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Delayed management of fracture of the lateral humeral condyle in children

Dhillon KS, Sengupta S, Singh BJ

Acta Orthop Scand, 1988 Aug;59(4):419-24.
PMID: 3421080

Thirty-nine displaced fractures of the lateral humeral condyle in children were followed for an average of 5 (2-5) years. The results were evaluated from functional and cosmetic aspects. Patients treated within 2 weeks by open reduction and internal fixation did well. Those operated on after 6 weeks did not do better than nonoperated on cases. Complications included cubitus varus and valgus deformities, osteonecrosis, nonunion and malunion, and loss of motion. We recommend that patients presenting late be left alone and any sequelae evaluated at a late stage.

Matched MeSH terms: Humeral Fractures/surgery*; Humeral Fractures/therapy
Fulltext Concomitant fat embolism syndrome and pulmonary embolism in a patient with patent foramen ovale

Dk Yeak R, Liew SK

Acta Orthop Traumatol Turc, 2020 Jul;54(4):465-468.
PMID: 32812879 DOI: 10.5152/j.aott.2020.20035

We present a rare case of a patient with concurrent fat embolism and pulmonary embolism, in a closed femur fracture with patent foramen ovale (PFO). A 24-year-old man was involved in a motor vehicle accident with a closed left midshaft femur fracture. He developed fat embolism syndrome (FES) on day 3 of admission, and plating was performed. The D-dimer concentration was also high, which raised the suspicion of pulmonary artery embolism. Computed tomography pulmonary angiography (CTPA) revealed right inferior lobar pulmonary artery embolism and FES. A transthoracic echocardiogram (TEE) was performed, which showed a PFO. The presence of a PFO in patients with pulmonary embolism increases the risk of systemic embolism. Therefore, we recommend the routine echocardiogram for patients with pulmonary embolism to exclude any cardiac defect in causing right-to-left shunts, which predisposes the patient to paradoxical embolism.

Matched MeSH terms: Humeral Fractures/diagnosis; Humeral Fractures/therapy
Displaced medial epicondyle fractures of the humerus: surgical treatment and results. A report of 139 cases

Louahem DM, Bourelle S, Buscayret F, Mazeau P, Kelly P, Dimeglio A, et al.

Arch Orthop Trauma Surg, 2010 May;130(5):649-55.
PMID: 19960347 DOI: 10.1007/s00402-009-1009-3

Elbow instability is a common feature after medial epicondyle fractures, displaced or not, even in the absence of dislocation. Undisplaced or minimally displaced fractures often have an underestimated degree of instability secondary to unrecognised capsuloligamentous and muscular injuries. The purpose of this retrospective study was to analyze and to assess objectively the results of the surgical treatment of these acute injuries.

Matched MeSH terms: Humeral Fractures/complications; Humeral Fractures/radiography; Humeral Fractures/surgery*
Fulltext Biomechanical Analysis of Crossed Pinning Construct in Supracondylar Fracture of Humerus: Does the Point of Crossing Matter?

Hanim A, Wafiuddin M, Azfar MA, Awang MS, Nik Abdul Adel NA

Cureus, 2021 Mar 22;13(3):e14043.
PMID: 33898129 DOI: 10.7759/cureus.14043

Introduction This appears to be the first biomechanical study that compares the stability of various locations of the crossing points in crossed pinning Kirschner wiring (K-wire) construct in treating pediatric supracondylar humerus fracture (SCHF). Additionally, this study compared the biomechanical stability between crossed pinning K-wire construct and the three-lateral divergent K-wire construct. Methods For the study purpose, 30 synthetic humerus bones were osteotomised at mid-olecranon fossa, anatomically reduced, and pinned using two 1.6-millimeter K-wires in five different constructs. A total of six samples were prepared for each construct and tested for extension, flexion, valgus, varus, internal rotation, and external rotation forces. Results As for crossed pinning K-wire construct, the center crossing point emerged as the stiffest construct in both linear and rotational forces, in comparison to the lateral crossing point, superior crossing, and medial crossing point Conclusion Based on this analysis, it is highly recommended that, if the crossed pinning construct is selected to treat supracondylar humerus fracture, the surgeon should aim for center crossing point as it is the most stable construct. Nevertheless, if lateral and superior crossing points are obtained during the initial attempt of fixation, the fixation may be accepted without revising the K-wire as the stability of these two constructs are comparable and portrayed no significant difference when compared to that of the center crossing point. Additionally, it is essential to avoid the medial crossing point as it is significantly less stable in terms of rotational force when compared to the center crossing point.

Matched MeSH terms: Humeral Fractures
Lateral closing wedge supracondylar osteotomy of humerus for post-traumatic cubitus varus in children

Devnani AS

Injury, 1998 6 13;28(9-10):643-7.
PMID: 9624344

Cubitus varus deformity following mal-union of a supracondylar fracture of the humerus in children causes no functional disability, but surgical correction is often requested to improve the appearance of the arm. Maintaining the correction after supracondylar osteotomy is a difficult aspect of the operative treatment and remains controversial. Nine children aged between 6 and 12 years (average 8 years and 11 months) underwent lateral closing wedge supracondylar osteotomy of the humerus, for deformity ranging between 10 and 20 degrees (average 13 degrees). The correction required ranged between 16 and 30 degrees (average 21 degrees). The osteotomy was internally fixed with a two hole marrow plate. At follow-up, which ranged between 3 months and 6 years (average 34 months), six patients were graded as good, two as satisfactory and one as a poor result. One patient had transient radial nerve palsy which recovered completely in 2 months. The patient who was graded poor had undercorrection of the deformity at the original operation. There was no incidence of loss of correction due to implant failure. Complete section of the bone to allow medial displacement of the distal fragment is recommended, thereby avoiding lateral bony prominence at the elbow.

Matched MeSH terms: Humeral Fractures/rehabilitation; Humeral Fractures/surgery*
Long bone fractures among children in Malaysia

Iqbal QM

Int Surg, 1974 Aug;59(8):410-5.
PMID: 4853031
Matched MeSH terms: Humeral Fractures/epidemiology
Letter to the Editor: Minimally invasive plate osteosynthesis for proximal humeral fractures

Sinha N, Rao BS, Trivedy PD, Rao AS

J Orthop Surg (Hong Kong), 2016 04;24(1):139.
PMID: 27122535
Matched MeSH terms: Humeral Fractures/surgery
Comparison of two methods of percutaneous pin fixation in displaced supracondylar fractures of the humerus in children

Foead A, Penafort R, Saw A, Sengupta S

J Orthop Surg (Hong Kong), 2004 Jun;12(1):76-82.
PMID: 15237126

To conduct a prospective randomised controlled study to compare the stability and risk of nerve injury between fractures treated by medial-lateral pin fixation and those treated by 2-lateral pin fixation.

Matched MeSH terms: Humeral Fractures/rehabilitation; Humeral Fractures/surgery*
A modified surgical technique for neglected fracture of lateral humeral condyle in children

Sulaiman AR, Munajat I, Mohd EF

J Pediatr Orthop B, 2011 Nov;20(6):366-71.
PMID: 21716140 DOI: 10.1097/BPB.0b013e32834920df

Operative treatment for neglected fracture of lateral humeral condyle (LHC) is difficult because of contracted muscle, fibrous tissue formation, and indistinct bony edges. Its success depends on the ability to preserve blood supply during the surgery. We retrospectively reviewed eight cases of neglected fracture of LHC in children treated with open reduction with selected multiple 'V' lengthening of common extensor muscle and internal fixation. The patients were between 3 and 8 years of age. The period of neglect was between 3 and 20 weeks. Four patients with displacement of more than 10 mm and neglect for 5 weeks or more required lengthening of common extensor muscle aponeurosis. The follow-up assessments were between 1 and 6.3 years with a mean of 4.4 years. All patients had union by 2 months. They gained improvement of flexion range of motion between 60° and 120° with a mean of 86.3°. Loss of final range of motion compared with the normal side was between 5° and 35° with a mean of 10°. No patient had limitation of activities or pain. Six cases had excellent and two cases had good Dillon functional score. All patients had lateral condyle prominent with different severities. There was one mild avascular necrosis and one fishtail deformity. Both of them had almost full range of motion. All patients had early physeal closure, except one, who had only 1 year follow-up. There was no case of progressive valgus deformity. Children with neglected fracture of LHC would benefit from anatomical reduction and internal fixation through a proper exposure and if indicated combined with multiple 'V' lengthening of common extensor muscle aponeurosis. This is a level IV study.

Matched MeSH terms: Humeral Fractures/physiopathology; Humeral Fractures/radiography; Humeral Fractures/surgery*
An elbow dislocation in a child with missed medial epicondyle fracture and late ulnar nerve palsy

Haflah NH, Ibrahim S, Sapuan J, Abdullah S

J Pediatr Orthop B, 2010 Sep;19(5):459-61.
PMID: 20555271 DOI: 10.1097/BPB.0b013e32833b6032

Elbow dislocations associated with a medial epicondyle fracture and ulnar nerve palsy are uncommon injuries. We present the case of an 11-year-old girl with an elbow dislocation treated by closed manual reduction. The medial epicondyle fracture was missed initially until she developed an ulnar nerve palsy 2 months later. Intraoperatively we discovered the bony epicondyle piercing the joint capsule and compressing the ulnar nerve. Removal of the bony fragment relieved her symptoms and she returned to normal activities at 1 year follow-up. We would like to highlight this rare occurrence and present the detailed history and management of this case.

Matched MeSH terms: Humeral Fractures/complications; Humeral Fractures/diagnosis*
Nerve injuries in supracondylar fractures of the humerus in children: is nerve exploration indicated?

Khademolhosseini M, Abd Rashid AH, Ibrahim S

J Pediatr Orthop B, 2013 Mar;22(2):123-6.
PMID: 23222035 DOI: 10.1097/BPB.0b013e32835b2e14

A retrospective study of nerve injuries with displaced supracondylar fractures of the humerus in children younger than 12 years of age, treated in Hospital Universiti Kebangsaan Malaysia. Our objectives were to determine the incidence of primary and iatrogenic nerve injuries in supracondylar humerus fractures Gartland types II and III and to determine the outcome of nerve recovery. A total of 272 patients with displaced supracondylar humerus fractures who required admission to Hospital Universiti Kebangsaan Malaysia from January 2000 to December 2007 were reviewed. There were 182 boys (67%) and 90 girls (33%). The mean age was 6.0 years, ranging from 1 to 12 years. Of 272 supracondylar fractures, 79 were type II and 193 were type III. Fifty-one (19%) patients had closed reduction, 160 (59%) had closed reduction and percutaneous crossed Kirschner (K) wires, and 61 (22%) had open reduction and crossed K-wires. Associated nerve injuries involving the median, radial, and ulnar nerves were observed in 48 (18%) patients. Nerve injuries were observed in nine (3%) patients upon admission. Thirty-nine (14%) patients developed nerve injuries following treatment. Of these 39 patients, 34 had ulnar, three had radial, and two had median nerve injuries. Nerve exploration was performed in five patients (in four patients following debridement of open fracture and in one because of unacceptable postoperative radiographs, and they subsequently underwent open reduction and exploration). Except for these five patients, the K-wires were not removed earlier nor were the nerves surgically explored in others. The nerve injuries resolved clinically on an average time of 3.5 months (range from 3 weeks to 8 months). Our study found complete resolution of all patients with nerve injuries confirmed by clinical assessment. On the basis of our study, we believe that there is no indication to remove the K-wires immediately or to explore the nerve surgically following a mini-open technique, which reduces the risk of penetrating a nerve during pinning.

Matched MeSH terms: Humeral Fractures/radiography; Humeral Fractures/surgery*
A child with elbow pain

Mat Yudin ZA, Wan Ahmed WA, Chanmekun SB

Malays Fam Physician, 2019;14(2):44-45.
PMID: 31827738

Elbow injuries are common in children. Supracondylar fractures occurred in 16% of all pediatric fractures. Supracondylar fractures can be classified into 4 types according to the Gartland classification, depending on the degree of the fracture present in the lateral radiograph. This case highlights the case of a child with a Gartland Type I fracture. A misdiagnosis of this fracture will compromise the management of the injury with regards to immobilization and subsequent care. As this injury can be managed on an outpatient basis, primary care frontliners need to be aware of the condition.

Matched MeSH terms: Humeral Fractures
Fulltext Is A New Combination of Tendon Transfers For Radial Nerve Palsy (RNP) Needed?

Ramdhan I, Nawfar S, Paiman M

Malays Orthop J, 2014 Mar;8(1):75-8.
PMID: 25347622 MyJurnal DOI: 10.5704/MOJ.1403.006

Radial nerve palsy following traumatic humeral diaphyseal fractures occurs uncommonly. Most recover with good outcome. However the cases with poor outcome or recovery will have tendon transfers to regain the lost functions. Various tendon transfer methods and choices are available in literatures citing acceptable to good results. We report a case of radial nerve transection secondary to a closed traumatic diaphyseal fracture of the humerus which did not improve despite the repair. As many conventional technique produce asynergistic muscle action with secondary post-transfer deformity, thus we had resorted to tendon transfer procedure using an unconventional donor and recipient tendons yielding good results. This new combination of tendon transfers was invented involves better dynamic correlation of synergistic muscles action and produces good outcome and hand function.

Matched MeSH terms: Humeral Fractures
Fulltext Minimal Invasive Plate Osteosynthesis (MIPO) Technique Using Anterolateral Approach for Treating Closed Proximal Humerus Fracture

Ismail H, Boedijono D, Hidayat H, Simbardjo D

Malays Orthop J, 2012 Mar;6(1):18-24.
PMID: 25279037 DOI: 10.5704/MOJ.1203.008

ABSTRACT: Proximal humerus fracture is the second most common fracture of the upper extremity and presents several unique problems such as anatomical complexity, high risk of avascular necrosis, minimal bone stock for purchase, significant morbidity, and lack of a universally accepted treatment. Recent treatments for proximal humerus fractures include use of minimally invasive plate osteosynthysis (MIPO). The aim of this cross-sectional study was to evaluate the outcomes of our less invasive technique using a modified anterolateral approach for treatment of proximal humerus fractures. Ten such operative procedures were performed in patients of varying age and with varied mechanism of injury from 2002-2011. All cases were conducted in an acute setting. There were no cases of infection and the functional outcome scores were good. This approach represents an alternative treatment for closed proximal humerus fracture but more extensive studies are needed.
KEY WORDS: Proximal humerus fracture, MIPO, less invasive,anterolateral approach.

Matched MeSH terms: Humeral Fractures
Remodelling of Humeral Fracture in a Child with Osteopetrosis Tarda following Conservative Management - A 7-year Follow-up: A Case Report

Erkus S, Turgut A, Kose O, Kalenderer O

Malays Orthop J, 2019 Jul;13(2):42-44.
PMID: 31467651 DOI: 10.5704/MOJ.1907.008

Osteopetrosis (OP) is a rare hereditary sclerosing bone dysplasia characterised by generalised hard and brittle bone secondary to defective osteoclastic function. Osteopetrotic bone is brittle, thus these subjects are prone to frequent fractures, particularly of the long bones. Due to defective osteoclastic function, remodeling is also defective in OP. This report is a case of humeral fracture in a 9 years old girl who was followed seven years. The fracture had remodeled totally similar to healthy bone at the final follow-up. Conservative treatment should be kept in mind in the management of fractures in children with OP, and fractures within acceptable angulations and/or translations should be treated conservatively without hesitation.

Matched MeSH terms: Humeral Fractures
Fulltext Olecranon Osteotomy Approach for Complex AO-13C Fractures of Distal Humerus: A Prospective Analysis of 24 Cases

Singh R, Singh H, Kanodia N

Malays Orthop J, 2019 Mar;13(1):30-35.
PMID: 31001381 DOI: 10.5704/MOJ.1903.005

Introduction: Olecranon osteotomy is well described approach for complex intra-articular distal humeral fractures. In this study, we investigated the usefulness and complications of olecranon osteotomy approach for such fractures. We hypothesise that outcome is comparable in young adults and middle age group and also functional outcome is independent of fracture subtype following surgical fixation. Materials and Methods: Between December 2012 and September 2015, twenty-four adult patients (male: 15, female: 9) having mean age of 41.4 years with closed intra-articular fracture (AO-13C) were surgically managed using olecranon osteotomy approach and were followed-up for a mean of 28.5 months (range: 22-35 months). Functional outcome was measured using Mayo Elbow Performance Score (MEPS) and complications were observed. Statistical analysis was done using Student t-test and Kruskal Wallis test. Results: All fractures united by the end of three months. Mean elbow flexion achieved was 123°, mean extension lag was 9° and mean active arc of motion was 114°. Mean MEPS was 87 (excellent: 8, good: 14, fair: 1 and poor: 1). Post-operative transient ulnar nerve palsy was noted in two cases, heterotopic ossification (HO) was in one case, infection in two cases, implant prominence in five and elbow stiffness in three cases. Motion arc was higher in young adults and MEPS was comparable in both age group. Functional outcome was also dependent on fracture subtype. Conclusion: The olecranon osteotomy approach for distal humerus fractures had good functional outcome with fewer complications. Joint congruity and fixation could easily be assessed intraoperatively.

Matched MeSH terms: Humeral Fractures
Fulltext The Role of Nerve Exploration in Supracondylar Humerus Fracture in Children with Nerve Injury

Anuar R, Gooi SG, Zulkiflee O

Malays Orthop J, 2015 Nov;9(3):71-74.
PMID: 28611917 MyJurnal DOI: 10.5704/MOJ.1511.019

The supracondylar humerus fracture (SCHF) in children is common and can be complicated with nerve injury either primarily immediate post-trauma or secondarily posttreatment. The concept of neurapraxic nerve injury makes most surgeons choose to 'watch and see' the nerve recovery before deciding second surgery if the nerve does not recover. We report three cases of nerve injury in SCHF, all of which underwent nerve exploration for different reasons. Early reduction in the Casualty is important to release the nerve tension before transferring the patient to the operation room. If close reduction fails, we proceed to explore the nerve together with open reduction of the fracture. In iatrogenic nerve injury, we recommend nerve exploration to determine the surgical procedure that is causing the injury. Primary nerve exploration will allow early assessment of the injured nerve and minimize subsequent surgery.

Matched MeSH terms: Humeral Fractures
Fulltext Intra-articular Entrapment of Medial Epicondyle Fracture Fragment in Elbow Joint Dislocation Causing Ulnar Neuropraxia: A Case Report

Syed J, Zamri AR, Jamaluddin S, Ruben JK, Gopindran M

Malays Orthop J, 2017 Mar;11(1):82-84.
PMID: 28435584 MyJurnal DOI: 10.5704/MOJ.1703.016

Traumatic elbow dislocations in children are rare but most of them are complex dislocations, and in such dislocations, medial humerus epicondyle fractureis the most common associated injury. Fracture incarceration in the elbow joint occurs in 5-18% of medial humerus epicondyle fractures but ulnar neuropraxia is very rare. Open reduction internal fixation is indicated in medial humerus epicondyle fracture with fracture incarceration, ulnar neuropraxia, marked instability or open fracture. Operative treatment options include fragment excision and sutures, closed or open reduction and Kirschner wire fixation, open reduction and suture fixation, open reduction and smooth pin fixation, and open reduction and screw fixation. However, ulnar nerve transposition is debatable as good outcome had been reported with and without nerve transposition. We report a case of a 13-year old boy, who presented with right elbow dislocation and intra-articular entrapment of medial humerus epicondyle fracture fragment, complicated with sensory ulnar neuropraxia, following a fall onto his right outstretched hand in a motor vehicle accident. The elbow joint was reduced using close manipulative reduction but the fracture fragment remained entrapped post-reduction. The patient then underwent open reduction and screw fixation of the medial humerus epicondyle fracture without ulnar nerve transposition. He had good functional outcome six weeks after surgical intervention, with complete recovery of ulnar neuropraxia six months later. Currently, he is doing well at school and is active with his sporting activity.

Matched MeSH terms: Humeral Fractures
Fulltext Humeral Supracondylar Fractures in Children: A Novel Technique of Lateral External Fixation and Kirschner Wiring

Kow RY, Zamri AR, Ruben JK, Jamaluddin S, Mohd-Nazir MT

Malays Orthop J, 2016 Jul;10(2):41-46.
PMID: 28435560 MyJurnal DOI: 10.5704/MOJ.1607.008

Introduction: Supracondylar fracture of the humerus is the most common fracture around the elbow in children. Pinning with Kirschner wires (K-wires) after open or closed reduction is generally accepted as the primary treatment modality. However, it comes with the risk of persistent instability and if the K-wire is not inserted properly, it may cause displacement and varus deformity. We present our two-year experience with a new technique of lateral external fixation and K-wiring of the humeral supracondylar fracture. Materials and Methods: A total of seven children with irreducible Gartland Type III supracondylar humeral fracture were treated with closed reduction and lateral external fixation and lateral Kirschner wiring. Patients with ipsilateral radial or ulnar fracture, open fracture and presence of neurovascular impairment pre-operatively were excluded. All the patients were followed up at one, three and six weeks and three and six months. The final outcomes were assessed based on Flynn's criteria. Results: All the patients achieved satisfactory outcomes in terms of cosmetic and functional aspects. All patients except one (85.5%) regained excellent and good cosmetic and functional status. One patient (14.3%) sustained pin site infection which resolved with oral antibiotic (Checketts- Otterburn grade 2). There was no neurological deficit involving the ulnar nerve and radial nerve. Conclusion: The introduction of lateral external fixation and lateral percutaneous pinning provide a promising alternative method for the treatment of humeral supracondylar fracture. This study demonstrates that it has satisfactory cosmetic and functional outcomes with no increased risk of complications compared to percutaneous pinning.

Matched MeSH terms: Humeral Fractures
Fulltext A Limb-Threatening Long Arterial Dissection Caused by Humerus Neck Fracture: A Case Report

Kurnaz R, Ikizler M, Ozbayburtlu M, Gunes T

Malays Orthop J, 2018 Mar;12(1):51-53.
PMID: 29725515 DOI: 10.5704/MOJ.1803.012

Proximal humerus fracture is a common arm trauma and rarely occurs with vascular injury which however is a serious complication. In this case report, we present a long segment dissection of the axillary and brachial arteries as a rare complication due to fragmented proximal humerus fracture and shoulder dislocation. An 80-year old female patient was seen at the emergency department. Radiograph examination has revealed a fragmented proximal humerus fracture besides dislocation of the head of humerus towards the axillary area. On vascular examination, acute arterial occlusion such as absence of radial and ulnar pulses were observed in her left hand. The patient was immediately taken to the operating room. The dissection included the entire segment approximately 20cm between the distal subclavian artery and the distal brachial artery. This injured segment was removed and a 6mm Polytetrafluroethylene (PTFE) graft with rings was interpositoned between subclavian and brachial arteries. This case is a rarity because of such a significant complication after a small injury. Axillary artery injuries caused by humeral neck fractures are rare but should not be missed by the physician.

Matched MeSH terms: Humeral Fractures

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