Abstract: Objective: To explore the application of the clinical nursing pathway (CNP) in the operation of pediatric supracondylarhumerusfractures. Methods: 92 children with supracondylarhumerusfractures who underwent internal fixation in our hospital were randomly divided into group A (N=46) and group B (N=46). The visual analogue scale (VAS) and modified objective pain score (MOPS) were used to assess the children’s pain before and after nurs- ing. The Mayo elbow function score was used to evaluate the recovery of elbow function in children. The incidences of complications, treatment compliance, and nursing satisfaction were observed during treatment. Results: The VAS and MOPS scores of group A and group B were lower than they were before nursing (P<0.001). The scores of VAS and MOPS in group A were lower than those in group B after nursing (P<0.01). The stability of the elbow joints, pain, daily activities, motor function scores and Mayo scores in group A and group B were higher than those before nursing and group A showed higher scores than group B (P<0.001). The incidence of complications in group A was lower than it was in group B (P<0.01). The scores of group A in compliance with medical drugs, a reasonable diet, combined exercise, and regular follow-up were much higher than those in group B (P<0.001). A higher satisfaction was recorded in group A than in group B (P<0.05). Conclusion: CNP intervention can alleviate the pain of pediatric supracondylarhumerusfractures, promote the rehabilitation of elbow joint function, reduce the incidence of post- operative complications, and improve treatment compliance and nursing satisfaction.
Abstract: Objective: A meta-analysis was conducted to compare the effectiveness and safety of open or closed reduction and percutaneous pinning for pediatric displaced supracondylarhumerusfractures. Methods: Embase, Medline and Cochrane Library were searched to identify the relevant studies published from the year of 1992 to 2015. All the controlled clinical trials and random controlled trails published to compare the open and closed reduction and percutaneous pinning (CRPP, ORPP) for pediatric displaced supracondylarhumerusfractures were enrolled in the study. The study included randomized controlled trials (RCTs) and controlled clinical trial (CCT) to compare the effectiveness and safety of CRPP and ORPP for pediatric displaced supracondylarhumerusfractures. Two investigators independently searched articles, extracted data, and assessed the quality of included studies. Cochrane RevMan software version 5.3 was utilized to perform the meta-analysis. Meta-analysis was performed using random-effect model. Results: 1 RCTs and 6 CCTs involving a total number of 502 patients were enrolled in the study, while 273 subjects adopted CRPP and 229 cases adopted ORPP. No significant differences were detected for the results of carrying angel, Bauman angel and complication rate [MD=-1.62, 95% CI (-3.35, 0.10), P=0.07, I 2 =0%; MD=-1.17, (-5.50, 3.15), P=0.6, I 2 =87%; OR=1.23, 95% CI (0.67, 2.28), P=0.5, I 2 =31%]. Less mean hospital
Supracondylar fracture of the distal humerus is a common fracture in the pediatric population, accounting for approxi- mately 60% of all fractures of the elbow . Since1948, Swenson firstly described two K-wires of different sizes for closed reduction of supracondylarhumerusfractures . The classical treatment of displaced supracondylar humeral fractures is closed reduction and percutaneous fixation of Kirschner wires (K-wires). Previous studies have shown that medial and lateral crossed-pin fixation provided more sta- bility in biomechanical analysis than two lateral pin fixation . However, crossed K-wire placement is associated with the risk of iatrogenic ulnar nerve injury up to 3 to 4%. Lee et al.  reported that three lateral divergent or parallel pin fixations were effective and safe in avoiding iatrogenic ulnar nerve injury in supracondylar humeral fractures. In Bogdan et al.’ s  study, the humero-ulnar external fixation is a good alternative to lateral or crossed pinning in supracon- dylar humeral fractures. The optional K-wire configuration could provide the adequate stability of fracture without the risk of neurovascular injury.
distal fragment and avoid post-operative complications, especially iatrogenic nerve injuries and malunion due to loss of reduction with poor cosmetic and functional outcome. The most debated subject is the optimal pin configurations to hold the reduced fracture. Various pin configurations have been recommended for the treatment of displaced supracondylarhumerusfractures on the basis of choice between the stability versus the risk of iatrogenic ulnar nerve injury. 7-10
Abstract: Objective: Closed reduction and percutaneous fixation is known as the optional treatment for displaced supracondylarhumerusfractures. The retrospective study is to compare external fixator versus K-wires to evaluate the clinical and radiological results for displaced supracondylarhumerusfractures. Methods: Among all of 40 pa- tients, there were 16 girls and 24 boys with the mean age of 7.26 years (range from 4 to 13 years). Closed reduction followed by percutaneous fixation of external fixator or K-wires were performed in our department. Medical records were reviewed to obtain demographic information as well as preoperative and postoperative clinical and radiologi- cal data regarding fracture type, displacement of fracture, neurovascular status, range of motion and infections. The Flynn’s criteria et al. was used to evaluate the clinical outcomes. Results: There was no significant different in age, gender, affected sides, the type and displacement of fracture and nerve palsy between two group (P>0.05). According to the Flynn’s criteria et al., two groups showed the similar to clinical outcome (P>0.05). Two (13.3%) children presented skin infection around screws, while five (20%) patients presented skin infection in K-wires, in which four (80%) patients develop the migration of K-wires. There was significant different in skin infection between two groups. Three (12%) patients presented ulnar nerve palsy in K-wires, while one (6.7%) patient presented radial nerve palsy in external fixator. Conclusion: The percutaneous K-wires or external fixator fixation following closed reduction is an effective method in the treatment of displaced supracondylarfractures of humerus. K-wires have the risk of ulnar nerve palsy and skin infection or the migration of wires. External fixator could facilitate to reduce the fracture by the direct manipulation of external fixing frame and provide the stabilization of fracture without the neurological risk to ulnar nerve.
fractures. These have extension in the sagittal plane and rotation in the frontal and/or transverse planes. Closed reduction and percutaneous pinning (CRPP) using intra-operative fluoroscopy is the preferred treatment strategy. In our set-up as C-arm imaging was not available in emergency operation theatre we operated all the cases included in our study group by open reduction percutaneous pinning (ORPP). This protocol not only avoided delayed treatment in busy main
upracondylar fractures of the humerus are the most common elbow injuries in children and make up approximately 60% of all elbow injuries in the first decade of life  . These injuries can be one of the most difficult to treat, owing to the presence of associated immediate and late complications like compartment syndrome, neurovascular damage, Volkman’s ischaemic contracture and malunion [2-4] . These injuries are broadly classified as extension and flexion type with the former being more common  . Extension injuries are further sub classified as undisplaced fractures (Type I), partially displaced fractures with intact posterior hinge (Type II) and completely displaced fractures (Type III). It was Wilkins  , who further classified Type III fractures on the basis of coronal displacement as Gartland IIIA- posteromedial and IIIB – posterolateral type respectively.
Immediate complications like compartment syndrome are rare and long-term complications are decreased. Chance of infection and implant failure are minimum with this method of treatment. Basic aim in supracondylarhumerusfractures is to gain full range of motion of elbow and to obtain a normal appearance of elbow. This modality of treatment is associated with excellent functional outcomes by achieving a full range of motion at the elbow joint in majority of cases and no residual deformity due to malunion. Another advantage is that the removal of implant is an outdoor procedure.
Supracondylar fracture of humerus is the most common fracture of elbow in children, and one of the most difficult fractures to treat. While some authors have relied on remodelling capability of distal humerus to compensate for inadequate reduction, most authors agree that accurate reduction with minimum soft tissue trauma is required to achieve the best possible functional results. Many different methods have been suggested for management of supracondylarhumerusfractures. A cast requires the elbow to be kept in acute flexion to maintain reduction. However, this increases the risk of ischemia and its irrevocable sequelae. Treatment by traction may give good cosmetic results but at the expense of function, requires prolonged stay in hospital and constant surveillance by frequent radiographs. Simple closed manipulation has been considered to be adequate in minimally displaced fractures, but with varying displacement, the results may be both cosmetically and functionally unacceptable. Open reduction of supracondylarhumerusfractures has been believed to cause severe stiffness, infection and myositis ossificans, mainly after lateral or posterior approach. Closed percutaneous K-wiring of these fractures has many advocates, but it is difficult in severe swelling and there occurs a probability of pin track infection and injury to nerve, mainly to the ulnar nerve with a placement of medial pin ulnar nerve gets injured.
Abstract: Humerusfractures are infrequent in children, except for supracondylarhumerusfractures. Historically, most of the humerusfractures in children and adolescents have been treated non-operatively based on the tremen- dous remodeling potential of the proximal humeral physis and the great arc of shoulder motion. However, in older patients, less-than-anatomic reduction may lead to prolonged pain and restricted shoulder mobility and expose the gleno-humeral joint and rotator cuff to higher stress with unknown long-term effects. Elastic stable intramedullary nailing (ESIN) had encountered slower acceptance as a standard of treatment for humeral fractures than for any other long bone in pediatric patients. A retrospective analysis of 32 patients aged 5.5-17.8 years who were treated with ESIN for humeral fractures was performed. The most common cause of injury was fall, followed by traffic acci- dents. There were 16 proximal, 12 shaft and 4 distal humeral fractures. Twenty-five patients had isolated fractures, while 7 had polytrauma. Most of the patients underwent surgery within 24 hours after injury. Closed reduction of the fracture was achieved in 23 patients. The nails were inserted in a retrograde direction in 28 patients (22 from the lateral and medial sides, 6 only from the lateral side) and in an anterograde direction in 4. The mean duration of surgery was 83.13 min. No major complications were observed. All fractures healed without delayed unions or non-unions. Nail protrusion was encountered in 3 patients, skin irritation in 1 and difficult extraction in 2 patients. The average duration of follow up was 1.2 years. ESIN is a reliable method of treatment for displaced humeral frac- tures in children and adolescents. Once the patient is under general anesthesia and in the operating theatre for the reduction of humeral fracture, stabilization with ESIN is a better option than any type of plaster immobilization.
Background: Management of Gartland type III supracondylarhumerusfractures is conducted by open and closed repositioning. An adequate repo- sition and a stable and accurate fixation are des- perately needed to prevent fixation failure, defor- mity, and complication. The study aims to com- pare the clinical and radiological result between crossed and lateral fixation techniques.
34. Cuomo F, Flatow EL, Maday MG, Miller SR, McIlveen SJ, Bigliani LU. Open reduction and internal fixation of two- and threepart displaced surgical neck fractures of the proximal humerus. J Shoulder Elbow Surg, 1992; 1: 287–95.
Supracondylar fracture of humerus is the most common fracture in the children and needs proper management. This fracture is common in the first decade of life (1) due to various causes mainly ligament laxity and anatomical structure of humerus tube(shaft) to flat transformation at lower end of humerus. Its incidence decreases with age (2) . Its incidence is about 75% of fractures around elbow in children. Boys have a higher incidence than the girls. Common in left side or non dominant side.
Fracture of the trochlea is usually associated with elbow dislocation and capitellar or medial condylar fracture . Isolated fracture of the humeral trochlea is very rare. This is explained by its position deep within the trochlear notch cavity and the absence of any muscular or ligamentous at- tachments at this level, which protects it against direct and indirect trauma . Furthermore, the ulno-humeral joint is subjected to very light compressive and shear forces compared to those experienced by the radio- humeral joint, which explains the high frequency of capitellar fractures compared to trochlear fractures .
Other than conservative treatment, transosseous suture fixation techniques are well defined in the orthopaedic literature. Park et al. reported 78% excellent results in patients with two-part and three-part proximal humeral fractures treated with suture fixation. The use of strong nonabsorbable suture provides the advantage of incorporating the rotator cuff insertion to increase fixation in patients with poor bone quality. Percutaneous pinning has the advantage of avoiding further damage to the soft tissue envelope and the blood supply to the humeral head. It also is a relatively inexpensive technique, and several series have reported good results in two-part, three-part, and valgus- impacted four-part fractures. The procedure is technically challenging and requires a satisfactory closed reduction, adequate bone stock, minimal comminution (particularly of the tuberosities), an intact medial calcar, and a compliant patient. In their series of 74 older patients (average age, 71 years), Calvo et al. demonstrated that reduction was associated with outcome. If satisfactory closed reduction cannot be obtained, another form of reduction and fixation should be used. Loss of fixation, pin track infections, and axillary nerve injuries are common complications. Terminally threaded Schanz pins and bicortical pins inserted from the greater tuberosity to the medial humeral shaft add stability to the overall construct. Percutaneous pinning is contraindicated for fractures with metaphyseal comminution.
Kuntcsher introduced the concept of elastic intramedullary nailing based on the principle of elastic impingement (i.e. radial compliance). The nail, which has a slot, could be compressed while insertion. The nail will expand and occupy the entire medullary canal, once the insertion is complete. This was used in fixation of femur, tibia and the humerus. Even though his concept was successful in treatment of the fractures of the lower limb, it was found not to be effective in treating the humeral diaphyseal fractures.
3 patients sustained head injuries for which a CT scan of the brain was done. The initial assessment included a neu- rological assessment, pupil size and the Glasgow Coma Scale (GCS). A clinical and radiological assessment of the neck was done to look for cervical spine injuries. None of these patients had intracranial bleeds or haematomas that needed intervention by the neurosurgeons. All of these patients were diagnosed to have cerebral concussion and had supplemental oxygen till the post operative period. Surgical fixation of the fractures was done once they were neurologically stable with a GCS of 15. 2 head injured patients had contralateral tibia & femur fractures respec- tively. (Table 4) There was a mean delay in surgical man- agement of the floating knee due to head injury of 2 days (Range 1–3 days). There was no delay in rehabilitation due to the head injury and all the three patients had an excellent final outcome when assessed using the Karl- strom criteria. (Table 4) None of the patients in the study sustained neck injuries.
In the modern world with the increase in speed and number of fast moving vehicles there is great increase in number and severity of fractures. Fractures may be associated with multiple system injuries and polytrauma. When a bone is fractured, it loses its structural continuity. The loss of the structural continuity renders it mechanically useless because it is unable to bear any load. The goal of fracture treatment is to obtain union of the fracture in the most compatible anatomical position which allows maximal functional restoration of the extremity. Long term disability following a fracture is almost never the result of damage to the bone itself; it is the result of the soft tissues and of stiffness of neighboring joints, Locking plates are fracture fixation devices with threaded screw holes, which allow screws to angle device. These mixture of holes that allow placement of
One patient suffered another fall two months after nailing and sustained a fracture of the shaft of the femur around the proximal end of the nail. This was treated by exchange nailing using a longer supracondylar nail. Both fractures healed in a satisfactory alignment in 18 weeks time. In one patient, distal locking screws became loose and had to be removed but this did not affect the final out- come as the fracture had already healed (Fig. 2). One patient continued to complain of pain and inability to fully straighten the knee joint. Due to persistent symptoms, the