Management of Supracondylar Humeral Fracture in Children / Manejo da fratura supracondiliana do úmero na criança

Abstract Supracondylar humeral fracture represents ~ 3 to 15% of all fractures in children. It is the fracture that most requires surgical treatment in the pediatric population. Advances in treatment and care have contributed to a reduction in the most dramatic complication: Volkmann ischemic contracture. Nevertheless, the risks inherent to the fracture remain. Absence of palpable pulse in type-III fractures is reported in up to 20% of the cases. Careful sensory, motor, and vascular evaluation of the affected limb is crucial in determining the urgency of treatment. Older children, male patients, floating elbow, and neurovascular injury are risk factors for compartment syndrome. Medial comminution can lead to varus malunion, even in apparently innocent cases. The recommended treatment of displaced fractures is closed reduction and percutaneous pinning. Technical errors in pin placement are the main cause of loss of reduction. There is enough evidence for the addition of a third lateral or medial Kirschner wire in unstable fractures (types III and IV). Medial comminution may lead to cubitus varus even in mild displaced fractures. Based on current concepts, a flowchart for the treatment of supracondylar humeral fracture in children is suggested by the authors.

Resumo A fratura supracondiliana do úmero representa cerca de 3 a 15% de todas as fraturas na criança, sendo a que mais requer tratamento cirúrgico na população pediátrica. Apesar de os avanços no tratamento e na assistência terem contribuído para uma redução drástica da complicação mais temida, a contratura isquêmica de Volkmann, os riscos inerentes à fratura permanecem. Ausência de pulso palpável em fraturas tipo III é reportada em até 20% dos casos. Uma cuidadosa avaliação sensitiva, motora e vascular do membro acometido é fundamental na determinação da urgência do tratamento. Crianças mais velhas, sexo masculino, cotovelo flutuante, e lesão neurovascular são fatores de risco para a síndrome de compartimento. A cominuição medial pode levar à consolidação em varo, mesmo nos casos aparentemente inocentes. O método de escolha para o tratamento da fratura desviada é a redução fechada e fixação percutânea. Os erros na fixação e posicionamento inadequado dos implantes são as principais causas de perda de redução. Já existem evidências suficientes para a utilização de um terceiro fio de Kirschner, lateral ou medial, nas fraturas instáveis (tipo III e IV). Baseado nos conceitos atuais, um fluxograma para o tratamento da fratura supracondiliana do úmero na criança é sugerido pelos autores.

Management of Dislocation of the Shoulder Joint with Ipsilateral Humeral Shaft Fracture: Initial Experience.

OBJECTIVE: To gain a better understanding of the traumatic mechanism and to develop appropriate treatment for dislocation of the shoulder joint with an ipsilateral humeral shaft fracture. METHODS: This was an observational and descriptive study. Nine patients with traumatic shoulder dislocations associated with ipsilateral humeral shaft fractures who visited the emergency room and received treatment from January 2012 to June 2018 were retrospectively analyzed. CT with three-dimensional reconstruction was performed to provide precise anatomical information of the fractures. The traumatic event and the type of fracture of the humeral shaft were analyzed to help determine the trauma mechanism. Closed reduction of the dislocation was attempted at once under intravenous anesthesia. One patient died the following day due to unrelated causes. All humeral shaft fractures of the eight patients received internal fixation, and then reduction of the dislocation was performed again if previous attempts failed. The affected limb was immobilized in a sling for 3 weeks postoperatively, and then active and passive movement was encouraged. Patients were evaluated based on clinical and radiographic examinations, shoulder joint range of motion, Constant-Murley score, and subjective shoulder value. RESULTS: Four cases in the present study could not give a clear description of the traumatic procedure. The other five patients suffered a second strike on their upper arms when they were hurt, with low mobility and high pain in the shoulder region. Seven cases were simple fractures and two were wedge fractures. According to the AO/OTA classification system, four cases were type 12-A2, three were type 12-A3, and two were type 12-B2. Six patients successfully obtained closed manipulative reduction of the shoulder dislocation in the acute stage. The follow-up time ranged from 18 to 31 months. No deep wound infections were encountered. All fractures healed uneventfully. The union time ranged from 4 to 6 months. At the final follow-up, shoulder range-of-motion values were found to range from 140° to 170° forward flexion, 30° to 40° extension, 40° to 45° adduction, 150° to 170° abduction, 50° to 60° internal rotation, and 50° to 60° external rotation; no recurrent instability of the shoulder joint occurred; the Constant-Murley score was 89.5 ± 3.7 points (range: 84-94 points); the subjective shoulder value was 89.4% ± 6.3% (range: 75%-95%). CONCLUSION: Shoulder dislocation most likely occurs first with an axial force or a direct posteroanterior force and a subsequent force results in the shaft fracture. For patients with mid-distal humerus fractures, closed manipulative reduction of the joint is usually effective. After success of closed reduction, surgery for the humeral shaft fracture is advocated to ensure stability and to make patient nursing convenient. In cases with fractures in the proximal third of the humeral shaft, fixation is suggested beforehand to help reduce the shoulder dislocation.

Health-related quality of life after paediatric supracondylar humeral fractures.

AIMS: We aimed to evaluate the health-related quality of life (HRQoL) in children with supracondylar humeral fractures (SCHFs), who were treated following the recommendations of the Paediatric Comprehensive AO Classification, and to assess if HRQoL was associated with AO fracture classification, or fixation with a lateral external fixator compared with closed reduction and percutaneous pinning (CRPP). METHODS: We were able to follow-up on 775 patients (395 girls, 380 boys) who sustained a SCHF from 2004 to 2017. Patients completed questionnaires including the Quick Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH; primary outcome), and the Pediatric Quality of Life Inventory (PedsQL). RESULTS: An AO type I SCHF was most frequent (327 children; type II: 143; type III: 150; type IV: 155 children). All children with type I fractures were treated nonoperatively. Two children with a type II fracture, 136 with a type III fracture, and 141 children with a type IV fracture underwent CRPP. In the remaining 27 children with type III or IV fractures, a lateral external fixator was necessary for closed reduction. There were no open reductions. After a mean follow-up of 6.3 years (SD 3.7), patients with a type I fracture had a mean QuickDASH of 2.0 (SD 5.2), at a scale of 0 to 100, with lower values representing better HRQoL (type II: 2.8 (SD 10.7); type III: 3.3 (SD 8.0); type IV: 1.8 (SD 4.6)). The mean function score of the PedsQL ranged from 97.4 (SD 8.0) for type I to 96.1 (SD 9.1) for type III fractures, at a scale of 0 to 100, with higher values representing better HRQoL. CONCLUSION: In this cohort of 775 patients in whom nonoperative treatment was chosen for AO type I and II fractures and CRPP or a lateral external fixator was used in AO type III and IV fractures, there was equally excellent mid- and long-term HRQoL when assessed by the QuickDASH and PedsQL. These results indicate that the treatment protocol followed in this study is unambiguous, avoids open reductions, and is associated with excellent treatment outcomes. Cite this article: Bone Joint J 2020;102-B(6):755-765.

Management of distal humerus fractures.

Distal humeral fractures represent approximately 2% of fractures in adults and are often treated operatively to restore stable humeral columns and allow early elbow motion. Diagnosis is made with orthogonal radiographs. The traction view radiograph and computed tomography with three-dimensional reconstruction can be helpful in preoperative planning. Treatment options include: (1) nonoperative management, which is reserved for lower-demand, medically unwell, elderly patients, (2) surgical osteosynthesis, which remains the treatment of choice for most fractures, and (3) prosthetic replacement with either hemiarthroplasty or total elbow arthroplasty, which is indicated for distal complex comminuted fracture patterns in elderly, low-demand patients with poor bone quality. A thorough understanding of the anatomy around the elbow is critical when planning surgical approach and reduction. Controversies exist in the following areas: (1) surgical approach, (2) management of the ulnar nerve, (3) plating technique-parallel versus orthogonal, and (4) whether osteosynthesis or prosthetic elbow replacement is superior in the elderly population.

Retrospective study of open reduction and internal fixation of lateral humeral condyle fractures with absorbable screws and absorbable sutures in children.

BACKGROUND: Lateral humeral condyle fractures are the second most common elbow fracture in children. Displaced and rotated fractures require stabilization and reduction. Kirschner wires (K-wires) are most commonly used in the fixation of these fractures. Here, we introduce a new fixation method that uses an absorbable screw. We aim to determine if it is feasible to treat lateral humeral condyle fractures with an absorbable screw by comparing functional outcomes following absorbable screw fixation vs. K-wire fixation. METHODS: Between May 2007 and September 2010, 86 patients were treated with absorbable screws (43 patients) or K-wire (43 patients). All patients had been diagnosed with lateral condyle fractures that were classified as either Jacob type II (unstable) or III. One absorbable screw (3.5 mm-diameter) was used for fixation in 1 group, while two 1.6 to 1.8 mm K-wires were used in the other group. Patients were followed 6 months about the elbow function according to Broberg and Morrey standard. On 5-7 years, the patients were followed about the carrying angle (valgus deformities and varus deformities), range of motion (flexion loss and extension loss), prominent lateral condyle, symptomatic implants, and fishtail deformity. RESULTS: Anatomic reduction was achieved in all patients. Each group had one radial nerve injury that were present preoperatively. Nerve function recovered spontaneously within 3 to 4 weeks of surgery in both patients. No patient developed necrosis of the capitulum in both groups. Nine patients in K-wires group and 2 in absorbable screw group developed symptomatic implants (P = .048). On the sixth month, there was no significant difference on elbow function according to Broberg and Morrey standard. On 5 to 7 years (average, 6.7 ±â€Š1.3 years), valgus deformities was 6.8 ±â€Š1.2 vs 5.7 ±â€Š0.8, varus deformities was 7.2 ±â€Š1.5 vs 5.1 ±â€Š1.9, flexion loss was 12.4 ±â€Š2.2 vs 9.5 ±â€Š3.1, extension loss was 11.1 ±â€Š3.1 vs 10.2 ±â€Š2.7, prominent lateral condyle was 27.9% vs 37.2%, fishtail deformity was 7.3% vs 4.9%, no significant difference between these groups. CONCLUSIONS: Open reduction with absorbable screw fixation is feasible and safe for the treatment of lateral condyle fractures of the humerus in children. LEVEL OF EVIDENCE: Therapeutic III.

Auxiliary Kirschner wire technique in the closed reduction of children with Gartland Type III Supracondylar humerus fractures.

This study aimed to investigate the effect of auxiliary Kirschner wire (K-wire) technique in the closed reduction of children with Gartland type III supracondylar humerus fractures by comparing with manual reduction alone.Retrospective analysis was performed on the clinical data of 68 cases of supracondylar humerus fractures. Thirty-six patients received closed reduction and percutaneous fixation with auxiliary K-wire technique (group A). Thirty-two patients received conventional manual reduction and percutaneous pin fixation (Group B).In group A, the average operation time was 20.5 ±â€Š8.5 minutes, the average frequency of intraoperative radiographic observations was 4.3 ±â€Š1.1, the average fracture healing time was 6.2 ±â€Š1.8 weeks, and the complication rate was 3/36, 8.3%. The mean operation time was 36.1 ±â€Š10.2 minutes, the average frequency of intraoperative radiography was 8.9 + 1.7 times, the average fracture healing time was (6.1 ±â€Š1.6) weeks, and the complication rate was 2/32, 6.3%. The operation time in group A was significantly shorter than that in group B. The difference between the 2 groups was statistically significant (P = .012). The frequency of radiography in group A was significantly less than that in group B (P = .001).Compared with manual reduction, auxiliary K-wire technology can significantly shorten the operation time, reduce the radiant quantity of the surgeon, improve the efficiency of closed reduction of children with Gartland type III supracondylar humerus fractures, and reduce the risk of developing postoperative complications. And meanwhile, there is no significant effect on the imaging and functional outcomes of affected extremities, which is worthy of respect.

Operative Time and Cost Vary by Surgeon: An Analysis of Supracondylar Humerus Fractures in Children.

Operative time is a critical driver of cost in orthopedics and an important target for improving value in health care. This study used an archetypal pediatric orthopedic procedure to identify surgeon-dependent variability in operative time. The authors reviewed patients 12 years or younger treated with closed reduction and percutaneous pinning for extension-type supracondylar humerus fractures. Variability in operative time across surgeons was assessed. Surgeon experience at the time of the procedure and case volume (quarterly) were evaluated to explain variations in operative time. A total of 1472 patients were reviewed (57% Gartland type II and 43% type III fractures). Procedures were performed by 12 fellowship-trained pediatric orthopedists with 2 weeks to 32.8 years of experience. For individual surgeons, the mean operative time ranged from 20.4 to 33.7 minutes for type II fractures and from 31.0 to 46.8 minutes for type III fractures. There was significant variation across surgeons in mean operative time and cost (P<.001). Analysis showed no significant effect of surgeon experience or quarterly case volume. Surgeons' mean operative time for type II fractures was strongly positively correlated with their mean operative time for type III fractures (r2=0.74). Mean operative time and cost for supracondylar humerus fracture closed reduction and percutaneous pinning vary significantly between surgeons, but this variation is not explained by experience or volume. Surgeons who required more time for type II fractures were also slower for type III fractures. Because of the high per minute cost of the operating room, surgeon variability significantly impacts cost. Identification and modification of sources of variation in surgeon behavior will allow for reduction in the cost of surgical care. [Orthopedics. 2019; 42(3):e317-e321.].

Sliding the Medial Pin: A Safer Approach to Cross-pinning Humerus Supracondylar Fractures?

INTRODUCTION: Many methods have been described to minimize the risk of ulnar nerve injury during the insertion of a medial pin for the percutaneous pinning of pediatric supracondylar humerus fractures (SCHF). The most recent AAOS Clinical Practice Guidelines suggests that physicians might want to avoid the use of medial-entry pins due to considerations of potential injury to the ulnar nerve. However, there are circumstances whereby a cross pin configuration is required. These include cases where there is medial wall comminution or due to the obliquity of the fracture. In this study, we present a group of patients with SCHF in which the medial pin was inserted using a new technique. MATERIALS AND METHODS: This is a retrospective case series approved by the local centralized institutional review board. The medical records of all patients who underwent closed reduction and percutaneous pinning for SCHF using a new technique-the sliding method-by a single pediatric orthopedic surgeon from August 2017 till January 2018 were reviewed. Patient demographics, fracture type, operative time, postoperative Baumann's angle, postoperative lateral capitellohumeral angle, and the rate of ulnar nerve palsy were recorded. RESULTS: This new technique was used in a total of 35 patients. Two patients were excluded as one had multiple same limb injuries, while another had a Gustilo 3A humerus supracondylar fracture. The average patient age at the time of surgery was 6.2 years (range: 2 to 12 y). There were 22 children with Gartland grade 3 fractures, 10 with grade 2b fractures, and 1 had a flexion type fracture. The average operative time was 21 minutes (range: 7 to 58 min). The average postoperative Baumann's angle was 73.9 degrees (range: 63.8 to 79.6 degrees) and the average postoperative lateral capitellohumeral angle was 44.6 degrees (range: 31.1 to 56.8 degrees). There were no cases of ulnar nerve palsy. CONCLUSIONS: The sliding method is a novel technique of protecting the ulnar nerve during closed reduction percutaneous pinning of SCHF. LEVEL OF EVIDENCE: Level IV.

Is the "Appropriate Use Criteria" for Type II Supracondylar Humerus Fractures Really Appropriate?

INTRODUCTION: The Appropriate Use Criteria for the treatment of supracondylar humerus fractures (SCHFs), developed by American Academy of Orthopaedic Surgeons, recommends pinning for all type II SCHFs. However, previous studies have suggested that, with close follow-up some of the less severe type II SCHF's can be successfully treated without surgery. Our purpose was to analyze data collected prospectively on a large cohort of type II SCHF's. METHODS: We reviewed clinical and radiographic information on all type II pediatric SCHF (n=1120) that were enrolled in a prospective registry and were followed for a minimum of 8 weeks. The characteristics of the patients who were treated without surgery were compared with those of patients who were ultimately treated surgically. Treatment outcomes, as assessed by the final clinical and radiographic alignment, range of motion of the elbow, and complications were compared between the groups to define clinical and radiographic features that related to success or failure of nonoperative management. RESULTS: Ultimately, 812 fractures (72%) were treated nonoperatively, and 309 fractures (28%) were treated surgically. At final follow-up, outcome measures of change in carrying angle, range of motion, and complications did not show clinically significant differences between treatment groups. Binary logistic regression analysis indicated that initial radiographic features, specifically rotational deformity, varus malalignment, valgus malalignment, and a shaft-condylar angle of <30 degrees were strongly related to selection for surgery. Patients with isolated extension deformity, but none of the other features, were more likely to complete successful nonoperative management. CONCLUSIONS: Pinning all type II SCHF, as recommended by the Appropriate Use Criteria, would have resulted in unnecessary surgery in 72% of patients in this series. Given the wide range of injury severity within the type II category of SCHF, better discrimination of factors commonly associated with successful nonoperative treatment is required. In this particular series, fractures with an isolated extension deformity (without rotational or coronal malalignment) were more likely to complete successful nonoperative management.

Reliability of the Anterior Humeral Line Index Compared With the Gartland Classification for Posteriorly Hinged Supracondylar Humerus Fractures.

The Gartland classification of pediatric supracondylar humerus (SCH) fractures is commonly used but inconsistently defined regarding type 1 and type 2 (posteriorly hinged) SCH fractures. This study examined the reliability of the anterior humeral line (AHL) index compared with the Gartland classification. Fifty consecutive SCH fractures on anteroposterior and lateral elbow radiographs in pediatric patients (age range, 18 months to 15 years) were classified by 11 observers (9 attendings and 2 residents) according to the Gartland classification (types 1, 2, and 3) and the AHL index (AHL0, AHL passes anterior to the capitellum; AHL1, anterior one-third capitellum; and AHL2, middle one-third capitellum), with recommendations for treatment (cast immobilization vs surgery). Five attendings repeated the evaluation 4 to 6 weeks later. Interobserver and intraobserver reliability were scored using kappa statistics. Interobserver agreement for AHL with AHL1 and AHL2 combined (AHL1/2) was substantial (kappa=0.68) and moderate (kappa=0.55) when differentiating between AHL1 and AHL2. Anterior humeral line intraobserver reliability was almost perfect (kappa=0.83). Overall interobserver agreement on Gartland fracture type was fair (kappa=0.36), with type 2 fractures having the lowest (kappa=0.27), and with substantial (kappa=0.71) intraobserver reliability. For treatment, the interobserver agreement was fair (kappa=0.39), with substantial intraobserver reliability (kappa=0.72). Observers agreed more when using the AHL index than when using the Gartland classification. Observers differed on the degree of extension in posteriorly hinged SCH fractures that requires closed reduction. The AHL index is a more consistent method than the Gartland classification in differentiating posteriorly hinged SCH fractures and may be useful in guiding treatment. [Orthopedics. 2018; 41(4):e502-e505.].

The impact of associated injuries and fracture classifications on the treatment of capitellum and trochlea fractures: A systematic review and meta-analysis.

BACKGROUND: Capitellum and trochlea fractures are truly rare and the treatment is not fully appreciated. So we evaluate the impact of associated injuries and fracture classifications on elbow functional outcomes after open reduction and internal fixation. MATERIALS AND METHODS: PubMed, Embase, Ovid Medline, and the Cochrane Library were searched from January 1, 1974 to January 1, 2017. All English literature with the treatment of capitellum and trochlea fractures by open reduction and internal fixation were included. RESULTS: For associated injuries, the results suggested that the MEPI score of patients without associated injuries was higher than that of patients with associated injuries (P = 0.001). However, there was no significant difference in the arc of motion between the two groups (P = 0.052). For Bryan and Morrey classification, there was no significant difference in the MEPI score (P = 0.622) and in the arc of motion (P = 0.652) between type-I fractures and type-IV fractures. For Dubberley classification, there was significant difference only in the MEPI score between subtype-A fractures and subtype-B fractures (P = 0.005). CONCLUSION: The associated injury of fracture may have a negative impact on the functional outcomes of elbow. And Dubberley classification is more suitable to classify this kind of fracture. Furthermore, high-quality studies are required to attain robust evidence.

Cross-sectional study of Gartland II and III humerus supracondylar fracture treatment in childhood: Brazilian orthopedists' opinion / Estudo transversal sobre o tratamento das fraturas supracondilianas do úmero na infância dos tipos Gartland II e III: opinião do ortopedista brasileiro

ABSTRACT Objective: This study is aimed at determining, through a cross-sectional study, the preferred therapeutic method in Brazil considering the approach to Gartland type II and III supracondylar humerus fractures during childhood. Methods: The research project was approved by the Research Ethics Committee of Plataforma Brasil and the material was collected during the 46th Brazilian Orthopedics and Traumatology Congress. A questionnaire was developed to analyze two clinical scenarios about Gartland type II and III fractures. Results: The sample consisted of 301 questionnaires obtained from 5500 participants of the Congress who met the inclusion and non-inclusion criteria. In case 1, the following was observed: 140 (46.5%) of physicians opted for closed reduction with immobilization and 116 (38.5%) selected closed reduction and osteosynthesis, of whom 82 (70.7%) preferred two crossed Kirschner wires. In case 2, 294 (97.7%) considered that the treatment is urgent, and 225 (74.8%) of the interviewed orthopedists answered that they perform osteosynthesis with two crossed Kirschner wires. Conclusions: The opinion of orthopedic surgeons in Brazil varies for Gartland type II fractures. Type III fractures have a uniform conduct and they are treated urgently (97.7%). When osteosynthesis is necessary, it was observed that 82 (70.7%) and 225 (74.8%) of the interviewed surgeons opted for fixation with two crossed Kirschner wires.

RESUMO Objetivo: Este trabalho teve como objetivo determinar, num estudo transversal, qual é o método terapêutico preferencial usado no Brasil quando são abordadas as fraturas supracondilianas do úmero na infância dos tipos II e III da classificação de Gartland. Métodos: O projeto de pesquisa foi aprovado pelo Comitê de Ética em Pesquisa da Plataforma Brasil e o material foi coletado durante o 46° Congresso Brasileiro de Ortopedia e Traumatologia. Elaboramos um questionário para averiguar a conduta nas duas situações clínicas de fraturas do tipo Gartland II e III. Resultados: A amostra constou de 301 questionários obtidos de 5.500 participantes do Congresso que contemplaram os critérios de inclusão e não inclusão. Para o caso 1 observamos que 140 (46,5%) médicos optam pela redução incruenta e imobilização e 116 (38,5%), pela redução incruenta e osteossíntese, dos quais 82 (70,7%) preferem a osteossíntese com dois fios de Kirschner cruzados. Para o caso 2, 294 (97,7%) entrevistados consideram que essas lesões devam ser abordadas na urgência, na qual 225 (74,8%) fazem a osteossíntese com dois fios de Kirschner cruzados. Conclusões: A opinião do ortopedista no Brasil varia para as fraturas do tipo II. Para as do tipo III, observamos que existe uma conduta uniforme, pois essas são tratadas na urgência (97,7%). Quando é necessária a osteossíntese, observamos que 82 (70,7%) e 225 (74,8%) dos entrevistados optam pela fixação com dois fios de Kirschner cruzados.

Paediatric lateral condyle fractures: a systematic review.

INTRODUCTION: Lateral condyle fractures of the humerus are common paediatric fractures. However, no conclusive statement has been made about their risk of complications, the management and epidemiology. MATERIALS AND METHODS: A systematic review was conducted according to PRISMA guidelines. All studies with paediatric lateral condyle fracture were included, with 2440 children. RESULTS: Most fractures had union, with 0.9% delayed union, 1.6% non-union and 1.5% malunion. Complications included valgus deformities (6.1%), varus deformities (7.8%), flexion loss (9.7%), extension loss (11.5%), prominent lateral condyle (27.3%), fishtail deformity (14.3%), avascular necrosis (1.7%), premature epiphyseal closure (5.4%) and neurological deficits (10.6%). Risk factors of complications include concomitant ipsilateral upper limb fractures, classification by Milch or Jakob, fracture displacement, fixation device, and inappropriate diagnosis and management. CONCLUSIONS: It is recommended for fractures that are non-displaced on all radiographic views to be managed conservatively, while displaced fractures of > 2 mm requires surgical intervention. Minimally displaced fractures could be treated conservatively, though follow-up is recommended to detect displacement. Radiographs are also recommended at 1-week follow-up, with serial radiographs having no clinical significance. Kirschner wires or lag screws could be employed, and it is recommended that the Kirschner wires be left exposed and removed when there is clinical and radiographic evidence of fracture consolidation, typically at the 6-week interval. These fractures need close follow-up.

Humeral shaft fractures.

Fractures of the humeral shaft are common injuries with multiple management strategies. Many still regard nonoperative management as the standard of care; however, as the understanding of these injuries increases, treatment recommendations are also evolving. Fracture pattern, fracture location, and identifiable patient risk factors may predict poor outcome with nonoperative management, and earlier operative intervention may be recommended. Operative management includes open reduction and internal fixation through a variety of exposures, intramedullary nail fixation, and external fixation. With increasing rates of shoulder arthroplasty, periprosthetic humeral shaft fractures also deserve special consideration.

Soft Tissue Injury Severity is Associated With Neurovascular Injury in Pediatric Supracondylar Humerus Fractures.

BACKGROUND: Neurovascular injury in pediatric supracondylar fractures (SCHFx) has been associated with fracture classification but not with soft tissue injury. The purpose of this study is to correlate clinical soft tissue damage to neurovascular injuries in SCHFx. METHODS: This is an institutional review board approved prospective study from January 2010 through December 2013 of 748 operatively treated pediatric SCHFx. Prospective data were gathered both preoperatively and intraoperatively regarding detailed neurovascular examination as well as soft tissue status, with qualitative descriptives for swelling (mild/moderate/severe), ecchymosis, abrasions, skin tenting, and skin puckering. RESULTS: A total of 7.8% of patients (41/526) had a nonpalpable radial pulse preoperatively. Compared with those with a palpable pulse, a nonpalpable pulse was associated with severe elbow swelling (P<0.0001), tenting (P=0.0085), puckering (P=0.0011), ecchymoses (P<0.0001), and open fracture (P=0.044). Ten patients had a loss of a palpable pulse from initial orthopaedic consult to time of surgery, and when compared with the patients who did not have a loss of pulse, this was associated with swelling severity (P=0.0001) and ecchymosis (P=0.053). A total of 14% of patients (71/526) had a neurological injury preoperatively, and this was associated with severe elbow swelling (P<0.0001), tenting (P=0.0008), puckering (P=0.0077), and ecchymoses (P<0.0001) when compared with patients who did not have a neurological injury. In total, 17 patients had a decline in their neurological examination from the time of initial orthopaedic consult to the time of surgery, and this was associated with severe elbow swelling (P=0.0054) and ecchymoses (P=0.011). After multivariate logistic regression analysis, severe swelling and ecchymoses were significantly associated with a nonpalpable pulse as well as neurological injury (P<0.05). No patient had compartment syndrome. CONCLUSIONS: Soft tissue injury, as measured by swelling, ecchymosis, puckering, and tenting, had a clinically significant association with neurovascular compromise in pediatric SCHFx, and assessment of soft tissue injury is as important as the radiographic appearance when examining these patients. The physical examination signs of soft tissue injury may play a factor in determining urgency of surgical treatment in these fractures. LEVEL OF EVIDENCE: Level II-therapeutic.

Capitellar Fractures in Children and Adolescents: Classification and Early Results of Treatment.

BACKGROUND: There has been limited published information regarding capitellar fractures in the pediatric population. The purpose of this investigation was to characterize capitellar fracture patterns in children and adolescents and to assess early clinical and radiographic treatment outcomes. METHODS: A retrospective analysis of 37 children and adolescents with capitellar fractures presenting to a tertiary pediatric hospital from 2004 to 2014 was performed. The mean patient age at the time of injury was 11.8 years. Medical records and radiographs were evaluated for fracture pattern, treatment, healing, and complications. Fractures were categorized on the basis of prevailing patterns of injury, and a classification system is proposed that aids in treatment decision-making. Thirty-two patients had follow-up of at least 6 weeks and were included for assessment of treatment outcomes. The mean follow-up was 12.3 months. RESULTS: Three predominant capitellar fracture patterns were identified. Type-I fractures (n = 25) were anterior shear injuries. Nondisplaced anterior shear fractures were successfully treated with cast immobilization. Displaced anterior shear fractures were treated with open reduction and internal fixation, with good results in a majority of patients. Of the 21 patients with Type-Ib fractures eligible for analysis, 6 (29%) required a secondary surgical procedure for loss of motion related to soft-tissue contracture, osteonecrosis, implant prominence, and/or intra-articular loose bodies. Type-II fractures (n = 9) were posterolateral shear injuries, typically associated with ulnohumeral dislocations. Among 5 patients with displaced fractures and adequate follow-up, 3 patients were treated nonoperatively and had poor results, with loss of elbow motion or mechanical symptoms, and 2 patients were treated surgically and achieved good functional restoration. Type-III fractures (n = 3) were acute chondral shear injuries, which achieved full restoration of motion after surgical treatment. CONCLUSIONS: A classification of pediatric capitellar fractures is proposed, guiding treatment and prognosis. Nondisplaced fractures heal successfully with cast immobilization. Good results may be expected with surgical fixation of displaced Type-I fractures (anterior shear). Type-II fractures (posterolateral shear) and Type-III fractures (chondral shear) are more subtle; advanced imaging and timely surgical management for displaced injuries are recommended to optimize clinical results. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

The Utility of Routine Postoperative Radiographs After Pinning of Pediatric Supracondylar Humerus Fractures.

BACKGROUND: The purpose of this study was to determine the frequency with which postoperative radiographs resulted in a change in management following closed reduction and percutaneous pinning of displaced pediatric supracondylar humerus fractures. We hypothesize that only the initial postoperative radiograph will lead to changes in management of operative supracondylar humerus fractures. METHODS: A retrospective review was performed at 2 level I pediatric trauma centers. Inclusion criteria were patients below 18 years of age who sustained supracondylar humerus fractures (Gartland type II, III, IV) who were operatively treated from 2008 to 2013 with adequate radiographic follow-up. Patients with flexion type, intra-articular, transphyseal, and open fractures were excluded from the study. Routine radiographs were taken at initial follow-up (1 wk postoperatively) and at pin removal (3 to 4 wk postoperatively). RESULTS: The final analysis included 572 patients. Initial postoperative radiographs changed treatment in 9 patients (1.6%), including revision surgeries, 2 pin adjustments, and 2 early pin removals. At the time of pin removal, 20 (3.5%) patients required further immobilization. There were no changes to the initial plan for continued nonoperative treatment at final follow-up (6 to 8 wk postoperatively). CONCLUSIONS: In this large retrospective series of patients treated with closed reduction and percutaneous pinning of displaced supracondylar humerus fractures, radiographs at 3 weeks do not reveal a need to return to the operating room or other significant pathology. These findings suggest that radiographs should be obtained within 7 to 10 days postoperatively for type III fractures and may only need to be repeated if the clinical situation warrants it, such as severe fracture pattern, persistent pain, or clinical deformity. LEVEL OF EVIDENCE: Level IV-case series.

Intercondylar fracture of the distal humerus in a 7-year-old child: A case report and a review of the literature.

RATIONALE: Intercondylar fracture of the distal humerus is an extremely rare injury in children, especially in those under 8 years of age. To our best knowledge, there have been 55 reported cases of this fracture type in children in the English literature, 12 of which involved children under 8 years of age. PATIENT CONCERNS: We report a case of intercondylar fracture of the distal humerus in a7-year-old boy fell in a gymnasium, injuring his left elbow. INTERVENTIONS: Closed reduction was initially attempted under fluoroscopic guidance, but anatomic reduction could not be achieved because the fragments were extremely unstable and irreducible. Considering the displacement and the failure of closed reduction, ORIF through a posterior approach was performed. Open reduction and double cross-pinning across the medial and lateral condylar fragments were performed through a posterior approach. DIAGNOSES: Plain radiographs showed a displaced intercondylar fracture of the distal humerus. Arthrography under general anesthesia showed a severely displaced intra-articular fracture, with rotational displacement of the lateral condyle. OUTCOMES: Thirteen months after surgery, there was no functional disturbance or radiographic evidence of avascular necrosis or epiphyseal growth arrest. LESSONS: Open reduction and double cross-pinning through a posterior approach can be a reliable procedure for intercondylar fracture of the distal humerus in children.