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Treatment of type III supracondylar fracture of humerus in children, backslab vs. no backslab after open reduction internal fixation.

Byline: Nouman Maqbool and Amjad Iqbal

Abstract

Objectives: To compare the results of application of pop back slab Vs no back slab after Open reduction internal fixation in type III supracondylar humeral fracture.

Study Design: Randomized controlled trial

Place and Duration of Study: Department of orthopedics, Fauji Foundation Hospital Rawalpindi. Duration: From 01 August, 2008 to 31july, 2009.

Material and Method: Patients with type III supracondylar humeral fracturers aged between 05 to 12 years were recruited from the outpatient and emergency department of Orthopaedic surgery Fauji Foundation Hospital (FFH), Rawalpindi. Open reduction internal fixation was done, Kochers approach was used and fixation was secured with two k-wires.

Result: Of total 70 patients, 52(74.28%) were males and 18(25.72%) were females. Forty two (60 %) of the patients had age range between 05 to 08, and 28 (40 %) were between 09 to 12 years old. In 51(72.85%) left elbow was involved while right elbow was involved in 19 patients (27.15%). Outcome of the procedure was analyzed according to Flynn's criteria showing excellent results in 21 patients (60%), good in 9 (25.71%), fair in 04 (11.43%) and poor in 01(2.86%) in Group-I (with back slab) while in Group-II(without back slab) the results were excellent in 22 patients (62.85%), good in 7 (20%), fair in 04 (11.43%) and poor in 02(5.72%)

Conclusion: By comparing patients with and without back slabs after ORIF of supracondylar fractures, we found no additional benefit in terms of stability, instead achieving early rehabilitation period, avoids extra cost and save valuable time of the surgical team without compromising any functional and cosmetic difference.

Article

INTRODUCTION

Supracondylar humeral fractures are the most common fractures seen in children, It has a greater rate of malunion, nerve injury, and poor results than any type of extremity fracture.1, 2 In the past, it was thought that cubitus varus or cubitus valgus occurred because of growth arrest of the distal humeral epiphysis.3 Now it has been established that it is because of malreduction of the fracture.4

Supracondylar fracture has an extension variety which is caused by fall on out stretched hand and flexion variety, caused by a fall on the point of the flexed elbow. Gartland's5 proposed a useful classification of supracondylar fractures of humerus in children, and it is most commonly used. Gartland Type I being non-displaced, Type II hinged, and Type III displaced with circumferential break in the cortex with total displacement (no cortical contact). Extension type fractures, account for approximately 97% to 99%5 while 2.2% are flexion type.

The age range in which most fractures occur is between five to seven years.6 and it occurs through the weak metaphysis of distal humerus.5

Several studies8-10 have been carried out for the treatment of these fractures in children, i.e. with open reduction and internal fixation and some with closed reduction and internal fixation but in both techniques after performing the procedure, backslab was applied and then removed usually at 4 to 6 weeks.

This was the first study planned to determine the outcome of the patients after performing open reduction and internal fixation followed by no backslab by using flynn's criteria at 6 weeks and at 12 weeks follow up.

MATERIALs AND METHODS

These randomized controlled trials were conducted at the department of Orthopedics Fauji Foundation Hospital Rawalpindi from August 2008 to July 2009.

Study consisted of 70 cases of Gartland's type III supracondylar fractures in children admitted in FFH from 01 August, 2008 to 31 July, 2009.

The inclusion criteria was children of 5-12 years of age with close type III supracondylar fracture of humerus presented within one week after fracture. The exclusion criteria were Gartland type I & II, open fractures, maltreated fractures and those with severe edema at elbow.

Upon admission informed consent was obtained from the patient parents or guardian and then the patients were divided into two groups with 35 cases in each, using randomized number table. 35 cases (Group I) were treated by open reduction internal fixation followed by back slab while 35 cases in Group II were treated by open reduction and internal fixation without back slab application at the end of procedure. Standard Kocher's approach was used. The fractures were fixed with two parallel, cross or three K wires, to obtained stability at the time of surgery and were left protruding through the skin, covered with sterile dressings and secured by bending the distal tip. Patients were discharged on an average three to four days after surgery, active exercises of fingers, wrist, elbow, shoulder were started in patients without back slab, i.e. groupII, but elbow exercises were not possible in patients with backslab i.e. group 1.

First follow up was done at 2 weeks for stitch removal for both groups but backslab was reapplied in group 1. Second follow up was made at 6 weeks from the date of surgery for removal of pins in both groups and backslab in group 1 and first assessment was made at that time by using Flynn's criteria. Third follow up was made at 12 weeks from the date of surgery and assessment was done by using Flynn criteria11 (table 1) i.e. functional and cosmetic factors.

Data was analyzed using computer software SPSS version 11. Descriptive statistics were used to describe the data. Chi-square test was used to compare the outcome of both the groups. A p-value of <0.05 was considered as significant.

RESULTS

Of total 70 patients, number of male patients in group 1 were 23 (65.71%) and 29 (82.86%) were in group 11. where as number of female patients in group 1 were 12 (34.29%) and 06(17.14%) were in group 11 (Table.1).

Table-1: Gender distiibution

###Group-I###Group-II

Gender###(n=35)###(n=35)

###Numbers###%###Numbers###%

Male###23###65.71###29###82.86

Female###12###34.29###06###17.14

Total###70###100###35###100

Total Numbers of patients with age range of 05-08 years were 42 (60 %), n=18 in group 1 and n=24 in group 11 and with 09-12 years were 28 (40 %), as n= 10 in group 1 and n= 8 in group 11 (Table-2).

Table-2: A~e distiibution

###Group-I###Group-II

(Age in years)###(n=35)###(n=35)

###Number###%###Number###%

5-8###18###51.43###24###68.57

9-12###10###28.57###8###22.86

Total###35###100###35###100

Mean and###7.51+-2.28###7.37+-1.98

SD.

P Value =0.778

In majority of the patients 51(72.85%) left elbow was involved while right elbow was involved in 19 patients (27.15%). Follow up Table no 4, was done at 02nd week for stitch removal and reapplication of back slab and only stitch removal in group 11. At 06th week for pin removal and first assessment and at 12th week post operatively for final assessment and results are analyzed according to Flynn"s criteria.

Table-3. Outcome of the procedure was excellent in 21 patients (60%), good in 9 (25.71%), fair in 04 (11.43%) and poor in 01(2.86%) in Group-I while in Group-II excellent in 22 patients (62.85%), good in 7 (20%), fair in 04 (11.43%) and poor in 02(5.72%). Table 4.

Table-3: Criteria for fracture assessment Flynn criteria

###cosmetic factor - loss Functloini facior

Results###ofcrying angel###of motion

###(degree)###(degree)

Excellent###0-5###0-5

Good###6-10###6-10

Fair###11-5###11-15

Poor###Greater than###15###Greater than 15

Group II

Table-3. Outcome of the procedure was excellent in 21 patients (60%), good in 9 (25.71%), fair in 04 (11.43%) and poor in 01(2.86%) in Group-I while in Group-II excellent in 22 patients (62.85%), good in 7 (20%), fair in 04 (11.43%) and poor in 02(5.72%). Table 4.

Table-4 Outcome of the procedure (Cosmetic and functional Factor)

###Group - I###Group - II

Outcome###(n=35)###(n=35)

###Numbers###%###Numbers###%

Excllent###21###60###22###62.85###

Good###09###25.71###07###20

Fair###04###11.43###04###11.43

Poor###01###2.86###02###5.72

Total###35###100###35###100

pvalue=0.05

DISCUSSION

Supracondylar fracture of the humerus is one of the commonest fractures in children.13 Gartland extension type III fractures may present problems in their management by plaster immobilization only, even after acceptable initial reduction.

In this study, the results of two techniques i.e. application of post operative back slab were compared with those patients in which back slab not applied. In this series total male patients were 52, 74.28% while 18, 25.72% cases were females. These findings are in accordance with a study conducted by Shoaib Muhammad13 and colleagues where 70% male and 30% female patients were recorded.

By comparing cosmetic and functional factors according to Flynn criteria, 12 excellent, good, fair and poor results had no significance difference and both groups had almost similar results at the end of 12 weeks which shows that after ORIF application of back slab has no effect on cosmetic and functional outcome of the patients. However at 6 weeks in group 1 there was limited painful range of motion at elbow ranging from 80 to 110 degree (flexion and extension respectively) whereas in group II, there was comparatively good range of motion ranging from 45 to 110 degrees with minimal pain. Further at 12 weeks in group 1 there was active range of motion ranging from 0 to 140 degree and in group 2 range of motion was from 0 to 150 degrees with no pain. However, these results are also comparable with other studies as well, where excellent results are found in 65%, good 20%, and poor only 15%.

CONCLUSION

The literature have stressed upon application of backslab after ORIF however its application at the end of surgery, at the time of removal of drain and at the time of removal of stitches do cause pain and discomfort to the patient. Whereas our method of treatment without backslab avoid such pain and discomfort without compromising any cosmetic and functional results. This study also indicates that application of backslab has no additional benefit in terms of stability rather this allows early rehabilitation avoid extra cost and save valuable time of the surgical team. Patient feels much more comfortable and can pursue more unrestricted activity comparing that of with pop backslab at the elbow.

Reference

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2.Bamrungthin N. Comparison of posterior and lateral surgical approach in management of type III supracondylar fractures of the humerus among the children. J Med Assoc Thai 2008; 91: 502-6.

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5.Ozcelik A, Tekcan AF, Omeroglu H. Correlation between iatrogenic ulnar nerve injury and angular insertion of the medial pin in supracondylar humerus fractures. J Pediatr Orthop B 2006; 15: 58-61.

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8.Devkota P, Khan JA, Acharya BM, et al. Outcome of Supracondylar Fractures of the Humerus in Children Treated by Closed Reduction and Percutaneous Pinning. J Nepal Med Assoc 2008; 47(170):66-70.

9.Wael A. El-Adl, Mohammed A. Results of treatment of displaced supracondylar humeral fractures in children by percutaneous lateral cross-wiring technique. Strategies Trauma Limb Reconstr. 2008; 3: 1: 1-7.

10.SU Khan. Open reduction and internal fixation of severely displaced humeral supracondylar fractures in children. Indian J Orthop 2003; 37(1):

11.Flynn JC, Mattews JG, Beriot RL. BUCD pinning of displaced supracondylar fracture of humerus in children. J Bone Joint Surg 1974: 56-A: 263-72.

12.B Garg, A Pankaj, R Malhotra, S Bhan. Treatment of flexion-type supracondylar humeral fracture in children. Journal of Orthopaedic Surgery 2007;15: 2: 174-6.

13.Khan MS, Sultan S, Ali MA, Khan A, Younis M. Comparison of percutaneous pinning with casting in supracondylar humeral fractures in children. J Ayub Med Coll Abottabad 2005; 17: 2: 33-6.

Correspondence: Dr Nouman Maqbool, Consultant Orthopaedic Surgeon, Fauji Foundation Hospital Rawalpindi
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Author:Maqbool, Nouman; Iqbal, Amjad
Publication:Pakistan Armed Forces Medical Journal
Article Type:Clinical report
Geographic Code:9PAKI
Date:Mar 31, 2011
Words:2112
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