Pediatric Floating Elbow Injuries Are Not as Problematic as They Were Once Thought to Be: A Systematic Review

Abstract

Background: Pediatric ipsilateral supracondylar humerus and forearm fractures (floating elbow), are historically reported to have a high rate of complications, including pediatric acute compartment syndrome (PACS). As a result, treatment paradigms for these types of injuries differ in the urgency, extent of fixation, and type of immobilization than if each fracture were treated in isolation. We aimed to systematically review the literature on pediatric floating elbow injuries and assess the reported risk of PACS along with risk factors for poor outcomes. Methods: A systematic review was performed in November 2019 in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. An exhaustive search of the PubMed and Embase databases was conducted for peer-reviewed literature between 1999 and 2019. Two reviewers filtered the results, looking for articles in English that reported >10 pediatric floating elbow cases. Primary outcomes were the rate and risk factors for developing PACS. Secondary outcomes included patient and injury characteristics, treatment strategies, other complications (eg, neurovascular injuries), and final outcomes. Results: The initial search yielded a total of 150 studies. Following review, 11 studies were included, with 433 patients available for review. The mechanism of injury was a fall in 96% of cases. Closed reduction and percutaneous pinning was the most common treatment performed for both fractures. Only 8/433 patients (2%) developed PACS. The incidence of a pulseless limb at presentation was 4%, and all patients regained a pulse following reduction. Three cases of iatrogenic ulnar nerve injury were reported in the setting of medial pin placement. Good to excellent results were reported in 83% to 100% of patients, based on the modified Flynn criteria. Conclusions: Despite being limited to heterogenous and retrospective case series, the evidence reviewed in this study contradicts the current belief of a high risk of PACS or other complications in pediatric floating elbows. PACS is much more common with displaced fractures in the setting of delayed treatment. The rate of other complications is comparable to isolated supracondylar humerus fractures. Evidence supports treating these injuries in an urgent fashion in the setting of a displaced fracture, although fixation of both distal and proximal fractures is not supported by evidence. The outcomes of pediatric floating elbows are generally good and do not reflect the poor prognosis that adult floating elbows represent. Level of Evidence: Level IV—systematic review of level IV studies.

Pediatric Floating Elbow Caused by a Novel Mechanism: A Case Report

“…Moreover, it could be an open or closed injury. The prevalence of open injuries varies from 13-22% and are more in humeral rather than forearm fractures [ 7 , 8 , 11 , 12 ]. In our case, we report a peculiar rotational injury by a semi-automatic washing machine.…”

“…In our case, the patient came with an impending compartment due to a delay of more than 12 hours, which also could elevate the compartmental pressure [ 14 ]. Contrary to what was believed about the risk of compartment syndrome, some authors propose that it could be an overestimation and it was likely secondary to other factors rather than being from the pattern of the injury itself [ 12 , 14 , 15 ]. Hence, simultaneous ipsilateral forearm fractures and supracondylar fractures do not increase the latter's own risk of acute compartment syndrome [ 16 ].…”

Early Versus Delayed Treatment for Gartland Type III Supracondylar Humeral Fractures in Children: A Systematic Review and Meta-analysis

“…From our analysis, four studies assessed the risk of compartment syndrome in which no cases were identified within either the early or delayed surgery group. Recent evidence supports this finding; a systematic review of 11 studies, Baghdadi et al [ 26 ] found that the rate of compartment syndrome in patients with supracondylar fractures was low, ranging from 0 to 12% in incidence with a frequency-adjusted incidence of 2% [ 26 ]. A retrospective analysis in Yaokreh et al [ 27 ] study of 89 children with delayed surgery of 4.5 days for severe supracondylar fractures found that none of the children had developed compartment syndrome as a complication [ 27 ].…”

Pediatric Acute Compartment Syndrome

“…Several small series have reported the development of compartment syndrome after flexible intramedullary nailing of forearm or tibia fractures. The incidence of compartment syndrome after flexible intramedullary fixation of pediatric forearm fractures ranges from 2-7.5%, [23][24][25] (Figures 2a and 2b) with increased operative time and multiple attempts at reduction considered risk factors. Timing may also be an important factor.…”