Kaye E. Wilkins

Fracture-separation of the distal humeral epiphysis

Sixteen patients were seen with fracture-separation of the distal humeral epiphysis. The difficulty that may be encountered in making the diagnosis is thought to be partly responsible for the relative paucity of previous reports of this condition. All sixteen patients revealed posteromedial displacement of the distal humeral epiphysis on the initial roentgenogram. Child-abuse was documented or suspected as a cause in six of the sixteen fractures. Treatment consisted of closed reduction and immobilization with the elbow in 90 degrees of flexion and the forearm pronated, for three weeks. Post-injury cubitus varus, which developed in three patients and was thought to be due to inadequate reduction, did not progress.

Supracondylar Fractures: What's New?

In the past 5 to 7 years many advances have been made in the treatment of type III supracondylar fractures of the humerus. Gartlands three-type classification has continued to be used as a valuable tool to determine the aggressiveness of treatment. Use of cast immobilization for type III injuries has been shown to produce inferior results. Percutaneous pin fixation for reduced fractures has been established as the ideal treatment for most type III displaced fractures. Mediolateral or three lateral pin constructs provide the most rigid fixation. It is now apparent that the anterior interosseous nerve is probably the most commonly injured nerve. Recent technology in evaluating the vascular system has shown that the incidence of injuries to the brachial artery is probably higher than originally suspected. However, the management of these arterial injuries in patients who appear to have adequate profusion of the forearm musculature for normal function is still controversial, with recommendations varying from simple observation to aggressive primary arterial repair. Cubitus varus has been found to be due primarily to angulation in the coronal plane. Fortunately the incidence of complications after corrective osteotomies with this deformity has decreased from 50% to less than 15%. Although ipsilateral fractures are usually the result of greater forces of trauma, the incidence of associated neurovascular compromise does not appear to be any greater. Better recognition of flexion-type injuries has shown that the incidence is greater than originally suspected. A large percentage of these completely displaced flexion injuries may require open surgical intervention to obtain adequate reduction.

Deformity following distal humeral fracture in childhood.

We are reporting five cases of a seldom-reported complication following fracture of the distal end of the humerus during childhood. The complication consists of dissolution of a variable portion of the trochlea at a variable time after fracture. The fractures ranged from non-displaced to severely displaced supra-condylar fractures along with a lateral condylar fracture and a Salter-Harris Type-I fracture. The severity of the fracture did not correlate with the severity of the deformity. When the defect in the trochlea was wide enough to permit migration of the ulna proximally, the range of flexion and extension was severely affected. Excision of the olecranon in one twelve-year-old boy resulted in a moderate increase in extension.

The patterns of spinal deformity in Duchenne muscular dystrophy.

In a clinical and roentgenographic study of spinal deformities in sixty-two patients in the later stages of Duchenne muscular dystrophy, many patients had marked scoliosis and kyphosis, while others with hyperextended spines had comparatively little scoliosis. Based on an analysis of the data, it is suggested that the development of spinal deformity in patients with Duchenne muscular dystrophy may progress in two ways: one leading to the early establishment of a position of extension and a maximum intrinsic stability with minor deformity, and the other leading to progressive deformity. It was concluded that management for these patients should be designed to guide the early straight spine toward the late extended pattern by attempting to prevent kyphosis and pelvic obliquity.

Femur fractures in infants: a new therapeutic approach.

Fourteen patients with 16 femur fractures sustained between birth and 18 months of age were treated with a Pavlik harness rather than traditional casting methods. All of the fractures went on to stable union within 5 weeks. Eleven fractures have been followed-up for > 12 months, with a range of 12-30 months, and a mean of 20.1 months. All of the fractures healed in good alignment, with leg-length discrepancies < 1 cm. There have been no adverse results or complications as a result of treatment with the Pavlik harness to treat femur fractures, including fractures of the proximal and middle thirds of the femur; nonambulatory infants; < 4 months old at the start of treatment or small size in selected infants up to 6 months old; and shortening of < 2 cm. Advantages of the use of the Pavlik harness include ease of application without general anesthesia, minimal hospitalization, ease of reduction, ability to adjust the harness (and therefore the fracture alignment) if the reduction is lost, minimal cost, and ease of nursing, bonding with, and changing diapers on the infant.

Changes in the management of Monteggia fractures

Recognition of Monteggia lesions has improved over the past 2 decades. The mechanism of injury of the various types of lesions is better understood. Surgical indications for treatment, including management of the patient with a chronically dislocated radial head post Monteggia injury, have been clarified. Type IV lesions, once thought to be almost unknown in children, are now recognized with increasing frequency in the pediatric age group. Outcomes for Monteggia lesions are recognized to be quite good in children in contrast to adults. Giovanni Battista Monteggia first described this eponymic fracture pattern in 1814 (12). During the early 1900s, other investigators (7,14,17,18,20,24) theorized on the injury mechanisms of the varieties of Monteggia fractures. The most complete description of various Monteggia patterns was proposed in 1958 by Jose Luis Bado of Montevideo, Uruguay. He coined the term “Monteggia Lesions,” subdividing this group of injuries into four types with subgroup equivalents of each type (1–3). In my opinion, this is the most useful available classification system (Fig. 1). The work in previous studies gave us a better understanding of this injury. Management of the Monteggia complex has improved on several fronts. We now have clearer concepts of the mechanism of injury of the various types. We have better surgical indications, including reconstruction for cases that are diagnosed late. Type IV lesions previously were thought to be virtually unknown in the pediatric age group. There now have been enough reports on this subgroup that show that this fracture/dislocation pattern is not rare and carries a better prognosis in the pediatric age group than in adults (8,21,22).

The treatment of displaced supracondylar humerus fractures: evidence-based guideline.

Background: Supracondylar humerus fractures are widely considered the most common fracture of the elbow in children. Fractures can range from a less severe, nondisplaced type I fracture to a more severe, displaced type III fracture with no cortical contact. Type III fractures can lead to adverse physical, social, and emotional consequences if they are not treated effectively. The American Academy of Orthopaedic Surgeons recently carried out a systematic review of the literature to develop a clinical practice guideline. The guidelines provided answers for the following questions regarding the treatment for type III supracondylar fractures (1) which is the preferred treatment for displaced supracondylar fractures of the humerus: reduction and casting versus closed reduction and percutaneous pinning; (2) which is the preferred method for fixing displaced supracondylar fractures of the humerus: medial (crossed) versus lateral pinning; and lastly, (3) does open reduction cause increased stiffness or have a high rate of complication? The purpose of this paper is to summarize and highlight the major findings from this systematic review. Methods: PubMed, EMBASE, CINAHL, and The Cochrane Central Register of Controlled Trials were searched to locate 1726 relevant articles published from January 1966 to July 29, 2010. Of these, 44 met our criteria for inclusion and were reviewed systematically. Results: On the basis of the results from the systematic review: (1) we suggest closed reduction with pin fixation for patients with displaced (eg, Wilkins type II and III and displaced flexion) pediatric supracondylar fractures of the humerus. (2) The practitioner might use 2 or 3 laterally introduced pins to stabilize the reduction of displaced pediatric supracondylar fractures of the humerus. Considerations of potential harm indicate that the physician might avoid the use of a medial pin. (3) The practitioner might perform open reduction for displaced pediatric supracondylar fractures of the humerus after closed reduction if varus or other malposition of the bone occurs. Conclusions: Clearly, controversy exists regarding the best treatments for pediatric supracondylar humerus fractures. Properly designed randomized controlled trials comparing treatment options are necessary to determine optimal treatments. Level of Evidence: Level II.

Lateral External Fixation-A New Surgical Technique for Displaced Unreducible Supracondylar Humeral Fractures in Children

BACKGROUNDnPercutaneous Kirschner wire fixation represents the classic treatment for displaced supracondylar humeral fractures in childhood. This type of treatment first requires satisfactory reduction of the fracture. Failure to achieve a satisfactory reduction or inadequate stabilization can result in instability of the fracture fragments, which can result in either an unsatisfactory cosmetic or functional outcome. In our experience, these problems can be overcome with the use of a small lateral external fixator.nnnMETHODSnBetween 1999 and 2005, thirty-one of 170 Gartland type-III supracondylar humeral fractures were treated with a lateral external fixator. The outcome of treatment was analyzed with regard to limb alignment, elbow movement, cosmetic appearance, and patient satisfaction.nnnRESULTSnIn twenty-eight of the thirty-one patients, a satisfactory reduction was achieved with closed methods. All children except one had a normal or good range of movement. The cosmetic result was excellent in all cases. All of the children and their parents stated that they would choose this treatment again.nnnCONCLUSIONSnThe use of a small lateral external fixator seems to be a safe alternative for the treatment of displaced supracondylar fractures of the humerus when a closed reduction appears to be unattainable by means of manipulation alone or when sufficient stability is not achieved with standard methods of Kirschner wire fixation.

Acute insufficiency of the posterior cruciate ligament in children. Two case reports.

Injury to the ligaments of the knee in young children is relatively rare due to the resiliency of the ligaments and the relative weakness of the physis. Epiphyseal injury therefore is more apt to occur. The most common injury that occurs when the cruciate ligaments in children are stressed is avulsion of the anterior tibial spine, and this isolated injury usually does not result in significant laxity of the ligaments after healing I-3,9-1I Acute insufficiency of the posterior cruciate ligament has been recognized in adults and has recently been reported in a child7. We saw two young children with an avulsion of the posterior cruciate ligament that apparently occurred after hyperextension of the knee. In our experience, when hyperextension injury produces insufficiency of the postenor cruciate ligament, the ligament is avulsed from its femoral attachment together with a chondral fragment.

Absent posterior tibial artery in an infant with talipes equinovarus.

We report the absence of the posterior tibial artery in a 3-month-old patient with idiopathic clubfoot. Although anomalies of the anterior tibial artery are common, complete absence of the posterior tibial artery associated with talipes equinovarus deformity has not been reported.