France and Strong  compared the various modalities of treatment of these fractures and found closedreduction and percutaneouspinning to be superior. Cheng et al  and Topping et al  compared lateral and cross k- wiring and found equivalent excellent results in both groups. The results of our study indicate that the majority of widely displacedsupracondylarfractures of the humerus even with a delay in presentation of up to 6 days can be safely treated with our technique of closedreduction and percutaneouspinning with excellent clinical results. In our series, closedreduction and percutaneouspinning was possible in all our patients. The rate of conversion to open reduction in delayed presentations of these fractures has been reported in literature as ranging from less than 10% up to 36% [4, 13]. Archibeck et al  reported entrapment of brachialis muscle as a cause in 90% of irreducible supracondylarfractures. We did not encounter any such problems in our series.
Fracture of Supracondylar humerus is a very common injury in children. Complications associated with this fracture warrant appropriate and optimum management of this injury. Closedreduction and percutaneouspinning with medial and lateral cross K-wires offers an excellent method to reduce and fix these fractures accurately. Some biomechanical studies advocate cross pinning technique as a more stable biomechan- ical construct. Increased time from presentation to surgery is not associated with increased morbidity from the injury or treatment complications. Early mobilization is an advantage with this treatment. The use of a medial entry pin for the treatment of paediatricsupracondylar humerus fractures is safe as far as iatrogenic ulnar nerve injury and vascular complications are concerned, if an adequate technique is followed. None of the patients had any vascular compromise.
Background Supracondylarhumeralfractures are one of the most common skeletal injuries in children. In cases of displacement and instability, the standard procedure is early closedreduction and percutaneous Kirschner wire fixation. However, between 10 and 20 % of patients pres- ent late. According to the literature, patients with neglected fractures are those patients who presented for treatment after 14 days of injury. The delay is either due to lack of medical facilities or social and financial constraints. The neglected cases are often closed injuries with no vascular compromise. However, the elbow may still be tense and swollen with abrasions or crusts. In neglected cases, especially after early appearance of callus, there is no place for closedreduction and percutaneouspinning. Tradition- ally, distal humeralfractures have been managed with surgical approaches that disrupt the extensor mechanism with less satisfactory functional outcome due to triceps weakness and elbow stiffness. The aim of this study is to evaluate the outcome of delayed open reduction using the triceps-sparing approach and Kirschner wire fixation for treatment of neglected, displacedsupracondylar and distal humeralfractures in children.
This is to certify that this dissertation titled “OUTCOME ANALYSIS OF CROSS PINNING VERSUS LATERAL PINNING IN SUPRACONDYLARFRACTURES OF HUMERUS IN CHILDREN” is a bonafide record of work done by Dr.R.SENTHIL KUMAR, during the period of his Post graduate study from May 2012 to November 2013 under guidance and supervision in the Institute of Orthopaedics and Traumatology, Madras Medical College and Rajiv Gandhi Government General Hospital, Chennai-600003, in partial fulfillment of the requirement for M.S.ORTHOPAEDIC SURGERY degree Examination of The Tamilnadu Dr. M.G.R. Medical University to be held in April 2014.
study, the shoulder function scores were similar among the surgical groups and the conservative groups, and the VAS scores and forward elevation were only better in the surgical groups in the management of 2-part and 3-part fractures at 6-month follow-up. However, the shoulder external rotation remained significantly lesser in the conservative group for 2-part and 3-part fractures. The pain might partially compromise the range of motion, especially the forward elevation. Moreover, the external rotation mainly depends on infraspinatus and teres minor, which are attached to the greater tuberosity of humerus. 26,27 Displacedfractures were
The treatment of femoral neck fractures by percutaneous pinning Med J Malaysia Vol 45 No 4 December 1990 The treatment of femoral neck fractures by percutaneous pinning M N Manukaran, MD, MS(Orth) Dep[.]
All patients received general anesthesia. First, under the guide of the C-arm image intensifier, a leverage K-wire with a 2.0 mm diameter was percutaneously inserted into the bone fragment from the displacement direction of the fractured radial neck fragment. Reduction of the fracture was achieved by leveraging the K-wire and through man- ual reduction. Then reduction was confirmed with an image intensifier (Fig. 1a, b, c). If the reduction failed, the proximal fracture portion moved dorsally and ventrally after several manipulations, one additional maneuver followed. Keeping the injured elbow flexion and neutral position, we let the assistant or surgeon himself with their thumb and index or middle finger to clamp toughly the anterior and posterior of the space between the distal frac- ture and capitellum to prevent movement in the proximal fracture portion (Fig. 1d and Fig. 2). Then, leverage was
The extensile lateral approach used was similar to the previously referenced technique . For closed reduc- tion percutaneous fixation, the patient was positioned in the prone position. After surgical draping, a localization K-wire on the skin was positioned perpendicular to the subtalar joint on the lateral view. Two K-wires were sep- arately placed to penetrate perpendicularly to the calca- neus axis in the talus neck and into the calcaneus tuberosity. In some more comminuted cases (such as Sanders type IV), the front traction K-wire should be im- planted in both the tibia and the navicular bone instead of the talus bone. Subsequently, we assembled the trac- tion device on both sides of the calcaneus and gradually initiated traction with the pair of devices simultaneously. The traction was monitored by lateral views to confirm the subtalar joint was distracted. The length of the calca- neus was reduced, and the presence of the subtalar joint gap to elevate the compressed articular surface and lat- eral wall was verified. Then, an axial view of the calca- neus was obtained to permit calcaneus varus and valgus adjustment by retracting the unilateral or bilateral trac- tion device. Additionally, the width was reduced by com- pression on both sides of the calcaneus applied by the assistant’s fists as monitored on the axial view. Next, an
All patients and their parents gave informed consent prior to being included in the study. This retrospective research was approved by our institutional ethics committee and was performed in accordance with the ethical standards of the 1964 Declaration of Helsinki as revised in 2000. Inclusion criteria were: a recent closed, displaced radial neck fracture with an angulation of more than 30° (Judet type III and IV) in children with open growth plates ( \ 16 years). Between 2000 and 2011, 21 children, with ages ranging between 6 and 16 years, with an average of 11 years, were treated in our university hospital. According to Judet classification, there were 15 (73 %) type III, and 6 (27 %) type IV fractures. Twelve (59 %) patients were boys and nine (41 %) were girls. The dominant side was injured in 16 (76 %) patients. Two patients had an associated compound fracture of the ipsilateral olecranon, and one patient had displaced olecranon fracture with a lesion of the lateral collateral ligament (LCL). The two cases with an associated com- pound olecranon fracture were treated conservatively, whereas the case with a displaced olecranon fracture with a lesion of the LCL was surgically treated with closed Kirschner wire-assisted reduction.
Procedure: All cases were initially assessed and admitted in the Accident and Emergency department for Bone and Joint hospital GMC Srinagar. They were provided first aid in the form analgesia, splintage and other resuscitation measures. In case of compound fractures wound wash and wound debridement was done besides starting I/V antibiotics and checking the tetanus immunization status. Compound fractures were classified according to Gustilo and Anderson classification. The patients were subjected to history taking, thorough clinical examination with analysis of preoperative radiographs. The radiographic analysis includes evaluation of standard antero-posterior and lateral views of X- rays of the wrist joint of bilateral upper limbs.
In our study, less invasive surgical techniques for treating displaced intra-articular calcaneus fractures have been undertaken in an attempt to reduce complications and improve recovery when surgery is indicated. These early results reported reduce complication rates and promising clinical and radiographic outcomes in certain fracture patterns and patient populations (4).These recent techniques include limited-incision sinus tarsi ORIF, percutaneous stabilization with pins and /or screws, and minimal invasive plate osteosynthesis .
From January 2001 through March 2002 we prospec- tively enrolled consecutive patients with distal radius fracture at one emergency department in northeastern Scania health district in southern Sweden. The orthope- dic department is the only facility in that health district where closed or open reduction of distal radius fractures is performed and all patients were treated at this facility. The inclusion criteria for the present study were acute fracture of the distal radius treated with closed reduc- tion and cast or with closedreduction and external fixa- tion or percutanoues pin fixation and patient age above 18 years. The exclusion criteria were residence outside the region at the time of fracture according to the national population register, severe medical illness or cognitive disorder precluding participation in the follow- up examination, unwillingness to participate, treatment with open reduction and internal fixation (ORIF), and death within one year from fracture date. The study was approved by the Regional Ethical Review Board and informed consent was obtained from each patient.
As Fernandas(17) and Hung et al.(6)stated that it is impossible to predict which patients who have a good reduction from the surgery’s point of view at the time of surgery will finally have a good outcome. In our study the reason of undergoing osteotomy in addition to closedreduction was existence of post reduction deformities, while patients in traditional CR group no longer had post reduction deformities. Our findings confirmed the views have been stated by previous studies (6, 17).
The nail is driven below the cortical surface of the humeral head to prevent subacromial impingement and ro- tator cuff irritation (Figure 5). Multiple fluoroscopic images of the arm in various positions must be obtained to confirm that the nail is below the horizon of the humeral head and adequately countersunk by a 3.5 mm screw driver.
All the fractures united radiologically with the average union time being 12 weeks ( 9 – 16wks) which is comparable with other studies 2,7,15 . 13 out of 23 patients had operating time less than 2 hours and the remaining more than 2 hours with the minimum being 1 hour and 30 minutes and the maximum being 3 hours, with the average being 2 hours and 15 minutes. Among 13 patients who had operating time less than 2 hours, 11 were under tourniquet control and among 10 patients who had operating time more than 2 hours all were without tourniquet control. The average blood loss was 200ml(range 100-500ml). Ulnar nerve transposition was done in all the cases. Orthogonal plating done in 14(60%), parallel plating in 9(40%). Olecranon osteotomy fixed with K wire and TBW in 15(65.25%) cases, 5(21.75%) cases with cancellous screw and TBW and 3(12%) with cancellous screw alone.
radius metaphyseal fracture. The most important problem in this treatment is to maintain the reduction in a plaster brace; loss of reduction and malunions are frequently seen (Dicke and Nunley, 1993; Younger et al., 1997). In order to choose the best treatment modality, it is very important to identify the patients with high risk of reduction loss. Although this subject is not clear in the English literature, translation to either radial or ulnar side more than half of the bone diameter was reported as the most important risk factor (Mani et al., 1993). Beside this, volar angulation, non-anatomic reduction (in the first manupulation), associated ulnar fracture at the same level of radius fracture, experience of the surgeon, quality of the plaster and type of anesthesia are common risk factors for the loss of reduction of conservative treatment (Mani et al., 1993; Miller et al., 2005; Mostafa et al., 2009; Nilsson and Obrant, 1977; Noonan and Price, 1998; Prevot et al., 1997). Metaphyseal fractures of the distal radius in children have high capability of remodelling when compared with adults, therefore functional loss is infrequent in children. However loss of rotational capacity of the forearm was reported in 15-29% of the cases after closed treatment (Mani et al., 1993; Friberg, 1979; Daruwalla, 1979). Functional loss could be persistent even after prompt remodelling of the angular deformity (Daruwalla, 1979; Davis and Green, 1976; Dicke and Nunley, 1993;Edmonds et al., 2009; Friberg, 1979; Gandhi et al., 1962; Gibbons et al.,
perforations with rates between 8 %–20 %, avascular necrosis between 10 %–33 %, loss of fixation up to 16 %, impingement up to 6 %–11 % and infection between 4 %–19 % [10, 21]. In this study, we found complication and reoperation rates of 30 % for patients treated with the PHILOS plate and 23 % for the Humerusblock. Radiologic signs of AVN were found in 4 patients in the PHILOS group and in 2 in the Humerusblock group. Oc- currence of AVN is influenced not only by surgical factors but also by nonsurgical factors, such as fracture type, medial hinge, short calcar fragment or head split fracture, as well as the comorbidities of the patient . However, nonanatomical reduction and extended soft tissue dissec- tion are suggested to promote AVN development [22, 23]. The Humerusblock is removed from the fracture zone without harming soft tissue in the injured area. Reduction is performed in a closed or percutaneous manner, thus preserving remaining periosteal bridges between fracture fragments and reducing the risk of AVN [8, 12, 13]. Unlike pin perforation after treatment using the Humerusblock, screw cut-out after angular stable plating is a serious com- plication . In the literature, screw perforations seem to be one of the most frequent complications after plating, with reported rates up to 20 % [11, 24]. In a study by Jost et al. , 57 % of patients with screw perforations showed glenoid destruction, and this represents a devas- tating complication. In our study, 5 patients with screw perforations needed reosteosynthesis. In contrast to screw perforation, in angular stable plating, pin perforation after treatment using the Humerusblock, as long as the tips of the k-wires do not aim at the glenoid surface, is consid- ered a minor complication. Quite to the contrary, the Humerusblock allows for the dynamic stabilization and controlled sintering and fracture consolidation of the head fragment. In this study, pin perforation occurred in 2 pa- tients (7 %), but rates up to 41 % are reported in the litera- ture . In the studies by Brunner et al.  and Bogner et al. , secondary impaction of the head leads to k-wire perforation in 22 % and 10 % of patients, respectively. Pin perforation can be easily detected in standard x-rays. Treatment is simple and doesn’t influence final outcome or bony healing . If pin perforation occurs before bony healing and the k-wires aim at the glenoid surface, re- trieval at the subcortical level is performed under local anesthesia. If the k-wires don’t aim at the glenoid sur- face, immediate k-wire removal after bony healing and before sling removal is performed. In general, the Humerusblock is not required to be removed. As men- tioned, such as in angular stable plates, only in cases of k-wire perforation or due to the wish of the patient should the Humerusblock be removed.
Management of displaced proximal humeralfractures is subject of ongoing debate (1-4). The PROFHER random- ized clinical trial recently showed no superiority of surgi- cal over non-surgical treatment of adults with displacedfractures of the proximal humerus (4). Previous studies showed that the treatment of proximal humeralfractures largely depends on patient characteristics and surgeon’s preferences and is not necessarily associated with fracture classification (5). For similar Neer types of 2-, 3- and 4- part fractures there are Level II and III studies supporting non- operative treatment, open reduction and internal fixation using various techniques, and arthroplasty (6-9).
This is to certify that Dr.E.R.MITHUN, post graduate student (2008-2011) in the Department of Orthopedic Surgery, Government Royapettah Hospital/ Kilpauk Medical College , has done dissertation on ‘‘COMPARISION OF FUNCTIONAL AND COSMETIC OUTCOME OF SUPRACONDYLARFRACTURES IN CHILDREN TREATED BY PERCUTANEOUSPINNING AND OPEN REDUCTION AND INTERNAL FIXATION WITH K- WIRES’’ under my guidance and supervision in partial fulfillment of the regulation laid down by the ‘THE TAMILNADU DR MGR MEDICAL UNIVERSITY, CHENNAI -32’ for M.S.(Orthopaedic Surgery) degree examination to be held in April 2011.