Supracondylar Fracture Elbow Classification Essay

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1. Introduction

Supracondylar humerus fractures (SCHF) are common injury in children and represent the most frequent fractures involving the elbow [1,2,3]. These fractures affect mainly the male gender and occur prevalently in consequence of an extension mechanism [4]. The current treatment of displaced supracondylar fractures consists of closed reduction and percutaneous pin fixation using Kirschner wires, while some controversies still exist regarding the placement of the pins [5,6,7].

Percutaneous pinning has proven to be the least invasive and safest techniques for bone healing. It is characterized by a low incidence of complications (2%–8%) and mainly consisting of pin migration under the skin, pin infections and loss of fracture reduction [8,9]. Only in cases of open fractures, irreducible fractures by interposition of soft tissues or in cases of possible neurovascular complications, should open surgery interventions be performed as soon as possible [10,11,12].

Controversy still exists about the optimal placement of the pins. A crossed-pin technique is thought to be mechanically more stable than lateral pin alone even if with the use of the last one, the ulnar nerve could be more easily injured. Slobogean et al. [12] suggest that there is a greater risk of iatrogenic ulnar nerve injury with crossed pinning versus lateral pinning in children with SCHF.

The aim of this study is to clinically and radiographically compare the effectiveness of SCHF treatment and the complications using the two more common percutaneous K-wire pinning: cross and lateral configurations.

2. Patients and Methods

During the period between May 2005 and December 2012, 35 patients were examined at the Orthopedic Clinic of the University of Catania. All subjects gave their informed consent for inclusion before they participated in the study. The study was conducted in accordance with the Declaration of Helsinki, and the protocol was approved by the Ethics Committee of Catania.

The exclusion criteria concerned open fractures of the distal humerus, patients who were adolescents or older at the time of injury, and patients with multiple bone injuries that required multidisciplinary treatment and/or admission to intensive care.

Age at time of surgery, gender, side injured, mechanism of injury, and type of fracture according to Gartland classification were reported. The direction of fracture displacement, time between injury and surgery, time from injury to admission, and the onset of major complications were collected using clinical and radiographic data and parental information on the lesion dynamics. Patients underwent clinical examination and conventional radiography of the anteroposterior and lateral side of the affected limb.

All patients were surgically treated, using a closed reduction and fixation with K-wires. Two different pin configurations, cross (Group 1) and lateral (Group 2).

All treated subjects were evaluated clinically according to Flynn’s criteria [13] and the Mayo Elbow Performance Score (0–100 points) [14,15] and radiographically (including the measurement of the Baumann angle) [16]. All patients were assessed at 1, 3, 6, and 12 months, and then every year. The statistical significance of the results was analyzed by the independent sample Student’s t-test and Fisher’s exact test. A p value of <0.05 was considered to be statistically significant.

3. Results

The average age of the patients was 6 years (range 2.4–8.9), and the cohort comprised 25 males (72.4%) and 10 females (27.6%) with displaced supracondylar fractures of the humerus (all with Gartland type III fractures) (Figure 1A,B). In 24 patients (69%) the involved limb was on the left and in 11 (31%) cases on the right. The fractures were linked to a trauma in extension resulting from a fall on the palm of the hand with a hyperextended elbow. This occurred in games in 31 (89.6%) and motor vehicle accidents in 4 (10.4%). Regarding the direction of displacement, there were 28 (79%) fractures of type IIIA and 7 (21%) of IIIB.

Figure 1. Anteroposterior (A) and lateral (B) radiographs of a patient with a Gartland type III fracture surgically treated eight hours after presentation.

Figure 1. Anteroposterior (A) and lateral (B) radiographs of a patient with a Gartland type III fracture surgically treated eight hours after presentation.

All subjects were treated within eight hours of presentation with a closed reduction and percutaneous pin fixation. After inducing general anesthesia, the patients were positioned in a supine position at the edge of the operating table with the affected limb thoroughly supported by the side. The arm was positioned at a “C” on the brightness amplifier plate. A closed reduction and fixation with 1.6 to 2 mm K-wire were used according to the young age of the patients. In the cross pin configuration, the first wire was positioned at the center of the lateral condyle and the second wire was medially inserted taking care to not injure the ulnar nerve. To avoid this complication, a landmark for the insertion of the medial wire was the small area of the medial epicondyle in which the pin must be positioned as far anterior as possible. Using the lateral pin configuration, the first pin was placed centrally and just lateral to the olecranon; the second pin was inserted laterally.

For both configurations (crossed and lateral pins), the wires were positioned distant from each other and careful attention was given to ensure that the pins did not cross the fracture at the same point. After stabilization with wires, the children were immobilized with a simple posterior splint at 90 degrees of flexion. The goal was to optimize perfusion and minimize swelling. In all cases, K-wires protruded outside the wound.

The children, belonging to this study, were randomly submitted to two different wires techniques: 22 patients (62.1%) were treated by closed reduction and percutaneous fixation with the crossed wires technique (Group 1) (Figure 2A,B) and 13 (37.9%) had the lateral-wire configuration (Group 2) (Figure 3A,B). The average age of the 22 children forming Group 1 was 6.26 ± 2.48 including 16 males (72.4%) and 6 females (27.6%). Group 2 consisted of 13 children aged 5.69 ± 2.52 years on average and comprised 9 males (72.7%) and 4 females (27.3%). There were no substantial differences between the groups in terms of age, sex, or injured limb.

Figure 2. Clinical Case Group 1. (A) Pre-op AP radiograph of crossed pinning; (B) immediate postoperative AP radiograph of crossed pinning; and (C) follow-up after three years.

Figure 2. Clinical Case Group 1. (A) Pre-op AP radiograph of crossed pinning; (B) immediate postoperative AP radiograph of crossed pinning; and (C) follow-up after three years.

Figure 3. Clinical Case Group 2. (A) Pre-op AP radiograph of lateral-entry pinning; (B) immediate postoperative AP radiograph of lateral-entry pinning; and (C) follow-up after three years.

Figure 3. Clinical Case Group 2. (A) Pre-op AP radiograph of lateral-entry pinning; (B) immediate postoperative AP radiograph of lateral-entry pinning; and (C) follow-up after three years.

The subjects were usually discharged the day after treatment and returned for assessment 5–10 days after surgery for clinical and radiographic evaluation. On average, the wires were removed four weeks after outpatient X-ray control, and each subject received an intensive rehabilitation protocol to restore the full range of motion of the elbow.

The mean follow up was 44 ± 11.15 months (range 13–67). According Flynn’s criteria, Group 1 had excellent cosmetic outcome in 21 subjects (94.4%) and good in one (5.6%). The functional factor was satisfactory in 21 patients (94.4%). On examination at final follow-up, the range of motion in the treated arm resulted in values for flexion-extension of 103° ± 12.05° (range 90°–130°), and supination to pronation of 87° ± 2.42° (range 82°–90°). The carrying angle was measured at an average of 4.4° ± 2.11° (range 2.6°–6.5°). In one case, a 7.5° deficit of extension was noticed (Figure 2C). In Group 2, the cosmetic and functional factors were satisfactory in all patients (100%). At the final follow-up, the range of articulation gave a flexion-extension range of about 110.27° ± 14.39° (range 92°–135°) and supination to pronation of about 87.7° ± 1.62° (range 85°–90°). The difference in the carrying angle was on average 4.46° ± 1.91° (range 2.8°–6.6°) (Figure 3C). These data were compared to those of the contralateral limb, and the figures for the average amplitude of movement were similar.

The results of the Mayo Elbow Performance Score (Max 100 points) were: Group 1, 96 points, and Group 2, 98 points (Table 1, Table 2 and Table 3). Radiographically, measurements of the angle of Baumann between the injured limb and the normal limb were: Group 1—a difference of 5.3° ± 2.12° (range 4°–6.6°), and Group 2—a difference of 4.9° ± 2.82° (range 3.1°–6.7°).

Table 1. Twenty-nine patients with displaced (Gartland type III) extension type supracondylar fractures of the humerus randomly treated by closed reduction and percutaneous fixation with crossed medial-lateral pins or two lateral pins; and comparative outcome measures at the last follow-up.

CharacteristicsGroup 1—K-Wire Cross Configuration (n = 22)Group 2—Lateral K-Wire Configuration (n = 13)p Value
Age * (years)6.26 ± 2.485.69 ± 2.520.55 ¤
Gender † (% of patients)0.66 §
Male †16 (72)9 (73)
Female †6 (28)4 (27)
Side † (% of patients)0.53 §
Left Side †15 (67)9(73)
Right Side †7 (33)4(27)
Type of Displacement † (% of patients)0.59 §
Posteromedial (III A) †17 (78)11 (82)
Posterolateral (III B) †5 (22)2 (18)
Dynamics of injury † (% of patients)0.68 §
Childish games †19 (89)12 (91)
Motor Accident †3 (11)1 (9)
Time between admission to surgery * (h)7.8 ± 2.988.64 ± 3.510.49 ¤
Time between injury to admission * (h)43.61 ± 9.541.18 ± 8.50.45 ¤
Follow up * (months)44.39 ± 10.7442.91 ± 15.770.76 ¤
Flynn Criteria Cosmetic Factor †(% of patients)0.62 §
Excellent21 (94)13 (100)
Good1 (6)0
Fair00
Poor00
Flynn Criteria Functional Factor † (% of patients)
Flexion—Extension103 ± 12.05110.27 ± 14.390.16
Supination—Pronation87 ± 2.4287.7 ± 1.620.39
Modification Carrying Angle (deg) *4.4 ± 2.114.46 ± 1.910.94 ¤
Mayo Elbow Performance Score96/10098/100
Modification Baumann’s Angle (deg) *5.3 ± 2.124.9 ± 2.820.53 ¤
Reoperations †001.0 §
Return to function †

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