Controversial Issues in Closed Reduction and percutaneous pinning of Supracondylar Fractures of Humerus in children

Vol 1 | Issue 1 | July-Sep 2015 | page:11-15 | Taral Nagda, Jaideep Dhamele, Chetan Pishin.


Authors : Taral Nagda[1], Jaideep Dhamele[1], Chetan Pishin[2].

[1] Consultant Institute of Pediatric Orthopedic Disorders Mumbai India.
[2] Fellow Institute of Pediatric Orthopedic Disorders Mumbai India.

Address of Correspondence
Dr . Taral Nagda
Consultant Institute of Pediatric Orthopedic Disorders Mumbai India.
Email address: taralnagda@gmail.com


Abstract

Introduction: Closed reduction and percutaneous pinning is the mainstay in treatment of supracondylar humerus fractures in children. Although most of the issues are quite straight forward, but in certain situations, there exists difference in opinion in literature. Individual/ group of researchers will always find data to favor one approach over other, but the metaanalysis of the entire literature on the topics fails to show any advantage of one over other. We have tried to touch upon few such questions like Pin Configurations, emergency vs delayed fixation, radiation exposure etc. The pattern of the article is quite unique in terms of referencing the references in details and one after the other. The results are then compiled and guidelines are suggested according to current literature.
Keywords: Closed reduction, supracondylar humerus fracture, percutaneous pinning.


Introduction
Percutaneous pinning of supracondylar fracture is one of the commonest procedures in paediatric orthopaedics, yet there remain certain areas of controversy or lack of consensus. This article is prepared in separate dialectic sections each dealing with a unique question. Relevant literature is then reviewed to reach a logical answer.

A] Pin configurations: Lateral v/s Cross
Closed reduction and pinning is a gold standard in the management of displaced supracondylar fractures of humerus in chidren [1]. It allows the elbow to be maintained in a position of relative extension thus minimizing chances of compartment syndrome and vascular compromise yet providing stability and avoiding malunion associated with the fracture. There is an ongoing debate on choice of the the pin configuration while fixing SCFH [2]. In laboratory settings, cross pinning appears to have better stability but in clinical setting both seem to do equally well with additional risk of iatrogenic ulnar nerve palsy with medial pinning. We examined some of recent papers which can guide an orthopedic surgeon solve the dilemma.

Literature 

1. Medial and Lateral Crossed Pinning Versus Lateral Pinning for Supracondylar Fractures of the Humerus in Children: Decision Analysis [1].

Salient Features
-A decision analysis model was designed containing the probability of iatrogenic ulnar nerve palsy and malunion caused by unstable fixation for each of lateral pinning and medial and lateral crossed pinning techniques. The final outcome was function adjusted life year and used as a utility in the decision tree, where function was evaluated using the McBride disability evaluation.
-Medial and lateral crossed pinning and lateral pinning have opposite aspects to each other in terms of mechanical stability and iatrogenic ulnar nerve injury.
-Iatrogenic ulnar nerve injury after percutaneous pinning of a supracondylar fracture of the humerus can be devastating and irreversible, whereas malunion is correctable. Therefore, the authors recommend the lateral pinning technique for supracondylar fracture of the humerus in children.
-If the minimal medial incision technique could reduce the iatrogenic ulnar nerve injury rate down to 0.7%or a surgeon used a crossed pinning technique with an iatrogenic ulnar nerve injury rate of <0.7%, then the medial and lateral crossed pinning technique could be a better choice than the lateral pinning technique.

2. Is lateral pin fixation for displaced supracondylar fractures of the humerus better than crossed pins in children? [2]

Salient features
-A meta-analysis of the data from pubmed, embase and cochrane library of RCTs.
-Using varoius stastical analytic tools, it was found out that iatrogenic ulnar nerve palsy rate was higher in patients who underwent cross pinning.
-There were no statistical differences in radiographic outcomes, function, and other surgical complications. No significant heterogeneity was found in these pooled results.
-Authors recommended 2 lateral k wires.

3. Meta-Analysis of Pinning in Supracondylar Fracture of the Humerus in Children [3]

Salient Features
-All randomized controlled trials and cohort studies comparing outcomes (ie, loss of fixation, iatrogenic ulnar nerve injury, and Flynn criteria) between crossed and lateral pinning were identified.
-The risk of iatrogenic ulnar nerve injury was 4.3times higher in cross pinning compared with lateral pinning.
-There was no significant difference for loss of fixation, late deformity, or Flynn criteria between the two types of pinning.
-The study concluded that lateral pinning is preferable to cross pinning for fixation of pediatric supracondylar humerus fractures as a result of decreased risk of ulnar nerve injury.

4. Treatment of displaced supracondylar humeral fractures among children: Crossed versus lateral pinning.[4]

Salient features
-108 children were treated by closed reduction and percutaneous pinning: 37 with crossed pins, 37 with two lateral pins and 34 with two lateral and one medial pin
-Fractures fixed by two lateral pins were found significantly prone to postoperative instability, late complications and need for medial pin fixation.
-Of the 48 type III fractures fixed primarily with two lateral pins, 31 showed intraoperative instability that warranted an additional medial pin. Of the 17 fractures fixed by lateral pins alone, 8 demonstrated significant postoperative instability and 4 of these developed
cubitus varus deformity.
-There was a significant relation between either delay to surgery or postoperative instability and occurrence of complications.
-Fixation by two lateral pins only is not recommended for treating type III supracondylar humeral fractures, but could be used initially to fix severely unstable fractures to allow extension of the elbow before inserting a medial pin. Every effort should be made to avoid iatrogenic ulnar nerve injury while inserting the medial pin.
-Measures taken to avoid iatrogenic ulnar nerve damage while inserting a medial pin include relative extension of the elbow with a maximum of 60 flexion, after inserting the lateral pin. This should reduce possible ulnar nerve subluxation before inserting the medial pin. In very unstable fractures, a second lateral pin may be needed to provide more stability before partially extending the elbow for safe medial pin placement. If the ulnar nerve and groove can not be identified with confidence, a small incision should be made over the pin insertion site and blunt dissection should be performed down to the bone, to place the pin under direct vision. Dorgan’s technique of inserting crossed pins from the lateral side of the arm, as described by Shannon et al. offers the biomechanical advantages of cross-pinning while avoiding the risk of iatrogenic ulnar nerve injury.

5. Crossed pinning in paediatric supracondylar humerus fractures: a retrospective cohort analysis. [5]

Salient features
-Clinical and radiological results of 78 paediatric patients treated with closed reduction and percutaneous pinning
-No iatrogenic ulnar nerve palsy but one iatrogenic radial palsy which recovered in 13 weeks
-All paients were operated within 6 hours of injury
-Authers concluded that In cases were the ulnar nerve is palpable in the ulnar groove, blind percutaneous crossed pin placement is safe. If closed reduction fails or ulnar nerve subluxation cannot be excluded, a medial mini-open approach to visualise the nerve is certainly safer and should be preferred.

6. Biomechanical Analysis of Pin Placement for Pediatric Supracondylar Humerus Fractures: Does Starting Point, Pin Size, and Number Matter? [6]

Salient features
-20 synthetic humeri were sectioned in mid-olecraon fossa, and were directly reduced and fixed with 2 lateral k wires. There were 2 groups, one where both wires had a lateral entry and one group where one wire was put through capitellum and other through more lateral entry. Capitellar group provided greater stiffness in internal and external rotation. Capitellar entry provides for better stiffness of the construct compared to direct lateral entry by engaging sufficient bone and providing enough separation between the wires.
-Authors concluded that a capitellar entry should be used for one of the k wires.

7. Radial nerve safety in Dorgan’s lateral cross-pinning of the supracondylar humeral fracture in children: a case report and cadaveric study [7].

Salient Features
-Authors encountered a radial nerve palsy while using a lateral proximal pin entry for the cross K wire fixation for supra-condylar fracture of humerus.
-They did a cadaveric study in a pediatric humeri and noted that radial nerve is farthest from the wire in the postero lateral plane.
-Authers concluded that direction of the pin should be posterolateral within 2 cm of the lateral epicondyle.

8. Safe Zone for Superolateral Entry Pin Into the Distal Humerus in Children: An MRI Analysis [8]

Salient features
To determine the course of the radial nerve at the lateral distal humerus, authors reviewed 23 elbow radiographs and MRIs of 22 children and mapped radial nerve course.
-They concluded that Percutaneous direct lateral entry Kirschner wires and half-pins can be safely inserted in the distal humerus in children along the transepicondylar axis, either at or slightly posterior to the lateral supracondylar ridge, when placed caudal to the point located where the lateral supracondylar ridge line diverges from the proximal extent of the supracondylar ridge on AP elbow radiograph.

9. A retrospective analysis of loss of reduction in operated supracondylar humerus fractures [9].

Salient features
-18% patients had loss of reduction. Technical errors were noted to be higher in those patients were reduction was lost.

10. Management of Pediatric Type III Supracondylar Humerus Fractures in the United States: Results of a National Survey of Pediatric Orthopaedic Surgeons [10].

Salient features
-A short survey was sent to Pediatric Orthopaedic Society of North America (POSNA) members using an online survey and questionnaire service. The purpose of the survey was to establish an overview of current practices in the United States concerning treatment of type III supracondylar humerus fractures and the influence of the recent literature on the management of these injuries. — A total of 309 members, representing a wide range of locations and years in practice, responded to the survey
They reported 3 lateral pins (37%), 2 lateral pins (33%), and cross pins (30%) as the preferred method of fixation among respondents. This does show that two thirds of survey participants were using lateral pins primarily.
-However, many of those responding noted that they will add a medial pin to a lateral pin construct if they feel like more stability is needed intraoperatively. Some said that medial cortex comminution is one instance where a medial pin may be needed.
-The respondents that do place a medial pin regularly, advise placement of the lateral pin first for stability, followed by extension of the elbow for placement of the medial pin. This plus opening the medial side and exposing the medial epicondyle has been shown as a reliable technique to assist in protecting the ulnar nerve during medial pin placement. Overall, the sense was that ulnar nerve injury is not a common occurrence if proper precautions are taken.

Authors Comments and recommendations
1. The battle between lateral pinning and cross pinning is a battle between safety and stability
2. The supracondylar fractures are of different configurations and hence pin configurations have to be customized to the specific fracture geometry
3. Most cases of transverse and lateral oblique variety can be well treated by two or three lateral parallel or divergent pins. The stability of lateral pins can be improved in these cases by following measures
a. Capitellar entry point for one of the pins
b. Divergent pin configuration
c. Using wires more than 2 mm diameters
d. Pass pins from anterior to posterior direction at 15-300 to shaft of humerus to have maximum purchase in the distal humerus which is inclined 45 to shaft of humerus
e. Avoid multiple attempts. Multiple attempts weaken the pin bone interphase and weakens the hold of the K wire
4.In some situations medial pin may be added in addition to lateral pins These indications are
a. Intraoperative instability after passing lateral pins
b. Medial comminution
c. Medial oblique fracture
d. Adolescent supracondylar fracture
e. Low supracondular fractures
f. Obliquity in coronal plane which signifies instability
5. Some medial oblique fractures may need only medial pinning
6. The safety of medial pinning can be improved in these cases by
a. Pinning in relative extension The elbow should not be flexed more than 60
b. Pinning from anterior to epicondyle to posterior
c. Feeling the medial epicondyle and pushing ulnar nerve manually with a thumb pressure
d. In doubt or whenever there is a swelling using a mini opening on medial side to make sure the pin is well away from the nerve and does not entangle it
e. Use of a K wire protecting sleeve to prevent entanglement of ulnar nerve sheath.

B] Timing of surgery Emergency v/s Elective
Traditionally supracondylar fractures have been treated as emergency cases. The delay in management of supracondylar fracture may be because of delay in presentation of patient to the hospital or delay after the patient pesents to the hospital. If the patient presents in the morning hours the emergency management is not an issue but when the patient presents to hospital the emergency management poses issues of availability of senor consultant, anaesthesia risk, support staff and cost. The main concerns associated with delayed treatment are as follows:
1. the failure of closed reduction due to swelling
2. the need to convert to open reduction
3. the complications of neurovascular compromise and compartment syndrome.
One study found that children who underwent later surgery after injury (more than 8 h) were more likely to require an open reduction as compared with those who underwent earlier surgery after injury (8 h or less)[3], whereas other studies found no such statistically significant association [4,5]. One of the issues in the management of displaced supracondylar fracture is to manage the patient as emergency or do the surgery the next morning on a routine list. We have again explored recent literature to show some guidelines for treating orthopedic surgeons on this issue.

1. A systematic review of early versus delayed treatment for type III supracondylar humeral fractures in children [11].

Salient features
-Using medline and Cochrane database 156 publications were scrutinized. Only 7 studies were identified were the effect of early versus delayed treatment were studied. Treatment given in all of them was closed reduction and percutaneous pinning. All the studies were non-randomized and retrospective.
-The authers concluded that chances of failure of closed reduction and conversion to open reduction were significantly high if surgery was delayed beyond 12 hours.

2. Delayed surgery in displaced paediatric supracondylar fractures: a safe approach? Results from a large UK tertiary paediatric trauma centre [12].

Salient features
-Authors reviewed charts of patients :115 children into those treated before 12 h (early surgery) and after 12 h (delayed surgery) .
-The results indicate that delayed surgery appears to offer a safe management approach in the treatment of displaced supracondylar fractures, but it is important that cases are carefully evaluated on an individual basis

3. Operative Treatment of Type II Supracondylar Humerus Fractures: Does Time to Surgery Affect Complications? [13]

Salient Features
-Retrospective review of a consecutive series of 399 modified Gartland type II supracondylar fractures treated operatively at a tertiary referral center over 4 years. A total of 48% were pinned within 24 hours, 52% pinned >24 hours after the injury.
-Delay in surgery did not result in an increased rate of major complications following closed reduction and percutaneous pinning of type II supracondylar humerus fractures in children.

4. Management of Pediatric Type III Supracondylar Humerus Fractures in the United States: Results of a National Survey of Pediatric Orthopaedic Surgeons [10].

Salient features
-An overwhelming majority of respondent to the survey (81%) noted that they do not treat type III supracondylar humerus fractures on an emergent basis if they present after normal work hours, assuming the patient has no obvious reason for emergent intervention, such as, impending compartment syndrome, open injury, vascular injury, or skin compromise
-NPO status and aspiration risk is a concern during emergency surgery. This is a complication that can potentially be avoided with delayed treatment.
– Some respondents treated these on an emergent basis if the fracture is severely displaced or that reduction has seemed more difficult as swelling increases. Other participants cite the lack of OR time the following morning as a reason to fix some of these fractures after normal work hours.
-However, the majority of respondents felt like delayed surgical fixation in this setting was appropriate.

Authors Comments and recommendations
1. We feel that every displaced supracondylar fracture is different and need to have different strategy
2. A displaced supracondylar fracture should be splinted in 60 flexion in an above elbow slab and note be made of neurovascular status, swelling, compartment syndrome, open injury, pucker sign, medial spike
3. Most who present in routine hours get fixed in routine list
4. Those who present in after routine hours are classified into two types
a. Those who can wait till next day
1. Those not fitting into emergency fixation check list
2. Those Presenting after 48 hours where delay of few hours will not make a difference
b. Those who need to be fixed immediately
1. Open injury
2. Compartment syndrome or impending compartment syndrome or even suspicion of compartment syndrome
3. Nerve palsy
4. Pulseles hand pink or pale
5. Difficult reductions due to swelling medial spike puckering etc as the difficulty will increase with increasing time
5. In borderline cases or when doubt exists the case is operated as emergency in presence of senior consultant
6. Even in emergency situation make sure that facilities for open reduction if required are available.

C] Radiation Exposure – What is the risk?

The use of fluoroscopy facilitates the accurate placement of K wires while fixing supracondylar fractures. One negative side effect of fluoroscopic imaging, however, is ionizing radiation. It is a practice to use image intensifier in inverted fashion while doing CRPP for SCFH in children. The issue is what are the factors affecting direct beam and scattered radiation exposure and how to minimize this.

1. The Effect of C-Arm Position on Radiation Exposure During Fixation of Pediatric Supracondylar Fractures of the Humerus [14].

Salient features
-There is a concern that using image intensifier as operating table during surgery may lead to increased radiation exposure to the patient and to the surgeon. This study was done to determine radiation exposure from c-arm configurations.
-It was noted that there was 16% less scatter at waist level but 54% more scatter at the neck level when using c arm as operating table as compared to using an arm board.
-Although the statiscal difference was significant between the 2, yet neither of the 2 was safe.

2. Direct Beam Radiation Exposure to Surgeons During Pinning of Supracondylar Humerus Fractures: Does C-Arm Position and the Attending Surgeon Matter?

3842 fluoroscopic still images from 78 closed reduction and percutaneous pinning surgeries for supracondylar humerus fractures performed or supervised by 6 attending surgeons. The percentage of images containing a surgeon’s body was calculated as an indicator of direct beam radiation exposure. Total fluoroscopy time, C-arm position (standard or inverted), and whether the primary surgeon was an attending, resident, or both were recorded.
-They noted that fluoroscopy was significantly longer and surgeon’s exposure to direct beam radiation higher when the C-arm position was inverted when compared with the standard position.

Authors Comments and recommendations
1. Direct exposure delivers approximately 100 times more ionizing radiation to the surgeon compared with scatter radiation.
2. Standard radiation dosimeter badges are worn on the neck and waist of surgeons, which measure only scatter radiation unless the fluoroscopy beam directly hits the badge.
3. The surgeons’ hands are the most exposed part of the body during surgery, with the fingertips and the dominant index finger being at greatest risk.
4. Suggestions for minimizing the radiation exposure to both the patient and the surgeon.
a. Use of protective lead aprons, thyroid seals, leadlined eyeglasses, and lead-lined gloves.
b. Lead-lined gloves, however, may produce a false sense of security by providing little additional protection.
c. Being close to the radiation source side of the platform and reducing the fluoroscopy time is shorter.
d. Using a laser light guidance beam with the conventional C-arm.

D] Other issues

1. Can CRPP for supracondylar fractures be considered as being a day care procedure?
Answer : Yes. Provided fracfture is not open or associated with a neuro-vascular injury [16].

2. Does the Pin Size influence the stability of supracondylar fixation
Answer – Large pin sizes improved radiographic sagittal alignment at final follow-up without an increased rate of infection or ulnar nerve palsy. The commonly used 1.6-mm K-wire may be considered a “large” pin if used in a young or small patient, but also could be considered a “small” pin if used in an older or larger individual. The pin diameter should be similar to the thickness of the midshaft cortex. At the time of fracture reduction, the ratio of the diameter of the pin to the patient’s humeral midshaft cortical thickness can quickly and easily be determined by placing the pin over the arm during fluoroscopy. For a “large” pin, the ratio should be atleast 1 [17,18]

3. How long does it take for children supracondylar fractures to regain full range of motion after closed pinning?
Answer: By 6 weeks children gain 72% of elbow ROM of contralateral elbow and by 52 weeks 98% of elbow ROM of contralateral elbow [19].


References

1. Lee KM, Chung CY, Gwon DK, Sung KH, Kim TW, Choi IH, Cho TJ, Yoo WJ, Park MS. Medial and lateral crossed pinning versus lateral pinning for supracondylar fractures of the humerus in children: decision analysis. J Pediatr Orthop. 2012 Mar;32(2):131-8.
2. Zhao JG, Wang J, Zhang P. Is lateral pin fixation for displaced supracondylar fractures of the humerus better than crossed pins in children? Clin Orthop Relat Res. 2013 Sep;471(9):2942-53.
3. Woratanarat P, Angsanuntsukh C, Rattanasiri S, Attia J, Woratanarat T, Thakkinstian A. Meta-analysis of pinning in supracondylar fracture of the humerus in children. J Orthop Trauma. 2012 Jan;26(1):48-53.
4. Zamzam MM, Bakarman KA. Treatment of displaced supracondylar humeral fractures among children: crossed versus lateral pinning. Injury. 2009 Jun;40(6):625-30.
5. Krusche-Mandl I, Aldrian S, Köttstorfer J, Seis A, Thalhammer G, Egkher A. Crossed pinning in paediatric supracondylar humerus fractures: a retrospective cohort analysis. Int Orthop. 2012 Sep;36(9):1893-8.
6. Gottschalk HP, Sagoo D, Glaser D, Doan J, Edmonds EW, Schlechter J. Biomechanical analysis of pin placement for pediatric supracondylar humerus fractures: does starting point, pin size, and number matter? J Pediatr Orthop. 2012 Jul-Aug;32(5):445-51.
7. Gangadharan S, Rathinam B, Madhuri V. Radial nerve safety in Dorgan’s lateral cross-pinning of the supracondylar humeral fracture in children: a case report and cadaveric study. J Pediatr Orthop B. 2014 Nov;23(6):579-83.
8. Bloom T, Zhao C, Mehta A, Thakur U, Koerner J, Sabharwal S. Safe zone for superolateral entry pin into the distal humerus in children: an MRI analysis. Clin Orthop Relat Res. 2014 Dec;472(12):3779-88.
9. Balakumar B, Madhuri V. A retrospective analysis of loss of reduction in operated supracondylar humerus fractures. Indian J Orthop. 2012 Nov;46(6):690-7.
10. Carter CT, Bertrand SL, Cearley DM. Management of pediatric type III supracondylar humerus fractures in the United States: results of a national survey of pediatric orthopaedic surgeons. J Pediatr Orthop. 2013 Oct-Nov;33(7):750-4.
11. Loizou CL, Simillis C, Hutchinson JR. A systematic review of early versus delayed treatment for type III supracondylar humeral fractures in children. Injury. 2009 Mar;40(3):245-8.
12. Mayne AI, Perry DC, Bruce CE. Delayed surgery in displaced paediatric supracondylar fractures: a safe approach? Results from a large UK tertiary paediatric trauma centre. Eur J Orthop Surg Traumatol. 2014 Oct;24(7):1107-10.
13. Larson AN, Garg S, Weller A, Fletcher ND, Schiller JR, Kwon M, Browne R, Copley LA, Ho CA. Operative treatment of type II supracondylar humerus fractures: does time to surgery affect complications? J Pediatr Orthop. 2014 Jun;34(4):382-7.
14. Hsu RY, Lareau CR, Kim JS, Koruprolu S, Born CT, Schiller JR. The Effect of C-Arm Position on Radiation Exposure During Fixation of Pediatric Supracondylar Fractures of the Humerus. J Bone Joint Surg Am. 2014 Aug 6;96(15):e129.
15. Eismann EA, Wall EJ, Thomas EC, Little MA. Direct beam radiation exposure to surgeons during pinning of supracondylar humerus fractures: does C-arm position and the attending surgeon matter? J Pediatr Orthop. 2014 Mar;34(2):166-71.
16. Nayak AR, Natesh K, Bami M, Vinayak S. Is closed manipulative reduction and percutaneous Kirschner wiring of supracondylar humeral fracture in children as day-care surgery a safe procedure ? Malays Orthop J. 2013 Jul;7(2):1-5.
17. Srikumaran U, Tan EW, Erkula G, Leet AI, Ain MC, Sponseller PD. Pin size influences sagittal alignment in percutaneously pinned pediatric supracondylar humerus fractures. J Pediatr Orthop. 2010 Dec;30(8):792-8.
18. Srikumaran U, Tan EW, Belkoff SM, Marsland D, Ain MC, Leet AI, Sponseller PD, Tis JE. Enhanced biomechanical stiffness with large pins in the operative treatment of pediatric supracondylar humerus fractures. J Pediatr Orthop. 2012 Mar;32(2):201-5.
19. Zionts LE, Woodson CJ, Manjra N, Zalavras C. Time of return of elbow motion after percutaneous pinning of pediatric supracondylar humerus fractures. Clin Orthop Relat Res. 2009 Aug;467(8):2007-10.


How to Cite this Article: Nagda T, Dhamele J, Pishin C. Controversial Issues in Closed Reduction and percutaneous pinning of Supracondylar Fractures of Humerus in children. International Journal of Paediatric Orthopaedics July-Sep 2015;1(1):11-15.          

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Cubitus Varus Deformity – Rationale of Treatment and Methods

Vol 1 | Issue 1 | July-Sep 2015 | page: 26-29 | Sandeep Patwardhan,  Ashok K Shyam.


Authors : Sandeep Patwardhan[1],  Ashok K Shyam1[1].

[1] Sancheti Institute for Orthopaedics and Rehabilitation 16, Shivajinagar, Pune, India.

Address of Correspondence
Dr. Sandeep Patwardhan
Sancheti Institute for orthopaedics and Rehabilitation
16, Shivajinagar, Pune, India.
Email- sandappa@gmail.com


Abstract

Background: Cubitus varus is commonest complication of paediatric supracondylar humerus fracture. These deformities are most commonly result of malunion, however avascular necrosis of trochlea or growth arrest of medial physis may also cause the deformity. Cubitus varus mostly presents as cosmetic deformity but it may also cause posterolateral instability, increased risk of secondary fractures, tardy ulna nerve palsy and snapping elbow. Current trend is to offer surgical correction for cubitus varus deformity in form of supracondylar osteotomy of the humerus. Various kinds of surgical approaches, osteotomy configuration and fixation methods are described in literature. The main guiding principles in deformity correction should be complete correction of sagittal varus deformity, correction of hyperextension deformity in older children. Rotational deformities may not be corrected but some authors do recommend triplanar correction. In our view lateral closed wedge oblique equal limb osteotomy fixed with reconstruction plate offers best results and is enough to treat most of the cubitus varus cases with minimal complication.
Keywords: Cubitus varus, osteotomy, complications.


Introduction
Cubitus varus or gunstock deformity as it is commonly known is the most common complication of displaced supracondylar fractures in children with an incidence ranging from 3% to 57% [1]. The deformity involves not only loss of coronal alignment to make the distal forearm and hand deviate to the midline of the body ,but also has recurvatum deformation in the sagittal plane and internal rotation deformity in the axial plane. Recurvatum deformity is in the plane of motion of the joint and remodels well. The internal rotation deformity is compensated by shoulder movements and is tolerated well. Both these deformities may not require corrections and most of the times correction is focussed on coronal plane deformity.
Malunion seems to the cause of the deformity in majority of the cases, though very rarely growth disturbances in trochlea or avascular necrosis of trochlea may cause progression of the deformity. The causative factors for malunion are:
1. Impacted / comminuted type I supracondylar fractures
2. Rotationally unstable type II fractures treated in a cast with subsequent loss of reduction
3. Poorly stabilised or reduced type III fractures or delayed neglected fractures

Should we correct these deformities?
The clinical presentation of a child with cubitus varus is usually an unsightly deformity with a reasonably good ROM at the elbow. Although some studies have reported asymmetrical flexion arc with limitation of elbow flexion range on affected side [3] but functional arc was maintained. This led most authors to believe that the deformity has no functional implications
However studies have shown that long term follow up of children with cubitus varus may result in a problems such as increased chances of lateral condyle fractures or other secondary fractures, posterolateral elbow pain and instability, tardy ulnar nerve palsy [4-9]. There are some reports of alteration in morphology and alignment of the elbow joint in cubitus varus, but the clinical significance of the same is still debatable [a] Cosmetic appearance still is the most common cause why the parents bring their child to clinician. The above mentioned complications along with cosmetic concerns justify surgical management, although many times this deformity is neglected and patients are asymptomatic. In fact there are two of our colleagues (orthopaedic surgeons) who have cubitus varus deformities and they do not wish to correct it. On the contrary they mention that it is an advantage to them as their rotational profile helps them to extend their reach during surgery, specifically while operating on pelvi-acetabular fractures. Thus, although the decision making tips more in favour of surgical correction of deformity, the treatment should be individualised.

What surgeries are available?
Most authors now recommend surgery in the form of corrective osteotomies to achieve a normal carrying angle. At times in cases with physeal arrest in young child, epiphyseiodesis is needed.
Various types of osteotomies have been described each claiming improvements in cosmesis as well as lesser complication rates with their techniques. The osteotomies described are lateral closing wedge osteotomy [10], French modified osteotomy [11], medial open wedge osteotomy [12], lateral oblique osteotomy [13], lateral Equal limb osteotomy [14], step cut osteotomy [15], dome osteotomy [16,17], distraction osteogenesis [18,19]. Many variations of these main techniques are reported in literature [20-27] but essential principles remain the same. The first osteotomy described by Siris was simple lateral closed wedged osteotomy [10] which was modified by French to have intact periosteal hinge and fixation with screws and tension looped steel wires [11]. This was reported to have a lateral prominence which increased with increasing deformity. This was tackled by doing an oblique osteotomy with both arms slanting proximally from the medial epicondyle in such a way that the contact dimensions of both proximal and distal ends are approximately same (equal limb osteotomy) [14]. A step – cut was included by some to add stability, however it simply adds more contact surface and helps in good healing [15]. Dome osteotomies can correct large magnitude of varus but are limited in rotational and extension deformity correction [17]. Three dimensional osteotomies and ilizarov fixators are described by some authors but has not gained wide clinical use [28,29].

When to do the Surgery?
Surgery should be done only after allowing for maximum remodelling. A rough estimate will be around a year after the original injury. Again patients demands, growth potential and status of physis should be taken into account while planning surgery.
Surgical Approach. Three surgical approaches are described namely medial [30], lateral [11,13] and posterior [20,31]. Lateral approach is most frequently used as it provides good exposure with less dissection. Complex osteotomies may require posterior approach which offer more extensive exposure [31].

Which deformities need correction?
As mentioned earlier cubitus varus is a triplanar deformity with components of varus, hyperextension and internal rotation. There still exists significant debate over the deformities that need to be corrected. In younger child the hyperextension deformity will remodel with time and some authors recommend correction of hyperextension in children beyond 10 years of age as the remodelling potential is less after that [32]. Rotational correction has been advocated by authors who propose triplanar osteotomy to correct all three deformities [28,29]. However other have raised questions on using such complex procedures and have commented that rotational deformities need not be corrected at all [32]. The final decision will depend on surgeons experience and choice. We believe a sagittal plane correction of varus by lateral closed wedge osteotomy will be enough in most cases with addition of hyperextension correction in older children.

What Fixation modalities to stabilise the osteotomy?
Stabilisation methods vary from simple above elbow cast, k wires, single or double cortical screw, Screws with tension wire loops, plates and external fixators [11-29]. Smooth K wires are reported to back out with loss of fixation and a threaded wire of Steinmann pin would be more appropriate. Wires should be used in younger child with smaller bone and should be used with postoperative cast support. In older child single or crossed screws can be used. Inadvertent translation is a possibility while passing the screws and should be taken care of. Use of screws with tension band wire loop was proposed by French. This method should be used only when the medial cortical and periosteal integrity is maintained [ie the osteotomy is not complete]. In cases where the osteotomy is complete this method may fail with chances of loss of fixation. Also this method does not allow rotational or translational correction. Osteotomies in older children may be stabilised with one third tubular plate or reconstruction plate. This will offer more rigid fixation with less chances of loss of fixation and may allow early mobilisation depending on stability of fixation. External fixation is used by some authors, but it will require the distal fragment to be big enough to hold at least two wires. Also pin tract care and compliance in young child is always an issue with this method. The decision will depend on the size of the bones with smaller bones doing well with K wires and older children requiring plate fixation. Screws with wire loop fixation was reported by French, but there a high chances of loss of fixation with this method. Reconstruction plates have been successfully used with minimal risk of loss of fixation.
We prefer a reconstruction plate fixation of the osteotomy to work well with minimal risk of loss of fixation.

What are the Problems/Complications of cubitus varus correction?
The main complications are lateral prominence, incomplete correction, loss of correction, nerve palsies, infection and re-operations [33,34]. Lateral prominence was reported in French osteotomy due to prominence of distal fragment laterally. An equal limb oblique osteotomy minimises this issues. Medialisation of the distal fragment may also reduce the lateral fragment prominence [27]. In a recently published studies of French osteotomy it is pointed that the lateral prominence does remodel in younger children (less than 11 years of age) [35,36]. Dome and step cut osteotomies do not have issues of lateral prominence.
Incomplete Correction is generally a complication of incomplete planning and execution and is not a function of selecting the osteotomy. It is reported in 5.9% of patients [33]. Loss of correction is a function of kind of osteotomy and type of fixation used. As mentioned earlier screws with tension loop wires will fail if the medial continued is compromised. Similarly fixation with smooth K wires have more chances of loss of fixation.  Nerve palsies have been reported in about 2.5% of cases of cubitus varus correction osteotomies with decreasing frequencies of involvement of ulnar, radial and median nerves [33]. Almost 78% of these palsies are temporary and recover. Nerve injuries are more commonly seen in dome osteotomies with minimal risk in distraction osteogenesis [33]. Overall complication rate for osteotomies is reported to be 14.5% with poor results are seen around 12% cases [33]. Most complications are seen in cases with K wire fixation and lowest overall complication rate is seen in external fixation. However external fixation patients have highest rate of infection. The complexity of osteotomy does not affect the overall complication rate but specific complications may be more with certain osteotomies, like nerve injuries in dome osteotomies.

Figure 1

Our Management protocol
We advise surgical correction of all cubitus varus deformities but decision is to be made by the patient and parents after informed discussion about advantages and disadvantages. We prefer a lateral closed wedge oblique equal limb osteotomy using a lateral approach. Osteotomy is planned preoperatively taking into account the ulno humeral angle and clinically the carrying angle. Intraoperatively the wedge is resected and osteotomy is closed (Fig 1). Limb is aligned and carrying angle is checked. If the limb is still in varus, the osteotomy is extended to achieve >5° of carrying angle. Fixation is done using 3 or 4 hole reconstruction plate. Postoperative ???
Rehabilitation
Special situation
In cases where there is avascular necrosis of the trochlea or physeal arrest of the medial physeal plate, epiphysiodesis of the lateral physis is needed (depending on calculations of growth potential of the child). In such cases the supracondylar osteotomy needs to be combined with epiphysiodesis (Fig 2).

Figure 2

Conclusion
Cubitus varus deformity requires surgical correction or may lead to various consequences like secondary fractures, lateral instability and nerve palsies. Lateral closed wedge osteotomy is a good method to correct the deformity. Appropriate stabilisation preferably with plate and screw will minimise complications. Surgeons should be aware of complications and should counsel the patients for the same. The lateral bump index post correction and the appearance and placement of the scar are the two variables which may affect the cosmetic aspect of the correction and should be considered while decision making.


References

1. Tellisi N, Abusetta G, Day M et al (2004) Management of Gartland’s type III supracondylar fractures of the humerus in children: the role audit and practice guidelines. Injury 35:1167– 1171
2. Wong HK, Balasubramaniam P. Humeral torsional deformity after supracondylar osteotomy for cubitus varus: its influence on the postosteotomy carrying angle. J Pediatr Orthop. 1992 Jul-Aug;12(4):490-3.
3. . Oppenheim WL, Clader TJ, Smith C, Bayer M. Supracondylar humeral osteotomy for traumatic childhood cubitus varus deformity. Clin Orthop Relat Res 1984;(188):34– 39.
4. Takahara M, Sasaki I, Kimura T, et al. Second fracture of the distal humerus after varus malunion of a supracondylar fracture in children. J Bone Joint Surg [Br] 1998;80- B:791–797.
5. Davids JR, Maguire MF, Mubarak SJ, Wenger DR. Lateral condylar fracture of the humerus following posttraumatic cubitus varus. J Pediatr Orthop 1994;14:466– 470.
6. O’Driscoll SW, Spinner RJ, McKee MD, et al. Tardy posterolateral rotatory instability of the elbow due to cubitus varus. J Bone Joint Surg [Am] 2001;83-A:1358– 1369.
7. Abe M, Ishizu T, Morikawa J. Posterolateral rotatory instability of the elbow after posttraumatic cubitus varus. J Shoulder Elbow Surg 1997;6:405–409.
8. Mitsunari A, Muneshige H, Ikuta Y, Murakami T. Internal rotation deformity and tardy ulnar nerve palsy after supracondylar humeral fracture. J Shoulder Elbow Surg 1995;4:23–29.
9. Fujioka H, Nakabayashi Y, Hirata S, Go G, Nishi S, Mizuno K. Analysis of tardy ulnar nerve palsy associated with cubitus varus deformity after a supracondylar fracture of the humerus: a report of four cases. J Orthop Trauma. 1995;9(5):435-40.
a. Kawanishi Y, Miyake J, Kataoka T, Omori S, Sugamoto K, Yoshikawa H, Murase T. Does cubitus varus cause morphologic and alignment changes in the elbow joint? J Shoulder Elbow Surg. 2013 Jul;22(7):915-23.
10. Siris IE. Supracondylar fractures of the humerus: an analysis of 330 cases. Surg Gynecol Obstet 1939;68:201–222.
11. French PR. Varus deformity of the elbow following supracondylar fractures of the humerus in children. Lancet 1959;2:439–441.
12. King D, Secor C. Bow elbow (cubitus varus). J Bone Joint Surg [Am] 1951;33-A:572– 576.
13. Gong HS, Chung MS, Oh JH, Cho HE, Baek GH. Oblique closing wedge osteotomy and lateral plating for cubitus varus in adults. Clin Orthop Relat Res. 2008 Apr;466(4):899-906.
14. El-Adl W. The equal limbs lateral closing wedge osteotomy for correction of cubitus varus in children. Acta Orthop Belg. 2007 Oct;73(5):580-7.
15. DeRosa GP, Graziano GP. A new osteotomy for cubitus varus. Clin Orthop Relat Res. 1988 Nov;(236):160-5.
16. . Kanaujia RR, Ikuta Y, Muneshige H, Higaki T, Shimogaki K. Dome osteotomy for cubitus varus in children. Acta Orthop Scand 1988;59:314–317.
17. Pankaj A, Dua A, Malhotra R, Bhan S. Dome osteotomy for posttraumatic cubitus varus: a surgical technique to avoid lateral condylar prominence. J Pediatr Orthop. 2006 Jan-Feb;26(1):61-6.
18. Piskin A, Tomak Y, Sen C, Tomak L. The management of cubitus varus and valgus using the Ilizarov method. J Bone Joint Surg Br. 2007 Dec;89(12):1615-9.
19. Butt MF, Dhar SA, Farooq M, Kawoosa AA, Mir MR. Lateral invaginating peg (LIP) osteotomy for the correction of post-traumatic cubitus varus deformity. J Pediatr Orthop B. 2009 Sep;18(5):265-70.
20. Moradi A, Vahedi E, Ebrahimzadeh MH. Surgical technique: Spike translation: a new modification in step-cut osteotomy for cubitus varus deformity. Clin Orthop Relat Res. 2013 May;471(5):1564-71
21. Tanwar YS, Habib M, Jaiswal A, Singh S, Arya RK, Sinha S. Triple modified French osteotomy: a possible answer to cubitus varus deformity. A technical note. J Shoulder Elbow Surg. 2014 Nov;23(11):1612-7.
22. Bali K, Sudesh P, Krishnan V, Sharma A, Manoharan SR, Mootha AK. Modified step-cut osteotomy for post-traumatic cubitus varus: our experience with 14 children. Orthop Traumatol Surg Res. 2011 Nov;97(7):741-9.
23. Davids JR, Lamoreaux DC, Brooker RC, Tanner SL, Westberry DE. Translation step-cut osteotomy for the treatment of posttraumatic cubitus varus. J Pediatr Orthop. 2011 Jun;31(4):353-65.
24. Eamsobhana P, Kaewpornsawan K. Double dome osteotomy for the treatment of cubitus varus in children. Int Orthop. 2013 Apr;37(4):641-6.
25. Yun YH, Shin SJ, Moon JG. Reverse V osteotomy of the distal humerus for the correction of cubitus varus. J Bone Joint Surg Br. 2007 Apr;89(4):527-31.
26. Takeyasu Y, Oka K, Miyake J, Kataoka T, Moritomo H, Murase T. Preoperative, computer simulation-based, three-dimensional corrective osteotomy for cubitus varus deformity with use of a custom-designed surgical device. J Bone Joint Surg Am. 2013 Nov 20;95(22):e173.
27. Moon MS, Kim SS, Kim ST, Lee SR, Lee BJ, Jin JM, Moon JL. Lateral closing wedge osteotomy with or without medialisation of the distal fragment for cubitus varus. J Orthop Surg (Hong Kong). 2010 Aug;18(2):220-3.
28. Uchida Y, Ogata K, Sugioka Y. A new three-dimensional osteotomy for cubitus varus deformity after supracondylar fracture of the humerus in children. J Pediatr Orthop. 1991 May-Jun;11(3):327-31.
29. Usui M, Ishii S, Miyano S, Narita H, Kura H. Three-dimensional corrective osteotomy for treatment of cubitus varus after supracondylar fracture of the humerus in children. J Shoulder Elbow Surg. 1995 Jan-Feb;4(1 Pt 1):17-22.
30. Hui JH, Torode IP, Chatterjee A. Medial approach for corrective osteotomy of cubitus varus: a cosmetic incision. J Pediatr Orthop. 2004 Sep-Oct;24(5):477-81.
31. Banerjee S, Sabui KK, Mondal J, Raj SJ, Pal DK. Corrective dome osteotomy using the paratricipital (triceps-sparing) approach for cubitus varus deformity in children. J Pediatr Orthop. 2012 Jun;32(4):385-93.
32. Takagi T, Takayama S, Nakamura T, Horiuchi Y, Toyama Y, Ikegami H. Supracondylar osteotomy of the humerus to correct cubitus varus: do both internal rotation and extension deformities need to be corrected? J Bone Joint Surg Am. 2010 Jul 7;92(7):1619-26.
33. Solfelt DA, Hill BW, Anderson CP, Cole PA. Supracondylar osteotomy for the treatment of cubitus varus in children: a systematic review. Bone Joint J. 2014 May;96-B(5):691-700.
34. Raney EM, Thielen Z, Gregory S, Sobralske M. Complications of supracondylar osteotomies for cubitus varus. J Pediatr Orthop. 2012 Apr-May;32(3):232-40.
35. Cho CH, Song KS, Min BW, Bae KC, Lee KJ. Long-term results of remodeling of lateral condylar prominence after lateral closed-wedge osteotomy for cubitus varus. J Shoulder Elbow Surg. 2009 May-Jun;18(3):478-83.
36. Lee SC, Shim JS, Sul EJ, Seo SW. Remodeling after lateral closing-wedge osteotomy in children with cubitus varus. Orthopedics. 2012 Jun;35(6):e823-8
.


How to Cite this Article: Patwardhan S, Shyam AK. Cubitus Varus Deformity – Rationale of Treatment and Methods. International Journal of Paediatric Orthopaedics July-Sep 2015;1(1):26-29.        

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Nerve Injuries and Myositis Ossificans associated with Supracondylar Humerus Fracture

Vol 1 | Issue 1 | July-Sep 2015 | page:30-32 | Maulin Shah, Maulik Patel.


Authors : Maulin Shah[1], Maulik Patel[2].

[1] Consultant Pediatric Orthopedic Surgeon, Orthokids Clinic, Ahmedabad, India.
[2] Clinical Fellow , Orthokids Clinic, Ahmedabad, India.

Address of Correspondence
Dr. Maulin Shah
OrthoKids Clinic,
Kamdhenu House, Opp. Apang Manav Mandal,
Drive-in Road, Memnagar, Ahmedabad – 380 052.
Email : orthokidsclinic@gmail.com


Abstract

Background: Angular deformities around the knee joint in skeletally immature children are treated with methods of reversible hemiepiphysiodesis like staples, transphyseal screw and eight plate. Hemiepiphysiodesis using Eight plate has showed good results with advantage being faster correction, less complications and can be used in younger age.
Methods: The aim of this retrospective study is show the efficacy of eight plate application and its complication rate. Nineteen patients (37 physes) (unilateral: 3; bilateral: 16) with angular deformity were treated with eightplate application. Seven with pathological physes and twelve with idiopathic physes. Outcome assessment was done clinically with calculation of intermalleolar /intercondylar distance and radiologicaaly with mechanical and anatomical axis. Correction achieved was considered when anatomical/mechanical axis were within normal limits and intermalleolar/intercondylar distance was less than 5 cm.
Results: The average age of intervention was 7.4±2.96 years (range 2.4 -11.2years). Rate of correction of IMD/ICD was 1.14 cm per month. Rate of correction of mechanical axis was 0.76 o per month. Rate of correction of anatomical axis was 1.04o per month. The average duration of eight plate removal 12.4 months (range 7-24 months).There were two complications one patient with screw backout and other with overcorrection.
Conclusion: Reversible hemiepiphysiodesis using eight plate is and effective method with minimal complications and faster rates of correction. Idiopathic physes show faster rates of correction than pathological physes. Physeal growth arrest is not seen with eight plate application. Larger data and long term follow up is required to assess the rebound deformity after eight plate removal.
Keywords: Reversible, hemiepiphysiodesis, angular deformity, eight plate.


Introduction
Supracondylar humerus fractures are the most common upper limb injury amongst children. Due to the vicinity of the important nerves in this area, nerve injuries are frequently encountered with these fractures.

Incidence
Incidence of nerve injuries associated with supracondylar humerus fractures is reported to be 10 to 20% in different published studies. Most of these injuries can be identified preoperatively by proper clinical evaluation. Anterior interosseous nerve is the most commonly encountered nerve injury in extension type of fractures with incidence of 12 to 15%.[1-3] Radial nerve injury is second most common in this group with occurrence about 8%. Ulnar nerve injury is least commonly seen in extension injuries & approximate incidence is about 3%[4,5]. Flexion type of supracondylar fractures have more common association with Ulnar nerve injury.
Fracture morphology & Nerve Injuries
In extension type of fractures, median nerve is injured with postero-lateral displacement & radial nerve is injured with postero-medial displacement of fracture. In a study of 59 consecutive cases of type -III fractures, Crowford and collegues reported that 87% of median nerve injuries were associated with postero-lateral displacement and all radial nerve injuries were associated with postero-medial displacement[6]. The rate of acute neurologic injury in ipsilateral supracondylar humerus and forearm fractures is almost twice than that found in patients with isolated supracondylar humerus fractures. In a series of 150 patients with ipsilateral injuries, Muchow et. al. observed that the overall incidence of nerve palsy was 18.9% when a forearm fracture required reduction compared with only 7.3% in a forearm fracture that was not reduced[7]. In a series of 26 open supracondylar humerus fractures, Ozkul et. al. reported the incidence of nerve injury to be as high as 34%. A careful pre-operative evaluation to identify the nerve injury is thus advocated in open injuries[8]. Correlation was also found between severity of fracture type and incidence of nerve injury. Gartland type- II had 7%, type -III had 19% and type-IV had 36% chances of nerve injuries[9]. Nerve interposition between fracture fragments can cause failure of closed reduction. In a series of 41 failed closed reduction, Fleuriau-Chateau et. al. reported that 15 patients had entrapment of Median Nerve or Radial Nerve. Thus, incidence of nerve injury in failed closed reduction is approximately 35%[10].

Clinical Evaluation for Nerve Injury
Although it is difficult to do complete neurological evaluation in an injured child, it is very important to note the status of pre-operative movements. Trainees should note the ability of a child to carry out specific tasks rather than pointing specific nerve injuries. Median nerve injury can be identified by loss of thumb & index finger inter-phalangeal flexion. “Pointing index finger” while the child is asked to flex the fingers is a cardinal sign. Loss of extension at Metacarpo-phalangeal joints of fingers & thumb extension is suggestive of Radial Nerve involvement. Clawing of ulnar fingers & loss of adduction-abduction of fingers suggests Ulnar Nerve injury. Sensory deficits are difficult to indentify in acute injuries[11].

Types of Nerve Injuries
Most of the nerve injuries associated with supracondylar fractures are neuropraxic in nature. It is produced by the perineural fibrosis induced by direct compression of the fractured bony fragment. These injuries have good potential of spontaneous recovery. Complete transaction of the nerve is rare and radial nerve is the most commonly involved in this category[12]. Nerve can get entrapped in callus and produce symptoms of nerve injury. Radiologically, it gives appearance of a hole in the bone & is known as “Metev’s Sign”[3]. Compartment syndrome is an uncommon but known complication of Supracondylar fracture in today’s era. Increased pressure in the compartment causes nerve ischemia. Median Nerve paresis is the most commonly observed in this category. Majority of Ulnar Nerve injuries are caused Iatrogenically rather than direct injury.

Iatrogenic Nerve Injuries
Ulnar nerve injury is observed more as iatrogenic injury rather than post traumatic injury. Recent literature reports iatrogenic Ulnar nerve injury incidence to be 3% – 4%[13]. Cross pinning configuration has shown more chance to contracting Ulnar nerve injury compared to lateral pinning.[14] Passage of Ulnar nerve between Olecranon and the medial epicondyle makes it more prone to injure when medial pin I s passed in the cubital groove. Skaggs et. al. reported that hyperflexion of elbow increases chance of Ulnar nerve injury threefold & they recommend reducing elbow flexion after placing the first lateral pin in extension variety of supracondylar fractures[9]. Majority of instances the Ulnar nerve is injured by direct trauma or compression of sheath due to winding while drilling of wire. Shtarker et. al. used Ulnar nerve monitoring through electrical stimulation during & at the end of medial pinning. They found this technique safe, simple & easily applicable. In a series of 138 patients, by using this method, they did not notice any Ulnar nerve injury after doing crossed pinning[15]. Mulpuri et. al. found a mini-open technique useful to reduce the incidence of iatrogenic Ulnar nerve injuries while doing cross pinning. They recommended retraction of Ulnar nerve under direct vision by a 1.5 cm medial incision before introducing medial pin[16]. Literature reports that about 17-30% children have Ulnar nerve instability. An ultrasound study of the Ulnar nerve anatomy done by Eraze & colleagues, suggested that the incidence of anterior subluxation & dislocation of the Ulnar nerve is significantly high in patients with generalized hyperlaxity compared to normal population. They suggested that the ultrasound evaluation and assessment of ligamentous laxity are additional tools which can identify children at risk of iatrogenic nerve injury[17]. Iatrogenic radial nerve injury is rare and associated with piercing by medial pin as it exists through the anterolateral cortex. Most of these injuries are neuropraxia and spontaneous recovery occurs usually. Medial pin penetration in the opposite cortex should be limited to 1 mm to 2mm to prevent radial nerve injury[18].

Treatment approach to Nerve Injuries
Most nerve injuries are neuropraxias in nature & they generally show spontaneous recovery in 3 months time. Franklin et. al. suggested need of immediate exploration in nerve palsy with accompanying pulselessness[12]. Reducible fractures with nerve injuries should be treated with closed reduction and close follow up. Irreducible fractures with nerve deficits require open reduction to rule out nerve entrapment. If nerve deficit is found within a few hours of cross pinning then pin should be removed and nerve should be explored. It is advisable to change to lateral pinning. Nerve deficit after a few weeks of cross pinning can be managed by pin removal and observation for 5 to 6 months. If recovery does not occur then neurolysis is the mainstay of treatment. Rarely nerve grafting is indicated.

Conclusion
Nerve injuries associated with supracondylar humerus fracture is a frequent occurrence. One should have high degree of suspicion about it & a careful pre-operative clinical examination is needed to report it. Median nerve injury is the most common nerve injury associated with extension variety of fractures. Incidence significantly increases in open fractures, ipsilateral forearm fractures & fractures with vascular compromise. Ulnar nerve injury is commonly happen as iatrogenic injury due to cross pinning. A mini-open technique or ultrasound evaluation or electric nerve monitoring during surgery are recommended tools to reduced its incidence. Most of the nerve injuries are neuropraxias and they spontaneously resolve by 6 months. Small percentage of patients may need nerve exploration & repair.

Myositis ossificans in Supracondylar humerus fractures
Wilkins reported 1.4% incidence of myositis ossificans in his meta-analysis of 470 cases of supracondylar humerus fractures[19]. Brachialis is the commonest muscle to get involved and causes restriction of range of motion[20]. High energy trauma, manipulation by bone setter, aggressive postoperative physiotherapy and overzealous dissection while open reduction are the risk factors[21]. In early stage, patients present with pain, redness, local warmth and swelling. In late stage, once the ossification settles, bony mass is palpable separately from the underlying bone and it causes restriction of motion at the elbow[22]. On plain radiographs, myositis looks like calcification in its early stages. Mature myositis mass demonstrates well defined outer shell of the bone, commonly at anterolateral aspect of the elbow. CT scan is helpful to confirm[23]. Early stage is treated by analgesics & anti-inflammatory medicines and restriction of passive exercises. Mature myositis mass should be excised completely. Material should be sent for the histopathological examination[22,24]. Preoperative or early postoperative radiotherapy has been reported to prevent myositis ossificans occurrence in at-risk patients. Prophylactic dose should be between 600 and 1000 cGy[25, 26].


References

1. Cramer KE, Green NE, Devito DP. Incidence of anterior interosseous nerve palsy in supracondylar humerus fractures in children. Journal of Pediatric Orthopaedics. 1993;13(4):502-505.
2. Spinner M, Schreiber SN. Anterior interosseous-nerve paralysis as a complication of supracondylar fractures of the humerus in children. Journal of Bone Joint Surgery (Am). 1969; 51(8):1584-1590.
3. McGraw JJ, Akbarnia BA, Hanel DP, et al. Neurological complications resulting from supracondylar fractures of the humerus in children. Journal of Pediatric Orthopaedics.1986; 6(6):647-650.
4. Skaggs DL, Hale JM, Bassett J, et al. Operative treatment of supracondylar fractures of the humerus in children. The consequences of pin placement. Journal of Bone Joint Surgery (Am). 2001; 83A(5):735-740.
5. Cheng JC, Lam TP, Shen WY. Closed reduction and percutaneous pinning for type III displaced supracondylar fractures of the humerus in children. Journal of Orthopaedic Trauma. 1995; 9(6):511-515.
6. Crowford CC, Peters WM, John EB, James KR, Michael MB. Neurovascular injury and Displacement in Type III Supracondylar Humerus Fractures. Journal of Pediatric Orhtopaedics. 1995 Jan:Feb ;15(1) : 47-52
7. Muchow RD, Riccio AI, Garg S, Ho CA, Wimberly RL. Neurological and vascular injury associated with supracondylar humerus fractures and ipsilateral forearm fractures in children. Journal of Pediatric Orthopaedics. 2015 March;35(2):121-5.
8.Ozkul E , Gem M, Arslan H, Alendar C, Demirtas A, Kisin B. Surgical treatment outcome for open supracondylar humerus fractures in children. Acta Orthopaedics Belgium. 2013 October;79(5):509-513.
9. Joiner ER, Skaggs DL, Arkader A, Andras LM, Lightdale-Miric NR, Pace JL, Ryan DD. Iatrogenic nerve injuries in the treatment of supracondylar humerus fractures: are we really just missing nerve injuries on preoperative examination? Journal of Pediatric Orthopaedics. 2014 June; 34(4):388-92.
10. Fleuriau-Chateau P, McIntyre W, Letts M. An analysis of open reduction of irreducible supracondylar fractures of the humerus in children. Canadian Journal of Surgery. 1998; 41(2):112-128.
11. RW Culp, AL Osterman, RS Davidson, T Skirven, FW Bora. Nerural injuries associated with supracondylar fractures of humerus in children. Journal of Bone Joint Surgery.1990 Sep; 72(8):1211-1215.
12. Franklin CC, Skaggs DL. Approach to the pediatric supracondylar humeral fracture with neurovascular compromise. Instructional Course Lectures. 2013;62:429-33.
13. Cheng JC, Ng BK, Ying SY, Lam PK. A 10-year study of the changes in the pat- tern and treatment of 6,493 fractures. Journal of Pediatric Orthopaedics. 1999;19:344-50.
14. Wilkins KE. Fractures and dislocations of the elbow region. In: Rockwood CA Jr, Wilkins KE, King RE, editors. Fractures in children. Volume 3. 3rd edition. New York: JB Lippincott; 1991. p 526-617.
15. Shtarker H, Elboim-Gabyzon, Bathish E, Laufer Y, Rahamimov N, Volpin G. Ulnar nerve monitoring during percutaneous pinning of supracondylar fractures in children. Journal of Pediatric Orhtopaedics. 2014March;34(2):161-5.
16. Mulpuri K, Tritt BL. Low incidence of ulnar nerve injury with crossed pin placement for pediatric supracondylar humerus fractures using a mini-open technique. Journal of Orthopaedic Trauma. 2006 March;20(3);234
17. Erez O, Khalil JG, Legakis JE, Tweedie J, Kaminski E, Reynolds RA. Ultrasound evaluation of ulnar nerve anatomy in the pediatric population. Journal of Pediatric Orthopaedics. 2012 September ;32(6):641-6.
18. Sairyo Koichi, Henmi Tatsuhiko, Kanematsu Yoshiji, Nakano Shunji, Kajikawa Tomomasa. Radial Nerve Palsy Associated with Slightly Angulated Pediatric Supracondylar Humerus Fracture. Journal of Orthopaedic Trauma. 1997 April;11(3):227-229.
19. Wilkins KE. Fractures and dislocations of the elbow region. In: Rockwood CA, Wilkins KE, King RE. Fractures in Children. 3rd edition. New York: JB: Lippincott; 1991; 509-28.
20. Naranje S1, Kancherla R, Kannan A, Malhotra R, Sharma L, Sankineani SR. Extraarticular bony ankylosis in a child with supracondylar fracture of humerus. Chinese Journal Traumatology. 2012;15(5):300-2.
21. Hartigan BJ1, Benson LS. Myositis ossificans after a supracondylar fracture of the humerus in a child. American Journal of Orthopedics. 2001 Feb;30(2):152-4.
22. Spinner, Robert J.; Jacobson, Scott R.; Nunley, James A. Case Report Fracture of a Supracondylar Humeral Myositis Ossificans. Journal of Orthopaedic Trauma: June 1995; 183-277
23. Zeanah WR, Hudson TM. Myositis ossificans: radiologic evaluation of two cases with diagnostic computed tomograms. Clinical Orthopedic Related Research. 1982 Aug;(168):187-91.
24. Augustus Thorndike Jr. Myositis ossificans traumatica. Jounal of Bone Joint Surg Am, 1940 Apr; 22 (2): 315 -323.
25. Brady LW. Radiation-induced sarcomas of bone. Skeletal Radiology 1979;4:72-8.
26. Kim JH, Chu FC, Melamed HQ, Huvos A, Cantin J. Radiationinduced soft-tissue and bone sarcoma. Radiology 1978;129:501-8.


How to Cite this Article: Shah M, Patel M. Nerve Injuries and Myositis Ossificans associated with Supracondylar Humerus Fracture. International Journal of Paediatric Orthopaedics July-Sep 2015;1(1):30-32.         

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Classifications of Supracondylar Humerus Fractures: Are they Relevant? Are we Missing Something?

Vol 1 | Issue 1 | July-Sep 2015 | page:6-10 | Mandar Agashe.


Authors : Mandar Agashe[1*].

[1] Director, Centre for Paediatric Orthopaedic Care (CPOC) at Dr. Agashe’s Hospital, Kurla, Maharashtra, India.

Address of Correspondence
Dr Mandar Agashe
Centre for Paediatric Orthopaedic Care (CPOC) at Dr. Agashe’s Hospital, Kurla, Mumbai, India.
Email: mandarortho@gmail.com


Abstract

 Classification systems are developed with focus on easy communication in research and academic discussion and also to have prognostic importance. Paediatric supracondylar fractures have been classified on basis of variety of criterias in fracture geometry, pattern of fractures etc. However it seems no single classification offers complete diagnostic and prognostic picture. This article attempts to provide overview of all the existing classifications of supracondylar fractures and tries to provide a clinical guidelines towards classifying the fractures.
Keywords: Supracondylar Humerus fracture, classification, management.


Introduction
Fractures of the supracondylar humerus constitute one of the most commonly encountered fractures in paediatric age group and are the most common fractures around the elbow [1,2,3]. They have also been historically associated with a number of complications. In fact, Gartland [4], in his seminal article in 1959, noted “the trepidation with which men, otherwise versed in the management of trauma, approach a fresh supracondylar fracture”. These fractures have been a topic of great amount of debate and discussion not just for the treatment modalities involved and these potential complications but also on the way these fractures need to be classified [5].  The first radiological classification of fracture supracondylar humerus could be attributed to Felsenreich in 19316 but the first (and probably the most) widely used classification was described by Gartland in 1959 [4]. The basic classification of supracondylar humerus fracture into extension (commonest- seen in 95-98% of times) and flexion type (seen in 3-5%) is not disputed. It is the internal classification of extension type supracondylar humerus fractures which has generated huge amount of controversy. In this article, we will be dealing primarily with the various classification systems for extension type supracondylar humerus fractures unless specified otherwise.

Incidence
As in any major fracture, it is the endeavor of the treating clinician to be able to classify the fracture with help of a classification system which is simple, reliable, reproducible and which can determine the protocol for management [7-10]. Though fractures of the supracondylar humerus have been studied by many authors, search is still on for a classification which fulfills all the criteria for widespread clinical as well as research use. The Gartland classification along with its Modified version is the main classification used in English speaking countries while the Lagrange and Rigault classification [11-12] is widely used in France and most French-speaking countries. Shortcomings in both these classifications led clinicians to develop different modifications as well as new classifications. Till date, as many as six to seven major classification systems exists which are used in various parts of the world, all of whom have their own positive and negative points [1,3,13,14].

Figure 1

Gartland/ Wilkins Modified Gartland’s classification
Gartland4 described his classification of extension type supracondylar fractures in 1959 according to degree of displacement into three types- Undisplaced, minimally displaced and displaced. However this classification was described to be too simplistic and as such was modified by K. Wilkins in 1984 (Fig 1) [5,15] with much more elaboration and explanation. In this classification, Type I fracture was undisplaced or minimally displaced such that the anterior humeral line passes through the centre of the ossification centre of the capitellum. Type II fracture had an obvious fracture line with displacement of the distal fragment. The anterior humeral line passes anterior to the capitellum. The anterior cortex is disrupted but the posterior cortex is still intact. The direction of displacement may be directly posteriorly or angulated medially or laterally and there may be a rotatory component. Type III fractures are those which are significantly displaced with no cortical contact with either posteromedial or posterolateral displacement. For ease of understanding, Wilkins also subclassified type II and III fractures into A (without rotation) and B (with rotation). A general protocol for management was put forth by Gartland according to the types with Type I fractures being immobilized with a long arm cast in about 75-80o of flexion. Type II and stable type III fractures were treated with manipulative reduction under anaesthesia and long arm cast while unstable type III fractures were treated with skeletal traction through the olecrenon with the elbow in extension (k-wire fixation was not the standard or care at that time). Since the concept of “stability” as described by Gartland was very vague, Wilkins described the component of rotation in the decision making process. He said that Type II fractures without rotation (Type IIA) required only manipulative reduction and long arm cast, while those with rotation (type IIB) required closed reduction and k-wire fixation and as such need to be dealt with like type II injuries. A modification of the Wilkins classification was described by Leitch et al in 2006 where multi-directionally unstable fracture was described as type IV(Fig 2) [16,17]. This type of fracture is unstable in both flexion and extension and is a high energy injury which results in circumferential loss of the periosteal hinge which helps in maintaining reduction in type II and III injuries. The treatment of these type IV injuries is very challenging and various authors have recommended their own modifications of k-wiring techniques for the same. The Wilkins modification of the Gartland classification though very simple and elegant, was not universally accepted due to problems with its reliability and reproducibility especially in type II and type IIIA injuries. There have been many studies describing the inter- and intra-observer variability of the modified Gartland classification. Heal et al [18] in their article found poor interobserver reliability in type I and only fair to moderate reliability in type II injuries. As expected, type III and flexion type injuries had good to very good inter-observer reliability. Another study by Barton et al [19] showed moderate to good inter- as well as intra-observer reliability though they said that 10% of the time, the second reading by the same person is different and they concluded that “this makes treatment recommendations based on only fracture types imprecise.” These studies led to the search for newer and better classifications which do not have the disadvantages of the modified Gartland’s classification while still retaining its simplicity.

Figure 2

Lagrange and Rigault classification
Lagrange and Rigault [11] described this classification in 1962 and since then it has become the most widely used classification system in France and other French speaking countries (Fig 3). It has divided extension type supracondylar humerus fractures into 5 types- Type I- undisplaced fractures involving primarily the anterior cortex of the humerus. Type II are fractures which involve both the cortices but with little or no displacement. Type III fractures are displaced fractures but in which there is some contact between the proximal and distal fragments. Type IV fractures are severely displaced with no contact between the proximal and distal fragments. The last type, type V fractures are basically meta-diaphyseal fractures (high supracondylar fractures) which are quite unstable. Since the Lagrange and Rigault system is used in only a few countries, there have been very scanty literature about the reliability and reproducibility of this system. De Gheldere et al in 2010 [12], discussed about the reproducibility of the classification and found good inter- and intra-observer reliability, though in the similar range of the Gartland classification. So what is the need for these two classifications and what is the difference between the two? Most clinicians feel that type I Gartland is the same as Legrange I and type III Gartland is the same as type IV Legrange. The types II and III of Legrange classification are similar to type II of the Gartland in some cases and type I and type III in some cases and that has in fact added to the confusion in classifying and treating these injuries.

Figure 3

AO displacement based validated classification
Looking at the shortcomings of the two main classification systems, the AO group put forth a classification system in continuity with the AO paediatric long bone fracture classfication which was being developed (Fig 4). They planned to design a simple but clinically relevant system which is standardised , validated and reproducible. Lutz et al [13] with a group of six experienced paediatric orthopaedic surgeons at five different centres validated this method and put forth their findings in their article in 2011. According to Lutz et al, they got good to very good diagnostic accuracies as well as reliability with this classification. The feature of this classification was that there was some importance given to the AP view also as against the Gartland classification where most of the stress was on the lateral view. The classification is as follows:
Grade I: Incomplete fractures: Here the Rogers (anterior humeral line) Line was intersecting the capitellum and there is not more than 2 mm of varus valgus angulation on the AP view.
Grade II: Incomplete fracture but with angulation: This corresponds to the type II injury of the Gartland’s classification but with more elaboration. Here the Rogers line fall anterior to the capitellum. The size of the capitellum is defined by drawing a circle with the diameter equal to the shaft of the humerus and placing that circle over the capitellum. There is also more than 2 mm of varus-valgus angulation on the AP view.
Grade III: Complete fractures: There is no bony continuity but still some contact between the fracture fractures irrespective of the type of displacement.
Grade IV: Complete fractures: There is no bony continuity and absolutely no contact between the fractured fragments. There is significant bony shortening and overlapping of fragments.
This classification system was extensively evaluated by a group of experienced paediatric orthopaedic surgeons and found to have excellent inter- and intra-observer reliability. The addition of grade III also seems to have precluded one of the main concerns about the Wilkins-Gartland classification, which was that there are some fractures which are more displaced than grade II fractures but less displaced than grade III fractures.The AO classification definitely goes a long way in making a standardized reliable and relatively easy to use system for supracondylar humerus fractures. However it still has some shortcomings. The most important is probably those fractures which are grossly rotated, which appear less displaced than conventional type IV (according to AO classification) and as such are classified as type III in the AO classification. These fractures are sometimes even more difficult to reduce than severely displaced type IV fractures. Hence to classify them as lower than type IV fractures may be fallacious. The other issue is that there are some characteristics about each fracture pattern which are much more important than just simple types or grades of fractures in deciding the prognosis of that particular pattern. Characteristics like coronal and sagittal plane angulation, obliquity of the fracture and level of the fracture are very important and as such have been proved to have a definite impact on the eventual healing of the fracture. With such a view in mind, an excellent classification has been put forth by Bahk et al [3] which elucidates these points.

Figure 4 final

The “pattern-based” classification: (Bahk et al)[3]
Bahk et al in 2008[3], retrospectively evaluated more than 200 cases of various patterns of supracondylar humerus fractures and classified them according to their fracture patterns (Fig 5). Accordingly four coronal plane patterns (typical transverse, medial oblique, lateral oblique and high fractures) and 2 sagittal patterns (low sagittal and high sagittal) were described. With the help of these patterns, it becomes very easy for the practicing clinician to understand the severity of injury, the possibility of communition, the chance of complications like rotational mal-alignment and extension mal-union. Medial and lateral obliquity of the fracture also helps to decide on the pin configuration as a medial oblique fracture is amenable to medial pinning while lateral obliques and transverse fractures are very stable with lateral-only pinning. High supracondylar fractures require medial and lateral cross pinning. The authors also have quantified the obliquity of the fracture planes on coronal and sagittal views and have said that coronal obliquity of more than 10o and sagittal plane obliquity of more than 20o are associated with more complications. Hence any fracture which falls beyond 10o coronal and 10o sagittal obliquity needs additional stability in the form of a third pin or cross pins. This fracture was relatively easy to use, simple and was found to have excellent reliability in inter- and intra-observer studies.

Figure 5 final

Further imaging and future trends
The basic fallacy of most of the current classification systems for supracondylar humerus is the difficulty in getting a proper true AP and Lateral view in a child in tremendous amount of pain. There is always some component of rotation which precludes taking a proper Lateral view and hence any classification which is based only on plain radiographs is theoretically likely to be prone for errors. Hence, some authors have endeavored to evaluate these fractures by multi-slice CT scan. According to Douira- Khomsi et al, the 3-D spiral CT scan gives a much better understanding of the fracture patterns including the rotational component which may be missed on the plain radiograph. This method enabled them to describe 3 different types of partially displaced supracondylar humerus fractures- sub-type I- only the anterior cortices of the 2 columns are completely fractured, sub-type II- fracture of the anterior two and one posterior cortex of the medial cortex and type III- three cortices are fractured with the posterior cortex of the lateral column being involved. However, the authors of this article are quite clear that this classification is still not completely validated and needs to be confirmed on further studies with a larger set of patients as well as more number of investigators in order to test its inter-observer reliability. This method, with the easier availability of CT scans as well as the faster process of performing a CT, certainly has a promise for the future and may result in a simple, accurate and 3-dimensional classification which may find general acceptance.

Conclusion
Thus to conclude, in spite of being so common, fracture of the supracondylar humerus still remains one of the most difficult fractures to accurately and reliably classify, with the resultant difficulty in standardization of care. The Wilkins modification of the Gartland classification still remains the most commonly used classification worldwide though concerns have been raised about its reliability and accuracy. The AO classification and the Bahk’s pattern based classification have improved our understanding of the fracture patterns and are also helpful in deciding the management of these injuries. Other classifications like the Lagrange and Rigault classifications are used in some parts of the world with limited success. Inspite of these classification, the perfect, completely accurate, reliable and easy to use classification still remains elusive.


References

1. Lee BJ, Lee SR, Kim ST, Park WS, Kim TH, Park KH, Radiographic outcomes after treatment of pediatric supracondylar humerus fractures using a treatment-based classification system. J Orthop Trauma. 2011 Jan;25(1).
2. Minkowitz B, Busch MT. Supracondylar humerus fractures. Current trends and controversies. Orthop Clin North Am. 1994 Oct;25(4):581-94.
3. Bahk MS, Srikumaran U, Ain MC, Erkula G, Leet AI, Sargent MC, Sponseller PD. Patterns of pediatric supracondylar humerus fractures. J Pediatr Orthop. 2008 Jul-Aug;28(5):493-9.
4. Gartland JJ. Management of supracondylar fractures of the humerus in children. Surg Gynecol Obstet. 1959 Aug;109(2):145-54.
5. Wilkins KE. Supracondylar fractures of the distal humerus. In: Rockwood CA Jr, Wilkins KE, Beaty JH , eds. Fractures in Children. 4th Ed.
6. Felsenreich F. Kindliche supracondylaive fracturen und posttraumatisch deformotaten des ellenbogen gelenhes [in German]. Arch Orthop Unfall-Chir 1931;29:555–9.
7. Garbuz DS, Masri BA, Esdaile J, Duncan CP. Classification systems in orthopaedics. J Am Acad Orthop Surg. 2002 Jul-Aug;10(4):290-7. Review.
8. Audigé L, Bhandari M, Kellam J. How reliable are reliability studies of fracture classifications? A systematic review of their methodologies. Acta Orthop Scand. 2004 Apr;75(2):184-94. Review
9. Burstein AH. Fracture classification systems: do they work and are they useful? J Bone Joint Surg Am. 1993 Dec;75(12):1743-4.
10. Slongo T, Audigé L, Schlickewei W, Clavert JM, Hunter J; International Association for Pediatric Traumatology. Development and validation of the AO pediatric comprehensive classification of long bone fractures by the Pediatric Expert Group of the AO Foundation in collaboration with AO Clinical Investigation and Documentation and the International Association for Pediatric Traumatology. J Pediatr Orthop. 2006 Jan-Feb;26(1):43-9.
11. Martin JS, Marsh JL. Current classification of fractures. Rationale and utility. Radiol Clin North Am. 1997 May;35(3):491-506.
12. Lagrange J, Rigault P. [Treatment of supra-condylar fractures of the humerus in children]. Presse Med. 1970 Dec 12;78(53):2382. French.
13. de Gheldere A, Legname M, Leyder M, Mezzadri G, Docquier PL, Lascombes P. Reliability of the Lagrange and Rigault classification system of supracondylar humerus extension fractures in children. Orthop Traumatol Surg Res. 2010 Oct;96(6):652-5.
14. Lutz N, Audigé L, Schmittenbecher P, Clavert JM, Frick S, Slongo T. Diagnostic algorithm for a validated displacement grading of pediatric supracondylar fractures. J Pediatr Orthop. 2011 Mar;31(2):117-23.
15. Douira-Khomsi W, Smida M, Louati H, Jlalia Z, Ghachem MB, Bellagha I. Multi slice computed tomography approach in the assessment of supracondylar humeral fractures in children Acta Orthop Belg. 2012 Aug;78(4):458-64.
16. Wilkins KE. Fractures and dislocations of the elbow region. In: Rockwood CA Jr, Wilkins KE, King RE, eds. Fractures in Children. Vol 3, 4th ed. Philadelphia: Lippincott-Raven, 1996: 680-1.
17. Leitch KK, Kay RM, Femino JD, Tolo VT, Storer SK, Skaggs DL. Treatment of multidirectionally unstable supracondylar humeral fractures in children. A modified Gartland type-IV fracture. J Bone Joint Surg Am. 2006 May;88(5):980-5
18. Silva M, Cooper SD, Cha A. The Outcome of Surgical Treatment of Multidirectionally Unstable (Type IV) PediatricSupracondylar Humerus Fractures. J Pediatr Orthop. 2014 Nov 6. [Epub ahead of print.
19. Heal J, Bould M, Livingstone J, Blewitt N, Blom AW. Reproducibility of the Gartland classification for supracondylar humeral fractures in children. J Orthop Surg (Hong Kong). 2007 Apr;15(1):12-4.
20. Barton KL, Kaminsky CK, Green DW, Shean CJ, Kautz SM, Skaggs DL. Reliability of a modified Gartland classification of supracondylar humerus fractures. J Pediatr Orthop. 2001 Jan-Feb;21(1):27-30.


How to Cite this Article: Agashe M. Classifications of supracondylar humerus fractures: Are they relevant? Are we missing something?.  International Journal of Paediatric Orthopaedics July-Sep 2015;1(1):6-10.

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Delayed presentation of SC fractures – Open Reduce now or accept for Future Osteotomy

Vol 1 | Issue 1 | July-Sep 2015 | page:23-25 | Premal Naik, Hitesh Chauhan.


Authors : Premal Naik[1*], Hitesh Chauhan[1].

[1] Rainbow Superspeciality hospital & Children’s Orthopaedic Centre, Ahmedabad, Gujarat, India.

Address of Correspondence
Dr Premal Naik
Rainbow Superspeciality hospital & Children’s Orthopaedic Centre, Ahmedabad, Gujarat, India.
Email: premalnaik@gmail.com


Abstract

Background: Delayed presentations of paediatric supracondylar humerus fractures presents a unique situation. The decision between conservative management, closed reduction and fixation and open reduction are to be weighed against malunion and correction at later date. The existing literature talks about delay in terms of hours or days, however we in our country see patients presenting weeks later after injury. There are no clear existing guidelines for such delayed presentation and decision making is multifactorial depending on age, amount of displacement, degree of union and days of delay. In this review we have presented the various available treatment modality and a treatment algorithm for management of delayed presentation of paediatric supracondylar humerus fracture.
Keywords: Supracondylar Humerus fracture, delayed presentation, management.


Introduction
In our practice we still encounter patients with supracondylar fracture of distal Humerus presenting late, though recently the number is drastically reducing. Late presentation is considered when there is delay in presentation of more than 2 days after injury[1, 2]. The reasons of delay could be due to lack of awareness and initial treatment by bone-setters, injury in areas remote from health facilities. Sometimes primary centers (not well equipped) tend to shift patients with excessive swelling and associated neurovascular problems to higher centers leading to further delay in final treatment.  Treatment of late cases has higher chances of perioperative and postoperative complications like iatrogenic nerve injury, Volkmann’s ischemic contracture, cubitus varus, elbow stiffness and myositis ossificans [3-5]. There remains a dilemma while managing late cases, whether to treat it as fresh supracondylar fracture or to allow it to mal-unite and consider for corrective surgery at later stage. Unfortunately in literature there are no clear guide lines or consensus regarding management of delayed presentation of supracondylar fractures.

Literature review
In delayed presentation cases up to 2 weeks we can adopt one of the following treatment modalities
1. Gradual reduction of fracture with traction (skin traction or skeletal)
2. Skeletal traction followed by percutaneous fixation
3. Trial of gentle manipulation and percutaneous fixation
4. Open reduction and internal fixation
In cases presenting three weeks after injury gradual reduction with traction is mostly not helpful. In such cases open reduction becomes technically difficulty because of difficulty in delineating uniting fracture fragments and need for greater soft tissue dissection. Hence it is imperative to allow fracture to unite and perform secondary corrective osteotomy at later stage (if required) after remodeling stage. Devnani et. al [6] in their series of 28 children with average delay in presentation of 5.6 days (2 to 21 days) advocated gradual fracture reduction with traction. Average hospital stay for treatment was 14 days (12 – 18 days) and 71% patients had good results according to Flynn criteria [7]. No patient had treatment related neurological injuries or new bone formation. They observed that overall functional outcome was better in patients presenting within 7 days of injury.
Agus et al [8] reported 13 patients with delay of more than 1 day and extensive swelling. Patients were treated with skeletal traction till satisfactory healing of skin and soft tissue, followed by percutaneous pinning. In his series average hospitalization was 7 days, 85% patient had excellent functional outcome and 77% had excellent cosmetic outcome. Tiwari et al [9] in their series of 40 patients presenting within 7 days, could successfully reduce 25 fractures by gentle closed manipulation under image intensifier and stabilize percutaneously. They advocated open reduction using mediolateral (posterior triceps sparing) approach in patients presenting after 7 days.  Lal and Bhan [10] in their series of 20 patients with a delay of 11 – 17 days , performed open reduction by posterior approach after primary immobilization in Thomas splint and healing of skin and soft tissue oedema. They performed V-Y plasty of triceps in all cases for improvement of flexion. All patients had unsatisfactory functional recovery according Mitchell’s and Adam’s criteria [11]. In their series 35% patients had cubitus varus deformity and 85 % patient developed myositis ossificans. Abdullah Eren[12] in their series of 31 patient with an average delay of 6 days (2- 19 days) performed open reduction by medial approach and cross K-wire fixation. All patients had full functional recovery at 5 months. They reported 6.5% pin tract infection and 22.5 % of cubitus varus. Tahir et al [13] performed open reduction by Kocher’s incision in 40 patients with an average delay of 5 days. List of complication in this series included myositis ossificans and restricted elbow movements in 5% and pin tract infection in 6.5 %. Most of patients (95%) achieved full range of motion.
Yildirim et al [14] in their prospective study of 190 patients on timing of surgical treatment of type III supracondylar humerus fracture showed that open surgery was inevitable after a delay of 32 hours after injury.

Discussion
Surgeons tend to choose modalities of treatment depending on expertise level, type of set up and patient factors (time of presentation, amount of swelling, neurovascular injury, ipsilateral injury).
Conservative treatment:This modality would be considered when resources are not adequate or patient condition precludes more aggressive treatment. One can choose between skin traction and skeletal traction to maintain reduction. For skeletal traction pin is passed through the olecranon.
Advantages of gradual reduction by traction
1.Traction allows simultaneous healing of soft tissues along with reduction of fracture
2. Chances of iatrogenic neurovascular injury are remote
3. Many authors have reported Incidence of cubitus varus to be comparable to other method with traction [6, 15]
4.Technically easy and can be performed at small centers
Disadvantages of gradual reduction 1. Prolonged hospital stay with cumbersome nursing care
2. Patient presenting late (more than 7 days) tend to have inferior results [6]

Operative treatment: In fully equipped set up with good patient parameters and experienced surgical team, operative treatment is commonly chosen.
Advantages of open reduction and internal fixation are:-
1. Accurate reduction, appropriate fixation and early mobilization
2. Lesser hospital stay
Disadvantages are –
1. Technically demanding procedure and requires experienced surgeon
2. Higher chances of myositis ossificans due to soft tissue stripping and iatrogenic nerve injury.

Chart 1

Authors preferred treatment
In patients presenting within 2 weeks and if skin condition permits, we prefer trial of gentle manipulation and reduction under anesthesia. If satisfactory reduction is achieved then fracture is stabilized with percutaneous K wire fixation (Illustrative case 1).
At the same stage if satisfactorily reduction is not achieved, we proceed for open reduction. We use anteromedial or anterolateral approach depending on direction prominent spike of proximal fragment (if proximal fragment has medial spike we use anteromedial approach and with lateral spike anteriolateral) (Case 2).
We prefer shortening of proximal fragment to achieve easy and accurate reduction over performing extensive soft tissue dissection.
In patients presenting after 3 weeks we prefer to accept union in malposition and consider for corrective osteotomy at later date.
Illustrative cases
Case 1:- 1 year old female, sustained injury in right arm while playing. Primarily she was treated conservatively with above elbow slab (Fig. 1). She presented to us 15 days post injury, with progressive medial collapse Successful reduction was obtained after gentle manipulation under anaesthesia and fixation was done with lateral wires.

Figure 1
Case 2 – 7 year, Male with RTA, sustained injury in left upper limb which was primarily treated elsewhere with above elbow slab. He presented to us two weeks after injury. He had ipsilateral distal radial physeal injury and type 3 supracondylar fracture (Fig. 2). After failed gentle attempt of closed reduction, open reduction was planned by anterolateral approach (as proximal spike was protruding laterally). Due to severe soft tissue contracture reduction of fracture was not possible as length could not be achieved. Instead of aggressive soft tissue dissection, shortening of proximal fragment was performed, translation was accepted and fracture was fixed with K wires.

Figure 2


References

1. Sankar WN, Hebela NM, Skaggs DL, Flynn JM. Loss of pin fixation in displaced supracondylar humeral fractures in children: causes and prevention. The Journal of Bone & Joint Surgery. 2007;89(4):713-7.
2. Shannon FJ, Mohan P, Chacko J, D’Souza LG. “Dorgan’s” percutaneous lateral cross-wiring of supracondylar fractures of the humerus in children. Journal of Pediatric Orthopaedics. 2004;24(4):376-9.
3. Campbell WC, Preston RL. Operative Orthopaedic. Annals of Surgery. 1939;110(4):800.
4. Harris I. Supracondylar fractures of the humerus in children. Orthopedics. 1992;15(7):811-7
5. Minkowitz B, Busch MT. Supracondylar humerus fractures. Current trends and controversies. The Orthopedic clinics of North America. 1994;25(4):581-94.
6. Devnani A. Late presentation of supracondylar fracture of the humerus in children. Clinical orthopaedics and related research. 2005;431:36-41.
7. Flynn JC, Matthews JG, Benoit RL. Blind pinning of displaced supracondylar fractures of the humerus in children. The Journal of Bone & Joint Surgery. 1974;56(2):263-72.
8. Agus H, Kalenderer Ö, Kayal C, Eryanlmaz G. Skeletal traction and delayed percutaneous fixation of complicated supracondylar humerus fractures due to delayed or unsuccessful reductions and extensive swelling in children. Journal of Pediatric Orthopaedics B. 2002;11(2):150-4.
9. Tiwari A, Kanojia R, Kapoor S. Surgical management for late presentation of supracondylar humeral fracture in children. Journal of Orthopaedic Surgery. 2007;15(2).
10. Lal G, Bhan S. Delayed open reduction for supracondylar fractures of the humerus. International orthopaedics. 1991;15(3):189-91.
11. Mitchell WJ, Adams JP. Supracondylar fractures of the humerus in children: a ten-year review. JAMA. 1961;175(7):573-7.
12. Eren A, Güven M, Erol B, Cakar M. Delayed surgical treatment of supracondylar humerus fractures in children using a medial approach. Journal of children’s orthopaedics. 2008;2(1):21-7.
13. Tahir A, Majid F, Ali MN, Qureshi MA. Treatment of Old Supracondylar Fractures of Humerus In Children. Journal of Surgery Pakistan (International). 2012;17:4.
14. Yildirim AO, Unal VS, Oken OF, Gulcek M, Ozsular M, Ucaner A. Timing of surgical treatment for type III supracondylar humerus fractures in pediatric patients. Journal of children’s orthopaedics. 2009;3(4):265-9.
15. Piggot J, Graham H, McCoy G. Supracondylar fractures of the humerus in children. Treatment by straight lateral traction. Journal of Bone & Joint Surgery, British Volume. 1986;68(4):577-83
.


How to Cite this Article: Naik P, Chauhan H. Delayed presentation of SC fractures – Open Reduce now or Accept for Future Osteotomy. International Journal of Paediatric Orthopaedics July-Sep 2015;1(1):23-25.         

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