RESUMO
BACKGROUND: Approximately 5% of supracondylar humerus fractures in children are associated with an ipsilateral forearm fracture, often referred to as a floating elbow when both injuries are displaced. Historically, these patients have higher complication rates than patients with an isolated supracondylar humerus fracture. The purpose of this study was to review the acute neurologic and vascular injuries in patients with ipsilateral, operative supracondylar humerus and forearm fractures and compare the findings with a cohort of isolated, operative supracondylar humerus fractures. METHODS: We performed an IRB-approved, retrospective review of all pediatric patients with ipsilateral, operative supracondylar humerus and forearm fractures from a single institution and compared our findings to a cohort of isolated, operative supracondylar humerus fractures. RESULTS: A total of 150 patients with operative supracondylar humerus and ipsilateral forearm fractures were compared with 1228 patients with isolated, operative supracondylar humerus fractures. Twenty-two of the 150 (14.7%) floating elbow patients had documented pretreatment nerve palsies compared with 96/1228 (7.8%) of isolated injury patients (P=0.006). Eighteen of 22 nerve palsies were in patients with forearm fractures that required reduction. The overall incidence of nerve palsy was 18.9% (18/95) when a forearm fracture required reduction compared with only 7.3% (4/55) in a forearm fracture that was not reduced (P=0.05). We did not find a significant difference in the rate of pulseless extremities when comparing the ipsilateral (6/150 4%) and isolated (50/1228 4.1%) injury patients. No compartment syndromes were identified in any patient with an ipsilateral injury. CONCLUSIONS: The rate of acute neurologic injury in ipsilateral supracondylar humerus and forearm fractures is almost twice than that found in patients with isolated supracondylar humerus fractures. This rate increases further when the forearm fracture requires a manipulative reduction. The likelihood of a pulseless extremity was not dependent upon the presence of a forearm injury in our study. The presence of an ipsilateral forearm fracture should alert the surgeon to carefully assess the preoperative neurovascular status of patients with supracondylar humerus injuries. LEVEL OF EVIDENCE: Level III.
Assuntos
Síndromes Compartimentais/etiologia , Fraturas do Úmero , Traumatismos dos Nervos Periféricos/etiologia , Fraturas do Rádio , Fraturas da Ulna , Lesões do Sistema Vascular/etiologia , Estudos de Casos e Controles , Criança , Pré-Escolar , Feminino , Antebraço , Humanos , Fraturas do Úmero/complicações , Fraturas do Úmero/cirurgia , Masculino , Exame Neurológico , Cuidados Pré-Operatórios/métodos , Fraturas do Rádio/complicações , Fraturas do Rádio/cirurgia , Estudos Retrospectivos , Fraturas da Ulna/complicações , Fraturas da Ulna/cirurgia , Estados Unidos , Lesões no CotoveloRESUMO
BACKGROUND: Because of the changing referral patterns, operative pediatric supracondylar humerus fractures are increasingly being treated at tertiary referral centers. To expedite patient flow, type II fractures are sometimes pinned in a delayed manner. We sought to determine if delay in surgical treatment of modified Gartland type II supracondylar humerus fractures would affect the rate of complications following closed reduction and percutaneous pinning. METHODS: We performed a retrospective review of a consecutive series of 399 modified Gartland type II supracondylar fractures treated operatively at a tertiary referral center over 4 years. Mean patient age in the type II group was 5 years (range, 1 to 15 y). A total of 48% were pinned within 24 hours, 52% pinned >24 hours after the injury. RESULTS: No difference was in detected in rates of major complications between the early and delayed treatment group. Four percent of patients sustained a complication (16 patients). There were no compartment syndromes, vascular injuries, or permanent nerve injuries. Complications included nerve injury (3), physical therapy referral for stiffness (3), pin site infection (2 treated with oral antibiotics, 4 treated with debridement), refracture (2), and loss of fixation or broken hardware (2). Of the 3 patients who sustained nerve injuries, all underwent surgery within 24 hours of injury. One patient developed an ulnar motor and sensory nerve palsy after fixation with crossed K-wires. This resolved by 7 weeks postoperatively. Two patients presented with an anterior interosseous nerve palsy-1 resolved 1 week after surgery, the other by 8 weeks postoperatively. CONCLUSIONS: Delay in surgery did not result in an increased rate of major complications following closed reduction and percutaneous pinning of type II supracondylar humerus fractures in children. Further prospective work is necessary to determine if there are subtle treatment benefits from emergent treatment of type II supracondylar humerus fractures. LEVEL OF EVIDENCE: Level III-retrospective comparative series.