Search Results (34)

Supracondylar humeral fractures are the most common type of elbow fractures in children. The treatment methods vary depending on the type of fracture (Gartland classification), which can be conservative or surgical. There is no clear consensus or guidelines to dictate the treatment of complicated supracondylar humeral fractures (Gartland types II and III). Gartland type II and III fractures are most frequently treated with closed reduction and percutaneous Kirchner-wire pinning or open reduction with K-wire pinning, depending on the degree of displacement and the orthopedic surgeon’s preference. Most studies recommend avoiding open reduction because of prolonged hospitalization and higher rates of complications. Orthopedic surgeons have different opinions regarding the Kirschner pin placement technique. Studies suggest that only lateral pinning is safe and effective, but medial and lateral pinning is proven to give more stability; there is always a risk of iatrogenic ulnar nerve damage during surgery. Modern treatment of supracondylar humeral fracture in children should focus on minimally invasive techniques and avoid open reduction, when possible, to ensure the best outcome for the patients. This scoping review’s purpose is to gather the available information on the topic in one place and to underline the lack of clear protocols. 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 and Clinical Significance: Neurological complications in extension-type-III supracondylar humeral fractures (SCHFs) in children represent 11% of cases. An extension-type-III SCHF with posterolateral displacement of the distal fragment is commonly associated with damage to the median nerve and the anterior interosseous nerve (AIN). Neurological complications are often unnoticed, and their immediate postoperative diagnosis is difficult, particularly in young children. Neurapraxia, the most common complication, usually undergoes spontaneous nerve recovery. Case Presentation: We report a case of a 7-year-old patient with postoperative median nerve palsy after an SCHF (Gartland type III) who was referred to our unit from another hospital due to a lack of spontaneous recovery. In addition, motor and sensory functions were absent. As ultrasound (US) indicated nerve kinking at the fracture site, an exploration was performed. The nerve was trapped within the fracture and the callus. It was surgically extracted, and intraoperative examination with US indicated that resecting the kinked nerve, freeing the two stumps, and attempting a primary end-to-end suture represented the best course of action. We present this case with a 5-year follow-up surgery, which showed a good clinical outcome. Conclusions: This case is noteworthy because of its diagnostic and therapeutic pathways, and it is complemented by surgical and ultrasound images that can assist other surgeons in similar circumstances. 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

Background and Objectives: The reduction of two-part oblique or spiral fractures of the distal femur using steel wire cerclage prior to plate osteosynthesis is a proven procedure. In addition to being useful in fracture reduction, wire cerclage was also shown to increase the stability of osteosynthesis. Nevertheless, metal corrosion and the allergenic potency of steel remain problematic disadvantages of this method. A biomechanical study was carried out to evaluate titanium cable cerclage as an alternative supplement for plate osteosynthesis of a distal femoral two-part fracture. Materials and Methods: An unstable AO/OTA 32-A2.3 fracture was created in eleven pairs of nonosteoporotic human cadaver femora. All the samples were treated with polyaxial angular stable plate osteosynthesis. One femur from each pair was randomly selected for an additional fracture fixation with multifilament titanium cable cerclage. Stepwise cyclic axial loading was applied in a load-to-failure mode using a servohydraulic testing machine. Results: All specimens (mean age: 80 years; range: 57–91 years) withstood a cycling force of at least 1800 N. With a mean load of 2982 N (95% CI: 2629–3335 N), the pressure forces resulting in osteosynthesis failure were significantly higher in specimens with an additional titanium cerclage (Group 1) than in samples that were solely treated with plate osteosynthesis (Group 2) at 2545 N (95% CI: 2257–2834 N) (p = 0.024). In both groups, cutting out the distal screws at the condyle region, resulting in shearing of the distal fragment proximal to the fracture line, was the most frequent cause of construct failure. Among the specimens assigned to Group 1, 36% exhibited a specific fracture pattern, namely, a fracture of the dorsal buttress above the cerclage. Analysis of axial stiffness (p = 0.286) and irreversible deformity of the specimens revealed no differences between the groups (p = 0.374). Conclusion: Titanium cable cerclage application, as a supplement to an angular stable plate, resulted in an increased load to failure. In terms of stability, the use of this adjunct for fracture fixation of supracondylar two-part oblique femoral fractures might, therefore, be an option, especially in patients who are sensitive to nickel. Full article

Pediatric elbow fractures and dislocations have always been a challenge from a diagnostic and therapeutic point of view, primarily due to the complex nature of the pediatric elbow, especially its developmental anatomy. They must be diagnosed and treated on time to prevent numerous complications with long-term consequences. With the development of radiology and pediatric surgery and orthopedics, as well as the development of modern osteosynthesis materials, concerning current scientific and professional knowledge, the outcomes are getting better, with fewer acute and chronic complications. This comprehensive review aims to provide clinicians current knowledge about pediatric elbow fractures and dislocations so that in daily practice they have as few doubts as possible with the best possible treatment outcomes. 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

Background and Objectives: Long-term outcomes of immediately postoperative rotational malreduction in the axial plane after operative treatment of supracondylar humeral fractures (SCHF) are unknown. This study aimed to investigate the long-term clinical outcomes and associated factors for immediately postoperative rotational malreduction of SCHF. Materials and methods: In this retrospective case–control study, 88 patients who underwent surgery for Gratland type III SCHF were enrolled between January 2012 and January 2020. Among them, 49 patients had immediately postoperative malrotational reduction (rotational malreduction group) and 39 patients had no rotational deformity (control group). To evaluate the associated factors for immediately postoperative rotational malreduction, demographic data, fracture patterns, physical examination signs, and preoperative radiological parameters were analyzed. To compare the clinical outcomes, operation time, range of motion of the elbow, time from operation to full range of motion, and Flynn criteria were evaluated. The Oxford elbow score was used to investigate long-term clinical outcomes for patients five years after operation. Results: The mean age was 5.7 ± 2.3 years and mean follow-up period was 15.7 ± 4.0 months. The rotational malreduction group had significantly more patients with oblique fracture pattern (p = 0.031) and Pucker sign (p = 0.016) and showed a significantly longer operative time (p = 0.029) than the control group. Although there was no significant difference in the range of elbow motion and the Flynn criteria, the Kaplan–Meier survival curve showed a longer time to recover the full range of elbow motion in the rotational malreduction group (p = 0.040). There were no significant differences in the long-term clinical outcomes assessed using the Oxford elbow score (p = 0.684). Conclusions: Oblique fracture pattern and Pucker sign may be associated with immediately postoperative rotational malreduction in the axial plane. Although patients with immediately postoperative rotational malreduction showed favorable results of long-term clinical outcomes, they required more weeks to recover the full range of elbow motion. Full article

Background: Recently, the T2 alpha nailing system (Stryker, Inc.), which has advanced locking screws that can attach a screw to a rod, has been used worldwide and is expected to improve fracture fixation. We analyzed two cases of supracondylar femoral fractures in older adult patients, in which intraoperative fractures occurred during the insertion of advanced locking screws of the T2 alpha femur retrograde intramedullary nail. Case presentation: A 93-year-old and an 82-year-old woman each underwent T2 alpha femur retrograde nail fixation for supracondylar femur fractures at separate hospitals, and advanced locking screws were used as the proximal transverse locking screws. In both patients, a fracture line was observed at the proximal screw postoperatively, and the fractures were refixed with distal cable wiring and/or femoral distal plates. The patients were subsequently discharged from the same facility with no remarkable pain. Conclusions: When inserting advanced locking screws, it is necessary to enlarge the screw hole in the near-bone cortex with a counterbore drill, which might add torque to the bone cortex that could result in fractures. If the sleeve is distant from the bone, the counterbore drill will not reach the bone, the screw hole will not expand, and the insertion of advanced locking screws will apply a strong torque to the bone cortex and may result in fracture. Moreover, it is important to confirm that the counterbore drill is securely inserted under fluoroscopy and to carefully enlarge the bony foramen manually to prevent fractures during screw insertion. Full article

Supracondylar fractures of the humerus are frequent paediatric injuries. The aims of this study were to evaluate the applicability and reproducibility of the Gartland and Wilkins classification, the Baumann angle (BA) and the Anterior Humeral Line (AHL). This retrospective monocentric observational study was conducted on 217 patients. Four observers assessed the pre-operative radiographs by applying the Gartland and Wilkins classification and the post-operative X-rays by measuring the BA and AHL. The kappa coefficient (K) and the Cohen’s kappa were used for the reliability of the Gartland classification; the Intraclass Correlation Coefficient (ICC) for that of the BA. The AHL was evaluated in a double manner by using first the K and the Cohen’s kappa and then the ICC. A total of 186 patients were eligible. Inter-observer reliability for the Gartland classification was K = 0.73–0.61 for type III, 0.65–0.61 for type Ia and 0.43–0.26 for type IIb. The Baumann angle mean value in the first data collection was 73.5 ± 6.85 (inter-observer ICC 0.74) and 72.9 ± 6.83 (inter-observer ICC 0.77) for the second data collection; AHL: inter-observer ICC 0.87 for the first evaluation and 0.80 for the second one. Gartland’s classification modified by Wilkins has a high degree of reliability. BA and AHL appear reproducible and reliable. 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

Supracondylar fractures are common injuries in children. Diagnosis typically relies on radiography, which can involve long wait times in the ED, emits ionizing radiation, and can miss non-displaced fractures. Ultrasound (US) has the potential to be a safer, more convenient diagnostic tool, especially with new highly portable handheld 2D point of care US (POCUS). This study aimed to determine the reliability of 2D POCUS for the detection of supracondylar fractures and elbow joint effusions, to contrast the accuracy of 2D POCUS vs. 3DUS vs. radiographs, and to determine whether blinded image interpretation could produce similar results to non-blinded real-time imaging. Fifty-seven children were scanned with 2D POCUS and 3DUS on the affected elbow. US scans were then read by three blinded readers, and the results were compared to gold-standard radiographs. Compared to a gold standard of 30-day radiographic diagnosis, readers of 2D POCUS detected supracondylar fracture and effusion with sensitivities of 0.91 and 0.97, respectively, which were both higher than with 3DUS. Inter-rater reliability of fracture detection was moderate for 2D POCUS (k = 0.40) and 3DUS (k = 0.53). Consensus sensitivities, although high, were lower than reports from some non-blinded studies, indicating that clinical presentation serves as an important factor in detection rates. Our results from consensus US diagnosis support the validity of using 2D POCUS in children for supracondylar fracture and elbow effusion diagnosis. Full article

Background: The most common treatment modality for supracondylar humerus fractures (SCHFs) in children is closed reduction and percutaneous pinning (CRPP). Nonetheless, debate persists regarding the optimal technique used. Therefore, the purpose of our study was to investigate the impact of surgeon experience, surgeon subspecialty and pin configuration on short-term radiological outcomes following CRPP of displaced SCHFs. Methods: Patients less than 14 years of age who underwent CRPP for displaced SCHFs in the prone position between January 2018 and December 2022 were analyzed. Patients were separated into subgroups based on fracture type (low vs. high sagittal), pin configuration (lateral, cross, other), number and configuration of K-wires and first operator surgical experience. The following outcome measurements were collected: postoperative Baumann angle (BA), Shaft-Condylar angle (SCA), surgical duration (SD), duration of radiation exposure (DRE) and number of clinical and radiological follow-ups (FU). Results: A total of 44 patients with a mean age of 6 ± 2.5 years were included in the final analysis. The mean post-operative BA and SCA were 74.8° ± 4.9° and 37.7° ± 10.2°, respectively. No significant differences were found in the post-operative Baumann’s angle or SCA among the subgroups. Regarding secondary outcomes, no differences were found among each subgroup regarding SD, DRE and FUs. Conclusion: Short-term radiological outcomes following the treatment of SCHFs treated in the prone position are not affected by fracture patterns and pinning configuration, regardless of the surgeon’s years of experience or subspecialty. 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