Short-term effectiveness of transverse antecubital incision for failed closed reduction of Gartland type Ⅲ supracondylar humerus fractures in children / 中国修复重建外科杂志

OBJECTIVE@#To investigate the short-term effectiveness of transverse antecubital incision in the treatment of failed closed reduction of Gartland type Ⅲ supracondylar humeral fractures (SHFs) in children.@*METHODS@#Between July 2020 and April 2022, 20 children with Gartland type Ⅲ SHFs who failed in closed reduction were treated with internal and external condylar crossing Kirschner wire fixation through transverse antecubital incision. There were 9 boys and 11 girls with an average age of 3.1 years (range, 1.1-6.0 years). The causes of injuries were fall in 12 cases and fall from height in 8 cases. The time from admission to operation ranged from 7 to 18 hours, with an average of 12.4 hours. The healing of the incision and the occurrence of complications such as nerve injury and cubitus varus were observed after operation; the elbow flexion and extension range of motion after removing the gypsum, after removing the Kirschner wire, and at last follow-up were recorded and compared, as well as the elbow flexion and extension and forearm rotation range of motion at last follow-up between healthy and affected sides; the Baumann angle was measured on the X-ray film, and the fracture healing was observed. At last follow-up, the effectiveness was evaluated according to the Flynn elbow function evaluation criteria.@*RESULTS@#All incisions healed by first intention, and there was no skin necrosis, scar contracture, ulnar nerve injury, and cubitus varus. Postoperative pain occurred in the radial-dorsal thumb in 2 cases. The gypsum was removed and elbow flexion and extension exercises were started at 2-4 weeks (mean, 2.7 weeks) after operation, and the Kirschner wire was removed at 4-5 weeks (mean, 4.3 weeks). All the 20 patients were followed up 6-16 months, with an average of 12.4 months. The fracture healing time was 4-5 weeks, with an average of 4.5 weeks, and there was no complication such as delayed healing and myositis ossificans. The flexion and extension range of motion of the elbow joint gradually improved after operation, and there were significant differences between the time after removing the gypsum, after removing the Kirschner wire, and at last follow-up ( P<0.017). There was no significant difference in the flexion and extension of the elbow joint and the forearm rotation range of motion between the healthy and affected sides at last follow-up ( P>0.05). There was no significant difference in Baumann angle between the time of immediate after operation, after removing the Kirschner wire, and at last follow-up ( P>0.05). According to Flynn elbow function evaluation standard, 16 cases were excellent and 4 cases were good, the excellent and good rate was 100%.@*CONCLUSION@#The treatment of Gartland type Ⅲ SHFs in children with failed closed reduction by internal and external condylar crossing Kirschner wire fixation through transverse antecubital incision has the advantages of complete soft tissue hinge behind the fracture for easy reduction and wire fixation, small incision, less complications, fast fracture healing, early functional recovery, reliable reduction and fixation, and can obtain satisfactory results.

Late Presentation of Paediatric Pink Pulseless Supracondylar Fracture of Humerus: A Case Report

@#Supracondylar humeral fracture is the most common elbow injury in children. It may be associated with a vascular injury in nearly 20% of the cases with a pink pulseless limb. We present a unique case of a paediatric pink pulseless supracondylar humeral fracture, seen late, on the 16th-day post-trauma. Open reduction, cross Kirschner wiring, and brachial artery exploration and repair were performed, and the patient recovered well. Early open reduction and exploration of the brachial artery with or without prior CT angiography was a safe approach in treating patients who presented at 16 days.

Early Vessels Exploration of Pink Pulseless Hand in Gartland III Supracondylar Fracture Humerus in Children: Facts and Controversies

The management of pink pulseless limbs in supracondylar fractures has remained controversial, especially with regards to the indication for exploration in a clinically well-perfused hand. We reviewed a series of seven patients who underwent surgical exploration of the brachial artery following supracondylar fracture. All patients had a non-palpable radial artery, which was confirmed by Doppler ultrasound. CT angiography revealed complete blockage of the artery with good collateral and distal run-off. Two patients were more complicated with peripheral nerve injuries, one median nerve and one ulnar nerve. Only one patient had persistent arterial constriction which required reverse saphenous graft. The brachial arteries were found to be compressed by fracture fragments, but were in continuity. The vessels were patent after the release of obstruction and the stabilization of the fracture. There was no transection of major nerves. The radial pulse was persistently present after 12 weeks, and the nerve activity returned to full function.

The Role of Nerve Exploration in Supracondylar Humerus Fracture in Children with Nerve Injury

The supracondylar humerus fracture (SCHF) in children is common and can be complicated with nerve injury either primarily immediate post-trauma or secondarily posttreatment. The concept of neurapraxic nerve injury makes most surgeons choose to ‘watch and see’ the nerve recovery before deciding second surgery if the nerve does not recover. We report three cases of nerve injury in SCHF, all of which underwent nerve exploration for different reasons. Early reduction in the Casualty is important to release the nerve tension before transferring the patient to the operation room. If close reduction fails, we proceed to explore the nerve together with open reduction of the fracture. In iatrogenic nerve injury, we recommend nerve exploration to determine the surgical procedure that is causing the injury. Primary nerve exploration will allow early assessment of the injured nerve and minimize subsequent surgery.

The Rubber Stopper: A Simple and Inexpensive Technique to Prevent Pin Tract Infection following Kirschner Wiring of Supracondylar Fractures of Humerus in Children

Percutaneous pinning after closed reduction is commonly used to treat supracondylar fractures of the humerus in children. Minor pin tract infections frequently occur. The aim of this study was to prevent pin tract infections using a rubber stopper to reduce irritation of the skin against the Kirschner (K) wire following percutaneous pinning. Between July 2011 and June 2012, seventeen children with closed supracondylar fracture of the humerus of Gartland types 2 and 3 were treated with this technique. All patients were treated with closed reduction and percutaneous pinning and followed up prospectively. Only one patient, who was a hyperactive child, developed pin tract infection due to softening of the plaster slab. We found using the rubber stopper to be a simple and inexpensive method to reduce pin tract infections following percutaneous pinning.