Treatment of pediatric lateral condylar humerus fractures with closed reduction and percutaneous pinning

Abstract

Background Lateral condylar humerus fractures (LCHFs) are the second most common pediatric distal humerus fractures. Open reduction and internal fixation is recommended for fractures displaced by more than 2 mm. Few studies described using closed reduction and percutaneous pinning (CRPP) for treating fractures with greater displacements. This study aims to explore the feasibility of CRPP in treating displaced LCHFs. Methods All patients underwent attempted CRPP first. Once a satisfying reduction was obtained, as determined using fluoroscopy based on the relative anatomical position of the fragments, an intraoperative arthrogram was performed to further confirm the congruence of the articular surface of the distal humerus. Open reduction is necessary to ensure adequate reduction if the fracture gap is more than 2.0 mm on either anteroposterior view or oblique internal rotational view by fluoroscopy after CRPP. All included fractures were treated by a single pediatric surgeon. Results Forty-six patients were included, 29 boys and 17 girls, with an average age of 5.2 years. Of these, 22/28 (78%) Jakob type II fractures and 14/18 (78%) Jakob type III fractures were treated with CRPP. All cases in Song stages II and III, 19/25 (76%) cases in Song stage IV, and 14/18 (78%) cases of Song stage V were treated with CRPP. The remaining converted to open reduction with internal fixation. Overall, 36 of the 46 patients (78%) were treated with CRPP. The average pre-op displacement was 7.2 mm, and the average post-op displacement was 1.1 mm on the anteroposterior or oblique internal rotational radiograph in cases treated with CRPP. CRPP was performed in an average of 37 min. The average casting period was 4 weeks and the average time of pin removal was 6 weeks postoperatively. The average time of follow-up was 4 months. All patients achieved union, regardless of closed or open reduction. No infection, delayed union, cubitus varus or valgus, osteonecrosis of the trochlea or capitellum, or pain were recorded during follow-up. Conclusions Closed reduction and percutaneous pinning effectively treats LCHFs with displacement more than 4 mm. More than 3/4 of Song stage V or Jakob type III patients can avoid an incision.

Closed reduction and percutaneous pinning vs open reduction and internal fixation in pediatric lateral condylar humerus fractures displaced by > 4 mm: an observational cross-sectional study

“…For such cases, it is recommended that CRPP should be attempted first, and if this fails, ORIF should be performed [ 1 , 2 , 9 ]. However, there is no consensus about the optimal treatment for LCHFs displaced by > 4 mm: most clinicians advocate for the use of ORIF, and only a few recommend CRPP [ 1 – 15 ].…”

“…All patients achieved fracture union. The final follow-up found no dysfunction or major complications [ 15 ].…”

“…In our previous work, the first 10 consecutive attempts of CRPP failed before we became skilled at performing CRPP for Song stage 4 and 5 LCHFs. Later, we achieved an approximate 75% CRPP success rate, even in Song stage 5 cases [ 15 ]. In the present study, we achieved an overall CRPP success rate of 78% (45/58).…”

“…However, Ramo et al could not replicate the success of CRPP in Song stage 5 LCHFs in their series [ 14 ]. We previously reported a series of 46 LCHFs displaced by > 2 mm at our institute, where CRPP was attempted with an approximate 75% success rate, even in Song stage 5 cases [ 15 ]. These results illustrate the potential promise of the CRPP technique [ 13 – 15 ].…”

Does an elbow arthrogram change management after closed reduction of mildly displaced lateral condyle fractures in children?

“…The authors stated that it is common practice to perform an arthrogram after closed reduction and percutaneous pinning (CRPP) of minimally displaced lateral condyle fractures (LCFs) but in contrary to the former, we could only identify five other articles in the literature which documented the use of an arthrogram after CRPP [2][3][4][5][6]. Two of the former authors [2,3] stated that the arthrogram did not change the treatment decision, two [4,5] did not provide this information and Xie et al [6] reported a conversion of CRPP to open reduction and K-wire fixation (ORIF) in 10 of 46 patients. Kang et al [7] converted nine of 39 CRPPs to ORIF after arthroscopic assessment.…”