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Original article

Evaluation of upper-extremity function following surgical treatment of displaced proximal humerus fractures in children Federico Canavesea, Lionel Athlania, Lorenza Marengob, Marie Rousseta, Nadege Rouel-Rabiauc, Antoine Sambaa and Antonio Andreacchiob This study aims to assess the functional outcome of children treated with elastic stable intramedullary nailing (ESIN) for displaced proximal humerus fractures using the short version of the disabilities of the arm, shoulder, and hand outcome questionnaire (Quick DASH). Fifty-eight consecutive children with displaced proximal humerus fractures were treated with ESIN. Fifty-two children (89.7%) were available for follow-up and responded to the questionnaire after hardware removal. Average age at time of injury was 11.1±2.8 years (range, 4–15.9). Among the 52 patients available for evaluation, 37 had a Quick DASH score of 0 (71.1%), seven a score of 2.3 (13.5%), four a score of 4.5 (7.7%), and four a score of 6.5 (7.7%). Shoulder and elbow ranges of motion were comparable with the noninjured side. No skin irritation or local infections were observed. There was no radiographic evidence of delayed union, refracture, hardware migration, or secondary displacement. Mean follow-up was 18.3±8.3 months (range, 6–39.5). Our study reports good functional

Introduction Displaced metaphyseal and diaphyseal fractures of the long bones of both upper and lower extremities in children can be managed by elastic stable intramedullary nailing (ESIN). Me´taizeau described the original technique in 1982 [1,2] and its applications have been widely developed in pediatric orthopedic surgery. This technique is easy to learn, minimally invasive, and has a low reported rate of postoperative complications [3–7]. Fractures of the proximal humerus in children are less frequent than elbow, forearm, and wrist fractures. Most of these fractures, especially nondisplaced, are typically treated conservatively because of their rapid consolidation and significant remodeling capacity [8]. However, displaced fractures often require surgical treatment and can be managed by percutaneous pinning [9] or ESIN [10–13]. To date, none of the studies reporting the surgical outcome of displaced proximal humerus fractures in children have used a standardized rating scale to evaluate functional outcome [10–13]. It has been shown that the Quick DASH questionnaire can be used to measure disability and symptom severity in a variety of arm disorders. The Quick DASH consists of 11 items. To calculate a Quick DASH score at least 10 of the 11 items must be completed. Each item has five response c 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins 1060-152X

outcomes in children with closed isolated fractures, both physeal and metaphyseal, of the proximal humerus treated with ESIN. The use of a standardized rating scale is recommended to homogeneously compare functional outcome and may facilitate the comparison of clinical outcome in different patient populations. J Pediatr c 2014 Wolters Kluwer Health | Orthop B 23:144–149 Lippincott Williams & Wilkins. Journal of Pediatric Orthopaedics B 2014, 23:144–149 Keywords: displaced fractures, elastic stable intramedullary nailing, humerus, surgical treatment a

Department of Pediatric Surgery, University Hospital, Clermont Ferrand, France, Department of Pediatric Orthopaedic, Regina Margherita Children’s Hospital, Turin, Italy and cCIC Inserm 501 CRCTCR, University Hospital Estaing, Clermont Ferrand, France b

Correspondence to Federico Canavese, MD, PhD, Department of Pediatric Surgery, University Hospital Estaing, 1 Place Lucie et Raymond Aubrac, 63003 Clermont Ferrand, France Tel: + 33 4 73750296; fax: + 33 4 73750291; e-mail: [email protected]

options and, from the item scores, scale scores are calculated, ranging from 0 (no disability) to 100 (most severe disability). The aim of our study was to assess the functional outcome of children treated with ESIN for displaced proximal humerus fractures using a standardized functional scale, that is Quick DASH.

Materials and methods From January 2008 to July 2012, 58 consecutive children with displaced proximal humerus fractures were treated with ESIN. All children were operated in two institutions (one in France and one in Italy) by four pediatric orthopedic surgeons (two surgeons per institution) according to the surgical technique described by Me´taizeau [1,2,10]. Children were admitted to the emergency department and sex, age at time of injury, mechanism and side of injury, and the presence of associated lesions or neurovascular complications were recorded. Each child underwent standard anteroposterior (AP) and lateral (L) radiographs of the injured bone to allow the treating surgeon to identify, evaluate, and classify each fracture. Inclusion criteria for the study were closed displaced fractures of the proximal humerus, absence of associated neurovascular injuries, and growth cartilage visible on standard radiographs. Exclusion criteria were polytraumatized patients, pathological fractures, and absence of growth cartilage on standard radiographs. The study was approved by the institutional review boards of both hospitals. DOI: 10.1097/BPB.0000000000000009

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Evaluation of proximal humerus fractures Canavese et al. 145

Classification

All fractures were classified according to the AO Paediatric Comprehensive Classification of Long Bone Fractures [14–17]. Long bones are identified by the numerals 1 (humerus), 2 (radius and ulna), 3 (femur), and 4 (tibia and fibula). Depending on the segment of the fracture, a second number is attributed: 1 = proximal, 2 = intermediate, and 3 = distal. A letter is assigned after the first two numbers depending on the fracture location: E = physis, M = metaphysis, and D = bone shaft. After the letter, two additional numbers define the type and complexity of the fracture [14–17]. Thus, fractures of the upper end of the humerus can be 11E1.1 (epiphyseal fracture, Salter-Harris I), 11E2.1 (epiphyseal fracture, Salter-Harris II), 11M3.1 (metaphyseal fracture, simple), or 11M3.2 (metaphyseal fracture, complex) (Fig. 1). Angulation and translation

Displacement is defined on AP and L radiographs. Angulation is the angle between the axis of the proximal and the distal fragments of the fracture with values expressed in degrees. Translation is defined as the percentage of proximal fragment not overlapping the distal fragment. A fracture with an angle of 501 and/or a translation of at least 50% was defined as displaced. Surgical treatment and follow-up

All patients were treated under general anesthesia with the same surgical technique. Patients were placed in

supine position. The fracture was first reduced by external maneuver under fluoroscopic control. When reduction was achieved, two titanium elastic nails were introduced through a 2 cm incision located on the lateral side of the distal humerus metaphysis. Two nails of the same diameter were used to stabilize each fracture; the diameter of each nail was equal to B40% of the diameter of the narrowest part of the humeral shaft. After surgery, patients were immobilized in a splint for a period of 3 weeks. All patients were regularly followed clinically and radiographically. Follow-up visits were performed at 1, 3, 6, 12, 26, and 52 weeks. AP and L radiographs were performed at each visit to evaluate the consolidation of the fracture and to identify complications such as secondary displacement, hardware migration, delayed union, nonunion or malunion, and refracture. Subjective data, such as perceived pain, stiffness, and impact on daily activities, and objective data, such as range of motion, skin lesions, or surgical site infection, were recorded. Patients were allowed to return to full physical and sport activities at 2–3 months after surgery. Hardware was removed 5–8 months after index surgery.

Functional outcome

After hardware removal, functional outcome was assessed by the short version of the disabilities of the arm, shoulder, and hand outcome questionnaire (Quick DASH). Assessment was carried out at the outpatient clinic or by telephone.

Fig. 1

Displaced metaphyseal fracture of the humerus (11M3.1) (a). Postoperative (b) and 6-month follow-up radiographs (c). Consolidation after hardware removal (d).

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Quick DASH is a self-report questionnaire consisting of 11 items corresponding to different activities of daily living and symptoms experienced by the patient. The patient rates each item according to the perceived degree of severity ranging from 1 (no discomfort or symptoms) to 5 (major discomfort or severe symptoms). The final score is calculated according to the algorithm [(sum of responses N/N) – 1]  25 where N is equal to the number of responses. The Quick DASH score ranges from 0 (least disability) to 100 points (most disability) and allows the evaluation of the overall performance of the upper limb [18,19]. Data were expressed as frequencies and percentages, and means and SDs as appropriate. Statistical analysis was performed using Student’s t-test, and statistical significance was established at P value less than 0.05.

Results The study included a total of 58 children and adolescents [23 male (39.6%) and 35 female (60.4%); male : female ratio, 2 : 3] with 58 surgically treated fractures of the proximal humerus. Average age at time of injury was 11.1±2.8 years (range, 4–15.9). The right side was affected in 30 patients and the left in 28. The mechanism of injury was direct in 50 patients and indirect in eight. All were isolated closed fractures without any neurovascular compromise (Tables 1 and 2). Two fractures were graded as 11E1.1 (3.5%), 10 as 11E2.1 (17.2%), 28 as 11M3.1 (48.3%), and 18 as 11M3.2 (31%). Mean angulation was 47.8±21.31 (range, 10–90) and mean translation was 68.3±33.9% (range, 10–100) (Table 1). Mean age at surgery, male : female ratio, mean angulation and translation, mean follow-up, and mean Quick DASH score of patients treated in the two institutions are shown in Table 2. Surgical treatment and follow-up

Fifty-seven fractures could be reduced by external maneuvers under image intensifier and stabilized by ESIN. One patient had to have an open reduction because of the incarceration of the biceps tendon into the fracture. Three fractures (5.2%) were treated in children below 6 years of age, 25 lesions (43.1%) in patients between 6 and 11 years of age, and 30 lesions (51.7%) in children over the age of 11 years. Overall, 116 titanium elastic nails (Synthes, Etupes, France) were used (two nails per fracture). Fifty fractures were treated with 2.5 mm nails (100 nails), five fractures with 3 mm nails (10 nails), and three fractures with 2 mm nails (six nails). Six patients (10.3%) were lost to follow-up. For the remaining 52, mean follow-up was 18.3±8.3 months (range, 6–39.5). All fractures healed without malunion. Functional outcome

All patients were pain-free at last follow-up. Shoulder and elbow ranges of motion were comparable with the

noninjured side. The mean Quick DASH score was 1.2 (range, 0–6.5). Among the 52 patients available for evaluation, 37 had a score of 0 (71.1%), seven a score of 2.3 (13.5%), four a score of 4.5 (7.7%), and four a score of 6.5 (7.7%) (Table 1). Among the 11 children with physeal fractures (11E1.1 and 11E2.1), the mean Quick DASH score was 1.6 (range, 0–6.5). Among the 41 children with simple (11M3.1) or complex (11M3.2) metaphyseal fractures, the mean Quick DASH score was 1 (range, 0–6.5). No significant difference in functional outcome was observed between these two groups of patients (P > 0.05). All children were able to return to daily life and sport activities without discomfort or residual pain. Complications

No skin irritation or local infections were observed. Similarly, there was no radiographic evidence of delayed union, refracture, hardware migration, or secondary displacement.

Discussion A total of 58 children treated with ESIN for displaced proximal humeral fractures were included in the study. All fractures were isolated, closed, and without any neurovascular compromise. Mean follow-up was 18.3 months. Fifty-two children had a clinical and radiological follow-up. The mean score of functional assessment with the Quick DASH questionnaire was 1.2. Quick DASH is a region-specific outcome instrument developed as a measure of self-rated, upper-extremity disability and symptoms [18,19] and allowed a comparison of the functional outcome of patients with physeal fractures versus those with metaphyseal injuries. Functional outcome was good in both patient groups and no significant differences were observed. To the best of our knowledge, this is the first study that uses a standardized rating scale, that is the Quick DASH questionnaire, for functional outcome in children with displaced proximal humeral fractures. The Quick DASH questionnaire has the advantage of allowing a reproducible comparison of functional outcome postsurgery over time in patients with this type of fracture, including the capacity to detect and differentiate small and large changes in disability [18]. The Quick DASH questionnaire was originally developed to assess upper-extremity disabilities in adults. It was introduced by Hudak et al. and the Upper Extremity collaborative group in 1996 [20]. In 2005, Beaton et al. [21] developed the 11-item Quick DASH questionnaire to minimize time and responder burden. Both DASH and Quick DASH questionnaires are available in multiple languages. Although there is no set age limit, general guidelines are 18–65 years of age. The average age of our patients was 11.1 years with an upper limit of 15.9 years. Most children were able to understand

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Evaluation of proximal humerus fractures Canavese et al. 147

Table 1 Institution 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 Mean SD

Characteristics of patients included in the study Male/female

Age at surgery (years)

Side

AO classification

Angulation (deg.)

Translation (%)

Quick DASH

Follow-up (months)

M F F F M F M M F F F M M M F M F F F F F F F M M F F M F F M F F F M M F M F F F F F M F F M F M M M F F F M F F M

8.2 8.1 11.1 9.5 15.9 9.9 10.1 14.6 7.1 9 14.2 15.5 8 15.4 12.1 14.1 10.1 10.3 12.6 11.3 11.4 12.1 12.6 7.5 14.5 10.5 8.4 14 14.1 15.1 12.1 13.6 13.4 11.6 12 12.1 7 12.2 10.1 7.3 13.2 10.2 13.4 14 5.1 12 9.8 5.7 6.9 14.6 10.3 8.5 11.4 4 9.7 11.1 10.7 14.6 11.1 2.8

R R R L L L R L L L R L R L L R L R L L R L R R R L L R L R L R L L R R L R L R R R R L R L L R L L R R L R R L L R

11M3.1 11M3.1 11E2.1 11M3.1 11E1.1 11M3.2 11M3.1 11M3.1 11M3.1 11M3.2 11E2.1 11E1.1 11M3.1 11M3.1 11M3.2 11M3.2 11M3.2 11M3.1 11E2.1 11M3.1 11M3.1 11M3.1 11E2.1 11M3.1 11M3.1 11M3.1 11M3.2 11E2.1 11E2.1 11M3.2 11M3.1 11M3.1 11M3.1 11M3.2 11E2.1 11M3.2 11M3.2 11M3.2 11M3.2 11M3.1 11M3.1 11M3.1 11M3.1 11M3.1 11M3.2 11M3.1 11M3.2 11M3.2 11M3.1 11M3.1 11M3.2 11M3.1 11E2.1 11M3.2 11E2.1 11E2.1 11M3.2 11M3.1

20 90 50 45 65 70 50 55 60 30 70 65 50 30 80 50 50 80 90 50 45 75 50 20 30 90 50 60 50 30 30 90 40 55 75 25 55 40 30 45 30 35 30 35 20 45 30 70 85 10 20 20 35 10 40 45 50 30 47.8 21.3

100 100 10 70 50 95 10 10 60 50 30 60 10 10 50 10 90 80 30 20 80 50 70 100 60 100 20 30 15 100 50 100 100 50 100 100 100 100 60 100 100 100 100 100 100 100 30 100 100 100 50 30 80 40 100 100 100 100 68.3 33.9

4.5 2.3 – 0 2.3 0 6.5 4.5 0 – 6.5 0 4.5 0 0 6.5 0 0 4.5 0 0 0 0 0 0 6.5 0 2.3 0 0 0 0 0 0 0 0 0 0 0 0 0 2.3 2.3 0 0 2.3 0 0 0 – – – 0 0 0 2.3 – 0 1.2 –

17.1 21.3 Lost to FU 17.8 12 11 11 9.5 16.2 Lost to FU 17.8 20.8 12 22.3 13 17.5 19.1 28.5 8.1 17.2 13 7.5 8.6 7.5 20.1 6 19.3 6.1 27.3 6.7 34.8 32.6 32.6 30.8 29.6 29.6 26.1 26 26 20.4 17.8 17.8 17.8 17.2 15.2 14.8 14.8 13 9.6 Lost to FU Lost to FU Lost to FU 28.2 25.2 10.3 10.3 Lost to FU 39.5 18.3 8.3

F, female; FU, follow-up; L, left; M, male; R, right.

the questions and answer them without any help. Those under 8 years of age (eight patients) answered the questionnaire with the help of their parents. As the Quick DASH questionnaire is a subjective rating scale, all children also underwent a clinical evaluation by their respective treating surgeon to obtain an objective assessment. Long-term follow-up results could not identify any range of motion limitation and all children

were able to resume to full activities without any discomfort. The good clinical and radiological outcomes observed in the present study are similar to those reported by Sessa et al. [10] and, more recently, by Xie and colleagues [11–13]. Xie et al. [11] reported 25 children between 6 and 15 years of age treated with ESIN for displaced proximal humeral

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fractures with translation and angulation above 65% and 451, respectively. Mean follow-up was 20 months. All fractures healed. Functional outcomes were assessed by shoulder range of motion and the degree of subjective satisfaction. Wei et al. [12] reported 43 children between 3 and 17 years of age treated with ESIN for displaced proximal humeral fractures (Neer type III and type IV) [22]. Mean follow-up was 20 months. All fractures healed and all patients returned to full sport activities [12]. Fernandez et al. [13] reported 35 children treated with ESIN for displaced proximal humeral fractures (Neer type III and type IV). Mean age at surgery was 12.7 years with a mean follow-up of 26 months. All children had good functional outcome and did not report any residual pain or discomfort [13]. However, none of these authors used a standardized scale to assess outcome and functional assessment was performed by various surgeons. Thus, the lack of a standardized tool to evaluate outcome makes the comparison of patients difficult. Moreover, obtaining this functional score during the early postoperative period may provide additional useful data to compare this treatment with nonoperative management.

The Quick DASH questionnaire has not been frequently used in children. Colovic et al. [23] used a modified version of the DASH questionnaire to evaluate elbow function after supracondylar fractures in children. Colovic et al. [23] shortened the original questionnaire and did ask only age-related questions. The scoring system was also simplified, according to the ability of children to differentiate various options. They found the questionnaire a valuable tool to estimate the effects of physical therapy, and the clinical outcome of children with supracondylar fractures. To date this is the only reported application of the DASH questionnaire in children. More recently, Bae et al. [24] used the DASH questionnaire to evaluate shoulder motion, strength, and functional outcomes in children with established malunion of the clavicle. Similarly, Behr et al. [25] used the DASH questionnaire to evaluate scaphoid nonunions in skeletally immature adolescents.

Although our study presents a higher number of patients with a similar mean follow-up compared with previous reports [10–13], we encountered some limitations in the analysis of our results. First, although there is no set age limit, the Quick DASH questionnaire was developed for adults. However, 86.3% of our patients were older than 8 years of age and they were able to fully understand the questions and answer independently [18,19]. Moreover, results were not significantly different when patients under the age of 8 years were excluded from data analysis.

Third, stable fixation of the proximal humerus could only be achieved by anchoring the tip of the nails in the epiphysis [11,13]. Crossing the proximal humerus growth plate once with each nail does not sufficiently damage the epiphyseal plate to create permanent growth disturbances [26–28]. Radiographs showed that all fractures healed without shortening deformity or epiphyseal arrest at an early stage; clinically, the arm length was equal in all children. Some patients had short follow-up and therefore it is not possible to exclude growth plate disturbances. Our findings are in contrast to those reported by Chee et al. [29] that found one out of 14 patients (7%) of humeral shortening following ESIN crossing the growth plate. However, we could identify only one case of humeral shortening out of 132 patients treated with ESIN for proximal humerus fracture published to date (Table 3).

Table 2

Comparison of patients between institutions

Number of patients Sex ratio (male : female) Right : left Mean age (years) Mean angulation (deg.) Translation (%) Open reduction (n) Physeal : metaphyseal fracture ratio Lost to follow-up Mean Quick DASH score

Institution 1

Institution 2

P

30 11 : 19 14 : 16 11.6±2.7 55±19.8 52.3±33.6 0 8 : 22 2 1.8

28 11 : 17 15 : 13 10.6±2.9 40.2±20.3 85.4±25.0 1 4 : 24 4 0.4

NA > 0.05 > 0.05 < 0.05 > 0.05 < 0.05 NA NA NA > 0.05

NA, not available.

Second, although the number of physeal fractures was lower compared with metaphyseal injuries, we did not observe any statistically significant difference among the two patient groups.

Conclusion

Our study reports good, long-term, functional outcomes in children with closed isolated fractures, both physeal and metaphyseal, of the proximal humerus treated surgically. The use of a standardized rating scale is recommended to homogeneously compare functional

Table 3 Reported humeral shortening in case series dealing with fractures, both physeal and metaphyseal, of the proximal humerus treated surgically with elastic stable intramedullary nailing

References Chee et al. [29] Fernandez et al. [13] Xie et al. [11] This study Total

Number of patients 14 35 25 58 132

Mean follow-up (months) 14.6 26.0 20.4 18.3

(6–32) (6–58) (7–40) (6–39.5) –

Growth disturbances (humeral shortening)

Clinical outcome

1 0 0 0 1

Good Good Good Good –

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Evaluation of proximal humerus fractures Canavese et al.

outcome and may facilitate the comparison of clinical outcome in different patient populations.

Acknowledgements

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Conflicts of interest

There are no conflicts of interest.

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Evaluation of upper-extremity function following surgical treatment of displaced proximal humerus fractures in children.

This study aims to assess the functional outcome of children treated with elastic stable intramedullary nailing (ESIN) for displaced proximal humerus ...
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