Suprakondiler humerus kırıklarının klinik sonuçları: Kapalı- açık redüksiyonun karşılaştırılması

Abstract

Amaç: Suprakondiler humerus kırıkları çocuklarda en sık görülen yaralanmalar arasındadır. Gartland tip 2 ve 3 kırıkların tedavisinde kapalı veya açık redüksiyondan sonra perkutan pinleme uygulanır. Bu çalışmanın amacı Gartland tip 2 ve 3 suprakondiler humerus kırıklarında klinik sonuçları ve kapalı- açık redüksiyonun sonuçlara etkisini değerlendirmektir.

Materyal ve metot: Çalışmamıza 2015-2018 yılları arasında suprakondiler humerus kırığı nedeniyle tedavi edilen, Gartland tip 2 ve 3 kırığı olan, 10 yaşın altında olan, en az 3 ay takibi olan 48 hasta dahil edildi. Hastaların medikal kayıtlarından ve radyografilerinden elde edilen veriler değerlendirildi. Hastaların demografik bilgileri, kırık geçirdiği taraf, kırık tipi, pin konfigürasyonu, cerrahi yapılana kadar geçen zaman, takip süresi kaydedildi. Radyografilerinde ölçülen Baumann açıları, son kontrolde değerlendirilen eklem hareket açıklıkları ve taşıma açıları değerlendirildi. Sonuçlar Flynn kriterleri kullanılarak değerlendirildi. Hastalar kapalı redüksiyon uygulananlar (Grup 1), açık redüksiyon uygulananlar (Grup 2) olmak üzere iki gruba ayrıldı ve sonuçlar karşılaştırıldı.

Bulgular: Hastaların ortalama yaşı 5,94’dü(1-10yaş). 21 hastadan oluşan kapalı redüksiyon grubu (Grup 1) ve 27 hastadan oluşan açık redüksiyon grubu (Grup 2) arasında yaş, cinsiyet ve etkilenen taraf açısından fark yoktu. Hastalar ortalama 11,06 saat sonra (8-48 saat) ameliyata alındı ve ortalama 18,60 ay (3-44 ay) takip edildi. Gruplar arasında ameliyata alınma zamanı ve takip süresi açısından fark yoktu. Flynn kriterlerine göre 43 hastada (%89,5) mükemmel ve iyi sonuç elde edildi. Grup 1’deki hastaların Flynn kriterlerine göre 20’sinde (%95,2) mükemmel ve iyi sonuç elde edildi. Grup 2’deki hastaların Flynn kriterlerine göre 22’sinde (%81,5) mükemmel ve iyi sonuç elde edildi. 3 hastada orta sonuç (%11,1), 2 hastada (%7,4) kötü sonuç elde edildi. Gruplar karşılaştırıldığında kapalı redüksiyon grubunda mükemmel ve iyi sonucun daha fazla oranda olduğu görüldü, fakat istatistiksel olarak anlamlı fark yoktu.

Sonuç: Suprakondiler humerus kırıklarının tedavisinde kapalı ve açık redüksiyon sonrasında pinlerle fiksasyon etkili ve güvenli bir tedavi yöntemidir. Öncelikle kapalı redüksiyon uygulanmalıdır, fakat kapalı redüksiyon sağlanamazsa açık redüksiyon da tatminkar sonuçlar sunar. Bu çalışmada kapalı- açık redüksiyonla tedavi edilen hastaların klinik sonuçları arasında anlamlı fark tespit edilmedi. Kapalı- açık redüksiyonun klinik sonuçlar üzerine etkisini daha iyi değerlendirebilmek için, daha fazla sayıda hasta içeren prospektif çalışmalar yapılabilir.

Keywords

• Humerus kırıkları,Dirsek,Kapalı kırıklar

Clinical results of supracondylar humerus fractures: Comparison of closed- open reduction

Abstract

 

Background: Humerus supracondylar fractures are among the most common injuries in children. Percutaneous pinning  is applied after closed or open reduction for the treatment of Gartland type 2 and 3 fractures. The aim of this study is to evaluate the clinical results in Gartland type 2 and 3 humerus supracondylar fractures and the effect of closed- open reduction on results.

Methods: Between 2015- 2018, 48 patients who were treated for Gartland type 2 and 3 humerus supracondylar fractures, below 10 years, minumum 3 months follow-up were included in our study. The data which were obtained from medical records and radiographs were evaluated. Demographic data, fracture side, fracture type, pin configuration, time to surgery, follow-up time were recorded. Measured Baumann angles on radiographs, range of motions and carrying angles on last follow-up were evaluated. Postoperative results were evaluated by using Flynn criteria. Patients were divided into two groups as patients were treated with closed reduction (Group 1), treated with open reduction (Group 2), and results were compared.

Results: Mean patient age was 5,94 (1-10 years). Group 1 (21 patients) and Group 2 (27 patients) were not different according to patient age, sex and fracture side. Patients were operated after a mean of 11,06 hours (8- 48 hours), and the mean follow-up was 18,60 months (3- 44 months). The groups were not different according to time to operation and follow-up period. Excellent and good results were obtained in 43 patients (89,5 %) according to Flynn criterias. Excellent and good results were obtained in 20 patients (95,2 %) according to Flynn criterias in Group 1. Excellent and good results were obtained in 22 patients (81,5 %) according to Flynn criterias in Group 2. Fair results were obtained in 3 patients (11,1 %), poor results in 2 patients (7,4 %). In comparison, more excellent and good result rates were seen in closed reduction group, but there was no statistically significant difference.

Conclusions: Percutaneus pinning after closed and open reduction is effective and safe in the treatment of humerus supracondylar fractures. First closed reduction must be performed, but if closed reduction could not obtained, open reduction serves satisfactory results. In this study, there was no significant difference between patients who were treated with closed or open reduction. For better evaluation of the effect of closed- open reduction on clinical results, prospective studies with more patients could be performed. 

References

1. 1. Zorrilla S de Neira J, Prada-Canizares A, Marti-Ciruelos R, Pretell-Mazzini J. Supracondylar humeral fractures in children: current concepts for management and prognosis. Int Orthop. 2015;39:2287–96.
2. 2. Khoshbin A, Leroux T, Wasserstein D, Wolfstadt J, Law PW, Mahomed N, et al. The epidemiology of paediatric supracondylar fracture fixation: a population-based study. Injury. 2014; 45:701–8.
3. 3. Mulpuri K, Wilkins K. The treatment of displaced supracondylar humerus fractures: evidence-based guideline. J Pediatr Orthop. 2012; 32 (Suppl 2): S143–S152.
4. 4. Gartland JJ. Management of supracondylar fractures of the humerus in children. Surg Gynecol Obstet. 1959;145–54.
5. 5. Skaggs DL, Hale JM, Bassett J, Kaminsky C, Kay RM, Tolo VT. Operative treatment of supracondylar fractures of the humerus in children. The consequences of pin placement. J Bone Joint Surg Am. 2011;83-A:735–40.
6. 6. Campbell CC, Waters PM, Emans JB, Kasser JR, Millis MB. Neurovascular injury and displacement in type III supracondylar humerus fractures. J Pediatr Orthop. 1995;15(1):47-52.
7. 7. Baratz M, Micucci C, Sangimino M. Pediatric supracondylar humerus fractures. Hand Clin. 2006; 22(1):69–75. 8. Reitman RD, Waters P, Millis M. Open reduction and internal fixation for supracondylar humerus fractures in children. J Pediatr Orthop. 2001;21(2):157-161.
8. 9. Chen TL, He CQ, Zheng TQ, Gan YQ, Huang MX, Zheng YD, Zhao JT. Stiffness of various pin configurations for pediatric supracondylar humeral fracture: a systematic review on biomechanical studies. J Pediatr Orthop B. 2015;24(5):389-99.

9. 10. Worlock P. Supracondylar fractures of the humerus. Assessment of cubitus varus by the Baumann angle. J Bone Joint Surg Br. 1986; 68(5):755–757
10. 11. Flynn JC, Matthews JG, Benoit RL. Blind pinning of displaced supracondylar fractures of the humerus in children. Sixteen years’experience with long-term follow-up. J Bone Joint Surg Am. 1974;56:263–72.
11. 12. Howard A, Mulpuri K, Abel MF, et al. American Academy of Orthopaedic Surgeons. The treatment of pediatric supracondylar humerus fractures. J Am Acad Orthop Surg. 2012;20(5):320e327.
12. 13. Loizou CL, Simillis C, Hutchinson JR. A systematic review of early versus delayed treatment for type III supracondylar humeral fractures in children. Injury. 2009;40(3):245-8.
13. 14. Walmsley PJ, Kelly MB, Robb JE, et al. Delay increases the need for open reduction of type-III supracondylar fractures of the humerus. J Bone Joint Surg Br. 2006;88(4):528e530.
14. 15. Wingfield JJ, Ho CA, Abzug JM, Ritzman TF, Brighton BK. Open Reduction Techniques for Supracondylar Humerus Fractures in Children. J Am Acad Orthop Surg. 2015;23(12):e72-80.
15. 16. Kızılay YO, Aktekin CN, Özsoy MH, Akşahin E, Sakaoğullar A, Pepe M, Kocadal O. Gartland Type 3 Supracondylar Humeral Fractures in Children: Which Open Reduction Approach Should Be Used After Failed Closed Reduction? J Orthop Trauma. 2017;31(1):e18-e23. 17. Payvandi SA, Fugle MJ. Treatment of pediatric supracondylar humerus fractures in the community hospital. Tech Hand Up Extrem Surg. 2007;11(2):174-8.
16. 18. Kao HK, Lee WC, Yang WE, Chang CH. Clinical significance of anterior humeral line in supracondylar humeral fractures in children. Injury. 2016;47(10):2252-2257.
17. 19. Slobogean BL, Jackman H, Tennant S, Slobogean GP, Mulpuri K. Iatrogenic ulnar nerve injury after the surgical treatment of displaced supracondylar fractures of the humerus: number needed to harm, a systematic review. J Pediatr Orthop. 2010;30(5):430-6.
18. 20. Woratanarat P, Angsanuntsukh C, Rattanasiri S, Attia J, Woratanarat T, Thakkinstian A. Meta-analysis of pinning in supracondylar fracture of the humerus in children. J Orthop Trauma. 2012;26:48–53.
19. 21. Hamdi A, Poitras P, Louati H, Dagenais S, Masquijo JJ, Kontio K. Biomechanical analysis of lateral pin placements for pediatric supracondylar humerus fractures. J Pediatr Orthop. 2010;30:135–9.
20. 22. Zamzam MM, Bakarman KA. Treatment of displaced supracondylar humeral fractures among children:crossed versus lateral pinning. Injury. 2009;40(6):625-630. 23. Zionts LE, McKellop HA, Hathaway R. Torsional strength of pin configurations used to fix supracondylar fractures of the humerus in children. J Bone Joint Surg Am. 1994;76:253–6.
21. 24. Dekker AE, Krijnen P, Schipper IB. Results of crossed versus lateral entry K-wire fixation of displaced pediatric supracondylar humeral fractures: A systematic review and meta-analysis. Injury. 2016;47(11):2391-2398. doi: 10.1016/j.injury.2016.08.022.
22. 25. Weiland AJ, Meyer S, Tolo VT, Berg HL, Mueller J. Surgical treatment of displaced supracondylar fractures of the humerus in children. Analysis of fifty-two cases followed for five to fifteen years. J Bone Joint Surg Am. 1978;60(5):657-661.
23. 26. Lewine E, Kim JM, Miller PE, Waters PM, Mahan ST, Snyder B, Hedequist D, Bae DS. Closed Versus Open Supracondylar Fractures of the Humerus in Children: A Comparison of Clinical and Radiographic Presentation and Results. J Pediatr Orthop. 2018;38(2):77-81.
24. 27. Aktekin CN, Toprak A, Ozturk AM, et al. Open reduction via posterior triceps sparing approach in comparison with closed treatment of posteromedial displaced Gartland type III supracondylar humerus fractures. J Pediatr Orthop B. 2008;17:171–178.
25. 28. Li YA, Lee PC, Chia WT, et al. Prospective analysis of a new minimally invasive technique for paediatric Gartland type III supracondylar fracture of the humerus. Injury. 2009; 40:1302–1307.
26. 29. Sibly TF, Briggs PJ, Gibson MJ. Supracondylar fractures of the humerus in childhood: range of movement following the posterior approach to open reduction. Injury. 1991;22:456–458.