Closed reduction and percutaneous pinning vs open reduction and internal fixation in pediatric lateral condylar humerus fractures displaced by > 4 mm: an observational cross-sectional study

Abstract

Background Although open reduction and internal fixation (ORIF) is recommended for lateral condylar humerus fractures (LCHFs) displaced by > 4 mm, several studies have reported the use of closed reduction and percutaneous pinning (CRPP) to treat LCHFs with significant displacement. However, little is known about the clinical differences between these two surgical techniques. This study aimed to compare the therapeutic effects of CRPP and ORIF in treating LCHFs displaced by > 4 mm. Methods We retrospectively reviewed pediatric LCHFs displaced by > 4 mm treated with either CRPP or ORIF at our center from June 2019 to October 2020. Song and Milch fracture classifications were used. Variables such as age at injury, sex, side injured, fracture displacement, fracture type, operating time, postoperative treatment, and complications were compared between the two techniques. Results One hundred twenty LCHFs met inclusion criteria. There were 36 Milch type I and 84 type II LCHFs, and 69 Song stage 4 and 51 stage 5 LCHFs. CRPP was performed in 45 cases and ORIF in 75 cases. No differences were found in age, sex, side injured, preoperative displacement, postoperative displacement, and length of immobilization between the CRPP and ORIF groups. There was a difference between operation time and pin duration. The CRPP group had shorter operation times and pin duration, and required no additional operations to remove internal pins. The average follow-up duration was 13.9 months. All patients achieved fracture union, and no complications such as infection, nonunion, delayed union, osteonecrosis, fishtail deformity, cubitus varus or valgus, or pain were recorded during follow-up. Bone spurs, lateral prominences, and decreased carrying angle were common complications in all groups. No obvious cubitus varus was observed. Unaesthetic scars were only observed in the ORIF groups. No differences in range of motion or elbow function was found among the different therapies. Conclusions Both CRPP and ORIF can achieve satisfactory clinical outcomes in treating LCHFs displaced by > 4 mm. No differences were found in complications or prognoses between the two groups. However, CRPP shows some advantages over ORIF, like less invasive surgery, no obvious scarring, and no need for secondary surgery with anesthesia for pin removal.

A Comparative Study on Closed Reduction vs. Open Reduction Techniques in the Surgical Treatment of Rotated Lateral Condyle Fractures of the Distal Humerus in Children

“…This technique for displaced LCFs has received increasing attention. In the last decade, CRPP has still been favored by other surgeons when joint congruity can be confirmed because it is less invasive and potentially minimizes complications, and some promising results have been found ( 16 ). The present study also found that the LCFs treated by CRPP had a shorter fracture healing time than those treated by ORPP.…”

“…Undoubtedly, accumulated experience is necessary for the skilled manipulation during closed reduction ( 16 ). For the same reason, we had a limited success rate (66.67%) for rotated LCFs with CRPP in this study.…”

Impacts of Fracture Types on Success Rate of Closed Reduction and Percutaneous Pinning in Pediatric Lateral Condyle Humerus Fractures Displaced >4 mm

“…We read with interest the recent publication by Xie and colleagues 1. Xi et al2 already published data from the same patients in 2021 but stated in their current publication1 that all 50 fractures were a Jakob type III, which is equivalent to a Song stage 5 (displaced and rotated fragment) 1,3. We would like to ask the authors how they explain the inconsistency of them having reported that only 30 of 50 fractures were a Song type 51 and what the Song type 5 rate was for each Milch type group, since malrotation might be a contributing factor to the failed closed reduction rate?…”

“…In their previous publication Xi et al2 reported a mean elbow flexion of 133.1 degrees, mean extension of 6.7 degrees and mean total range of movement (ROM) of 140.2 degrees at a mean follow-up of 13.9 months for patients who had either closed reduction or open reduction for failed closed reduction (no difference compared with their primary open reduction group), without providing data for the uninjured side. McKay et al5 reported normative ROM data from normal children 3 to 9 years of age, with mean elbow flexion of 146 degrees, mean extension of 3 degrees and mean ROM of 149 degrees.…”

“…In conclusion, we think that there is a need for a lateral condyle fracture classification which considers the anatomy, displacement, and malrotation. Xi et al’s1,2 fair Flynn outcomes with mean loss of flexion of 12.9 degrees for their closed and failed closed reduction groups and 13.3 degrees for their primary open reduction group indicates a possible need for the authors to reassess and change their management strategy. Areas we are concerned about because of a potential negative impact on functional recovery are: accuracy of intraoperative arthrogram assessment of post-reduction displacement, acceptance of an articular step of up to 2 mm, the use of 3 or 4 wires (all of Xi et al’s1,2 depicted fixations) in these small children (mean age 5.6 y) which increases potential damage to the soft tissues and growth plate, and leaves wires in place for a mean of >15 weeks following open reduction 2…”