Underlying causes of poor outcomes in the treatment of children with fractures of the capitulum of the distal humeru

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Abstract


This study aimed to determine the causative factors underlying poor outcomes in the treatment of children with fractures of the capitulum of the distal  humerus.

Materials and Methods: We conducted a retrospective analysis of community-based treatment of 36 patients with fractures of the capitulum of the distal humerus who presented to the Department of rehabilitation between 2010 and 2015 owing to poor treatment outcomes. Analysis only involved patients presenting with an extensive dataset with regard to their treatment, including X-rays taken at the time of the injury and at subsequent stages of treatment.

Results: It was found that there had been inaccuracies at the stage of diagnosis in 47.2% of patients, errors in the selection of treatment in 13.9%, and errors in post-operative management in 38.9%.

Conclusion: When interpreting radiographs, it is important that physicians clearly assess the degree of displacement when evaluating fractures of the capitulum of the distal humerus. Dislocated fractures require the most accurate reposition. When choosing a treatment method, it is important to predict the possibility of post-traumatic complications. Accumulating evidence of clinical errors indicates that more attention should be paid to the treatment of elbow fractures during the postgraduate education of specialists.


Introduction

Diagnosis and treatment of elbow joint injuries in children remains one of the most difficult and not completely solved problems to date. This is due to the complex anatomic structure of the elbow joint, as well as its propensity for the development of various complications, such as delayed consolidation, formation of post-traumatic ossifications, circulatory disruptions in the fracture area, and other problems, which result in the restriction of the elbow function.

According to the literature, fractures of the distal humerus represent 70%–90% of all elbow bone fractures [1−3]. Humeral capitulum fractures are complex intra-articular injuries of the distal (meta) epiphysis due to their anatomic and radiographic features. Treatment of these fractures is difficult, and the rate of complications is high, with an average prevalence of 18% [4, 5]. In 67% of the children with elbow trauma, there are serious errors in the diagnosis and treatment of the pathology, which leads to unsatisfactory results [5].

During diagnostic procedures, imaging is frequently inaccurate, and the radiologic results are misinterpreted, which is due to the complex shape of the joint [6, 7] and its age-related anatomic and radiologic characteristics [8, 9].

According to many authors, the variety of approaches and methods of treatment, lack of a uniform viewpoint on the timing, and type of fixation and immobilization during closed repositioning of fragments make the choice of optimal treatment difficult, which, subsequently, leads to the development of complications and unsatisfactory results [10–4]. Later, complications such as secondary displacement of fragments, delayed consolidation with possible formation of a pseudarthrosis, valgus deformity of the elbow [14], development of avascular necrosis [15, 16], tardy ulnar nerve palsy, and severe osteoarthritis [4] may arise.

Kuksov [13] recommends surgery for fractures of the humeral condyle and argues that it is necessary to take into account the intra-articular nature of these fractures for exact positioning of fragments. At the same time, Bairov [17] believed that it is advisable to proceed with closed reduction first, and surgical intervention is indicated only when displacement is not eliminated.

The objective of this study was to determine the causes of unsatisfactory treatment results in children with fractures of the humeral capitulum.

Materials and methods

A retrospective analysis of treatment in 36 children (age, 5–17 years) with humeral condyle fractures was conducted. The patients received treatment at their residence and later came to the Turner’s Institute Department of Trauma Consequences due to unsatisfactory results between 2010 and 2015. Only the patients who presented with complete treatment records, including X-rays at the time of injury and at the different stages of treatment, were included in the study.

Results and discussion

Analysis of the treatment results of patients with humeral capitulum fractures demonstrated delayed consolidation in the fracture area in six patients. This diagnosis was made if consolidation was absent within 3–6 months after injury. However, the early signs of sclerosis and development of endplates in the fracture area made the probability of consolidation in future highly unlikely. Formation of post-traumatic pseudarthrosis of the humerus during a period of more than 6 months was observed in 10 patients. In 12 patients, delayed consolidation was combined with displacement of the capitulum, outward as a rule. There was posterior outward displacement in four patients. All patients had a limited range of motion, and a valgus deformity of the elbow joint was usually found.

Post-traumatic deformity of the distal humerus (meta) epiphysis was present in 16 patients. The displaced fragment consolidated in the wrong position, which resulted in the deformity of the distal section of the humerus and flexor–extensor contracture of the elbow joint.

In four children, fragments consolidated in a satisfactory position. Post-traumatic contracture of the elbow joint was caused by ectopic ossification.

According to the results of the analysis, we divided patients into three groups.

In the first group, the diagnosis of the pathology was delayed in 16 patients (47.2%). Five patients had anterior displacement of the humeral capitulum together with a portion of the metaphysis and a simultaneous outward displacement by one-third of its diameter; in three patients, there was an outward displacement without rotation. Four patients had posterior downward displacement by more than 60°, with insignificant rotation of the fragment. There was anterior upward displacement of the capitulum by more than 80°in five cases.

All patients in this group required a reduction surgery. However, a retrospective analysis of the treatment at their residence showed that the surgery had not been performed because the displacements were deemed acceptable or were not diagnosed at all. These patients were treated using a plaster splint immobilization for up to 4 weeks followed by physical therapy. In this group, the treatment resulted in a fusion of the bone fragments in an incorrect position; deformity of the distal humerus and limited function of the elbow joint developed in all these children.

A case study of patient S. is presented.

Figure 1 shows the X-ray of a 13-year-old patient S.; the anterior upward displacement of the humeral capitulum is visible. The joint had been immobilized using a plaster splint for 4 weeks. Subsequently, the patient underwent physical therapy; however, the elbow joint function was not restored. Upon admission to our department, he had extension contracture of the elbow with a maximum movement range of 80°.

The second group included 13 children (36.1%). In these patients, the errors were made at the stage of treatment method selection. Patients in this group complained of restricted elbow joint movement. Five patients had deformity of the distal humerus due to fusion of the capitulum in the wrong position, four had post-traumatic false pseudarthrosis, and four had ossification of the elbow joint.

According to the radiographic analysis, the degree of fragment displacement was determined correctly. Two patients with displacement of the humeral capitulum underwent a single closed reduction surgery without fixation with pins. Later, secondary displacement and fusion of the capitulum in the wrong position developed in these patients. Two patients with anterior fragment displacement underwent closed reduction surgery and fixation with pins, whereas one with posterior downward capitulum displacement (Fig. 2a) underwent open reduction surgery with fixation of the fragments with pins.

In these patients, accurate placement of the fragments could not be achieved (Fig. 2b). This resulted in capitulum fusion in a wrong position (Fig. 2c). The pins were removed 3 weeks postoperatively, and the plaster cast was removed 4 weeks after injury. In the long term, functional restrictions and deformities of the elbow joint developed in these children.

The remaining eight patients in this group underwent multiple (two or more) closed reduction surgeries. After unsuccessful closed reductions, five patients underwent open reduction surgery of the humeral capitulum with fixation by pins (Figs. 3a, b). In three cases, after repeated closed reduction procedures, the fragment was fixed in the wrong position using pins. In the long term, heterotopic ossifications developed in the elbow area in four patients and pseudarthrosis of the humeral capitulum in other four (Fig. 3c).

In the third group (16.7%, 6 children), there were treatment errors in the postoperative period. In four children, fixation with pins was not sustained for enough duration (it lasted 14–18 days). However, according to most investigators [3,11,14], the average recommended duration of fixation is 3 weeks.

Two patients experienced an early termination of the plaster splint immobilization after closed reduction surgery without fixation. The splint was removed after 14 days in one patient and after 16 days in another. After plaster splint removal, the patients underwent rehabilitation (physical therapy and massage), aimed at improving the elbow joint range of motion.

The treatment results in this group were unsatisfactory: by the time the patients contacted the Turner Institute, two children had signs of pseudarthrosis development and four had pseudarthrosis of the humeral capitulum.

The data analysis shows that in all cases, the cause of unsatisfactory treatment of the humeral capitulum fractures was the serious errors committed, particularly (83.3% of cases) in the diagnostic phase and in choice of treatment. The degree of capitulum displacement was estimated incorrectly, and in some cases, the fracture was not diagnosed at all. X-ray imaging of the distal humerus has significant age-related peculiar features in children. Without a knowledge of these features, the diagnosis and estimation of fragment displacement is almost impossible, as previously reported [1, 18]. When choosing a treatment plan, the preference was given to a less traumatic closed reduction, which is not always the best choice. We believe that in case of a noticeable displacement of the humeral capitulum as well as a single unsuccessful closed reduction attempt, open reduction surgery with internal fixation with pins is indicated. Multiple closed reduction attempts result in serious soft tissue damage and significantly increase the possibility of pseudarthrosis and heterotopic ossification development. It should be emphasized that in most cases, both with closed and open reduction, a proper matching of fragments was not achieved, resulting in consolidation in a wrong position or nonunion. Furthermore, numerous errors were committed in the course of (postoperative) treatment. Several investigators argue that in young children, immobilization for a period of 10–17 days may be sufficient in cases with fractures without displacement or acceptable displacement [1,10]. However, our results indicated that even in very young children, this treatment is insufficient. We consider the period of immobilization to be 3–4 weeks, and in children above 14 years, this period may be extended to 6–8 weeks. We believe that radiologic evidence of bone consolidation is an essential prerequisite for the termination of immobilization.

Conclusion

Based on the identified causes of the poor results of humeral capitulum treatment, we came to the following conclusions:

  1. The degree of the capitulum condyle fragment displacement should be accurately accessed on X-ray.
  2. For treatment of humeral capitulum fractures, the positioning of the fragment should be most precise.
  3. If the first attempt at closed reduction proves unsuccessful, open reduction with internal fixation of the fragments is indicated.
  4. Termination of immobilization requires a radiologic evidence of bone consolidation.

Considering the complexity of fractures at this location and high prevalence of complications, orthopedic surgeons should pay special attention to diagnosis and treatment of this trauma in children.

The authors would like to express their sincere gratitude for the help in the publication of this article to Ovechkina Alla Vladimirovna, MD PhD, Science Secretary of the Turner Scientific and Research Institute for Children’s Orthopedics and to Lapkin Yuri Alekseevich, MD PhD, a leading researcher at the same Institute.

Olga A Kuptsova

The Turner Scientific and Research Institute for Children’s Orthopedics

Author for correspondence.
Email: fake@eco-vector.com

Russian Federation MD, PhD student of the department of trauma effects and rheumatoid arthritis. The Turner Scientific and Research Institute for Children’s Orthopedics

Alexei G Baindurashvili

The Turner Scientific and Research Institute for Children’s Orthopedics

Email: turner01@mail.ru

Russian Federation MD, PhD, professor, corresponding member of RAS, honored doctor of the Russian Federation, Director of The Turner Scientific and Research Institute for Children’s Orthopedics. Head of the chair of pediatric traumatology and orthopedics of North-Western State Medical University n. a. I.I.Mechnikov

Maksim S Nikitin

The Turner Scientific and Research Institute for Children’s Orthopedics

Email: fake@eco-vector.com

Russian Federation MD, orthopedic and trauma surgeon of the department of trauma effects and rheumatoid arthritis. The Turner Scientific and Research Institute for Children’s Orthopedics

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