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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 […]

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 […]

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

Cubitus Varus Deformity – Rationale of Treatment and Methods

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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.

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).

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.

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

Cubitus Varus Deformity – Rationale of Treatment and Methods

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Cubitus Varus Deformity – Rationale of Treatment and Methods

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

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

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Cubitus Varus Deformity – Rationale of Treatment and Methods

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

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