Search Results (22)

Background/Objectives: Closed reduction and percutaneous pinning is the standard surgical treatment for displaced pediatric supracondylar humerus fractures. Although crossed-pin fixation provides excellent biomechanical stability, medial pin insertion remains associated with the risk of iatrogenic ulnar nerve injury. The modified medial para-olecranon technique has been introduced as an alternative medial wire insertion strategy while preserving the principles of crossed-pin fixation. This study compared its clinical performance with conventional crossed pinning. Methods: A retrospective comparative cohort study was conducted at a tertiary referral trauma center between January 2017 and December 2024. Seventy children younger than 14 years with Gartland type II–IV supracondylar humerus fractures met the inclusion criteria. All patients treated with the modified medial para-olecranon technique (n = 35) were included. A comparison cohort of 35 patients treated with conventional crossed pinning was selected from 68 eligible conventionally treated patients by computer-generated random sampling stratified by Gartland type (frequency matching), after application of identical eligibility criteria. The primary outcome was functional outcome assessed using the Flynn criteria. Secondary outcomes included operative time, radiographic alignment, fracture union, and postoperative complications. Results: Baseline demographic and fracture characteristics were comparable between groups. Mean age was 6.7 ± 2.8 years in the modified medial para-olecranon group and 6.9 ± 2.6 years in the conventional crossed-pin group. The modified medial para-olecranon group had a lower mean Flynn score (6.80 ± 3.31 vs. 10.74 ± 3.70; mean difference, −3.94; 95% CI, −5.61 to −2.27; p < 0.001) and a higher proportion of excellent Flynn outcomes (77.1% vs. 28.6%). Operative time was shorter in the modified medial para-olecranon group (47.49 ± 7.50 vs. 66.00 ± 8.19 min; mean difference, −18.51 min; 95% CI, −22.26 to −14.76; p < 0.001). Fracture union occurred at a comparable time in both groups (27.71 ± 3.94 vs. 28.34 ± 4.12 days; mean difference, −0.63 days; 95% CI, −2.55 to 1.29), and postoperative Baumann angles were similar. No postoperative iatrogenic ulnar nerve injuries occurred in the modified medial para-olecranon group, whereas two occurred in the conventional crossed-pin group; both were transient sensory paraesthesia that resolved without exploration within six months. Overall complications occurred in 1 patient (2.9%) and 7 patients (20.0%), respectively (odds ratio, 0.17; 95% CI, 0.03 to 1.02; Fisher exact p = 0.055). Conclusions: In this retrospective comparative cohort, the modified medial para-olecranon technique was associated with favorable functional outcomes, shorter operative time, and fewer observed postoperative ulnar nerve injuries, although the difference in complications did not reach statistical significance, while maintaining comparable radiographic alignment and fracture healing. Because treatment was not randomized and potential confounders could not be adjusted for, these between-group differences should be interpreted as associations rather than as evidence of a causal treatment effect. Further prospective multicenter studies and dedicated anatomical investigations are required before broader recommendations can be made. Full article

Background/Objectives: Supracondylar humerus fractures are among the most common pediatric fractures and may be associated with neurovascular complications. Brachial artery entrapment is a rare but limb-threatening condition requiring urgent recognition and management. Methods: We present two pediatric cases of brachial artery entrapment associated with displaced supracondylar humerus fractures. Clinical presentation, imaging findings, surgical management, and outcomes were analyzed. Results: Both patients presented with absent radial pulse following trauma. Initial fracture reduction and fixation did not restore vascular flow. CT angiography confirmed brachial artery compromise. Surgical exploration with arterial decompression resulted in restoration of perfusion. One patient achieved full recovery, while the other developed severe neuropathy with partial recovery after rehabilitation. Conclusions: Brachial artery entrapment should be suspected in cases of persistent vascular compromise after fracture reduction. Prompt surgical intervention and thorough perioperative neurovascular assessment are essential to prevent long-term morbidity. Full article

Background/Objectives: Gartland Type III supracondylar humerus fractures (SCHFs) represent the most surgically challenging pediatric elbow injuries, yet controversy persists regarding whether the timing of surgery, specifically after-hours versus working-hours operations, influences clinical and radiological outcomes. This study aimed to compare the functional, cosmetic, and radiological outcomes of Gartland Type III SCHFs managed during working hours versus after hours, with a secondary analysis incorporating the surgical approach (open vs. closed reduction). Methods: A retrospective cohort study was conducted, including 91 pediatric patients who underwent surgical treatment for Gartland Type III SCHFs between January 2020 and June 2025. Patients were stratified into working-hours (n = 48) and after-hours (n = 43) groups. Outcomes were assessed using Flynn’s criteria, radiological parameters, range-of-motion measurements, and complication rates. A secondary subgroup analysis was performed across four groups formed by combining surgical timing and approach. Results: The mean patient age was 70.36 ± 32.97 months with a mean follow-up of 28.07 ± 14.66 months. The time to surgery was significantly shorter in the working-hours group (median 16.0 h; IQR 13.5–20.0) compared with the after-hours group (median 20.0 h; IQR 17.0–27.0) (p = 0.009). No significant differences were observed between the two groups with respect to functional outcomes, cosmetic outcomes, radiological parameters, or overall complication rates (all p > 0.05). However, four-group subgroup analysis revealed a significant difference in Flynn’s functional outcomes (p = 0.019), with the after-hours open reduction subgroup demonstrating a lower rate of excellent results (76.92%) compared with the remaining subgroups (96.88–100%). Conclusions: Working-hours versus after-hours surgical timing alone does not significantly alter clinical or radiological outcomes in Gartland Type III SCHFs. However, the combination of after-hours surgery with open reduction appears to be associated with inferior functional outcomes and a trend toward higher complication rates, suggesting that open reduction for complex fractures should preferably be performed during working hours when optimal theatre conditions and experienced senior surgical teams are readily available. Full article

Background/Objectives: The objective was to evaluate whether surgical timing (daytime vs. nighttime) influences intraoperative and postoperative outcomes in pediatric supracondylar humerus fractures. Methods: A retrospective observational cohort study was conducted at a tertiary center. Pediatric patients aged ≤14 years who underwent surgery for supracondylar humerus fractures between January 2010 and December 2022 were included. Fractures were classified according to the Gartland system. Patients with open fractures, associated neurovascular injury, compartment syndrome, or incomplete follow-up were excluded. Primary outcomes included need for open reduction, reoperation, neuropathy, and loss of joint mobility. Patients were grouped according to the time of surgery: daytime (08:00–22:00) or nighttime (22:00–08:00). Stratified analyses were performed based on fracture severity. Results: Eighty-six patients were included: 56 underwent daytime surgery and 30 underwent nighttime surgery. Groups were comparable in age, sex, and fracture severity. Nighttime surgery was associated with a significantly higher rate of open reduction (33.3% vs. 10.7%, p = 0.023; RR = 3.11). Reoperation (16.6% vs. 5.4%, p = 0.121) and postoperative neuropathy (23.3% vs. 8.9%, p = 0.131) were more frequent in the nighttime group, although these differences were not statistically significant. In complex fractures (Gartland III–IV), nighttime surgery was associated with a significantly higher reoperation rate (20.8% vs. 2.6%, p = 0.026). Conclusions: Nighttime surgery was associated with higher rates of open reduction and reoperation, particularly in complex supracondylar humerus fractures. However, given the retrospective design and limited sample size, these findings may be influenced by residual confounding and should be interpreted as exploratory. Full article

Background/Objectives: Transphyseal fracture of the distal humerus (TFDH) is a rare but clinically important pediatric elbow injury that predominantly affects children under 3 years of age. Due to the radiolucent nature of the cartilaginous distal humeral epiphysis in this age group, TFDH is often misdiagnosed as elbow dislocation, supracondylar fracture, or lateral/medial condyle fracture. Time pressures, limited pediatric musculoskeletal expertise, and incomplete clinical histories in emergency settings further compound this diagnostic challenge. Despite the importance of early and accurate diagnosis to prevent complications such as cubitus varus, systematic studies on diagnostic pitfalls and strategies for improving recognition remain scarce. We therefore aim to characterize misclassification patterns, standardize radiographic cues, and evaluate management outcomes. Methods: We conducted a single-center retrospective review of 25 pediatric patients with TFDH who were misdiagnosed at initial presentation between 2012 and 2022. Clinical records, radiographic features, treatment modalities, and complications were analyzed over a minimum follow-up period of 24 months. Results: All 25 cases were initially misdiagnosed. The most common misdiagnoses were supracondylar and lateral condyle fractures (each 6/25, 24%), followed by elbow dislocation (4/25, 16%). Misclassification was primarily attributed to failure to assess global forearm–humerus alignment and misinterpretation of the radiocapitellar line. All patients underwent emergency management, with 18/25 (72%) receiving closed reduction and percutaneous K-wire fixation, and 7/25 (28%) undergoing closed reduction and cast immobilization. Cubitus varus developed in 5/25 (20%) overall and was more frequent after closed reduction with cast immobilization (3/7, 43%) than after K-wire fixation (2/18, 11%). Overall, 92% achieved excellent functional outcomes according to the Mayo Elbow Performance Index (MEPI). The implementation of a targeted curriculum improved diagnostic accuracy among trainees from 70% to 100%. Conclusions: TFDH poses substantial cognitive and radiographic diagnostic challenges. A structured radiographic assessment, early senior review, and targeted education may improve recognition and outcomes. These findings offer actionable insights to enhance diagnostic accuracy and optimize care for this vulnerable patient population. Full article

Background: Displaced pediatric supracondylar humerus fractures (PSHFs) commonly require surgical treatment. Medial pin placement can cause iatrogenic ulnar nerve injury. This study presents a modified, step-by-step cross-pinning technique for PSHFs designed to avoid iatrogenic ulnar nerve injury. Methods: We retrospectively included patients with PSHF (Gartland types III or IV) who underwent closed reduction and percutaneous cross-pinning at our hospital from June 2014 to December 2024. Demographic data, fracture type, and preoperative and postoperative neurological deficits were recorded. Results: A total of 40 patients (16 boys and 24 girls) with a mean age of 6.6 ± 2.2 years (range, 2–14) were included. Most injuries were type III (35/40; 87.5%), whereas five patients (12.5%) had type IV injuries. Our technique resulted in no new cases of postoperative ulnar neuropathy. Conclusions: This study describes a modified medial pin insertion technique for unstable PSHFs. Careful attention to medial pin placement can minimize iatrogenic ulnar nerve injury. Full article

Background: Gartland type III pediatric supracondylar humerus fractures can be unstable and prone to loss of reduction. The Internal Rotational Stress Test (IRST) aims to assess and address rotational instability during surgery. Method: This retrospective study analyzed treatments for Gartland type III pediatric supracondylar humerus fractures at our institution from January 2020 to December 2022. Only patients who underwent IRST were included. IRST was performed after inserting either two or three lateral pins. Patients were divided into Group 1 (IRST +) or 2 (IRST −) based on IRST results. Radiographic and clinical outcomes were compared between the two groups. Result: A total of 46 patients were included in the study. The mean age at the time of diagnosis was 5.7 years (range, 4 to 11 years), and the mean duration of follow-up was 2.8 years (range, 1.0 to 4.8 years). Group 1 consisted of 24 patients, and Group 2 comprised 22 patients. We did not find any differences in radiographic parameters and clinical scores between the two groups. Additionally, in both groups, there were no instances of major loss of reduction, defined as greater than 12 degrees or 12%. In five patients, we identified two types of fracture patterns that were stable with only two lateral pins. Conclusions: In patients with Gartland type III supracondylar humerus fractures, if reduction is adequately achieved and sufficient fixation force is maintained, the IRST results do not significantly impact radiologic and clinical outcomes. The pattern of the fracture can influence instability, necessitating further research on this matter. Full article

Background/Objectives: Supracondylar humerus fractures (SCHFs) are the most common pediatric elbow injuries and often require surgical intervention. Despite guidelines, optimal timing for surgical management, particularly for cases without neurovascular compromise, remains unclear. This study evaluates the influence of surgical timing on short-term outcomes, focusing on fracture reduction quality and surgical parameters. Methods: In total, 62 pediatric patients who had been treated for Gartland type II and III SCHF between 2018 and 2023 were retrospectively assessed. Patients were grouped based on time of admission (morning, afternoon, early evening, and night shifts) and time to surgery (<12 h vs. >12 h). Primary outcomes included immediate radiological reduction, assessed via the Baumann’s angle (BA) and shaft-condylar angle (SCA). Secondary outcomes encompassed surgery duration and radiation exposure. Statistical analyses used ANOVA and chi-square tests, with p < 0.05 considered significant. Results: No significant differences were observed in BA (p = 0.84) or SCA (p = 0.79) between early and delayed surgical groups. Similarly, surgical timing (shift or delay >12 h) did not significantly affect surgery duration (p = 0.92) or radiation exposure (p = 0.12). The complication rate was 6.45%. Conclusions: Surgical timing, including delays beyond 12 h, does not adversely affect short-term outcomes in SCHFs. However, after-hours procedures may pose practical challenges, emphasizing the importance of surgeon experience and institutional protocols. Larger prospective studies are warranted to validate these findings and examine them in the long term. Full article

This study describes the outcome of supracondylar humerus fractures in children using crossed K-wires after closed or open reduction with the medial, lateral or bilateral approach. Patients treated between January 2000 and December 2019 were classified according to the Von Laer classification, complications were classified according to the Sink classification and clinical outcomes were classified according to modified Flynn criteria. In total, 364 patients with a mean age of 5.23 ± 2.45 years were included. The majority were type IV fractures (156; 42.9%) and 94 (60.3%) needed an open reduction for which the medial approach (53; 56.4%) was predominantly used. Overall, of 50 complications (31 using closed reduction, 19 open reduction), 17/50 (34%) needed revision surgery. An excellent clinical outcome was achieved in 348/364 (95.6%) patients. The approach used for open reduction as such had no influence on the complication rate or clinical outcome. For severely displaced fractures, the data showed that an open approach for crossed K-wires tended to result in fewer complications and better clinical outcomes than a closed reduction. If an open reduction is indicated, the required approach (medial, lateral or bilateral) should be primarily selected according to the requirements of the fracture pattern and eventual cosmetic considerations. Full article

To assess changes in treatment modalities for supracondylar humerus fractures (SCHFs) at a large pediatric university hospital, we analyzed patient data from 2014 to 2022. A total of 233 SCHFs treated surgically at our hospital were included. To evaluate postoperative outcome and quality of life, DASH and EuroQol-5D-Y questionnaires were sent to patients. In addition to a significant fluctuation in fracture severity, we found an increase in training interventions (more surgeries were performed by trainees) and a significant decrease in surgery times after 2016. From 2020, there was a significant shift in the type of surgical method away from closed reduction with elastic stable intramedullary nailing (ESIN) and towards closed reduction and crossed K-wire osteosynthesis (CRK). Surgeries performed in the morning and evening hours increased, while those performed in the afternoon and after midnight decreased. After a mean follow-up of 4 years, there was no difference in elbow function between ESIN and open reduction and K-wires (ORK). Treatment with ESIN was equivalent to ORK in terms of function, at least in the medium-term follow-up. In summary, the combination of shifting treatment from SCHF to daytime hours, increasing trainee participation and using cross K-wire fixation instead of ESIN had no negative impact on surgery times. In our setting, these measures have reduced resource utilization and increased efficiency without compromising patient care. Full article

Purpose: Up to 12% of paediatric supracondylar humerus fractures (SCHFs) have an associated traumatic nerve injury. This review aims to summarize the evidence and guide clinicians regarding the timing of investigations and/or surgical interventions for traumatic nerve palsies after this injury. Methods: A formal systematic review was undertaken in accordance with the Joanna Briggs Institute (JBI) methodology for systematic reviews and PRISMA guidelines. Manuscripts were reviewed by independent reviewers against the inclusion and exclusion criteria, and data extraction, synthesis, and assessment for methodological quality were undertaken. Results: A total of 51 manuscripts were included in the final evaluation, reporting on a total of 510 traumatic nerve palsies in paediatric SCHFs. In this study, 376 nerve palsies recovered without any investigation or intervention over an average time of 19.5 weeks. Comparatively, 37 went back to theatre for exploration beyond the initial treatment due to persistent deficits, at an average time of 4 months. The most common finding at the time of exploration was entrapment of the nerve requiring neurolysis. A total of 27 cases did not achieve full recovery regardless of management. Of the 15 reports of nerve laceration secondary to paediatric SCHFs, 13 were the radial nerve. Conclusions: Most paediatric patients who sustain a SCHF with associated traumatic nerve injury will have full recovery. Delayed or no recovery of the nerve palsy should be considered for exploration within four months of the injury; earlier exploration should be considered for radial nerve palsies. Full article

Background: Supracondylar humeral fracture is probably the most common elbow fracture in children requiring surgical intervention. We observed a subtype of pediatric supracondylar humeral fracture with a sideward translation, without substantial displacement in the sagittal plane on initial radiographs. The purpose of this study was to calculate the incidence of this fracture subtype and suggest a modification to the standard operative technique, to achieve the desired fracture alignment and fixation. Methods: We reviewed the clinical records and radiographs of all pediatric patients with supracondylar humeral fractures surgically treated in our institution between the years 2006 and 2014. The fracture types, fixation configuration and any complications were recorded. Results: Overall, 263 consecutive patients were included. The incidence of supracondylar fracture of the humerus with solely sideward displacement was 6%. The fracture was characterized clinically and radiographically. We proposed a modification to the standard operative technique for this fracture subtype for successful closed reduction and percutaneous pinning. Conclusions: Special attention to this fracture subtype, including appropriate operating room setup and the application of a suitable reduction and pinning technique, has the potential to achieve successful results and avoid the need for open reduction. Full article

The most common cause leading to supracondylar humerus fractures in children is falling onto an outstretched arm. A correlation between fall height and fracture severity may be assumed but has not yet been described. The aim of this study was to show that fracture severity increases with fall height. Furthermore, the correlation between fracture severity and outcome was examined. A total of 971 children with supracondylar humerus fractures between January 2000 and December 2019 were included in this study. The correlations between fall height and fracture severity and between fracture severity and outcome were assessed. Increasing fall height correlates with fracture severity (p < 0.001; r = 0.24). Furthermore, the incidence of complications increases with fracture severity and a correlation was present accordingly (p < 0.001; r = 0.28). A total of 30 (3.1%) patients showed limitations in range of motion and/or persistent neurologic deficits at the latest follow-up. Type I fractures rarely lead to subsequent limitations. The correlation between increasing fall height and fracture severity was significant. Furthermore, children with type III and IV supracondylar fractures are more likely to develop complications or restrictions in movement than children with type I and II fractures. Hence, the initial fall height may be an indirect indicator of a more or less favorable outcome. Full article

Background and Objectives: Supracondylar fractures of the humerus (SCHF) make up about one-third of pediatric fractures and are the most common elbow fractures in children. Reduction and fixation of SC fractures can be performed with the patient in the prone or supine position. However, the role of the patient’s position during surgery is still unclear. The purpose of this systematic review is to evaluate, based on data from the literature, the role of patient position during closed reduction and fixation of pediatric SCHFs. Materials and Methods: A systematic review of the current literature from 1951 to 2021 was conducted according to PRISMA guidelines. Articles were identified from 6 public databases. Articles were screened and abstracted by two investigators and the quality of included publications (n = 14) was assessed (MINORS criteria). Statistical analyses were performed using R studio 4.1.2. Results: The systematic literature review identified 114 articles, from which, according to inclusion and exclusion criteria, 14 studies were identified. A total of 741 children were treated in the prone position and 538 in the supine position. The results of the systematic review showed that there were no statistical differences between the two positions with regard to clinical, radiographic, and complication outcomes. Conclusions:: The functional and radiographic outcome of displaced SCHFs is generally excellent regardless of the position, prone or supine, in which the patient is positioned for surgery. The choice of how to position the patient depends on the habit and experience of the surgeon and anesthesiologist performing the surgery. Full article

Socioeconomic status, race, and insurance status are known factors affecting adult orthopaedic surgery care, but little is known about the influence of socioeconomic factors on pediatric orthopaedic care. The purpose of this study was to determine if demographic and socioeconomic related factors were associated with surgical management of pediatric supracondylar humerus fractures (SCHFs) in the inpatient versus outpatient setting. Pediatric patients (<13 years) who underwent surgery for SCHFs were identified in the New York Statewide Planning and Research Cooperative System database from 2009–2017. Inpatient and outpatient claims were identified by International Classification of Diseases-9-Clinical Modification (CM) and ICD-10-CM SCHF diagnosis codes. Claims were then filtered by ICD-9-CM, ICD-10-Procedural Classification System, or Current Procedural Terminology codes to isolate SCHF patients who underwent surgical intervention. Multivariable logistic regression analysis was performed to determine the effect of patient factors on the likelihood of having inpatient management versus outpatient management. A total of 7079 patients were included in the analysis with 4595 (64.9%) receiving inpatient treatment and 2484 (35.1%) receiving outpatient treatment. The logistic regression showed Hispanic (OR: 2.386, p < 0.0001), Asian (OR: 2.159, p < 0.0001) and African American (OR: 2.095, p < 0.0001) patients to have increased odds of inpatient treatment relative to White patients. Injury diagnosis on a weekend had increased odds of inpatient management (OR: 1.863, p = 0.0002). Higher social deprivation was also associated with increased odds of inpatient treatment (OR: 1.004, p < 0.0001). There are disparities among race and socioeconomic status in the surgical setting of SCHF management. Physicians and facilities should be aware of these disparities to optimize patient experience and to allow for equal access to care. Full article