A comparison of two approaches for the closed treatment of low-energy tibial fractures in children.

BACKGROUND: Many orthopaedic surgeons treat tibial shaft fractures in children with a period of non-weight-bearing after application of a long leg cast, presumably to prevent fracture angulation and shortening. We hypothesized that allowing children to immediately bear weight as tolerated in a cast with the knee in 10° of flexion would lessen disability, without increasing the risk of unacceptable shortening or angulation. METHODS: We divided eighty-one children, between the ages of four and fourteen years, with a low-energy, closed tibial shaft fracture into two groups. One group (forty children) received a long leg cast with the knee flexed 60° and were asked not to bear weight. The second group (forty-one children) received a long leg cast with the knee flexed 10° and were encouraged to bear weight as tolerated. All patients were switched to short leg walking casts at four weeks. We compared time to healing, overall alignment, shortening, and physical disability as determined by the Activities Scale for Kids-Performance (ASK-P) questionnaire. RESULTS: The mean time to fracture union was 10.8 weeks in both groups (p = 0.47). At the time of healing, mean coronal alignment was within 1.3° in both groups, mean sagittal alignment was within 1°, and mean shortening was <0.5 mm, with no significant differences. The ASK-P scores showed that both groups had overall improvement in physical functioning over time. However, at six weeks, the children who were allowed to bear weight as tolerated had better overall scores (p = 0.03) and better standing skills (p = 0.01) than those who were initially instructed to be non-weight-bearing. CONCLUSIONS: Children with low-energy tibial shaft fractures can be successfully managed by immobilizing the knee in 10° of flexion and encouraging early weight-bearing, without affecting the time to union or increasing the risk of angulation and shortening at the fracture site.

Type II supracondylar humerus fractures: can some be treated nonoperatively?

BACKGROUND: The range of injury severity that can be seen within the category of type II supracondylar humerus fractures (SCHFs) raises the question whether some could be treated nonoperatively. However, the clinical difficulty in using this approach lies in determining which type II SCHFs can be managed successfully without a surgical intervention. METHODS: We reviewed clinical and radiographic information on 259 pediatric type II SCHFs that were enrolled in a prospective registry of elbow fractures. The characteristics of the patients who were treated without surgery were compared with those of patients who were treated surgically. Treatment outcomes, as assessed by the final clinical and radiographic alignment, range of motion of the elbow, and complications, were compared between the groups to define clinical and radiographic features that related to success or failure of nonoperative management. RESULTS: During the course of treatment, 39 fractures were found to have unsatisfactory alignment with nonoperative management and were taken for surgery. Ultimately, 150 fractures (57.9%) were treated nonoperatively, and 109 fractures (42.1%) were treated surgically. At final follow-up, outcome measures of change in carrying angle, range of motion, and complications did not show clinically significant differences between treatment groups. Fractures without rotational deformity or coronal angulation and with a shaft-condylar angle of >15 degrees were more likely to be associated with successful nonsurgical treatment. A scoring system was developed using these features to stratify the severity of the injury. Patients with isolated extension deformity, but none of the other features, were more likely to complete successful nonoperative management. CONCLUSIONS: This study suggests that some of the less severe pediatric type II SCHFs can be successfully treated without surgery if close follow-up is achieved. Fractures with initial rotational deformity, coronal malalignment, and significant extension of the distal fragment are likely to fail a nonoperative approach. An algorithm using the initial radiographic characteristics can aid in distinguishing groups.

The effects of surgical delay on the outcome of pediatric supracondylar humeral fractures.

BACKGROUND: Occasionally, the treatment of a pediatric supracondylar humeral fracture is delayed owing to lack of an available treating physician, necessitating transfer of the child, or delay in availability of an operating room. The purpose of this study is to prospectively evaluate whether delayed pinning of these fractures affects the outcome or number of complications. METHODS: We reviewed information that was prospectively collected on 145 pediatric supracondylar humeral fractures that were treated by closed reduction and percutaneous pinning, with a minimum follow-up of 8 weeks. To determine the effect of delayed treatment, we compared a group of fractures that was treated within the first 21 hours after their presentation to our urgent care center (Group A) with a group that was treated after more than 21 hours (Group B). We compared the following variables: need for open reduction, length of surgery, length of hospitalization, the presence of neurologic complications, vascular complications including compartment syndrome, pin tract infection, loss of fixation, final carrying angle, range of motion, and outcome. RESULTS: Overall, the mean time from presentation to surgery for both groups was 52 hours. This interval was greater for Gartland type II fractures (65 h) than for Gartland type III fractures (19 h) (P=0.00001). There was no need for an open reduction in either group. There were no significant differences between the groups regarding iatrogenic nerve injuries, vascular complications, compartment syndromes, surgical time, final carrying angle, range of motion, and outcome. CONCLUSIONS: The results of this prospective study found that a delay in pinning closed supracondylar humeral fractures in children did not lead to a higher incidence of open reduction or a greater number of complications. Although the urgency of treating any child with a supracondylar fracture should be individualized, our study suggests that most of these injuries can be managed safely in a delayed fashion without compromising the clinical outcome. We recommend careful monitoring of any patient with type 3 injury whose treatment is delayed. LEVEL OF EVIDENCE: II.