Comparison of Outcome of Three Different Approaches for Supracondylar Humerus Fractures in Children

Objective: The aim of this study is compare the outcomes among three different approaches (lateral approach, medial approach and posterior approach) for supracondylar humerus fractures in children. Study Design: Retrospective cohort study Place and Duration: The study was conducted at Orthopedics department of Ayub Teaching Hospital, Abbottabad for duration of one year from January 2020 to December 2020. Methods: There were one hundred and thirty five children had supracondylar humerus fracture were presented. Patients were aged between 3-12 years. Informed written consent was taken from authorities for detailed demographics age, sex, cause of fracture and side of fracture. Patients were categorized into three equal groups, group A had 45 patients and received lateral approach, group B had 45 patients and received medial approach and group C received posterior approach with 45 cases. Shaft Condylar Angle (SCA) and Baumann angle were used to analyze the radiological result. All children were assessed using Flynn's criteria for functional outcomes, and the results were divided into Excellent, Good, Fair and Poor. Post-operative outcomes among all the three groups were calculated and compared. SPSS 23.0 version was used to analyze complete data. Results: There were 90 (66.7%) males (30 in each group and 45 (33.3%) females (15 in each group). In group A mean age was 6.88±5.45 years, mean age in group B was 7.11±5.33 years and in group C mean age was 7.17±5.66 years. Sports 85 (62.9%) was the most common cause of fracture followed by traffic accidents 30 (22.2%) and the rest were 20 (14.8%) fall from the height. According to radiological outcomes, Mean shaft condylar Angle in group A was 41.5±6.3, in group B was 41.8±1.9 and in group C was 40.1±3.8 respectively (P>0.05). Mean Bauman angle in group A was 18.8±6.11, group B was 19.4±7.5 and in group C 20.4±5.3 with (P>0.05). According to Flynn’s criteria, excellent outcomes were observed in 33 (73.3%) in LA group, 24 (53.3%) in MA group and 22 (48.9%) in PA group, good results were observed in 11(24.4%), 19 (42.2%) and 21 (46.7%), fair outcomes in 1 (2.2%), 2 (4.4%) and 2 (4.4%). Conclusion: As a result of this research, we have concluded that the lateral technique for supracondylar fractures is superior to the medial or posterior approaches in terms of radiological and functional results. However, there was no statistically significant difference between the three groups. Keywords: Supracondylar fractures, Flynn’s criteria, Functional outcome, Open reduction

Anatomical Study for the Treatment of Proximal Humeral Fracture Through the Medial Approach

Background: The treatment of complex 3- and 4- part proximal humeral fractures has been controversial due to numerous postoperative complications. With the further study of medial support and blood supply of humeral head, new techniques and conception are developing. The study aims to illustrate the medial approach of the proximal humeral fracture through cadaver autopsy.Method: Upper limbs from 19 cadavers have been dissected to expose the shoulder joint. We selected the coracoid process as the bony reference. Vernier caliper will be used to measure the following data, including distance from coracoid process to circumflex brachial artery, distance between anterior humeral circumflex artery (ACHA) and posterior circumflex brachial artery (PCHA) and their diameters. Assessment included the characteristics of the vascular supply around the humeral head, identification of the structures at risk, quality of exposure of the bony structures, and feasibility of fixation.Results: Medial plate can be easily placed in 86.84% anatomical patterns. An interval of 2 to 3cm (24.29 ± 3.42 mm) was available for internal fixation. ACHA (49.35 ± 8.13 mm, 35.14 - 68.53 mm) and PCHA (49.62 ± 7.82 mm, 37.67 - 66.76 mm) were about 5cm away from the coracoid process. Risk factors including ACHA and PCHA originate in common, PCHA originated from the deep brachial artery (DBA), the presence of perforator vessels; musculocutaneous nerve intersects with ACHA, the diameter of PCHA: ACHA < 1.5. In 13.15% anatomical patterns, this risk factor should be taken seriously. Conclusion: The medial approach opens a new perspective in the optimal management of complex fractures of proximal humerus. Anatomical research proves that the medial approach is feasible. The interval between ACHA and PCHA is suitable for placement. Anatomical pattern and indication have been discussed, and we hypothesized that ACHA has been destroyed in complex PHFs. With further studies on the anatomy and mechanism of injury, the development of more clinical cases will be an important work of our institution in the future.

Functional Popliteal Artery Entrapment Syndrome: An Approach to Diagnosis and Management

Popliteal Artery Entrapment Syndrome (PAES) is an uncommon syndrome that predominantly affects young athletes. Functional PAES is a subtype of PAES without anatomic entrapment of the popliteal artery. Patients with functional PAES tend to be younger and more active than typical PAES patients. A number of differential diagnoses exist, the most common of which is chronic exertional compartment syndrome. There is no consensus regarding choice of investigation for these patients. However, exercise ankle-brachial indices and magnetic resonance imaging are less invasive alternatives to digital subtraction angiography. Patients with typical symptoms that are severe and repetitive should be considered for intervention. Surgical intervention consists of release of the popliteal artery, either via a posterior or medial approach. The Turnipseed procedure involves a medial approach with a concomitant release of the medial gastrocnemius and soleal fascia, the medial tibial attachments of the soleus and excision of the proximal third of the plantaris muscle. Injection of botulinum A toxin under electromyographic guidance has recently shown promise as a diagnostic and/or therapeutic intervention in small case series. This review provides relevant information for the clinician investigating and managing patients with functional PAES.

Comparison of the Posterior-anterior Approach and Lateral-medial Approach for Complex AO/OTA Type C Intra-articular Fractures of Distal Humerus

Objective: The aim of this retrospective study was to investigate clinical effects of the treatment of intra-articular distal humeral fractures via the combined posterior olecranon osteotomy and anterior approach and the combined lateral Kaplan approach associated with the medial approach. Methods: Between July 2010 and September 2019, 28 cases of intercondylar fractures of the distal humerus (AO/OTA type C) were treated by open reduction and internal fixation (ORIF) via the posterior and anterior approach and combined lateral-medial approach, which were divided into the P-A (n = 13) and L-M (n = 15) groups, respectively. The outcomes in terms of function were assessed using the range of motion (ROM) of the elbow and forearm, humerotrochlear (HT) angle, Visual Analogue Scale (VAS) scores, Mayo Elbow Performance Score (MEPS), and efficacy grade evaluated using the scoring system of Orthopaedic Trauma Association (OTA) at the one-year follow-up. Results: The flexion-extension of elbows and pronation-supination of forearms were respectively 114.1° ± 12.4° and 157.3° ± 9.6° in the P-A group and 117.1° ± 14.5° and 161.3° ± 10.7° in the L-M group. No significant difference was observed between the two groups for the elbow and forearm ROM (p > 0.05). Furthermore, surgery duration, blood loss volume, HT angle, MEPS, VAS scores, OTA rating, and the morbidity of postoperative complications during the one-year follow-up did not differ between groups. Conclusion: The posterior olecranon osteotomy and anterior approach can be used efficiently for exposure of complex distal humeral injuries with similar clinical efficacy and complications in the treatment of intra-articular distal humeral fractures as compared to the lateral-medial approach.