Stuart L Mitchell1, Brian T Sullivan1, Christine A Ho2,3,4, Joshua M Abzug5, Micheal Raad1, Paul D Sponseller1. 1. Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland. 2. Department of Orthopaedic Surgery, Texas Scottish Rite Hospital for Children, Dallas, Texas. 3. Department of Orthopaedic Surgery, Children's Medical Center, Dallas, Texas. 4. Department of Orthopaedic Surgery, UT Southwestern Medical Center, Dallas, Texas. 5. Department of Orthopaedic Surgery, University of Maryland Medical Center, Baltimore, Maryland.
Abstract
BACKGROUND: Knowledge is limited about the diagnosis and treatment of modified Gartland type-IV supracondylar humeral fractures. We determined the prevalence of type-IV fractures, identified preoperative characteristics associated with these injuries, and assessed operative treatment characteristics. METHODS: We retrospectively identified patients <16 years of age who underwent operative treatment of a supracondylar humeral fracture at 2 centers between 2008 and 2016. We compared patient, injury, and treatment characteristics between type-IV and type-III fracture groups (1:4, cases:controls). Preoperative radiographs were assessed by 4 pediatric orthopaedists blinded to fracture type. The odds of a fracture being type IV were assessed using univariate logistic regression for individual radiographic parameters. Significance was set at alpha = 0.05. RESULTS: Type-IV fractures accounted for 39 (1.3%) of the supracondylar humeral fractures treated operatively during the study period. A type-IV fracture was associated with the following radiographic parameters: flexion angulation (odds ratio [OR] = 17; 95% confidence interval [CI] = 4.9 to 59), valgus angulation (OR = 5.6; 95% CI = 1.6 to 20), and lateral translation (OR = 4.1; 95% CI = 1.6 to 11) of the distal fragment; osseous apposition between the proximal and distal fragments (OR = 4.0; 95% CI = 1.8 to 9.0); and propagation of the fracture line toward the diaphysis of the proximal segment (OR = 9.2; 95% CI = 1.6 to 53). We found no significant differences in patient or injury characteristics between the groups. Compared with type-III fractures, type-IV fractures were treated more frequently with open reduction and percutaneous pinning (13% compared with 3.8%; p = 0.04) and were associated with longer mean operative time (82 ± 42 compared with 63 ± 28 minutes; p = 0.001). CONCLUSIONS: We identified 5 preoperative radiographic parameters associated with greater odds of a supracondylar humeral fracture being type IV rather than type III. No patient or injury characteristic differed significantly between the groups. Substantial overlap likely exists between type-IV and flexion-type fractures. Type-IV fractures were associated with longer operative time and were treated with open reduction more frequently than were type-III fractures. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
BACKGROUND: Knowledge is limited about the diagnosis and treatment of modified Gartland type-IV supracondylar humeral fractures. We determined the prevalence of type-IV fractures, identified preoperative characteristics associated with these injuries, and assessed operative treatment characteristics. METHODS: We retrospectively identified patients <16 years of age who underwent operative treatment of a supracondylar humeral fracture at 2 centers between 2008 and 2016. We compared patient, injury, and treatment characteristics between type-IV and type-III fracture groups (1:4, cases:controls). Preoperative radiographs were assessed by 4 pediatric orthopaedists blinded to fracture type. The odds of a fracture being type IV were assessed using univariate logistic regression for individual radiographic parameters. Significance was set at alpha = 0.05. RESULTS: Type-IV fractures accounted for 39 (1.3%) of the supracondylar humeral fractures treated operatively during the study period. A type-IV fracture was associated with the following radiographic parameters: flexion angulation (odds ratio [OR] = 17; 95% confidence interval [CI] = 4.9 to 59), valgus angulation (OR = 5.6; 95% CI = 1.6 to 20), and lateral translation (OR = 4.1; 95% CI = 1.6 to 11) of the distal fragment; osseous apposition between the proximal and distal fragments (OR = 4.0; 95% CI = 1.8 to 9.0); and propagation of the fracture line toward the diaphysis of the proximal segment (OR = 9.2; 95% CI = 1.6 to 53). We found no significant differences in patient or injury characteristics between the groups. Compared with type-III fractures, type-IV fractures were treated more frequently with open reduction and percutaneous pinning (13% compared with 3.8%; p = 0.04) and were associated with longer mean operative time (82 ± 42 compared with 63 ± 28 minutes; p = 0.001). CONCLUSIONS: We identified 5 preoperative radiographic parameters associated with greater odds of a supracondylar humeral fracture being type IV rather than type III. No patient or injury characteristic differed significantly between the groups. Substantial overlap likely exists between type-IV and flexion-type fractures. Type-IV fractures were associated with longer operative time and were treated with open reduction more frequently than were type-III fractures. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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