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ORIGINAL ARTICLE
Year : 2021  |  Volume : 24  |  Issue : 11  |  Page : 1590-1595

Predictors of early elbow function following paediatric humeral supracondylar fractures: A retrospective analysis


1 Department of Surgery, Alex Ekwueme Federal University Teaching Hospital, Abakaliki, Ebonyi, Nigeria
2 Department of Orthopaedic Surgery, National OrthopaedicHospital, Thinkers Corner, Enugu, Nigeria
3 Department Plastic and Reconstructive Surgery, National Orthopaedic Hospital, Thinkers Corner, Enugu, Nigeria

Date of Submission12-Jan-2021
Date of Acceptance23-Jun-2021
Date of Web Publication15-Nov-2021

Correspondence Address:
Dr. H C Ekwedigwe
Department of Surgery, Alex Ekwueme Federal University Teaching Hospital, Abakaliki, Ebonyi
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njcp.njcp_18_21

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   Abstract 


Background: Supracondylar fracture usually occurs as a result of fall on an outstretched hand. Prompt management is essential to prevent complications. Functional outcome after management of this fracture may be predicted by some factors. Aims: The study aimed to review the management of supracondylar fractures and determine what factors have an impact on the functional outcome of the elbow using MEPS score in the early post-operative period. Patients and Methods: This study was a retrospective study of all patients with supracondylar fractures that presented at the accident and emergency department of a tertiary institution over a 2-year period. Their relevant data were retrieved from their folders and analysis done using SPSS 20. The MEPS score at 6 months was calculated. Multiple linear regressions were used to determine factors that can predict early elbow function using the MEPS score at 6 months. Results: In the study, 61.4% (35) patients were males and 38.6% (22) females. The commonest mechanism of injury was fall on the outstretched hand (FOOSH), 70.2%. The mean duration of presentation to the hospital was 38 h (SD = 56.9). Among treatment offered to the patients, a higher number had open reduction with pinning. The mean postoperative Mayo elbow score was 87.6. Age of patients, Gartland type and the duration of cast immobilization were significant predictors of the MEPS at 6 months after treatment. Conclusion: The Gartland type and duration of cast immobilization are the most important predictors of the MEPS score at 6 months in this study.

Keywords: Elbow function, humeral supracondylar fractures, pediatric


How to cite this article:
Ekwedigwe H C, Anyaehie U E, Ede O, Anikwe I A, Eyichukwu G O, Anieze J K. Predictors of early elbow function following paediatric humeral supracondylar fractures: A retrospective analysis. Niger J Clin Pract 2021;24:1590-5

How to cite this URL:
Ekwedigwe H C, Anyaehie U E, Ede O, Anikwe I A, Eyichukwu G O, Anieze J K. Predictors of early elbow function following paediatric humeral supracondylar fractures: A retrospective analysis. Niger J Clin Pract [serial online] 2021 [cited 2021 Nov 27];24:1590-5. Available from: https://www.njcponline.com/text.asp?2021/24/11/1590/330456




   Introduction Top


Supracondylar fractures of the humerus are the commonest of the distal humeral fractures. It is the second most common fracture in children and accounts for 13 to 18% of all pediatric fractures.[1],[2],[3] It equally accounts for about 55 to 80% of total elbow fractures in children and up to two-thirds of pediatric elbow injuries requiring hospitalization.[4],[5]

The distal humerus anatomy is especially predisposed to injury because its configuration in two columns connected by thin bone represents a zone of weakness. Also at the peak age for supracondylar fracture, there is a naturally occurring hyperextension of the elbow, which predisposes the distal humerus to this injury.[4],[6] Many authors had documented that the injury commonly occurs as a result of fall on outstretched hand, with the arm fully extended, the olecranon engages with the olecranon fossa and acts as a fulcrum, this results in the fracture which starts from the anterior surface.[4],[6],[7],[8] Flexion injury is usually caused by direct trauma to the flexed elbow.[4] Gartland's classification is the most widely used classification system for supracondylar fractures, it is a reliable classification system with high-intra and inter-observer concordance.[9],[10]

Prompt evaluation and treatment of these patients when they present to the hospital emergency is very important so that limb-threatening complications could be averted. Notable amongst these complications are injuries to arteries and nerves. Nerve injuries after supracondylar fractures most commonly affect the median nerve. Ulnar and radial nerve injuries can also occur.[4] injuries to the Brachial artery is quite common following humerus supracondylar fracture.[11],[12] Associated forearm fractures and elbow hyperflexion increase compartment pressures.[13],[14] Compartment syndrome has been reported in 0.1% to 0.3% of cases of humeral supracondylar fractures.[5] Moreover because of preponderance of traditional bone setters and ignorance in a developing nation like ours, some of these patients present to the traditional bone setters first. The resultant mismanagement and delay lead to increased incidence of complications like compartment syndrome, Volkmann ischemic contracture, elbow stiffness, malunion, and gangrene.

Some factors may predict the functional outcome after management of this fracture. There is limited remodeling potential at the distal humerus, therefore younger patients may still need anatomic reduction to have a better functional outcome.[6],[7] It had also been documented that more severe fracture pattern is more likely to be associated with complications,[15] some authors had documented that delayed treatment does not significantly affect the outcome; however, that it may increase the likelihood of doing open reduction instead of closed reduction.[16],[17] There has not been any publication on the predictors of elbow function following management of supracondylar humerus fracture in our environment, hence the need for this study.

The study aims to review the management of supracondylar fractures and determine what factors have an impact on functional outcome of the elbow using the Mayo Elbow Performance score (MEPS) postoperation.


   Methodology Top


This is a retrospective review of cases of supracondylar fractures that presented at the accident and emergency department of a tertiary institution over a 2-year period. Their demographics, mechanism of injury, time of presentation, history of Traditional bone setter intervention, classification of supracondylar fracture, treatment as well as outcome were retrieved from the folders and analysis done using SPSS statistics for windows version 20. The MEPS at 6 months calculated from the documentation was noted. All pediatric patients with supracondylar fracture of the humerus were included in the study. Those with incomplete information and those that discharged against medical advice were excluded from the study. Also excluded were those with medial or lateral condyle fracture only and all patients above 18 years. All the patients are routinely subjected to active range of motion exercises post cast removal. Multiple linear regression was used to determine factors that can predict early elbow function using the MEPS score at 6 months.


   Results Top


There were 35 males (61.4%) and 22 females (38.6%) in the study, with the mean age of the patients being 5.65 years (S.D = 3.28). Fall on the outstretched hand (FOOSH) was the dominant mechanism of injury 70.2% (40) followed by direct fall on the point of the elbow 28.1% (16), see [Figure 1]. The left elbow was affected more than the right; 38 (66.7%) vs. 19 (33.3%).
Figure 1: The mechanism of injury

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The mean duration of presentation to the hospital after injury was 38.0 hours (SD = 56.9), with the majority of the patients presenting within 48 hours of trauma to the accident and emergency department. [Table 1] illustrates the timeline of the presentation to the hospital after pediatric supracondylar fractures.
Table 1: Duration of injury before hospital presentation

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Nine patients, 15.8%, visited the traditional bone setters before presenting for treatment. Out of these nine patients, three had developed compartment syndrome. Gartland Type 3 fracture was the commonest pattern of fracture seen in this work. [Table 2] shows the distribution of the fractures according to their Gartland class.
Table 2: Fracture class on assessment based on the Gartland classification

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Treatment offered to the patients included casting without manipulation in 20 patients, manipulation and casting in 14 cases, closed reduction with percutaneous pinning in two cases and open reduction with pinning in the remaining 21 patients. Those who had developed compartment syndrome had fasciotomy done at the point of ORIF, while the individual with gangrene had an above elbow amputation. [Fiigure 2] shows the treatment interventions done.
Figure 2: The various treatment modalities. MUA = manipulation under anesthesia, CRIF = Closed reduction and internal fixation, ORIF = Open reduction and internal fixation

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The mean duration of cast immobilization was 4.08 weeks (SD = 1.48) with an earlier cast removal in patients whose fractures were stabilized with pin. The mean post-operative MEPS done at 6 months was 87.6 (SD = 16.82). Multiple linear regression was done to determine factors that can predict early elbow functional outcome using the MEPS score at 6 months. Such factors include the age of the patient, duration of injury before the presentation, Gartland type, duration of cast immobilization, and the type of treatment given. The analysis showed that the age of the patient, Gartland type, and the duration of cast immobilization were significant predictors of the MEPS at 6 months after treatment. [Table 3] summarizes these results.
Table 3: Predictors of MEPS score at 6-months after treatment

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The table shows that the MEPS decreased by 2 with a unit increase in the patients' age, by 10 with a higher Gartland type and by approximately 4 with a unit increase in the duration of cast immobilization. From the standardized coefficients, the Gartland type and duration of cast immobilization are the most important predictors of the MEPS score at 6 months in this study. There was no infection noted in our series.


   Discussion Top


Supracondylar fracture of the humerus is the most common fracture of the elbow in children. Unfortunately, it can be one of the most difficult fractures to treat. This is because accurate reduction with minimum joint and soft tissue trauma is required to achieve the best possible functional result.[18],[19]

The epidemiological data in this series is consistent with earlier publications.[4],[6],[7],[8],[20],[21],[22] There are more boys (61.4%) than girls, the mean age of patients in this study is 5.65 ± 3.28 years, and fall on outstretched hand is the commonest mechanism of injury. The non-dominant upper limb is the commonest side involved in this injury, this was also reported by earlier publications.[4],[6],[7],[8],[20],[21],[22]

The mean duration of presentation to the hospital after injury is 38.0 hours. Most patients who presented to the hospital after 48 hours had initial interactions with quacks and thence presented with neglected and mismanaged injuries. Late presentation is quite common in developing nations where majority of individuals in some communities are ignorant and poor. Similar finding was reported by a study in south India,[8] 60.08% of their patients presented to the hospital 48 hours after injury out of which 74.68% had contact with traditional bone setters. Gartland type III fracture was the predominant fracture type in our series, the least common type was type II, similar finding was reported by the south India study.[8] The current preferred method of treatment for displaced supracondylar fracture has been closed reduction and percutaneous pin fixation, this method has given excellent result reported by various authors.[23],[24],[25] About 25 patients in this study were managed by surgical fixation of their fractures with kirschner wires, two patients had closed reduction while 23 had open reduction of their fractures. Documentations in literature have shown that there are relatively few complications with open reduction.[4] In a combined series of 470 fractures treated by open reduction, there were no neurovascular complications, the incidence of infection was 2.5%, all of which resolved.[4] There was no case of infection in our series. The most frequent complication of open reduction appears to be loss of range of motion especially when triceps splitting approach was used.[4] Noteworthy is that presently majority of the surgeons in our center have embraced closed reduction and percutaneous pin fixation as the major form of treatment for displaced supracondylar fractures except for late presenters.

The outcome of treatment of supracondylar fractures in this study is good, this is shown by the mean Mayor Elbow Performance Score of 87.6 (SD = 16.82) that was obtained from this study. Sinikumpu et al.[26] in their study on long-term outcome of supracondylar fractures in children reported mean MEPS of 96.4. The higher value obtained from their study may be because they followed up their patients for longer period (minimum 10 yrs).

Table 3 shows from the standardized coefficients that gartland type and duration of cast immobilization are the most important predictors of the MEPS score at 6 months in this study. Ideally, a fracture classification system should be both prognostic and provide a guide to clinical management; however, adequate reduction is important to functional outcome despite the class of injury. Non-displaced Gartland I fractures usually heal well without complications. Gartland II fracture with medial comminution can develop cubitus varus if this was not recognized, reduced, and stabilized. Gartland III fractures are more likely to be associated with neurovascular injuries. However, timely appropriate treatment can lead to excellent outcomes.[15] Young et al.[27] documented a statistically significant increase in elbow extension of 3.5o in fractures treated with plaster of Paris application compared to patients treated with crossed pin fixation, they also noted 4o more loss of carrying angle in the K-wire group than POP group, the explanation they found was that in the POP group, fractures were less displaced than in the crossed wire group. Their finding corroborates with the finding in this study.

Prolonged cast immobilization will lead to stiffness of the joints; stiffness which has earned the sobriquet, “fracture disease”, is the problem with conventional casts. While the swelling and hematoma resolve, adhesions may form that bind muscle fibers to each other and to the bone, this results in joint stiffness and muscle atrophy.[28] This will subsequently lead to impaired function. Several authors[6],[7],[25] had reported 2 to 4 weeks as the ideal period of immobilization in cast, after which physiotherapy is commenced to avoid stiffness. The mean duration of cast immobilization from this study is 4.08 weeks, this is slightly higher than what was recommended by previous authors. Our slightly higher mean duration of cast immobilization which reflects slightly late commencement of physiotherapy may have also contributed to the slightly lower MEPS from this study.

Table 3 shows that the MEPS score decreased by 2 with a unit increase in patients' age, however from the standardized coefficients age was not one of the most important predictors of MEPS score in this study. Wang et al.[15] in their study on outcome of Gartland III fractures reported that there was no significant difference in outcome based on age of patients. The reason for this is not farfetched, it has been documented in the literature that the distal humerus contributes only 20% of the longitudinal growth of the humerus. As a result, the supracondylar region of the distal humerus does not have a significant ability to remodel in cases of malunion.[6],[7] The ability to remodel is limited after 4 years and this remodeling is only for sagittal plane deformity, coronal plane deformity does not remodel. After the ages of 8 to 10 years, only 10% of growth of the humerus remains. Therefore, anatomical reduction is thought to be imperative to get good functional outcome from humeral supracondylar fractures with coronal deformity no matter the age of the patient.

Duration of injury before presentation was not a significant predictor of the MEPS at 6 months after treatment in this study. The mean duration of presentation of patients to the hospital post-injury is 38.0 hours in this study and majority of the patients presented within 24 h of injury. A study done in India reported mean delay of 4 days, they had satisfactory results in 88% of 40 patients, and closed reduction was not performed more than 7 days after injury.[29] In another study of 42 patients, it was reported that in type II and type III injuries without neurovascular compromise, delaying surgery until the following day did not compromise the quality of reduction.[30] Qing-lin Han et al.[17] in their study on early versus delayed surgery for Gartland type III supracondylar humeral fractures did not find any significant differences between early and delayed surgery groups; however, there was no patient that presented beyond 72 hours in their delay group. It has been documented that delayed presentation increases the probability of switching from closed reduction to open reduction.[16],[17] In another study,[31] it was reported that delayed open reduction 11 to 17 days after injury did not increase the frequency of myositis ossificans; therefore, if a supracondylar fracture is unreduced or poorly reduced, delayed open reduction and pin fixation appear to be justified.

Treatment given was also not a significant predictor of the MEPS at 6 months. This is supported by a study by Sven Young et al.[27] on the functional outcome after treatment of supracondylar humeral fractures in children, they compared the outcome after different treatment options for supracondylar fractures: plaster cast, skeletal traction, closed reduction, and crossed k-wire and open reduction and k-wire fixation. They found out that there was no significant difference in the outcome between the treatment groups. Another study that compared surgical and non-surgical treatment outcome of type II humerus supracondylar fracture showed no clinically significant differences in the change in carrying angle, range of motion, and complications between the 2 groups; however, they pointed out that fractures without rotational deformity or coronal angulation and with a shaft-condylar angle of >15o were more likely to be associated with successful nonsurgical treatment.[32]


   Conclusion Top


The Gartland type and duration of cast immobilization are the most important predictors of the MEPS score at 6 months in this study. The epidemiologic data in this study is consistent with what was previously reported by other authors. The outcome of treatment of supracondylar fractures in this study is good, as shown by the mean Mayo Elbow Performance Score of 87.6

Recommendation

We recommend that cast immobilization be limited to 3–4 weeks post-surgery while encouraging early physiotherapy.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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