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.

Tips and pitfalls of reduction and fixation in displaced supracondylar fractures in children

Supracondylar humeral fractures are the most common injury of the elbow in children. Compared to flexion type fractures, extension type fractures are more common, up to 98%. Gartland classification has been used to guide the management of this injury, which is based on the extent of the displacement. If not adequately managed, completely displaced (type III) fractures may have a higher incidence of concomitant injury or complications, including neurovascular injury, compartment syndrome, or cubitus varus. Closed reduction followed by percutaneous pinning has been suggested as the standard operative method for the displaced supracondylar humeral fractures. However, these fractures can be challenging to reduce, with the traditional technique of closed reduction. Lateral-entry pinning is known as a sufficient method of fixation for this injury. However, the lateral pin only fixation technique may also result in loss of reduction in some particular patterns of fractures, such as fractures with medial column comminution. We discuss and describe the reduction techniques of completely displaced supracondylar humeral fractures, including technical tips and pitfalls for closed reduction and open reduction. We also discuss indications of medial pinning, and its safe method, when the lateral-entry pins may not achieve adequate stability.

Emergency Treatment on Gartland Type III Pediatric Supracondylar Humeral Fractures: a Retrospective Analysis of Therapeutic Consequences of Surgery

Objective: The objective of this analysis was to investigate the effect of emergency treatment by simple reduction within 8 h of injury for Gartland type III pediatric supracondylar humeral fractures.Methods: One hundred twenty children with Gartland type III supracondylar humeral fractures were studied. All 120 patients had extension-type fractures and each was classified into one of two groups as follows: group A (n = 90), treated by closed reduction; group B (n = 30), treated by open reduction. Both groups underwent Kirschner wire internal fixation within 1 to 5 d after reduction. Information on the emergency treatments within 8 h of the fracture and the duration of the subsequent surgeries was collected and compared between the two groups. Results: There was no significant difference between the two patient groups in terms of the demographic parameters. Compared to non-emergency surgery, emergency surgery required shorter operation time and fewer complications (P<0.05). Nevertheless, the fracture healing time was significantly less (P＜0.05), and Flynn scores were higher in the closed reduction group compared to the open reduction group (P<0.05).Sixty-six of the 90 patients in group A received emergency treatment with an average subsequent surgery duration of 40 min. The remaining 24 patients did not receive emergency treatment and had an average surgery duration of 65 min. Of the 30 patients in group B, four received emergency treatment with a subsequent average surgery duration of 70 min. The remaining 26 patients did not receive emergency treatment and had an average surgery duration of 91 min. Conclusion: Emergency treatment by simple reduction within 8 h of fracture was important for subsequent surgical procedures and duration. Lack of this treatment could increase the risks during open reduction. Emergency treatment within 8 h of fracture could increase the healing rate and reduce the duration of the subsequent surgery.

COMPARISON OF TWO METHODS OF FIXATION OF SUPRACONDYLAR FRACTURES OF THE HUMERUS IN CHILDREN

ABSTRACT Objective: To compare the outcomes of the fixation of complete and displaced supracondylar humeral fractures in children with two different Kirschner wire configurations. Methods: The type of fixation was randomized to either crossed (19 cases), or two divergent lateral Kirschner wires (24 cases). The comparison was made six months later between the two treated groups and each group with the non-fractured elbow (clinical alignment, range of motion, Baumann angle, and lateral humeral capitellar angle). Results: 43 children were evaluated (65% boys) with a mean age of six years and five months. The carrying angle (p = 0.94), extension (p = 0.89), and the Flynn´s criteria (p = 0.56) were similar between the groups. The flexion was slightly smaller for the crossed wire group (p = 0.04), but similar to the uninjured side. The Baumann angle was not different between the two fixations (p = 0.79) and the contralateral side (p = 0.1). The lateral humeral capitellar angle was slightly greater for the lateral pinning (p = 0.08), but with no difference with the uninjured elbow (p = 0.62). No iatrogenic injuries were observed. Conclusion: Both fixations presented similar outcomes that did not significantly affect the carrying angle in relation to the non-fractured side. Level of evidence II, Therapeutic study - Investigating the results of treatment.

Efficacy of ultra-early rehabilitation on elbow function after Slongo’s external fixation for supracondylar humeral fractures in older children and adolescents

Objective To evaluate the efficacy of ultra-early rehabilitation on elbow function after Slongo’s external fixation for supracondylar humeral fractures in older children and adolescents. Methods We retrospectively analyzed clinical data from 49 older children (> 8 years) and adolescents with supracondylar humerus fracture who were treated with Slongo’s external fixation in our hospital from January 2016 to August 2020. Twenty-three patients received ultra-early postoperative rehabilitation (rehabilitation group) and 26 patients were not subjected to postoperative rehabilitation (control group). Time to ROM required for functional activity of daily living(ROM-ADL) in both groups was recorded postoperatively. Patients were followed up at 3 and 6 months after surgery to compare the elbow range of motion (ROM) and carrying angle (CA). Postoperative complications were assessed in both groups. Flynn scores and modified Mayo Elbow Performance Scores were also performed. Results The elbow function at 6 months after surgery was significantly better than that at 3 months in the control group (P = 0.32). Time to ROM-ADL in the rehabilitation group was significantly shorter than that of the control group (P = 0.028). The elbow function, Flynn scores, and modified Mayo scores in the rehabilitation group at 3 and 6 months after surgery were significantly better than that of the control group (P(ROM, 3 months and 6 months) = 0.012 vs 0.039; P(Flynn scores, ROM, 3 months and 6 months) = 0.028 vs 0.005; P(Flynn scores, CA, 3 months and 6 months) = 0.032 vs 0.026; P(Modified Mayo scores, 3 months and 6 months) = 0.039 vs 0.024; respectively). There were no iatrogenic injuries, secondary fracture displacements, myositis ossificans, elbow deformities, or other complications in either group. One case of nail tract infection occurred in the rehabilitation group and was cured. Conclusion Slongo’s external fixation is a safe and effective surgical treatment for supracondylar humeral fractures in children over 8 years old and adolescents. Ultra-early rehabilitation treatment for postoperative children can significantly speed up the recovery after surgery.