To investigate the clinical efficacy of closed-reset lateral percutaneous internal fixation with a gristle pin in the treatment of Gartland III supracondylar humerus fractures in children. METHODS: A total of 22 cases of Gartlandl type III supracondylar humerus fractures in children were admitted from 2009-05 to 2012-01, and all of them were treated with closed-replacement lateral percutaneous internal fixation with a distal humeral pin. RESULTS: The follow-up time was 6 months to 3 years, with a mean of 1 year and 6 months. According to the Flynn elbow score, 18 cases were excellent, 3 cases were good, and 1 case was moderate. The excellent rate was 95%. There was no postoperative nerve injury, one case of needle tract infection, and one case of elbow inversion deformity. CONCLUSION: Closed reduction lateral percutaneous internal fixation with a gristle pin is an effective method for treating Gartland type III supracondylar humerus fractures in children with minimal trauma, rapid recovery, and good prognosis.
Supracondylar humerus fracture is the most common elbow fracture in children, accounting for 5O-60% of all elbow fractures. The typing is generally divided into extension type and flexion type. Gartland I fractures can be treated by external fixation in a neutral position with a plaster rest for 2-4 weeks; Gartland II fractures that are stable after reduction can be treated as Gartland I fractures, while Gartland II fractures that are unstable after reduction and type III fractures can be treated with percutaneous internal fixation with a gristle pin.
From 2009-05 to 2012-01, 42 cases of Gartland type III supracondylar humerus fractures were treated in our department. 12 of them were treated with incisional internal fixation because of the difficulty in obtaining the ideal position during closed reduction or the inability to maintain the ideal position after reaching it; 30 cases were treated with closed reduction by percutaneous internal fixation with a percutaneous Clinique needle, among which 8 cases were treated with medial and lateral crossed pins and 22 cases All 30 cases were treated with closed-replacement percutaneous internal fixation, of which 8 cases were treated with medial and lateral cross-puncture and 22 cases were treated with simple lateral puncture. The 22 cases treated with closed repositioned lateral percutaneous internal fixation with a needle are summarized and analyzed as follows.
1. Data and methods
1.1 General information
There were 22 cases in this group, 17 males and 5 females. There were 13 cases on the left side and 9 cases on the right side. The age was 4-14 years old. The fracture displacement was type III according to Gartland’s classification, 2 cases combined with radial nerve injury, no vascular combined injury. Injury mechanism: 16 cases were injured during play, 2 cases were injured from a height (0.5m-2m), 2 cases were injured by bicycle, 1 case was injured during ice skating, and 1 case was injured while playing skateboard. Time from injury to consultation: 30 minutes to 7 days.
1.2 Treatment method
The surgery was performed under brachial plexus block anesthesia, with additional basic anesthesia for younger children. The child’s entire body is covered with a lead suit. All operators wear a lead suit. The towel is disinfected and laid out according to routine surgery. An assistant holds the proximal humerus of the affected limb, and another assistant holds the distal forearm with mild elbow flexion (40° to 5O°), and continuous longitudinal traction is performed. After the lateral (ulnar or radial) displacement is corrected and the line of force in the coronal plane is restored, the proximal end is fixed under traction, the forearm is rotated forward or backward, and the distal rotational deformity is corrected. When the lateral displacement and rotational deformity are corrected, the elbow is gradually flexed while traction is applied, and the operator pulls the proximal end backward with both hands and pushes the distal end forward with both thumbs simultaneously to correct the posterior displacement and maintain the stability after the revision by flexing the elbow 120°.
The assistant maintains extreme elbow flexion and forearm rotation anteriorly or posteriorly, and under C-arm x-ray fluoroscopy the first kerf pin is inserted percutaneously from the humeral epicondyle with an electric drill, oriented obliquely toward the proximal contralateral cortex. Then, the second and third Kirschner pins were inserted sequentially at the humeral epicondyle. After satisfactory repositioning and good fixation position of the Kirschner pin was determined under C-arm x-ray machine fluoroscopy, the Kirschner pin was bent and cut outside the skin, bent and disposed of with a gauze pad, and fixed in a 70° to 80° cast with the elbow flexed. All cases were fixed with three lateral Kirschner pins. The cast was fixed for 3 weeks, and the cast was removed for functional exercise after 3 weeks, and the time of removing the Kirschner pins was decided at 4 weeks on the basis of fracture healing on film. Generally, it was 4-6 weeks after surgery.
2. Results
All 22 cases in this group were followed up for 6 months to 3 years, with an average of 1 year and 6 months. Referring to the Flynn elbow score, excellent: reduction in carry angle <5°, reduction in mobility <5°; good: 6 cases, reduction in carry angle 5-10°, reduction in mobility 5-10°; moderate: reduction in carry angle 10-15°, reduction in mobility 1O-15°. Poor: reduction in lifting angle >15°, reduction in mobility >15°. There were 18 cases of excellent, 3 cases of good, 1 case of moderate, and 0 cases of poor, with an excellent rate of 95%. 1 case had a needle tract infection, which was controlled by drug exchange. 1 case had an inversion deformity of the elbow, with an inversion angle of 5-10°. The 2 cases with radial nerve symptoms before surgery were completely recovered at different times after surgery. There was no postoperative manifestation of nerve injury in 1 case, and there was no occurrence of ischemic muscle contracture and ossifying myositis.
3. Discussion
Children are active by nature, and the balance and stability of the body are poor, so they are prone to accidental falls, collisions, and wrestling, etc. At the same time, children themselves are not fully developed and have soft bones, plus they do not know how to take certain protective actions and postures when accidents occur, so they are prone to fractures [1]. Supracondylar humerus fractures are common in children, accounting for 50%- 60% of all elbow fractures, and Gartland type I fractures can be treated as non-displaced fractures with external fixation in a plaster brace in a neutral position with the forearm flexed for 2-4 weeks, and mildly displaced and stable fractures after repositioning. For some type II and type III fractures, various approaches were used to perform incisional internal fixation, which is very traumatic, bleeding and has many postoperative complications. Conservative treatment of type III fractures is prone to loss of reduction and has a higher incidence of elbow inversion after treatment.
Closed reduction percutaneous internal fixation for Gartland type III supracondylar humerus fracture in children is a minimally invasive treatment method with the advantages of less trauma, shorter hospital stay, faster postoperative recovery and satisfactory functional recovery. It is currently the preferred method for treating Gartland type III supracondylar humerus fractures in children.
Timing of treatment: Treatment is completed as much as possible before the swelling increases, and 3 days after the injury is the gradual increase of swelling. Those admitted to the hospital within 24 hours after injury should be treated as an emergency. If the injury is more than 24 hours post-injury, the affected limb should be temporarily fixed in a plaster cast, elevated, and the swelling reduced as soon as possible with intravenous anti-swelling drugs. In about 5 days after the injury, closed repositioning percutaneous needle treatment is more appropriate. Before repositioning, X-ray films should be read carefully to determine the direction of fracture displacement, and lateral displacement should be corrected first, and then rotation and anterior-posterior displacement should be corrected under traction.
The strength of the technique should be appropriate, too little is not enough to reset, too much is easy to overcorrect. The distal humerus has brachial artery and vein, median nerve, anterolateral radial nerve, and posterior medial ulnar nerve, so once the fracture is done, it is easy to damage the above important structures. If they are not normal, surgical exploration and open reduction should be performed. Since the fracture end is adjacent to the nerve and blood vessels, the repositioning and fixation process may damage them, so the blood vessels and nerves should be checked again after repositioning [2].
Selection of indications: for internal fixation with only external penetration of the needle, we select cases in which the fracture line is transverse or the fracture line is high external and low internal. In such cases, the fracture end is stable intraoperatively and postoperatively by performing only external needle penetration. In cases where the fracture line is low on the outside and high on the inside, a medial and lateral cross-piercing is required to achieve intraoperative and postoperative stability.
Requirements for needle penetration: The needle should be inserted at the humeral epicondyle, and the three needles should be separated in a fan shape, and all should pass through the contralateral cortex at the same time. This way the fixation is stable and there is no postoperative loss of fixation angle. zenios et al. treated 21 children with Gartland type III supracondylar humerus fractures and investigated whether the stability of postoperative rotation could be determined intraoperatively and the incidence of rotational instability after lateral pin insertion. rotational stability was obtained in 10 children with lateral 3 kerf pins fixation. larson et al[4] studied fracture model of medial column fragmentation found that for torsional loading, there was no significant difference between 3 medial and lateral cross-pins and 3 lateral pins.Bloom et al. found by biomechanical experiments that the stability of 3 kerf pins was better than 2 kerf pins in the non-anatomic reduction case and that the stability obtained with 3 kerf pins was similar to that in the anatomic reduction case.Skaggs et al[6] reported 124 cases of supracondylar humerus The results of the treatment of children with supracondylar fractures with solely lateral pins: 38% of type II fractures and 65% of type III fractures were fixed with 3 lateral pins, and 8 cases of loss of reposition occurred in those fixed with 2 pins, while none of those fixed with 3 lateral pins had any change in position.
Prevention of complications: 22 children in this group had one postoperative pin tract infection and one case of elbow inversion deformity. There were no cases of nerve injury. Two cases of ulnar nerve injury occurred in previous cases with medial-lateral cross-piercing, and the medial keratoplasty needle was removed immediately after discovery, and ulnar nerve function gradually returned to normal at postoperative follow-up. skaggs et al. concluded that purely lateral parallel or separate piercing of the needle was sufficiently stable and could avoid ulnar nerve injury. A study by Chao Feng et al. confirmed that there was no intrinsic stability difference between purely lateral penetration of the needle and medial and lateral crossed penetration of the needle. Therefore, we believe that purely lateral fixation can achieve good fixation in suitable cases and can avoid postoperative manifestations of nerve injury. There is a risk of infection because the tail of the Kirschner needle is left outside the skin after surgery.
One case of needle tract infection occurred in this group, and the infection was controlled by changing the medication. One case of elbow entropion deformity may be due to the wrong intraoperative Kirschner pin fixation and postoperative re-displacement of the broken end of the fracture. Therefore, it is important to assess the stability after intraoperative pin fixation. First, the distal fracture end was checked for displacement in the extended elbow position, and if there was no displacement, mild rotation and inversion stresses were applied, and the stability of the repositioning was observed under fluoroscopy. Otherwise, if there is a change in position, the position of the piercing pin needs to be adjusted and the stability rechecked [8]. Since it is not a strong internal fixation, it is important to achieve reliable and effective plaster fixation.
In children with supracondylar humerus fractures, closed reduction should not be pursued, but should be individualized according to the specific situation. In cases with severe swelling and difficulty in closed reduction, trial repositioning under the C-arm should be chosen for incisional internal fixation in cases where the ideal position is difficult to achieve or cannot be maintained after achieving the ideal position. Repeated repositioning is extremely damaging to the surrounding soft tissues. The goal of treatment is to achieve good alignment of the fracture break with as little trauma as possible.
Although the Gartland type III supracondylar humerus fracture in children is a serious injury with many complications of improper treatment, the vast majority of children can be treated with closed reduction percutaneous internal fixation with a gristle. If properly indicated and performed, closed reduction lateral percutaneous internal gristle fixation is a safe and effective method of treating Gartland type III supracondylar humerus fractures in children.