Evaluation of Functional Results in the Management of Supracondylar Fracture of Humerus in Children by Various Methods

Introduction: Supracondylar fractures of Humerus are one of the most common fractures in pediatric age group. The aim ofthe study was to evaluate the functional results in the management of supracondylar fracture of humerus in children by variousmethods.Materials and Methods: This study was conducted at the Orthopaedics department of Mahatma Gandhi MemorialHospital, Warangal. This was a 2 years prospective, longitudinal, hospital based, observational study and its outcomes.Participants were a total of 30 children aged 0 to 14 years (21 males, 9 females) diagnosed with supracondylar fractureof humerus.Results: Patients were assessed by Flynn’s criteria. Results were excellent in 70%, good in 20%, fair in 6.66%, and poor in 3.33%.Conclusion: Closed reduction and external immobilization are reserved for Gartland’s type 1 and select type 2 fractures. Inunstable type 2 and type 3, closed or open reduction and K-wire fixation give better results.

Percutaneous Pinning For Management of Non-Comminuted Extra-Articular Distal Radial Fractures: A Prospective Study

Distal radius fractures are one of the common injuries for which orthopedic consultations are sought. These injuries make up to 10-15% of all bony injuries in adult population. High energy trauma as seen in road traffic accidents is common cause of these injuries. Noncomminuted extra-articular fractures of distal radius are common in adult males following vehicular accidents. Majority of the patients with distal radial fractures are managed by closed reduction and immobilization. Poor functional outcome and complications such as malunion has made many researchers to look for alternative methods of managing these patients. An attractive alternative for managing these cases consist of Percutaneous pinning followed by immobilization of the fracture for 3 weeks. This method is simple and affordable and reported to have excellent functional outcome.Methods:This was a prospective cohort study conducted in the department of orthopedics of a tertiary care medical college situated in an urban area. 40 adult patients with Noncomminuted extraarticular fractures of distal radius were included in this study on the basis of a predefined inclusion and exclusion criteria. All patients were treated by closed reduction followed by percutaneous pinning using K-wires. Below elbow plaster cast was given for 3 weeks after which plaster was removed and physiotherapy was started. Follow up X-rays were taken at 3 and 6 weeks. Functional outcome was assessed by Quick DASH scores. SSPE 21.0 was used for statistical analysis and p value less than 0.05 was taken as statistically significant.Results: Out of the 40 studied cases there were 34 (85%) males and 6 (15%) females a M:F ratio of 1:0.17. The most common affected age group was found to be <30 years (55%) and most common mechanism of injury was motor vehicular accidents (65%). All patients were treated by closed reduction followed by percutaneous pinning using K-wires. Excellent or good functional outcome was seen in 34 (85%) patients. 4 (10%) patients were found to have fair functional outcome and remaining 2 (5%) patients were found to have poor functional outcome as assessed by Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire.Conclusion:Percutaneous pinning followed by immobilization of the fracture is an effective treatment for Non-comminuted extra-articular fractures of distal radius having excellent functional outcome.

Paediatric supracondylar humeral fractures: a technique for safe medial pin passage with zero incidence of iatrogenic ulnar nerve injury

INTRODUCTION@#The cross Kirschner wire (K-wire) configuration in closed reduction and percutaneous pinning of paediatric supracondylar humeral fracture affords superior stability. However, medial pin placement presents a risk of iatrogenic ulnar nerve injury. This study describes, in step-by-step detail, another safe method of percutaneous medial pin insertion.@*METHODS@#The technique involved placing the patient's arm in external rotation, with elbow flexed no more than 45° after closed reduction. The surgeon held the K-wire close to its sharp end to pass it percutaneously onto the medial epicondyle, then adjusted his grip toward the blunt end. After fluoroscopy check, the wire driver was engaged and an anteriorly directed force was applied to the distal humerus fragment using the thumb of the surgeon's free hand. The K-wire was inserted at a 45° angle to the longitudinal axis of the humerus shaft. Clinical notes and radiographs of patients who underwent surgery with this technique from 2006 to 2008 were reviewed.@*RESULTS@#A total of 125 patients (84 boys, 41 girls) were included, with a mean age of 7.1 (range 2-14) years. Most injuries were left-sided (72.8%, n = 91, vs. right: 27.2%, n = 34). 72 (57.6%) patients had two-pin cross K-wire configuration, while 53 (42.4%) patients had an additional lateral pin inserted. No patient had postoperative ulnar neuropathy. There were no complications of non-union, malunion or infection.@*CONCLUSION@#This safe method of medial pin placement for surgical stabilisation of paediatric supracondylar humeral fractures is easily learnt and reproducible, and produces excellent results.

Efficacy of External Fixation and Transfixation Pinning of Distal Radioulnar Joint in Distal Radius Fracture

PURPOSE: The purpose of this study is to evaluate efficacy of percutaneous pinning of distal radioulnar joint in patient with distal radius fracture. METHODS: Thirty-eight patients who underwent percutaneous pinning and external fixation for distal radius fracture were included in this study. Radiologic and clinical outcomes were compared between the patients who underwent percutaneous pinning on the radius only (PD group) and the patients with supplementary pinning on distal radioulnar joint (DRU group) after percutaneous pinning on the radius. External fixation was performed in all patients. RESULTS: Twenty-three patients were PD group and fifteen patients were DRU group. Radial height and radial inclination was significantly higher in DRU group. There was no significant difference in ulnar variance, volar tilt and articular step off between two groups. Among the clinical outcome, there was no significant difference in range of motion between two groups but grip strength was significantly larger in DRU group. CONCLUSION: Percutaneous pinning with K-wires on distal radioulnar joint in distal radius fracture can be a useful procedure for prevention of radial shortening without loss of range of motion of the wrist.

Management of Grossly Displaced Paediatric Supracondylar Humeral Fractures with Delayed Presentation by Closed Reduction and Percutaneous Pinning.

Background: Management guidelines are not yet clear for these patients who present late with displaced supracondylar fracture. The aim of this prospective study was to evaluate the clinical, radiological and functional outcome following closed reduction and percutaneous pinning of widely displaced supracondylar fractures of the humerus presenting 24 hours or more after injury. Patients and Methods: This prospective study was conducted at the Orthopaedic and Trauma Department of Dr Pinnamaneni Siddartha Institute of Medical Sciences and Research Foundation, Chinnoutpalli from January 2010 to July 2011. A total of 44 children were included in this study who had displaced supracondylar fracture of humerus presenting late ie, after 24 hours after injury and within a week. They were treated with closed reduction of the fracture and percutaneous pinning. Follow-up was done up to 12 months. Results: Patients were assessed on the basis of Flynn’s criteria, there were 37 excellent, 6 good results and fair results in 1 case. There were 25 boys and 19 girls. The average age of the patients was 7.5 years (range: 4 to 12 years). Fall on the outstretched hand was the mechanism of injury in 36 patients, and the other 8 patients were pedestrians struck by a motor vehicle. Non-dominant extremity was more commonly involved (30 patients). In 24 patients the fracture was displaced posteromedially (54.54%), in 18 patients posterolaterally (40.90%), and 2 patients had isolated posterior displacement (2.54%). The average delay in presentation was 57.56 hours (range: 1 day to 6 days). The mean time to surgery after presentation was 9.83 hours (range: 4 hours to 13 hours) and the mean time to surgery after trauma was 67.39 hours. Sixteen patients had one or more attempts of reduction by massaging by a quack and in 2 patients it was attempted by a qualified surgeon before they presented to us. 26 patients (59.09) visited a quack prior to presentation to us. There was a direct relation between duration of delayed presentation and the times of manoeuvre. Sixteen patients (36.36%) had neurologic complications at presentation to the emergency room of which three had median nerve palsy (6.81%) where as seven (15.90%) had isolated anterior interosseous nerve palsy and six (13.6%) had radial nerve palsy all patients showed total neurological recovery at 12 weeks follow-up. Six patients (13.63%) had vascular compromise at initial presentation of which five patients had feeble radial pulse and one had absent radial pulse, but capillary filling was adequate in all. The pulse was restored within 24 hours in all patients following reduction. Conclusion: Our preliminary results support our recommendation ie, closed reduction and percutaneous pin fixation as an effective treatment option for grossly displaced supracondylar fractures presenting late but requires good and careful judgment and also technique by the surgeon to avoid complications. Our results also support the chances of spontaneous recovery of peripheral nerve palsy and brachial artery spasm post reduction over a period of time in majority of cases though they present late.

Functional Outcomes of Percutaneous K-Wire Fixation for Distal Radius Fractures with or without Osteoporosis

PURPOSE: To determine the influence of osteoporosis on the results of percutaneous K-wire fixation for distal radius fractures. MATERIALS AND METHODS: Between March 2007 and February 2011, Fifty seven patients who underwent fixative surgery with K-wires after closed reduction and those available for follow-up for at least 6 months were reviewed. They were divided into the two groups of T score -3 or more (group 1) and T score less than -3 (group 2). These groups were compared by the range of motion of the wrist and Disabilities of the Arm, Shoulder and Hand (DASH) score. Radiologic evaluations consisting of radial length, radial inclination and volar tilt were compared. In group 1 with 34 cases, the average age was 65.4 years (50 to 78 years) and T score was -1.97 (-0.1 to -2.93). In group 2 with 23 cases, the average age was 74 years (54 to 89 years) and T score was -4.11 (-3.1 to -6.97). RESULTS: There was no statistical difference between group 1 and group 2 in terms of range of motion, DASH score and radiologic evaluations. CONCLUSION: In the case of no volar side cortical comminution, percutaneous K-wire fixation can be applied for the treatment of distal radius fracture with osteoporosis.

Intercarpal Ligament Injuries Associated with Distal Radius Fractures: Relation with the Radiographic Findings and Arthroscopic Treatment / 대한정형외과학회잡지

PURPOSE: The purpose of this study was to analyze the relationship between intercarpal ligament injuries associated with distal radius fracture and the fracture patterns and radiologic parameters, and to report on the clinical results of arthroscopic treatment for these injuries. MATERIALS AND METHODS: Fifty-two patients who underwent arthroscopic surgery for intercarpal ligaments injuries associated with distal radius fracture and who had a minimum 1 year follow-up were enrolled. There were 44 patients who sustained scapholunate interosseous ligament injury (SLIL) and 30 patients who sustained lunotriquetral interosseous ligament (LTIL) injury. Among them, 22 patients had both SLIL and LTIL injuries. The carpal ligament injuries were graded according to the Geissler classification and they treated with arthroscopic debridement only for a grade I and II injury and arthroscopic reduction and percutaneous pinning for a grade III and IV injury. The patients were divided into two groups and we assessed the functional and radiological outcomes: Group 1 consisted of the patients with a grade I and II injury and group 2 consisted of the patients with a grade III and IV injury. RESULTS: The preoperative mean radial inclination of group 2 with lunotriquetal interosseous ligament injury was 15.1+/-9.9degrees, which was significantly different from 20.4+/-5.1degrees of group 1, and the extra-articular type injury was more common in group 2 (p<0.05). On the follow-up radiographs, the mean scapholunate interval measured 2.1+/-0.5 mm in group 1 and 1.7+/-0.5 mm in group 2, which was significantly different (p<0.05). CONCLUSION: The grade of LTIL injury combined with distal radius fractures is associated with the loss of radial inclination and the extra-articular fracture type at the time of initial presentation. Complete tears of the SLIL can be stabilized with arthroscopic reduction and percutaneous pinning.

A Comparative Study of Three Different Fixation Techniques for Displaced Two- and Three-Part Proximal Humeral Fractures / 대한정형외과학회잡지

PURPOSE: To analyze and compare the results of three different surgical methods - closed reduction and percutaneous pinning (Group I), bifurcated plate and tension band wiring (Group II), locking compression plate (Group III), - for displaced two- and three-part proximal humeral fractures. MATERIALS AND METHODS: Sixteen patients were treated with a closed reduction and percutaneous pinning, 19 with bifurcated plate and tension band wiring and 18 with locking compression plate. All patients were followed up for more than 1 year, and were reviewed and evaluated with respect to radiological and clinical results. The radiological results were evaluated by bony union and humerus neck shaft angle using the Paavolainen method. The clinical results were evaluated by Neer's evaluation criteria. RESULTS: Bony union rate, time period to achieve bony union, neck shaft angle and clinical results in Groups II and III were better than those in Group I (p<0.05). There were no significant differences between Groups II and III. We observed trends for worse clinical outcomes in patients older than 65 years compared with those in patients younger than 65 years. Clinical outcome for patients older than 65 years in Group III (average 87.5 points) was better than that for the same age group in Groups I (average 77.2 points) and II (average 79.3 points), but the cohorts were too small to obtain statistical significance. Complication rate in Groups II, III was lower than that in Group I (p=0.005). CONCLUSION: The radiological and clinical results in Groups II and III were significantly better than those in Group I, and there were no significant differences between Groups II and III. We thought that bifurcated plate and tension band wiring and locking compression plate were useful surgical methods for displaced two- and three-part proximal humeral fractures.

Clinical Results after Percutaneous Surgical Treatment of Intra-articular Fracture of the Distal Radius

PURPOSE: To evaluate the clinical and radiologic results of percutaneous surgical treatment of the intra-articular fractures of the distal radius, we have compared the results of percutaneous pinning and the combination of percutaneous pinning with external fixation after closed reduction. MATERIALS AND METHODS: We analysed the results of 52 patients with intra-articular fracture who received the operative treatment with closed reduction in the period of June, 1995 to June, 2001 and also were in regular follow-up at least one year. We used the subjective analysis by Cole & Obletz and the objective analysis by Scheck. RESULTS: We have found the outcome that 83.3% of percutaneous pinning were graded above "Good" in type B and C1 and 82.2% of the combination treatment of percutaneous pinning with external fixation were graded above "Good" in type C2 and C3. CONCLUSION: The percutaneous pinning and external fixator after closed reduction in intra-articular fractures of the distal radius are considered useful to restore the articular congruity and make good clinical results.

Treatment of the Distal Radius Intraarticular Fractures with Percutaneous Pinning and External Fixator / 대한정형외과학회잡지

PURPOSE: We reviewed the functional and radiological results of unstable intraarticular fractures of the distal radius treated by percutaneous pinning with an external fixator. MATERIALS AND METHODS: Twenty-seven cases of unstable intraarticular fractures of the distal radius were treated by percutaneous pinning and external fixation between October 1996 and September 1999, and followed up for more than 1 year. We classified them using the Frykman classification and evaluated functional and radiological results according to the subjective point system of Cole & Obletz and the objective evaluation by Scheck. RESULTS: Subjectively, we obtained the following results: excellent in 7 cases, good in 13 cases, fair in 6 cases and poor in 1 case, and objectively, 8 cases were excellent, 14 cases were good, 4 cases were fair and 1 case was poor. Radiographically, mean volar tilt, radial inclination and radial length were 9.5degrees, 22.1degrees and 10.3 mm respectively on the last follow-up. Two cases of reflex sympathetic dystrophy and one of each of skin necrosis, pin tract infection, joint stiffness and metacarpal bone fracture occurred during the follow-up period. CONCLUSION: Percutaneous pinning and external fixation is a useful method for reducing mal-alignment and radial length maintenance, preventing reduction loss and restoring the articular surface and function of the distal radius in cases of intraarticular comminution, open fracture with soft tissue injury and multiple injury.

A Percutaneous Cross Pinning Method for Supracondylar Fracture of the Humerus : The Significance of Elbow Position during Pinning to Avoid Ulnar Nerve Damage / 대한정형외과학회잡지

The percutaneous pinning is a simple, effective method for the treatment of displaced supracondylar fractures of the humerus in children. But there is some controversy in the number of pins used and the method of pin insertion. The cross pinning method provides more stability at the fracture site but the risk of ulnar nerve damage is higher than in lateral pinning method, The senenty-one displaced extension type supracondylar fractures were treated by closed reduction and percutaneous cross pinning from January 1991 to October 1994. Among them, the medial pin was inserted in elbow extension in twenty-eight cases and in forty- three cases the medial pin was inserted in elbow flexion. Ulnar nerve injury occured postoperatively in six cases, in which the pin was inserted with the elbow in flexion position. These results may suggest that when percutaneous cross pinning method is selected to fix the supracondylar fracture of the humerus, it would be safer to insert one or two lateral pins with the elbow in full flexion position followed by one medial pin in extension position in order to reduce the risk of loss of reduction and ulnar nerve damage.

A New Design of Miniplate Staple for High Tibial Osteotomy: Biomechanical Study / 대한정형외과학회잡지

Colles' fracture is a common injury encountered in emergency departments. Despite the frequent experience of every orthopedic surgeon with Colles' fracture, considerable variation remains in the treatment of fracture of the distal radius. Everyone nearly agress that reduction of the fracture is not difficult, but maintenance of reduction is the problem. Eighty patients with Colles' fracture were treated with closed reduction and percutaneous pinning under the C-arm fields and followed up more than 1 year, from January 1990 to May 1993 at the Department of Orthopedic Surgery, Dae Han Hospital. The results of this study were as follows: 1. The fractures were classified according to the system of Gartland and Werley. Of the 80 cases, 12(5%) were type 1; 25(31%) type 2; and 43(54%) type 3. 2. Complications were such as; temporary neuropathy of median nerve 2 cases, redisplacement 2 cases, radiocarpal arthritis 1 cases, stiff hand 1 case and shoulder hand syndrome 1 case. 3. The overall assessment showed exellent in 29 patients(36.2%), good in 44 patients(55,0%) and poor in 7 patients(8.8%) under the subjective and objective criteria of Gartland and Werley and the objective criteia of Scheck. 4. The results were mainly correlated with maintenance of an anatomical reduction. 5. The percutaneous pinning was suitable for anatomical restoration and maintence, had less com plication and more advantage such as the early range of joint and simple technique. Conclusively, it was considered to be one of ideal method for the treatment of Colles' fracture in selected cases.

Treatment of Colles' Fracture with Percutaneous Pinning / 대한정형외과학회잡지

Colles' fracture is a common injury encountered in emergency departments. Despite the frequent experience of every orthopedic surgeon with Colles' fracture, considerable variation remains in the treatment of fracture of the distal radius. Everyone nearly agress that reduction of the fracture is not difficult, but maintenance of reduction is the problem. Eighty patients with Colles' fracture were treated with closed reduction and percutaneous pinning under the C-arm fields and followed up more than 1 year, from January 1990 to May 1993 at the Department of Orthopedic Surgery, Dae Han Hospital. The results of this study were as follows: 1. The fractures were classified according to the system of Gartland and Werley. Of the 80 cases, 12(5%) were type 1; 25(31%) type 2; and 43(54%) type 3. 2. Complications were such as; temporary neuropathy of median nerve 2 cases, redisplacement 2 cases, radiocarpal arthritis 1 cases, stiff hand 1 case and shoulder hand syndrome 1 case. 3. The overall assessment showed exellent in 29 patients(36.2%), good in 44 patients(55,0%) and poor in 7 patients(8.8%) under the subjective and objective criteria of Gartland and Werley and the objective criteia of Scheck. 4. The results were mainly correlated with maintenance of an anatomical reduction. 5. The percutaneous pinning was suitable for anatomical restoration and maintence, had less com plication and more advantage such as the early range of joint and simple technique. Conclusively, it was considered to be one of ideal method for the treatment of Colles' fracture in selected cases.

Percutaneous Pinning for Intra-articular Calcaneal Fracture / 대한정형외과학회잡지

Calcaneus was the most commonly involved bone among the tarsal bone fracture. Many different methods have been tried for the treatment of fractures of the calcaneus in order to search for better results. But there is no general agreement on the treatment of the fracture of the calcaneus, especially involving the subtalar joint. From Jan. 1986 to Jan. 1990, 25 feet in 20 patients of calcaneal fractures involving the subtalar joint were treated by closed reduction & percutaneous pinning at the Dept. of Orthopedic Surgery, Chosun University Hospital and the results were as follows; 1. Of these intra-articular fractures, 15 fractures were tongue type and 10 fractures were joint depression type by Essex-Lopresti classification. 2. According to the Salama unit system, the results of treatment were excellent or good in 11 cases of 15 tongue types and 6 cases of 10 joint depression types. 3. The results were excellent in which reduction is achieved near anatomical reduction. 4. Even if the joint depression type fracture which is not severely comminuted, the treatment with closed reduction & percutaneous pinning is thought to be good method.

Treatment of Displaced Extension type Supracondylar Fractures of the Humerus in Children by Percutaneous Pining or Open Reduction / 대한정형외과학회잡지

The treatment of supracondylar fracture of humerus in children has so many pitfalls as to be once called "supracondylar dilemma". The authors analyzed the follow-up results of fifty-six displaced extension type supracondylar fractures treated by percutaneous pinning and by open reduction from 1982 to 1989. The mean age was 7.6 years, ranging from three years to fifteen years. Forty three fractures were treated by percutaneous pinning and thirteen by open reduction. According to the modified Flynn's criteria, the results of the treatment by percutaneous pinning were excellent 36%, good 32%, fair 25% and poor 7%, while those of open reduction were 8%, 42%, 8% and 42% , respectively, on average follow up of 1.4 years. Post-operative complications were found in seven cases (16.7%) of percutaneous pinning, and in five cases(38.5%) of open reduction. Poorly chosen surgical approach for open reduction was appeared to be related with unsatisfactory results. We believe that percutaneous pinning was a simple, effective method for treatment of displaced supracondylar fractures of the humerus. We agree, however, that open reduction is still indicated if manipulative reduction before pinning is unacceptable, or if the fracture is complicated by neurovascular or open injury.