Open reduction and K-wires fixation of medial humeral epicondyle fractures with intra-articular elbow entrapment in children

Background. Medial epicondyle fracture (MEF) is a common injury of all elbow fractures in the pediatric and adolescent population and is often associated with elbow dislocation. Traditional management by cast immobilization increasingly is being replaced with early open reduction and K-wires or screws fixation. A consensus about the correct treatment of MEF is currently lacking in the medical literature. The aim of this study was to report the clinical and radiographic outcomes and the complications of patients affected from MEF with intra-articular fragment incarceration treated by open reduction and K-wire fixation. Materials and methods. Thirteen children (aged 813 years) with medial epicondyle fractures (MEF) with intra-articular elbow entrapment were retrospectively reviewed. All the enrolled patients were surgically treated with open reduction and k-wire fixation without exploration of ulnar nerve. Clinical outcomes were evaluated using upper limb alignment in the frontal plane, elbow range of motion (ROM), the Mayo Elbow Performance Score (MEPS) and with the Visual Analogue Scale (VAS). Radiographic outcomes and complications were also evaluated. Results. At a mean follow-up of 24.1 months no patients showed axial deformity of the upper limb or instability of the elbow and with preserved elbow ROM. The mean MEPS was 98.8 and the mean value of the VAS score was 1. The final X-rays showed fracture healing in 11 patients while 2 (15.3%) reported asymptomatic nonunion. Six patients of 13 presented with preoperative paresthesia in the ulnar nerve field but all of them reported a complete recovery after a mean of 4.3 months. All patients returned to their sporting activities at a mean of 5.4 months after surgery. One patient (7.7%) reported a superficial surgical wound infection treated with oral antibiotic medication without further surgery. No other complication was found. Conclusions. The results demonstrate that open reduction and K-wires fixation without exploration of ulnar nerve for MEF with intra-articular elbow entrapment treatment is a safe and effective procedure.

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ANATOMICAL STUDY OF ARCADE OF STRUTHERS

Hand Surgery ◽

10.1142/s0218810410004941 ◽

2010 ◽

Vol 15 (03) ◽

pp. 157-159 ◽

Cited By ~ 3

Author(s):

Piyapong Tiyaworanan ◽

Surut Jianmongkol ◽

Tala Thammaroj

Keyword(s):

Ulnar Nerve ◽

Anatomical Study ◽

Medial Epicondyle ◽

Anatomical Location ◽

Greater Tuberosity ◽

Lateral Epicondyle ◽

Surgical Exploration ◽

Fresh Frozen ◽

The Mean ◽

Proximal Border

The incidence and the anatomical location of the arcade of Struthers as related to the arm length were studied in 62 arms of adult fresh-frozen cadavers. The distance between the greater tuberosity and the lateral epicondyle was designated as the arm length. The arcades of Struthers were identified in 85.4%. The mean arm length was 27.85 ± 1.3 cm. The mean of the distance between proximal border of the arcade of Struthers and the medial humeral epicondyle was 8.24 ± 2.06 cm. The mean ratio between the distance from the proximal border of the arcade to the tip of the medial epicondyle and arm length was 0.29 ± 0.07. We concluded that the anatomical location of the arcade as related to the arm length was 29% proximally, from the tip of the medial epicondyle. This report of the anatomical location of the arcade of Struthers related to the arm length can be useful to identify this structure in the arms which have differences in arm length during the surgical exploration and anterior transposition of the ulnar nerve procedures.

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Comparison of cross pinning versus lateral three pins in type three supracondylar fracture of distal humerus in children.

Asian Journal of Medical Sciences ◽

10.3126/ajms.v10i2.22034 ◽

2019 ◽

Vol 10 (2) ◽

pp. 58-61

Author(s):

Krishna Sapkota ◽

Krishna Wahegaonkar ◽

Niraj Ranjeet ◽

Pabin Thapa ◽

Upendra Jung Thapa ◽

...

Keyword(s):

Nerve Injury ◽

Ulnar Nerve ◽

Distal Humerus ◽

Supracondylar Fracture ◽

Good Stability ◽

Lateral Side ◽

Supracondylar Fractures ◽

Wire Fixation ◽

Ulnar Nerve Injury ◽

K Wires

Background: Supracondylar fracture of distal humerus is the most common paediatric fracture. Type III supracondylar fractures should be treated with anatomical reduction and stable Kirschner wire (K- wire, pin) fixation to prevent the cosmetic deformity. The configuration of wires is debatable. Although two crossed K-wires are bio-mechanically stable, there is a risk of iatrogenic ulnar nerve injury. Lateral 3 K-wires is a good alternative. This study was done to compare the outcome of cross K- wire and lateral 3 K-wires in terms of stability. Materials and Methods: This is a prospective study done in Manipal Teaching Hospital. All the Gartland type 3 supracondylar fractures of the distal humerus were treated with closed reduction and stabilized with K wires. In Group I, fractures were stabilized with cross K wire fixation and in group II they were stabilized with 3 lateral K-wires. The patients were followed up at 4-5 weeks for wire removal and at 3 months and 6 months after surgery. Baumann's angle, a functional outcome as per Flynn's criteria, and range of motion were recorded in each visit. Outcomes were compared in term of displacement of fracture. Result: Seventeen children in each group were taken up for the study. There were no significant differences in term of patients and fracture character. No patients had significant loss of reduction at final follow up. There is no statistically significant difference seen in mean changes of Bauman's angle. According to Flynn's criteria good result was seen in more than 95% of cases in both groups. Conclusion: Both cross K-wires and Lateral 3 K-wires provide good stability. Fixation of supracondylar fracture from lateral side had an advantage of no risk of iatrogenic Ulnar nerve injury. Addition of third K-wire from lateral side provides good stability as that of cross K- wire fixation.

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Anatomy of the palmar branch of the ulnar nerve: application to ulnar and median nerve decompressive surgery

Journal of Neurosurgery ◽

10.3171/2010.3.jns091249 ◽

2011 ◽

Vol 114 (1) ◽

pp. 263-267 ◽

Cited By ~ 16

Author(s):

R. Shane Tubbs ◽

Jason M. Rogers ◽

Marios Loukas ◽

Ayhan Cömert ◽

Mohammadali M. Shoja ◽

...

Keyword(s):

Median Nerve ◽

Ulnar Nerve ◽

Ulnar Artery ◽

Medial Epicondyle ◽

Palmar Arch ◽

Medial Side ◽

Fourth Digit ◽

Palmar Cutaneous Branch ◽

Cutaneous Branch ◽

The Mean

Object The palmar cutaneous branch of the ulnar nerve (PCUN) has received little attention in the literature, and to the authors' knowledge, has received no attention in the neurosurgical literature. The present study was performed to help the surgeon minimize postoperative complications of nerve decompression at the wrist. Methods Forty cadaveric upper limbs underwent dissection of the ulnar nerve in the forearm, at the wrist, and in the palm. The PCUN was investigated and when identified, measurements were made and relationships documented between this cutaneous branch and the ulnar artery. The length and width of the PCUN were measured, as was the distance from the medial epicondyle of the humerus to the origin of the PCUN from the ulnar nerve. Results A PCUN was found on 90% of sides. The origin of the PCUN from the ulnar nerve was found to lay a mean of 14.3 cm distal to the medial epicondyle. The mean length and width of this branch were 13 and 0.08 cm, respectively. In the forearm, the PCUN traveled lateral to the ulnar artery on 75% of sides and on the medial side of this vessel on the remaining sides. The PCUN perforated the fascia of the anterior forearm just proximal to the distal wrist crease. In the palm, the PCUN traveled superficial to the superficial palmar arch on all but 5 sides, where it traveled deep to this vascular structure's distal extent. On 2 sides each, the PCUN communicated with the superficial and deep ulnar nerves. On 2 sides, the PCUN communicated with the palmar cutaneous branch of the median nerve. The majority of the terminal fibers of the PCUN were found on the ulnar side of a hypothetical line drawn longitudinally through the fourth digit and supplied an area roughly 3 × 3 cm over the proximal medial palm. Conclusions The authors hope that the present data may be useful to the surgeon during decompressive procedures at the wrist, such as carpal tunnel and the Guyon canal. Based on this study, skin incisions of the palm made longitudinally along a line through the middle of the fourth digit would minimize injury to the PCUN.

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Comparison of closed reduction and percutaneous cross verses parallel k wire fixation in supracondylar fractures of the humerus in children.

The Professional Medical Journal ◽

10.29309/tpmj/2020.27.03.3091 ◽

2020 ◽

Vol 27 (03) ◽

pp. 476-480

Author(s):

Farhan Majeed ◽

Mudasser Saddique ◽

Hafiz Nasir ◽

Ahmad Shams

Keyword(s):

Nerve Injury ◽

Ulnar Nerve ◽

Closed Reduction ◽

Functional Results ◽

Supracondylar Fractures ◽

Fractures In Children ◽

Wire Fixation ◽

Group A ◽

Ulnar Nerve Injury ◽

K Wires

Around the elbow, supracondylar injury of humerus is one of the conventional fractures which usually occurs at the age of 7 to 8 years. Various conservative techniques have been used for the management, which comprises of the splintage, tractions, open or closed reduction with k wire fixation. However, closed reduction and percutaneous pinning remains the mainstay of surgical management, for they have shown splendid outcomes according to many authors. Objectives: The aim of this study is to summarise and compare the radiological and functional results of two ways of fixation (cross and parallel closed K wires) of supracondylar fractures in children. Study Design: Randomized controlled trial. Setting: Department of Orthopaedics Surgery, Services Hospital, Lahore. Period: 1st January 2018 to 31st June 2018. Material & Methods: We included 180 patients (90 in each group). Results: The mean age was 6.45±2.34 years with 115(63.9%) male and 65(36.1%) female. Among the children who underwent fixation with cross k-wires, ulnar nerve injury was seen in 2(2.2%) cases and none were seen in the other group post operatively. Group A attained higher union rate at last follow up. 4(4.4%) cases in Cross K-wires and 19(21.1%) in two lateral k-wires gave outstanding outcome. In a nutshell, 60 in group A and 45 in group B showed excellent outcomes based on Flynn's criteria, p-value < 0.05. Conclusion: According to Flynn’s criteria, closed percutaneous cross K-wire fixation of supracondylar fracture of humerus is an effective management option in terms of finer functional results as compared to Parallel k-wires. Although, the rate of radiological union is higher in cross k-wire fixation, there are 2.2% chances of ulnar nerve injury.

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Cannulated screw versus Kirschner-wire fixation for Milch II lateral condyle fractures in a paediatric sawbone model: a biomechanical comparison

Journal of Children s Orthopaedics ◽

10.1302/1863-2548.12.170090 ◽

2018 ◽

Vol 12 (1) ◽

pp. 29-35 ◽

Cited By ~ 2

Author(s):

D. Franks ◽

J. Shatrov ◽

M. Symes ◽

D. G. Little ◽

T. L. Cheng

Keyword(s):

Screw Fixation ◽

Cannulated Screw ◽

Screw Placement ◽

Lateral Condyle ◽

Rigid Fixation ◽

Cannulated Screws ◽

Lateral Column ◽

Elbow Fractures ◽

Wire Fixation ◽

K Wires

Purpose Lateral condyle fractures of the humerus are common in the paediatric population, accounting for up to 20% of elbow fractures. Traditional management involves internal fixation with Kirschner (K)-wires, however, this has been associated with complications and insufficiently rigid fixation. Recently, cannulated screws have been proposed as a more stable method of fixation. While cannulated screws have been thought to allow earlier range of movement and shorten time to union, data regarding the biomechanical performance and optimal screw placement is scarce. We hypothesize that cannulated screw fixation is superior to K-wire fixation and screw placement can enhance the stability of the construct. Methods Paediatric humerus sawbones with Milch II fractures were fixed with one of three methods. Fractures were reduced with either a single cannulated screw either through the centre of the capitellum (oblique), or placed up the lateral column across the growth plate (lateral), or fixed with two K-wires. Fixed sawbone fractures were then mechanically tested in two directions simulating in vivo forces. Results The lateral screw construct had a higher maximum force to failure, higher stiffness and absorbed higher energy as compared with the K-wire fixation and oblique screw under an anterior force. When loaded from the posterior direction, only the lateral column screw was better than K-wire fixation. Conclusions Screw fixation is a biomechanically effective alternative to K-wire fixation, especially when placed up the lateral column of the distal humerus. Further clinical studies are required before transcapitellar screw fixation can be adopted.

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Buried or unburied K-wires for lateral condyle elbow fractures

Annals of The Royal College of Surgeons of England ◽

10.1308/003588412x13171221592375 ◽

2012 ◽

Vol 94 (7) ◽

pp. 513-516 ◽

Cited By ~ 15

Author(s):

L McGonagle ◽

S Elamin ◽

DM Wright

Keyword(s):

Deep Infection ◽

Lateral Condyle ◽

Non Union ◽

Increased Risk ◽

Elbow Fractures ◽

Wire Fixation ◽

Superficial Wound ◽

Fracture Configuration ◽

K Wires ◽

Humeral Condyle

INTRODUCTION Lateral humeral condyle fractures typically require a longer period of internal fixation than other distal humeral fractures due to the increased risk of non-union. K-wires can be buried and left in situ until union or they can be left unburied and require removal after four weeks, with plaster immobilisation until union. There is no consensus as to whether wire burial is preferable or not. The aim of this study was to determine whether K-wire burial is associated with more complications than non-buried wires in treating lateral condyle fractures of the elbow. METHODS All patients with lateral humeral condyle fractures treated with K-wire fixation at our institution from May 2008 to August 2011 were included in the study. Fracture configuration, mode of reduction, wire burial and complications were assessed. RESULTS Sixty-seven patients (19 girls and 48 boys, mean age: 6.5 years, range: 1–17 years) were included in the study. All had closed injuries and were treated with open reduction and K-wire fixation. K-wires were buried in 55 patients. Thirteen cases of buried wires eroded through skin and were removed on average 45 days (range: 30–58 days) post-operatively. Of the wire erosion cases, three developed microbiologically proven infections, one of which was a deep infection. There were a further three superficial wound infections in the absence of wire erosion through the skin. There were complications in 2 of the 12 cases in the unburied wires group: 1 microbiologically proven superficial wire site infection and 1 wire backed out after 11 days, requiring refixation. CONCLUSIONS Wire erosion through the skin is the most common complication of K-wire burial. This may be due to the decrease in swelling after fracture fixation, making the wires more prominent under the skin. Skin integrity should be monitored closely if wires are buried.

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Cast immobilisation in situ versus open reduction and internal fixation of displaced medial epicondyle fractures in children between 7 and 16 years old. A study protocol for a randomised controlled trial

BMJ Open ◽

10.1136/bmjopen-2020-044627 ◽

2021 ◽

Vol 11 (5) ◽

pp. e044627

Author(s):

Tero Hämäläinen ◽

Matti Ahonen ◽

Ilkka Helenius ◽

Jenni Jalkanen ◽

Markus Lastikka ◽

...

Keyword(s):

Internal Fixation ◽

Ulnar Nerve ◽

Operative Treatment ◽

Open Reduction ◽

Nonoperative Treatment ◽

Medial Epicondyle ◽

University Hospital ◽

Fractures In Children ◽

Patient Reported ◽

Nerve Dysfunction

IntroductionMedial epicondyle fracture of the humerus is a common injury in childhood. There is uniform agreement that minimally displaced fractures (dislocation ≤2 mm) can be treated nonoperatively with immobilisation. Open fractures, fractures with joint incarceration or ulnar nerve dysfunction require surgery. There is no common consensus in treatment of closed medial epicondyle fractures with >2 mm dislocation without joint incarceration or ulnar nerve dysfunction. We hypothesise that there is no difference in treatment outcomes between nonoperative and operative treatment.Methods and analysisThis is a multicentre, controlled, prospective, randomised noninferiority study comparing operative treatment to non-operative treatment of >2 mm dislocated paediatric medial epicondyle fractures without joint incarceration or ulnar nerve dysfunction. A total of 120 patients will be randomised in 1:1 ratio to either operative or nonoperative treatment. The study will have a parallel nonrandomised patient preference arm. Operative treatment will be open reduction and internal fixation. Nonoperative treatment will be upper limb immobilisation in long arm cast for 4 weeks. Data will be collected at baseline and at each follow-up up to 2 years. Quick-DASH is used as primary outcome measure. Secondary outcomes are patient-reported pain, differences in range of motion, Pediatric Quality of Life Inventory, cosmetic visual analogue scale and Mayo Elbow Performance Score.Ethics and disseminationEthical approval has been obtained from Helsinki University Hospital (HUS) ethical board HUS/1443/2019. Each study centre has obtained their own permission for the study. A written authorisation from legal guardian will be acquired and the child will be informed about the trial. Results of the trial will be disseminated as published articles in peer-reviewed journals.Trial registrationThe trial has been registered at clinicaltrials.gov with registration number NCT04531085.

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Management of supracondylar fracture humerus type 3 in children with percutaneous K-wire vs. open reduction and internal fixation with K-wire

International Journal of Research in Orthopaedics ◽

10.18203/issn.2455-4510.intjresorthop20175659 ◽

2017 ◽

Vol 4 (1) ◽

pp. 120

Author(s):

Shaik Md Waseem Ahmed ◽

R. Biju

Keyword(s):

Internal Fixation ◽

Ulnar Nerve ◽

Closed Reduction ◽

Open Reduction ◽

Reduction Technique ◽

P Value ◽

Supracondylar Fractures ◽

Ulnar Nerve Palsy ◽

Supracondylar Humerus Fractures ◽

Wire Fixation

Background: Aim of the study is to determine the relation between the reduction technique percutaneous pinning and open reduction and internal fixation with K-wire used in management of supracondylar humerus fractures in paediatric age group and the ultimate elbow status (functional and cosmetic), so that appropriate reduction technique can be adopted for better functional and cosmetic outcome.Methods: Children below 12 years with Gartland’s type III supracondylar fractures managed by closed reduction and percutaneous K-wire fixation and open reduction and K-wire fixation and Flynn’s criteria was used to grade the outcome of surgical fixation. 10 Closed reduction and K-wire fixation and 10 open reduction and K-wire fixation were done.Results: Most of the fractures were sustained when the patient had fallen down on out stretched hand while playing or slip and fall. According to Flynn’s grading, there are 7 excellent, 2 good and 1 fair functional result observed in closed reduction and k wire fixation. There are 4 excellent, 3 good and 3 fair functional results observed in open reduction and k wire fixation with statistically significant p value 0.04. Conclusions: Open reduction through lateral approach and internal fixation wire K wires is safe and effective method of treatment, if indicated, in supracondylar fractures of humerus in children and is associated with a good outcome. A small incision medially in cases where medial epicondyle cannot be defined to visualize the epicondyle and the ulnar nerve, by which iatrogenic ulnar nerve palsy in percutaneous fixation can be prevented.

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Outcomes following open reduction for late-presenting developmental dysplasia of the hip

Journal of Children s Orthopaedics ◽

10.1302/1863-2548.12.180078 ◽

2018 ◽

Vol 12 (4) ◽

pp. 323-330 ◽

Cited By ~ 5

Author(s):

P. Castañeda ◽

K. Z. Masrouha ◽

C. Vidal Ruiz ◽

L. Moscona-Mishy

Keyword(s):

Open Reduction ◽

Pelvic Osteotomy ◽

Developmental Dysplasia ◽

High Rate ◽

Type I ◽

Radiographic Outcomes ◽

Femoral Shortening ◽

The Mean ◽

Dysplasia Of The Hip

Purpose Patients with late-presenting developmental dysplasia of the hip (DDH) are more likely to require an open reduction. Since many developing countries do not have mandated screening, there continues to be a relatively high incidence of late-presenting DDH. We report the clinical and radiographic outcomes of open reduction in a series of patients who presented late. Patients and methods This was a retrospective review of 712 hips in 645 patients that underwent open reduction, alone or in combination with a pelvic osteotomy. In all, 91 hips had open reduction alone and 621 had open reduction and pelvic osteotomy. Femoral shortening was performed in 221 hips. The mean age at the time of surgery was 2.1 years (1 to 6.5) and the mean follow-up time was 9.3 years (6 to 14). We used the Children’s Hospital Oakland Hip Evaluation Score (CHOHES) to determine functional outcomes and the Severin classification was used to evaluate radiographic outcomes. The rate of avascular necrosis (AVN) and the need for a reoperation were also recorded and analyzed. Results In all 80% (570 hips) had good radiographic outcomes (Severin type I or II) and 87% had a CHOHES score of > 90 at final follow up. There was a 14% rate of AVN and only a 2% rate of redislocation. Better radiographic outcomes and lower reoperation rates were seen with patients who underwent both an open reduction and pelvic osteotomy. A trend was observed towards worse outcomes in older patients. Conclusions There was a high rate of good clinical and radiographic outcomes at a minimum six-year follow-up in patients with late-presenting DDH who underwent open reduction. Those who underwent open reduction in combination with a pelvic osteotomy had a higher rate of good radiographic outcomes and a lower rate of complications, particularly reoperation.

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Comparative analysis of surgical outcome of treatment of supracondylar humerus fractures Gartland’s extension type III by using closed reduction and K –wire fixation versus open reduction and K –wire fixation method

International Journal of Research in Orthopaedics ◽

10.18203/issn.2455-4510.intjresorthop20170080 ◽

2017 ◽

Vol 3 (2) ◽

pp. 271

Author(s):

Nilesh Janardan Keche ◽

Abhijit Bhimrao Kale ◽

Binoti Arun Sheth ◽

Ashok Kumar Rathod

Keyword(s):

Internal Fixation ◽

Closed Reduction ◽

Open Reduction ◽

Fixation Method ◽

Elbow Fracture ◽

Supracondylar Humerus Fractures ◽

Wire Fixation ◽

Group 2 ◽

K Wires ◽

Group 1

Background: Supracondylar fractures of the humerus are the most common elbow fracture in children of the age group 4-12 years. The modern approach for its treatment includes closed reduction or open reduction and internal fixation with K wires. The aim of the present study was to evaluate the clinical and radiological results of children who were treated with the two surgical approaches.Methods: In our institute children who underwent surgical treatment for supracondylar humeral fractures by closed reduction or open reduction and internal fixation with K wires and whose data were available with regular follow-up of at least 1 year were included in the study. Each group included 25 children in each. Clinical and radiological outcomes were evaluated and compared among the study groups.Results: The mean age of the patients in both the groups were 6.84 and 6.64 in group 1 and group 2 respectively. Fractures were more in boys compared to girls in both the groups. Most of the fractures were seen on left side with posteromedial displacement of distal fragment in almost 80% in both the groups. Mean change in Baumann’s angle (BA), carrying angle and range of motion (ROM) as compared to normal side in both the groups after 3rd and 9th month of follow ups was found to be not statistically significant. Overall result according to Flynn’s criteria was 60% excellent in group 1 as compared to 52% in group 2. Mean satisfaction score was also more in group 1 children when compared to group 2. Conclusions: Closed reduction with internal fixation with K wires was found to be a better choice of treatment with good functional results.

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