrasound (US), or other modalities. In addition, patterns of nerve injury and timing of nerve recovery differ amongst different fractures. This review article describes the nerve injuries and specific details of humeral shaft, supracondylar, Monteggia fracture-dislocations, and forearm fractures as well as the various available diagnostic tests. We synthesize the available literature, of which most is in the adult population, as well as the extensive clinical experience of the authors, all of whom specialize in pediatric hand and upper extremity. Key Concepts•The vast majority of nerve injuries associated with pediatric upper extremity fractures are neuropraxias.•The most common nerve injured in humeral shaft fractures is the radial nerve; in supracondylar humerus fractures, it is the median nerve/anterior interosseous nerve; in elbow dislocations, it is the ulnar nerve in conjunction with a medial epicondyle fracture, although the median nerve can become incarcerated during reduction of the dislocation; and in Monteggia fracture-dislocations, it is the posterior interosseous nerve. All nerves are at risk, depending on the apex of the deformity, in forearm fractures.•Observation is the mainstay of early management; progressive documented nerve recovery does not require further diagnostic studies.•Referral to a pediatric upper extremity surgeon or hand surgeon should be strongly considered when there is no documented nerve recovery after 3-4 months post-injury.
Collapse
Affiliation(s)
- Christine A. Ho
- Texas Scottish Rite Hospital, Department of Orthopaedics, University of Texas Southwestern Medical Center, Dallas, TX
| | - Hilton P. Gottschalk
- Department of Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, Austin, TX
| | | | | | - Sonia Chaudhry
- Department of Orthopaedics, University of Connecticut School of Medicine, Farmington, CT
| |
Collapse
|
|
31
|
Aydin M, Surucu S. Supracondylar humerus fractures in children caused by monkey bar-related injuries: a comparative study. J Pediatr Orthop B 2023; 32:117-120. [PMID: 35412504 DOI: 10.1097/bpb.0000000000000980] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
We evaluated the functional and radiological outcomes of surgically treated supracondylar humerus fractures based on injury mechanisms, as well as the therapeutic and prognostic aspects of monkey bar-related injuries, in this study. Between December 2014 and December 2018, pediatric patients who had undergone surgical treatment for supracondylar humerus fractures were analyzed retrospectively. According to the mechanism of injury, patients were divided into two groups: monkey bar-related injuries and other injuries. Patients were evaluated functionally using the Mayo elbow performance score, while radiographically using the anterior humeral line, humero-capitellar angle, and Baumann angle. This study enrolled a total of 50 patients, 27 females and 23 males. Each patient was followed for a minimum of 24 months. There were no significant differences in age, sex or complications between the groups. The Mayo elbow performance score and fracture types were shown to be significantly associated with injury mechanisms ( P = 0.017, P < 0.001). Additionally, a significant correlation between the necessity for open reduction and the mechanism of injury was found ( P = 0.038). There were no significant differences in radiological evaluation between the groups. Supracondylar humerus fractures caused by falling from the monkey bar were more severe in children than supracondylar humerus fractures caused by other mechanisms of injury, and surgical treatment outcomes were worse for supracondylar humerus fractures caused by falling from the monkey bar.
Collapse
Affiliation(s)
- Mahmud Aydin
- Department of Orthopaedic Surgery, Haseki Training and Research Hospital, Sultangazi, Istanbul
| | - Serkan Surucu
- Department of Orthopaedic Surgery, University of Missouri Kansas City, Kansas City, Missouri, USA
| |
Collapse
|
|
32
|
Sapienza M, Testa G, Vescio A, Panvini FMC, Caldaci A, Parisi SC, Pavone V, Canavese F. The Role of Patient Position in the Surgical Treatment of Supracondylar Fractures of the Humerus: Comparison of Prone and Supine Position. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:374. [PMID: 36837576 PMCID: PMC9963727 DOI: 10.3390/medicina59020374] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Revised: 02/11/2023] [Accepted: 02/12/2023] [Indexed: 02/18/2023]
Abstract
Background and Objectives: Supracondylar fractures of the humerus (SCHF) make up about one-third of pediatric fractures and are the most common elbow fractures in children. Reduction and fixation of SC fractures can be performed with the patient in the prone or supine position. However, the role of the patient's position during surgery is still unclear. The purpose of this systematic review is to evaluate, based on data from the literature, the role of patient position during closed reduction and fixation of pediatric SCHFs. Materials and Methods: A systematic review of the current literature from 1951 to 2021 was conducted according to PRISMA guidelines. Articles were identified from 6 public databases. Articles were screened and abstracted by two investigators and the quality of included publications (n = 14) was assessed (MINORS criteria). Statistical analyses were performed using R studio 4.1.2. Results: The systematic literature review identified 114 articles, from which, according to inclusion and exclusion criteria, 14 studies were identified. A total of 741 children were treated in the prone position and 538 in the supine position. The results of the systematic review showed that there were no statistical differences between the two positions with regard to clinical, radiographic, and complication outcomes. Conclusions:: The functional and radiographic outcome of displaced SCHFs is generally excellent regardless of the position, prone or supine, in which the patient is positioned for surgery. The choice of how to position the patient depends on the habit and experience of the surgeon and anesthesiologist performing the surgery.
Collapse
Affiliation(s)
- Marco Sapienza
- Department of General Surgery and Medical Surgical Specialties, Section of Orthopaedics and Traumatology, P.O. “Policlinico Gaspare Rodolico”, University of Catania, Via Santa Sofia 78, 95123 Catania, Italy
| | - Gianluca Testa
- Department of General Surgery and Medical Surgical Specialties, Section of Orthopaedics and Traumatology, P.O. “Policlinico Gaspare Rodolico”, University of Catania, Via Santa Sofia 78, 95123 Catania, Italy
| | - Andrea Vescio
- Department of General Surgery and Medical Surgical Specialties, Section of Orthopaedics and Traumatology, P.O. “Policlinico Gaspare Rodolico”, University of Catania, Via Santa Sofia 78, 95123 Catania, Italy
| | - Flora Maria Chiara Panvini
- Department of General Surgery and Medical Surgical Specialties, Section of Orthopaedics and Traumatology, P.O. “Policlinico Gaspare Rodolico”, University of Catania, Via Santa Sofia 78, 95123 Catania, Italy
| | - Alessia Caldaci
- Department of General Surgery and Medical Surgical Specialties, Section of Orthopaedics and Traumatology, P.O. “Policlinico Gaspare Rodolico”, University of Catania, Via Santa Sofia 78, 95123 Catania, Italy
| | - Stefania Claudia Parisi
- Department of General Surgery and Medical Surgical Specialties, Section of Orthopaedics and Traumatology, P.O. “Policlinico Gaspare Rodolico”, University of Catania, Via Santa Sofia 78, 95123 Catania, Italy
| | - Vito Pavone
- Department of General Surgery and Medical Surgical Specialties, Section of Orthopaedics and Traumatology, P.O. “Policlinico Gaspare Rodolico”, University of Catania, Via Santa Sofia 78, 95123 Catania, Italy
| | - Federico Canavese
- Department of Pediatric Orthopedic Surgery, Jeanne de Flandre Hospital, Lille University Centre, 59000 Lille, France
| |
Collapse
|
|
33
|
Crowe CS, Shin AY, Pulos N. Iatrogenic Nerve Injuries of the Upper Extremity: A Critical Analysis Review. JBJS Rev 2023; 11:01874474-202301000-00003. [PMID: 36722824 DOI: 10.2106/jbjs.rvw.22.00161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
» Iatrogenic nerve injuries may occur after any intervention of the upper extremity. » Causes of iatrogenic nerve lesions include direct sharp or thermal injury, retraction, compression from implants or compartment syndrome, injection, patient positioning, radiation, and cast/splint application, among others. » Optimal treatment of iatrogenic peripheral nerve lesions relies on early and accurate diagnosis. » Advanced imaging modalities (e.g., ultrasound and magnetic resonance imaging) and electrodiagnostic studies aid and assist in preoperative planning. » Optimal treatment of iatrogenic injuries is situation-dependent and depends on the feasibility of direct repair, grafting, and functional transfers.
Collapse
Affiliation(s)
- Christopher S Crowe
- Division of Plastic Surgery, Department of Surgery, University of Washington, Seattle, Washington
| | - Alexander Y Shin
- Division of Hand and Upper Extremity Surgery, Department of Orthopaedics, Mayo Clinic, Rochester, Minnesota
| | - Nicholas Pulos
- Division of Hand and Upper Extremity Surgery, Department of Orthopaedics, Mayo Clinic, Rochester, Minnesota
| |
Collapse
|
|
34
|
Ito R, Otsuka J, Horii E, Koh S. Gartland Type III Pediatric Supracondylar Humerus Fracture with Radial Nerve Laceration: A Case Report. JBJS Case Connect 2023; 13:01709767-202303000-00053. [PMID: 36870051 DOI: 10.2106/jbjs.cc.22.00658] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2023]
Abstract
CASE A 6-year-old boy sustained complete radial nerve palsy with a Gartland type III supracondylar humerus fracture (SCHF). Posteromedial displacement of the distal fragment was so severe that the tip of the proximal fragment protruded subcutaneously at the anterolateral aspect of the antecubital fossa. Immediate surgical exploration was performed to reveal radial nerve laceration. Neurorrhaphy after fixation of the fracture resulted in full recovery of radial nerve function 1 year postoperatively. CONCLUSIONS Severe posteromedial displacement with complete radial nerve palsy may warrant acute surgical exploration even in a closed SCHF because primary neurorrhaphy may achieve better results than late reconstruction.
Collapse
Affiliation(s)
- Rina Ito
- Department of Orthopedic Surgery, Nishio Municipal Hospital, Nishio, Japan
| | - Junko Otsuka
- Department of Orthopedic Surgery, Japanese Red Cross Aichi Medical Center Nagoya Daiichi Hospital, Nagoya, Japan
| | - Emiko Horii
- Department of Orthopedic Surgery, Japanese Red Cross Aichi Medical Center Nagoya Daiichi Hospital, Nagoya, Japan
| | - Shukuki Koh
- Department of Orthopedic Surgery, Japanese Red Cross Aichi Medical Center Nagoya Daiichi Hospital, Nagoya, Japan
| |
Collapse
|
|
35
|
Siu C, Farrell S, Schaeffer EK, Doan Q, Dobbe A, Bone J, Reilly CW, Mulpuri K. Long-Arm Splinting Versus Above-Elbow Casting for Type 1 Supracondylar Fractures of the Humerus in Children: a Randomized Controlled Trial. SN COMPREHENSIVE CLINICAL MEDICINE 2023; 5:72. [PMID: 36776416 PMCID: PMC9896433 DOI: 10.1007/s42399-023-01417-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 01/23/2023] [Indexed: 02/05/2023]
Abstract
Type 1 supracondylar humerus (SCH) fractures tend to heal well when immobilized by above-elbow casting or long-arm splinting. There is no consensus as to whether one treatment method is more effective than the other for this injury. The purpose of this study was to compare the radiographic and functional outcomes of long-arm splinting and above-elbow casting as the definitive treatment for children with type 1 SCH fractures. The study was set up as a randomized controlled non-inferiority trial. Patients between three and 12 years old presenting with a type 1 SCH fracture were randomized into splint or cast groups, or an observational arm. Baumann's angle, functional assessment scores, and Flynn's criteria score were measured at initial injury and at six months post-injury. In total, 34 patients were enrolled in the study with 13 in the randomized arm and 21 in the observational arm. Due to lack of follow-up data at 6 months post-injury, five splint patients and 10 cast patients were included in the final cohort for data analysis. The average change in Baumann's angle at 6-month follow-up was 3° or less for each treatment arm. The splint group obtained excellent Flynn's criteria scores while the cast group reported good and excellent scores. Complications reported in the splint group included device breakdown, a conversion to above-arm cast, and significant itchiness. Preliminary findings suggest functional and radiological outcomes with splinting are non-inferior to casting; however, a larger sample size is required to more accurately compare the two modalities. This study was registered with the U.S. National Institutes of Health (ClinicalTrials.gov, #NCT01912365).
Collapse
Affiliation(s)
- Caitlyn Siu
- Department of Orthopaedic Surgery, BC Children’s Hospital, 1D.66-4480 Oak Street, Vancouver, BC V6H 3V4 Canada
| | - Sarah Farrell
- Department of Orthopaedics, Children’s Hospital Queensland, South Brisbane, QLD Australia
| | - Emily K. Schaeffer
- Department of Orthopaedic Surgery, BC Children’s Hospital, 1D.66-4480 Oak Street, Vancouver, BC V6H 3V4 Canada
- Department of Orthopaedics, University of British Columbia, Vancouver, BC Canada
| | - Quynh Doan
- Department of Emergency Medicine, BC Children’s Hospital, Vancouver, BC Canada
| | - Ashlee Dobbe
- Department of Orthopaedic Surgery, Kelowna General Hospital, Kelowna, BC Canada
| | - Jeffrey Bone
- Department of Orthopaedic Surgery, BC Children’s Hospital, 1D.66-4480 Oak Street, Vancouver, BC V6H 3V4 Canada
| | - Christopher W. Reilly
- Department of Orthopaedic Surgery, BC Children’s Hospital, 1D.66-4480 Oak Street, Vancouver, BC V6H 3V4 Canada
- Department of Orthopaedics, University of British Columbia, Vancouver, BC Canada
| | - Kishore Mulpuri
- Department of Orthopaedic Surgery, BC Children’s Hospital, 1D.66-4480 Oak Street, Vancouver, BC V6H 3V4 Canada
- Department of Orthopaedics, University of British Columbia, Vancouver, BC Canada
| |
Collapse
|
|
36
|
Mahan ST, Miller PE, Park J, Sullivan N, Vuillermin C. Fully displaced pediatric supracondylar humerus fractures: Which ones need to go at night? J Child Orthop 2022; 16:355-365. [PMID: 36238148 PMCID: PMC9550999 DOI: 10.1177/18632521221119540] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 07/26/2022] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Challenges remain in determining which displaced supracondylar humerus fractures are safe to postpone surgical treatment until daylight hours. The purpose of this study is to determine which characteristics can be identified to guide the timing of treatment of supracondylar humerus fractures. METHODS 225 completely displaced Gartland extension type 3/4 supracondylar humerus fractures in healthy patients that presented between 6 am and 7 am were identified. Data were collected retrospectively. Data analysis included univariate, multivariable logistic regression and classification and regression tree analysis. RESULTS 5% (78/225) underwent surgical treatment the night they presented, while 65% (147/225) were treated the next day. Overall complication rate was 6%, with no difference based on timing of surgery. 12% (28/225) presented with a motor nerve injury, while 6% (14/225) a "pink pulseless" extremity. Statistical analysis found the most reliable radiographic predictor to be the maximum displacement on the anterior-posterior or lateral view. Classification and regression tree analysis developed a clinical algorithm; patients with a "pink pulseless" extremity or motor nerve injury were recommended for surgery overnight, while those with an anterior-posterior or lateral view < 25 mm were recommended for surgery the next day. CONCLUSION This study provides guidance on the timing of treatment for displaced supracondylar humerus fractures that present overnight. We provide a simple algorithm with three key clinical predictors for timing of treatment: presence of a "pink pulseless" arm, presence of a motor nerve injury, and displacement of any cortex by at least 25 mm (anterior-posterior or lateral view). This provides a step forward to help practitioners make safer evidenced-based timing decisions for their patients. LEVEL OF EVIDENCE Prognostic Study, Level II.
Collapse
Affiliation(s)
- Susan T Mahan
- Department of Orthopaedic Surgery,
Boston Children’s Hospital, Boston, MA, USA,Orthopaedic Surgery, Harvard Medical
School, Boston, MA, USA,Susan T Mahan, Department of Orthopaedic
Surgery, Boston Children’s Hospital, 300 Longwood Avenue, Boston, MA 02115, USA.
Email
| | - Patricia E Miller
- Department of Orthopaedic Surgery,
Boston Children’s Hospital, Boston, MA, USA
| | - Jiwoo Park
- Department of Orthopaedic Surgery,
Boston Children’s Hospital, Boston, MA, USA
| | - Nicholas Sullivan
- Department of Orthopaedic Surgery,
Boston Children’s Hospital, Boston, MA, USA
| | - Carley Vuillermin
- Department of Orthopaedic Surgery,
Boston Children’s Hospital, Boston, MA, USA,Orthopaedic Surgery, Harvard Medical
School, Boston, MA, USA
| |
Collapse
|
|
37
|
Jiaqi W, Hui L, Yanzhou W, Long L, Tianyou L. Radial nerve trapped posterior to the proximal fracture end after closed reduction of supracondylar humerus fracture in children: A case report. Int J Surg Case Rep 2022; 99:107628. [PMID: 36108377 PMCID: PMC9568743 DOI: 10.1016/j.ijscr.2022.107628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 09/05/2022] [Accepted: 09/07/2022] [Indexed: 11/28/2022] Open
Abstract
Introduction and importance Radial nerve injury is very common in supracondylar humerus fractures, but radial nerve entrapment between the fracture ends after closed reduction is very rare, and we report a case of radial nerve entrapment after closed reduction. Case presentation A 7-year-old boy was admitted to the Department of Pediatric Orthopedics 24 days after closed reduction of a supracondylar fracture of the humerus with radial nerve injury. Preoperative ultrasound showed radial nerve entrapment between the fracture ends, which was confirmed by surgery. After nerve release surgery, the radial nerve recovered well. Clinical discussion How to treat supracondylar humerus fractures in case of nerve damage remains controversial. We presented a rare case with radial nerve injury after supracondylar humerus fracture caused complete motor palsy in which the main trunk of the radial nerve above the right elbow traveled posterior to the fracture site. Awareness of the status of the nerve before and after surgery can help in the clinical decision to perform a concomitant nerve exploration, and in the context of this, ultrasound may be more helpful. Conclusion We recommend identifying the radial nerve using ultrasound during the closed reduction. If the nerve is entrapped between the fracture ends, exploration is recommended. For cases without entrapment, closed reduction with Kirschner wire fixation can be performed first, and the nerve should be re-examined with ultrasound.
Radial nerve entrapped posterior to the proximal fracture end after closed reduction of SCHF was very rare. The use of ultrasound to identify the nerve status can reduce unnecessary surgery in the presence of radial nerve in SCHF. We proposed the management of SCHF with radial nerve injury through a review of the literature.
Collapse
Affiliation(s)
- Wang Jiaqi
- Department of Pediatric Orthopedics, Shandong Provincial Hospital Affiliated to Shandong First Medical University, People's Republic of China
| | - Li Hui
- Department of Anesthesiology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, People's Republic of China
| | - Wang Yanzhou
- Department of Pediatric Orthopedics, Shandong Provincial Hospital Affiliated to Shandong First Medical University, People's Republic of China
| | - Li Long
- Department of Pediatric Orthopedics, Shandong Provincial Hospital Affiliated to Shandong First Medical University, People's Republic of China
| | - Li Tianyou
- Department of Pediatric Orthopedics, Shandong Provincial Hospital Affiliated to Shandong First Medical University, People's Republic of China.
| |
Collapse
|
|
38
|
Abstract
BACKGROUND A high index of suspicion for nerve palsy is essential in the setting of a displaced supracondylar humerus fracture (SCHF) with careful attention to the examination. We hypothesize that nerve injuries are more prevalent in higher energy type III and flexion SCHFs compared with type II fractures. METHODS A retrospective review was performed of 1085 operatively treated SCHFs in pediatric patients, aged 0 to 14 years, between January 1, 2015 and December 31, 2018. There were 979 patients eligible for analysis. Exclusion criteria included follow-up <3 weeks, polytrauma, pathologic fracture, and prior fracture of the ipsilateral elbow. RESULTS The overall rate of nerve injury was 10.6% (104/979). A significant difference in the rate of nerve palsy was identified between fracture types: 0.9% type II, 19.3% type III, and 10.7% flexion type SCHFs ( P <0.001). Median nerve palsy was the most common (n=65). An increased rate of ulnar nerve palsy was observed in flexion type SCHFs. The rate of nerve palsy was higher in the medial pin group (14.9%, P =0.035) but no significant association with iatrogenic ulnar nerve palsy was present. In type III and flexion SCHFs, operative time >60 minutes ( P =0.023) and the need for open reduction ( P =0.012) were significantly associated with postoperative nerve palsy. Referral to therapy was required in 30.8% of patients with a nerve palsy compared with 7.9% of patients without ( P <0.001). CONCLUSION Longer operative times, need for open reduction, and significantly higher rates of nerve palsy among type III and flexion SCHFs are best explained by the unstable nature of the fracture and greater degree of soft tissue trauma. Given prolonged duration of follow-up and more frequent need for therapy demonstrated in patients with a nerve palsy, these data can be used to improve counseling for families and patients after displaced SCHF. LEVEL OF EVIDENCE Level III-retrospective comparative study.
Collapse
|
|
39
|
Yawar B, Khan MN, Asim A, Qureshi A, Yawar A, Faraz A, McAdam A, Mustafa S, Hanratty B. Comparison of Lateral and Crossed K-wires for Paediatric Supracondylar Fractures: A Retrospective Cohort Study. Cureus 2022; 14:e27267. [PMID: 35949806 PMCID: PMC9357392 DOI: 10.7759/cureus.27267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/26/2022] [Indexed: 11/09/2022] Open
Abstract
Background Supracondylar elbow fractures occur most frequently in children aged five to seven years and have equal incidence in both genders. They are classified as flexion or extension type injuries with extension type being more common. We aimed to ascertain radiological stability with lateral and crossed wires in this study. We also identified any complications after operative management of these injuries. Methods As part of this retrospective cohort study, we identified all patients who presented with this injury from January 1, 2020, until February 28, 2022. Basic demographic data and type of operation were noted. Baumann angle (BA) and lateral capitellohumeral angle (LCHA) were measured intra-operatively and x-rays were done at the final clinic appointment. The mean of these angles in lateral and crossed wire groups was compared using paired sample t-test. Unpaired t-test was used to compare the means of both groups with normal values for these angles based on previous studies (BA=71.5±6.2 degrees, LCHA= 50.8±6 degrees). Results Fifty patients were admitted during this period. Thirty-three patients had lateral wires and 17 had crossed wires for fixation. No significant change was noted in the mean BA and mean LCHA in both groups on x-rays done intra-operatively and final clinic follow-up (no loss of reduction). No significant difference was noted between BA and LCHA noted for both groups at the final clinic follow-up with previous studies outlining normal values for these angles. No cases of iatrogenic neurovascular injury were identified. Four patients (8%) were referred to physiotherapy due to stiffness. Conclusion Both lateral and crossed wire configurations led to achievement of good radiological stability with BA and LCHA within normal limits. No loss of reduction was noted with both techniques and no risk of iatrogenic nerve injuries was noted in experienced hands.
Collapse
|
|
40
|
Sondermann S, Bäumer T, Suss J, Bohn B, Fieseler K, Schramm P, Tueshaus L, Boppel T. Detection of Traumatic and Postoperative Nerve Lesions following Upper Extremity Fractures in a Pediatric Cohort Using MR Neurography. Eur J Pediatr Surg 2022. [PMID: 35853469 DOI: 10.1055/s-0042-1751221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Fractures of the upper extremity are common traumatic injuries in children. Nerve lesions are a rare but typical complication of these fractures. Additional to physical, electrophysiological, and sonographic examinations, magnetic resonance neurography (MRN) can be used to assess the degree and exact localization of nerve damage. This retrospective study was conducted to evaluate the potential role of this examination technique for children and to test a proposed MRN classification of traumatic nerve injury according to Chhabra in a pediatric cohort. MATERIALS AND METHODS Pediatric patients undergoing MRN for traumatic nerve injury from January 2016 to December 2020 were retrospectively identified. A total of 12 consecutive patients with sufficient clinical data, an MRN, and if available follow-up examination were enrolled and analyzed. RESULTS In 10 of 12 cases one or more nerve lesions could be identified by MRN using the classification proposed by Chhabra et al. MRN was used to assess nerve injuries, imaging results were compared with clinical course. Clinical follow-up examinations of 10 patients showed an overall good clinical recovery, even in one case with severe trauma and nerve surgery. CONCLUSION MRN as a noninvasive procedure can help in the evaluation of nerve injury, especially for the identification of lower grade nerve damage and to objectify suspected nerve damage in case of uncertain clinical examination results; thus, can help in decision making whether surgical revision or conservative treatment is preferable.
Collapse
Affiliation(s)
- Stefan Sondermann
- Department of Neuroradiology, University Medical Center Schleswig Holstein Lübeck Campus, Lübeck, Germany
| | - Tobias Bäumer
- Institute of System Motor Science, University Medical Center Schleswig Holstein Lübeck Campus, Lübeck, Germany
| | - Joachim Suss
- Department of Pediatric Surgery, Wilhelmstift Catholic Children's Hospital Hamburg, Hamburg, Germany
| | - Boy Bohn
- Department of Orthopedics and Trauma Surgery, BG Trauma Hospital Hamburg, Hamburg, Germany
| | - Katharina Fieseler
- Department of Neuroradiology, University Medical Center Schleswig Holstein Lübeck Campus, Lübeck, Germany
| | - Peter Schramm
- Department of Neuroradiology, University Medical Center Schleswig Holstein Lübeck Campus, Lübeck, Germany
| | - Ludger Tueshaus
- Department of Pediatric Surgery, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Tobias Boppel
- Department of Neuroradiology, University Medical Center Schleswig Holstein Lübeck Campus, Lübeck, Germany
| |
Collapse
|
|
41
|
Marson BA, Ikram A, Craxford S, Lewis SR, Price KR, Ollivere BJ. Interventions for treating supracondylar elbow fractures in children. Cochrane Database Syst Rev 2022; 6:CD013609. [PMID: 35678077 PMCID: PMC9178297 DOI: 10.1002/14651858.cd013609.pub2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Elbow supracondylar fractures are common, with treatment decisions based on fracture displacement. However, there remains controversy regarding the best treatments for this injury. OBJECTIVES To assess the effects (benefits and harms) of interventions for treating supracondylar elbow fractures in children. SEARCH METHODS We searched CENTRAL, MEDLINE, and Embase in March 2021. We also searched trial registers and reference lists. We applied no language or publication restrictions. SELECTION CRITERIA We included randomised and quasi-randomised controlled trials comparing different interventions for the treatment of supracondylar elbow fractures in children. We included studies investigating surgical interventions (different fixation techniques and different reduction techniques), surgical versus non-surgical treatment, traction types, methods of non-surgical intervention, and timing and location of treatment. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. We collected data and conducted GRADE assessment for five critical outcomes: functional outcomes, treatment failure (requiring re-intervention), nerve injury, major complications (pin site infection in most studies), and cosmetic deformity (cubitus varus). MAIN RESULTS: We included 52 trials with 3594 children who had supracondylar elbow fractures; most were Gartland 2 and 3 fractures. The mean ages of children ranged from 4.9 to 8.4 years and the majority of participants were boys. Most studies (33) were conducted in countries in South-East Asia. We identified 12 different comparisons of interventions: retrograde lateral wires versus retrograde crossed wires; lateral crossed (Dorgan) wires versus retrograde crossed wires; retrograde lateral wires versus lateral crossed (Dorgan) wires; retrograde crossed wires versus posterior intrafocal wires; retrograde lateral wires in a parallel versus divergent configuration; retrograde crossed wires using a mini-open technique or inserted percutaneously; buried versus non-buried wires; external versus internal fixation; open versus closed reduction; surgical fixation versus non-surgical immobilisation; skeletal versus skin traction; and collar and cuff versus backslab. We report here the findings of four comparisons that represent the most substantial body of evidence for the most clinically relevant comparisons. All studies in these four comparisons had unclear risks of bias in at least one domain. We downgraded the certainty of all outcomes for serious risks of bias, for imprecision when evidence was derived from a small sample size or had a wide confidence interval (CI) that included the possibility of benefits or harms for both treatments, and when we detected the possibility of publication bias. Retrograde lateral wires versus retrograde crossed wires (29 studies, 2068 children) There was low-certainty evidence of less nerve injury with retrograde lateral wires (RR 0.65, 95% CI 0.46 to 0.90; 28 studies, 1653 children). In a post hoc subgroup analysis, we noted a greater difference in the number of children with nerve injuries when lateral wires were compared to crossed wires inserted with a percutaneous medial wire technique (RR 0.41, 95% CI 0.20 to 0.81, favours lateral wires; 10 studies, 552 children), but little difference when an open technique was used (RR 0.91, 95% CI 0.59 to 1.40, favours lateral wires; 11 studies, 656 children). Although we noted a statistically significant difference between these subgroups from the interaction test (P = 0.05), we could not rule out the possibility that other factors could account for this difference. We found little or no difference between the interventions in major complications, which were described as pin site infections in all studies (RR 1.08, 95% CI 0.65 to 1.79; 19 studies, 1126 children; low-certainty evidence). For functional status (1 study, 35 children), treatment failure requiring re-intervention (1 study, 60 children), and cosmetic deformity (2 studies, 95 children), there was very low-certainty evidence showing no evidence of a difference between interventions. Open reduction versus closed reduction (4 studies, 295 children) Type of reduction method may make little or no difference to nerve injuries (RR 0.30, 95% CI 0.09 to 1.01, favours open reduction; 3 studies, 163 children). However, there may be fewer major complications (pin site infections) when closed reduction is used (RR 4.15, 95% CI 1.07 to 16.20; 4 studies, 253 children). The certainty of the evidence for these outcomes is low. No studies reported functional outcome, treatment failure requiring re-intervention, or cosmetic deformity. The four studies in this comparison used direct visualisation during surgery. One additional study used a joystick technique for reduction, and we did not combine data from this study in analyses. Surgical fixation using wires versus non-surgical immobilisation using a cast (3 studies, 140 children) There was very low-certainty evidence showing little or no difference between interventions for treatment failure requiring re-intervention (1 study, 60 children), nerve injury (3 studies, 140 children), major complications (3 studies, 126 children), and cosmetic deformity (2 studies, 80 children). No studies reported functional outcome. Backslab versus sling (1 study, 50 children) No nerve injuries or major complications were experienced by children in either group; this evidence is of very low certainty. Functional outcome, treatment failure, and cosmetic deformity were not reported. AUTHORS' CONCLUSIONS: We found insufficient evidence for many treatments of supracondylar fractures. Fixation of displaced supracondylar fractures with retrograde lateral wires compared with crossed wires provided the most substantial body of evidence in this review, and our findings indicate that there may be a lower risk of nerve injury with retrograde lateral wires. In future trials of treatments, we would encourage the adoption of a core outcome set, which includes patient-reported measures. Evaluation of the effectiveness of traction compared with surgical fixation would provide a valuable addition to this clinical field.
Collapse
Affiliation(s)
- Ben A Marson
- Department of Trauma and Orthopaedics, University of Nottingham, Nottingham, UK
| | - Adeel Ikram
- Department of Trauma and Orthopaedics, University of Nottingham, Nottingham, UK
| | - Simon Craxford
- Department of Trauma and Orthopaedics, University of Nottingham, Nottingham, UK
| | - Sharon R Lewis
- Bone and Joint Health, Blizard Institute, Queen Mary University of London, London, UK
| | - Kathryn R Price
- Department of Trauma and Orthopaedics, Nottingham Children's Hospital, Nottingham, UK
| | - Benjamin J Ollivere
- Department of Trauma and Orthopaedics, University of Nottingham, Nottingham, UK
| |
Collapse
|
|
42
|
Radaideh AM, Rusan M, Obeidat O, Al-Nusair J, Albustami IS, Mohaidat ZM, Sunallah AW. Functional and radiological outcomes of different pin configuration for displaced pediatric supracondylar humeral fracture: A retrospective cohort study. World J Orthop 2022; 13:250-258. [PMID: 35317252 PMCID: PMC8935329 DOI: 10.5312/wjo.v13.i3.250] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2021] [Revised: 10/08/2021] [Accepted: 02/13/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The 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.
AIM To compare the functional and radiological outcomes of lateral and cross pinning in the management of humeral supracondylar fracture.
METHODS A 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.
RESULTS Amongst 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).
CONCLUSION Both lateral pinning and crossed pinning fixation configuration for displaced pediatric supracondylar humeral fractures provide similar functional and radiological outcomes.
Collapse
Affiliation(s)
- Ahmad M Radaideh
- Department of Special Surgery, Orthopaedic Division, Faculty of Medicine, Jordan University of Science and Technology, Irbid 22110, Jordan
| | - Mohammad Rusan
- Department of Special Surgery, Orthopaedic Division, Faculty of Medicine, Jordan University of Science and Technology, Irbid 22110, Jordan
| | - Omar Obeidat
- School of Medicine, Jordan University of Science and Technology, Irbid 22110, Jordan
| | - Jowan Al-Nusair
- School of Medicine, Jordan University of Science and Technology, Irbid 22110, Jordan
| | - Iyad S Albustami
- School of Medicine, Jordan University of Science and Technology, Irbid 22110, Jordan
| | - Ziyad M Mohaidat
- Department of Special Surgery, Orthopaedic Division, Faculty of Medicine, Jordan University of Science and Technology, Irbid 22110, Jordan
| | - Abdulkarim W Sunallah
- Department of Special Surgery, Orthopaedic Division, Faculty of Medicine, Jordan University of Science and Technology, Irbid 22110, Jordan
| |
Collapse
|
|
43
|
Schultz JD, Rees AB, Wollenman LC, Lempert N, Moore-Lotridge SN, Schoenecker JG. Bruise Location in Supracondylar Humerus Fractures Predicts Specific Neurovascular Injuries. J Pediatr Orthop 2022; 42:e250-e256. [PMID: 34923508 PMCID: PMC8815824 DOI: 10.1097/bpo.0000000000002027] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE The presence of soft tissue injury in pediatric supracondylar humerus fractures (SCHFs) has been shown to be an independent predictor of any neurovascular injury. Potentially expanding this concept, the specific neurovascular structure injured around the elbow is thought to be dependent upon the direction and magnitude of fracture displacement and subsequent soft tissue injury. Therefore, it was hypothesized that the bruise location following SCHF is indicative of the anatomic location of maximal soft tissue injury and therefore is a specific prognosticator of which neurovascular structure may be injured. METHODS Retrospective chart review of all SCHFs treated at a tertiary pediatric hospital from 2007 to 2017 collected information on bruise location, neurovascular injury patterns, and outcomes. Bruise location was classified as anterior, anterolateral, anteromedial, or posterior. Injury radiographs were reviewed by a blinded pediatric orthopaedic surgeon to neurovascular structure injured. RESULTS Of 2845 SCHFs identified, 267 (9.4%) had concomitant neurovascular injury-of which 128 (47.9%) met inclusion criteria. Among the vascular injuries, all bruising was anteromedial (28/45, 62.2%, P<0.05) or anterior (17/45, 37.8%, P>0.05). Fractures with anteromedial bruising correlated with median nerve injury (24/27, 88.9%, P<0.05), whereas fractures with anterolateral bruising correlated with radial nerve injuries (24/25, 96.0%, P<0.05). Bruising or radiographic evaluation correctly identified 60.2% and 64.1% of neurovascular injuries, respectively, whereas the combination identified 82.0% of neurovascular injuries correctly. Bruise location identified 23 neurovascular injuries not predicted by radiographic evaluation alone. CONCLUSION Bruise location is an important physical examination finding that can be used as an adjunct to improve the diagnostic accuracy of neurovascular injury in SCHFs in conjunction with neurovascular physical examination and radiographic evaluation. SCHFs with anterior or anteromedial bruising should raise concern for vascular injury. In addition, anteromedial bruising is predictive of a median nerve injury and anterolateral bruising is predictive of radial nerve injury. This adjunct diagnostic is particularly helpful in a noncooperative child or if performed by a clinician with limited experience in diagnosing neurovascular injuries or interpreting pediatric elbow radiographs. LEVEL OF EVIDENCE Level IV, case series.
Collapse
Affiliation(s)
| | | | | | - Nathaniel Lempert
- Division of Pediatric Orthopaedics, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, TN
- Departments of Orthopaedics
| | - Stephanie N. Moore-Lotridge
- Division of Pediatric Orthopaedics, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, TN
- Departments of Orthopaedics
- Center for Bone Biology, Vanderbilt University Medical Center, Nashville, TN
| | - Jonathan G. Schoenecker
- Department of Pharmacology, Vanderbilt University
- Division of Pediatric Orthopaedics, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, TN
- Departments of Orthopaedics
- Pediatrics
- Pathology, Microbiology, and Immunology
- Medicine
- Center for Bone Biology, Vanderbilt University Medical Center, Nashville, TN
| |
Collapse
|
|
44
|
Supracondylar Fractures of the Humerus: Association of Neurovascular Lesions with Degree of Fracture Displacement in Children—A Retrospective Study. CHILDREN 2022; 9:children9030308. [PMID: 35327679 PMCID: PMC8946881 DOI: 10.3390/children9030308] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Revised: 02/20/2022] [Accepted: 02/21/2022] [Indexed: 11/17/2022]
Abstract
Supracondylar humerus fractures (ScHF) account for 60% of fractures of the elbow region in children. We assessed the relationship between neurovascular complications and the degree of fracture displacement as rated on the basis of modified Gartland classification. Moreover, we aimed to evaluate predisposing factors, e.g., age and gender, and outcomes of neurovascular complications in ScHF. Between 2004 and 2019, we treated 329 patients with ScHF at the Department of Traumatology and Orthopedics of the Upper Silesian Child Centre, Katowice, Poland. Mean age of patients (189 boys and 140 girls) was 7.2 years (Confidence interval: 6.89, 7.45). Undisplaced fractures were treated conservatively with a cast. Displaced fractures were managed by closed reduction and percutaneous Kirschner wire fixation using two pins inserted laterally. We retrospectively assessed the number of neurovascular lesions at baseline and recorded any iatrogenic injury resulting from the surgical intervention. Acute neurovascular lesions occurred in 44 of 329 ScHF patients (13.4%). The incidence of accompanying neurovascular injuries was positively associated with the severity of fracture displacement characterized by Gartland score. Vascular injuries occurred mainly in Gartland type IV ScHF, while nerve lesions occurred in both Gartland type III and IV ScHF. We noted a significantly higher mean Gartland score and mean age at injury in the group of children suffering from neurovascular injuries when compared to those in the group without such injuries (p = 0.045 and p = 0.04, respectively). We observed no secondary nerve lesions after surgical treatment. For the treatment of ScHF in children, we recommend closed reduction and stabilization of displaced fractures with K-wires inserted percutaneously from the lateral aspect of the upper arm. We advocate vessel exploration in case of absent distal pulses after closed reduction but do not consider primary nerve exploration necessary, unless a complete primary sensomotoric nerve lesion is present.
Collapse
|
|
45
|
Yano K, Ishiko M, Iida K, Sasaki K, Kojima T, Kaneshiro Y, Sakanaka H. High Median Nerve Entrapment by Fracture Callus in Surgically Treated Pediatric Supracondylar Humeral Fracture: A Case Report. JBJS Case Connect 2022; 12:01709767-202203000-00041. [PMID: 35108237 DOI: 10.2106/jbjs.cc.21.00737] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE We describe a patient with incomplete high median nerve palsy after surgical treatment of pediatric supracondylar humeral fracture (SCHF). Preoperative images after 11 months after the surgical treatment of the SCHF showed rotational deformity and an isolated median nerve entrapped between the proximal humerus anteriorly and callus posteriorly in the bony tunnel of the distal humerus. Two years after neurolysis, he showed clinical recovery. Four cases similar to our case were reported previously. CONCLUSION Common pediatric fractures may cause unusual neuropathy. Rotational deformity of fracture might be an important factor for isolated median nerve entrapment after SCHF.
Collapse
Affiliation(s)
- Koichi Yano
- Department of Orthopaedic Surgery, Seikeikai Hospital, Sakai City, Osaka, Japan
| | - Megumi Ishiko
- Department of Orthopaedic Surgery, Seikeikai Hospital, Sakai City, Osaka, Japan
| | - Ken Iida
- Department of Orthopaedic Surgery, Seikeikai Hospital, Sakai City, Osaka, Japan
| | - Kosuke Sasaki
- Department of Orthopaedic Surgery, Shiraniwa Hospital, Ikoma, Japan
| | - Takahito Kojima
- Department of Orthopaedic Surgery, Seikeikai Hospital, Sakai City, Osaka, Japan
| | - Yasunori Kaneshiro
- Department of Orthopaedic Surgery, Seikeikai Hospital, Sakai City, Osaka, Japan
| | - Hideki Sakanaka
- Department of Orthopaedic Surgery, Seikeikai Hospital, Sakai City, Osaka, Japan
| |
Collapse
|
|
46
|
Omitting the Early Postoperative Follow-up in Uncomplicated Operative Supracondylar Humerus Fractures in Children Does Not Negatively Affect Outcomes. J Pediatr Orthop 2022; 42:e109-e114. [PMID: 34759191 DOI: 10.1097/bpo.0000000000002011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Supracondylar humerus (SCH) fractures are the most common surgically treated elbow injuries in children. There have been debates regarding if an early postoperative follow-up before pin removal is necessary to decrease the complications related to surgical fixation. To date, studies examining this topic have included smaller sample sizes, limiting the generalizability of their findings. METHODS A retrospective chart review of outcomes after operative management of Gartland type II and III SCH fractures at a single level 1 pediatric trauma center between 2005 and 2015 was performed. Patient demographics, fracture characteristics, pin number and configuration, timing of initial follow-up, change in treatment plan after initial follow-up, time to pin removal, initial and final fracture radiographic parameters, and complications were observed via chart review. RESULTS A total of 1518 SCH fractures underwent operative fixation: 755 Gartland type II and 765 type III. Of the 1518 SCH fractures identified, 1370 met inclusion criteria and were included for analysis. Of these, 1196 patients returned for initial follow-up within 1 to 2 weeks of surgery, and 174 patients had their initial follow-up 3 to 4 weeks postoperatively. There were 8 incidences where initial early follow-up resulted in a change of management; however, change in management was limited to cast alteration in 7 of these cases. CONCLUSIONS Closed reduction and percutaneous pin fixation of otherwise uncomplicated closed SCH fractures have good outcomes and a very low complication rate at a level 1 pediatric trauma center. Early postoperative follow-up before the pin removal visit provides minimal utility in decreasing complications and may be safely omitted as long as the initial fracture fixation is deemed to be stable. LEVEL OF EVIDENCE Level III.
Collapse
|
|
47
|
Schulze A, Schultz J, Dragu A, Fitze G. Diagnostics and Treatment of Volkmann Ischemic Contracture in a Seven-Year-Old Child. European J Pediatr Surg Rep 2022; 10:e68-e72. [PMID: 35865511 PMCID: PMC9296264 DOI: 10.1055/s-0042-1749210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 03/02/2022] [Indexed: 11/10/2022] Open
Abstract
A 7-year-old boy presented 6 weeks after open reduction and crossed Kirschner wire (K-wire) fixation of a supracondylar humerus fracture. Previous treatments had restored skeletal anatomy without documented complications. However, the patient would not move the entire arm, including his forearm and hand. Any passive movement led to anxious adverse reactions, and there was partial numbness of all fingers. After intensive physio- and occupational therapy supported by nerve stimulation and psychological counseling, anxiety-related functional deficits of the shoulder and elbow resolved to reveal the severe Volkmann contracture of the right hand developed fully. Electroneurography, X-ray, magnetic resonance imaging of the forearm, and ultrasonography showed nonfunctional ulnar and a partially disturbed radial motor nerve distal to the elbow along with damaged flexor muscles of the forearm after compartment syndrome. In addition, damage to the median nerve at the elbow level was diagnosed. After intense conservative therapy, we partially resected fibrotic fascia of the superficial flexor compartment, freed ulnar and median nerves, and performed staircase-like releases of tendons and tenotomies. We achieved a full range of motion of all fingers and markedly improved the range of motion of the wrist. The Disabilities of the Arm, Shoulder and Hand scores for function improved from 80 to 16 at the 2-year follow-up postoperatively, but some impairments of fine motor function persisted. Subtle symptoms of a developing compartment syndrome need to be recognized. Overlooked and untreated, a consecutive Volkmann contracture can turn the extremity nonfunctional. Intensive physical, psychological, and surgical therapy in a specialized center can restore function but requires endurance and perseverance throughout the lengthy recovery.
Collapse
Affiliation(s)
- Annekatrin Schulze
- Department of Pediatric Surgery, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Jurek Schultz
- Department of Pediatric Surgery, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Adrian Dragu
- Department of Plastic Surgery, OUPC, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Guido Fitze
- Department of Pediatric Surgery, University Hospital Carl Gustav Carus, Dresden, Germany
| |
Collapse
|
|
48
|
Sullivan MH, Stillwagon MR, Nash AB, Jiang H, Lin FC, Chen AT, Louer CR. Complications With Surgical Treatment of Pediatric Supracondylar Humerus Fractures: Does Surgeon Training Matter? J Pediatr Orthop 2022; 42:e8-e14. [PMID: 34545018 DOI: 10.1097/bpo.0000000000001969] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION National trends reveal increased transfers to referral hospitals for surgical management of pediatric supracondylar humerus (SCH) fractures. This is partly because of the belief that pediatric orthopaedic surgeons (POs) deliver improved outcomes compared with nonpediatric orthopaedic surgeons (NPOs). We compared early outcomes of surgically treated SCH fractures between POs and NPOs at a single center where both groups manage these fractures. METHODS Patients ages 3 to 10 undergoing surgery for SCH fractures from 2014 to 2020 were included. Patient demographics and perioperative details were recorded. Radiographs at surgery and short-term follow-up assessed reduction. Primary outcomes were major loss of reduction (MLOR) and iatrogenic nerve injury (INI). Complications were compared between PO-treated and NPO-treated cohorts. RESULTS Three hundred and eleven fractures were reviewed. POs managed 132 cases, and NPOs managed 179 cases. Rate of MLOR was 1.5% among POs and 2.2% among NPOs (P=1). Rate of INI was 0% among POs and 3.4% among NPOs (P=0.041). All nerve palsies resolved postoperatively by mean 13.1 weeks. Rates of reoperation, infection, readmission, and open reduction were not significantly different. Operative times were decreased among POs (38.1 vs. 44.6 min; P=0.030). Pin constructs were graded as higher quality in the PO group, with a higher mean pin spread ratio (P=0.029), lower rate of "C" constructs (only 1 "column" engaged; P=0.010) and less frequent crossed-pin technique (P<0.001). Multivariate analysis revealed minimal positive associations only for operative time with MLOR (odds ratio=1.021; P=0.005) and INI (odds ratio=1.048; P=0.009). CONCLUSIONS Postsurgical outcomes between POs and NPOs were similar. Rates of MLOR were not different between groups, despite differences in pin constructs. The NPO group experienced a marginally higher rate of INI, though all injuries resolved. Pediatric subspecialty training is not a prerequisite for successfully treating SCH fractures, and overall value of orthopaedic care may be improved by decreasing transfers for these common injuries. LEVEL OF EVIDENCE Level III-retrospective cohort study.
Collapse
Affiliation(s)
| | | | - Alysa B Nash
- Department of Orthopaedics, University of North Carolina School of Medicine
| | - Huijun Jiang
- Department of Biostatistics, University of North Carolina, Chapel Hill, NC
| | - Feng-Chang Lin
- Department of Biostatistics, University of North Carolina, Chapel Hill, NC
| | - Andrew T Chen
- Department of Orthopaedics, University of North Carolina School of Medicine
| | - Craig R Louer
- Department of Orthopaedics, University of North Carolina School of Medicine
| |
Collapse
|
|
49
|
Sun J, Shan J, Meng L, Liu T, Wang E, Jia G. Rotation of both X- and Y-axes is a predictive confounder of ulnar nerve injury and open reduction in pediatric lateral flexion supracondylar humeral fractures: A retrospective cohort study. Front Pediatr 2022; 10:962521. [PMID: 36268037 PMCID: PMC9577068 DOI: 10.3389/fped.2022.962521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 07/28/2022] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Rotation of the distal fragment often occurs in flexion-type supracondylar humerus fractures (SCHFs), potentially leading to ulnar nerve injury (UNI) and open reduction. We analyzed the correlation between the rotations and UNI or open reduction and then assessed the risk factors associated with these rotations. METHODS Data of Wilkins type III lateral flexion SCHFs were collected over a 10-year time period (1 January 2012 to 31 December 2021) in Children's Hospital of Fudan University Anhui Hospital. We defined the rotation of the distal fragment on the coordinate axis as two types, IIIA (X-axis rotation) and IIIB (the rotation of both X- and Y-axes) on X-ray radiography. Demographic data, the incidence of the two-type rotation, odds ratios (ORs) of UNI and open reduction, and risk factors of the rotation of both X- and Y-axes were analyzed. RESULTS Totally, 152 patients were found (50 with IIIA vs. 102 IIIB). The UNI rate was 13%, and the open reduction rate was 22%. The UNI rate of the IIIB was five-fold higher than that of the IIIA [OR, 5.143; 95% confidence interval (CI), 1.414-23.125; p = 0.019], and the open reduction rate of the IIIB was nearly five-fold higher than that of the IIIA (OR, 4.729, 95%CI, 1.584-14.495; p = 0.003). In these two types, patients with UNI had a higher risk of open reduction than those without UNI (OR, 9.816; 95%CI, 3.503-27.508; p = 0.001). In the multiple regression analysis, a high level of fracture was identified as a risk factor for the rotation of both X- and Y-axes. CONCLUSION Type IIIB lateral flexion-type SCHFs have higher rates of UNI and open reduction, and a high level of fracture is a risk factor associated with this type.
Collapse
Affiliation(s)
- Jun Sun
- Children's Hospital of Anhui Province, Hefei, China
| | - Jing Shan
- Children's Hospital of Anhui Province, Hefei, China
| | - Lian Meng
- Children's Hospital of Anhui Province, Hefei, China
| | - Tianjing Liu
- Pediatric Orthopedics, Shengjing Hospital of China Medical University, Shenyang, China
| | - Enbo Wang
- Pediatric Orthopedics, Shengjing Hospital of China Medical University, Shenyang, China
| | - Guoqiang Jia
- Children's Hospital of Anhui Province, Hefei, China
| |
Collapse
|
|
50
|
Hell AK, Gadomski C, Braunschweig L. Spontaneous humeral torsion deformity correction after displaced supracondylar fractures in children. BMC Musculoskelet Disord 2021; 22:1022. [PMID: 34872541 PMCID: PMC8650349 DOI: 10.1186/s12891-021-04909-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 11/22/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND After displaced supracondylar humerus fractures (SCHF) in children, residual deformities are common with cubitus varus (CV) being the clinically most visible. Distal fragment malrotation may lead to instability, fragment tilt and subsequent CV. Detection and assessment of malrotation is difficult and the fate of post-traumatic humeral torsion deformity is unknown. The aim of this study was to evaluate the incidence of humeral torsion differences in children with surgically treated SCHF and to observe spontaneous changes over time. METHODS A cohort of 27 children with displaced and surgically treated SCHF were followed prospectively from the diagnosis until twelve months after trauma. Clinical, photographic, sonographic and radiological data were obtained regularly. Differences in shoulder and elbow motion, elbow axis, sonographic humeral torsion measurement and radiological evaluation focusing on rotational spur were administered. RESULTS Six weeks after trauma, 67% of SCHF children had a sonographically detected humeral torsion difference of > 5° (average 14.0 ± 7.6°). Of those, 44% showed a rotational spur, slight valgus or varus on radiographs. During follow-up, an average decrease of the difference from 14° (six weeks) to 7.8° (four months) to 6.5° (six months) and to 4.9° (twelve months) was observed. The most significant correction of posttraumatic humeral torsion occurred in children < 5 years and with internal malrotation > 20°. CONCLUSION After displaced and surgically treated SCHF, most children had humeral torsion differences of both arms. This difference decreased within one year after trauma due to changes on the healthy side or correction in younger children with severe deformity. LEVEL OF EVIDENCE/CLINICAL RELEVANCE Therapeutic Level IV.
Collapse
Affiliation(s)
- Anna K Hell
- Pediatric Orthopaedics; Department of Trauma, Orthopaedic and Plastic Surgery, University Medical Center Goettingen, 37075, Goettingen, Germany.
| | - Claudia Gadomski
- Pediatric Orthopaedics; Department of Trauma, Orthopaedic and Plastic Surgery, University Medical Center Goettingen, 37075, Goettingen, Germany
| | - Lena Braunschweig
- Pediatric Orthopaedics; Department of Trauma, Orthopaedic and Plastic Surgery, University Medical Center Goettingen, 37075, Goettingen, Germany
| |
Collapse
|