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Paediatric T-condylar fractures of the humerus: Clinical experience and outcomes in 19 cases
Injury, Int. J. Care Injured 45 (2014) 1876–1879
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Paediatric T-condylar fractures of the humerus: Clinical experience and outcomes in 19 cases Sinisa Ducic *, Marko Bumbasirevic, Radivoj Brdar, Borko Stojanovic, Miroslav Djordjevic School of Medicine, University of Belgrade, Serbia
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 5 July 2014
Introduction: T-condylar fractures of the humerus are very rare in children. The treatment options vary from simple reduction and percutaneous stabilisation to open reduction and fixation with plates, screws and Kirchner wires. We evaluated 19 patients who underwent different types of treatment aiming to compare two different approaches of reduction, postoperative results and complications. Methods: The study encompassed total of 19 patients with T-condylar fracture, aged from 3 to 16 years, who underwent either closed or opened reduction between February 2005 and September 2012. Closed reductions were performed in 7, and open reductions in 12 patients. Results were analysed using the Orthopaedic Trauma Association scoring system with 6 domains (range of motion, anatomic restitution, return to activity level, pain, subjective feeling and disability). Results were measured on a 4-point scale (1-excellent, 2-good, 3-fair and 4-poor). Results: The mean follow-up was 49 months (range from 12 to 97 months). According to the type of fracture, excellent results were achieved in 10, good in 8 and poor in one patient. According to method of treatment, an excellent outcome was noted in 6 and 4 patients, following closed and opened reduction, respectively. No statistical analysis was performed because of the small sample size. Conclusion: The present study concludes that any type of T-condylar fracture of the humerus can be solved to a satisfactory degree, either closed or open reduction and with proper stabilisation. ß 2014 Elsevier Ltd. All rights reserved.
Keywords: Distal humerus T-condylar fracture Reduction Outcomes
Introduction T-condylar (intercondylar) fracture of the humerus is a very rare occurrence in the paediatric age group. Incidence of this type of fracture is unknown since the majority of literature is limited to case reports or case series, without outlining the number of cases appearing over the time period in which the cases were observed [1,2]. A paediatric intercondylar fracture can sometimes be confused with an extension type supracondylar fracture of the humerus. The difference between the two lies in the fracture line, which extends into the intercondylar region of the distal humerus. Therefore, high quality radiographs are necessary for making a correct initial diagnosis and then for adequate follow-up once the fracture is properly treated [3]. According to the classification by Toniolo and Wilkinson [4], there are three types of intercondylar fractures: minimally
displaced fracture (Type I), displaced but not comminuted fracture (Type II), and displaced and comminuted fracture (Type III). Despite the small number of reported clinical series, it is widely accepted that this fracture should be treated by open reduction and internal fixation to reduce and stabilise the displaced intraarticular fragments. However, this can cause further iatrogenic injury of the surrounding soft tissue and may lead to postoperative stiffness [5,6]. In young children, a closed reduction with percutaneous pinning could be a good method since their thicker periosteum and elasticity of articular cartilage makes displacement of fracture fragments less likely and offers good possibilities for closed treatment. Herein, we evaluated the clinical experience and outcomes of both closed and open reductions in 19 paediatric cases with T-condylar fracture of the humerus. Materials and methods
* Corresponding author at: University Children’s Hospital, Department of Orthopaedics and Traumatology, Tirsova 10, Belgrade 11000, Serbia. Tel.: +381 64 11 61 051; fax: +381 11 2684 672. E-mail address: [email protected] (S. Ducic). http://dx.doi.org/10.1016/j.injury.2014.07.002 0020–1383/ß 2014 Elsevier Ltd. All rights reserved.
Between February 2005 and September 2012, 19 patients (17 boys and 2 girls) with the average age of 12.5 years (range 3–16 years) who had T-condylar fracture of the humerus were treated by closed or opened reduction with percutaneous or internal
S. Ducic et al. / Injury, Int. J. Care Injured 45 (2014) 1876–1879
stabilisation, respectively. For all patients, the clinical data collected included age at presentation, arm injured, hand dominance, type of injury and treatment, outcome and complications. After the relevant history was taken, complete clinical examination was performed, with a particular emphasis on the distal neurovascular status. Six patients had fractured their dominant arms and 13 their non-dominant arms. The fractures were the result of landing onto flexed elbows and bringing the tips of olecranon directly in contact with the ground when falling. Nine fractures were a result of pedestrian falls, six from biking injuries, and four from a skateboarding injury. Twelve fractures involved the left elbow, and seven involved the right elbow. All patients were examined by plain X-ray radiography, which included antero-posterior and
1877
lateral views. Type I, II and III fractures were observed in 3, 4 and 12 patients, respectively. All the patients underwent surgery under general anaesthesia. The patients were positioned on plain orthopaedic tables in supine position. The patients with Type I or II T-fractures underwent closed reduction, while the patients with Type III fracture were subjected to open reduction. Closed reduction of the intercondylar parts of the fractures was obtained, keeping the elbows of the patients flexed and held using a large pointed pelvic clamp placed percutaneously, with care taken to avoid the ulnar nerve medially. The reduction was then checked under a C-arm. Once an adequate reduction was achieved, Kirchner wires were passed horizontally, parallel to the elbow joints, from the lateral to the
Fig. 1. Preoperative appearance of T-condylar fracture – anteroposterior (A) and lateral (B) radiographs; appearance six months after open reduction and fixation – anteroposterior (C) and lateral (D) view; outcome 2 years after surgery – anteroposterior (E) and lateral (F) radiograph.
S. Ducic et al. / Injury, Int. J. Care Injured 45 (2014) 1876–1879
1878 Table 1 Study population and postoperative results. No.
Patient age
Range of motion (degree)
Anatomic restitution
Subjective
Return to activity level
Pain
Disability
Type of fracture
Method of treatment
Follow up (months)
Rating
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19.
15 13.5 13.5 9 14 14.5 14 14.5 16 13 13.5 13 14 13.5 14.5 12.5 9.5 3 7
140 135 138 120 105 50 142 124 120 122 145 120 130 135 122 135 120 142 145
Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
Excellent Excellent Excellent Excellent Good Good Excellent Excellent Excellent Good Excellent Good Excellent Excellent Good Excellent Good Excellent Excellent
Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
None None None Occasional Occasional Occasional None None Occasional Occasional None Occasional None Occasional None None None None None
None None None Minimum Minimum Moderate None None None None None Minimum None None None None None None None
II III II III III III II III III III I II III III III III III I I
CRP OR CRP OR (failed CRP) OR OR CRP OR OR OR CRP CRP OR OR OR OR OR CRP CRP
97 74 58 26 16 12 14 58 54 19 96 68 75 63 86 42 20 36 24
Excellent Excellent Excellent Good Good Poor Excellent Good Good Good Excellent Good Excellent Excellent Good Excellent Good Excellent Excellent
CRP, closed reduction and percutaneous pinning; OR, open reduction.
medial epicondyles. Two or more Kirschner wires were passed through the medial and the lateral epicondyles of the humerus into the proximal fragment, to achieve a permanent fixation. The final positions of the fractures following the closed reduction with percutaneous stabilisation were checked using the standard radiological criteria. In all cases, wires were left protruding out of the skin at approximately 2 cm. Following the surgeries, the elbows were immobilised with a posterior plaster splint. Open reduction was performed in cases with displaced and comminuted fractures (Type III) as well in cases when the closed reduction was not successful. The fracture was exposed using the posterior approach described by Bryan and Morrey [7]. Articular surface was reconstructed and the intercondylar fracture was converted to a supracondylar fracture. Internal fixation was achieved using Kirchner wires, screws or plates. The final fracture reduction was ascertained using radiography. Wound was closed routinely and elbows were immobilised with a posterior plaster splint. Broad-spectrum antibiotics were administered to all patients one hour prior to surgery. First X-ray follow-up was taken on the second day following surgery. Thereafter, the maintenance of the reduction was checked on a weekly basis, which included anteroposterior and the lateral view radiographs. Three weeks after treatment, the splints were removed. In cases with closed reduction and percutaneous stabilisation, Kirchner wires were removed five weeks after treatment. In the patients treated by open reduction and internal fixation, screws and plates were removed six months later, and regular follow-up was carried on. Results The follow-up ranged from 12 to 97 months (mean 49 months). Closed reduction and percutaneous stabilisation was initially performed in 8, and the other technique, using open reduction and internal fixation, in 11 patients. One patient (number 4) with type III fracture was referred to our hospital for further treatment after failed closed reduction in other institution, and underwent open reduction with internal fixation, with good outcome. All patients included in this study were evaluated at 3, 6 and 12 months postoperatively (Fig. 1A–F). Functional assessment at last followup was performed according to the scoring system published by the Orthopaedic Trauma Association and additional parameters modified by Jupiter et al. [8,9]. All 6 domains were considered, including range of motion, anatomic restitution, return to activity
level, pain, subjective feeling and disability. Results were measured on a 4-point scale (1-excellent, 2-good, 3-fair and 4poor), and presented in Table 1. Excellent results were achieved in 10, good in 8 and poor in 1 patient. Classified by the type of fracture, excellent results were obtained in 3 patients with Type I, 3 with type II and 4 with type III fracture. According to the method of treatment, excellent outcomes were noted in 6 and 4 patients after closed and opened reduction, respectively (Table 2). A poor result was observed in one patient, following an open reduction with internal screw fixation, which was then solved by stabilisation with two additional Kirschner wires. A pin tract infection was seen in one patient, who was treated successfully conservatively.
Discussion T-condylar fractures are extremely rare at an early age. Intercondylar fracture of the distal humerus results from a direct blow onto a flexed elbow, the force wedging the olecranon directly up into the trochlear groove. The treatment is aimed at reconstructing the articular surface of the distal humerus and establishing the widest possible range of movement in the elbow joint, as well as at reducing other complications, primarily inadequate internal fixation, improper healing or avascular necrosis of the trochlea [1,2]. There are few articles on different methods of treatment for transcondylar fractures of the humerus in the existing literature. Because of the rarity of this injury, treatment recommendations cannot be based on multiple case experiences and there is no standard recommended treatment. Most of the experiences are based on isolated cases or small series [6,10]. The generally accepted treatment method is surgical reposition through a Table 2 Treatment outcome by type of fracture. Type of fracture Type I Type II Type III
Number of patients
Result Excellent
Good
Poor
3 4 12
3 3 4
0 1 7
0 0 1
S. Ducic et al. / Injury, Int. J. Care Injured 45 (2014) 1876–1879
posterior approach, followed by an internal fixation with plates and screws [5,6,11]. Authors giving preference to a surgical treatment point out the stability of the fracture and the possibility for early mobilisation of the elbow joint, preventing elbow stiffness, as its advantages [5,11]. Those in favour of less invasive treatment methods emphasise that, by avoiding surgery, further injuries to the soft tissues of the elbow joint are prevented, primarily those of the extensor apparatus, thereby reducing the degree of elbow stiffness [1,2]. Aiming to present our experiences and results in a slightly larger number of patients, we reviewed the reposition methods and fixation types in 19 children with a T fracture. Our first consideration in these fractures is to re-establish the integrity of the articular surface to maintain the congruity of the joint. There are no clear criteria to indicate a certain type of fracture fixation. Method selection was influenced by the age of the patient, type of fracture, appearance of fracture fragments, appearance of the articular surface of the distal humerus following reposition and the stability of the fracture after reposition, as well as the surgeon’s experience, of course. In patients treated by an orthopaedic repositioning, monitored under image intensifier, stabilisation was achieved using Kirschner wires. In those cases in which it was impossible to achieve a satisfactory position of the fragments by orthopaedic repositioning, surgical repositioning was undertaken. Following a surgical repositioning, different fixation options were used to stabilise the fracture fragments. Our guiding principle was to use a minimally invasive approach, aimed at preventing further tissue damage to the elbow joint which certainly contributes to joint stiffness, while simultaneously respecting the principle of reconstructing the articular surface of the distal humerus and achieving a stable fixation. The results were evaluated based on the scoring system published by the Orthopaedic Trauma Association and additional parameters modified by Jupiter et al. [8,9]. In the mean follow-up period of 49 months, excellent results were achieved in 10, good in 8 and poor in only one patient. In the group of 7 patients treated by orthopaedic repositioning, an excellent result was achieved in 6 patients. Advantages of orthopaedic repositioning are the minimally invasive procedure, shorter surgery time and the fact that there’s no need to put the patient under general anaesthesia to remove the fixation devices; however, its disadvantages are a decreased stability allowing for fracture redislocation and delayed physical therapy, which could result in a decreased range of motion of the elbow joint. By examining patients treated by surgical repositioning, a somewhat poorer result is observed in comparison to orthopaedic repositioning. It is noticed in patients with the more severe type III where closed reduction was not deemed appropriate and open reduction was performed. One of the reasons could be the damage to soft tissues during repositioning; but also the fact that this method of treatment was used in patients with the most severe, type III transcondylar fracture. According to literature, surgical repositioning is the method of choice in the treatment of such severe fractures, given its excellent visibility and the possibility of achieving an almost ideal reconstruction of the elbow surfaces. However, its disadvantages, such as greater stiffness of the elbow joint, present the practitioner with a dilemma on whether this type of treatment is the best option in each particular case [5,6]. One shortcoming of this study lies in the fact that there are no standardised parameters for evaluation of the results achieved.
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Parameters used are those used for adult patients. When comparing the range of motion in the treated arm, which was scored as excellent according to the Jupiter criteria, with the range of motion in the contra-lateral arm, we observed that in three patients treated by open repositioning there was a discrepancy of 5 degrees (in one patient) to 10 degrees (two patients). Related to final results, we had only one patient with poor result, who had been followed up for only 12 months after internal fixation, and we believe that there is a scope for improvement over the next years. We consider that prolonged immobilisation resulted in stiffness, since anatomic restitution was satisfactory after additional stabilisation with Kirschner wires. We therefore believe that far more studies are needed in the future to help standardise the parameters and make them applicable for evaluating results of treatment in paediatric patients. In addition, another shortcoming lies in the fact that it is impossible to compare different types of treatment statistically due to an insufficient number of patients treated and due to the fact that these were different types of transcondylar fractures of the humerus that were fixated with different fixation means.
Conclusions Intercondylar fracture is rare in children and presents a great challenge for treatment. Both closed and open reduction offers a good possibility for a successful outcome. However, more reviews, articles and standardised protocols are necessary to provide us with an idea on how to improve our approach.
Conflict of interest The authors declare no financial or other conflicts of interest. References [1] Kanellopoulos AD, Yiannakopoulos CK. Closed reduction and percutaneous stabilization of pediatric T-condylar fractures of the humerus. J Pediatr Orthop 2004;24:13–6. [2] Julfiqar, Pant A, Huda N, Ahmed W. Closed reductions and percutaneous ‘K’ wire fixation for adolescent intercondylar fractures of the distal humerus. J Clin Diagn Res 2013;7:1666–8. [3] Ruiz AL, Kealey WD, Cowie HG. Percutaneous pin fixation of intercondylar fractures in young children. J Pediatr Orthop B 2001;10:211–3. [4] Toniolo MR, Wilkins KE. T-condylar fractures. In: Rockwood CA, Wilkins KE, Beaty JH, editors. Fractures in children. 4th ed., Philadelphia: LippincottRaven; 1996. p. 653–904. [5] Re PR, Waters PM, Hresko T. T-condylar fractures of the distal humerus in children and adolescents. J Pediatr Orthop 1999;19:313–8. [6] Papavasiliou VA, Beslikas TA. T-condylar fractures of the distal humeral condyles during childhood: an analysis of six cases. J Pediatr Orthop 1986;6:302–5. [7] Bryan RS, Morrey BF. Extensive posterior exposure of the elbow. A tricepssparing approach. Clin Orthop Relat Res 1982;166:188–92. [8] Pajarinen J, Bjorkenheim JM. Operative treatment of type C intercondylar fractures of the distal humerus: results after a mean follow-up of two years in a series of 18 patients. J Shoulder Elbow Surg 2002;11:48–52. [9] Jupiter JB, Neff U, Holzach P, Allgo¨wer M. Intercondylar fractures of the humerus. An operative approach. J Bone Joint Surg Am 1985;67:226–39. [10] Mok CY, Lui TH. T-condylar fractures of the distal humerus in children: report on three cases. BMJ Case Rep )2013;(July). http://dx.doi.org/10.1136/bcr2013-009685. [11] Kundel K, Braun W, Wieberneit J, Ru¨ter A. Intraarticular distal humerus fractures. Factors affecting functional outcome. Clin Orthop Relat Res 1996;332:200–8.
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Paediatric T-condylar fractures of the humerus: Clinical experience and outcomes in 19 cases Sinisa Ducic *, Marko Bumbasirevic, Radivoj Brdar, Borko Stojanovic, Miroslav Djordjevic School of Medicine, University of Belgrade, Serbia
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 5 July 2014
Introduction: T-condylar fractures of the humerus are very rare in children. The treatment options vary from simple reduction and percutaneous stabilisation to open reduction and fixation with plates, screws and Kirchner wires. We evaluated 19 patients who underwent different types of treatment aiming to compare two different approaches of reduction, postoperative results and complications. Methods: The study encompassed total of 19 patients with T-condylar fracture, aged from 3 to 16 years, who underwent either closed or opened reduction between February 2005 and September 2012. Closed reductions were performed in 7, and open reductions in 12 patients. Results were analysed using the Orthopaedic Trauma Association scoring system with 6 domains (range of motion, anatomic restitution, return to activity level, pain, subjective feeling and disability). Results were measured on a 4-point scale (1-excellent, 2-good, 3-fair and 4-poor). Results: The mean follow-up was 49 months (range from 12 to 97 months). According to the type of fracture, excellent results were achieved in 10, good in 8 and poor in one patient. According to method of treatment, an excellent outcome was noted in 6 and 4 patients, following closed and opened reduction, respectively. No statistical analysis was performed because of the small sample size. Conclusion: The present study concludes that any type of T-condylar fracture of the humerus can be solved to a satisfactory degree, either closed or open reduction and with proper stabilisation. ß 2014 Elsevier Ltd. All rights reserved.
Keywords: Distal humerus T-condylar fracture Reduction Outcomes
Introduction T-condylar (intercondylar) fracture of the humerus is a very rare occurrence in the paediatric age group. Incidence of this type of fracture is unknown since the majority of literature is limited to case reports or case series, without outlining the number of cases appearing over the time period in which the cases were observed [1,2]. A paediatric intercondylar fracture can sometimes be confused with an extension type supracondylar fracture of the humerus. The difference between the two lies in the fracture line, which extends into the intercondylar region of the distal humerus. Therefore, high quality radiographs are necessary for making a correct initial diagnosis and then for adequate follow-up once the fracture is properly treated [3]. According to the classification by Toniolo and Wilkinson [4], there are three types of intercondylar fractures: minimally
displaced fracture (Type I), displaced but not comminuted fracture (Type II), and displaced and comminuted fracture (Type III). Despite the small number of reported clinical series, it is widely accepted that this fracture should be treated by open reduction and internal fixation to reduce and stabilise the displaced intraarticular fragments. However, this can cause further iatrogenic injury of the surrounding soft tissue and may lead to postoperative stiffness [5,6]. In young children, a closed reduction with percutaneous pinning could be a good method since their thicker periosteum and elasticity of articular cartilage makes displacement of fracture fragments less likely and offers good possibilities for closed treatment. Herein, we evaluated the clinical experience and outcomes of both closed and open reductions in 19 paediatric cases with T-condylar fracture of the humerus. Materials and methods
* Corresponding author at: University Children’s Hospital, Department of Orthopaedics and Traumatology, Tirsova 10, Belgrade 11000, Serbia. Tel.: +381 64 11 61 051; fax: +381 11 2684 672. E-mail address: [email protected] (S. Ducic). http://dx.doi.org/10.1016/j.injury.2014.07.002 0020–1383/ß 2014 Elsevier Ltd. All rights reserved.
Between February 2005 and September 2012, 19 patients (17 boys and 2 girls) with the average age of 12.5 years (range 3–16 years) who had T-condylar fracture of the humerus were treated by closed or opened reduction with percutaneous or internal
S. Ducic et al. / Injury, Int. J. Care Injured 45 (2014) 1876–1879
stabilisation, respectively. For all patients, the clinical data collected included age at presentation, arm injured, hand dominance, type of injury and treatment, outcome and complications. After the relevant history was taken, complete clinical examination was performed, with a particular emphasis on the distal neurovascular status. Six patients had fractured their dominant arms and 13 their non-dominant arms. The fractures were the result of landing onto flexed elbows and bringing the tips of olecranon directly in contact with the ground when falling. Nine fractures were a result of pedestrian falls, six from biking injuries, and four from a skateboarding injury. Twelve fractures involved the left elbow, and seven involved the right elbow. All patients were examined by plain X-ray radiography, which included antero-posterior and
1877
lateral views. Type I, II and III fractures were observed in 3, 4 and 12 patients, respectively. All the patients underwent surgery under general anaesthesia. The patients were positioned on plain orthopaedic tables in supine position. The patients with Type I or II T-fractures underwent closed reduction, while the patients with Type III fracture were subjected to open reduction. Closed reduction of the intercondylar parts of the fractures was obtained, keeping the elbows of the patients flexed and held using a large pointed pelvic clamp placed percutaneously, with care taken to avoid the ulnar nerve medially. The reduction was then checked under a C-arm. Once an adequate reduction was achieved, Kirchner wires were passed horizontally, parallel to the elbow joints, from the lateral to the
Fig. 1. Preoperative appearance of T-condylar fracture – anteroposterior (A) and lateral (B) radiographs; appearance six months after open reduction and fixation – anteroposterior (C) and lateral (D) view; outcome 2 years after surgery – anteroposterior (E) and lateral (F) radiograph.
S. Ducic et al. / Injury, Int. J. Care Injured 45 (2014) 1876–1879
1878 Table 1 Study population and postoperative results. No.
Patient age
Range of motion (degree)
Anatomic restitution
Subjective
Return to activity level
Pain
Disability
Type of fracture
Method of treatment
Follow up (months)
Rating
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19.
15 13.5 13.5 9 14 14.5 14 14.5 16 13 13.5 13 14 13.5 14.5 12.5 9.5 3 7
140 135 138 120 105 50 142 124 120 122 145 120 130 135 122 135 120 142 145
Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
Excellent Excellent Excellent Excellent Good Good Excellent Excellent Excellent Good Excellent Good Excellent Excellent Good Excellent Good Excellent Excellent
Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
None None None Occasional Occasional Occasional None None Occasional Occasional None Occasional None Occasional None None None None None
None None None Minimum Minimum Moderate None None None None None Minimum None None None None None None None
II III II III III III II III III III I II III III III III III I I
CRP OR CRP OR (failed CRP) OR OR CRP OR OR OR CRP CRP OR OR OR OR OR CRP CRP
97 74 58 26 16 12 14 58 54 19 96 68 75 63 86 42 20 36 24
Excellent Excellent Excellent Good Good Poor Excellent Good Good Good Excellent Good Excellent Excellent Good Excellent Good Excellent Excellent
CRP, closed reduction and percutaneous pinning; OR, open reduction.
medial epicondyles. Two or more Kirschner wires were passed through the medial and the lateral epicondyles of the humerus into the proximal fragment, to achieve a permanent fixation. The final positions of the fractures following the closed reduction with percutaneous stabilisation were checked using the standard radiological criteria. In all cases, wires were left protruding out of the skin at approximately 2 cm. Following the surgeries, the elbows were immobilised with a posterior plaster splint. Open reduction was performed in cases with displaced and comminuted fractures (Type III) as well in cases when the closed reduction was not successful. The fracture was exposed using the posterior approach described by Bryan and Morrey [7]. Articular surface was reconstructed and the intercondylar fracture was converted to a supracondylar fracture. Internal fixation was achieved using Kirchner wires, screws or plates. The final fracture reduction was ascertained using radiography. Wound was closed routinely and elbows were immobilised with a posterior plaster splint. Broad-spectrum antibiotics were administered to all patients one hour prior to surgery. First X-ray follow-up was taken on the second day following surgery. Thereafter, the maintenance of the reduction was checked on a weekly basis, which included anteroposterior and the lateral view radiographs. Three weeks after treatment, the splints were removed. In cases with closed reduction and percutaneous stabilisation, Kirchner wires were removed five weeks after treatment. In the patients treated by open reduction and internal fixation, screws and plates were removed six months later, and regular follow-up was carried on. Results The follow-up ranged from 12 to 97 months (mean 49 months). Closed reduction and percutaneous stabilisation was initially performed in 8, and the other technique, using open reduction and internal fixation, in 11 patients. One patient (number 4) with type III fracture was referred to our hospital for further treatment after failed closed reduction in other institution, and underwent open reduction with internal fixation, with good outcome. All patients included in this study were evaluated at 3, 6 and 12 months postoperatively (Fig. 1A–F). Functional assessment at last followup was performed according to the scoring system published by the Orthopaedic Trauma Association and additional parameters modified by Jupiter et al. [8,9]. All 6 domains were considered, including range of motion, anatomic restitution, return to activity
level, pain, subjective feeling and disability. Results were measured on a 4-point scale (1-excellent, 2-good, 3-fair and 4poor), and presented in Table 1. Excellent results were achieved in 10, good in 8 and poor in 1 patient. Classified by the type of fracture, excellent results were obtained in 3 patients with Type I, 3 with type II and 4 with type III fracture. According to the method of treatment, excellent outcomes were noted in 6 and 4 patients after closed and opened reduction, respectively (Table 2). A poor result was observed in one patient, following an open reduction with internal screw fixation, which was then solved by stabilisation with two additional Kirschner wires. A pin tract infection was seen in one patient, who was treated successfully conservatively.
Discussion T-condylar fractures are extremely rare at an early age. Intercondylar fracture of the distal humerus results from a direct blow onto a flexed elbow, the force wedging the olecranon directly up into the trochlear groove. The treatment is aimed at reconstructing the articular surface of the distal humerus and establishing the widest possible range of movement in the elbow joint, as well as at reducing other complications, primarily inadequate internal fixation, improper healing or avascular necrosis of the trochlea [1,2]. There are few articles on different methods of treatment for transcondylar fractures of the humerus in the existing literature. Because of the rarity of this injury, treatment recommendations cannot be based on multiple case experiences and there is no standard recommended treatment. Most of the experiences are based on isolated cases or small series [6,10]. The generally accepted treatment method is surgical reposition through a Table 2 Treatment outcome by type of fracture. Type of fracture Type I Type II Type III
Number of patients
Result Excellent
Good
Poor
3 4 12
3 3 4
0 1 7
0 0 1
S. Ducic et al. / Injury, Int. J. Care Injured 45 (2014) 1876–1879
posterior approach, followed by an internal fixation with plates and screws [5,6,11]. Authors giving preference to a surgical treatment point out the stability of the fracture and the possibility for early mobilisation of the elbow joint, preventing elbow stiffness, as its advantages [5,11]. Those in favour of less invasive treatment methods emphasise that, by avoiding surgery, further injuries to the soft tissues of the elbow joint are prevented, primarily those of the extensor apparatus, thereby reducing the degree of elbow stiffness [1,2]. Aiming to present our experiences and results in a slightly larger number of patients, we reviewed the reposition methods and fixation types in 19 children with a T fracture. Our first consideration in these fractures is to re-establish the integrity of the articular surface to maintain the congruity of the joint. There are no clear criteria to indicate a certain type of fracture fixation. Method selection was influenced by the age of the patient, type of fracture, appearance of fracture fragments, appearance of the articular surface of the distal humerus following reposition and the stability of the fracture after reposition, as well as the surgeon’s experience, of course. In patients treated by an orthopaedic repositioning, monitored under image intensifier, stabilisation was achieved using Kirschner wires. In those cases in which it was impossible to achieve a satisfactory position of the fragments by orthopaedic repositioning, surgical repositioning was undertaken. Following a surgical repositioning, different fixation options were used to stabilise the fracture fragments. Our guiding principle was to use a minimally invasive approach, aimed at preventing further tissue damage to the elbow joint which certainly contributes to joint stiffness, while simultaneously respecting the principle of reconstructing the articular surface of the distal humerus and achieving a stable fixation. The results were evaluated based on the scoring system published by the Orthopaedic Trauma Association and additional parameters modified by Jupiter et al. [8,9]. In the mean follow-up period of 49 months, excellent results were achieved in 10, good in 8 and poor in only one patient. In the group of 7 patients treated by orthopaedic repositioning, an excellent result was achieved in 6 patients. Advantages of orthopaedic repositioning are the minimally invasive procedure, shorter surgery time and the fact that there’s no need to put the patient under general anaesthesia to remove the fixation devices; however, its disadvantages are a decreased stability allowing for fracture redislocation and delayed physical therapy, which could result in a decreased range of motion of the elbow joint. By examining patients treated by surgical repositioning, a somewhat poorer result is observed in comparison to orthopaedic repositioning. It is noticed in patients with the more severe type III where closed reduction was not deemed appropriate and open reduction was performed. One of the reasons could be the damage to soft tissues during repositioning; but also the fact that this method of treatment was used in patients with the most severe, type III transcondylar fracture. According to literature, surgical repositioning is the method of choice in the treatment of such severe fractures, given its excellent visibility and the possibility of achieving an almost ideal reconstruction of the elbow surfaces. However, its disadvantages, such as greater stiffness of the elbow joint, present the practitioner with a dilemma on whether this type of treatment is the best option in each particular case [5,6]. One shortcoming of this study lies in the fact that there are no standardised parameters for evaluation of the results achieved.
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Parameters used are those used for adult patients. When comparing the range of motion in the treated arm, which was scored as excellent according to the Jupiter criteria, with the range of motion in the contra-lateral arm, we observed that in three patients treated by open repositioning there was a discrepancy of 5 degrees (in one patient) to 10 degrees (two patients). Related to final results, we had only one patient with poor result, who had been followed up for only 12 months after internal fixation, and we believe that there is a scope for improvement over the next years. We consider that prolonged immobilisation resulted in stiffness, since anatomic restitution was satisfactory after additional stabilisation with Kirschner wires. We therefore believe that far more studies are needed in the future to help standardise the parameters and make them applicable for evaluating results of treatment in paediatric patients. In addition, another shortcoming lies in the fact that it is impossible to compare different types of treatment statistically due to an insufficient number of patients treated and due to the fact that these were different types of transcondylar fractures of the humerus that were fixated with different fixation means.
Conclusions Intercondylar fracture is rare in children and presents a great challenge for treatment. Both closed and open reduction offers a good possibility for a successful outcome. However, more reviews, articles and standardised protocols are necessary to provide us with an idea on how to improve our approach.
Conflict of interest The authors declare no financial or other conflicts of interest. References [1] Kanellopoulos AD, Yiannakopoulos CK. Closed reduction and percutaneous stabilization of pediatric T-condylar fractures of the humerus. J Pediatr Orthop 2004;24:13–6. [2] Julfiqar, Pant A, Huda N, Ahmed W. Closed reductions and percutaneous ‘K’ wire fixation for adolescent intercondylar fractures of the distal humerus. J Clin Diagn Res 2013;7:1666–8. [3] Ruiz AL, Kealey WD, Cowie HG. Percutaneous pin fixation of intercondylar fractures in young children. J Pediatr Orthop B 2001;10:211–3. [4] Toniolo MR, Wilkins KE. T-condylar fractures. In: Rockwood CA, Wilkins KE, Beaty JH, editors. Fractures in children. 4th ed., Philadelphia: LippincottRaven; 1996. p. 653–904. [5] Re PR, Waters PM, Hresko T. T-condylar fractures of the distal humerus in children and adolescents. J Pediatr Orthop 1999;19:313–8. [6] Papavasiliou VA, Beslikas TA. T-condylar fractures of the distal humeral condyles during childhood: an analysis of six cases. J Pediatr Orthop 1986;6:302–5. [7] Bryan RS, Morrey BF. Extensive posterior exposure of the elbow. A tricepssparing approach. Clin Orthop Relat Res 1982;166:188–92. [8] Pajarinen J, Bjorkenheim JM. Operative treatment of type C intercondylar fractures of the distal humerus: results after a mean follow-up of two years in a series of 18 patients. J Shoulder Elbow Surg 2002;11:48–52. [9] Jupiter JB, Neff U, Holzach P, Allgo¨wer M. Intercondylar fractures of the humerus. An operative approach. J Bone Joint Surg Am 1985;67:226–39. [10] Mok CY, Lui TH. T-condylar fractures of the distal humerus in children: report on three cases. BMJ Case Rep )2013;(July). http://dx.doi.org/10.1136/bcr2013-009685. [11] Kundel K, Braun W, Wieberneit J, Ru¨ter A. Intraarticular distal humerus fractures. Factors affecting functional outcome. Clin Orthop Relat Res 1996;332:200–8.