Closed reduction and percutaneous pinning vs open reduction and internal fixation in pediatric lateral condylar humerus fractures displaced by > 4 mm: an observational cross-sectional study

Background Although open reduction and internal fixation (ORIF) is recommended for lateral condylar humerus fractures (LCHFs) displaced by > 4 mm, several studies have reported the use of closed reduction and percutaneous pinning (CRPP) to treat LCHFs with significant displacement. However, little is known about the clinical differences between these two surgical techniques. This study aimed to compare the therapeutic effects of CRPP and ORIF in treating LCHFs displaced by > 4 mm. Methods We retrospectively reviewed pediatric LCHFs displaced by > 4 mm treated with either CRPP or ORIF at our center from June 2019 to October 2020. Song and Milch fracture classifications were used. Variables such as age at injury, sex, side injured, fracture displacement, fracture type, operating time, postoperative treatment, and complications were compared between the two techniques. Results One hundred twenty LCHFs met inclusion criteria. There were 36 Milch type I and 84 type II LCHFs, and 69 Song stage 4 and 51 stage 5 LCHFs. CRPP was performed in 45 cases and ORIF in 75 cases. No differences were found in age, sex, side injured, preoperative displacement, postoperative displacement, and length of immobilization between the CRPP and ORIF groups. There was a difference between operation time and pin duration. The CRPP group had shorter operation times and pin duration, and required no additional operations to remove internal pins. The average follow-up duration was 13.9 months. All patients achieved fracture union, and no complications such as infection, nonunion, delayed union, osteonecrosis, fishtail deformity, cubitus varus or valgus, or pain were recorded during follow-up. Bone spurs, lateral prominences, and decreased carrying angle were common complications in all groups. No obvious cubitus varus was observed. Unaesthetic scars were only observed in the ORIF groups. No differences in range of motion or elbow function was found among the different therapies. Conclusions Both CRPP and ORIF can achieve satisfactory clinical outcomes in treating LCHFs displaced by > 4 mm. No differences were found in complications or prognoses between the two groups. However, CRPP shows some advantages over ORIF, like less invasive surgery, no obvious scarring, and no need for secondary surgery with anesthesia for pin removal.

Prevalence and Treatment Outcome of Displaced High-Long Oblique Supracondylar Humeral Fractures in Children

Aim: The treatment protocol for supracondylar humeral fracture has mainly been based only on the severity of displacement and percutaneous pinning has been recommend as a first treatment. However, a long oblique fracture line is difficult to fix by the traditional cross pinning. The purpose of this study is to assess the prevalence of high-long oblique supracondylar humeral (HLO) fracture and evaluate the surgical outcome of percutaneous pin fixation.Methods: We reviewed 690 children who had undergone an operation for the displaced supracondylar humeral fracture. HLO fracture was defined as having a fracture line starting from either cortex above the metaphyseal-diaphyseal junction and finishing at the opposite cortex around or below the olecranon fossa. Clinical and radiographic parameter outcomes were assessed.Results: There were 14 patients diagnosed with the HLO fracture (14/690) and all the patients were treated by pin fixation. The median age was 5 years 1 month (range, 2–11 years). The common mode of injury was direct contact injury to the elbow. There were 6 patients with lateral HLO fracture, and 8 patients had medial HLO type. In medial HLO type, medial pinning only was done in 3 patients due to the difficulty in lateral pin insertion. In addition, the lateral pin was not a bicortical fixation through capitellum entry in 2 patients who had it fixed by cross pinning. The final Baumann angle and lateral humero-capitellar angle were 20.5 (5–67.6) degrees and 49.3 (23.3–71.9) degrees, respectively, without statistical significance compared to the normal side. Flynn's cosmetic grade showed satisfactory results in all patients.Conclusion: The prevalence of HLO fractures was 2% in the displaced supracondylar humeral fracture. The mechanism of injury of HLO fractures may be direct contact injury. In medial HLO fractures, medial pinning is important for stability, and sometimes lateral pinning was impossible. Contrarily, lateral HLO fracture could easily be fixed by lateral-only pinning, but the correct lateral pinning is necessary because medial pinning is difficult. The HLO fracture is a difficult pattern to treat by traditional percutaneous pinning and another surgical option should be considered.

Application of ultrasound in the closed reduction and percutaneous pinning in supracondylar humeral fractures

Background Ultrasound examination can be applied to the diagnosis of pediatric elbow fracture. This study aims to analyze the application value of ultrasound in the surgical treatment of supracondylar humeral fractures. Methods 64 children with supracondylar humeral fractures were treated with ultrasound-guided closed reduction and percutaneous pinning (CRPP), 31 patients were treated with CRPP under radiography guidence. The reduction effect of supracondylar humeral fractures was determined through the perioperative ultrasound images of the lateral, medial and posterior aspects of the elbow. Percutaneous pinning was performed after supracondylar humeral fractures were well reduced. A follow-up examination was performed and all the patients were evaluated according to Flynn’s criteria. Results The mean duration of surgery was 58.3 min (42–108 min) in the ultrasound group and 41.5 min (24-63 min) in the radiography group (P < 0.05). The mean carrying angle was 8.2° (0°–15°) in the ultrasound group and 9.4°(3°–16°) in the radiography group; The mean Baumann’s angle was 75.5°(60°–85°) in the ultrasound group and 73.4°(62°–82°) in the radiography group; The mean lateral humerocapitellar angle was 38.4° (26°–54°) in the ultrasound group and 41.6°(29°–52°) in the radiography group; No significant differences were observed between the two groups. According to the Flynn’s criteria, 49 (76.6%) patients had excellent, 10 (15.6%) patients achieved good, 3 (4.7%) patients showed fair results and 2 (3.1%) patients achieved poor results in the ultrasound group; 22 (70.9%) patients had excellent, 6 (19.4%) patients achieved good, 2 (6.5%) patients showed fair results and 1 (3.2%) patients achieved poor results in the radiography group; No statistically significant difference was noted between the results of these two groups (P > 0.05). After surgery, three patients had pin tract infection. One patient had ulnar nerve neurapraxia in the radiography group. No cases with Volkmann’s contracture were reported. Conclusion Ultrasound-guided CRPP is a safe and reliable surgical treatment of pediatric supracondylar humeral fractures. Trial registration Retrospectively registered.

Late Deep Infections Complicating Percutaneous Pinning of Supracondylar Humerus Fractures

Objectives. Complications following treatment of supracondylar humerus fractures are typically seen shortly postoperatively. Late complications occurring years after percutaneous pinning are rare but can be indolent and have permanent sequelae. We present cases of children presenting with late deep infections to discuss their diagnosis and treatment. Methods. After institutional review board approval, we retrospectively reviewed records of three children who developed deep infections at least one year after percutaneous pinning of their supracondylar humerus fracture. Patient details and outcomes were analyzed. Radiographs and magnetic resonance imaging were reviewed along with each patient’s clinical course and treatment. Results. We report 3 cases of osteomyelitis and/or septic arthritis presenting at least one year after supracondylar humerus fractures treated with closed reduction and percutaneous pinning. The patients required several irrigation and debridement procedures with placement of antibiotic beads in addition to a prolonged course of antibiotics. Conclusion. Delayed deep infections can occur after closed reduction and percutaneous pinning of supracondylar humerus fractures in children. Vigilance is required to diagnose and treat such occurrences, and prolonged follow-up is needed to monitor for recurrent or intractable infections.