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Functional outcomes in paediatric supracondylar fracture humerus treated with percutaneous pinning with cross K-wires
APME-401; No. of Pages 8 apollo medicine xxx (2017) xxx–xxx
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Original Article
Functional outcomes in paediatric supracondylar fracture humerus treated with percutaneous pinning with cross K-wires Hemant Chaturvedi a, Vikram Khanna b,*, Rakesh Bhargava c, Raju Vaishya d a
Department of Orthopaedics, NIMS Medical College and Hospital, Jaipur, India Resident, Department of Orthopaedics, NIMS Medical College and Hospital, Jaipur, India c Professor, Head of Department, Department of Orthopaedics, NIMS Medical College and Hospital, Jaipur, India d Senior Consultant, Department of Orthopaedics, Indraprastha Apollo Hospital, Delhi, India b
article info
abstract
Article history:
Background: Supracondylar fracture of humerus is the most common elbow fractures in
Received 10 January 2017
children. Percutaneous pinning is an effective modality of treatment, as it obliterates the
Accepted 21 January 2017
problem of maintenance of reduction of the fracture and minimizes the risk of circulatory
Available online xxx
insufficiency. Methods: 30 patients coming to the hospital during the period from November 2012 to
Keywords:
November 2014 with closed Gartland type II and III supracondylar humerus fracture and
Supracondylar fracture
managed with percutaneous pinning with two cross K-wires were included. Anteroposterior
Gartland
and lateral view X-rays of the affected as well as the normal elbow were taken and assessed
Baumann's angle
regarding union, carrying angle, Baumann's angle and metaphyseal–diaphyseal angle. Flynn
Metaphyseal–diaphyseal angle
criteria were used for evaluation of the final functional outcome.
Flynn criteria
Results: The mean follow-up of the patients in this study was 6.3 months. None of the patient had a final carrying angle less than 108 and more than 168 with mean final carrying angle being 12.38. The final functional outcome assessed according to Flynn criteria, was excellent in 83.33%, good in 3.33%, fair in 6.67% and poor in 6.67% patients. Conclusion: Use of a medial entry pin for the treatment of paediatric supracondylar humerus fractures by closed reduction and percutaneous pinning using cross K-wires is safe as far as iatrogenic ulnar nerve injury and vascular complications are concerned, if an adequate technique is followed. Closed reduction and percutaneous pinning with medial and lateral cross K-wires offers a practically feasible, economically viable and an effective treatment method for displaced supracondylar fracture humerus. © 2017 Indraprastha Medical Corporation Ltd. All rights reserved.
* Corresponding author. Tel.: +91 7073647974. E-mail address: [email protected] http://dx.doi.org/10.1016/j.apme.2017.01.010 0976-0016/© 2017 Indraprastha Medical Corporation Ltd. All rights reserved.
Please cite this article in press as: Chaturvedi H, et al. Functional outcomes in paediatric supracondylar fracture humerus treated with percutaneous pinning with cross K-wires, Apollo Med. (2017), http://dx.doi.org/10.1016/j.apme.2017.01.010
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1.
Introduction
2.
Supracondylar fracture of humerus is the most common elbow fractures in children1–3 and needs proper management. This fracture is common in the 1st decade of life4,5 due to various causes, of which main is ligament laxity and anatomical structure of humerus tube (shaft) to flat transformation at the lower end of humerus. Boys have had a higher incidence of this fracture than girls. The left or nondominant side is most frequently injured.6–9 Many different treatment modalities have been devised for supracondylar fracture of humerus in children, with closed reduction and immobilization in flexion, Dunlop's traction, overhead olecranon skeletal traction, open reduction and internal fixation and closed reduction and percutaneous pinning being the commonly used modalities. Goals of treatment are avoidance of complications and achievement of excellent functional results. In this aspect, percutaneous pinning seems to be useful and effective modality of treatment with least complication rate, as it obliterates the problem of maintenance of reduction of the fracture and minimizes the risk of circulatory insufficiency. The chances of cubitus varus deformity are markedly reduced, with marked reduction in the severe amount of swelling and hospitalization time. Of all the complications associated with supracondylar fractures, nerve injury ranks highest, although reports of the incidence of specific neuropraxia vary. Nerve injury in supracondylar fracture humerus occurs in at least 7% cases and significant vascular injury is seen in 1% cases.10 The radial nerve has been the most frequently involved nerve in older studies; however, the median nerve is much more commonly injured, particularly the anterior interosseous nerve, in more recent studies.11,12 The ulnar nerve is most commonly injured iatrogenically during pinning or in a flexion-type of supracondylar fracture.
Materials and methods
30 skeletally immature patients coming to the hospital during the period from November 2012 to November 2014 with closed Gartland type II and III supracondylar humerus fracture and managed with percutaneous pinning with two cross K-wires were included. Patients with Gartland type I supracondylar fracture of the humerus, open fractures and supracondylar humerus fractures with neurological deficit were excluded from the study. An informed consent was taken. All the 30 cases turned up for the final follow-up. All patients with supracondylar fracture of humerus were first seen either in the accident and emergency services or the orthopaedic outpatient department. They were assessed clinically with special reference to the neurovascular status of the involved limb. Antero-posterior and lateral view skiagrams of the affected elbow were taken (Fig. 1). The Xrays were assessed regarding the type of fracture and the degree of displacement based on Gartland classification. Patients were immobilized in an above elbow slab, and Gartland type II and III supracondylar fracture of the humerus were admitted to the hospital and scheduled for closed reduction and percutaneous pinning under general anaesthesia (Figs. 2–5). The arm was immobilized in 30–608 of flexion in an above elbow slab. The child was observed overnight and post-pinning antero-posterior and lateral view check X-rays of the affected elbow were taken and assessed regarding posterior, medial and lateral displacement as well as rotation of the distal fragment in sagittal, coronal and horizontal plane. Baumann angle and metaphyseal–diaphyseal angle were measured (Fig. 6).
3.
Results
This study included 30 cases of supracondylar fracture of humerus treated with percutaneous pinning with two cross
Fig. 1 – Pre-operative skiagrams after medial and lateral cross-pinning. Please cite this article in press as: Chaturvedi H, et al. Functional outcomes in paediatric supracondylar fracture humerus treated with percutaneous pinning with cross K-wires, Apollo Med. (2017), http://dx.doi.org/10.1016/j.apme.2017.01.010
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Fig. 2 – Intra-operative fluoroscopic images after medial and lateral cross-pinning.
Fig. 3 – Intra-operative image after medial and lateral crosspinning and K-wires bent and cut leaving the pins protruding out of skin.
K-wires. The mean age at the time of injury was 6.8 years (Fig. 7). In this study, 21 patients had injury on the left side and 9 cases had injury on right side. 23 patients suffered injury due to fall while the remaining patients suffered injury in road accident. 6 patients came to the hospital on the date of injury, while 23 patients came next day after the injury and only 1 patient reported 2 days after injury. The post-reduction Baumann angle was in the range of 98–128 in 9 cases, 138– 168 in 17 cases, 178–208 in 4 cases which is 30%, 57% and 13%, respectively and the mean being 13.78. The post-reduction metaphyseal-diaphyseal angle was in the range of 808–828 in 1 case, 838–858 in 6 cases, 918–958 in 1 case, 868–888 in 21 cases and 898–918 in 2 cases. Mean final carrying angle on the affected side was 12.38, distributed between 108–168 (Fig. 8). Final functional results were excellent in 25(83.33%) cases, good in 1(3.33%) case, fair in 2 cases (6.67%), and poor in 2 (6.67%) patients (Fig. 9). The results were excellent in 6(20%) cases with postreduction Baumann angle in the range of 98–128, in 15(50%) cases with angle ranging between 138–168 and in 4(13.3%) cases, the results were excellent with angle in the range of 178–208 (Fig. 10). The final functional outcome was excellent
Fig. 4 – Intra-operative fluoroscopic images after medial and lateral cross-pinning. Please cite this article in press as: Chaturvedi H, et al. Functional outcomes in paediatric supracondylar fracture humerus treated with percutaneous pinning with cross K-wires, Apollo Med. (2017), http://dx.doi.org/10.1016/j.apme.2017.01.010
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Fig. 5 – Immediate post-operative skiagrams after medial and lateral cross-pinning. Fig. 7 – Age distribution.
(1 case) when the percutaneous pinning was done on the same day of injury. Of 11 patients operated on the next day of injury, 10 had excellent functional outcome and 1 had a poor outcome.15 cases were operated on the 2nd day of injury, of which 12 had excellent outcomes, 1 had good, 1had fair and
1 had a poor functional outcome. 1 patient operated on the 3rd day had an excellent functional outcome. Of the 2 patients operated after 3 days of injury, 1 had an excellent outcome while the other had a fair functional outcome (Fig. 11). At final follow-up, 2 (6%) cases had full range of motion, 23(77%) cases
Fig. 6 – Final functional outcome at 20 weeks (A) full flexion, (B) full extension, (C) carrying angle of the affected side compared with the normal side. Please cite this article in press as: Chaturvedi H, et al. Functional outcomes in paediatric supracondylar fracture humerus treated with percutaneous pinning with cross K-wires, Apollo Med. (2017), http://dx.doi.org/10.1016/j.apme.2017.01.010
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had 58 loss, 1 (3%) case had 108 loss and 2 (7%) cases had 158 loss. The remaining 2 (7%) cases had 208 loss of flexion and extension (Fig. 12).
Fig. 11 – Delay from injury to percutaneous pinning vs. final functional result.
Fig. 8 – Distribution of final carrying angle.
Fig. 12 – Residual loss of range of motion.
4. Fig. 9 – Final functional result Flynn criteria.
Fig. 10 – Comparison of post-reduction Baumann angle with results.
Discussion
In this study, 6 patients reported to the hospital on the same day of injury, while the majority of the patients (23 patients) came next day after the injury. Only 1 patient reported 2 days after injury. None of the patients reported after more than 2 days of injury. In a study by Boparai et al.,13 31 patients attended emergency same day, 11 came next day, 5 within 2 days and rest 3 came in 2–7 days after injury. The cause for delay was due to the fact that the patients come from far off areas and they take initial domiciliary treatment in the form of massage or wooden splintage and tight bandage. 2 patients reported with the tight bandage and both of them reported on next day of injury but none of them had any signs of compartment syndrome. Patients were also having fear of operation in hospital. In the present study, 1 case was operated on the day of injury, while 11 cases were operated on the next day, with maximum number of patients (15) being operated within a
Please cite this article in press as: Chaturvedi H, et al. Functional outcomes in paediatric supracondylar fracture humerus treated with percutaneous pinning with cross K-wires, Apollo Med. (2017), http://dx.doi.org/10.1016/j.apme.2017.01.010
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delay of 2 days. Only 1 case was operated on the 3rd day. 2 cases were operated more than 3 days after the injury as both had a concomitant head injury. Of the 28 patients, operated within 3 days of injury, 24 had excellent functional outcome, 1 had good, 1 had fair and 2 had a poor outcome. Of the 2 patients operated after 2 days of injury, 1 had an excellent outcome while the other had a fair functional outcome, thereby showing no association of the final functional outcome with the increased time between presentation and surgery. This is comparable to the studies by Larson et al. (2014),14 Mehlman et al. (2001),15 Lett et al. (2002),16 Gupta et al. (2004),17 who concluded that increased time from presentation to surgery was not associated with increased morbidity from the injury or treatment complications. Baumann (1929)18 described an angle formed between the lateral distal humeral epiphysis and the long axis of the humerus. Sandegard (1944)19 stated that this angle helps one rapidly and definitely decide whether or not displacement towards the axis is present. In this series, the final Baumann angle, in majority of the patients (27) was in the range of 13–168 and the remaining 3 patients had a Baumann angle in range of 9–128. The mean final Baumann angle on the affected side was 14.48 and on the normal side was 15.28. None of the patient had a change in final Baumann angle of more than 48. 6 out of 9 patients with post-reduction Baumann angle between 98 and 128 and 15 of the 17 patients with post-reduction Baumann's angle ranging between 138 and 168 had an excellent functional outcome while all the patients with post-reduction Baumann angle ranging between 178 and 208 had excellent outcomes. The normal angle varies from 88 to 288. Depending on the patient, there is little side-to-side variance in any one individual. A common rule of thumb is that a Baumann angle of at least 108 is acceptable.20 Iyengar et al. (2003),21 concluded that for acceptable closed reduction, Baumann angle should be within 48 of the normal side. The final metaphyseal–diaphyseal angle, in majority of the patients (16) was in the range of 86–888. 16 (53.3%) patients had final metaphyseal–diaphyseal angle ranging between 838 and 858 and the remaining 1 patient had a metaphyseal–diaphyseal angle in range of 89–918. The mean final metaphyseal– diaphyseal angle on the affected side was 85.98 and on the normal side was 84.678. Normal angle is 908. A variation of greater than 108 from the normal side is significant. Angle of more than 908 indicates varus angulation. In this series, no case of cubitus varus was seen and the final metaphyseal– diaphyseal angle was within normal limits in all patients. In this study, no case was admitted with nerve injury. Lawrence (1956),22 Eid (1978)23 reported radial nerve injury
most frequently. In a review of 61 major series by Wilkins (1991),24 he observed 7.7% cases having neurological deficit with radial nerve being the most commonly injured. ElSharkawi and Fattah (1965),25 Prietto26 and El-Ahwany (1974)27 found in their studies that median nerve had most common involvement. None of the patients had any vascular compromise. Ottolenghi (1960),28 in a study reported vascular injury or compromise rate of nearly 5%, of which less than 1% developed Volkmann's ischaemic contracture. Krishna Kumar (2000)29 in his study, also reported no case of Volkmann's ischaemic contracture. No case of post-operative ulnar nerve injury was observed as a complication of insertion of medial K-wire for stabilization of the reduced fracture. Mangwani et al. (2005),30 in a study of 291 children with supracondylar fracture humerus, found post-operative neurological deficit in nine patients, of which 3 required exploration of the ulnar nerve. Kwak-Lee et al. (2014)31 concluded that that the use of a medial-entry pin for the treatment of paediatric supracondylar humerus fractures is safe as far as iatrogenic ulnar nerve injury and vascular complications are concerned, if an adequate technique is followed, as was the case in this study. In most of the studies, chances of myositis ossificans were almost 0% due to early management with very less manipulation. None of the patient had a final carrying angle less than 108 and more than 168. 13 cases had a final carrying angle in a range of 10–128, with majority of the patients (16) having a carrying angle in the range of 13–158, while only 1 patient having a final carrying angle in the range of 16–188. Mean final carrying angle on the affected side was 12.38, distributed between 108 and 168 and on the normal side was distributed between 128 and 178 with a mean of 14.08. None of the patient had a cubitus varus or valgus deformity. The criteria used in the analysis of results have been the final range of motion. Holmberg (1945)32 stated that flexion continues to increase at a slow rate for up to 2 years. At final follow-up, 2 (6%) cases had full range of motion, 23 (77%) cases had 58 loss, 1 (3%) case had 108 loss and 4 (14%) cases had more than 108 loss of flexion and extension. The findings of this study are almost comparable with those of Hernikson (1966)33 who reported that less than 5% of cases have greater than 58 loss of flexion. The final functional outcome assessed according to Flynn criteria (1974),34 was excellent in 25 (83.33%) cases, good in 1 (3.33%) case, fair in 2 (6.67%) cases, and poor in 2 (6.67%) patients (Table 1).
Table 1 – Comparison of final functional outcome with other series. Series
Satisfactory
39
Bhan et al. (2000) Iyengar (2003)40 Gurkan et al. (2008)41 Lee (2008)42 Present study
Unsatisfactory
Excellent
Good
Fair
Poor
81% 85.7% 77% 91.8% 83.3%
3.2% 10.7% 15% 8.2% 3.33%
11.3% 3.1% 3% 0% 6.67%
4.5% 0.5% 5% 0% 6.67%
Please cite this article in press as: Chaturvedi H, et al. Functional outcomes in paediatric supracondylar fracture humerus treated with percutaneous pinning with cross K-wires, Apollo Med. (2017), http://dx.doi.org/10.1016/j.apme.2017.01.010
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The results of this study are comparable to those in the other series, in which the displaced supracondylar fracture of humerus was treated by percutaneous pinning. Swenson (1948)35 had good results in his 10 cases, Fowels and Kassab (1974),36 87.5% good results in 110 cases, Flynn et al. (1974)34 had satisfactory overall results in 98% of his 52 cases. Ariño et al. (1977)37 had 160 satisfactory results in 189 cases, Aronson and Prager (1987),38 had 70 satisfactory results in 71 cases. Open reduction and internal fixation has been opposed on the grounds of capsular contracture, joint stiffness, myositis ossificans, leading to restriction of range of motion at elbow. This study achieved 86.63% excellent and good results in 30 cases of displaced supracondylar fracture of humerus treated by closed reduction and percutaneous pinning with medial and lateral cross K-wires. The mean hospital stay was 4.9 days. None of the patient in the study developed iatrogenic ulnar nerve injury, cubitus varus, or myositis ossificans, thereby, proving closed reduction and percutaneous cross pinning an effective treatment method for displaced supracondylar fracture humerus.
5.
Conclusion
Supracondylar fracture of humerus is a very common injury in children. Complications associated with this fracture warrant appropriate and optimum management of this injury. Closed reduction and percutaneous pinning with medial and lateral cross K-wires offers an excellent method to reduce and fix these fractures accurately. Some biomechanical studies advocate cross pinning technique as a more stable biomechanical construct. Increased time from presentation to surgery is not associated with increased morbidity from the injury or treatment complications. Early mobilization is an advantage with this treatment. The use of a medial entry pin for the treatment of paediatric supracondylar humerus fractures is safe as far as iatrogenic ulnar nerve injury and vascular complications are concerned, if an adequate technique is followed. Immediate complications like compartment syndrome are rare and long-term complications are decreased. Chance of infection and implant failure are minimum with this method of treatment. Basic aim in supracondylar humerus fractures is to gain full range of motion of elbow and to obtain a normal appearance of elbow. This modality of treatment is associated with excellent functional outcomes by achieving a full range of motion at the elbow joint in majority of cases and no residual deformity due to malunion. Another advantage is that the removal of implant is an outdoor procedure. Closed reduction and percutaneous pinning with medial and lateral cross K-wires offers a practically feasible, economically viable and an effective treatment method for displaced supracondylar fracture humerus.
Conflicts of interest The authors have none to declare.
references
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Original Article
Functional outcomes in paediatric supracondylar fracture humerus treated with percutaneous pinning with cross K-wires Hemant Chaturvedi a, Vikram Khanna b,*, Rakesh Bhargava c, Raju Vaishya d a
Department of Orthopaedics, NIMS Medical College and Hospital, Jaipur, India Resident, Department of Orthopaedics, NIMS Medical College and Hospital, Jaipur, India c Professor, Head of Department, Department of Orthopaedics, NIMS Medical College and Hospital, Jaipur, India d Senior Consultant, Department of Orthopaedics, Indraprastha Apollo Hospital, Delhi, India b
article info
abstract
Article history:
Background: Supracondylar fracture of humerus is the most common elbow fractures in
Received 10 January 2017
children. Percutaneous pinning is an effective modality of treatment, as it obliterates the
Accepted 21 January 2017
problem of maintenance of reduction of the fracture and minimizes the risk of circulatory
Available online xxx
insufficiency. Methods: 30 patients coming to the hospital during the period from November 2012 to
Keywords:
November 2014 with closed Gartland type II and III supracondylar humerus fracture and
Supracondylar fracture
managed with percutaneous pinning with two cross K-wires were included. Anteroposterior
Gartland
and lateral view X-rays of the affected as well as the normal elbow were taken and assessed
Baumann's angle
regarding union, carrying angle, Baumann's angle and metaphyseal–diaphyseal angle. Flynn
Metaphyseal–diaphyseal angle
criteria were used for evaluation of the final functional outcome.
Flynn criteria
Results: The mean follow-up of the patients in this study was 6.3 months. None of the patient had a final carrying angle less than 108 and more than 168 with mean final carrying angle being 12.38. The final functional outcome assessed according to Flynn criteria, was excellent in 83.33%, good in 3.33%, fair in 6.67% and poor in 6.67% patients. Conclusion: Use of a medial entry pin for the treatment of paediatric supracondylar humerus fractures by closed reduction and percutaneous pinning using cross K-wires is safe as far as iatrogenic ulnar nerve injury and vascular complications are concerned, if an adequate technique is followed. Closed reduction and percutaneous pinning with medial and lateral cross K-wires offers a practically feasible, economically viable and an effective treatment method for displaced supracondylar fracture humerus. © 2017 Indraprastha Medical Corporation Ltd. All rights reserved.
* Corresponding author. Tel.: +91 7073647974. E-mail address: [email protected] http://dx.doi.org/10.1016/j.apme.2017.01.010 0976-0016/© 2017 Indraprastha Medical Corporation Ltd. All rights reserved.
Please cite this article in press as: Chaturvedi H, et al. Functional outcomes in paediatric supracondylar fracture humerus treated with percutaneous pinning with cross K-wires, Apollo Med. (2017), http://dx.doi.org/10.1016/j.apme.2017.01.010
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1.
Introduction
2.
Supracondylar fracture of humerus is the most common elbow fractures in children1–3 and needs proper management. This fracture is common in the 1st decade of life4,5 due to various causes, of which main is ligament laxity and anatomical structure of humerus tube (shaft) to flat transformation at the lower end of humerus. Boys have had a higher incidence of this fracture than girls. The left or nondominant side is most frequently injured.6–9 Many different treatment modalities have been devised for supracondylar fracture of humerus in children, with closed reduction and immobilization in flexion, Dunlop's traction, overhead olecranon skeletal traction, open reduction and internal fixation and closed reduction and percutaneous pinning being the commonly used modalities. Goals of treatment are avoidance of complications and achievement of excellent functional results. In this aspect, percutaneous pinning seems to be useful and effective modality of treatment with least complication rate, as it obliterates the problem of maintenance of reduction of the fracture and minimizes the risk of circulatory insufficiency. The chances of cubitus varus deformity are markedly reduced, with marked reduction in the severe amount of swelling and hospitalization time. Of all the complications associated with supracondylar fractures, nerve injury ranks highest, although reports of the incidence of specific neuropraxia vary. Nerve injury in supracondylar fracture humerus occurs in at least 7% cases and significant vascular injury is seen in 1% cases.10 The radial nerve has been the most frequently involved nerve in older studies; however, the median nerve is much more commonly injured, particularly the anterior interosseous nerve, in more recent studies.11,12 The ulnar nerve is most commonly injured iatrogenically during pinning or in a flexion-type of supracondylar fracture.
Materials and methods
30 skeletally immature patients coming to the hospital during the period from November 2012 to November 2014 with closed Gartland type II and III supracondylar humerus fracture and managed with percutaneous pinning with two cross K-wires were included. Patients with Gartland type I supracondylar fracture of the humerus, open fractures and supracondylar humerus fractures with neurological deficit were excluded from the study. An informed consent was taken. All the 30 cases turned up for the final follow-up. All patients with supracondylar fracture of humerus were first seen either in the accident and emergency services or the orthopaedic outpatient department. They were assessed clinically with special reference to the neurovascular status of the involved limb. Antero-posterior and lateral view skiagrams of the affected elbow were taken (Fig. 1). The Xrays were assessed regarding the type of fracture and the degree of displacement based on Gartland classification. Patients were immobilized in an above elbow slab, and Gartland type II and III supracondylar fracture of the humerus were admitted to the hospital and scheduled for closed reduction and percutaneous pinning under general anaesthesia (Figs. 2–5). The arm was immobilized in 30–608 of flexion in an above elbow slab. The child was observed overnight and post-pinning antero-posterior and lateral view check X-rays of the affected elbow were taken and assessed regarding posterior, medial and lateral displacement as well as rotation of the distal fragment in sagittal, coronal and horizontal plane. Baumann angle and metaphyseal–diaphyseal angle were measured (Fig. 6).
3.
Results
This study included 30 cases of supracondylar fracture of humerus treated with percutaneous pinning with two cross
Fig. 1 – Pre-operative skiagrams after medial and lateral cross-pinning. Please cite this article in press as: Chaturvedi H, et al. Functional outcomes in paediatric supracondylar fracture humerus treated with percutaneous pinning with cross K-wires, Apollo Med. (2017), http://dx.doi.org/10.1016/j.apme.2017.01.010
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Fig. 2 – Intra-operative fluoroscopic images after medial and lateral cross-pinning.
Fig. 3 – Intra-operative image after medial and lateral crosspinning and K-wires bent and cut leaving the pins protruding out of skin.
K-wires. The mean age at the time of injury was 6.8 years (Fig. 7). In this study, 21 patients had injury on the left side and 9 cases had injury on right side. 23 patients suffered injury due to fall while the remaining patients suffered injury in road accident. 6 patients came to the hospital on the date of injury, while 23 patients came next day after the injury and only 1 patient reported 2 days after injury. The post-reduction Baumann angle was in the range of 98–128 in 9 cases, 138– 168 in 17 cases, 178–208 in 4 cases which is 30%, 57% and 13%, respectively and the mean being 13.78. The post-reduction metaphyseal-diaphyseal angle was in the range of 808–828 in 1 case, 838–858 in 6 cases, 918–958 in 1 case, 868–888 in 21 cases and 898–918 in 2 cases. Mean final carrying angle on the affected side was 12.38, distributed between 108–168 (Fig. 8). Final functional results were excellent in 25(83.33%) cases, good in 1(3.33%) case, fair in 2 cases (6.67%), and poor in 2 (6.67%) patients (Fig. 9). The results were excellent in 6(20%) cases with postreduction Baumann angle in the range of 98–128, in 15(50%) cases with angle ranging between 138–168 and in 4(13.3%) cases, the results were excellent with angle in the range of 178–208 (Fig. 10). The final functional outcome was excellent
Fig. 4 – Intra-operative fluoroscopic images after medial and lateral cross-pinning. Please cite this article in press as: Chaturvedi H, et al. Functional outcomes in paediatric supracondylar fracture humerus treated with percutaneous pinning with cross K-wires, Apollo Med. (2017), http://dx.doi.org/10.1016/j.apme.2017.01.010
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Fig. 5 – Immediate post-operative skiagrams after medial and lateral cross-pinning. Fig. 7 – Age distribution.
(1 case) when the percutaneous pinning was done on the same day of injury. Of 11 patients operated on the next day of injury, 10 had excellent functional outcome and 1 had a poor outcome.15 cases were operated on the 2nd day of injury, of which 12 had excellent outcomes, 1 had good, 1had fair and
1 had a poor functional outcome. 1 patient operated on the 3rd day had an excellent functional outcome. Of the 2 patients operated after 3 days of injury, 1 had an excellent outcome while the other had a fair functional outcome (Fig. 11). At final follow-up, 2 (6%) cases had full range of motion, 23(77%) cases
Fig. 6 – Final functional outcome at 20 weeks (A) full flexion, (B) full extension, (C) carrying angle of the affected side compared with the normal side. Please cite this article in press as: Chaturvedi H, et al. Functional outcomes in paediatric supracondylar fracture humerus treated with percutaneous pinning with cross K-wires, Apollo Med. (2017), http://dx.doi.org/10.1016/j.apme.2017.01.010
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had 58 loss, 1 (3%) case had 108 loss and 2 (7%) cases had 158 loss. The remaining 2 (7%) cases had 208 loss of flexion and extension (Fig. 12).
Fig. 11 – Delay from injury to percutaneous pinning vs. final functional result.
Fig. 8 – Distribution of final carrying angle.
Fig. 12 – Residual loss of range of motion.
4. Fig. 9 – Final functional result Flynn criteria.
Fig. 10 – Comparison of post-reduction Baumann angle with results.
Discussion
In this study, 6 patients reported to the hospital on the same day of injury, while the majority of the patients (23 patients) came next day after the injury. Only 1 patient reported 2 days after injury. None of the patients reported after more than 2 days of injury. In a study by Boparai et al.,13 31 patients attended emergency same day, 11 came next day, 5 within 2 days and rest 3 came in 2–7 days after injury. The cause for delay was due to the fact that the patients come from far off areas and they take initial domiciliary treatment in the form of massage or wooden splintage and tight bandage. 2 patients reported with the tight bandage and both of them reported on next day of injury but none of them had any signs of compartment syndrome. Patients were also having fear of operation in hospital. In the present study, 1 case was operated on the day of injury, while 11 cases were operated on the next day, with maximum number of patients (15) being operated within a
Please cite this article in press as: Chaturvedi H, et al. Functional outcomes in paediatric supracondylar fracture humerus treated with percutaneous pinning with cross K-wires, Apollo Med. (2017), http://dx.doi.org/10.1016/j.apme.2017.01.010
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delay of 2 days. Only 1 case was operated on the 3rd day. 2 cases were operated more than 3 days after the injury as both had a concomitant head injury. Of the 28 patients, operated within 3 days of injury, 24 had excellent functional outcome, 1 had good, 1 had fair and 2 had a poor outcome. Of the 2 patients operated after 2 days of injury, 1 had an excellent outcome while the other had a fair functional outcome, thereby showing no association of the final functional outcome with the increased time between presentation and surgery. This is comparable to the studies by Larson et al. (2014),14 Mehlman et al. (2001),15 Lett et al. (2002),16 Gupta et al. (2004),17 who concluded that increased time from presentation to surgery was not associated with increased morbidity from the injury or treatment complications. Baumann (1929)18 described an angle formed between the lateral distal humeral epiphysis and the long axis of the humerus. Sandegard (1944)19 stated that this angle helps one rapidly and definitely decide whether or not displacement towards the axis is present. In this series, the final Baumann angle, in majority of the patients (27) was in the range of 13–168 and the remaining 3 patients had a Baumann angle in range of 9–128. The mean final Baumann angle on the affected side was 14.48 and on the normal side was 15.28. None of the patient had a change in final Baumann angle of more than 48. 6 out of 9 patients with post-reduction Baumann angle between 98 and 128 and 15 of the 17 patients with post-reduction Baumann's angle ranging between 138 and 168 had an excellent functional outcome while all the patients with post-reduction Baumann angle ranging between 178 and 208 had excellent outcomes. The normal angle varies from 88 to 288. Depending on the patient, there is little side-to-side variance in any one individual. A common rule of thumb is that a Baumann angle of at least 108 is acceptable.20 Iyengar et al. (2003),21 concluded that for acceptable closed reduction, Baumann angle should be within 48 of the normal side. The final metaphyseal–diaphyseal angle, in majority of the patients (16) was in the range of 86–888. 16 (53.3%) patients had final metaphyseal–diaphyseal angle ranging between 838 and 858 and the remaining 1 patient had a metaphyseal–diaphyseal angle in range of 89–918. The mean final metaphyseal– diaphyseal angle on the affected side was 85.98 and on the normal side was 84.678. Normal angle is 908. A variation of greater than 108 from the normal side is significant. Angle of more than 908 indicates varus angulation. In this series, no case of cubitus varus was seen and the final metaphyseal– diaphyseal angle was within normal limits in all patients. In this study, no case was admitted with nerve injury. Lawrence (1956),22 Eid (1978)23 reported radial nerve injury
most frequently. In a review of 61 major series by Wilkins (1991),24 he observed 7.7% cases having neurological deficit with radial nerve being the most commonly injured. ElSharkawi and Fattah (1965),25 Prietto26 and El-Ahwany (1974)27 found in their studies that median nerve had most common involvement. None of the patients had any vascular compromise. Ottolenghi (1960),28 in a study reported vascular injury or compromise rate of nearly 5%, of which less than 1% developed Volkmann's ischaemic contracture. Krishna Kumar (2000)29 in his study, also reported no case of Volkmann's ischaemic contracture. No case of post-operative ulnar nerve injury was observed as a complication of insertion of medial K-wire for stabilization of the reduced fracture. Mangwani et al. (2005),30 in a study of 291 children with supracondylar fracture humerus, found post-operative neurological deficit in nine patients, of which 3 required exploration of the ulnar nerve. Kwak-Lee et al. (2014)31 concluded that that the use of a medial-entry pin for the treatment of paediatric supracondylar humerus fractures is safe as far as iatrogenic ulnar nerve injury and vascular complications are concerned, if an adequate technique is followed, as was the case in this study. In most of the studies, chances of myositis ossificans were almost 0% due to early management with very less manipulation. None of the patient had a final carrying angle less than 108 and more than 168. 13 cases had a final carrying angle in a range of 10–128, with majority of the patients (16) having a carrying angle in the range of 13–158, while only 1 patient having a final carrying angle in the range of 16–188. Mean final carrying angle on the affected side was 12.38, distributed between 108 and 168 and on the normal side was distributed between 128 and 178 with a mean of 14.08. None of the patient had a cubitus varus or valgus deformity. The criteria used in the analysis of results have been the final range of motion. Holmberg (1945)32 stated that flexion continues to increase at a slow rate for up to 2 years. At final follow-up, 2 (6%) cases had full range of motion, 23 (77%) cases had 58 loss, 1 (3%) case had 108 loss and 4 (14%) cases had more than 108 loss of flexion and extension. The findings of this study are almost comparable with those of Hernikson (1966)33 who reported that less than 5% of cases have greater than 58 loss of flexion. The final functional outcome assessed according to Flynn criteria (1974),34 was excellent in 25 (83.33%) cases, good in 1 (3.33%) case, fair in 2 (6.67%) cases, and poor in 2 (6.67%) patients (Table 1).
Table 1 – Comparison of final functional outcome with other series. Series
Satisfactory
39
Bhan et al. (2000) Iyengar (2003)40 Gurkan et al. (2008)41 Lee (2008)42 Present study
Unsatisfactory
Excellent
Good
Fair
Poor
81% 85.7% 77% 91.8% 83.3%
3.2% 10.7% 15% 8.2% 3.33%
11.3% 3.1% 3% 0% 6.67%
4.5% 0.5% 5% 0% 6.67%
Please cite this article in press as: Chaturvedi H, et al. Functional outcomes in paediatric supracondylar fracture humerus treated with percutaneous pinning with cross K-wires, Apollo Med. (2017), http://dx.doi.org/10.1016/j.apme.2017.01.010
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The results of this study are comparable to those in the other series, in which the displaced supracondylar fracture of humerus was treated by percutaneous pinning. Swenson (1948)35 had good results in his 10 cases, Fowels and Kassab (1974),36 87.5% good results in 110 cases, Flynn et al. (1974)34 had satisfactory overall results in 98% of his 52 cases. Ariño et al. (1977)37 had 160 satisfactory results in 189 cases, Aronson and Prager (1987),38 had 70 satisfactory results in 71 cases. Open reduction and internal fixation has been opposed on the grounds of capsular contracture, joint stiffness, myositis ossificans, leading to restriction of range of motion at elbow. This study achieved 86.63% excellent and good results in 30 cases of displaced supracondylar fracture of humerus treated by closed reduction and percutaneous pinning with medial and lateral cross K-wires. The mean hospital stay was 4.9 days. None of the patient in the study developed iatrogenic ulnar nerve injury, cubitus varus, or myositis ossificans, thereby, proving closed reduction and percutaneous cross pinning an effective treatment method for displaced supracondylar fracture humerus.
5.
Conclusion
Supracondylar fracture of humerus is a very common injury in children. Complications associated with this fracture warrant appropriate and optimum management of this injury. Closed reduction and percutaneous pinning with medial and lateral cross K-wires offers an excellent method to reduce and fix these fractures accurately. Some biomechanical studies advocate cross pinning technique as a more stable biomechanical construct. Increased time from presentation to surgery is not associated with increased morbidity from the injury or treatment complications. Early mobilization is an advantage with this treatment. The use of a medial entry pin for the treatment of paediatric supracondylar humerus fractures is safe as far as iatrogenic ulnar nerve injury and vascular complications are concerned, if an adequate technique is followed. Immediate complications like compartment syndrome are rare and long-term complications are decreased. Chance of infection and implant failure are minimum with this method of treatment. Basic aim in supracondylar humerus fractures is to gain full range of motion of elbow and to obtain a normal appearance of elbow. This modality of treatment is associated with excellent functional outcomes by achieving a full range of motion at the elbow joint in majority of cases and no residual deformity due to malunion. Another advantage is that the removal of implant is an outdoor procedure. Closed reduction and percutaneous pinning with medial and lateral cross K-wires offers a practically feasible, economically viable and an effective treatment method for displaced supracondylar fracture humerus.
Conflicts of interest The authors have none to declare.
references
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Please cite this article in press as: Chaturvedi H, et al. Functional outcomes in paediatric supracondylar fracture humerus treated with percutaneous pinning with cross K-wires, Apollo Med. (2017), http://dx.doi.org/10.1016/j.apme.2017.01.010