Capitellar Fractures in Children and Adolescents: Classification and Early Results of Treatment.

BACKGROUND: There has been limited published information regarding capitellar fractures in the pediatric population. The purpose of this investigation was to characterize capitellar fracture patterns in children and adolescents and to assess early clinical and radiographic treatment outcomes. METHODS: A retrospective analysis of 37 children and adolescents with capitellar fractures presenting to a tertiary pediatric hospital from 2004 to 2014 was performed. The mean patient age at the time of injury was 11.8 years. Medical records and radiographs were evaluated for fracture pattern, treatment, healing, and complications. Fractures were categorized on the basis of prevailing patterns of injury, and a classification system is proposed that aids in treatment decision-making. Thirty-two patients had follow-up of at least 6 weeks and were included for assessment of treatment outcomes. The mean follow-up was 12.3 months. RESULTS: Three predominant capitellar fracture patterns were identified. Type-I fractures (n = 25) were anterior shear injuries. Nondisplaced anterior shear fractures were successfully treated with cast immobilization. Displaced anterior shear fractures were treated with open reduction and internal fixation, with good results in a majority of patients. Of the 21 patients with Type-Ib fractures eligible for analysis, 6 (29%) required a secondary surgical procedure for loss of motion related to soft-tissue contracture, osteonecrosis, implant prominence, and/or intra-articular loose bodies. Type-II fractures (n = 9) were posterolateral shear injuries, typically associated with ulnohumeral dislocations. Among 5 patients with displaced fractures and adequate follow-up, 3 patients were treated nonoperatively and had poor results, with loss of elbow motion or mechanical symptoms, and 2 patients were treated surgically and achieved good functional restoration. Type-III fractures (n = 3) were acute chondral shear injuries, which achieved full restoration of motion after surgical treatment. CONCLUSIONS: A classification of pediatric capitellar fractures is proposed, guiding treatment and prognosis. Nondisplaced fractures heal successfully with cast immobilization. Good results may be expected with surgical fixation of displaced Type-I fractures (anterior shear). Type-II fractures (posterolateral shear) and Type-III fractures (chondral shear) are more subtle; advanced imaging and timely surgical management for displaced injuries are recommended to optimize clinical results. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Mini-open versus extended open release for severe carpal tunnel syndrome.

BACKGROUND: This study aims to compare surgical outcomes of severe carpal tunnel syndrome (CTS) treated with mini-incision versus extensile release. METHODS: The method employed in this study was a retrospective review of patients with severe CTS, defined by electrophysiologic studies showing non-recordable distal sensory latency of the median nerve. Patients underwent either a mini-incision (2 cm) release of the transverse carpal ligament (group 1) or extensile release proximal to the wrist flexion crease (group 2). Exclusion criteria included prior carpal tunnel release, use of muscle flap, multiple concurrent procedures, or a prior diagnosis of peripheral neuropathy. Group 1 included 70 wrists (40 females, 30 males). Group 2 included 64 wrists (35 females, 29 males). Reported outcomes included pre- and post-operative grip strength as well as Boston Carpal Tunnel Questionnaires (BCTQ). RESULTS: Patients in group 1 had a 22.6 % increase in grip strength postoperatively (4.5 months ± 5.0), while patients in group 2 had a 59.3 % increase (10.0 months ± 6.9). BCTQ surveys from group 1 (n = 46) demonstrated a symptom severity score of 12.93 and functional status score of 9.39 at an average follow-up of 41.9 ± 10.6 months. Group 2 (n = 42) surveys demonstrated averages of 12.88 and 9.10 at 43.1 ± 11.6 months. One patient in the mini-incision cohort required revision surgery after 2 years, while no patient in the extended release cohort underwent revision. CONCLUSION: No significant differences between the two procedures with regard to patient-rated symptom severity or functional status outcomes were found. Both techniques were demonstrated to be effective treatment options for severe CTS.

The tenosynovial flap for recalcitrant carpal tunnel syndrome.

Operative intervention for recalcitrant carpal tunnel syndrome often utilizes local vascularized tissue to provide coverage of the median nerve in an attempt to limit scarring or adherence of the nerve to its surrounding structures. Although the hypothenar fat pad is the most commonly cited source of vascularized tissue, alternative options do exist. We review the technique of utilizing a pedicled tenosynovial flap as the source of local vascularized tissue for coverage of the median nerve in cases of recalcitrant carpal tunnel syndrome.