Learning Curve of Closed Reduction and Internal Fixation for Supracondylar Fractures of the Humerus in Children.

Background: This study aimed to identify the threshold for success in supracondylar humeral fracture surgery by describing the learning curve for beginners and exploring the relationship between the learning curve and the prognosis of supracondylar fractures of the humerus. Methods: Surgical information was collected of the first 100 humeral fractures treated by four pediatric orthopedic surgeons. The relationship between operation time, wire placement success rate, and surgical experience was determined using the restricted cubic strip (RCS). The inflection point in the curve and other risk factors that may affect fracture prognosis were collected and subjected to multiple logistic regression to clarify the relationship between the learning curve and prognosis of supracondylar fractures of the humerus. After the training, the four fresh surgeons were interviewed in the form of questionnaires to get feedback from the trainees. Results: A total of 400 supracondylar fractures of the humerus from four pediatric orthopedists were included in the study. On an RCS analysis, 65 surgical experiences were the inflection point of the learning curve. Before and after these 65 surgical experiences, there were significant differences in the patients' anatomical reduction (186 vs. 122, P < 0.001), conversion to incision (33 vs. 6, P = 0.008), and supervising physician guidance (28 vs. 2, P < 0.001). In the multiple logistic regression analysis, functional recovery after supracondylar fractures of the humerus was significantly associated with surgical experience, intraoperative conversion to incision, and post-operative infection. Four surgeons and a supervisor were interviewed. They believed that self-confidence establishment requires the experience accumulation of about 30 operations. The most critical surgical technique is the reduction of fractures. Conclusions: Although the accumulated experience of 30 operations can establish the self-confidence of trainers, fresh surgeons must accumulate experience with 65 operations to master closed reduction and internal fixation for supracondylar fractures. Surgical experience significantly impacts the post-operative recovery of patients with fractures. Level of Evidence: Level III.

Fractura compleja del húmero asociada a parálisis radial / Complex Fracture of the Humerus Associated with Radial Paralysis

Las fracturas de la diáfisis humeral son lesiones que se producen con frecuencia como parte de caídas o de accidentes de alta energía y se asocian con parálisis del nervio radial. Se presenta paciente de 43 años de edad, masculino, que sufre accidente automovilístico que le produce fractura diafisaria del húmero derecho multifragmentaria, por lo cual se le realiza reducción cerrada y osteosíntesis con clavo intramedular acerrojado y tratamiento conservador para la parálisis radial. La evolución fue satisfactoria, el paciente se recuperó de la parálisis a los 4 meses y logró la consolidación completa a los 5 meses. Tras un año de evolución no presenta dolor en el hombro, y tiene movilidad completa del hombro, muñeca y dedos a la extensión(AU)

Diaphyseal fracture of humerus are frequent lesions, resulting from falls or high energy accidents; they are associated to radial nerve palsy. We report the case of a 43 years old male patient, who suffered a multifragment diaphyseal fracture of his right humerus, as a result of a car accident. He underwent a closed reduction and osteosynthesis using a locking intramedullary nail for the radial paralysis. His evolution was satisfactory; this patient recovered from the paralysis after four months and he managed full consolidation five months later. After a year, he did not have any pain in his shoulder, he has full mobility of his shoulder, wrist and fingers when extendind(AU)

Distal-third diaphyseal fractures of the humerus: choice of approach and surgical treatment.

PURPOSE: Distal-third diaphyseal fractures of the humerus are often hard to treat due to location and pattern of the fractures, radial nerve injury, and quality of bone and age of patients. The aim of this retrospective study is to propose the best approach and the best surgical technique according to the pattern of extra-articular fracture of the distal humerus. METHODS: We have treated 37 fractures of the distal humerus between January 2010 and July 2015 classified according to the AO classification. There were 2 open fractures. We treated all fractures with open reduction and internal fixation with plates and screws. In 20 cases, we performed a posterior midline triceps-splitting approach, with patients in prone decubitus position; in 2 cases, the triceps-splitting approach with the patients in supine decubitus position; in 3 cases, the olecranon osteotomy approach in prone decubitus position; and in 12 cases, the lateral approach in supine decubitus position. RESULTS: Thirty cases had a medium follow-up of 6 months. We observe 2 post-operative radial nerve palsies healed in 5 months and 2 cases of non-union. The average time to union of remaining cases was 16 weeks (range 12-24). Elbow motility was complete in 25 cases, in 4 cases there was an extension loss of 5°, and in one case there was an extension loss of 10°. CONCLUSIONS: The use of plates allows an anatomical fracture reduction, a better control of alignment of humerus and, with a rigid fixation, an early elbow mobilization. The best approach and the best surgical technique depend on the pattern of the fracture of distal humerus.

Reproducibility of the AO/ASIF and Gartland classifications for supracondylar fractures of the humerus in children.

OBJECTIVE: To evaluate the reproducibility of the radiographic classifications of Gartland and the Association for Osteosynthesis/Association for the Study of Internal Fixation (AO/ASIF) for supracondylar fractures of the humerus in children. METHODS: On two occasions, 50 radiographs in anteroposterior and lateral views were evaluated by three pediatric orthopedists in accordance with the Gartland and AO/ASIF pediatric classifications. Their responses were subjected to statistical analysis consisting of calculation of the κ coefficient to assess the intra- and interobserver concordance, in both classifications. RESULTS: The strength of the intraobserver concordance was high or near perfect for the three examiners in the two classification systems. The strength of the interobserver concordance was high in the two systems, with κ coefficients of 0.756 for the Gartland classification and 0.766 for the AO/ASIF classification. CONCLUSION: The Gartland and AO/ASIF classification systems showed similar reproducibility and performance. High strength of concordance was seen in the intra- and interobserver analyses.

OBJETIVO: Avaliar a reprodutibilidade das classificações radiográficas de Gartland e Association for Osteosynthesis/Association for the Study of Internal Fixation (AO/ASIF) para fraturas supracondilianas de úmero em crianças. MÉTODOS: Em duas ocasiões foram avaliadas por três cirurgiões ortopedistas pediátricos 50 radiografias nas incidências anteroposteriores e perfil de acordo com as classificações de Gartland e AO/ASIF pediátrica. As respostas foram submetidas à análise estatística pelo cálculo do coeficiente κ para avaliar a concordância intra- e interobservador, em ambas as classificações. RESULTADOS: A força de concordância intraobservador foi grande ou quase perfeita para os três examinadores nos dois sistemas de classificação. A força de concordância interobservador foi grande nos dois sistemas, com coeficiente κ de 0,756 para classificação de Gartland e de 0,766 para classificação AO/ASIF. CONCLUSÃO: Os sistemas de classificação de Gartland e AO/ASIF mostraram reprodutibilidade e desempenho similar. Observou-se grande força de concordância nas análises intra- e interobservador.

Reprodutibilidade das classificações AO/ASIF e Gartland para fraturas supracondilianas de úmero em crianças / Reproducibility of the AO/ASIF and Gartland classifications for supracondylar fractures of the humerus in children

OBJETIVO:Avaliar a reprodutibilidade das classificações radiográficas de Gartland e Association for Osteosynthesis/Association for the Study of Internal Fixation (AO/ASIF) para fraturas supracondilianas de úmero em crianças.MÉTODOS:Em duas ocasiões foram avaliadas por três cirurgiões ortopedistas pediátricos 50 radiografias nas incidências anteroposteriores e perfil de acordo com as classificações de Gartland e AO/ASIF pediátrica. As respostas foram submetidas à análise estatística pelo cálculo do coeficiente κ para avaliar a concordância intra- e interobservador, em ambas as classificações.RESULTADOS:A força de concordância intraobservador foi grande ou quase perfeita para os três examinadores nos dois sistemas de classificação. A força de concordância interobservador foi grande nos dois sistemas, com coeficiente κ de 0,756 para classificação de Gartland e de 0,766 para classificação AO/ASIF.CONCLUSÃO:Os sistemas de classificação de Gartland e AO/ASIF mostraram reprodutibilidade e desempenho similar. Observou-se grande força de concordância nas análises intra- e interobservador.

OBJECTIVE: To evaluate the reproducibility of the radiographic classifications of Gartland and the Association for Osteosynthesis/Association for the Study of Internal Fixation (AO/ASIF) for supracondylar fractures of the humerus in children. METHODS: On two occasions, 50 radiographs in anteroposterior and lateral views were evaluated by three pediatric orthopedists in accordance with the Gartland and AO/ASIF pediatric classifications. Their responses were subjected to statistical analysis consisting of calculation of the κ coefficient to assess the intra- and interobserver concordance, in both classifications. RESULTS: The strength of the intraobserver concordance was high or near perfect for the three examiners in the two classification systems. The strength of the interobserver concordance was high in the two systems, with κ coefficients of 0.756 for the Gartland classification and 0.766 for the AO/ASIF classification. CONCLUSION: The Gartland and AO/ASIF classification systems showed similar reproducibility and performance. High strength of concordance was seen in the intra- and interobserver analyses.

Placa helicoidal en el tratamiento de fractura del húmero por cirugía mínimamente invasiva. Reporte de un caso / Helical plate in treating humerus fracture by minimally invasive surgery

Las fracturas del extremo proximal del húmero en pacientes osteoporóticos, pueden resultar en patrones complejos, como aquellos donde ocurre extensión a la diáfisis. El tratamiento de estas fracturas ha sido controversial durante largo tiempo, con distintos resultados. Las técnicas de osteosíntesis mínimamente invasiva con placa para el tratamiento de las fracturas del húmero han sido usadas para minimizar la disección de las partes blandas y lesión de estructuras neurovasculares. El principio helicoidal, es un concepto biomecánico aplicable al tratamiento de estas fracturas. Presentamos el caso de paciente femenino de 72 años de edad, quien sufrió fractura de húmero proximal con extensión a la diáfisis, tratado con placa larga helicoidal y técnica mínimamente invasiva. Mostramos el resultado del tratamiento y su evolución a largo plazo. Este caso muestra que con esta técnica innovadora se puede alcanzar la consolidación y la recuperación funcional satisfactoria, en pacientes con fracturas complejas(AU)

Humerus proximal fractures in osteoporotic patients may result in complex patterns such those which occur with shaft extension. The treatment of these fractures has been controversial for a long time with different results. The techniques of minimally invasive plate osteosynthesis for the treatment of theses fractures had been used to minimize soft tissue dissection and injury to neurovascular structures. The helical principle is a biomechanical concept can be applied for treatment of these fractures. We report the case of 72-year-old female who presented with proximal humerus fracture to the shaft extension that was treated with a long plate with minimally invasive plate osteosynthesis with helical principle, an innovative technique in the treatment of these fractures. We present the results of treatment and long-term evolution. This case shows that with this innovative technique can achieve consolidation and satisfactory functional recovery in patients with these complex fractures(AU)

Do computed tomography and its 3D reconstruction increase the reproducibility of classifications of fractures of the proximal extremity of the humerus? / A tomografia computadorizada e sua reconstrução 3D aumentam a reprodutibilidade das classificações das fraturas da extremidade proximal do úmero?

OBJECTIVE: to determine whether 3D reconstruction images from computed tomography (CT) increase the inter and intraobserver agreement of the Neer and Arbeitsgemeinschaft für Osteosynthesefragen (AO) classification systems. METHODS: radiographic images and tomographic images with 3D reconstruction were obtained in three shoulder positions and were analyzed on two occasions by four independent observers. RESULTS: the radiographic evaluation demonstrated that using CT improved the inter and intraobserver agreement of the Neer classification. This was not seen with the AO classification, in which CT was only shown to increase the interobserver agreement. CONCLUSION: use of 3D CT allows better evaluation of fractures with regard to their component parts and their displacements, but nevertheless the intraobserver agreement presented is less than ideal...

OBJETIVO: determinar se as imagens da reconstrução 3D da tomografia computadorizada (TC) aumentam a concordância inter e intraobservador dos sistemas de classificação de Neer e Arbeitsgemeinschaft für Osteosynthesefragen (AO). MÉTODOS: foram obtidas imagens radiográficas em três posições do ombro e imagens tomográficas com reconstrução 3D, que foram analisadas em dois tempos por quatro observadores independentes. RESULTADOS: a avaliação radiográfica demonstrou que o uso da TC melhora a concordância intra e interobservadores para a classificação de Neer. O mesmo não foi observado na classificação AO, na qual a TC demonstrou aumento somente da concordância interobservadores. CONCLUSÃO: o uso de TC 3D permite uma melhor avaliação da fratura quanto às partes que a compõem e aos seus desvios, mas mesmo assim apresenta uma concordância intraobservadores menor do que a ideal...

Do computed tomography and its 3D reconstruction increase the reproducibility of classifications of fractures of the proximal extremity of the humerus?

OBJECTIVE: to determine whether 3D reconstruction images from computed tomography (CT) increase the inter and intraobserver agreement of the Neer and Arbeitsgemeinschaft für Osteosynthesefragen (AO) classification systems. METHODS: radiographic images and tomographic images with 3D reconstruction were obtained in three shoulder positions and were analyzed on two occasions by four independent observers. RESULTS: the radiographic evaluation demonstrated that using CT improved the inter and intraobserver agreement of the Neer classification. This was not seen with the AO classification, in which CT was only shown to increase the interobserver agreement. CONCLUSION: use of 3D CT allows better evaluation of fractures with regard to their component parts and their displacements, but nevertheless the intraobserver agreement presented is less than ideal.

OBJETIVO: determinar se as imagens da reconstrução 3D da tomografia computadorizada (TC) aumentam a concordância inter e intraobservador dos sistemas de classificação de Neer e Arbeitsgemeinschaft für Osteosynthesefragen (AO). MÉTODOS: foram obtidas imagens radiográficas em três posições do ombro e imagens tomográficas com reconstrução 3D, que foram analisadas em dois tempos por quatro observadores independentes. RESULTADOS: a avaliação radiográfica demonstrou que o uso da TC melhora a concordância intra e interobservadores para a classificação de Neer. O mesmo não foi observado na classificação AO, na qual a TC demonstrou aumento somente da concordância interobservadores. CONCLUSÃO: o uso de TC 3D permite uma melhor avaliação da fratura quanto às partes que a compõem e aos seus desvios, mas mesmo assim apresenta uma concordância intraobservadores menor do que a ideal.

The effect comparison of anterograde reamed intramedullary nail and dynamic compression plate for the management of diaphyseal fractures of the humerus / 中国医师进修杂志

Objective To compare the clinical effects in patients treated with anterograde reamed intramedullary nail (IMN) and dynamic compression plate (DCP) for diaphyseal fractures of the humerus.Methods Forty-seven patients with diaphyseal fractures of the humerus,were divided into two groups by random digits table:IMN group (23 cases) and DCP group (24 cases),IMN and DCP were performed fixation,respectively.After the surgery,perioperative,functional outcomes of shoulder and elbow,postoperative complications between two groups were compared.Results The average follow-up time was (22.3 ± 5.7)months,3 cases were lost in 12-month-follow-up,1 case in IMN group and 2 cases in DCP group.The operation time,intraoperative blood loss in IMN group were significantly shorter than those in DCP group [(67.7 ± 15.3) min vs.(87.0 ± 12.5) min,(106.3 ±57.6) ml vs.(226.7 ±60.2) ml,P＜0.05].The incidence rate of subacromial impingement in IMN group was significantly higher than that in DCP group [18.2％ (4/22) vs.0,P ＜ 0.05].The incidence rate of wound infection in IMN group was significantly better than that in DCP group [4.5％(1/22) vs.22.7％(5/22),P ＜ 0.05].There were no statistically significant differences between two groups in other indexes (P ＞ 0.05).Conclusions DCP has some advantage in perioperative period,but they are comparable in the functional outcomes of shoulder and elbow and complications.

Treatment of GartlandⅢ Supracondylar Fracture of Humerus in Children by Overhead of Olecranon Traction / 实用儿科临床杂志

Objective To discuss the indication and complication of overhead traction of olecranon for displaced extension-type GartlandⅢ supracondylar fracture of the humerus in children.Methods Total of 87 patients(Gartland Ⅲ) proceeded with overhead skeletal traction of ulnar olecranon,including 68 cases of ulnar deviation and 19 cases of radial deviation.Eighteen cases had complicating revolve deviation.According portable X-ray results in the 2nd and 5th,three-dimension adjustment was performed within 1 week.Five patients were treated by open reduction because of symptoms nerves and blood vessel compression.When X-ray examination showed good callus formation and stable reduction,the patient was discharged after the elbow was stabilized in flexion position with plaster fixation,which was removed in 2 weeks.Results Sixty-seven of 87 patients were followed-up for 18 months.All of them had excellent results except one who had permanent ulnar nerve injury.No cubitus varus was observed.Conclusions The overhead olecranon skeletal traction is a simple,effective method,because it can increase joint motion,relieve elbow swell and pain rapidly,and improve upper limb line of traction.However,open reduction shall be done promptly if there is evidence of nerve,blood vessel or soft tissue between broken ends of fractured bone within 5 days.