A novel external-fixation technique for delayed, nonreducible Gartland type III supracondylar humerus fractures in children

doi:10.21203/rs.3.rs-4919285/v1

Download PDF

Research Article

A novel external-fixation technique for delayed, nonreducible Gartland type III supracondylar humerus fractures in children

https://doi.org/10.21203/rs.3.rs-4919285/v1

This work is licensed under a CC BY 4.0 License

You are reading this latest preprint version

Background

Percutaneous pinning is widely recognized as the gold-standard approach for managing supracondylar humerus fractures (SHFs) in pediatric patients. However, manual reduction of delayed SHFs can present significant challenges, and repeated attempts may result in iatrogenic injuries. Additionally, immobilizing the edematous elbow joint with a cast carries the risk for Compartment Syndrome. To address these concerns, we implemented a medial mini-open approach combined with external fixation.

Materials and Methods

The treatment outcomes of 32 patients treated with external fixation frames between 2015 and 2023 were analyzed. These outcomes encompassed limb alignment, elbow movement, appearance, and patient satisfaction.

Results

The resetting process was more direct in the open reduction than in the closed reduction and resulted in satisfactory reductions in all the patients, who achieved a normal or good range of motion. According to Flynn’s criteria, 30 patients showed a favorable prognosis, and 20 of them were classified as excellent. Both the patients and their parents expressed that they would choose this treatment approach again.

Conclusion

To treat delayed SHFs, utilization of medial mini-open reduction alongside external fixation appears to be a safe and efficacious approach.

pediatric

elbow

external fixator

supracondylar fractures

delayed treatment

Iatrogenic nerve injury

Pediatric supracondylar humeral fractures (SHFs), which occur 2–3 cm above the medial-lateral condyle of the distal humerus, are the most common type of elbow fracture in children. They account for 12–17% of all pediatric fractures and the highest incidence of pediatric fractures. However, their treatment is still challenging for most clinicians(1). The closed-reduction percutaneous pinning technique is commonly favored by pediatric orthopedic surgeons as the primary approach for treating SHFs. However, it should be noted that this method may not be suitable for irreducible fractures, despite their relatively low incidence among SHFs (2–20%)(2, 3). Surgery becomes more challenging if the fractured elbow joint is severely swollen and has developed tension blisters(4). Repeated manual reduction, repeated medial closed needle threading significantly increases the risk for iatrogenic injury, regardless of the experience level of the surgeon. The reported rate of exclusively employing the gold-standard treatment approach (closed-reduction percutaneous pinning technique) for resetting dislocations is as high as 18%(5). However, most cases require secondary treatment or may incur avoidable complications. Severe complications, such as iatrogenic ulnar nerve injury(6) and cubitus varus deformity(7), may also manifest. This seemingly counterintuitive pattern, characterized by an excessive pursuit of closed reduction, may manifest when pediatric orthopedic surgeons encounter delayed and unstable SHFs.

Managing delayed SHFs via closed reduction is challenging. In developed countries, “delay” is defined as effective treatment time > 8 h, and ≤ 8 h is categorized as the “early stage”(8). In developing countries, including China, various prevalent issues, such as parental reliance on “bone-setting therapy,” scarcity of pediatric orthopedic surgeons or necessary medical equipment, prolonged referral processes to external healthcare providers, and financial constraints faced by families, may cause delays in standardized treatment. Therefore, for this study a threshold of 36h was used to define late presentation.

Severe displacement of type III SHFs results in significant soft tissue damage, accompanied by noticeable limb swelling. These fractures are often unstable and challenging to maintain reduction after manual realignment, leading to the formation of ossifying myositis, joint stiffness, and Volkmann's contracture. Delayed medical intervention or excessively tight splinting or excessive elbow flexion immobilization can further exacerbate the swelling and even result in compartment syndrome. Approximately 52.5% of type III fractures require surgical treatment after initial reduction with plaster immobilization(9). Severe limb swelling can also lead to iatrogenic nerve injury(6). Traditional Kirschner wire fixation with plaster immobilization may not be the optimal approach for this type of injury.

This study aimed to assess whether a novel surgical approach, a small medial incision combined with a novel external fixator, can circumvent some of the problems associated with delayed type III SHFs, namely iatrogenic ulnar nerve injury, Kirschner-wire dislocation, elbow-joint stiffness, as well as Volkmann's contracture and compartment syndrome resulting from inappropriate plaster immobilization to facilitate the return of pediatric patients to normal learning and daily activities.

The study included pediatric patients with a delayed Gartland type III SHF who were treated at the Department of Pediatric Orthopedics between March 2015 and November 2022. Patients treated with lateral external fixators and regularly followed up for > 1 year were included in the analyses. We retrospectively reviewed medical charts to identify patients who had > 36 h between injury and surgery. We analyzed the demographic data of the patients (age, gender, and fracture side), fracture type, use external fixator of indications, operative time, postoperative data (usage period of the external fixator, range of motion, and Flynn’s criteria), and complications (pin-track infection, nerve palsy, and elbow varus deformity).

Surgical Technique

Incision and lateral-condyle-needle placement

All the procedures in this report were performed by the same experienced pediatric surgeon. The surgery was performed under aseptic conditions and brachial plexus anesthesia. First, the arm was rotated outward, bending the elbow 50°–60° to provide comfortable access to the internal epicondyle and reduce the tension on the ulnar nerve. A small incision was made directly above or in front of the internal epicondyle (approximately 2 cm). The index finger was inserted into the fracture site to assess alignment and potential periosteal incarceration. Following the fracture reduction, two 1.8-mm-wide K-wires were placed through the lateral condyle under pronation flexion. (Fig. 2.C.)

Medial-needle placement

The first crucial step in the safe insertion of the medial needle involves identifying the medial epicondyle. A blunt retractor was used to protect the ulnar nerve from any damage. After the ulnar nerve was separated and fixed behind the medial epicondyle, the medial K-wire was safely implanted(Fig. 2.B.). This step is the second crucial step. The risk of ulnar-nerve subluxation has been reported before. Although the incidence is not high, the consequences of injury to the ulnar nerve can be severe. The stability of the reduction was then dynamically assessed via finger palpation, the fracture was stressed via elbow flexion to 90°, and the arm was rotated inward to confirm the maintenance of the reduction.

Application of the novel technique

The medial nail was further inserted, and then a K-wire was fully inserted into the medial epicondylar cortex, eventually penetrating the lateral skin, to avoid damaging the radial nerve (Fig. 2.D.). The radial nerve runs posteriorly in the upper arm, making a forward turn against the humeral shaft at approximately one-third of the distance between the middle and lower upper arm. Subsequently, two tube-to-tube clamps was used to fasten the rod to the K-wire, and a short rod with a diameter of 3.0 mm was employed to connect the entire outer side firmly(Fig. 2.E.). As the last step, the maximum straightening and bending levels of the elbow were assessed. If achieving favorable levels of maximum elongation and bending proved challenging, adjustments to the external fixator were made.

Postoperative care

Since immobilization was usually very safe, immobilization typically necessitates only the utilization of an arm sling. In certain cases where patients exhibit no pain sensation, the use of an arm sling may even be deemed unnecessary. The affected side in the upper limb could be allowed free movement, avoiding weight-bearing activities. The medial K-wire did not preclude the patients from quickly returning to daily school activities, such as writing, with minimal impact of the fracture on academic performance. Regular needle care is essential for all patients. Radiographs were taken at 2-week intervals to monitor fracture-healing progress. Approximately 4–6 weeks post-operation, the K-wire and external fixator were removed under local anesthesia.

Evaluation criteria and follow-up

All the patients were followed up for > 6 months. The pain, stability, and range of motion of the a ffected elbow were assessed during the final postoperative follow-up, following Flynn's criteria. Postoperative radiographs comprised anteroposterior and lateral views of the elbow. Baumann Angle was measured on the anterior radiographs during the last follow-up session.

In total, 32 patients participated in the study. Their ages were 3–11 years, and 84% of the patients (26 patients) were aged 5–9 years. All the cases involved closed fractures, with no open injuries. The male-to-female ratio was 5.4 : 1, and the left upper limb was affected nearly twice as often (2.2 times) as the right upper limb. (Table 1.) The factors contributing to treatment delays are presented in Table 2.

Table 1

Patient Demographic Characteristics
Sex
Female	5
Male	27
Age
Median	6.72
Minimum	3
Maximum	11
Standard deviation	1.85

Table 2

Reason and duration of delay
Delay time
Median	50.72
Minimum	36
Maximum	127
Standard deviation	18.46
Reasons for delay
Bone-setting treatment	9
Long commute to the clinic	20
Negligence of parents	3

There were 9 cases of neurological impairment prior to the treatment of the fracture. Of them, 6 were radial-nerve injuries, and 3 were median-nerve injuries. (Table 3.)After fracture reduction and external fixation, the above symptoms disappeared. The nail-tract infection in 2 cases was effectively managed using oral antibiotics, leading to symptom resolution subsequent to the removal of the K-wire.

Table 3

Fracture Type and Injury Severity
Preoperative nerve injuries
Median nerve	2
Radial nerve	4
Ulnar nerve	4
Fracture type
Gartland III	22
Gartland IV	7
Flexion-type	1
Comminuted-type	2

The average Baumann Angle among the patients was 70.3° ± 5.8°. The bilateral elbow-joint axes in all the 32 cases were symmetrical, and the range of elbow valgus was 5°–10°. Physiological loss of valgus was found in 7 cases, and no cubitus varus deformity was detected. There were no cosmetic or functional concerns reported by parents or patients regarding this straight elbow deformity. Based on the Flynn rating, 25 cases (78.2%) were classified as excellent, 5 cases (15.6%) as good, and 2 cases (6.2%) fell within the acceptable category(Table 5.).

Table 5

Postoperative scores
Flynn’s Criteria
Excellent	25
Good	5
Fair	2
Bowman Angle
Median	70.34
Minimum	55
Maximum	81
Standard deviation	5.83

The external fixator was removed after 5.03 weeks on average (range, 4–7 weeks) without the necessity for a second general anesthesia. The mean follow-up duration was 14.8 ± 5.6 months (range, 6–25 months). Three months after removing the internal fixation, 30 patients exhibited normal or good elbow motion. Normal elbow motion was defined as flexion of 140°–150° with extension of 0°, and good elbow motion was defined as maximum flexion and extension of < 10°.

All the fractures healed within 8–12 weeks, and no iatrogenic-nerve injury or residual vascular defect was found. None of the patients requested scar revision, and both the patients and their parents had good acceptance of the external fixation. Additionally, all the parents stated that they would opt for the same treatment again if given the choice.

This study assessed the clinical outcomes of a novel lateral-external-fixation technique for the treatment of type III SHFs. Because of the substantial displacement observed in Gartland III SHFs, even experienced pediatric orthopedic surgeons find their treatment challenging. Various treatment methods exist(5, 10); however, they all aim for anatomical reduction, stable fixation, and optimal function and aesthetics. In most emergency cases, immediate closed reduction and operative stabilization by using crossed or multiple lateral pins are recommended(11, 12). Closed reduction becomes nearly impossible in severe cases characterized by substantial fracture displacement, swelling, or soft-tissue involvement(13). Open reduction appears to be a more effective treatment option in such severe cases than closed reduction(14). Accordingly, treatment approaches are frequently customized to suit individual patient situations, rather than adhering to strict protocols. Our experience with utilizing a lateral external fixator suggests that favorable cosmetic and functional outcomes can be achieved in most cases. The stability provided by the fixator effectively prevents secondary displacement and offers a safe means of immobilization for patients presenting with swelling associated with this type of injury.

Delayed surgery (> 12 h post-injury) in the treatment of displaced SHFs in children is common in developing countries with limited healthcare resources(15, 16). The incidence rate of closed-reduction failure, neurological or vascular complications, or elbow stiffness is higher in delayed cases, particularly following repeated attempts, than in promptly attended cases. Reports have consistently suggested that delayed treatment significantly contributes to the failure of closed reduction percutaneous pinning and subsequent conversion to open reduction(17, 18). Optimal alignment of fractured bone ends is crucial in minimizing deformities. Residual coronal plane deformities, such as ulnar collapse, can result in cubitus varus deformity(19). Additionally, severe sagittal plane anterior or posterior angulation can result in restricted elbow flexion-extension(20).

Closed reduction alongside percutaneous fixation is commonly considered the gold-standard approach for treating SHFs. However, this approach poses a higher risk for delayed swelling in supracondylar fractures than the open reduction. Multiple studies have suggested that open reduction is the optimal approach for treating delayed SHFs since closed reduction becomes unfeasible after 32 h(21). Additionally, closed reduction requires frequent utilization of imaging examinations, precludes direct observation of reduction quality, and thus demands more expertise than open reduction. Repeated and aggressive attempts at closed reduction may result in various complications, such as ossifying myositis, elbow stiffness, and nerve impairment, particularly when managing delayed Gartland III fractures. In comparison, open reduction exhibits a lower complication rate.(22)

Taller was the first to treat SHFs in children by using an external fixator(23), and Bogdan et al.(24) used an external-fixation technique to fix the humerus and ulna in SHFs in children. The utilization of trans-articular fixation in this approach poses a high risk for elbow stiffness among pediatric patients. Slongo et al. placed a Schanz screw at both ends of the fracture and inserted an anti-rotating K-wire on one side(25). Their method can lead to faster recovery of joint function and mobility than the K-wire gypsum technique, but it also requires more radiographic examinations to ensure that the distal Schanz screws have not damaged the epiphyseal plate. One study estimated that an average of nearly 23 fluoroscopes are needed per operation(26). The associated ionizing radiation may increase the cancer risk, particularly in pediatric patients. Kraus (27) emphasize the importance of safeguarding children from radiation. The approach we described in this report is akin to an enhanced iteration of traditional cross-pins, boasting a reduced learning curve and effortless mastery. Our study demonstrates that a proficient pediatrician would need a minimal number of fluoroscopy sessions (1.59 ± 0.61)(Table 4).

Table 4

İntra-operative information
Operative time
Median	45.09
Minimum	22
Maximum	77
Standard deviation	12.7
Intra-operative blood loss
Median	7.44
Minimum	2
Maximum	20
Standard deviation	3.94
İntra-operative fluoroscopy sessions
Median	1.59
Minimum	1
Maximum	3
Standard deviation	0.61

Certainly, this external-fixation approach carries inherent risks. The nerve at risk in this approach is not the ulnar nerve but the radial nerve, specifically where the nerve crosses the sulci of the radial nerve in front of the humerus. Two measures can be taken to prevent injury to the iatrogenic radial nerve. Firstly, precise insertion of the medial needle behind the middle and lower third of the humerus—not forward—is crucial. Secondly, when placing the medial K-wire, it should be positioned in front of the medial epicondyle as far as possible (Fig. 1.B.). The K-wire perforates the lateral humeral cortical bone either transversely or posteriorly from the medial epicondyle (Fig. 1.C.). Two studies by Slongo et al.(25, 28) indicated that the lateral insertion point should be kept within 2.5 cm above the fracture line to avoid injury to the radial nerve(Fig. 1.A.).

We acknowledge some limitations of this study, such as the low number of cases, short follow-up time, and retrospective nature and absence of a control group.Nevertheless, the described novel approach is very simple. Namely, it is derived from cross fixation, and thus the learning period is short. Upon removing the implants, patients exhibit a good range of active motion in the elbow, reducing the recovery time and accelerating the return of patients to daily activities.

Ethics approval and consent to participate

This study was approved by the Ethics Committee of Ningbo Sixth Hospital (approval number: 2023-21(K).), Patients were consented by an informed consent process that was reviewed by the Ethics Committee of Ningbo Sixth Hospital and certify that the study was performed in accordance with the ethical standards as laid down in the Declaration of Helsinki.

Consent for publication

All patients provided written informed consent to participate in the trial.

Availability of data and materials

All data included in this study are available upon request by contact with the corresponding author.

Competing interests

Each author certifies that there are no funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article related to the author or any immediate family members.

Funding

This study was supported by Medical and Health Science and Technology Program of Zhejiang Province (2024KY384)

Authors' contributions

All authors were involved in the conception of the paper. YHZ, HJS,JHZ, YYW collected the data. CG wrote the first draft of the manuscript. JC contributed to interpretation of data modified this paper and approved the final version.

Acknowledgements:

The author wishes to express sincere appreciation to Dr. Wei Liang Yi for his invaluable assistance in creating the illustrations, which greatly enhanced the visual impact and clarity of this paper.

Holland P, Highcock A, Bruce C. Distance of translation as a predictor of failure of fixation in paediatric supracondylar fractures. Annals of the Royal College of Surgeons of England. 2017;99(7):524-8.
Pirone AM, Graham HK, Krajbich JI. Management of displaced extension-type supracondylar fractures of the humerus in children. The Journal of bone and joint surgery American volume. 1988;70(5):641-50.
Weiland AJ, Meyer S, Tolo VT, Berg HL, Mueller J. Surgical treatment of displaced supracondylar fractures of the humerus in children. Analysis of fifty-two cases followed for five to fifteen years. The Journal of bone and joint surgery American volume. 1978;60(5):657-61.
Li J, Fu D, Yu C, Wang S, Ze R, Tang X. Surgical management of delayed irreducible Gartland III supracondylar fractures in children: open reduction and internal fixation versus external fixation. Journal of shoulder and elbow surgery. 2017;26(2):299-304.
Liu C, Kamara A, Liu T, Yan Y, Wang E. Mechanical stability study of three techniques used in the fixation of transverse and oblique metaphyseal-diaphyseal junction fractures of the distal humerus in children: a finite element analysis. Journal of orthopaedic surgery and research. 2020;15(1):34.
Graff C, Dounas GD, Sung J, Kumawat M, Huang Y, Todd M. Management of iatrogenic ulnar nerve palsies after cross pinning of pediatric supracondylar humerus fractures: A systematic review. Journal of children's orthopaedics. 2022;16(5):366-73.
Guven MF, Kaynak G, Inan M, Caliskan G, Unlu HB, Kesmezacar H. Results of displaced supracondylar humerus fractures treated with open reduction and internal fixation after a mean 22.4 years of follow-up. Journal of shoulder and elbow surgery. 2015;24(4):640-6.
Terpstra SES, Burgers P, van der Heide HJL, Witte PB. Pediatric Supracondylar Humerus Fractures: Should We Avoid Surgery during After-Hours? Children (Basel, Switzerland). 2022;9(2).
Tellisi N, Abusetta G, Day M, Hamid A, Ashammakhi N, Wahab KH. Management of Gartland's type III supracondylar fractures of the humerus in children: the role audit and practice guidelines. Injury. 2004;35(11):1167-71.
Marson BA, Ikram A, Craxford S, Lewis SR, Price KR, Ollivere BJ. Interventions for treating supracondylar elbow fractures in children. The Cochrane database of systematic reviews. 2022;6(6):Cd013609.
Reynolds RA, Jackson H. Concept of treatment in supracondylar humeral fractures. Injury. 2005;36 Suppl 1:A51-6.
Omid R, Choi PD, Skaggs DL. Supracondylar humeral fractures in children. The Journal of bone and joint surgery American volume. 2008;90(5):1121-32.
Vaquero-Picado A, González-Morán G, Moraleda L. Management of supracondylar fractures of the humerus in children. EFORT open reviews. 2018;3(10):526-40.
Das R, Borthakur B, Agarwala V, Ghosh S. Evaluation of anterior approach in failed closed reduction and delayed presentation of supracondylar humerus fractures in children. Journal of orthopaedics. 2022;30:51-8.
Yaokreh JB, Odehouri-Koudou TH, Tembely S, Dieth AG, Kouamé DB, Ouattara O, et al. Delayed treatment of supracondylar elbow fractures in children. Orthopaedics & traumatology, surgery & research : OTSR. 2012;98(7):808-12.
Mayne AI, Perry DC, Bruce CE. Delayed surgery in displaced paediatric supracondylar fractures: a safe approach? Results from a large UK tertiary paediatric trauma centre. European journal of orthopaedic surgery & traumatology : orthopedie traumatologie. 2014;24(7):1107-10.
Farrow L, Ablett AD, Mills L, Barker S. Early versus delayed surgery for paediatric supracondylar humeral fractures in the absence of vascular compromise: a systematic review and meta-analysis. The bone & joint journal. 2018;100-b(12):1535-41.
Loizou CL, Simillis C, Hutchinson JR. A systematic review of early versus delayed treatment for type III supracondylar humeral fractures in children. Injury. 2009;40(3):245-8.
Silva M, Wong TC, Bernthal NM. Outcomes of reduction more than 7 days after injury in supracondylar humeral fractures in children. Journal of pediatric orthopedics. 2011;31(7):751-6.
Gamble JG, Vorhies JS. Remodeling of Sagittal Plane Malunion After Pediatric Supracondylar Humerus Fractures. Journal of pediatric orthopedics. 2020;40(10):e903-e9.
Yildirim AO, Unal VS, Oken OF, Gulcek M, Ozsular M, Ucaner A. Timing of surgical treatment for type III supracondylar humerus fractures in pediatric patients. Journal of children's orthopaedics. 2009;3(4):265-9.
Rees AB, Schultz JD, Wollenman LC, Moore-Lotridge SN, Martus JE, Schoenecker JG, et al. A Mini-Open Approach to Medial Pinning in Pediatric Supracondylar Humeral Fractures May Be Safer Than Previously Thought. The Journal of bone and joint surgery American volume. 2022;104(1):33-40.
Taller S. [Use of external fixators in the treatment of supracondylar fractures of the humerus in children]. Acta chirurgiae orthopaedicae et traumatologiae Cechoslovaca. 1986;53(6):508-14.
Bogdan A, Quintin J, Schuind F. Treatment of displaced supracondylar humeral fractures in children by humero-ulnar external fixation. International orthopaedics. 2016;40(11):2409-15.
Slongo T, Schmid T, Wilkins K, Joeris A. Lateral external fixation--a new surgical technique for displaced unreducible supracondylar humeral fractures in children. The Journal of bone and joint surgery American volume. 2008;90(8):1690-7.
He M, Wang Q, Zhao J, Jin Y, Wang Y. Lateral entry pins and Slongo's external fixation: which method is more ideal for older children with supracondylar humeral fractures? Journal of orthopaedic surgery and research. 2021;16(1):396.
Kraus R, Dresing K. Rational Usage of Fracture Imaging in Children and Adolescents. Diagnostics (Basel, Switzerland). 2023;13(3).
Slongo T. [Radial external fixator for closed treatment of type III and IV supracondylar humerus fractures in children. A new surgical technique]. Operative Orthopadie und Traumatologie. 2014;26(1):75-96; quiz 7.

No competing interests reported.

media.mp4

Download PDF

Editorial decision: Revision requested
22 Aug, 2024
Editor assigned by journal
21 Aug, 2024
Submission checks completed at journal
21 Aug, 2024
First submitted to journal
15 Aug, 2024

You are reading this latest preprint version

A novel external-fixation technique for delayed, nonreducible Gartland type III supracondylar humerus fractures in children

Status:

Version 1

Abstract

Background

Materials and Methods

Results

Conclusion

Figures

Introduction

Materials and methods

Surgical Technique

Incision and lateral-condyle-needle placement

Medial-needle placement

Application of the novel technique

Postoperative care

Evaluation criteria and follow-up

Results

Discussion

Conclusion

Declarations

References

Additional Declarations

Supplementary Files

Status:

Version 1