Anterior Approach for Pediatric Supracondylar Humerus Fractures: A Systematic Review.

BACKGROUND AND PURPOSE: Open reduction is rarely performed in pediatric supracondylar humerus fractures. However, clear evidence is lacking regarding the optimal open approach to achieve satisfactory results. The anterior approach provides direct visualization of the fracture and excellent exposure to neurovascular structures, although its utilization is less common. The objective of this study was to review the indications, outcomes, and complications associated with the anterior approach for open reduction of these fractures. METHODS: Our protocol was registered at PROSPERO: CRD42023446923. MEDLINE/PubMed, Embase, Web of Science, Clinicaltrials.gov, and Cochrane Library were searched from database inception to search date (December 2023) and screened in duplicate for relevant studies. Data were collected regarding patient demographics, indications for open reduction, Flynn's functional and cosmetic outcomes, and complications. Study quality was assessed using the Methodological Index for Non-Randomized Studies Criteria. RESULTS: A total of 19 studies involving 483 patients were included. One study was classified as Level 2 evidence, ten as Level 3, and eight as Level 4. The mean MINORS score was 13.05 ± 3.47. The primary indication for open reduction was failed closed reduction, observed in 46% of patients. 97.7% and 98.6% of patients achieved Flynn's functional and cosmetic satisfactory results, respectively. The postsurgical neurovascular injury rate was 1.4%. One patient required reintervention. CONCLUSION: The anterior approach is safe and effective for managing pediatric supracondylar humerus fractures requiring open reduction. LEVEL OF EVIDENCE: Systematic review of Level 2-4 evidence studies.

Multiligament knee injuries. Ten years' experience at a public university, level I Trauma Center.

PURPOSE: To describe our institutional experience and results in the surgical management of multiligament knee injuries (MLKI). MATERIALS AND METHODS: Retrospective series of MLKI consecutively operated on at a single, level I Trauma Center. Data on patients' baseline characteristics, injuries, treatments, and outcomes were recorded up to one-year follow-up. Recorded outcomes included the Tegner-Lysholm Knee Scoring Scale (TLKSS), return to work, and patient satisfaction. RESULTS: MLKI incidence was 0.03% among 9897 orthopedic trauma admissions. Twenty-four patients of mean age 43.6 years were included in analysis. The mean Injury Severity Score was 12.6. Five patients presented with knee dislocations and six had fracture-dislocations, two of them open fractures. There was one popliteal artery injury requiring a bypass and four common peroneal nerve palsies. Staged ligamental reconstruction was performed in all cases. There were seven postoperative complications. The median TLKSS was 80 and, though patient satisfaction was high, and dissatisfaction was largely restricted to recreational activities (only 58.3% satisfied). Seventeen patients returned to their previous employment. CONCLUSIONS: We found a high aggregation of fracture-dislocations secondary to road traffic accidents. One in four patients experienced complications, particularly stiffness. Complications were more common in cases involving knee dislocation. Most patients had good functional results, but 25% were unable to return to their previous work, which demonstrates the long-lasting sequelae of this injury.

Shoulder extension impairment with residual neonatal brachial plexus injury.

BACKGROUND: Impairment of both shoulder extension and behind-the-back function are common in patients with residual neonatal brachial plexus injury (NBPI), but have scarcely been studied or reported in the literature. Behind-the-back function is classically evaluated using the hand-to-spine task used for the Mallet score. Angular measurements of shoulder extension with residual NBPI have generally been studied utilizing kinematic motion laboratories. To date, no validated clinical examination method for this has been described. METHODS: Intraobserver and interobserver reliability analyses of 2 shoulder extension angles-passive glenohumeral extension (PGE) and active shoulder extension (ASE)-were performed. Afterwards, a retrospective clinical study was conducted on prospectively collected data on 245 children with residual BPI treated from January 2019 through August 2022. Demographic characteristics, level of palsy, previous surgical procedures, modified Mallet score, and bilateral PGE and ASE data were analyzed. RESULTS: All inter- and intraobserver agreements were excellent, ranging from 0.82 to 0.86. The median patient age was 8.1 years (3.5-21). Among the 245 children, 57.6% had Erb's palsy, 28.6% extended Erb's palsy, and 13.9% global palsy. One hundred sixty-eight (66%) of the children could not touch their lumbar spine, among whom 26.2% (n = 44) had to swing the arm to reach it. Both the degrees of ASE and PGE achieved correlation significantly with the hand-to-spine score, the ASE strongly (r = 0.705) and the PGE weakly (r = 0.372) (both P < .0001). Significant correlations also were found between lesion level and the hand-to-spine Mallet score (r = -0.339; P < .0001) and ASE (r = -0.299; P < .0001), and between patient age and the PGE (P = .0416, r = -0.130). A statistically significant decrease in PGE and incapacity to reach the spine were found in patients who underwent glenohumeral reduction, shoulder tendon transfer, or humeral osteotomy, relative to those who had microsurgery or no surgery. Receiver operating curves showed that, for both PGE and ASE, the minimum extension angle required to successfully perform the hand-to-spine task was 10°, with sensitivity levels of 69.9 and 82.2, and specificity levels of 69.5 and 87.8 (both P < .0001), respectively. CONCLUSIONS: Glenohumeral flexion contracture and lost ASE are extremely common in children with residual NBPI. Both the PGE and ASE angles can be measured reliably with a clinical exam, with at least 10° of PGE and ASE necessary to perform the hand-to-spine Mallet task.