I declare that the dissertation entitled “OUTCOMEANALYSIS OF CROSSPINNINGVERSUSLATERALPINNING IN SUPRACONDYLARFRACTURES OF HUMERUS IN CHILDREN” submitted by me for the degree of M.S is the record work carried out by me during the period of May 2012 to August 2013 under the guidance of Prof.V.SINGARAVADIVELU, M.S.ortho., D.Ortho., Professor of Orthopaedics, Institute of Orthopaedics and Traumatology, Madras Medical College, Chennai. This dissertation is submitted to the Tamilnadu Dr.M.G.R. Medical University, Chennai, in partial fulfillment of the University regulations for the award of degree of M.S.ORTHOPAEDICS (BRANCH-II) examination to be held in April 2014.
Mehmet A. Altay, et al conducted a study to evaluate the outcomes of traditional medial-lateral and Dorgan’s lateralcross-wiring of supracondylarhumerusfractures in children they evaluated 51 children with mean follow-up periods were 18.4 months There were no statistically significant differences found between the groups for gender, age, follow-up periods, fracture types, neurological or function, and cosmetic results. Although postoperative iatrogenic ulnar nerve injuries occurred in 2 (8%) patients treated with the traditional medial-lateral (group 1) cross-wiring technique, no nerve injury occurred in the Dorgan’s lateral group(group 2) 
Objective: To compare the efficacy of medial and lateral entry pinning with lateral entry pinning for percutaneous fixation of displaced (Gartland type II and type III) extension type supracondylarfractures of the humerus in children. Methods: The study was a single center, prospective, randomized controlled clinical trial. Between October 2007 and September 2010, 160 patients who satisfy the inclusion and exclusion criterias were enrolled in the study, with 80 patients in each group. All the percutaneous pinning was done according to a uniform standardized technique. The patients were re-evaluated as outpatients at three weeks, six weeks and three months after the surgery. At three months follow-up visit, following informations were recorded as outcome measures: (i) Carrying angle (deg) (ii) passive range of elbow motion (deg) (iii) Flynn’s criteria for grading, based on the loss of carrying angle and loss of total range of elbow motion. (iv) Baumann angle (deg) (v) Change in Baumann angle (deg) between the Intraoperative radiographs after the surgery and radiographs at three months follow-up visit (vi) loss of reduction grading, based on the change in the Baumann angle.
Fracture of Supracondylarhumerus is a very common injury in children. Complications associated with this fracture warrant appropriate and optimum management of this injury. Closed reduction and percutaneous pinning with medial and lateralcross K-wires offers an excellent method to reduce and fix these fractures accurately. Some biomechanical studies advocate crosspinning 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 paediatric supracondylarhumerusfractures 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.
Although concerns about ORPP is iatrogenic soft- tissue injury, we did meticulous dissection and fracture reduction in our patients and didn’t encounter any major complications except one ulnar nerve injury during pin insertion. Bo Gou et al. in a meta-analysis found no significant differences between the two methods (CRPP and ORPP) for the results of carrying angle, Bauman angle, and complication rate  . In this study, four patients (11.11%) had pre-operative neurological (AIN) injury. Babal et al. in a meta-analysis on nerve injuries associated with pediatric SCH fractures reported injury rate of AIN in the range of 0-21%  . We encountered iatrogenic nerve injury rate of 2.7% which is similar to that reported in literature  . Loss of reduction was seen in 2 patients on post-operative radiographs and needed re-operation under fluoroscopic guidance. These were type IV SCH fractures with multidirectional instability and couldn’t be diagnosed during the first procedure as they are usuallydetermined on fluoroscopy when on a lateral view the capitellum is anterior to the AHL with elbow flexion, and posterior to the AHL with elbow extension  . Superficial pin tract infections
The second stage of this study started from January 2017 and ended in December 2017. Based on the findings of the first stage (see the “Results” section), two of the sur- geons (EW and LS), after placing the lower/distal lateral pins, started to insert the proximal lateral pins from lateral (pins laid in the lateral third of the ONC or lateral to the ONC) and posterior (pins laid in the posterior third of the ONC or posterior to the ONC) in hyperflexed position under Jones radiographs (Fig. 3), and intentionally aimed at exiting in zone + 1. The location and configuration of the pins were confirmed by intra-operative radiographs. When the lateral pin fixation was found to be satisfactory and stable with no distal fragment rotation, removal and reinsertion of the pins for further proximal exit or inser- tion of another new pin was avoided. Patients were then immobilized in a long arm cast in 80 to 90° flexion for a period of 4 to 5 weeks depending on the age of the patient. This group of data was collected as the intended group, while the data of the other surgeons, who continued to fix the fractures according to the regular, standard pinning protocol, were categorized as the random group. Similar demographic data, fracture characteristics, and measure- ment data were also collected and recorded as in the first stage of the study.
Supracondylar fracture of humerus has always been one of the most common and challenging fractures among the paediatric age groups. The main goal of the treatment is anatomical reduction and stable internal fixation. Thorough clinical examination is very crucial during the initial assessment of every patient. Closed reduction with K- wires fixation has been the gold standard in the management of these injuries. K-wires have the advantage of ease of use, decreased cost and reduced hospitalization stay [13,14] .
From the structural and functional stand points the distal humerus is divided into separate medial and lateral components each containing an articular and non-articulating portion. Included in the non-articulating portion are the epicondyle which are the terminal points of the supracondylar ridges. The lateral epicondyle contains a roughened anterolateral surface from which the superficial forearm extensor muscles arise. The medial epicondyle is larger than the lateral counter part and serves as the origin of forearm flexor muscles.
(Table 28). Three of the studies were randomized controlled trials. Kocher, et al. had flawed blinding and measurement domains (except for the outcomes infection and return to function which have unflawed measurement domains because the outcome is directly observable and is important to the patient). All 14 outcomes from Kocher, et al. were of moderate quality. Foaed, et al al. and Tripuranenei, et al. did not use stochastic methods to randomize patients to treatment groups, flawing the group assignment domain in addition to flawed blinding and measurement domains (except for the outcome infection which has an unflawed measurement domain because the outcome is directly observable and is important to the patient). Only the outcome infection from Foead, et al. and Tripuraneni, et al. was of moderate quality, the other 11 outcomes from these RCT’s were of low quality. All other quality analysis domains were not flawed (Table 35) Eleven of the remaining twelve comparing pinning techniques using lateral pins only to a single lateral pin with a medial cross pin were retrospective comparative studies which resulted in flawed prospective, group assignment, and blinding domains. Devkota, et al. was a prospective cohort study with flawed group assignment and blinding domains. All 38 outcomes from these 12 non-randomized comparative studies were of low quality (Table 28). The outcome infection had an unflawed measurement domain. The remaining 34 outcomes had flawed measurement domains because of the need for testing. All other quality analysis domains were not flawed (Table 35).
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
The data was assessed, analyzed, evaluated and the following conclusions were made-Supracondylarfractures of humerus are common in boys and girls. Although the transolecranon wire has the disadvantage of limiting the flexion and extension of the elbow, this does not influence the final outcome much as the elbow is fixed in a POP splint for minimum 3 weeks-in all patients in both groups. Since we have used smooth pin for the transolecranon trans-articular fixation of the fracture, we have not seen any feature of articular damage-in any case on final follow up X-rays. With both the techniques, consistently satisfactory results can be obtained both cosmetically and functionally. Early mobilisation of the elbow should be encouraged after K wire removal at 4 to 6 weeks to prevent stiffness. The pin placement can be individualised according the fracture and the stability of the fracture, as in final follow up no significant differences in seen in both the groups.
In Fig.(5), we show that pinning still arises in the microstructure model. As expected, the pinning effect is stronger when the hedger position is bigger. In the model the maximum amount of orders that the hedger can submit is limited by the overall trading activity in the market. In fact if the amount of orders submitted by the hedger is higher than the amount of orders submitted by the rest of the market, the book becomes empty. Hence there is a maximum option position that can be simulated. Thus there is a limit to the pinning generated by our model. Nonetheless the pinning probabilities we obtain in Fig.(5) are comparable with the empirical findings. Fig.(5) also shows that pinning is also more likely to arise when ǫ is large, i.e. when the price impact is linear. This provides a justification for this assumption in the theoretical models.
This is to certify that this dissertation titled “ FUNCTIONAL OUTCOMEANALYSIS OF MANAGEMENT OF MODIFIED BRISTOW’S REPAIR IN PATIENTS WITH RECURRENT ANTERIOR SHOULDER DISLOCATION” is a bonafide record of work done by DR. DINESH.C during the period of his Post graduate study from May 2010 to April 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 2013.
the left hand with elbow extended. She was submitted in local hospital where the clinical examination and X-ray were made and they confirmed the diagnosis of supracondylar fracture of the left elbow (Gartland Type III) (Figure 1). She was treated with closed reduc- tion (without anaesthesia) and cast immobilization (Fi- gure 2). The 3rd day after immobilization she complai- ned of swelling of the arm and the plaster was remodel- led. Plaster was removed after 18 days. With poor to no function of the left hand she was send to physical ther- apy for duration of 10 days, but she did not gain her functions of the left hand, almost all active movements of the left hand were impossible and the muscles of the left underarm were hypotonic. She also had angular de- formity of the left elbow because of mal-union of the fracture. Due to loss of left hand function, EMG was made and the EMG result showed acute lesion of the nerves of left forearm caused by possible nerve com- pression (n. medianus, n. radialis and n.ulnaris). Exten- sor muscles of the left forearm were active only with electrical stimulation. In that condition, she was sub-
We consider disordered pinning models, which are defined via a Gibbs change of measure of a renewal process, depending on an external i.i.d. random environment. First introduced in the physics and biology literature, these models have attracted much attention due to their rich structure, which is amenable to a rigorous investigation; see, e.g., the monographs of Giacomin [19,20] and den Hollander .
Methods: In January 2018, a systematic computer-based search was conducted in PubMed, EMBASE, Web of Science, Cochrane Database of Systematic Reviews, and Google database. Data on patients prepared for two different managements for supracondylar humeral fractures in children were retrieved. The primary endpoint was the cosmetic and clinical outcomes based on the criteria of Flynn, ulnar nerve injury, and the occurrence of infection. After testing for publication bias and heterogeneity between studies, data were aggregated for random-effects models when necessary.
Prevention of severe systolic hypertension (>160 mm Hg) is paramount; recommendations to maintain systolic pressures under 150 mm Hg and diastolic pressures under 100 mm Hg are reasonable goals. Labetolol, hydralazine, or nifedipine are the preferred agents for treatment of acute hypertension . Maternal- fetal status, gestational age, presence of labor, cervical Bishop Score, prior maternal obstetric history, and response to aggressive corticosteroids all impact management of the patient with a preterm viable fetus and HELLP syndrome. Immediate cesarean delivery is not generally indicated or recommended; vaginal or cesarean delivery after 24 to 48 hours of corticosteroids are better options to achieve maximal maternal and fetal benefit. Nevertheless, because vaginal delivery rates with HELLP syndrome are below 50% for gestations less than 30 weeks, some authors advocates elective cesarean delivery for all women diagnosed with HELLP syndrome at a gestation age less than 30 weeks when spontaneous labor is not present and the Bishop score is less than 5. A patient with a low Bishop score in association with fetal growth restriction and/ or oligohydramnios may not be a good candidate for trial of labor. Otherwise, vaginal delivery is attempted in patients in active labor less than 30 weeks with ruptured membranes or with a Bishop score 5 or more in the absence of obstetric contraindications. Once the 30-week gestational age threshold is reached, an attempt at vaginal delivery is usually recommended. Epidural or spinal anesthesia is the preferred anesthetic for patients with preeclampsia. Approximately 50% of patients with HELLP syndrome can be candidates for regional anesthesia during a trial of labor using a threshold of 100,000/µL platelets. In these circumstances, the decision of abdominal versus vaginal delivery becomes more of an obstetric issue rather than a response to a rapidly worsening maternal-fetal condition .
Supracondylarhumerusfractures (SHFs) are the most common fractures in children and account for approxi- mately 50–70% of pediatric elbow fractures [1, 2]. Com- promised vasculature occurs in 2.6–20% of cases of displaced SHFs in children [3–6], with two kinds of bra- chial artery injuries reported to be associated with SHFs: those presenting with a pale pulseless hand and those with a pink pulseless hand (PPH) which is well perfused without a palpable radial pulse [6–8]. While vascular compromise in elderly patients with SHFs is rare due to osteoporosis and low-energy trauma compared with pediatric patients, open reduction and plate fixation was recommended for satisfactory outcomes . In pediatric patients, urgent closed reduction and percutaneous pin- ning (CRPP) is the primary treatment in both situation, and vascular exploration is often required in the case of a pale pulseless hand [6–8, 10, 11]. However, the optimal treatment for a PPH in terms of whether to perform im- mediate vascular exploration or manage with close ob- servation is controversial in cases where the radial pulse is still not palpable after CRPP [10, 11].
It’s our routine practice to evaluate clinically and radio- logically all patients at 1 month, at 2 or 3 months, and thereafter at 6-monthly intervals. After obtaining informed consent from patients or patients & parents, all radiographs and hospital records were reviewed; moreover, all 20 patients treated with closed reduction received an extra clinical follow-up between May and June 2012. The fol- low-up period ranged from 15 to 63 months, with a mean of 42 months. The angulation of the radial neck was measured as the angle between a line drawn parallel to the superior articular surface of the radial head and a line perpendicular to the articular surface through the radial shaft in the primary radiographs. The postoperative clinical evaluation was performed by one of the authors (F.F.) and included analysis of passive and active range of motion (ROM), radiological evaluation of alignment, functional results using the Mayo elbow performance score (MEPS), and early or late complications. Flexion and extension of elbows, pronation and supination of the forearm and the angle of the extended elbows were measured by a goni- ometer. The uninjured elbows served as controls. The last follow-up radiographs included standard anteroposterior and lateral projections of the injured elbow. All measure- ments were performed on a picture archiving and com- munication system (PACS, software Fuji Synapse). Radiologically, the reduction was considered excellent when it healed in the anatomical position; good when the radial neck angle was less than 20°; medium when the angle was between 20° and 40°; poor with an angle of more than 40°. The MEPS is one of the most commonly used physician-based elbow rating systems (Table 1). The joint’s stability was graded as stable, mildly unstable or unstable. The functional score is determined on the basis of the patient’s ability to perform normal activities of daily Fig. 1 a Radial neck fracture Judet type III. b Osteosynthesis with
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.