A rare complication of tension band fixation of olecranon osteotomy: Distal migration of K-wire.

Tension band wiring (TBW) is one of the most commonly used fixation techniques to fix olecranon osteotomies. Hardware prominence has been the most commonly reported complication of TBW. However, distal migration of Kirschner (K)-wire after TBW fixation for olecranon osteotomy has not been reported. In this case report, we presented distal migration of K-wire detected nine months after initial surgery in a 46-year-old male patient. The patient was operated on for an intraarticular distal humerus fracture using an olecranon osteotomy. The osteotomy was fixed with TBW fixation. The patient missed routine follow-ups and presented to the outpatient clinic with a complaint of skin irritation at the elbow nine months after the surgery. On radiological examination, distal migration of one K-wire was detected. The K-wire was surgically removed without any complication. Physicians should be aware of possible complications of TBW and remove fixation after fracture union to avoid unexpected complications.

Achieving Bone Healing Non-Operatively in Humeral Fractures in Two Patients with Risk Factors for Nonunion Utilizing a Specialized Orthosis.

We report the treatment of two patient with humeral fractures with one or more risk factors for nonunion. The first patient was elderly with a previously diagnosed central nervous sys-tem injury. The second elderly patient previously sustained a cerebral vascular accident affecting the fractured arm. The fracture was oblique in the proximal third of the humerus. We achieved bone healing non-operatively utilizing a spe-cialized plastic orthosis that included a deforming element made of dense foam. This device asymmetrically increases the soft tissue pressure around the fracture.

Utility of Follow-up Radiographs in Type 1 Supracondylar Humerus Fractures.

OBJECTIVE: Supracondylar humerus (SCH) fractures are common among pediatric patients, with the severity categorized using the Gartland classification system. Type 1 SCH fractures are nondisplaced and treated with immobilization, while more displaced fractures require surgery. The need for follow-up radiographs, particularly for type 1 fractures, is an area where evidence is lacking. This study investigates the clinical value and financial implications of follow-up radiographs for type 1 SCH fractures, hypothesizing that they do not alter clinical management and, therefore, represent an unnecessary expense. METHODS: This retrospective cohort study, approved by the Institutional Review Board, focused on patients under 18 with nondisplaced SCH fractures treated nonoperatively. One hundred one type 1 SCH fractures, in which the fracture was visible on presenting radiographs, were chosen from patients presenting between January 2021 and December 2022. Charts were reviewed for demographic information, time of cast removal, and complications. A pediatric orthopaedic surgeon and orthopaedic resident reviewed the radiographs to confirm the injury to be a type 1 SCH fracture. RESULTS: Among the 101 patients, after the initial presentation, 79 attended an interim visit and 101 attended a "3-week follow-up" at an average of 23 days postinjury. All patients underwent radiographs during these visits for a total of 180 radiographs after confirmation of type 1 SCH fracture. No changes in management resulted from follow-up radiographs. One instance of refracture was noted ~3 months after cast removal. There were 180 superfluous follow-up radiographs taken at subsequent clinic visits. The total charge for these radiographs was $76,001.40, averaging $752.49 per patient. CONCLUSION: Follow-up radiographs for type 1 SCH fractures did not lead to changes in clinical management, aligning with previous findings in more severe SCH fractures. This approach can reduce costs, radiation exposure, and clinic time without compromising patient care. The study can reassure providers and parents about the lack of necessity for follow-up radiographs to document healing. LEVEL OF EVIDENCE: Level-IV.

[Effectiveness comparison of ultrasound-guided closed reduction and Kirschner wire fixation for different unstable humeral lateralcondylar fractures of children].

Objective: To compare the effectiveness of ultrasound-guided closed reduction and Kirschner wire fixation for different unstable humeral lateralcondylar fractures of children. Methods: The clinical data of 94 children with unstable humeral lateralcondylar fractures admitted to three medical centers between January 2021 and October 2022 were retrospectively analyzed. The children were divided into three groups according to the Song classification and whether the elbow joint was dislocated or not, including 42 cases of Song 4 type (group A), 38 cases of Song 5 type (group B), and 14 cases of elbow joint dislocation (group C). There was no significant difference in gender, age, side, cause of injury, and time from injury to operation among the three groups ( P>0.05). All children were treated with ultrasound-guided closed reduction and Kirschner wire fixation. The operation time and complications of the three groups were recorded and compared, and the failure of closed reduction was evaluated by ultrasound. X-ray examination was performed at last follow-up to measure the Baumann angle, condylar angle, carrying angle, and lateral osteophyte of the affected side; the extension, flexion, pronation, and supination range of motion of the affected elbow joint were measured; the function of the elbow joint was evaluated by Mayo score. Results: The operation time in group A was significantly longer than that in groups B and C ( P<0.05). There were 7, 2, and 5 cases of closed reduction failure in groups A, B, and C, respectively, and there was no significant difference in the incidence of the closed reduction failure ( P>0.05). All patients were followed up 6-28 months, with an average of 15.7 months. There was no significant difference in the follow-up time among the three groups ( P>0.05). Complications: in group A, there were 2 cases of delayed union, 4 cases of needle tract infection, 1 case of trochlear necrosis, and 39 cases of lateral osteophyte; in group B, there was 1 case of malunion, 5 cases of needle tract infection, 1 case of redisplacement, and 26 cases of lateral osteophyte; in group C, there were 2 cases of needle tract infection and 10 cases of lateral osteophyte. There was no significant difference in the incidence of complications among the three groups ( P>0.05). No cubitus varus or cubitus valgus deformity was found in all patients. At last follow-up, except that the condylar angle in group A was significantly greater than that in groups B and C ( P<0.05), there was no significant difference in other imaging indicators, elbow range of motion, or Mayo score between groups ( P>0.05). Conclusion: The Song type 4 of humeral lateralcondylar fracture treated with ultrasound-guided closed reduction and Kirschner wire fixation has a longer operation time, more postoperative complications, and is more prone to lateral osteophyte.

Outcome determinants for coronal shear fractures of the distal humerus.

PURPOSE: Coronal shear fractures of the distal humerus involving the capitellum and trochlea are rare injuries. Internal fixation with headless compression screws provides a stable construct facilitating early mobilisation. Our study aimed to identify the key determinants of both radiological and functional outcomes of patients with distal humerus coronal shear fractures treated with internal fixation. METHODS: A retrospective analysis of 61 patients with distal humerus coronal shear fractures who were treated surgically was done. Demographics, fracture morphology, time to surgery, operative details such as surgical approach and implant used, quality of reduction, time to union, and associated complications from hospital records. Radiological outcomes were assessed using plain radiographs, and the functional outcomes were by Oxford Elbow Score (OES) and Mayo Elbow Performance Index (MEPI). RESULTS: Patients with anatomical reduction of the fracture had better functional outcomes and range of motion. The presence of posterior comminution of capitellum resulted in poorer outcomes (p = 0.03). Delayed presentation did not alter the outcome when the anatomical reduction was achieved. Myositis ossificans was noted in nine patients and non-union in five patients. Two patients developed avascular necrosis of the capitellum and arthritis of the elbow joint. CONCLUSION: Anatomical reduction and posterior comminution are the two key determinants of the functional outcome in these coronal shear fractures of the distal humerus. Early mobilisation following a stable fixation is crucial in achieving a good outcome.

The efficacy of pediatric elbow radiographic guidance in diagnosis of lateral humeral condyle fracture.

Although lateral humeral condyle fracture is common, the incidence of missed diagnosis is very high. Delayed and missed diagnosis led to significant morbidities and loss of functions. We designed a pediatric elbow radiographic guidance aiming to improve the accuracy of diagnosis. This study was aimed to evaluate the efficacy of the radiographic guidance for the diagnosis of lateral condyle fracture. A cross-sectional study was conducted after defining the essential parameters as a guidance for assessing the pediatric elbow radiographs. We included medical students, emergency medicine, orthopedic, and radiology residents and fellows into this study. A questionnaire was used to evaluate the efficacy of the guidance. All participants underwent a pretest evaluation, followed by studying the guidance, and then finished a posttest evaluation. Baseline characteristics, diagnostic scores, and parameter evaluation scores were collected. The pretest and posttest scores were analyzed using paired t-test. Association between baseline characteristics and diagnostic scores were analyzed using multiple regression analysis. We included 177 participants. Average diagnostic score was significantly increased after using the guidance, from 12.2 ± 1.9 to 13.0 ± 1.7 (p < 0.0001). Medical students showed the most improvement, from 11.9 ± 1.9 to 13.1 ± 1.3 (p <0.001). All means of essential parameter evaluation scores were significantly improved in overall participants.The pediatric elbow radiographic guidance is useful for evaluation and diagnosis of lateral condyle fracture, especially for young physicians and trainees. Therefore, this should be recommended in routine medical education and general practice.

Treatment of Adult Distal Humerus Fracture with Fishtail Deformity: A Case Report.

CASE: We report a single case of a closed intra-articular distal humerus fracture in a 28-year-old man with a preexisting fishtail deformity characterized by concavity of the central trochlea and corresponding deformity of the olecranon. The patient was treated with open reduction and internal fixation. CONCLUSION: The case highlights the diagnosis and challenges of treatment. Conventional fixation choices and imaging techniques may need to be altered when treating a fracture with this deformity.

Long-standing Nonunited Fracture Lateral Humeral Condyle in Children. Evaluating a Two-stage Surgical Treatment Strategy With Critical Review.

OBJECTIVE: This work aimed to evaluate the results of using a 2-stage surgical treatment strategy without doing anterior transposition of the ulnar nerve (ATUN) for cases with long-standing nonunited fracture lateral humeral condyle (LHC) in children, accompanied by a critical review. METHODS: A consecutive 12 children with a long-standing ">2 years" nonunited LHC with evident radiologic gross anatomic distortion of the elbow were included in this study. A 2-stage surgical treatment strategy was applied, wherein the first stage, open functional reduction, osteosynthesis, and iliac bone graft were done. Then after 6 months, the second stage surgery was carried out in the form of supracondylar humeral corrective osteotomy if the cubitus valgus angle was ≥20 degrees. ATUN was not done for any of the cases even with those having ulnar nerve dysfunction. RESULTS: Union took place in 11 out of the 12 cases after a mean follow-up period of 11 weeks (range: 8 to 14 wk; SD: 1.6). All the 7 cases showed preoperative ulnar nerve dysfunction and reported clinical recovery at the end of their follow-up. CONCLUSIONS: Two-stage surgical treatment strategy without ATUN is a convenient, reproducible, and successful line of treatment for children presented with longstanding nonunited LHC with anatomically distorted elbow. LEVEL OF EVIDENCE: Level IV-case series.

Classification and Treatment of Pediatric Capitellar Fractures.

BACKGROUND: Fractures of the capitellum are rare in children. The purpose of this study was to report fracture characteristics, treatment, and outcomes of pediatric capitellar fractures at a single children's hospital. We also aimed to update the classification of these fractures based on a large sample size by revising the Murthy (Boston) classification. METHODS: In a retrospective study at a single tertiary care children's hospital, fractures of the capitellum in patients below 18 years of age were queried and reviewed for demographics, injury characteristics, imaging, treatment, outcomes, and complications. Three surgeons reviewed all imaging to classify the fractures and assess interobserver and intraobserver reliability. RESULTS: Forty-four patients (25 male) with capitellar fractures with a mean age of 11.7±3.7 years were identified. Seven fractures did not belong to an existing type and were grouped into a new type IV capitellar fracture, defined as LCL avulsions with extension to the articular surface of the capitellum. We found good to excellent inter-rater and intrarater reliability for the new classification system. Our raters believed that cross-sectional imaging was essential to classifying fractures in 84% of the cases. Thirty-three of 44 patients underwent early surgical intervention, with favorable outcomes. Five patients presented late with substantial elbow contracture and malunion and were treated surgically with the excision of the fragment. CONCLUSIONS: The new classification of pediatric capitellar fractures is more comprehensive and offers good to excellent reliability. We found excellent outcomes in the majority of cases with early diagnosis and management, but substantial risk for complications with missed and delayed diagnosis. Malunion and subsequent loss of ROM were the most common presentations of a missed diagnosis, which can be surgically treated with favorable outcomes. LEVEL OF EVIDENCE: Level III-retrospective cohort study.

The Gartland classification for expediting supracondylar humerus fracture triage: a collaborative approach to structured reporting between pediatric radiologists and orthopedists.

BACKGROUND: The modified Gartland classification is an important tool for evaluation of pediatric supracondylar humerus fractures (SCHF) because it can direct treatment decisions. Gartland type I can be managed outpatient, while emergent surgical consult occurs with type II and III. This study assesses the interobserver reliability of the Gartland classification between pediatric radiologists and orthopedic providers. METHODS: A retrospective review of 320 children diagnosed with a SCHF at a single tertiary children's hospital during 2022 was conducted. The Gartland classification documented in the radiographic report by a pediatric radiologist and the classification documented in the first encounter with an orthopedic provider was collected. Kappa value was used to assess interobserver reliability of classifications between radiologists and orthopedic providers. A second group of 76 Gartland type I SCHF from 2015, prior to our institution's implementation of structured reporting, was reviewed for comparison of unnecessary orthopedic consults at initial presentation. RESULTS: The Gartland classification has excellent interobserver reliability between radiologists and orthopedic providers with 90 % (289/320) agreement and kappa of 0.854 (confidence interval: 0.805-0.903). The most frequent disagreement that occurred was fractures classified as type II by radiology and type III by orthopedics. There were similar rates of consults for the 2015 and 2022 cohorts (p = 0.26). CONCLUSION: The Gartland classification system is a reliable and effective tool for communication between radiologists and orthopedic providers. Implementing a structured reporting system has the potential to improve triage efficiency for SCHF.

Demystifying the Radial Nerve The Management of Radial Nerve Palsy in the Setting of Humeral Shaft Fracture.

The association of radial nerve palsy and humeral shaft fracture is well known. Primary exploration and fracture fixation is recommended for open fractures and vascular injury while expectant management remains the standard of care for closed injuries. In the absence of nerve recovery, exploration and reconstruction is recommended 3 to 5 months following injury. When direct repair or nerve grafting is unlikely to achieve a suitable outcome, nerve and tendon transfers are potential options for the restoration of wrist and finger extension.

Kirschner Wire Prying and Leverage Technique: a new closed reduction method in treatment of pediatric "Irreducible Supracondylar Humerus Fractures".

BACKGROUND: This study employs an innovative closed reduction approach to treat pediatric "Irreducible Supracondylar Humerus Fractures" with the goal of demonstrating its practical application compared to conventional methods. METHODS: This study sampled 146 surgically treated cases of "Irreducible Supracondylar Humerus Fractures" in our department. After applying inclusion and exclusion criteria, 120 children were selected and divided into two groups based on treatment methods. Group 1 underwent Closed Reduction and Percutaneous Pinning (CRPP), while Group 2 received treatment using the Kirschner Wire Prying and Leverage Technique alongside CRPP. The relevant data to the study were collected and assessed during the follow-up period. RESULTS: Results indicate that Group 2 demonstrated significantly shorter operative times and fewer instances of intraoperative fluoroscopy compared to Group 1. Furthermore, the percentage of cases requiring open reduction was notably higher in Group 1 than in Group 2. The analysis also identified age, BMI, time from injury to surgery, and the initial deviation of the distal fragment as independent risk factors associated with the failure of closed reduction. The integration of CRPP with the Kirschner Wire Prying and Leverage Technique emerges as a safe and effective strategy for managing "Irreducible Supracondylar Humerus Fractures." This innovative approach not only reduces operative time and intraoperative fluoroscopy needs but also diminishes the reliance on open reduction without compromising safety.

Evaluation of surgical or conservative treatment of forearm fracture in pediatric floating elbow injuries.

OBJECTIVE: Floating elbow, which refers to a humerus fracture in the supracondylar region and a forearm fracture, is a very unusual injury. The purpose of this study is to compare the clinical results of patients with "floating elbows" who underwent surgical therapy and who were given forearm immobilization with a splint as follow-up care. PATIENTS AND METHODS: Fifteen patients who had been diagnosed with floating elbow owing to trauma were scanned retrospectively and followed up for at least a year. Eight individuals who suffered from broken forearms underwent surgical repair. After initial treatment, a lengthy arm splint was used to immobilize seven patients' arms. The modified Flynn criteria were used to analyze the data, and comparisons were made between the groups. RESULTS: The median age and mean follow-up time for patients whose forearms were conservatively followed was 6.1 years and 13.8 months, respectively. The median age of the patients who underwent forearm surgery was 8.5 years, and the average follow-up was 14.2 months. Five of the seven patients whose forearms underwent conservative follow-up had outstanding clinical outcomes, while two had poor and moderate outcomes. Four individuals who got surgical treatment for their forearms had excellent and good clinical outcomes, while the other four had intermediate and poor outcomes. Between the two groups, there was no discernible difference (p = 0.60). CONCLUSIONS: In the pediatric population with floating elbow injuries, using a cast for forearm fractures may not necessarily result in worse outcomes compared to surgical management.

Paediatric bilateral 'floating elbow'.

A child sustained an ipsilateral supracondylar humerus (SCH) and distal both-bone forearm fractures bilaterally, in addition to facial injuries, following a fall from height. He was managed surgically by closed reduction and pinning for both SCH and distal end radius fractures bilaterally. At the final follow-up, all the fractures had united uneventfully, and he had no functional limitations or cosmetic concerns. We conclude that a floating elbow in the paediatric population is an uncommon injury, and the bilateral scenario is even rarer. One should be vigilant for compartment syndrome; early surgical fixation may give better results.

The effects of postoperative malrotation alignment on outcomes of Gartland type III/IV paediatric supracondylar humeral fractures treated by close reduction and percutaneous K-wire fixation.

PURPOSE: In this study, we aimed to investigate the effects of postoperative malrotation alignment on the outcomes of Gartland type III/IV paediatric supracondylar humeral fracture (SCHF) treated by close reduction and percutaneous K-wire fixation. METHODS: Between January 2014 and December 2021, 295 Gartland type III/IV paediatric SCHFs treated by close reduction and percutaneous K-wire fixation were selected for this retrospective study. The demographic, clinical and radiographic parameters of all cases were collected. The lateral rotation percentage (LRP) was measured on X-rays to evaluate postoperative malrotation alignment of the fracture. All cases were categorized into 4 groups according to LRP: LRP ≤ 10% (210, 71.2%), 10% < LRP ≤ 20% (41, 13.9%), 20% < LRP ≤ 30% (26, 8.8%) and LRP > 30% (18, 6.1%). The carrying angle, ranges of multidirectional motions, Mayo Elbow Performance Score (MEPS) and Flynn's Standard Score (FSS) of the injured elbow were assessed 6 months postoperation and compared among different groups. ROC analysis based on LRP and the excellent/good rate of FSS was performed to determine the acceptable maximum degree of postoperative malrotation alignment. RESULTS: There was no difference in the demographic characteristics (age, sex, injured side and fracture type), postoperative Baumann angle, carrying angle or range of forearm rotation among the 4 groups (P > 0.05). The operation time and time from operation to K-wire removal were longer in the 20% < LRP ≤ 30% and LRP > 30% groups than in the LRP < 10% and 10% < LRP ≤ 20% groups (P < 0.001). The shaft condylar angle, range of elbow flexion, MEPS and FSS of the injured elbow 6 months postoperatively were lower in the 20% < LRP ≤ 30% and LRP > 30% groups than in the LRP < 10% and 10% < LRP ≤ 20% groups (P < 0.001). ROC analysis based on LRP and the excellent/good rate of FSS showed an area under the curve of 0.959 (95% CI 0.936-0.983), with a cutoff value of 26.5%, sensitivity of 95.3% and specificity of 90.1%. CONCLUSION: A certain degree of residual malrotation alignment deformity of the SCHF may reduce the shaft condylar angle and extend the time from operation to removing the K-wire and affect elbow function, especially the range of elbow flexion. The acceptable maximum degree of residual malrotation deformity expressed as the LRP value was 26.5%.

Megaprosthetic replacement in complex distal humerus fractures in elderly patients: a case series.

BACKGROUND: Managing distal humeral fractures can be challenging for orthopedic surgeons. There are several treatment options for managing this type of fracture, and the treatment method for these fractures should be based on patient-related factors. In elderly patients with osteoporotic bone and severe comminution of the fracture, adequate fixation can be a major challenge for surgeons. The use of megaprosthesis has been recently proposed in traumatology as an alternative to osteosynthesis or conventional prosthesis for the management of comminuted articular fractures in elderly patients with poor bone stock. METHODS: A consecutive case series of 5 patients who underwent reconstruction of the elbow joint with a trabecular hinged modular elbow megaprosthesis was reviewed retrospectively. All patients included had AO/OTA 13C2 and 13C3 fractures with metaphyseal extension and considerable bone loss of the distal humerus. The primary outcome was the evaluation of functional and clinical outcomes with the MEPS score in comminuted distal humerus fractures with metaphyseal extension and poor bone stock in elderly patients treated with elbow megaprosthesis. The secondary outcome was assessing the treatment-related complication rate of this technique in non-oncological fields. RESULTS: Five patients were included in the study with a mean age of 82.66 ± 7.72 years at surgery. The mean MEPS value was 63 ± 24.2 at 1 month, 81 ± 23.53 at 3 months, 83 ± 24.2 at 6 months, and 84 ± 24.57 at 12 months. No intraoperative complications were recorded in our series. Of 5 patients, four patients had excellent clinical and functional outcomes. We did not encounter wound dehiscence, prosthetic joint infection, aseptic loosening, or periprosthetic fractures. CONCLUSIONS: The indication for this type of treatment must be selected and narrowed down, as it is a salvage procedure, and any failure would cause even more complex situations. Short operating times and early mobilization of the elbow are the advantages of this technique.

Application of Kirschner wire placement guided technology in paediatric supracondylar humerus fractures.

BACKGROUND: To analyze the clinical efficacy of K-wire placement guided technology in paediatric supracondylar humerus fractures. METHODS: A retrospective study was conducted in 105 patients who underwent closed reduction and percutaneous pinning surgeries in our hospital from June 2019 to August 2022. 54 patients treated with a assisted reduction fixation device to assist in closed reduction and percutaneous K-wire cross-fixation were allocated into the Non-guided group, and 51 patients with K-wire placement guided technology to guide K-wire placement were assigned into the Guided group. The operation duration, number of disposable K-wire placement, intraoperative fluoroscopy frequency, Baumann angle, carrying angle, fracture healing time and Flynn score of elbow joint function at the final follow-up were compared between two groups. The postoperative complications of two groups were recorded. RESULTS: There were significant differences between two groups in terms of operation duration, intraoperative fluoroscopy frequency, and disposable K-wire placement rate (p < 0. 05), while no significant differences of Baumann angle, carrying angle and the fracture healing time between two groups were observed (p > 0. 05). In the control group, ulnar nerve injury in 2 case, pin site infection in 4 cases, mild cubitus varus in 2 cases and loss of reduction in 4 cases were detected. In the study group, ulnar nerve injury in 1 case, pin site infection in 2 cases and loss of reduction in 1 case was observed. There was no significant difference in Flynn scores between two groups. CONCLUSION: K-wire placement guided technology is simple and convenient. The application of K-wire placement guided technology could relatively improved disposable K-wire placement rate, shorten the intraoperative fluoroscopy frequencies and reduce complication rates.