ORIGINAL ARTICLE
Rate and Risk Factors for Delayed Healing Following Surgical Treatment of Lateral Condyle Humerus Fractures in Children Lissette Salgueiro, MD,* Joanna H. Roocroft, MA,w Tracey P. Bastrom, MA,w Eric W. Edmonds, MD,wz Andrew T. Pennock, MD,wz Vidyadhar V. Upasani, MD,wz and Burt Yaszay, MDw
Background: Lateral condyle humerus fracture nonunion after surgical fixation has been reported to be 2 mm of displacement be surgically fixed.2–4 The rate of nonunion after surgical fixation has been reported to be 0.05) or not confounding are removed from the multivariate model. Any variable that is nonsignificant, but changes the parameter estimates of any significant predictor variable by Z15% is included in the final model for its interactive or covariate effects. According to purposeful selection, confounders are not to be evaluated by their significance but by their influence on the parameter estimates of the significant variables. If the presence of
2 | www.pedorthopaedics.com
J Pediatr Orthop
Volume 00, Number 00, ’’ 2015
another variable changes the parameter estimates of a significant variable by at least 15%, it is considered a “confounding” variable. A confounder correlates with both the independent and dependent variable and can be considered a mediating factor that one should account for in a predictive model. SPSS version 12 was utilized to perform analysis (SPSS Inc, Chicago, IL).
RESULTS We identified 210 children that met criteria. The majority (192: 91%) were treated by open reduction internal fixation (ORIF). Nine percent (18) were treated with closed reduction and percutaneous pinning (CRPP). Fractures treated with CRPP underwent an elbow arthrogram to determine that the articular surface was intact and there was no articular step-off. Closed reduction was performed by supinating the forearm, extending the wrist, and applying a valgus force at the elbow. Percutaneous fixation was performed with two 1.6 k-wires. For the ORIF group, a lateral column approach to the distal humerus was performed. The fracture was identified under direct visualization. Care was taken to avoid dissection at the posterior cortex. Reduction method was performed by surgeon’s preference with either a dental pick, finger manipulation, and/or utilization of a pointed clamp. Percutaneous fixation was then performed with two or three 1.6 k-wires. The goal in placing the pins was to have good bone fixation at entry and exit of each pin (bicortical fixation). The pins were removed at the fourth week postoperative. Patients were casted with a univalved long arm cast intraoperatively which was overwrapped at the first week postoperatively. Patients used a cuff and collar or were provided a sling postoperative. There was no difference between the CRPP and ORIF groups in terms of delayed healing, therefore they were analyzed together. Mean age at time of presentation was 4.8 years (range, 1 to 12 y) and 64% were boys. Regarding laterality of injury, 44% were right-sided and 56% were left-sided fractures. All fractures were closed and had intact neurological and vascular examinations. Mean follow-up was 25 weeks (range, 4 wk to 5 y). Patients with under 8 weeks of follow-up were included if they were determined to be healed. Ninety-four percent of fractures were Milch type II. Distribution of Weiss et al classification was as follows: type 1, 8 (4%); type 2, 61 (29%); and type 3, 141 (67%). There were 33 (16%) delayed unions and 7 of these required further surgery to achieve healing (3% of the entire cohort). These 7 reoperative children underwent CT scan at a mean 11 weeks (range, 8.5 to 17.5 wk) postoperatively to confirm lack of healing before secondary intervention. Time to healing was 6.6 ± 1 weeks in the normal healing group and 17 ± 7 weeks in the delayed healing group (Table 1). In addition, the time of immobilization in a cast was longer in the later group (6.1 ± 2 wk for normal healing vs. 9.6 ± 4 wk in the delayed healing group, P < 0.001). There was no significant difference in rate of delayed healing and the Weiss et al classification. There was no significant difference in treating surgeon exCopyright
r
2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
J Pediatr Orthop
Volume 00, Number 00, ’’ 2015
Delayed Healing Risks of Lateral Condyle Fractures
FIGURE 1. Radiographic measurements to evaluate pin configuration. A, Angle between most separated pins. B, Distance between the most distal pin and the medial epicondyle. Angle between each pin and the long axis of the humerus in the AP (C) and lateral view (D).
perience between the delayed healing group and the normal healing group (Table 1, P = 0.64). However, all children that required secondary surgical intervention to achieve healing were initially treated by surgeons in their first 2 years of practice. None of the variables measured to assess pin configuration were found to be significantly different between groups (Table 2). Weiss et al classification, intraoperative fluoroscopy time, and intraoperative displacement after fixation met criteria for entry into the regression analysis (Table 3). While Weiss et al classification did not remain significant within the model, its removal resulted in a 30% change in the parameter estimate for intraoperative fluoroscopy time. This meets criteria for confounding variable according to purposeful selection, thus is preserved in the final model. The 30% change in parameter estimate for fluoroscopy time when Weiss et al classification is introduced to the model indicates there is a mediating effect of fracture severity between fluoroscopy time and delayed healing that needs to be controlled for. For each second in increased fluoroscopy time, there is a 3% increase in the risk of delayed healing. For every 0.1 mm increase in intraoperative displacement after fixation, there is an 18% increase in the risk of delayed healing. Further statistical Copyright
r
evaluation demonstrated that children with >1 mm displacement after fixation had an increased risk of delayed healing (OR = 4.78; 95% CI, 1.6-14.3; P < 0.001).
DISCUSSION In contrast to most intra-articular fractures, lateral condyle humerus fractures in children are treated with temporary fixation and a short period of immobilization. While the rate of nonunion following surgical fixation has been reported to be low, nonunion is not the only complication related to healing experienced after this treatment. We found a 16% rate of delayed healing as defined by continued radiolucency at 8 weeks postoperative with 7 of these children requiring further surgical intervention to achieve healing. Previous reports have not specifically evaluated delayed healing as a complication from this injury. We believe that delayed union is a relevant sequela of any fracture as this can result in prolonged casting which can be frustrating for the patient, increases costs and resource utilization, and increases risk of elbow stiffness. We defined delayed union as continued radiolucency at 8 weeks postoperative as determined by a consensus of 6 pediatric orthopaedic physicians. While
2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
www.pedorthopaedics.com |
3
J Pediatr Orthop
Salgueiro et al
TABLE 1. Descriptive Statistics and Univariate Analyses for Demographic, Preoperative, and Intraoperative Variables in Both Normal Healing and Delayed Healing Groups Normal Healing Time to healing (wk) 6.6 ± 1 Age 5±2 Sex (male/female) (%) 61/39 Sidedness (left/right) (%) 55/45 Initial fracture displacement 7.2 ± 6 Weiss et al classification (%) I 6 II 32 III 62 Milch classification (%) I 4 II 96 Operative technique (%) CRPP 8 ORIF 92 Surgeon experience (years in practice) (%) 2 mm of displacement with disruption of the articular surface. They reported that a type III lateral condyle fracture was associated with 3 times increased risk of complications as compared with a type II. In the present study, the rate of delayed healing did not differ Copyright
r
2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
J Pediatr Orthop
Volume 00, Number 00, ’’ 2015
Delayed Healing Risks of Lateral Condyle Fractures
TABLE 3. Final Regression Model Weiss Fluoroscopy time (s) Intraoperative displacement (mm)
P
OR
95% CI for OR
0.77 0.03 < 0.001
N/A 1.03 1.19
N/A 1.04-1.06 1.08-1.31
CI indicates confidence interval; OR, odds ratio.
between these 2 types of fractures. While Weiss et al classification did not remain significant within the model, its removal resulted in a 30% change in the parameter estimate for intraoperative fluoroscopy time. Therefore, there does seem to be an interaction between fracture severity and intraoperative fluoroscopy time and the risk of delayed healing. It is possible that fluoroscopy time is a surrogate for fracture severity or difficulty in achieving reduction. It can also be postulated that intraoperative fluoroscopy time is related to surgeon experience. Although there was no difference between the delayed healing and normal healing group in terms of surgeon’s experience, all patients that required secondary surgical intervention to achieve healing were found to have been treated by surgeons in their first 2 years of practice, which includes pediatric orthopaedic fellowship year. In combination with the intraoperative fluoroscopy finding, this suggests that there may be a learning curve on the treatment of these fractures as has been suggested with supracondylar fractures.16 Intraoperative fracture displacement after fixation was found to be a risk factor for delayed healing (Fig. 2). Our PACS system ruler tool measures the accuracy to the tenth, and therefore the regression suggests that for every 0.1 mm increase in displacement, there was an 18% increase in the risk of delayed healing. In more clinically relevant terms, fractures with >1 mm of displacement after fixation have an increased risk of complications related to healing with an odds ratio of 4.78. This emphasizes the importance of anatomic reduction and maintenance of that reduction through compression and stable pin fixation. No previous study has evaluated the amount of fracture displacement after fixation as a risk factor for delayed healing or nonunion. It is important to remember that this displacement is not analogous to preoperative fracture displacement as we know that fractures with up to 2 mm of displacement heal adequately without the need for surgery. Moreover, the fracture displacement of the delayed healing group increased over time with serial follow-up x-rays. In our delayed healing group, mean time to fracture healing was 17 ± 7 weeks. The optimal time to order a CT is still controversial. Even though it took >10 weeks, these fractures went on to heal; yet, the timing of obtaining the CT scans in the confirmed nonunion cohort was a mean 11 weeks. While not specifically measured in this study, the gestalt on radiographic review was that patients in the delayed healing group were demonstrating slow progression of healing in the course of their followup as compared with the patients who underwent CT scan and secondary surgical intervention. While we cannot make recommendations based on our data, it does appear Copyright
r
FIGURE 2. Intraoperative fracture displacement after fixation.
that the decision to order further imaging to evaluate for possible nonunion requiring return to the operating room should take into account whether there is any evidence of healing progression during the postoperative course. The lack of consistency in obtaining advanced imaging is one of the limitations of this study. Further research will be necessary to validate any recommendation for obtaining advanced imaging, and in the meantime we will consider continued lack of healing at 3 months a reasonable trigger to obtain imaging CT. Delayed union of lateral condyle fractures is still a matter of concern and the rate of secondary surgery due to lack of healing of 3% appears to be higher than previously reported (1%).5,6 In conclusion, risks for delayed healing include amount of residual displacement after reduction and the difficulty in attaining that reduction, as defined by fluoroscopy time. Fluoroscopy time may be a surrogate to both fracture severity and/or surgeon experience. Families with children who have severe fracture patterns, particularly in cases where complete anatomic reduction
2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
www.pedorthopaedics.com |
5
J Pediatr Orthop
Salgueiro et al
could not be obtained, should be counseled of the potential risk of complications related to healing. REFERENCES 1. Tejwani N, Phillips D, Goldstein RY. Management of lateral humeral condylar fracture in children. J Am Acad Orthop Surg. 2011;19:350–358. 2. Flynn JC. Nonunion of slightly displaced fractures of the lateral humeral condyle in children: an update. J Pediatr Orthop. 1989;9: 691–696. 3. Flynn JC, Richards JF Jr, Saltzman RI. Prevention and treatment of non-union of slightly displaced fractures of the lateral humeral condyle in children. An end-result study. J Bone Joint Surg Am. 1975;57:1087–1092. 4. Song KS, Waters PM. Lateral condylar humerus fractures: which ones should we fix? J Pediatr Orthop. 2012;32(suppl 1):S5–S9. 5. Thomas DP, Howard AW, Cole WG, et al. Three weeks of Kirschner wire fixation for displaced lateral condylar fractures of the humerus in children. J Pediatr Orthop. 2001;21:565–569. 6. Weiss JM, Graves S, Yang S, et al. A new classification system predictive of complications in surgically treated pediatric humeral lateral condyle fractures. J Pediatr Orthop. 2009;29:602–605. 7. Bloom T, Chen LY, Sabharwal S. Biomechanical analysis of lateral humeral condyle fracture pinning. J Pediatr Orthop. 2011;31:130–137.
6 | www.pedorthopaedics.com
Volume 00, Number 00, ’’ 2015
8. Launay F, Leet AI, Jacopin S, et al. Lateral humeral condyle fractures in children: a comparison of two approaches to treatment. J Pediatr Orthop. 2004;24:385–391. 9. Milch H. Fractures and fracture dislocations of the humeral condyles. J Trauma. 1964;4:592–607. 10. Klatt JB, Aoki SK. The location of the medial humeral epicondyle in children: position based on common radiographic landmarks. J Pediatr Orthop. 2012;32:477–482. 11. Bursac Z, Gauss CH, Williams DK, et al. Purposeful selection of variables in logistic regression. Source Code Biol Med. 2008;3:17. 12. Haraldsson S. On osteochondrosis deformas juvenilis capituli humeri including investigation of intra-osseous vasculature in distal humerus. Acta Orthop Scand Suppl. 1959;38:1–232. 13. Hausman MR, Qureshi S, Goldstein R, et al. Arthroscopicallyassisted treatment of pediatric lateral humeral condyle fractures. J Pediatr Orthop. 2007;27:739–742. 14. Perez Carro L, Golano P, Vega J. Arthroscopic-assisted reduction and percutaneous external fixation of lateral condyle fractures of the humerus. Arthroscopy. 2007;23:1131.e1–1131.e4. 15. Song KS, Shin YW, Oh CW, et al. Closed reduction and internal fixation of completely displaced and rotated lateral condyle fractures of the humerus in children. J Orthop Trauma. 2010;24:434–438. 16. Liu RW, Roocroft J, Bastrom T, et al. Surgeon learning curve for pediatric supracondylar humerus fractures. J Pediatr Orthop. 2011; 31:818–824.
Copyright
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2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Rate and Risk Factors for Delayed Healing Following Surgical Treatment of Lateral Condyle Humerus Fractures in Children Lissette Salgueiro, MD,* Joanna H. Roocroft, MA,w Tracey P. Bastrom, MA,w Eric W. Edmonds, MD,wz Andrew T. Pennock, MD,wz Vidyadhar V. Upasani, MD,wz and Burt Yaszay, MDw
Background: Lateral condyle humerus fracture nonunion after surgical fixation has been reported to be 2 mm of displacement be surgically fixed.2–4 The rate of nonunion after surgical fixation has been reported to be 0.05) or not confounding are removed from the multivariate model. Any variable that is nonsignificant, but changes the parameter estimates of any significant predictor variable by Z15% is included in the final model for its interactive or covariate effects. According to purposeful selection, confounders are not to be evaluated by their significance but by their influence on the parameter estimates of the significant variables. If the presence of
2 | www.pedorthopaedics.com
J Pediatr Orthop
Volume 00, Number 00, ’’ 2015
another variable changes the parameter estimates of a significant variable by at least 15%, it is considered a “confounding” variable. A confounder correlates with both the independent and dependent variable and can be considered a mediating factor that one should account for in a predictive model. SPSS version 12 was utilized to perform analysis (SPSS Inc, Chicago, IL).
RESULTS We identified 210 children that met criteria. The majority (192: 91%) were treated by open reduction internal fixation (ORIF). Nine percent (18) were treated with closed reduction and percutaneous pinning (CRPP). Fractures treated with CRPP underwent an elbow arthrogram to determine that the articular surface was intact and there was no articular step-off. Closed reduction was performed by supinating the forearm, extending the wrist, and applying a valgus force at the elbow. Percutaneous fixation was performed with two 1.6 k-wires. For the ORIF group, a lateral column approach to the distal humerus was performed. The fracture was identified under direct visualization. Care was taken to avoid dissection at the posterior cortex. Reduction method was performed by surgeon’s preference with either a dental pick, finger manipulation, and/or utilization of a pointed clamp. Percutaneous fixation was then performed with two or three 1.6 k-wires. The goal in placing the pins was to have good bone fixation at entry and exit of each pin (bicortical fixation). The pins were removed at the fourth week postoperative. Patients were casted with a univalved long arm cast intraoperatively which was overwrapped at the first week postoperatively. Patients used a cuff and collar or were provided a sling postoperative. There was no difference between the CRPP and ORIF groups in terms of delayed healing, therefore they were analyzed together. Mean age at time of presentation was 4.8 years (range, 1 to 12 y) and 64% were boys. Regarding laterality of injury, 44% were right-sided and 56% were left-sided fractures. All fractures were closed and had intact neurological and vascular examinations. Mean follow-up was 25 weeks (range, 4 wk to 5 y). Patients with under 8 weeks of follow-up were included if they were determined to be healed. Ninety-four percent of fractures were Milch type II. Distribution of Weiss et al classification was as follows: type 1, 8 (4%); type 2, 61 (29%); and type 3, 141 (67%). There were 33 (16%) delayed unions and 7 of these required further surgery to achieve healing (3% of the entire cohort). These 7 reoperative children underwent CT scan at a mean 11 weeks (range, 8.5 to 17.5 wk) postoperatively to confirm lack of healing before secondary intervention. Time to healing was 6.6 ± 1 weeks in the normal healing group and 17 ± 7 weeks in the delayed healing group (Table 1). In addition, the time of immobilization in a cast was longer in the later group (6.1 ± 2 wk for normal healing vs. 9.6 ± 4 wk in the delayed healing group, P < 0.001). There was no significant difference in rate of delayed healing and the Weiss et al classification. There was no significant difference in treating surgeon exCopyright
r
2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
J Pediatr Orthop
Volume 00, Number 00, ’’ 2015
Delayed Healing Risks of Lateral Condyle Fractures
FIGURE 1. Radiographic measurements to evaluate pin configuration. A, Angle between most separated pins. B, Distance between the most distal pin and the medial epicondyle. Angle between each pin and the long axis of the humerus in the AP (C) and lateral view (D).
perience between the delayed healing group and the normal healing group (Table 1, P = 0.64). However, all children that required secondary surgical intervention to achieve healing were initially treated by surgeons in their first 2 years of practice. None of the variables measured to assess pin configuration were found to be significantly different between groups (Table 2). Weiss et al classification, intraoperative fluoroscopy time, and intraoperative displacement after fixation met criteria for entry into the regression analysis (Table 3). While Weiss et al classification did not remain significant within the model, its removal resulted in a 30% change in the parameter estimate for intraoperative fluoroscopy time. This meets criteria for confounding variable according to purposeful selection, thus is preserved in the final model. The 30% change in parameter estimate for fluoroscopy time when Weiss et al classification is introduced to the model indicates there is a mediating effect of fracture severity between fluoroscopy time and delayed healing that needs to be controlled for. For each second in increased fluoroscopy time, there is a 3% increase in the risk of delayed healing. For every 0.1 mm increase in intraoperative displacement after fixation, there is an 18% increase in the risk of delayed healing. Further statistical Copyright
r
evaluation demonstrated that children with >1 mm displacement after fixation had an increased risk of delayed healing (OR = 4.78; 95% CI, 1.6-14.3; P < 0.001).
DISCUSSION In contrast to most intra-articular fractures, lateral condyle humerus fractures in children are treated with temporary fixation and a short period of immobilization. While the rate of nonunion following surgical fixation has been reported to be low, nonunion is not the only complication related to healing experienced after this treatment. We found a 16% rate of delayed healing as defined by continued radiolucency at 8 weeks postoperative with 7 of these children requiring further surgical intervention to achieve healing. Previous reports have not specifically evaluated delayed healing as a complication from this injury. We believe that delayed union is a relevant sequela of any fracture as this can result in prolonged casting which can be frustrating for the patient, increases costs and resource utilization, and increases risk of elbow stiffness. We defined delayed union as continued radiolucency at 8 weeks postoperative as determined by a consensus of 6 pediatric orthopaedic physicians. While
2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
www.pedorthopaedics.com |
3
J Pediatr Orthop
Salgueiro et al
TABLE 1. Descriptive Statistics and Univariate Analyses for Demographic, Preoperative, and Intraoperative Variables in Both Normal Healing and Delayed Healing Groups Normal Healing Time to healing (wk) 6.6 ± 1 Age 5±2 Sex (male/female) (%) 61/39 Sidedness (left/right) (%) 55/45 Initial fracture displacement 7.2 ± 6 Weiss et al classification (%) I 6 II 32 III 62 Milch classification (%) I 4 II 96 Operative technique (%) CRPP 8 ORIF 92 Surgeon experience (years in practice) (%) 2 mm of displacement with disruption of the articular surface. They reported that a type III lateral condyle fracture was associated with 3 times increased risk of complications as compared with a type II. In the present study, the rate of delayed healing did not differ Copyright
r
2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
J Pediatr Orthop
Volume 00, Number 00, ’’ 2015
Delayed Healing Risks of Lateral Condyle Fractures
TABLE 3. Final Regression Model Weiss Fluoroscopy time (s) Intraoperative displacement (mm)
P
OR
95% CI for OR
0.77 0.03 < 0.001
N/A 1.03 1.19
N/A 1.04-1.06 1.08-1.31
CI indicates confidence interval; OR, odds ratio.
between these 2 types of fractures. While Weiss et al classification did not remain significant within the model, its removal resulted in a 30% change in the parameter estimate for intraoperative fluoroscopy time. Therefore, there does seem to be an interaction between fracture severity and intraoperative fluoroscopy time and the risk of delayed healing. It is possible that fluoroscopy time is a surrogate for fracture severity or difficulty in achieving reduction. It can also be postulated that intraoperative fluoroscopy time is related to surgeon experience. Although there was no difference between the delayed healing and normal healing group in terms of surgeon’s experience, all patients that required secondary surgical intervention to achieve healing were found to have been treated by surgeons in their first 2 years of practice, which includes pediatric orthopaedic fellowship year. In combination with the intraoperative fluoroscopy finding, this suggests that there may be a learning curve on the treatment of these fractures as has been suggested with supracondylar fractures.16 Intraoperative fracture displacement after fixation was found to be a risk factor for delayed healing (Fig. 2). Our PACS system ruler tool measures the accuracy to the tenth, and therefore the regression suggests that for every 0.1 mm increase in displacement, there was an 18% increase in the risk of delayed healing. In more clinically relevant terms, fractures with >1 mm of displacement after fixation have an increased risk of complications related to healing with an odds ratio of 4.78. This emphasizes the importance of anatomic reduction and maintenance of that reduction through compression and stable pin fixation. No previous study has evaluated the amount of fracture displacement after fixation as a risk factor for delayed healing or nonunion. It is important to remember that this displacement is not analogous to preoperative fracture displacement as we know that fractures with up to 2 mm of displacement heal adequately without the need for surgery. Moreover, the fracture displacement of the delayed healing group increased over time with serial follow-up x-rays. In our delayed healing group, mean time to fracture healing was 17 ± 7 weeks. The optimal time to order a CT is still controversial. Even though it took >10 weeks, these fractures went on to heal; yet, the timing of obtaining the CT scans in the confirmed nonunion cohort was a mean 11 weeks. While not specifically measured in this study, the gestalt on radiographic review was that patients in the delayed healing group were demonstrating slow progression of healing in the course of their followup as compared with the patients who underwent CT scan and secondary surgical intervention. While we cannot make recommendations based on our data, it does appear Copyright
r
FIGURE 2. Intraoperative fracture displacement after fixation.
that the decision to order further imaging to evaluate for possible nonunion requiring return to the operating room should take into account whether there is any evidence of healing progression during the postoperative course. The lack of consistency in obtaining advanced imaging is one of the limitations of this study. Further research will be necessary to validate any recommendation for obtaining advanced imaging, and in the meantime we will consider continued lack of healing at 3 months a reasonable trigger to obtain imaging CT. Delayed union of lateral condyle fractures is still a matter of concern and the rate of secondary surgery due to lack of healing of 3% appears to be higher than previously reported (1%).5,6 In conclusion, risks for delayed healing include amount of residual displacement after reduction and the difficulty in attaining that reduction, as defined by fluoroscopy time. Fluoroscopy time may be a surrogate to both fracture severity and/or surgeon experience. Families with children who have severe fracture patterns, particularly in cases where complete anatomic reduction
2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
www.pedorthopaedics.com |
5
J Pediatr Orthop
Salgueiro et al
could not be obtained, should be counseled of the potential risk of complications related to healing. REFERENCES 1. Tejwani N, Phillips D, Goldstein RY. Management of lateral humeral condylar fracture in children. J Am Acad Orthop Surg. 2011;19:350–358. 2. Flynn JC. Nonunion of slightly displaced fractures of the lateral humeral condyle in children: an update. J Pediatr Orthop. 1989;9: 691–696. 3. Flynn JC, Richards JF Jr, Saltzman RI. Prevention and treatment of non-union of slightly displaced fractures of the lateral humeral condyle in children. An end-result study. J Bone Joint Surg Am. 1975;57:1087–1092. 4. Song KS, Waters PM. Lateral condylar humerus fractures: which ones should we fix? J Pediatr Orthop. 2012;32(suppl 1):S5–S9. 5. Thomas DP, Howard AW, Cole WG, et al. Three weeks of Kirschner wire fixation for displaced lateral condylar fractures of the humerus in children. J Pediatr Orthop. 2001;21:565–569. 6. Weiss JM, Graves S, Yang S, et al. A new classification system predictive of complications in surgically treated pediatric humeral lateral condyle fractures. J Pediatr Orthop. 2009;29:602–605. 7. Bloom T, Chen LY, Sabharwal S. Biomechanical analysis of lateral humeral condyle fracture pinning. J Pediatr Orthop. 2011;31:130–137.
6 | www.pedorthopaedics.com
Volume 00, Number 00, ’’ 2015
8. Launay F, Leet AI, Jacopin S, et al. Lateral humeral condyle fractures in children: a comparison of two approaches to treatment. J Pediatr Orthop. 2004;24:385–391. 9. Milch H. Fractures and fracture dislocations of the humeral condyles. J Trauma. 1964;4:592–607. 10. Klatt JB, Aoki SK. The location of the medial humeral epicondyle in children: position based on common radiographic landmarks. J Pediatr Orthop. 2012;32:477–482. 11. Bursac Z, Gauss CH, Williams DK, et al. Purposeful selection of variables in logistic regression. Source Code Biol Med. 2008;3:17. 12. Haraldsson S. On osteochondrosis deformas juvenilis capituli humeri including investigation of intra-osseous vasculature in distal humerus. Acta Orthop Scand Suppl. 1959;38:1–232. 13. Hausman MR, Qureshi S, Goldstein R, et al. Arthroscopicallyassisted treatment of pediatric lateral humeral condyle fractures. J Pediatr Orthop. 2007;27:739–742. 14. Perez Carro L, Golano P, Vega J. Arthroscopic-assisted reduction and percutaneous external fixation of lateral condyle fractures of the humerus. Arthroscopy. 2007;23:1131.e1–1131.e4. 15. Song KS, Shin YW, Oh CW, et al. Closed reduction and internal fixation of completely displaced and rotated lateral condyle fractures of the humerus in children. J Orthop Trauma. 2010;24:434–438. 16. Liu RW, Roocroft J, Bastrom T, et al. Surgeon learning curve for pediatric supracondylar humerus fractures. J Pediatr Orthop. 2011; 31:818–824.
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Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
