Screw fixation for pediatric elbow FXs

Ahmed M. Thabet MDStephen Heinrich MD

Incidence • 65-75 % of pediatric FXs involves Upper

extremity (UE)• 7-9% of UE FXs involve the elbow

– Supracondylar humerus FX (SCH) represents 55-65%

- Lateral condyle (LC) 2nd common pediatric elbow fracture

Poor outcome with pediatric elbow fractures may lead to Litigation

32 malpractice claims filed/24220 cases confirmed (63%)

Research question? Study Hypothesis:

Screw fixation provides better stability for unstable pediatric elbow fractures

Aim of the study: To report the clinical and radiographic

outcomes of screw fixation for pediatric elbow Fxs

Patients and methods • IRB approval • Design: retrospective• Chart & radiographs reviews • Study period: 2007-2013 • Inclusion DX: SCH Fxs & LC FXs• Patients RX operatively through CRIF or ORIF

with screws only or combined with smooth pins and /or screws

• RX by senior author

Outcome score - Flynn criteria

Radiographic review • Fracture type and classification • Fixation method • Union • Complications

ResultsDemographics

• Two groups:– LC: 11– SCH: 17

• Gender: – SCH:

• M/F: 8/9– LC:

• M/F: 8/3

Results Demographics

• Mean age @SX: – SCH:

• 8.6 (5-14) y/o– LC:

• 4.8 (1.6- 7) y/o• Side of injury:

– SCH• R/L: 6/11

– LC:• R/L: 3/8

ResultsSCH- FX pattern

• Types:– Extension type: 14– Flexion type: 2– Transcondylar FX: 1

• Gartland classification: – Type II: 4– Type III: 12

• Transcondylar fracture : 1

ResultsLC FX pattern

• Milch’s classification:– Type I:1– Type II:10

• Jakob’s classification: – Type I:1– Type II:8– Type III:2

Type I Type II

Type I Type II Type III

Results Associated injuries

• Vascular injury:– 2 needed vascular

repair • Distal radius FX: 3

– CRIF:1– Cast: 2

Results RX type

• SCH group: – CRIF:12– ORIF: 5

• LC:– CRIF:7 – ORIF:4

ResultsUnion

Union achieved in all cases Cast removal after fracture healing @

three weeks in SCH Fxs group ~ 4 weeks in LC group

ResultsComplications

No intra op complications Post op complication SCH FXs

group: Loss of reduction (1/17):

Type III SCH Fx, 5y/o Boy

Post OP radiographs

Loss of reduction

Revised with crossing pins

@ final FU (3+6 y/o)

Results Flynn criteria

• SCH:– 4/17 with poor outcome 2ry to loss

of motion >20º– 2 lost extension – 2 lost flexion

• LC: – 2/11 poor outcome according to Flynn criteria:

• Varus carrying angle --- 1 • Loss of ROM 1----(>20º)

ResultsHWR

• Smooth pins @ clinic• Screw removal needs 2nd trip to OR

Cases example

Case 1- LC, 6 y/o M, type II,II

RX with screw fixation

Final F/U @ 10 Months

Case 2-5 y/o M, type III SCH Fxs with vascular injury

Intra op radiographs

F/U radiographs

Final F/U @ 6 months

Conclusion • Screw fixation for SC and LC FXs is an

alternative option:– Markedly unstable Fx – Multiple injuries in the same extremity– LC Fxs– Associated vascular injury

• Further studies are planned to include control matched group Rx with pinning

Thank you