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Pediatric Supracondylar Humerus Fractures: Are Medial Pins Indicated?  [PDF]
Bobby Dezfuli, Christopher Larkins, John T. Ruth, Lisa M. Truchan
Open Journal of Orthopedics (OJO) , 2014, DOI: 10.4236/ojo.2014.45021
Abstract: Background: Pediatric supracondylar humerus fractures are the most common elbow fractures in children. Operative management includes closed reduction and placement of 2 to 3 laterally based pins. Occasionally, a medial pin is used to create a crossed fixation pattern, despite risk of nearly 10% iatrogenic ulnar nerve injury. The objective of this study was to assess the trends and outcomes in the operative management of pediatric supracondylar humerus fractures at a level one academic trauma center. Materials & Methods: A retrospective review was performed on all children sustaining a Gartland type II or III supracondylar humerus fractures treated by closed or open reduction and percutaneous pinning in 2006-2008 and 2009-2011 at a level one academic trauma center by two of the authors (JTR, LMT). Pin placement patterns were evaluated and compared based on year performed. Outcomes measured were rates of ulnar nerve symptoms, non-union, re-operation, and varus malalignment. Data analysis was performed using a Fisher exact test on STATA software. Results: A total of 49 patients met inclusion criteria. Of 22 patients treated in 2006-2008, 5 (23%) were type II and 17 (77%) were type III. From 2009-2011, 16 (59%) were type II and 11 (41%) were type III. Comparison of pinning pattern in type II fractures between 2006-2008 and 2009-2011 did not indicate statistical significance (p = 0.429). Comparison of pinning pattern in type III fractures during the same time period did show that there was a statistically significant decrease (p = 0.010) in the number of cross pin fixations. There were no ulnar nerve injuries, non-unions, re-operations, or varus malalignment in any patient on final follow-up. Conclusion: This study shows that there has been a significant decrease in cross pin fixation for pediatric type III supracondylar humerus fractures with equivalent clinical outcomes at a Level I trauma center. Furthermore, performing lateral pinning for type III fractures has eliminated the risk of iatrogenic ulnar nerve injury. Level of Evidence: Level III—Retrospective cohort study.
A Different Method of Pinning of Displaced Extension type Supracondylar Fracture of Humerus in Children.  [PDF]
Ram Krishan Arora
JK Science : Journal of Medical Education & Research , 2004,
Abstract: A new /different method of pinning of the displaced extension type supracondylar fractures of thehumerus in children is presented. Here two pairs of K wires are used. The fracture is reduced underC- arm image intensifier control and then two K wires are passed through lateral epicondyle andholding the reduction two more wires are passed from the lateral supra-condylar ridge obliquelydownwards and inwards across the fracture site into the medial epicondyle. Thirty cases, thus treated,are presented here. Mean follow up for 26 cases was 28 months. Four cases were lost to follow up.At the final follow up ,using Flynn's overall modified classification, the clinical result was consideredto be excellent in 19 (73%) patients, good in 5 (19.23%) and poor in 2 (7.69%) patients. The protocoldescribed here resulted in good to excellent results in 24/26 cases (92.30%) thus proving its usefulnessin displaced extension type supracondylar fractures in children.
Open Surgical Treatment of Extension Type Displaced Supracondylar Fractures of the Humerus in Children Through Combined Medial and Lateral Approaches
M.A. Mohseni,A. Moradi,A. Seddighi,A. Arzrum Chilar
Research Journal of Biological Sciences , 2012,
Abstract: Supracondylar fracture of the humerus is the most common fracture in the elbow region in children. Many methods have been proposed to treat Gartland type III supracondylar fractures of the humerus in children: one of them is open reduction and internal fixation with Kirschner wires through combined medial and lateral approaches. From Jan 1995 to Jan 2002, 60 children with extension type, Gartland type III supracondylar fracture of humerus underwent surgery using open reduction internal fixation method through combined medial and lateral approaches in Shohada and Imam Khomeini hospitals, Tabriz, Iran. The cases suffered from either of the following: severely displaced fracture, open fracture, primary neurovascular complication or unsuccessful closed reduction. Children were followed-up for a mean time of 5 years. Sixty children (63% boys, 37% girls), mean age 6.5 years (3-9 years) were followed up. Pin-tract infection occurred in 2 patients and was successfully treated with pin removal and antibiotics. Three cases of iatrogenic nerve injury (2 median and 1 ulnar) were reported but patients gradually regained full neurological function by a mean of 2.5 months. All fractures healed within 6-8 weeks. No compartment syndrome, non-union, mal-union, myositis ossificans, deformities or vascular deficits were noted. Only 10% of patients had a reduction of the carrying angle (less than 20 ). Six (10%) patients lost less than 20 of movement in flexion of the elbow. Ninety percent of children had excellent results and the others had good results according to the criteria developed by Innocenti. Operative reduction and pin fixation through combined medial and lateral approaches is one of the best methods to treat Gartland type III fractures.
Open Surgical Treatment of Extension Type Displaced Supracondylar Fractures of the Humerus in Children Through Combined Medial and Lateral Approaches
M.A. Mohseni,A. Moradi,A. Seddighi,A. Arzrum Chilar
Research Journal of Biological Sciences , 2008,
Abstract: Supracondylar fracture of the humerus is the most common fracture in the elbow region in children. Many methods have been proposed to treat Gartland type III supracondylar fractures of the humerus in children: one of them is open reduction and internal fixation with Kirschner wires through combined medial and lateral approaches. From Jan 1995 to Jan 2002, 60 children with extension type, Gartland type III supracondylar fracture of humerus underwent surgery using open reduction internal fixation method through combined medial and lateral approaches in Shohada and Imam Khomeini hospitals, Tabriz, Iran. The cases suffered from either of the following: severely displaced fracture, open fracture, primary neurovascular complication or unsuccessful closed reduction. Children were followed-up for a mean time of 5 years. Sixty children (63% boys, 37% girls), mean age 6.5 years (3-9 years) were followed up. Pin-tract infection occurred in 2 patients and was successfully treated with pin removal and antibiotics. Three cases of iatrogenic nerve injury (2 median and 1 ulnar) were reported but patients gradually regained full neurological function by a mean of 2.5 months. All fractures healed within 6-8 weeks. No compartment syndrome, non-union, mal-union, myositis ossificans, deformities or vascular deficits were noted. Only 10% of patients had a reduction of the carrying angle (less than 20°). Six (10%) patients lost less than 20° of movement in flexion of the elbow. Ninety percent of children had excellent results and the others had good results according to the criteria developed by Innocenti. Operative reduction and pin fixation through combined medial and lateral approaches is one of the best methods to treat Gartland type III fractures.
Comparison of Outcome of Lateral K-Wire Fixation Verses Medio-Lateral Crossed K-Wire Fixation for Displaced Extension Type of Supracondylar Humeral Fractures in Children  [PDF]
HK Gupta,D Chaurasia
Journal of Universal College of Medical Sciences , 2014, DOI: 10.3126/jucms.v2i3.11823
Abstract: INTRODUCTION: Supracondylar humeral fractures are the most common elbow fractures seen in children. The purpose of this study was to compare the efficacy of lateral entry pin fixation with that of medial and lateral entry pin fixation for the operative treatment of displaced extension supracondylar fractures of the humerus in children. MATERIAL AND METHODS: Total of 50 cases of displaced supracondylar fracture humerus were enrolled in study, 25 cases in two equal groups, Group A and group B. Group A received treatment by closed reduction with lateral k-wire fixation and Group B received treatment by closed reduction and medio-lateral k-wire fixation. The cases were followed at 4 weeks when slab was removed and physiotherapy started, and at 12 weeks for final outcome. The outcome was measured as per Flynn's criteria. RESULTS: The mean age of patents in group A was 6.40 years and in group B was 6.44 years. At final follow up, in group A, 18 (72%) cases had excellent, 7 (28%) good result, in group B; 20 (80%) had excellent, and 5 (20%) had good result. The p- value (0.08) derived between them was statistically not significant. Three pateints got superficial pin tract infection in group A and two iatrogenic ulnar nerve injury and one pin had pintract infection in group B. There were also no significant differences (p value- 0.697) between groups with respect to the baumann angle. CONCLUSION: Both lateral entry pin fixation and medio- lateral entry pin fixation are effective in the treatment of completely displaced (type-III) extension supracondylar fractures of the humerus in children. Although there remains subtle risk of ulnar nerve injury in medio-lateral pin fixation. DOI: http://dx.doi.org/10.3126/jucms.v2i3.11823 Journal of Universal College of Medical Sciences Vol.2(3) 2014: 20-25
Assessment of the Outcome of Anterior versus Posterior Approach in the Management of Displaced Pediatric Supracondylar Humerus Fracture  [PDF]
Rebar Muhammad Noori Fatah, Bakhtyar Rasul M. Amin, Hamid Ahmad Mahmud, Ammar Jamil Yusif
Open Journal of Orthopedics (OJO) , 2016, DOI: 10.4236/ojo.2016.65017
Abstract: Background: Supracondylar fractures of the humerus are among the most common type of pediatric fractures. The outcome of severely displaced supracondylar fracture of the humerus in children subjected to wide controversies in term of safety, functional and cosmetic outcome. Closed reduction and percutaneous pinning is now considered as the gold standard rule, but open reduction still applicable in certain cases where intraoperative imaging is not available, in comminuted lateral column fractures and uneducable fractures. Aim of the Study: To compare the outcome (functional and cosmetic) of anterior (Henry) approach with the posterior (Campbell) approach used in two groups of patients’ sustained displaced supracondylar fractures. Patients and Methods: This prospective study was performed on 48 pediatric patients who were been admitted to the Emergency Hospital in Sulaimani province sustained displaced supracondylar humeral fractures and treated during the period from the first of October 2009 to the thirty-one of January 2011. The study included 28 boys, 20 girls; their mean age was 7.5 years; their ages range 2 - 13 years. We used the modified Gartland classification to assess the fractures displacement and only Gartland type II B and III were included and managed operatively by open reduction and internal fixation with 2 crossed K-wires. Follow up continued for 6 months and the results finally assessed using Flynn’s criteria. Results: According to the criteria of Flynn et al., 20 patients (83.3%) treated by the anterior approach had excellent functional results while 4 patients (16.7%) had good functional results. While those treated by the posterior approach, 16 patients (66.6%) had excellent functional results, 6 patients (25%) had good results and 2 (8.3%) patients had fair outcome. Cosmetic results were excellent in 22 patients in the anterior approach group and 20 patients in the posterior approach group. Conclusion: Posterior Campbell approach is simpler than anterior Henry approach, but it creates additional soft tissue damage that can affect the circulatory status and hence possible osteonecrosis of the trochlea and a higher percentage of limitation in joint mobility. While the anterior approach is technically more demanding, but it gives better functional results.
Internal antecubital fold line: A new useful anatomical repair to identify the medial epicondyle and avoid iatrogenic ulnar nerve injury in patients with supracondylar fracture of the humerus
Cespedes,Luis José; Turriago,Camilo; Goyeneche,Jairo;
Revista de la Universidad Industrial de Santander. Salud , 2012,
Abstract: introduction: the supracondylar fracture of the distal humerus is the most common pediatric fracture around the elbow. the currently accepted techniques of fixation are two lateral parallel wires , crosswiring technique from the lateral side, two divergent wires laterally and two retrograde crossed wires. the retrograde crossed wires provide the best mechanical stability. many children with this fracture have swelling around the elbow, making difficult the feeling of the anatomic landmarks for percutaneous pinning, increasing the risk of ulnar nerve injury. objective: to evaluate the correspondence of the internal antecubital fold line with the internal epicondyle in patients with supracondylar fracture and the incidence of iatrogenic ulnar nerve injuries . methods: we conducted a series of clinical cases. in the first group we included 56 children with supracondylar fracture gartland type iii, from august 2000 to september 2007, who underwent closed reduction and crossed retrograde nail fixation. in the second group we included 241 (481 elbows) outpatients with no anatomic abnormality. we used the extension of antecubital fold line to find the internal epicondyle in both groups. results: the prolongation of the antecubital fold line intersected the medial epicondyle in all participants of the first group. in 96.3% of the participants in the second group, the extension of antecubital fold line intersected the internal epicondyle. none patient had iatrogenic ulnar nerve injury. conclusions: the use of the antecubital internal fold line may be useful to identify the internal epicondyle and thus avoid iatrogenic ulnar nerve injury. salud uis 2012; 44 (2): 9-14
SUPRACONDYLAR FRACTURE OF THE HUMERUS IN CHILDREN
Nikola Bojovi?,Zoran Marjanovi?,Dragoljub ?ivanovi?,Nina ?or?evi?
Acta Medica Medianae , 2012,
Abstract: Humeral supracondylar fractures are the second most common fractures seen in children and young teenagers (16.6%). They represent 60-70% of all the elbow fractures. The maximum incidence is found between the fifth and seventh year of age, slightly more often in boys and on non-dominant hand. We performed a retrospective study in our clinic which included 105 patients admitted to our facility during the period from January, 2008 to April, 2012. The included patients had humeral supracondylar fracture either type 2 or type 3 (Gartland classification). At the moment of admission the median age was 7.26 years. All the patients were treated during the first 12 hours, with no more than two attempts of closed reposition. Sixteen patients with type 2 fracture were treated by analgosedation, closed reduction followed by cast immobilization. All other patients were treated after induction of general anesthesia. Sixteen patients were treated by percutaneous fixation of the fragments after closed reduction and 73 were treated with open reduction and pinning with different number and positions of К“ wires. None of the patients had deep tissue infection; four patients had pin site infection. Three patients had cubitus varus deformity, two patients had elbow contracture, five patients had temporary limitation in extension, and one patient had iatrogenic lesion of the ulnar nerve. This makes 14.2% complication rate in our series. All the fractures healed in the expected period (3–4 weeks). Bauman’s angle, carrying angle and functional factor were measured postoperatively. Closed reposition with pinning, using radiographic control, for the dislocated supracondylar humeral fractures is the safest, as well as the least time consuming and cost-effective method. We also suggest treating these fractures within 12 hours and conversion of closed into open reposition in case of lacking crepitations (possibility of interposition of soft tissues between fragments).
Neurovascular injury in supracondylar fracture of Humerus  [PDF]
KR Shrestha,R Sapkota,N Rajbhandari,B Thapa,UK Shrestha
Journal of Institute of Medicine , 2012, DOI: 10.3126/joim.v34i3.8909
Abstract: Introduction: Supracondylar fractures of the humerus are the commonest upper limb fractures in children, accounting for up to 70% of all pediatric elbow fractures. Supracondylar fractures of the humerus can be managed in outpatient setting but are often complicated by neurovascular injury. Methods: Retrospective study including 187 patients who had presented with supracondylar fracture of humerus with 47 neurovascular injuries during the period of July 2007 to June 2011. Out of 142 patients with Gartland type III fracture 107 underwent immediate open reduction, exploration and internal fixation. Results: Vascular injury is commonly associated with type II supracondylar fracture with posterior displacement. Twenty two patients had vascular injury and all of them had satisfactory outcome after surgery. Conclusion: A careful clinical evaluation, urgent surgical treatment and adequate fracture reduction can prevent lifelong handicap. DOI: http://dx.doi.org/10.3126/joim.v34i3.8909 Journal of Institute of Medicine, December, 2012; 34:12-16
Close Reduction and Percutaneous K-wire Fixation without Image Intensifier in Supracondylar Fracture of Humerus in Children  [PDF]
Ruhullah Mohammad,Sanjay Kumar Ranjan Shah,HR Singh,KD Sinha,Dipan Barua,Mohammad Irshad,Sanjay Gupta
Nepal Orthopaedic Association Journal , 2013, DOI: 10.3126/noaj.v3i1.9321
Abstract: Introduction: Extension Type III supracondyla fractures of the humerus is most common fractures around the elbow in children. Closed reduction and percutaneous pinning under image intensifier guide has been the gold standard method of treatment. However, image intensifier is not readily available in most part of our country. Closed reduction and percutaneous pinning is possible even without image intensifier. we report our case series of 51 cases who underwent closed reduction and percutaneous pinning without image intensifier. Methods: Between November 2009 and April 2011 a total of 51 children with a displaced supracondylar fractures of the humerus were managed by close reduction and percuteneus k-wire fixation without using image intensifier. They were followed for a period of minimum 6 months up to one and a half years (average one year) and the final outcome was assessed using functional and cosmetic criteria used by Flynn and associates. Results: Of these 51 patients, 46 (90%) patients showed an excellent results. Satisfactory results were achieved in 4 (8%) patients, poor in 1(2%) patients. Conclusion: Close reduction and percutaneous K-wire fixation without using image intensifier is radiation free, cost effective and relatively safe method of management of displaced supracondylar fractures of humerus in children. It can be used in a remote hospital where the facilities of image intensifier or portable x-ray are not available. DOI: http://dx.doi.org/10.3126/noaj.v3i1.9321 Nepal Orthopedic Association Journal 2013 Vol.3(1): 19-22
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