Supracondylar Humeral Fractures in Children Omid, Reza; Choi, Paul D; Skaggs, David L
Journal of bone and joint surgery. American volume,
2008-May-01, 2008-May, 20080501, Letnik:
90, Številka:
5
Journal Article
Recenzirano
Operative fixation is indicated for most type-II and III supracondylar humeral fractures in order to prevent malunion.Medial comminution is a subtle finding that, if treated nonoperatively, is likely ...to lead to unacceptable varus malunion.Angiography is not indicated for a pulseless limb, as it delays fracture reduction, which usually corrects the vascular problem.A high index of suspicion is necessary to avoid missing an impending compartment syndrome, especially when there is a concomitant forearm fracture or when there is a median nerve injury, which may mask symptoms of compartment syndrome.Lateral entry pins have been shown, in biomechanical and clinical studies, to be as stable as cross pinning if they are well spaced at the fracture line, and they are not associated with the risk of iatrogenic ulnar nerve injury.
Background
The “terrible triad” of the elbow is a complex injury that can lead to pain, stiffness, and posttraumatic arthritis if not appropriately treated. The primary goal of surgery for these ...injuries is to restore stability of the joint sufficient to permit early motion. Although most reports recommend repair and/or replacement of all coronoid and radial head fractures when possible, a recent cadaveric study demonstrated that type II coronoid fractures are stable unless the radial head is removed and not replaced.
Questions/purposes
The purposes of this study were to determine the (1) range of motion; (2) clinical scores using the Disabilities of the Arm, Shoulder and Hand (DASH) and the Broberg-Morrey questionnaires; and (3) rate of arthritic changes, heterotopic ossification (HO), or elbow instability postoperatively in patients whose terrible triad injuries of the elbow included Reagan-Morrey type I or II coronoid fractures that were treated without fixation.
Methods
Between April 2008 and December 2010, 14 consecutive patients were treated for acute terrible triad injuries that included two Regan-Morrey type I and 12 Regan-Morrey type II coronoid fractures. Based on the senior author’s (DGS) clinical experience that coronoid fractures classified as such do not require fixation to restore intraoperative stability to the posterolaterally dislocated elbow, all injuries were treated by the senior author with a surgical protocol that included radial head repair or prosthetic replacement and repair of the lateral ulnar collateral ligament (LUCL) followed by intraoperative fluoroscopic examination through a range of 20° to 130° of elbow flexion to confirm concentric reduction of the ulnohumeral joint. Using this protocol, intraoperative stability was confirmed in all cases without any attempt at coronoid or anterior capsular repair. Repair of the medial collateral ligament or application of external fixation was not performed in any case. All patients were available for followup at a minimum of 24 months (mean, 41 months; range, 24–56 months). The mean patient age was 52 years (range, 32–58 years). At the followup all patients were evaluated clinically and radiographically by the senior author. Outcome measures included elbow range of motion, forearm rotation, elbow stability, and radiographic evidence of HO or arthritic changes using the Broberg and Morrey scale. Elbow instability was defined as clinical or radiographic evidence of recurrent ulnohumeral dislocation or subluxation at final followup. Clinical outcomes were assessed with the patient-reported DASH questionnaire and the physician-administered Broberg-Morrey elbow rating system.
Results
The mean arc of ulnohumeral motion at final followup was 123° (range, 75°–140°) and mean forearm rotation was 145° (range, 70°–170°). The mean Broberg and Morrey score was 90 of 100 (range, 70–100, higher scores reflecting better results) and the average DASH score was 14 of 100 (range, 0–38, higher scores reflecting poorer results). Radiographs revealed mild arthritic changes in one patient. One patient developed radiographically apparent but asymptomatic HO. None of the patients demonstrated instability postoperatively.
Conclusions
These findings demonstrate that terrible triad injuries with type I and II coronoid process fractures can be effectively treated without fixation of coronoid fractures when repair or replacement of the radial head fracture and reconstruction of the LUCL complex sufficiently restores intraoperative stability of the elbow through a functional range of motion.
Level of Evidence
Level IV, therapeutic study. See Guidelines to Authors for a complete description of levels of evidence.
Background
Surgical treatment for terrible triad injuries of the elbow (defined as elbow dislocations with concomitant fractures of the radial head and coronoid) remains a challenging clinical ...problem. Specifically, the question of whether to repair or replace the radial head remains controversial.
Questions/purposes
We compared patients with terrible triad injuries of the elbow whose radial head fracture was treated with either internal fixation and internal fixation (ORIF) or radial head arthroplasty in terms of (1) clinical outcome measures (DASH and Broberg-Morrey scores, ROM), (2) elbow stability and radiographic signs of arthrosis, and (3) complications and reoperation rates.
Methods
Retrospective review identified 39 patients with terrible triad injuries and minimum 18-month complete clinical and radiographic followup (mean, 24 months; range, 18–53 months). Patients were managed with a standard algorithm consisting of (1) repair (n = 9) or replacement (n = 30) of the radial head, (2) repair of the lateral ulnar collateral ligament, and (3) repair of the coronoid fracture. During the study period, the radial head generally was internally fixed when there were fewer than four articular fragments; otherwise, it was replaced. Evaluation included the DASH score, the Broberg-Morrey index, measurements of elbow stability and motion, and radiographic assessment for signs of arthrosis; chart review was performed for complications and reoperations. Complete followup was available on 87% (39 of 45 patients).
Results
There were no differences between groups in terms of ROM or elbow scores. All patients who underwent radial head arthroplasty at the index procedure had a stable elbow at final followup whereas three of nine patients who underwent ORIF were unstable (p = 0.009). However, 11 patients who underwent arthroplasty demonstrated radiographic signs of arthrosis compared to none in the ORIF group (p = 0.04). Eleven patients (28%) underwent reoperation (seven arthroplasty, four ORIF) for various reasons. With the numbers available, there was no difference in reoperation rate between groups (p = 0.45).
Conclusions
For terrible triad injuries, radial head arthroplasty afforded the ability to obtain elbow stability with comparable overall outcomes when compared to ORIF. As these injuries commonly occur in younger patients, longer-term studies will be required to ascertain whether the apparent benefits of radial head arthroplasty are offset by late complications of arthroplasty, such as loosening.
Level of Evidence
Level III, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.
Lateral condyle fractures of the humerus are the second most common fracture about the elbow in children. The injury typically occurs as a result of a varus- or valgus-applied force to the forearm ...with the elbow in extension. Plain radiographs are sufficient in making the diagnosis; however, an elbow arthrogram permits optimal visualization of the articular surface in minimally displaced fractures. Traditionally, nonsurgical management is indicated for fractures with ≤2 mm of displacement and a congruent articular surface. Closed reduction and percutaneous pinning is performed for fractures with >2 mm of displacement with an intact cartilaginous hinge at the articular surface. Open reduction and internal fixation is often necessary for fractures with ≥4 mm of displacement or if there is articular incongruity. Complications include malunion, delayed presentation, fishtail deformity, lateral spurring, and growth arrest. Evolving management concepts include relative indications for surgical management, the optimal pin configuration, and the use of cannulated screw and bioresorbable fixation.
Background
When treating complex radial head fractures, important goals include prevention of elbow or forearm instability, with restoration of radiocapitellar contact essential. When open reduction ...and internal fixation cannot achieve this, radial head replacement is routinely employed, but the frequency of and risk factors for prosthesis revision or removal are not well defined.
Questions/purposes
We determined (1) the frequency of prosthesis revision or removal after radial head replacement for acute complex unstable radial head fractures, (2) risk factors for revision or removal, and (3) functional outcomes after radial head replacement.
Methods
We identified from our prospective trauma database all patients over a 16-year period managed acutely for unstable complex radial head fractures with primary radial head replacement. Of the 119 patients identified, 105 (88%) met our inclusion criteria; mean age was 50 years (range, 16–93 years) and 57 (54%) were female. All implants were uncemented monopolar prostheses, of which 86% were metallic and 14% silastic. We recorded further procedures for prosthesis revision or removal for any cause, with a minimum followup of 1 year (n = 105). Cox regression analysis was used to determine independent factors associated with revision or removal when controlling for baseline patient (age, sex, comorbidities) and fracture (location, classification, associated injury) characteristics. Short-term functional outcomes (Broberg and Morrey score, ROM) were determined from retrospective review of clinic followup (n = 74), with a minimum followup of 3 months.
Results
Twenty-nine patients (28%) underwent prosthesis revision (n = 3) or removal (n = 26) at a mean of 6.7 years (range, 1.8–18 years) after injury. Independent risk factors for removal or revision were silastic implant type and lower age. At a mean of 1.1 years (range, 0.3–5.5 years) after surgery, mean Broberg and Morrey score was 80 out of 100 (range, 40–99). Mean elbow flexion was 133° (range, 90°–159°; SD, 13°), extension 21° (range, 0°–80°; SD, 17°), flexion arc 112° (range, 10°–140°; SD, 25°), pronation 84° (range, 0°–90°; SD, 18°), supination 73° (range, 0°–90°; SD, 28°), and forearm rotation arc 156° (range, 0°–180°; SD, 38°).
Conclusions
We demonstrated a high removal or revision rate after radial head replacement for acute unstable complex fractures, with lower age and silastic implants independent risk factors. Younger patients should be counseled regarding the increased risk of requiring further surgery after radial head replacement. Future work should focus on long-term patient-reported outcomes after these injuries.
Level of Evidence
Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.
Background
In acute treatment of radial head fractures, a radial head prosthesis can be considered if open reduction and internal fixation are not technically feasible.
Methods
We reviewed the data ...of 27 consecutive bipolar Judet radial head prostheses implanted in patients with unreconstructable radial head fractures and no other concomitant fractures (coronoid or olecranon factures). The lesions of the lateral collateral ligament were rated according to the McKee classification. Twenty-three patients with more than ten-year follow-up participated in this retrospective study All patients underwent assessments for pain, range of motion and stability using the Mayo Elbow Performance Score, the QuickDash questionnaire and a Visual Analogue Scale for pain.
Radiography assessment was performed to determine the correct setting of the implant, presence of periprosthetic loosening, prosthetic disassembly, heterotopic ossification, capitellum and ulnohumeral degenerative changes.
Results
Mean follow-up was 149 months (± 12.2). Mean range of motion in flexion-extension was 111° (± 10.55), mean extension was 18° (± 14.32) and mean flexion was 130° (± 11.4). Mean arc of motion in supination-pronation was 150° (± 12.26). The mean Mayo Elbow Performance Score was 88, the mean QuickDash score was 7.3; 86% of the patients were satisfied. Seven patients (26%) required secondary surgery. The most frequent complication was heterotopic ossification, which had negative consequences on the functional result.
Conclusions
Bipolar radial head prostheses are an option for acute treatment of isolated unreconstructable radial head fractures. During follow-up, three patients required implant revision and removal; the capitellum surface presented severe degenerative changes and the prosthesis was not replaced. Another complication was the risk of implant dislocation, in relation to implant design, incorrect positioning of the radial head stem or else to inadequate reconstruction of the lateral collateral ligament. Further work is needed to establish the long-term follow-up results of Judet implants in complex elbow fractures.
The primary aims of this work were to (1) describe normal range of motion (ROM) profiles for elite pitchers, (2) describe the characteristics of shoulder and elbow injuries in professional pitchers ...over a 6-year period in one Major League Baseball organization, and (3) identify ROM measures that were independently associated with a future shoulder or elbow injury.
Over 6 seasons (2010-2015), a preseason assessment was performed on all pitchers invited to Major League Baseball Spring Training for a single organization. ROM measures included shoulder flexion, horizontal adduction, external rotation (ER), internal rotation, as well as elbow flexion and extension, were measured for both the dominant and nondominant arm, and total range of motion and deficits were calculated. All noncontact shoulder and elbow injuries were identified. Using multivariate binomial logistic regression analysis to control for age, height, weight, and all other ROM measures, the factors associated with an increased risk of subsequent shoulder or elbow injury were identified.
A total of 53 shoulder (n = 25) and elbow (n = 28) injuries occurred during 132 pitcher seasons (n = 81 pitchers). The most significant categorical risk factor associated with increased elbow injury rates was the presence of a shoulder flexion deficit >5° (odds ratio OR 2.83; P = .042). For continuous variables, the risk of elbow injury increased by 7% for each degree of increased shoulder ER deficit (OR 1.07; P = .030) and 9% for each degree of decreased shoulder flexion (OR 1.09; P = .017). None of the measures significantly correlated with shoulder injuries.
Preseason shoulder ER and flexion deficits are independent risk factors for the development of elbow injuries during the upcoming season. Although prior work has supported the importance of reducing glenohumeral internal rotation deficits in pitchers, this study demonstrates that deficits in shoulder ER and flexion are more significant predictors of subsequent elbow injury.
Level III, retrospective comparative study.
BACKGROUND Open distal humeral fractures (DHFs) often lead to loss of elbow function, thereby seriously affecting patient quality of life. The aim of this study was to evaluate the treatment outcomes ...of 2 surgical techniques to determine the better method for repairing open DHFs. Both groups were treated with immediate debridement first, and then group I had only internal fixation (IF), while group II underwent initial external fixation (EF) followed by IF surgery. MATERIAL AND METHODS This retrospective study included 32 patients who had open DHFs between 2013 and 2018. Twelve patients underwent thorough debridement and temporary EF treatment and converted to IF as the ultimate treatment. Twenty patients were treated with immediate open reduction and internal fixation (ORIF). Data of final treatment outcomes were analyzed at the latest follow-up. A comparative analysis of radiological results, function observations, and complications was performed for the 2 surgical groups. RESULTS All DHFs and osteotomized olecranon united after a mean of 5.2±1.21 months. No significant differences were observed in other preoperative demographic data between the 2 groups. Moreover, there was no significant difference in postoperative complications, elbow range of motion, or fracture healing time between the 2 groups. CONCLUSIONS The evidence provided by our study highlights the efficacy of definitive IF in treating open DHFs, which is recommended whenever possible. Furthermore, the combination of EF and ORIF, according to the type of soft tissue damage, may be a promising treatment option with a low revision rate for patients with open DHFs.
BACKGROUND:Radial head arthroplasty is commonly used to treat acute unreconstructible radial head fractures. The purpose of this study was to report on the clinical and radiographic outcomes at a ...minimum follow-up of five years after radial head arthroplasty with a modular metallic implant for the treatment of acute radial head fractures.
METHODS:The cases of fifty-five patients with unreconstructible radial head fractures treated acutely with a smooth-stemmed modular metallic radial head implant were retrospectively reviewed. A wide variety of injuries, which ranged from isolated radial head fractures to so-called terrible triad injuries, were included. All patients returned for an interview, physical examination, and radiographic evaluation at a mean of eight years (range, five to fourteen years) postoperatively. Elbow and forearm motion, elbow strength, and grip strength were measured. Radiographs were evaluated, and validated patient-rated outcome questionnaires were completed. A longitudinal subgroup analysis was performed for thirty-three patients who were previously evaluated at two years postoperatively.
RESULTS:At a mean of 8.2 ± 2.9 years, the mean arc of flexion (and standard deviation) of the affected elbow was 11° ± 14° to 137° ± 15°. Elbow strength and motion were significantly diminished compared with the unaffected elbow (p < 0.05). The mean Mayo Elbow Performance Index (MEPI) was 91 ± 13 points. Twenty-five patients (45%) had stem lucencies; twenty-one (38%), ulnohumeral arthritis; and twenty (36%), heterotopic ossification, including one with radioulnar synostosis. Two patients underwent secondary elbow surgery, but no patient required implant removal or revision. In the subgroup evaluated longitudinally, there was a significant improvement in MEPI scores from the two-year to the eight-year follow-up (p = 0.012), with no loss of motion or strength (p > 0.05).
CONCLUSIONS:The mid-term outcomes of radial head arthroplasty with a smooth-stemmed modular metallic prosthesis are comparable with previously reported short-term outcomes, with no evidence of functional deterioration. Radial head arthroplasty with a smooth-stemmed metallic modular implant is a good treatment option for patients with acute unreconstructible radial head fractures, and sustained clinical outcomes may be expected beyond five years of follow-up.
LEVEL OF EVIDENCE:Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Supracondylar humeral fractures are the most common elbow fractures in children and represent 3 % of all paediatric fractures. The most common cause is a fall onto an outstretched hand with the elbow ...in extension, resulting in an extension-type fracture (97–99 % of cases). Currently, the Gartland classification is used, which has treatment implications. Diagnosis is based on plain radiographs, but accurate imaging could be limited due to patient pain. Based on fracture type, the definitive treatment could be either non-operative (type I) or operative (type III/IV); however, when handling type II fractures controversy remains. Neither pin configuration have shown higher efficacy over the other. Complications are ~1 %, the most common being pin migration, with compartment syndrome as the most devastating. Overall, functional outcomes are good, and physical therapy does not appear to be necessary.
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