Supracondylar Humerus Fractures- Does remodeling of the bone affect the clinical outcome? What is the bearing of fracture geometry and type of fixation on remodeling?

Adequacy of treatment, bone remodeling, and clinical outcome in pediatric supracondylar humeral fractures.

J Pediatr Orthop B. 2011 Sep 22. [Epub ahead of print]

Persiani P, Domenica MD, Gurzi M, Martini L, Lanzone R, Villani C.

Source: Department of Orthopedics, Policlinico Umberto I, Roma, RM, Italy.

Abstract

Background: Completely displaced Gartland type III fractures should be addressed surgically, whereas Gartland type I fractures should be treated by casting alone. The best way to approach type II remains controversial, as it could be the first or second synthesis method, depending on fracture fragment stability after closed reduction.   We focused our study on two main aspects that influence the final outcome; the adequacy of treatment in relation to the Gartland types of fracture and the physeal remodeling

Material and Methods: The aim of this study was to evaluate and compare, both clinically and roentgenographically, 62 extension-type supracondylar fractures on the basis of the synthesis method and severity of the fracture, with a mean follow-up of 4 years and 3 months. Range of motion, axial alignment of the elbow, muscle strength, and joint stability were estimated and the Mayo Elbow Performance Index and the Pediatric Orthopaedic Society of North America Pediatric Outcomes Data Collection Instrument questionnaire were used. Furthermore, we took radiographic measurements (Baumann's angle, humero-capitellar angle, and lateral rotational percentage).

Results: According to Flynn criteria, the clinical outcome of all our patients was satisfactory. According to the results of the questionnaires, no patient has reported any disabling limitation of the elbow function. Radiographic study proved a greater capacity of remodeling in the sagittal plane compared with the frontal one, irrespective of severity of fracture assessed by the Gartland classification. Statistical analysis stressed the validity of postoperative Baumann's angle as a predictor of final carrying angle. With regard to the synthesis method, the best way to approach Gartland II fractures proved to be by closed reduction and percutaneous pinning; the use of a third Kirschner wire in the treatment of Gartland III fractures did not lead to a better result.

Conclusion: To conclude, remodeling positively influenced the clinical outcome, however, irrespective of synthesis method and severity of the fracture, we should pay more attention to the adequacy of reduction in frontal plane than in the sagittal one, for which a greater capacity of remodeling was proved.

Late diagnosis of developmental dysplasia of the hip: an analysis of risk factors.

J Pediatr Orthop B. 2011 Jan;20(1):1-7.
Azzopardi T, Van Essen P, Cundy PJ, Tucker G, Chan A.


Source

Royal Hospital for Sick Children, Glasgow, UK. thomasazzopardi@hotmail.com

Abstract

A neonatal clinical screening program for developmental dysplasia of the hip (DDH) operates in South Australia to diagnose DDH as early as possible. However, some cases of DDH are diagnosed late (>3 months of age). The aims of this study were to identify the specific risk factors for late diagnosis by comparing early diagnosed DDH, late diagnosed DDH, and normal controls in the South Australian population. There were 1945 children with DDH born between 1988 and 2003, of which 67 cases were late diagnosis (3.4%). Maternal characteristics, pregnancy, and delivery details were analyzed, and compared with controls (early diagnosed DDH and the general population). There was a trimodal pattern of age at presentation with a gradual increase in the incidence of late diagnosed DDH over the time period in this study. Birthweight (<2500 g), birth in a rural setting, and early hospital discharge following delivery (<4 days) were significant risk factors for late diagnosed DDH. Breech presentation and delivery by caesarean section were protective for late diagnosed DDH. Risk factors for late diagnosed DDH relate to factors that influence the screening program. A rigorous population-based hip surveillance program is important for early diagnosis of DDH.

IORG Paediatric orthopaedic update

Effect of pressure applied during casting on temperatures beneath casts.

J Pediatr Orthop. 2011 Oct-Nov;31(7):791-7.
Deignan BJ, Iaquinto JM, Eskildsen SM, Woodcock CA, Owen JR, Wayne JS, Kuester VG.

Abstract

BACKGROUND:

Burns and pressure sores are common injuries during cast application. Various factors such as water temperature, padding, and cast material layers may play a role in these injuries; however, the effect of cast molding on temperatures and pressures has not been investigated. This raises the following questions, does the application of molding during cast application: (1) alter skin level temperatures in a variety of cast materials? and (2) risk inducing either thermal injury or pressure necrosis?

METHODS:

An upper extremity model was created to measure pressure and temperature underneath casting materials. Cast padding, water bath temperature, and cast thickness were standardized. A 3-point mold was simulated using 3 casting materials-Fiberglass only, Plaster Only splint, and Plaster splint overwrapped with Fiberglass-while pressure and temperature were recorded.

RESULTS:

: Pressure application led to a statistically significant (P<0.0001) increase in temperature at the sites where the mold was applied although absolute temperature did not reach the theoretical burn threshold of 49 to 50°C for the casting materials studied. With pressure applied, the Plaster/Fiberglass combination reached an average peak temperature of 47.9°C, which was maintained for up to 6 minutes. Neither Fiberglass nor Plaster Only reached peak temperatures of this magnitude (average of 42.7 and 43.6°C, respectively). Peak (369 mm Hg) and highest residual (21 mm Hg) pressures were below harmful levels.

CONCLUSIONS:

Pressure application during casting is a risk factor for burn injuries. Care should be taken when molding a plaster splint overwrapped in fiberglass by waiting until the plaster has fully cooled.

CLINICAL RELEVANCE:

Combined with other known risk factors, the pressure from molding a cast could increase the likelihood of causing cutaneous burns.

IORG Paediatric Orthopaedic Update