Does posterior approach always lead to poor functional and cosmetic outcomes in displaced pediatric supracondylar humeral fractures?

BACKGROUND: Supracondylar humerus fractures (SCHFs) are the most common types of elbow fractures in children. Closed reduction percutaneous pinning (CRPP) is the primary surgical treatment of SCHFs. In cases that cannot be managed with closed reduction, treatment with open reduction and internal fixation (ORIF) is necessary. We aimed to compare CRPP and ORIF through a posterior approach regarding clinical and functional outcomes in pediatric SCHF cases. METHODS: Patients with Gartland type III SCHF who underwent CRPP or ORIF with posterior approach at our clinic between January 2013 and December 2016 were included in this retrospective study. A total of 60 patients who underwent surgical treatment and had available data on our hospital database and no additional injuries were included in the study. We analyzed their data concerning age, gender, fracture type, neurovascular damage, and surgical treatment. In addition, we inspected the patients' anteroposterior and lateral radiographs at 1-year follow-up visits for Baumann (humerocapitellar) angle (BA) and carrying angle (CA) and checked their go-niometer assessments of elbow range of motion (ROM). The cosmetic and functional outcomes were determined using Flynn's criteria. RESULTS: Demographic, preoperative, and post-operative data of 60 patients between the ages of 2-15 were analyzed. 46 of these patients had CRPP, and 14 had posterior ORIF. CA, Baumann angle, and lateral capitello-humeral angle were measured for fractured elbow and contralateral elbow and compared statistically. There was no statistically significant difference between the two surgical ap-proaches in terms of CA (p=0.288), Baumann's angle (p=0.951) and LHCA (p=0.578). At the end of 1-year follow-up, elbow ROM was measured, and there was no statistically significant difference between the two groups (p=0.190). Furthermore, there is no statistically significant difference between the two surgical approaches in terms of both cosmetic (p=0.814) and functional (p=0.319) outcomes. CONCLUSION: A comprehensive literature review of pediatric SCHF shows that surgeons do not frequently prefer posterior incisions in Gartland type III fracture that cannot be managed with closed reduction. However, posterior open reduction is a safe and effective method since it provides more control over the distal humerus, allows for a complete anatomical reduction involving both cortices, reduces the risk of ulnar nerve injury, thanks to the nerve exploration, and yields positive cosmetic and functional outcomes.

Relationship Between Diagnostic Anatomic Shoulder Parameters and Degenerative Rotator Cuff Tears: An MRI Study.

Background: Numerous radiographic measurement methods related to rotator cuff tears (RCTs) have been described. The most widely used of these parameters is the critical shoulder angle (CSA) as measured via radiography. However, magnetic resonance imaging (MRI) measurements provide more accurate results than direct radiography. Purpose: To determine the relationship between anatomic shoulder parameters and RCT type via MRI scans. Study Design: Cross-sectional study; Level of evidence, 3. Methods: The data and physical examination notes of 389 patients were retrospectively analyzed, and 242 patients were included in the study. Patients were divided into 2 groups: those with RCT (n = 127) and those without RCT (control group; n = 115). Using suitable MRI sections, the CSA, lateral acromial angle, acromial index, superior glenoid inclination, acromion-greater tuberosity impingement index, and acromiohumeral distance were compared between the RCT and control groups. The correlation of these shoulder parameters with the presence of RCT was investigated, and the predictive value of each parameter was examined using receiver operating characteristic (ROC) analysis. Results: There were significant positive relationships between the presence of RCT and CSA, acromial index, acromion-greater tuberosity impingement index, and superior glenoid inclination, with the strongest correlation belonging to CSA (r = 0.716). There were also significant negative relationships between presence of RCT and lateral acromial angle (r = -0.510) and acromiohumeral distance (r = -0.222). The ROC analysis revealed CSA to be the best predictor for the presence of RCT (area under the ROC curve = 0.899). Conclusion: The study outcomes showed that CSA as measured on MRI is the best predictor for determining the presence of RCTs. In patients with shoulder pain attributed to RCT, it may be helpful to examine the CSA on MRI.

Effect of Vertical and Lateral Offset Restoration on Clinical Outcomes in Intracapsular and Extracapsular Hip Fractures Undergoing Hemiarthroplasty.

Objective We aimed to investigate whether there is a change in the postoperative lateral and vertical femoral offset (FO) in patients who underwent bipolar straight stem hemiarthroplasty (SSHA) and calcar stem hemiarthroplasty (CRHA) and whether this change makes a difference in the comparison of both groups. Material and methods This study included 109 patients who met these criteria. Patients are divided into two groups according to treatment methods. There were 58 patients (group 1) who underwent SSHA due to intracapsular (AO type 31-B neck and 31-C head fracture) femur fracture, and there were 51 patients (group 2) who underwent CRHA due to extracapsular (AO type 31-A intertrochanteric) femur fracture. We analyzed femoral vertical and lateral femoral offset, Wiberg angle, and head-neck angle difference in both groups. Results The median age was significantly higher in the CRHA group (p=0.042). The Harris hip score (HHS) was significantly higher in the SSHA group (p=0.023). The femoral offset difference was 5 mm in the SSHA group, while it was significantly lower (-6 mm) in the CRHA group (p<0.001). The Wiberg angle difference did not differ significantly between patient groups (p=0.214). The limb length difference was found to be similar in both surgical groups (p=0.483). Conclusions The study results show that there was no negative correlation between clinical and radiological outcomes in the SSHA group, whereas there was a negative correlation between clinical and radiological outcomes in the CRHA group. It is very difficult to control vertical and lateral offset reconstruction, especially in extracapsular hip fractures reconstructed by hemiarthroplasty. Deficiencies in lateral and vertical stabilization restoration may be associated with poor clinical outcomes in CRHA patients. Orthopedic surgeries should be performed carefully when restoring leg length and femoral offset, especially calcar replacement hemiarthroplasties.

Clinical and radiological results of three different techniques for fixation of the olecranon osteotomy in the surgical treatment of distal humerus fractures: A retrospective comparison of plate-screw, tension band and intramedullary nail.

OBJECTIVE: The aim of this study was to compare clinical and radiological results of three different techniques (plate-screw, tension band, and intramedullary nail) in the fixation of olecranon osteotomy in patients with intercondylar fracture of the distal humerus surgically treated by the olecranon osteotomy approach. METHODS: Between January 2010 and December 2018, the study was initiated with 52 patients who underwent an olecranon osteotomy approach for an AO Type C distal humerus fracture. Thirty-seven patients (19 male, 18 female) who had regular control data and a final control examination were included in the study. In osteotomy fixation, we used tension band (K wire cerclage + Screw cerclage) in 20 patients, plate-screw in eight patients, and intramedullary nail fixation in nine patients. The functional evaluation included a measurement of the range of joint motion (flexion, extension, supination, pronation); MAYO elbow performance score; disabilities of the arm, shoulder, and hand (DASH) score; and comparative grip strength measurement, and a subjective pain assessment was performed using the visual analogue scale. RESULTS: The mean duration of follow-up was 44 (12-84) months. The mean time to union was 14 (7-32) weeks in patients that achieved union. The mean DASH score was 22 (0-72.7), the meanMAYOelbow performance score was 84 (35-100), and the mean VAS score was 3 (1-7). The mean grip strength was 32 (8-64) kgw in the treated extremity and 37 (17-70) kgw in the intact extremity. No statistically significant difference was detected between olecranon osteotomy fixation methods (tension band, plate-screw osteosynthesis, and intramedullary nailing) in terms of union time, DASH score, MAYO scale score, VAS score, extension, supination, and pronation (P > 0.05). The average grip strength (kgw) was lower than that in the uninvolved extremity, and this ratio was statistically significant (P = 0.04). CONCLUSION: The results of this study have shown that successful and comparable radiological and functional outcomes can be obtained by all the three different olecranon osteotomy techniques in the surgical treatment of intercondylar fracture of the distal humerus. LEVEL OF EVIDENCE: Level III, Therapeutic Study.

Surgical management of displaced adolescent Tillaux Fractures with the mini-open technique.

BACKGROUND: There is no consensus on the optimal treatment of Tillaux-Chaput fractures. The results of our cases treated with mini-open surgery (open reduction and internal fixation) concerning efficacy and complications, we aim to compare other procedures (open, percutaneous, and arthroscopy-assisted) with the literature data and to look for an answer to the question of whether the primary treatment can be mini-open surgery. METHODS: Between the years 2014 and 2017, 22 of 30 patients with Tillaux-Chaput fractures were treated using mini-open surgery, open reduction and internal fixation with one cannulated screw. These cases were retrospectively examined concerning age, sex, side, surgery duration, complications, and American Orthopedic Foot and Ankle Score (AOFAS). Functional results were statistically evaluated 12 months after the injury. Follow-up included a clinical examination, imaging and AOFAS. RESULTS: Of the patients, 14 were male (63.6%) and eight were female (36.4%). The mean age of the patients was 13.8 years. The mean surgery duration was 21 minutes. All fractures healed after an average of 14 weeks. No complications were observed in any of the cases. The mean follow-up time was 24.7 months. The mean preoperative AOFAS score was 53.3 and the mean postoperative AOFAS score was 93.6, which was a statistically significant difference. At the last follow-up, the AOFAS score was perfect for all cases. CONCLUSION: Contrary to what is stated in the literature, the mini-open surgical procedure has many advantages. The operation is very short and the risk of nerve injury is very low. This study showed that Tillaux-Chaput fractures could be safely and efficiently treated with mini-open surgery. We recommend mini-open surgery, complete anatomical reduction, and internal fixation for successful results.

Analysis of Clinical Outcomes in Pediatric Distal Tibia Triplanar Fractures Treated Surgically and Conservatively.

Purpose We aimed to analyze the clinical and functional outcomes of patients who underwent surgery or received conservative treatment to look into the impact of treatment methods on clinical outcomes. Methods A retrospective study was performed on 25 patients with a minimum one-year follow-up. Patients were divided into two groups based on joint and physis displacement measured on preop CT images. Patients with a displacement of > 2 mm underwent surgery, while those with a displacement of < 2 mm received conservative treatment. The clinical results were assessed using the Ankle-Hindfoot Scale developed by the American Orthopedic Foot and Ankle Society (AOFAS) and the Modified Weber Protocol (MWP). Results The sample consisted of 14 patients who underwent surgery and 11 patients who received conservative treatment. The surgical group had a mean follow-up of 36.79±14.43 months, while the conservative group had a mean follow-up of 31.82±13.55 months. The surgical and conservative groups had a postop 1st-year AOFAS score of 96.64±3.54 and 93.64 ± 4.69, respectively. The difference was statistically insignificant (p > 0.05), but the surgical group had higher scores numerically. The surgical and conservative groups had a postop 6th-month AOFAS score of 84.64±1.64 and 80.82±2.85, respectively. The difference was statistically significant (p < 0.05). Conclusion The results of both surgical treatment and conservative treatment are satisfactory. Especially, surgical treatment should not be avoided in patients requiring surgery with a displacement of more than 2 mm and surgeons may consider surgery for better clinical outcomes and earlier rehabilitation in the treatment of triplane fractures.

Surgical treatment of pediatric forearm fractures with intramedullary nails: is it a disadvantage to leave the tip exposed?

Elastic intramedullary nailing is the main treatment method in the surgical treatment of pediatric forearm fractures. In this study, we compared the clinical outcomes of intramedullary nailing of forearm fractures with leaving the tips exposed and with placing the tip of the nails under the skin. We aimed to present the clinical outcomes of intramedullary nailing and determine the advantages and disadvantages of leaving the tips of the nails exposed. One hundred and ninety-two children with both-bone forearm fracture who were treated with titanium elastic nailing (TEN) in the Department of Orthopedics at Erzurum Regional Training and Research Hospital between January 2009 and December 2016 were included in the study. All cases had been followed up for at least 1 year. The tips of the TENs were left exposed in 74 and buried subcutaneously in 118 children. Union was achieved in all cases. Delayed union was observed in just one case. Skin irritation was observed in 11 (5.7%) of the exposed TEN cases. Superficial infection developed in two (1%) cases with exposed TEN tips. Migration developed during the follow-up of 11 (5.7%) cases with buried tips. The mean time to removal of TEN was 7.9 weeks in cases with exposed and 26.2 weeks in cases with buried cases. Refracture was observed in six buried (3.1%) cases and four exposed TEN (2.1%) cases in the first year after the removal of the nails. Perfect outcomes were achieved in 146 (76%) cases and good outcomes in 36 (19%) cases in our study. On comparing the rate of complications and clinicaloutcomes, leaving the TEN exposed seems to be safe.

Comparison of low-profile plate-screw and Kirschner-wire osteosynthesis outcomes in extra-articular unstable proximal phalangeal fractures.

BACKGROUND: We aimed to present the radiological and clinical results of Kirschner-wire (K-wire) fixation and low-profile plate-screw fixation applied to unstable proximal phalangeal fractures without extension to the joint. METHODS: Clinical and radiological data of 22 patients who underwent fixation with open reduction and low-profile 1.5-mm titanium mini plate and unlocked screws and 18 patients who underwent fixation with K-wire due to closed, unstable extra-articular proximal phalangeal fractures were retrospectively examined. All evaluation and statistical analyses were based on sixth postoperative month evaluation parameters. Active and passive metacarpophalangeal joint and interphalangeal joint range of motions, total joint range of motion, measurement of grip strength for fractured and healthy hands, visual analog scoring, disabilities of the arm, shoulder, and hand scores, measurement of distance between the pulpa and palmar curve in the operated finger, Belsky score, reoperation, and complications were evaluated. RESULTS: Radiological union was achieved in all patients in a mean duration of 4.2 (3-6) weeks. When the functional results of the patients were evaluated, the mean active metacarpophalangeal joint flexion was 87.3° (75°-90°), mean proximal interphalangeal joint flexion was 94.3° (65°-100°), mean distal interphalangeal joint flexion was 77.6° (75°-80°), and mean total range of motion was 259° (210°-270°). The grip strength of the fractured hand was 52.7 (40-58) kgW, whereas that of the healthy hand was 54.4 (42-60) kgW. The mean value of visual analog score was 0.8 (0-2), mean score for disabilities of the arm, shoulder, and hand was 7 (2-27), and mean distance between the finger pulpa and finger curve was 3 (0-8) mm. CONCLUSION: Plate-screw osteosynthesis in the extra-articular, unstable fractures of the proximal phalanx, which is "small" compared with the body but has a "major function" for the hand and upper extremity, allows for rigid fixation, short immobilization, and early motion in spiral/oblique-fragmented fractures. K-wire fixation, an alternative treatment modality, applied to selected fracture patterns with appropriate indications can achieve good-excellent results radiologically and functionally.

Elbow Posterolateral Dislocation Accompanying Flexor Group Origo Rupture without Fracture - A Case Report.

INTRODUCTION: We wished to present a case that had elbow posterolateral dislocation accompanying complete medial collateral ligament rupture(MCLR) and complete flexor group origo rupture (FGOR) without fracture. CASE REPORT: A30-year-old man came to emergency department after falling on the outstretched palm. After first physical examination and radiologic searches, elbow joint posterolateral dislocation was diagnosed. Together with sedoanalgesia, elbow dislocation was reduced, and instability evaluation by applying varus and valgus stress tests was performed. Positive valgus stress test and palpation sign which indicated soft tissue damage on the medial side of elbow were determined. Control roentgenograms showed no osseous pathology. By magnetic resonance imaging, elbow dislocation diagnosis accompanying MCLR and FGOR without fracture was confirmed. Using medial approach, ruptured MCL and elbow FGO repairing procedures were performed. CONCLUSION: The complications of elbow dislocation without fracture, which is barely seen, should be treated through appropriate treatment strategies after meticulous physical examination and radiologic evaluation. Hence, possible sequelae could be prevented or satisfactory results could be obtained.

Locked posterior dislocation of the shoulder: A systematic review.

Locked posterior dislocation of the shoulder is very rare. Seizures and trauma are the most common causes of this injury.There is no current benchmark treatment strategy for these rare cases.This study has shown that reconstruction of the shoulder joint in an anatomical way in acute and chronic cases up to 16 weeks provides good results.The purpose of this study is to evaluate the results of different treatment procedures with outcomes and to compare the results of the same procedures in acute and chronic cases. Cite this article: EFORT Open Rev 2017;3:15-23. DOI: 10.1302/2058-5241.3.160089.

Os subtibiale: Mimicking medial malleolar fracture.

There are numerous sesamoids and accessory ossicles around the foot which can easily be misdiagnosed as fractures. Os subtibiale is a very rare normal variant of the medial malleolus which is usually diagnosed incidentally in routine ankle radiographs. In this report, we present a case series of 3 patients with os subtibiale who were admitted to the emergency department with ankle sprains and misdiagnosed as medial malleolar fractures. We would like to raise awareness to the very rare and usually asymptomatic os subtibiale as a diagnostic pitfall.