We report the results of 116 consecutive displaced

Transcription

1 Systematic pinning of displaced extension-type supracondylar fractures of the humerus in children A PROSPECTIVE STUDY OF 116 CONSECUTIVE PATIENTS K. Mazda, C. Boggione, F. Fitoussi, G. F. Penneçot From Robert Debré Hospital, Denis Diderot - Paris VII University, France We report the results of 116 consecutive displaced extension supracondylar fractures of the elbow in children treated during the first two years after the introduction of the following protocol; closed reduction under general anaesthesia with fluoroscopic control and lateral percutaneous pinning using two parallel pins or, when closed reduction failed, open reduction and internal fixation by cross-pinning. Eight patients were lost to follow-up during the first postoperative year. The mean follow-up for the remaining 108 was 27.9 months (12 to 47, median 26.5). At the final follow-up, using Flynn s overall modified classification, the clinical result was considered to be excellent in 99 patients (91.6%), good in five (4.6%) and poor in four (3.7%). All the poor results were due to a poor cosmetic result, but had good or excellent function. Technical error in the initial management of these four cases was thought to be the cause of the poor results. The protocol described resulted in good or excellent results in 96% of our patients, providing a safe and efficient treatment for displaced supracondylar fractures of the humerus even in less experienced hands. J Bone Joint Surg [Br] 2001;83-B: Received 20 July 2000; Accepted after revision 18 December 2000 Extension supracondylar fracture of the humerus is the most common fracture around the elbow in children. 1,2 Immobilisation in a cast is generally accepted as the standard treatment for non-displaced fractures but there is controversy as to the best treatment for displaced fractures. K. Mazda, MD, Paediatric Orthopaedic Surgeon C. Boggione, MD, Orthopaedic Surgeon F. Fitoussi, MD, Paediatric Orthopaedic Surgeon G. F. Penneçot, MD, Paediatric Orthopaedic Surgeon, Professor of Paediatric Orthopaedic Surgery Robert Debré Hospital, Denis Diderot - Paris VII University, 48 Boulevard Serrurier, Paris, France. Correspondence should be sent to Dr K. Mazda British Editorial Society of Bone and Joint Surgery X/01/ $2.00 Our aim was to design a simple and effective protocol for the treatment of displaced extension supracondylar fractures in children that could be easily and safely used by relatively inexperienced orthopaedic surgeons. The reason for designing such a protocol was that in our centre, which is a reference University hospital admitting approximately 2500 paediatric orthopaedic emergencies each year, twothirds of the surgeons on call have less than four years experience after graduation. After a critical review of the literature, the following protocol was chosen; closed reduction under general anaesthesia with fluoroscopic control and lateral percutaneous pinning using two parallel Kirschner (K) wires. The K- wires had to be separated by a minimum distance of 10 mm and be more than 1.6 mm in diameter. If closed reduction failed, open reduction and internal fixation by cross-pinning was carried out using a medial approach with identification of the ulnar nerve. The K-wires had to cross above the level of the fracture and be more than 1.6 mm in diameter. We report the results in 116 patients treated during the first two years after the introduction of this protocol and with a follow-up of more than one year. Patients and Methods Between November 1993 and November 1995 we studied, prospectively, 116 patients with an extension displaced supracondylar fracture of the humerus. The inclusion criteria were an open humeral growth plate, unilateral extension type fracture, and displacement of more than 2 mm. There were 70 boys and 46 girls with a mean age at presentation of 5.7 years (0.5 to 12.4; median, 5.5). The initial displacement was classified according to Gartland, 3 30 being type II and 86 type III. The right elbow was involved in 51 patients and the left in 65. In three patients the fracture was open (2 Cauchoix type 1 and 1 type 2). In seven patients there was an associated fracture of the ipsilateral forearm. A purely sensory neurological deficit was present in 11 patients (9.5%). In these patients, the initial displacement was classified as type II in two and type III in nine. In five patients, all with type-iii displaced fractures, distal ischaemia with an absent radial pulse was found at presentation. Normal blood flow was restored after reduction in all patients and no exploration of blood vessels was necessary. 888 THE JOURNAL OF BONE AND JOINT SURGERY

2 SYSTEMATIC PINNING OF DISPLACED EXTENSION-TYPE SUPRACONDYLAR FRACTURES OF THE HUMERUS IN CHILDREN 889 Fig. 1 Radiograph showing the correct alignment as recommended by Judet. The wires are strictly parallel and separated by more than 10 mm. 2) was carried out in 26 patients when closed reduction failed. In all cases the wires were buried under the skin and the arm immobilised in an above-elbow cast and a light shoulder immobiliser. Six surgeons were involved in the study; four junior surgeons (with less than four years experience) and two senior surgeons. Training in the use of this protocol was supervised by a senior surgeon for six months. The mean number of injuries treated during a junior surgeon s period of training was six. The patients who had percutaneous pinning were discharged 12 to 24 hours after surgery and those who required open reduction on the second day. The wires and cast were removed after five to six weeks. The patients were not seen and no radiographs were taken during the period of immobilisation. Clinical evaluation at final follow-up was based on that of Flynn, Matthews and Benoit. 7 The overall rating was assessed using the modified Flynn classification reported by Webb and Sherman 8 and Boyd and Aronson 9 (Table I). Radiological assessment was made at the time of removal of the wires and at final follow-up, on anteroposterior (AP) and lateral views of both elbows and on frontal full-arm views of both sides. Postoperative AP radiographs were compared with those taken at the time of removal of the wires and at final follow-up. The Baumann, humeroulnar and lateral humerocapitellar angles 10 of both arms were recorded. A difference of more than 5 between two measurements was considered significant. The radiological evaluation and the final clinical evaluation were performed by one of the authors who was not involved in the care of the patients. Results Fig. 2 Radiograph showing satisfactory crossed K-wire fixation; the wires cross above the level of the fracture. Treatment was carried out as soon as possible when patients were seen less than 24 hours after injury but was delayed in ten patients who were seen three to ten days after injury. A total of 90 patients was treated using closed reduction under general anaesthesia with fluoroscopic control and lateral percutaneous pinning using two parallel wires of more than 1.6 mm in diameter with separation of more than 10 mm (Fig. 1) as described by Judet 4,5 and Pouliquen. 6 Open reduction via a medial approach with identification of the ulnar nerve and internal fixation by cross-pinning (Fig. Eight patients were lost to follow-up during the first postoperative year. The mean follow-up of the remaining 108 was 27.9 months (12 to 47, median 26.5). There were no local complications such as wound infection. At final follow-up, using Flynn s modified classification 7-9 (Table II), the clinical result was excellent in 99 patients (91.6%), good in five (4.6%) and poor in four (3.7%). All the poor results were due to a poor cosmetic result, but with good or excellent function. No significant difference could be detected with the numbers available between the two forms of initial treatment (closed or open reduction and fixation). All the patients with a poor final result had a Gartland type-iii initial displacement. A difference of more than 5 between the two sides was found in 17 patients for Baumann s angle, in nine for the humeroulnar angle and in 20 for the humerocapitellar angle (Table III). No correlation was found between those differences and the clinical results as evaluated by Flynn s classification. In eight patients (6.8%) a difference of more than 5 was found for Baumann s angle between the postoperative radiographs and those taken at the time of removal of the wires, all with type-iii fractures (three after VOL. 83-B, NO. 6, AUGUST 2001

3 890 K. MAZDA, C. BOGGIONE, F. FITOUSSI, G. F. PENNEÇOT Table I. Flynn s cosmetic and functional factors, 7 and the overall rating as reported by Webb et al 8 and Boyd, 9 for studying outcome after treatment for supracondylar fractures of the humerus Flynn s criteria 7 Cosmetic factor Functional factor carrying-angle loss movement loss (degrees) (degrees) Overall rating 8,9 Excellent 0 to 5 0 to 5 The lower of the two ratings, Good 5 to 10 5 to 10 and an elbow with a varus Fair 10 to to 15 deformity is automatically Poor >15 >15 graded as poor Table II. Final clinical results, and initial displacement and treatment for 108 children with supracondylar fractures of the humerus Flynn s global classification* Functional Cosmetic Overall Displacement Treatment E G F P E G F P E G F P Total Type II Percutaneous Open surgery Type III Percutaneous Open surgery * E, excellent; G, good; F, fair; P, poor Table III. Comparison of the Baumann, humeroulnar and humerocapitellar angles (degrees) at the latest follow-up of 108 children after systematic pinning of displaced extension-type supracondylar fractures of the humerus Difference between injured and opposite arm* >-5-5 to +5 >+5 Angle Mean Range (number of patients) (number of patients) (number of patients) Baumann to Humerocapitellar to Humeroulnar to * a negative angle means valgus for the Baumann, varus for the humeroulnar and extension for the humerocapitellar angle. A positive angle means varus for the Baumann, valgus for the humeroulnar and flexion for the humerocapitellar angle closed reduction and pinning and five after open reduction and cross-pinning). In two patients the end result was considered to be poor because of a poor cosmetic result with cubitus varus. In the remaining six patients remodelling occurred and all were classified as excellent. In all four patients with a poor final result, a technical error was found in the initial treatment. Three had been treated percutaneously; in two an anatomical reduction of the fracture was not obtained with persistent rotation between the fragments, and in the remaining elbow the wires were positioned too close together, leading to secondary displacement with rotation of the fragments around the axes of the wires (Fig. 3). In the fourth patient treated by open surgery, the technique was also poor, one of the wires being unicortical, allowing secondary displacement around the single bicortical wire (Fig. 4). All four technical mistakes were made by junior surgeons during their first six months of experience when the guideline criteria for a good reduction and a safe fixation had not been strictly followed. Discussion Extension supracondylar fractures are the most common fractures around the elbow in children and adolescents. Fractures with Gartland type-i displacement are commonly treated by an above-elbow cast without reduction. The treatment of more severely displaced (Gartland type II and type III) fractures remains controversial. The aim of our protocol was to develop a simple algorithm of treatment to provide the best functional and cosmetic result even when undertaken by less experienced surgeons, the shortest time in hospital and the simplest follow-up regime. Five methods of treatment for displaced supracondylar extension-type fractures are described in the literature. These are closed reduction and above-elbow casting. Blount s technique 11 (in which reduction is maintained by a flexed position of the elbow in a collar and cuff sling), skeletal traction, primary closed reduction and percutaneous fixation (using lateral wires or medial and lateral THE JOURNAL OF BONE AND JOINT SURGERY

4 SYSTEMATIC PINNING OF DISPLACED EXTENSION-TYPE SUPRACONDYLAR FRACTURES OF THE HUMERUS IN CHILDREN 891 Fig. 3 Radiograph showing a poor alignment. The wires are positioned too close and thus the configuration is mechanically equivalent to a single-wire construct, allowing rotation of the distal fragment around the axes of the wires. Fig. 4 Radiograph showing a crossed K-wire configuration with one unicortical wire which allows rotation of the distal fragment around the other. Table IV. Clinical findings compared with other series in the literature Lost to Flynn s global classification (%) Number follow-up Treatment Authors of cases (%) Excellent Good Fair Poor Closed reduction and cast Hadlow et al Olecranon traction Sutton et al Hadlow et al Paradis et al Closed reduction and Boyd and Aronson lateral K-wiring Hadlow et al Mazda et al (this study) Percutaneous cross-pinning Flynn et al Mehserle and Meehan Sutton et al Open reduction and Hadlow et al K-wiring Mazda et al (this study) cross-pinning) and open reduction and fixation. Closed reduction followed by immobilisation, either by casting or Blount s technique, is indicated in type-ii fractures but is usually considered to be unreliable for type-iii displaced fractures. 1,2 The incidence of secondary displacement during the healing period makes repeat follow-up radiographs essential particularly when using Blount s technique. Analysis of the initial stability after reduction requires considerable experience. Clavert et al 12 were only able to use this technique in 70% of displaced supracondylar fractures and 14 of their 120 cases treated by Blount s immobilisation required pinning. Skin or skeletal traction requires a longer period in hospital and does not provide any advantage over immediate reduction. 2 Primary closed reduction and percutaneous pinning is the preferred treatment for type-iii injuries with the lowest rate of compartment syndrome of the forearm and residual deformity. 2 In designing our guidelines, we extended the indication for this technique to all type-ii displacements in order to reduce the incidence of secondary displacement and the necessity for repeat radiographs. We did not use the modification of Wilkins et al 1 of the Gartland classification 3 which separates type-ii displacements into two groups in order to make the therapeutic decision easier. The technique of pinning is controversial. Percutaneous cross-pinning is theoretically the more stable biomechanical construct. 13,14 This technique has been popularised by VOL. 83-B, NO. 6, AUGUST 2001

5 892 K. MAZDA, C. BOGGIONE, F. FITOUSSI, G. F. PENNEÇOT Swenson 15 and others. 7,10 A precise technique of medial pinning avoids injury to the ulnar nerve. On the other hand, many cases of palsy of the ulnar nerve have been reported with the use of a medial percutaneous K-wire, causing direct injury to the nerve or a delayed neuropathy possibly due to contusion of the nerve with oedema, or stretching of the nerve over the medial pin Rassool 20 reported that the safety of percutaneous cross-pinning seemed to be related to the surgeon s experience. In a comparison of percutaneous crossed medial and lateral pinning with lateral pin fixation alone using two parallel pins, Topping et al 17 did not find any clinically significant biomechanical advantage of one pinning technique over the other. We therefore choose lateral pinning by two parallel pins as the primary treatment for displaced fractures. The technique has to be correctly applied. The K-wires must be strictly parallel and separated by a distance of more than 10 mm. If the wires are positioned too closely, the mechanical construct is equivalent to a single wire construct and allows rotation of the distal fragment around the axes of the wires. This was pointed out by Judet 5 who initially used a single wire. 4 Irreducible fractures have to be managed by open reduction and internal fixation which can be done either via a medial, posterior or lateral approach. We chose the medial approach in order to visualise the ulnar nerve during reduction, with the minimum of dissection. Crosspinning was chosen as the method of fixation after an open medial approach because of its ease and safety, if the medial wire is introduced on the anterior aspect of the medial condyle. We chose to bury the wires routinely, both when using the percutaneous and the open technique. This avoids pinsite infection which can have serious consequences. 9,21,22 It has the disadvantage of requiring anaesthesia for its removal. To evaluate our results, we chose Flynn s modified overall rating (Table I). This is the most rigorous classification since any cubitus varus deformity is considered to be a poor result, whatever the function of the elbow. Table IV compares our results with others in the literature which use the same classification. Our treatment protocol gave excellent or good results in 96% of cases with 7% of patients lost to follow-up at a mean of 28 months. Comparing the results of our treatment protocol with other published series, we consider it to be a safe method, even when undertaken by less experienced surgeons. All type-ii fractures were classified as having excellent or good results. The four poor results, all in type-iii fractures, were considered to be the result of technical errors when the guidelines were not followed, i.e., failure of initial reduction or poor mechanical pinning. This was probably due to the level of experience of the surgeons involved in the primary care; all four mistakes were by junior staff in their first six months. We did not find one technique of pinning to be superior to the other, confirming the experience of Topping et al. 17 Secondary displacement, with a difference of more than 5 in Baumann s angle between the postoperative radiograph and that taken at the time of removal of the wires, occurred in three of the 90 patients treated by lateral percutaneous pinning and in five of the 26 treated by open cross-pinning. All had type-iii fractures. In two cases of secondary displacement, poor results were due to technical errors (Figs 3 and 4). The displacement in the remaining six patients was less than 10 and of no clinical significance. No correlation was found between the modified Flynn s overall rating and the radiological AP and lateral angles at final follow-up. This may be due to the fact that a moderate variation in the position of the limb relative to the cassette or to the direction of the x-ray beam, may significantly alter the assessment of these angles. We thank Nathalie Boggione for her contribution. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. References 1. Wilkins K, Beaty JH, Chambers HG, Toniolo RM. Fractures and dislocations of the elbow region. In: Rockwood CA, Wilkins KE, Beaty JH, eds. Fractures in children. Fourth ed. Vol. 3. Philadelphia, etc:lippincott-raven, 1996: Devito DP. Management of fractures and their complications. In: Morrissy RT, Weinstein SL, eds. Lovell and Winter s Pediatric Orthopaedic. Vol. 2. Philadelphia: Lippincott-Raven, 1996: Gartland J. Management of supracondylar fractures in children. Surg Gynecol Obstet 1959;109: Judet J. Traitement des fractures épiphysaires de l enfant par broche trans-articulaire. Mém Acad Chir 1947: Judet J. Traitement des fractures sus-condyliennes transversales de l humérus chez l enfant. Rev Chir Orthop 1953;39: Pouliquen JC. Supracondylar elbow fractures. J Pediatr Orthop 1993;13: Flynn JC, Matthews JG, Benoit RL. Blind pinning of displaced supracondylar fractures of the humerus in children: sixteen years experience with long-term follow-up. J Bone Joint Surg [Am] 1974;56-A: Webb AJ, Sherman FC. Supracondylar fractures of the humerus in children. J Pediatr Orthop 1989;9: Boyd DW, Aronson DD. Supracondylar fractures of the humerus: a prospective study of percutaneous pinning. J Pediatr Orthop 1992;12: Mehserle WL, Meehan PL. Treatment of the displaced supracondylar fracture of the humerus (type III) with closed reduction and percutaneous cross-pin fixation. J Pediatr Orthop 1991;11: Blount WP, Schulz I. Fractures of the elbow in children. JAMA 1951;146: Clavert JM, Lecerf C, Mathieu JC, Buck P. Retention in flexion of supracondylar fracture of the humerus in children: comments à propos of the treatment of 120 displaced fractures. Rev Chir Orthop Reparatrice Appar Mot 1984;70: Herzenberg JE, Koreska J, Carroll NC, Rang M. Biomechanical testing of pin fixation techniques for pediatric supracondylar elbow fractures. Orthop Trans 1988;12: Zionts LE, McKellop HA, Hathaway R. Torsional strength of pin configurations used to fix supracondylar fractures of the humerus in children. J Bone Joint Surg [Am] 1994;76: Swenson AL. The treatment of supracondylar fractures of the humerus by Kirschner-wire transfixion. J Bone Joint Surg [Am] 1948;30-A: Royce RO, Dutkowsky JP, Kasser JR, Rand FR. 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6 SYSTEMATIC PINNING OF DISPLACED EXTENSION-TYPE SUPRACONDYLAR FRACTURES OF THE HUMERUS IN CHILDREN Topping RE, Blanco JS, Davis TJ. Clinical evaluation of crossed-pin versus lateral-pin fixation in displaced supracondylar humerus fractures. J Pediatr Orthop 1995;15: Brown IC, Zinar DM. Traumatic and iatrogenic neurological complications after supracondylar humerus fractures in children. J Pediatr Orthop 1995;15: Ikram MA. Ulnar nerve palsy: a complication following percutaneous fixation of supracondylar fractures of the humerus in children. Injury 1996;27: Rasool MN. Ulnar nerve injury after K-wire fixation of supracondylar humerus fractures in children. J Pediatr Orthop 1998;18: Aronson DD, Prager BI. Supracondylar fractures of the humerus in children: a modified technique for closed pinning. Clin Orthop 1987;219: Damsin JP, Langlais J. Supracondylar fractures. Rev Chir Orthop Reparatrice Appar Mot 1987;73: Hadlow AT, Devane P, Nicol RO. A selective treatment approach to supracondylar fracture of the humerus in children. J Pediatr Orthop 1996;16: Sutton WR, Greene WB, Georgopoulos G, Dameron TB Jr. Displaced supracondylar humeral fractures in children: a comparison of results and costs in patients treated by skeletal traction versus percutaneous pinning. Clin Orthop 1992;278: Paradis G, Lavallée P, Gagnon N, Lemire L. Supracondylar fractures of the humerus in children: technique and results of crossed percutaneous K-wire fixation. Clin Orthop 1993;297: VOL. 83-B, NO. 6, AUGUST 2001