The Reduction Maneuver for Pediatric Extension Type 3 Supracondylar Humerus Fractures.

Extension type supracondylar humerus fractures in children commonly displace in two directions: posteromedial and posterolateral. The traditional maneuver to reduce posteromedial displaced fractures utilizes pronation of the forearm, while the maneuver for posterolateral displaced fractures utilizes supination. Traditional teaching suggests that the periosteum is an aid to reduction. The purpose of this study is to take a second look at this periosteal hinge theory and reexamine the maneuver performed when reducing an extension type 3 supracondylar fracture. Sixty-nine consecutive displaced extension type 3 supracondylar fractures were studied. Intraoperative fluoroscopic radiographs were graded as posteromedial, posterolateral, or direct posterior displacement. All fractures were treated with closed reduction and percutaneous pinning. The best maneuver used to align the fracture during surgery was recorded in the operative note. The direction of displacement on radiographs was 32 (46.3%) posteromedial, 31 (45%) posterolateral, and six (8.7%) direct posterior. All of the 32 posteromedial displaced fractures were best aligned when pronation was utilized. All of the 31 posterolaterally displaced fractures were best aligned when supination was utilized. The six direct posteriorly displaced fractures obtained the best alignment in pronation. The current study reaffirms the classic teaching that the direction of displacement of the fracture indicates the site of the intact periosteum. The intact periosteal hinge can be used to obtain fracture reduction.

Epidemiological Analysis of Displaced Supracondylar Fractures.

INTRODUCTION:  Supracondylar fractures are one of the most common fracture patterns sustained by children, and one of the most common injuries requiring operative fixation. Understanding the complications associated with supracondylar fractures is vital for the practicing orthopedic surgeon. This analysis of supracondylar fractures examined the clinically important aspects including vascular injury, compartment syndrome, neurological injury, brachialis entrapment, associated injuries, and etiologies of injury. Recent advances in technology have resulted in a myriad of new forms of recreational equipment for children to play with. The purpose of this study is to compare the historical literature, the current literature, and a single surgeon's sample of supracondylar fractures. In addition, this study aims to evaluate if any changes in epidemiology or etiology have occurred due to the development of new recreational equipment. OBJECTIVE:  The purpose of this study is to evaluate and provide a qualitative overview of the epidemiology of displaced supracondylar fractures, to compare historically reported numbers to more recent literature as well as a single surgeon sample, and to evaluate if changes in epidemiology or etiology have occurred due to the new recreational equipment that children use. METHODS: Some 75 displaced supracondylar elbow fractures were reviewed. Data elements recorded from the electronic medical record (EMR) included patient age, gender, height, weight, handedness, date, time, location, mechanism, Gartland classification, concurrent injuries, and neurovascular status.  Results: In this study, there were 42 males and 33 females. The average age was six years. Some 70 of the 75 patients were older than the age three. One fracture was open, nine fractures had a pucker sign, seven presented with a nerve palsy, four presented without a pulse, and seven patients presented with an additional ipsilateral distal radius fracture. All fractures were the result of a fall. Falls from playground equipment resulted in 29 fractures. There were 10 from falls off of furniture, six from falls during sports, three from falls on the stairs, and three from fall off of bikes. The remaining fractures resulted from running, tripping, falling from a toy ball, sled, tree, wagon, fence, bounce house, van, deck, power wheels car, ATV, and a go-cart. Some 64 fractures were transferred from 27 different outside hospitals. Eleven fractures presented directly to the ED. Twenty-six fractures occurred during the summer, 20 occurred in the autumn, 6 occurred in the winter, and 23 occurred during the spring. Some 35 fractures occurred at home, 30 on the school grounds, four in a gymnasium, four in a park, one at a farm show, and one in a parking lot. Some 25 fractures were treated between midnight and 8 am, 16 were treated between 8 am and 5 pm, and 34 were treated between 5 pm and midnight.  Conclusion: Pediatric supracondylar fractures are common in children, and many of them require operative intervention. This study examined the most important aspects of supracondylar fractures. This update provides a look at the clinically important aspects of supracondylar fractures and compares them to previous teachings and canon. Despite the advancement and changes in recreational equipment that children are using, children are still sustaining supracondylar fractures in the most common ways including falls from playground equipment and falls from standing.

The Open Bankart Repair for Traumatic Anterior Shoulder Instability in Teenage Athletes.

BACKGROUND: Traumatic anterior shoulder instability from recurrent dislocations or subluxations is a debilitating problem for the teenage athlete. The risk of recurrent instability is high in this adolescent population. We performed a retrospective case series analysis of adolescent athletes with recurrent instability treated with open Bankart repair and evaluated functional outcomes as well as redislocation rates. METHODS: The retrospective study included 21 teenage patients with Bankart lesions and recurrent anterior shoulder instability. There were 19 males (90%) and 2 females (10%) with an average age of 16 years (range, 14 to 18 y). Patients were evaluated based on Rowe and UCLA shoulder scores, return to previous level of sport, external rotation, and recurrence. RESULTS: The average number of anchors used to repair the Bankart lesion was 3 (range, 2 to 5). One patient was lost to follow-up at 6 months after surgery. The remaining 20 patients all had at least 2-year follow-up. The recurrent instability rate was zero. In total, 100% of patients had an excellent result based on an average Rowe score of 96.5 points of 100 points (a score of 90 to 100 is an excellent result). In total, 100% of patients had good/excellent result based on an average UCLA shoulder score of 34 of 35 (a score >27 is a good/excellent result). At final follow-up, 7 patients (34%) had lost an average of 11 degrees of external rotation (range, 5 to 20 degrees) on the injured shoulder with the arm at the side compared with the noninjured shoulder. CONCLUSIONS: Contact teenage athletes with recurrent anterior shoulder instability can be treated with open Bankart repair with a low recurrence, excellent functional shoulder outcomes, and return to sport. A small amount of external rotation may be lost with this technique. Care must be taken when considering this method with throwing athletes (ie, quarterback or pitcher). The open Bankart should remain a viable alternative for the adolescent population with recurrent anterior instability. LEVEL OF EVIDENCE: Level IV.