RESUMEN
BACKGROUND: Although current clinical practice guidelines from the American Academy of Orthopaedic Surgeons suggest that Type II and III supracondylar humerus (SCH) fractures be treated by closed reduction and pin fixation, controversy remains as to whether type IIa fractures with no rotation or angular deformity require surgery. The purpose of our study was to prospectively compare radiographic and functional outcomes of type IIa SCH fractures treated with or without surgery. METHODS: Between 2017 and 2019, 105 patients between 2 and 12 years of age presenting with type IIa SCH fractures and without prior elbow trauma, neuromuscular or metabolic conditions, were prospectively enrolled. Ten orthopaedic surgeons managed the patients with 5 preferring surgical treatment and 5 preferring an initial attempt at nonoperative treatment. Patients in the nonoperative cohort were managed with a long-arm cast and close radiographic follow-up. Patients underwent a standardized protocol, including 3 to 4 weeks of casting, bilateral radiographic follow-up 6 months postinjury, and telephone follow-up at 6, 12, and 24 months. RESULTS: Ninety-nine patients met the inclusion criteria (45 nonoperative and 54 operatives). Of the nonoperative patients, 4 (9%) were converted to surgery up to their first clinical follow-up. No differences were identified between the cohorts with respect to demographic data, but patients undergoing surgery had on average 6 degrees more posterior angulation at the fracture site preoperatively (P<0.05). At the final clinical follow-up (mean=6 mo), the nonoperative group had more radiographic extension (176.9 vs 174.4 degrees, P=0.04) as measured by the hourglass angle, but no other clinical or radiographic differences were appreciated. Complications were similar between the nonoperative and operative groups: refracture (4.4 vs 5.6%), avascular necrosis (2.2 vs 1.9%) and infection (0 vs 1.9%) (P>0.05). Patient-reported outcomes at a mean of 24 months showed no differences between groups. CONCLUSION: Contrary to American Academy of Orthopaedic Surgeons guidelines, about 90% of patients with type IIa supracondylar fractures can be treated nonoperatively and will achieve good radiographic and functional outcomes with mild residual deformity improving over time. Patients treated nonoperatively must be monitored closely to assess for early loss of reduction and the need for surgical intervention.
Asunto(s)
Fracturas del Húmero , Procedimientos de Cirugía Plástica , Humanos , Estudios Retrospectivos , Resultado del Tratamiento , Fracturas del Húmero/diagnóstico por imagen , Fracturas del Húmero/cirugía , Fijación de Fractura/métodos , Húmero/cirugíaRESUMEN
BACKGROUND: The optimal treatment for pediatric lateral condyle fractures displaced >2 mm, but with little joint displacement is unclear. The purpose of this study was to assess clinical and radiographic outcomes and complication rates of patients undergoing open reduction internal fixation (ORIF) versus closed reduction and percutaneous pin fixation (CRPP) of lateral condyle fractures with >2 mm of displacement and no obvious articular surface incongruity. METHODS: A retrospective review of all children with acute lateral condyle fractures with 2.1 to 5.0 mm of displacement treated from 2006 to 2014 was performed. A total of 74 patients were treated who met inclusion criteria; 51 underwent ORIF and 23 underwent CRPP. No differences existed between the 2 groups with respect to age, sex, extremity, mechanism of injury, time to treatment, fracture displacement, or fracture classification. Charts and radiographs were reviewed and the following parameters were documented: operating room time, time to union, return to activities, magnitude of lateral spurring, and complications. Major complications were defined as those with presumptive long-term effects or requiring reoperation. RESULTS: All fractures healed within 12 weeks of surgery, regardless of treatment type and no differences were observed in time to union between groups. OR time averaged 30 minutes faster for the CRPP group (P<0.001). Nearly 10% of patients in each group developed elbow stiffness, requiring formal therapy. The overall complication rates were 25% for the ORIF group and 13% for the CRPP group (P=0.36). No major complications were observed in the CRPP group, whereas 3 (6%) were observed in the ORIF group, including 1 case of avascular necrosis, 1 case of osteomyelitis with an associated premature physeal closure, and 1 refracture requiring surgery. CONCLUSIONS: Surgical treatment of lateral condyle fractures displaced >2 mm, but with no significant articular surface incongruity has good outcomes with both CRPP and ORIF. CRPP, however, minimizes surgical time, avoids an incision and is thus our preferred treatment approach when joint congruity can be confirmed. LEVEL OF EVIDENCE: Level III-therapeutic study.