Lateral External FixationA New Surgical Technique for Displaced Unreducible Supracondylar Humeral Fractures in Children

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1 This is an enhance PDF from The Journal of Bone an Joint Surgery The PDF of the article you requeste follows this cover page. Lateral External FixationA New Surgical Technique for Displace Unreucible Supraconylar Humeral Fractures in Chilren They Slongo, Timo Schmi, Kaye Wilkins an Alexaner Joeris J Bone Joint Surg Am. 2008;90: oi: /jbjs.g This information is current as of August 10, 2008 Reprints an Permissions Publisher Information Click here to orer reprints or request permission to use material from this article, or locate the article citation on jbjs.org an click on the [Reprints an Permissions] link. The Journal of Bone an Joint Surgery 20 Pickering Street, Neeham, MA

2 1690 COPYRIGHT Ó 2008 BY THE JOURNAL OF BONE AND JOINT SURGERY, INCORPORATED Lateral External Fixation A New Surgical Technique for Displace Unreucible Supraconylar Humeral Fractures in Chilren By They Slongo, MD, Timo Schmi, MD, Kaye Wilkins, DVM, MD, an Alexaner Joeris, MD Investigation performe at the Department of Surgical Peiatrics, Chilren s Hospital, University of Berne, Berne, Switzerlan Backgroun: Percutaneous Kirschner wire fixation represents the classic treatment for isplace supraconylar humeral fractures in chilhoo. This type of treatment first requires satisfactory reuction of the fracture. Failure to achieve a satisfactory reuction or inaequate stabilization can result in instability of the fracture fragments, which can result in either an unsatisfactory cosmetic or functional outcome. In our experience, these problems can be overcome with the use of a small lateral external fixator. Methos: Between 1999 an 2005, thirty-one of 170 Gartlan type-iii supraconylar humeral fractures were treate with a lateral external fixator. The outcome of treatment was analyze with regar to limb alignment, elbow movement, cosmetic appearance, an patient satisfaction. Results: In twenty-eight of the thirty-one patients, a satisfactory reuction was achieve with close methos. All chilren except one ha a normal or goo range of movement. The cosmetic result was excellent in all cases. All of the chilren an their parents state that they woul choose this treatment again. Conclusions: The use of a small lateral external fixator seems to be a safe alternative for the treatment of isplace supraconylar fractures of the humerus when a close reuction appears to be unattainable by means of manipulation alone or when sufficient stability is not achieve with stanar methos of Kirschner wire fixation. Level of Evience: Therapeutic Level IV. See Instructions to Authors for a complete escription of levels of evience. Supraconylar humeral fractures constitute the most common fracture pattern aroun the elbow in the peiatric population 1-3. However, the treatment of these fractures represents a challenge for most surgeons 4. Problems with the correct iagnosis, reuction, an fixation appear to form the main reasons for the special position of this fracture in peiatric traumatology. Some surgeons prefer open reuction for the treatment of Gartlan type-iii isplace fractures 5, especially if they lack experience with these fractures or if a perfect reuction cannot be achieve by means of manipulation alone. Generally, the literature has escribe better results following close reuction of isplace supraconylar humeral fractures 6. Thus, it appears that the experience of the surgeon often etermines whether he or she will procee with open or close reuction 7,8. In most cases, fixation is achieve either with use of bilateral crosse Kirschner wires or with use of two Kirschner wires that are inserte through a lateral approach One of the problems with Kirschner wire fixation is the risk of persistent instability 14,15. If the wires are not place properly, rotational control may not be achieve, often resulting in isplacement an cubitus varus Usually a cast or splint is applie following stabilization with percutaneous Kirschner wire fixation, but oing so can elay the start of early motion to facilitate functional elbow recovery. Problems or complications associate with Kirschner wire fixation inclue iatrogenic ulnar nerve injury cause by meial pins, superficial an eep infections, an loss of fixation with malunion mainly in the cubitus varus position 19,20, finings that were confirme in a multicenter stuy from 1991 to We have use a small lateral external fixator to solve some of the problems associate with stabilizing type-iii su- Disclosure: The authors i not receive any outsie funing or grants in support of their research for or preparation of this work. Neither they nor a member of their immeiate families receive payments or other benefits or a commitment or agreement to provie such benefits from a commercial entity. No commercial entity pai or irecte, or agree to pay or irect, any benefits to any research fun, founation, ivision, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immeiate families, are affiliate or associate. J Bone Joint Surg Am. 2008;90: oi: /jbjs.g.00528

3 1691 Fig. 1 Cross-sectional image of the istal part of the humerus. R = raial (lateral) conyle, an U = ulnar (meial) conyle. praconylar fractures 22,23. Because external fixators are wiely utilize for the treatment of fractures, most surgeons are familiar with the technique of applying them. The small external fixator provies major avantages over other methos. First, it facilitates the achievement of a satisfactory reuction through an inirect approach. Secon, it provies rigi stability while allowing elbow motion, which eliminates the nee for aitional plaster immobilization. Thir, because it involves the use of a purely raial (lateral) approach, amage to the ulnar nerve is avoie. We present our experience with this metho, the technical etails of applying the fixator, an our initial results. We propose this metho as an alternative technique for the treatment of supraconylar humeral fractures in cases in which the reuction may be ifficult, open reuction may be neee, or sufficient stability cannot be achieve with Kirschner wires. Materials an Methos Between June 1999 an March 2005, 170 Gartlan type-iii isplace supraconylar humeral fractures 5 were treate surgically in our epartment. Thirty-one fractures (18%) were stabilize with the use of a lateral external fixator. The other fractures that were treate surgically were stabilize with either crosse pins or multiple lateral pin fixation. The lateral external fixator was use for type-iii supraconylar humeral fractures of several ifferent patterns, incluing (1) fractures in which an aequate close reuction coul not be achieve in the usual manner, (2) fractures with an angle in excess of 30 in the sagittal plane, which were by efinition oblique fractures with a higher risk of isplacement 24, (3) fractures with comminution for which simple pin fixation woul not achieve aequate stabilization, (4) fractures in which the original reuction that ha been achieve an stabilize with percutaneous pin fixation ha isplace, resulting in unacceptable alignment, an (5) open fractures an fractures with a risk for compartment synrome. The inications for the use of the external fixator were inepenent of age. We analyze patient charts an raiographs for emographic ata (age, sex, affecte sie), the type of fracture, the inication for the use of an external fixator, operative time, postoperative ata (the uration of external fixator use, cast use, an the uration of cast use), complications (pin-track infections, nerve palsy), range of movement before an after fixator removal, an patient/parent satisfaction. Principles of Lateral Fixator Application When applying the fixator, the surgeon must unerstan that the anatomy of the istal part of the humerus has a unique geometry, with a figure-of-eight cross section in the horizontal plane. The cross-sectional iameter of the lateral conylar (raial) column makes up approximately 60% to 65% of the total cross section of the supraconylar area (Fig. 1). If there is rotation of the istal fragment, there will be very little contact in the meial (ulnar) conylar column an therefore Kirschner wires may not be able to provie aequate fracture fixation, resulting in cubitus varus. When the lateral external fixator is use, the lateral conylar column can be stabilize by compressing the fragments, which will seconarily prevent meial column collapse. Surgical Technique All surgical proceures in the present report were performe by or in the presence of the same experience peiatric surgeon (T. Slongo). The proceure is performe in the operating suite with the patient uner general anesthesia. The small external fixator (Synthes), with 4-mm connector ros, is use.

4 1692 Fig. 2 Placement of the first Schanz pin approximately 2 cm proximal to the fracture line, shown in a bone moel (top) an clinically (bottom). If available, raiolucent carbon fiber ros are preferre as they allow better raiographic visualization of the fracture site. However, stanar 4-mm stainless steel ros can be use an can provie equally goo stabilization. Depening on the patient s age, we use two 2.5 or 3.0-mm self-rilling an selftapping Schanz pins an a 1.6-mm Kirschner wire. The chil is place in the supine position, as far laterally towar the sie of the table as possible, so that the affecte upper extremity can be lai easily on the surface of the receiver of the image intensifier. The entire upper extremity, incluing the shouler, is prepare an rape free. The image intensifier serves as the work table an shoul be set up so that it can be pivote 45 to each sie. The extremity is not rotate; rather, the image intensifier is rotate aroun the extremity. The fracture is first reuce prior to the insertion of the Schanz pins. In most cases, this reuction is achieve with close methos. Performing a provisional reuction first with the image intensifier facilitates correct axial rilling of the Schanz pins an prevents problems with the soft tissues. Placing the pins prior to achieving fracture reuction can result in tension on the soft tissues as the fracture fragments are manipulate. The first 3-mm-iameter Schanz pin is inserte 2 cm proximal to the fracture line, avoiing injury to the raial nerve. The raial nerve crosses the lateral supraconylar rige of the humerus at the iaphyseal-metaphyseal junction, an then it courses anterior to the cortex of the humeral iaphysis. The Schanz pin shoul be inserte at 90 to the longituinal axis of the proximal humeral fragment an secure in the meial cortex. In orer to avoi injury to the ulnar nerve, care shoul be taken not to fully perforate the meial cortex (Fig. 2). Next, the secon Schanz pin is inserte in the istal fragment. This pin shoul be 2.5 to 3.0 mm in iameter, epening on the size of the fragment. If the metaphyseal fragment is sufficiently large, the pin can be inserte proximal to the physis. If the istal fragment is very small, the istal Schanz pin can be inserte into the center of the capitellum. In our experience, single pin penetration of the epiphysis has not resulte in subsequent growth arrest. Again, this secon Schanz pin shoul be place perpenicular to the longituinal axis of the istal fragment, making it parallel to the elbow joint. As with the first pin, it is important to avoi fully perforating the meial cortex of the istal part of the humerus (Fig. 3). We o

5 1693 Fig. 3 Intraoperative placement of the secon Schanz pin in the istal metaphyseal fragment. In the case of a small istal metaphyseal fragment, the pin can be place centrally in the capitellum. not use percutaneous Kirschner wires as joysticks to manipulate the fragments because we have often foun that they o not provie satisfactory leverage to manipulate the fragments into position. The larger-iameter Schanz pins provie more rigi fixation of the fragments an can be use more effectively as joysticks to manipulate the fracture fragments. To use the two Schanz pins as joysticks, it is important that they are inserte perpenicular to the long axes of the respective fracture fragments. The avantage of placing the pins perpenicular to the respective fragments is that they can be use as guies to etermine the quality of the final reuction: if the pins are parallel in the coronal plane following the reuction maneuver, then the alignment of the fracture fragments shoul be satisfactory. To facilitate final attachment of the Schanz pins to the fixator, the tube-to-tube clamps an the steel or carbon ro are loosely applie to the Schanz pins. The final reuction is then monitore with use of the image intensifier. Once the esire reuction has been accomplishe, the tube-to-tube clamps are tightene, securing the bar to the Schanz pins. The external fixator an two single Schanz pins provie goo stabilization in the coronal plane, but there can still be some tenency for the fracture fragments to have rotational instability if forces are applie in the horizontal plane. To provie aitional rotational stability, a 2.0 or 1.6-mm Kirschner wire is rille retrograe from the lateral aspect (raial sie) of the istal fragment into the proximal-meial cortex of the proximal fragment, crossing the fracture just proximal to the olecranon fossa. Alternatively, if the obliquity of the fracture is in the same irection the Kirschner wire is suppose to be place, the pin can be passe antegrae from the lateral aspect of the proximal fragment to the meial aspect of the istal fragment. This single Kirschner wire is terme an anti-rotation wire, an it is fixe to the fixator ro with a combination clamp or it can be left free because it has no influence on axial stability (Fig. 4). Raiographic ocumentation of the reuction an fixation is accomplishe with raioulnar, ulnoraial, an anteroposterior images. As the final step, it is important to test the elbow range of motion an the stability of the fracture in maximum extension an flexion (Fig. 5) while observing the fracture site in real time with the image intensifier. If maximum extension an flexion are not possible or if the reuction is not stable, the external fixator an the fracture shoul be ajuste. Postoperative Care Depening on the chil s anxiety an the concern shown by the parents, a orsal splint can be applie for protection an/or comfort. Because fixation usually is very secure, supplemental support usually is not necessary. The chil can be allowe free motion of the affecte upper extremity, avoiing any weightbearing activities. Doing so has the avantage of permitting the chil to use the extremity for school activities such as writing. As with any external fixator, it is important to perform pin care on a aily basis. It is not necessary to initiate physical therapy in the immeiate postoperative perio. The first postoperative raiographs are mae between three an five weeks after the proceure to assess fracture-healing. We favor a longer timeperio between the operation an the first raiographs in orer to allow fracture consoliation to take place, thus reucing the number of raiographs mae. Once there is goo callus formation, as shown by callus briging at least three of four cortices, the external fixator can be remove with little or no seation. Results The ages of the thirty-one patients range from two to fifteen years, with 84% (twenty-six) of the chilren being between the ages of five an thirteen years. Three chilren ha

6 1694 Fig. 4 Correct placement of the external fixator in a bone moel (top) an clinically at the en of the operation (bottom). For aitional rotational stability, a Kirschner wire has been rille through both fragments from the raial sie. an open fracture: one ha a Gustilo an Anerson type-i fracture, an two ha a type-ii fracture 25,26. The male-female ratio was 1.5:1. The left upper extremity was involve two times more often than the right. In three of the thirty-one patients, open reuction was require. One of these three patients initially presente with an open fracture. In the secon patient, the fracture site was explore surgically because of concern about a neurovascular injury with an impening Fig. 5 At the en of the operation, it is manatory to test the range of motion an stability in flexion an extension.

7 1695 TABLE I Intraoperative an Postoperative Data on the Thirty-one Patients Mean (Range) Operative time (min) 56 (20 to 130*) Duration of external fixator in situ (wk) 5(4to7) Number of postoperative raiographs 3 (2 to 4) Number of outpatient visits 3 (2 to 6) *In one case, the ecision to use external fixation was mae intraoperatively after several faile attempts at fixation with use of crosse Kirschner wires an the operative time inclue the time spent waiting for a more experience surgeon. compartment synrome. In the thir patient, an open reuction was performe because of an inability to achieve a satisfactory reuction with use of the external fixator. The reuction was foun to be prevente by interpose muscle. The intraoperative an postoperative ata regaring the patients are presente in Table I. Eight chilren ha neurological eficits involving the raial nerve (n = 4), the ulnar nerve (n = 3), an the anterior interosseous branch of the meian nerve (n = 1) prior to the treatment of the fracture. In aition, one patient presente with no palpable istal pulse. All of these eficits resolve after the reuction of the fracture an stabilization with the external fixator. Two pin-track infections occurre an were successfully treate with oral antibiotics. Eleven patients use a supplemental orsal splint for comfort postoperatively. Following consoliation of the fracture an removal of the external fixator, twenty-eight chilren were foun to have bilateral symmetrical elbow axes within the physiological cubitus valgus range of 5 to 10. Two chilren ha a loss of physiological valgus, an one chil ha a cubitus varus eformity of 5. This varus eformity was not of any cosmetic or functional concern to the parents or the patient. Follow-up was performe at our outpatient clinic. The range of motion right before removal of the external fixator varie between a full range of motion to nearly no motion in one chil. In all cases, the external fixator was remove, without a secon session of general anesthesia, after a mean of five weeks (range, four to seven weeks). In the cases of twelve patients, seation was provie uring the removal proceure. The mean uration of follow-up (an stanar eviation) was 40.9 ± 23.6 months (range, seven to eighty-one months). Three months after removal of the fixator, thirty of the thirty-one chilren ha a normal or a goo range of motion of the elbow. A normal range of motion was efine as flexion of 140 to 150 with extension to 0 or even slight hyperextension, whereas a goo range of motion was efine as a maximum flexion-extension eficit of Onlyone patient ha severe limitation of elbow motion. In that patient, two months after removal of the fixator, the range of elbow flexion-extension was from 70 to 45. The motion improve with physiotherapy, but not to a satisfactory level, an the patient was still being followe in our outpatient clinic at the time of the latest follow-up. The cosmetic result was excellent in all cases, an the acceptance of the external fixator was consiere excellent by both the chilren an the parents. Subjectively, wearing the fixator was not seen as a hinrance either at home (in the case of smaller chilren) or at school. On the contrary, being able to use the arm freely for school was seen as positive. Aske if they woul accept the same type of treatment again, all chilren an parents replie that they woul. Discussion Supraconylar humeral fractures are common. The peak incience is between the ages of five an ten years 14. The type-iii supraconylar humeral fracture is challenging, as reflecte in the literature, an there is still some controversy with regar to the ieal treatment metho 20, In most cases, the stanar technique inclues close reuction with manipulation followe by stabilization with either cross-pins or multiple lateral pins 34. These techniques usually prouce a satisfactory cosmetic an functional result. However, there are occasions in which a more aggressive approach is neee. Often, an open reuction with or without an alternative metho of fixation is require. Although better results usually are reporte following close reuction, the optimal treatment is still unclear in the literature on severely isplace type-iii supraconylar humeral fractures Some authors have recommene a minimally invasive meial approach 20,39. Our experience with the use of the lateral external fixator emonstrate that, in most cases, an excellent cosmetic result an a goo functional result can be achieve an that open reuction can be eliminate. If aequate alignment cannot be achieve with manipulation, our experience emonstrate that, in the majority of cases, the fragments can be manipulate into a satisfactory position with use of the Schanz pins. These pins can then be secure to a small external fixator. The stability affore by the fixator can prevent seconary isplacement. However, it must be clearly emphasize that we see this metho as an alternative supplement to the existing methos. The main inications are (1) fractures that are irreucible with use of the usual close techniques, (2) oblique fractures that o not appear to be stabilize aequately with the classic methos, especially fractures with angulation of >30 in the sagittal plane, an (3) comminute fractures. The main goals are to avoi the nee for an open reuction an to achieve fracture stabilization, which prevents seconary isplacement with its risk of malunion in cubitus varus. We are aware of the limitations of this stuy because of its retrospective nature. Nevertheless, the review of our cases over the last seven years (comprising approximately 18% of all surgically treate supraconylar humeral fractures) emonstrate that this metho is very simple to use, requires little expeniture, an can achieve satisfactory results. Even in cases in which there is an inability to achieve complete correction of

8 1696 the rotation of the istal fragment, the stability provie by the fixator can prevent the istal fragment from tilting into varus. The avantage of this treatment, which allows early mobility of the elbow, was emonstrate by the goo active range of elbow motion that the patients exhibite at the time of fixator removal, thus reucing rehabilitation time. In conclusion, unstable or markely isplace supraconylar humeral fractures (Gartlan type-iii) remain a treatment challenge. The introuction of the lateral external fixator provies another metho with which close reuction an stabilization of this fracture can be achieve. Its stability prevents the occurrence of seconary isplacement. As all of the pins are inserte from the lateral sie of the istal part of the humerus, injury to the ulnar nerve can be avoie. This metho allows for immeiate elbow movement an is well accepte by the chilren an parents. The surgeon who treats peiatric trauma will fin this technique to be of use for avoiing open reuction when a satisfactory reuction cannot be achieve with the usual close manipulative methos. n They Slongo, MD Timo Schmi, MD Alexaner Joeris, MD Department of Surgical Peiatrics, Chilren s Hospital, University of Berne, CH-3010 Berne, Switzerlan. aress for T. Slongo: they.slongo@insel.ch. aress for T. Schmi: timo.schmi@insel.ch. aress for A. Joeris: alexaner.joeris@insel.ch Kaye Wilkins, DVM, MD Department of Orthopeics an Peiatrics, University of Texas Health Science Center at San Antonio, 560 Granview Avenue, San Antonio, TX References 1. Houshian S, Mehi B, Larsen MS. The epiemiology of elbow fracture in chilren: analysis of 355 fractures, with special reference to supraconylar humerus fractures. J Orthop Sci. 2001;6: Otsuka NY, Kasser JR. Supraconylar fractures of the humerus in chilren. J Am Aca Orthop Surg. 1997;5: Skaggs D, Persha J. Peiatric elbow trauma. 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