Augmented reality simulators offer opportunities for practice of orthopaedic procedures outside of theatre environments. We developed an augmented reality simulator that allows trainees to practice pinning of paediatric supracondylar humeral fractures (SCHF) in a radiation-free environment at no extra risk to patients. The simulator is composed of a tangible child's elbow model, and simulated fluoroscopy on a tablet device. The treatment of these fractures is likely one of the first procedures involving X-ray guided wire insertion that trainee orthopaedic surgeons will encounter. This study aims to examine the extent of improvement simulator training provides to real-world operating theatre performance.

This multi-centre study will involve four cohorts of New Zealand orthopaedic trainees in their SET1 year. Trainees with no simulator exposure in 2019 - 2021 will form the comparator cohort. Trainees in 2022 will receive additional, regular simulator training as the intervention cohort. The comparator cohort's performance in paediatric SCHF surgery will be retrospectively audited using routinely collected operative outcomes and parameters over a six-month period. The performance of the intervention cohorts will be collected in the same way over a comparable period. The data collected for both groups will be used to examine whether additional training with an augmented reality simulator shows improved real-world surgical outcomes compared to traditional surgical training. This protocol has been approved by the University of Otago Health Ethics committee, and the study is due for completion in 2024.

This study is the first nation-wide transfer validity study of a surgical simulator in New Zealand. As of September 2022, all trainees in the intervention cohort have been recruited along with eight retrospective trainees via email. We present this protocol to maintain transparency of the prespecified research plans and ensure robust scientific methods. This protocol may also assist other researchers conducting similar studies within small populations.

The Gartland extension-type supracondylar humerus fracture is the most common elbow fracture in the paediatric population. Depending on fracture classification, treatment options range from nonoperative treatment such as taping, splinting or casting to operative treatments such as closed reduction and percutaneous pinning or open reduction. Classification variability between surgeons is a potential contributing factor to existing controversy over nonoperative versus operative treatment for Type II supracondylar fractures. The purpose of this study was to investigate levels of agreement in classification of extension-type supracondylar humerus fractures using the Gartland classification system. A retrospective chart review was conducted on patients aged 2–12 years who had sustained an extension-type supracondylar fracture and received either operative or nonoperative treatment at a tertiary children's hospital. De-identified baseline anteroposterior (AP) and lateral plain elbow radiographs were provided along with a brief summary of the modified Gartland classification system to surgeons across Canada, United States, Australia, United Kingdom and India. Each surgeon was blinded to patient treatment and asked to classify the fractures as Type I, IIA, IIB or III according to the classification system provided. A total of 21 paediatric orthopaedic surgeons completed one round of classification, of these, 15 completed a second round using the same radiographs in a reshuffled order. Kappa values using pre-determined weighted kappa coefficients were calculated to assess interobserver and intraobserver levels of agreement. In total, 60 sets of baseline elbow radiographs were provided to survey respondents. Interobserver agreement for classification based on the Gartland criteria between surgeons was a mean of 0.68, 95% CI [0.67, 0.69] (0.61–0.80 considered substantial agreement). Intraobserver agreement was a mean of 0.80 [0.75, 0.84]. (0.61–0.80 substantial agreement, 0.81–1 almost perfect agreement). Radiographic classification of extension-type supracondylar humerus fractures at baseline demonstrated substantial agreement both between and within surgeon raters. Levels of agreement are substantial enough to suggest that classification variability is not a major contributing factor to variability in treatment between surgeons for Type II supracondylar fractures. Further research is needed to compare patient outcomes between nonoperative and operative treatment for these fractures, so as to establish consensus and a standardized treatment protocol for optimal patient care across centres

Over 500 supracondylar humerus fractures (SCHF) are treated at our institution each year. Our standard post-operative pathway includes a 3-week visit for splint removal, wire removal, and radiographs. Subsequent follow-up occurs at 12 weeks for a clinical examination. In an effort to minimize unnecessary follow-up visits, we investigated whether photographs and/or patient-reported outcome measure (PROM) scores could identify patients who do not need routine 3-month in-person follow-up. At the 3-month visit, 248 SCHF patients (mean 6.2 yrs; 0.75-11yrs) had bilateral elbow motion (ROM) and carrying angles measured; and photographs documenting frontal and sagittal alignment of both injured and uninjured upper extremities, in both maximum elbow flexion and extension. Two independent assessors made the same measurements off the clinical photographs to compare these with the clinical measurements. Two PROMs: Self-Assessment Questionnaire (SAQ: 0 best to 14 worst) and QuickDASH (0 best to 100 worst) were completed at the 3-month visit. Inter-rater reliability of the photograph measurements was excellent (Kappa: 0.88-0.93), but weakly concordant with clinical measurements (carrying angle Kappa=0.51;max flexion Kappa=0.68;max extension Kappa=0.64). SAQ moderately correlated with QuickDASH (Kappa=0.59) and performed better at identifying patients with abnormalities. SAQ score ≥ 4 identified patients meeting 3-month follow-up criteria, with sensitivity: 36.1%; specificity: 96.8% and negative-predictive-value (NPV): 87%. We did not find that photographs were reliable. Although SAQ-score has high NPV, a more sensitive fracture-specific PROM is needed to identify patients who do not need a 3-month follow-up visit

Lateral-entry wiring (LEW) for displaced supracondylar humeral fractures (SHFs) has been popularised internationally. BOAST guidance suggests either LEW or crossed wires; the latter has reported lower risk of loss of fracture reduction –we explore technical reasons why. We reviewed 8 years of displaced SHFs in two regional centres. Injuries were grouped using the Gartland Classification, with posterolateral or posteromedial displacement assessment for Gartland 3 injuries. We identified any loss of fracture reduction, and reviewed intra-operative imaging to identify learning points that may contribute to early rotational displacement (ERD). 345 SHFs were included, between 2012 and 2020. Gartland 2 (n=117) injuries had a 3.42% risk. ERD. Gartland 3 crossed wirings (n=114) had a 6.14% risk of ERD, with those moving all being posterolaterally displaced. Gartland 3, posterolaterally displaced LEW (n=56) had a 35.7% risk of ERD. Gartland 3, posteromedially displaced LEW (n=58) had a 22.4% risk of ERD. All injuries with ERD except 3 had identifiable learning points, the commonest being non-divergence of wires, or wires not passing through both fracture fragments. LEW requires divergent spread and bicolumnar fixation. Achieving a solid construct through this method appears more challenging than crossed wiring, with rates of ERD 3–5× higher. Low-volume surgeons should adhere to BOAST guidelines and choose a wiring construct that works best in their hands. They can also be reassured that should a loss of position occur, the risk of requirement for revision surgery is extremely low in our study (0.3%), and it is unlikely to affect long term outcomes

Timely and competent treatment of paediatric fractures is paramount to a healthy future working population. Anecdotal evidence suggests that children travel greater distances to obtain care compared to adults causing economic and geographic inequities. This study aims to qualify the informal regionalization of children's fracture care in Ontario. The results could inform future policy on resource distribution and planning of the provincial health care system. A retrospective cohort study was conducted examining two of the most common paediatric orthopaedic traumatic injuries, femoral shaft and supracondylar humerus fractures (SCH), in parallel over the last 10 years (2010-2020) using multiple linked administrative databases housed at the Institute for Clinical Evaluative Sciences (ICES) in Toronto, Ontario. We compared the distance travelled by these pediatric cohorts to clinically equivalent adult fracture patterns (distal radius fracture (DR) and femoral shaft fracture). Patient cohorts were identified based on treatment codes and distances were calculated from a centroid of patient home forward sortation area to hospital location. Demographics, hospital type, and closest hospital to patient were also recorded. For common upper extremity fracture care, 84% of children underwent surgery at specialized centers which required significant travel (44km). Conversely, 67% of adults were treated locally, travelling a mean of 23km. Similarly, two-thirds of adult femoral shaft fractures were treated locally (mean travel distance of 30km) while most children (84%) with femoral shaft fractures travelled an average of 63km to specialized centers. Children who live in rural areas travel on average 51km more than their adult rural-residing counterparts for all fracture care. Four institutions provide over 75% of the fracture care for children, whereas 22 institutions distribute the same case volume in adults.?. Adult fracture care naturally self-organizes with proportionate distribution without policy-directed systemization. There is an unplanned concentration of pediatric fracture care to specialized centers in Ontario placing undue burden on pediatric patients and inadvertently stresses the surgical resources in a small handful of hospitals. In contrast, adult fracture care naturally self-organizes with proportionate distribution without policy-directed systemization. Patient care equity and appropriate resource allocation cannot be achieved without appropriate systemization of pediatric fracture care

Aims. Comparison of the outcome between the supine or prone positioned child with a supracondylar humerus fracture by measuring anaesthetic and operating time, functional outcomes and complications. Methods. All children with isolated Gartland 2 and 3 supracondylar humerus fractures were who were admitted to our institute, were asked to participate in the the study. For surgery, the participating children were either operated on in a ‘supine’ or ‘prone’ position. The children were randomly allocated to either the ‘supine’ or ‘prone’ position. The fractures were preferably treated by closed reduction and percutaneous pinning with k-wires. However, if the fracture proved difficult to reduce, we proceeded to open reduction via medial and lateral approach. All fractures were stabilized with one medial and one lateral k-wire. The children were immobilized in a reinforced above elbow back-slab. Total anaesthetic and surgical time were meticulously recorded. Patients were followed up in our outpatient clinic at one week, four weeks (at which time the k-wires were removed). Three months post operatively, elbow extension, flexion and total range of movement was assessed in all children. Results Twenty children with isolated Gartland 2 and 3 supracondylar humerus fractures were included in this study. Nine children (5 ± 1 years, 7 boys and 2 girls) were operated on in a prone position, while 11 children (6 ± 2 years, 10 boys and 1 girls) were operated on in a supine position. Results. The anaesthetic time was significantly longer in the prone (20 ± 8 min) than in the supine position(10 ± 3 min) (p = 0.001). In line with this, surgical time showed a tendency to also be longer in prone (44 ± 36 min) than supine position (18 ± 18 min) (p = 0.08). No differences between prone and supine operated children was found for elbow extension (4.4 ± 7.7° vs. 3.6 ± 7.1°, respectively (p = 0.81)), elbow flexion (129.4 ± 8.8° vs. 127.0 ±8.8°, respectively (p = 0.67)) and/ or elbow range of motion (125.0 ± 16.0° vs. 124.1 ± 14.6°, respectively (p = 0.90)). Conclusion. As no differences were found in elbow mobility 3 months post-operatively and anesthetic and surgical time tends to be longer in a prone position, this study suggests that operating children with Gartland 2 and 3 supracondylar humerus fractures in a supine position is more favorable. NO DISCLOSURES

Closed reduction and percutaneous pinning has become the most common technique for the treatment of Type III displaced supracondylar humerus fractures in children. The purpose of this study was to evaluate whether the loss of reduction in lateral K wiring is non-inferior to crossed K wiring in this procedure. A prospective randomised non-inferiority trial was conducted. Patients aged three to seven presenting to the Emergency Department with a diagnosis of Type III supracondylar humerus fracture were eligible for inclusion in the study. Consenting patients were block randomised into one of two groups based on wire configuration (lateral or crossed K wires). Surgical technique and post-operative management were standardised between the two groups. The primary outcome was loss of reduction, measured by the change in Baumann's angle immediately post –operation compared to that at the time of K wire removal at three weeks. Secondary outcome data collected included Flynn's elbow score, the humero-capitellar angle, and evidence of iatrogenic ulnar nerve injury. Data was analysed using a t-test for independent means. A total of 52 patients were enrolled at baseline with 23 allocated to the lateral pinning group (44%) and 29 to the cross pinning group (56%). Six patients (5 crossed, 1 lateral) received a third wire and one patient (crossed) did not return for x-rays at pin removal and were therefore excluded from analysis. A total of 45 patients were subsequently analysed (22 lateral and 23 crossed). The mean change in Baumann's angle was 1.05 degrees, 95% CI [-0.29, 2.38] for the lateral group and 0.13 degrees, 95% CI [-1.30, 1.56] for the crossed group. There was no significant difference between the groups in change in Baumann's Angle at the time of pin removal (p = 0.18). Two patients in the crossed group developed post-operative iatrogenic ulnar nerve injuries, while none were reported in the lateral group. Preliminary analysis shows that loss of reduction in Baumann's angle with lateral K wires is not inferior to crossed K wires in the management of Type III supracondylar humerus fractures in children. The results of this study suggest that orthopaedic surgeons who currently use crossed K wires could consider switching to lateral K wires in order to reduce the risk of iatrogenic ulnar nerve injuries without significantly compromising reduction

The purpose of this study was to investigate if there is a relationship between the timing of reduction of displaced supracondylar humerus fractures in children and post-operative complications and open reduction rate and to evaluate the usefulness of the definition of early (eight hours or less following injury) and delayed (more than eight hours following injury) treatment used in the literature. The case notes of children who were treated at our institution for a Gartland grade 2b and 3 supracondylar humerus fracture between July 1995 and June 2002 were reviewed. We identified 431 patients with a Gartland grade 3 and 141 patients with a Gartland grade 2b fracture. The time from injury to surgery ranged from 2 hours to 13 days. The average time to reduction was 12 hours for grade 3 injuries and 21 hours for grade 2b injuries. None of the patients had an initial closed reduction in the emergency department. 229 patients were treated early with two compartment syndromes, five ulnar nerve, one lateral cutaneous nerve of the forearm, one median nerve - and one radial nerve palsy, one septic arthritis, one pin site infection, six open reductions; one re-manipulation was required for loss of reduction. The delayed group consisted of 343 patients with six ulnar nerve, three median nerve, one radial nerve and one lateral cutaneous nerve of the forearm palsy, three pin site infections, five open reductions; re-manipulation was required in one patient. All nerve palsies recovered post-operatively. The open reduction rate was two percent. The majority of displaced supracondylar humerus fractures in children do not need to be operated on as an emergency. Operation of fractures not associated with a neurovascular compromise within eight hours of the injury does not seem to reduce the rate of significant complications and open reduction rate. In contrary the most severe complication, the development of a compartment syndrome was only seen in the early group. We did not identify an association between complication rateS and a time threshold. Therefore the differentiation between early and delayed treatment used in the literature seems to be arbitrary and not useful

Purpose: The treatment algorithm for supracondylar humerus fractures in children under age seven is well-established. However, the best treatment option for these fractures in older children (8–14 year olds) is debated. The purpose of this study was to assess the efficacy of closed versus open fixation methods of this fracture type in older children. We hypothesize that closed reduction and percutaneous pinning (CRPP) is as effective as open reduction and internal fixation (ORIF). Method: A retrospective chart review was completed of all patients 8–14 years old treated for supracondylar humerus fractures at one centre from 2000–2007. IRB approval was obtained for this study. Demographics, treatment methods, pre- and post-operative complications, functional and radiographic outcomes were reviewed. Values are reported as mean ± standard deviation. Results: Seventy-eight eligible patients were identified: 60 (76.9%) were treated with CRPP, and 18 (23.1%) were treated with ORIF. Demographics and fracture characteristics were similar between the CRPP and ORIF groups, although patients treated with ORIF were older (p< 0.001) and weighed more (p< 0.001). The ORIF group had higher post-operative complication rates (p=0.016). Five patients treated with CRPP required additional surgery (3 underwent ORIF; 2 underwent repeat CRPP) compared with none in the ORIF group. Children treated with ORIF had greater limitations on active flexion (99.7o ± 18.2 ORIF, 140.5o ± 23.5 CRPP, p< 0.001) and active extension (34.3o ± 19.0 ORIF, 11.9o ± 21.2 CRPP, p< 0.001) at first follow-up. Limitations in active flexion persisted in the ORIF group, but not in the CRPP group, at time of last follow-up (120o ± 14.8 versus 150.4o ± 17.8, p< 0.001). There were no group differences in active extension at last follow-up (p=0.093). On radiographs, significant differences between the groups existed for Bauman’s angles (15.5o ± 5.5 ORIF, 19.3o ± 4.9 CRPP, p=0.013) and carrying angle (12.4o ± 5.7 ORIF, 16.6o ± 5.4 CRPP, p=0.008). Radiographic union was achieved in all cases. Conclusion: Open and closed surgical fixation are both acceptable treatment options for supracondylar humerus fracture in older children. While ORIF appears to result in reduced range of motion, no further operations were required for fracture alignment in this group

During the period 2004–2009, 35 children were admitted to the emergency department,(24 males:11 females), aged 3–14 years old,(MEAN 8,45 years), with supracondylar humeral fractures (33 extension type and 2 flexion type). All fractures were closed and result of sports injuries or games and were treated with closed reduction under general anesthesia and percutaneous k-w fixation. The postoperative follow-up lasted from 6 months to 4 years. The Bauman’s angle was evaluated postoperatively on the operated and normal elbow and was 76, 6 ±1° and 74, 7 ±0, 6°. According to Flynn’s criteria the functional outcome was excellent in 29 cases. In 6 cases where the Bauman’s angle was greater than 10–15° there has been observed varus deformity (4 cases), valgus deformity (1 case), and flexion deficit (1 case). The percutaneous k-w fixation and preservation of Bauman’s angle with carrying angle too, on supracondylar humeral fractures on children is a safe solution to avoid future complications

Purpose: The purpose of this biomechanical study is to compare the double reconstruction plate osteosynthesis versus double tension band osteosynthesis in the fixation of osteoporotic supracondylar humeral fractures. Materials and Methods: Sixteen fresh cadavers (mean age: 75, range:70–80) were randomized into two experimental groups. Same supracondylar transverse humeral fractures were formed in both groups. Fractures in the first group, were fixed with double tension band technique using 2mm in diameter Kirschner wires and 1mm in diameter tension wires. Fractures in the second group, were fixed with double reconstruction plate osteosynthesis using 3,5mm reconstruction plates each fixing medial and lateral columns. Distal fragment was fixed with only one screw. Axial loading, maximum load, failure load and failure patterns were analysed. Statistical analysis was performed with SPSS 13.90 soft ware program. Groups were compared with Mann Whitney U test. Results: Minimum load reqired for fracture displacement was statistically higher in double reconstruction plate osteosynthesis group (p< 0.005). Minumum load reqired for fixation failure was statistically higher in double reconstrution plate osteosynthesis group (p< 0,020). Conclusion: Fracture healing mainly depends on a stable fracture fixation. Double plate ostesynthesis should be preferred over double tension band technique in osteoporotic supracondylar humeral fractures as it provides more stability

Paediatric supracondylar fractures are the most common elbow fracture in children, and is associated with an 11% incidence of neurologic injury. The goal of this study is to investigate the natural history and outcome of motor nerve recovery following closed reduction and percutaneous pinning of this injury. A total of 246 children who underwent closed reduction and percutaneous pinning following supracondylar humerus fractures were prospectively enrolled over a two year period. Patient demographics (age, weight), Gartland fracture classification, and associated traumatic neurologic injury were collected and analyzed with descriptive statistics. Patients with neurologic palsies were separated based on nerve injury distribution, and followed long term to monitor for neurologic recovery at set time points for follow up. Of the 246 patient cohort, 46 patients (18.6%) sustained a motor nerve palsy (Group 1) and 200 patients (82.4%) did not (Group 2) following elbow injury. Forty three cases involved one nerve palsy, and three cases involved two nerve palsies. No differences were found between patient age (Group 1 – 6.6 years old, Group 2 – 6.2 years old, p = 0.11) or weight (Group 1 – 24.3kg, Group 2 – 24.5kg, p = 0.44). A significantly higher proportion of Gartland type III and IV injuries were found in those with nerve palsies (Group 1 – 93.5%, Group 2 – 59%, p < 0 .001). Thirty four Anterior Interosseous Nerve (AIN) palsies were observed, of which 22 (64.7%) made a full recovery by three month. Refractory AIN injuries requiring longer than three month recovered on average 6.8 months post injury. Ten Posterior Interosseous Nerve (PIN) palsies occurred, of which four (40%) made full recovery at three month. Refractory PIN injuries requiring longer than three month recovered on average 8.4 months post injury. Six ulnar nerve motor palsies occurred, of which zero (0%) made full recovery at three month. Ulnar nerve injuries recovered on average 5.8 months post injury. Neurologic injury occurs significantly higher in Gartland type III and IV paediatric supracondylar fractures. AIN palsies remain the most common, with an expected 65% chance of full recovery by three month. 40% of all PIN palsies are expected to fully recover by three month. Ulnar motor nerve palsies were slowest to recover at 0% by the three month mark, and had an average recovery time of approximately 5.8 months. Our study findings provide further evidence for setting clinical and parental expectations following neurologic injury in paediatric supracondylar elbow fractures

Technology within medicine has great potential to bring about more accessible, efficient, and a higher quality delivery of care. Paediatric supracondylar fractures are the most common elbow fracture in children and at our institution often have high rates of unnecessary long term clinical follow-up, leading to an inefficient use of healthcare and patient resources. This study aims to evaluate patient and clinical factors that significantly predict necessity for further clinical visits following closed reduction and percutaneous pinning. A total of 246 children who underwent closed reduction and percutaneous pinning following supracondylar humerus fractures were prospectively enrolled over a two year period. Patient demographics, perioperative course, goniometric measurements, functional outcome measures, clinical assessment and decision making for further follow up were assessed. Categorical and continuous variables were analyzed and screened for significance via bivariate regression. Significant covariates were used to develop a predictive model through multivariate logistical regression. A probability cut-off was determined on the Receiver Operator Characteristic (ROC) curve using the Youden index to maximize sensitivity and specificity. The regression model performance was then prospectively tested against 22 patients in a blind comparison to evaluate accuracy. 246 paediatrics patients were collected, with 29 cases requiring further follow up past the three month visit. Significant predictive factors for follow up were residual nerve palsy (p < 0 .001) and maximum active flexion angle of injured elbow (p < 0 .001). Insignificant factors included other goniometric measures, subjective evaluations, and functional outcomes scores. The probability of requiring further clinical follow up at the 3 month post-op point can be estimated with the equation: logit(follow-up) = 11.319 + 5.518(nerve palsy) − 0.108(maximum active flexion). Goodness of fit of the model was verified with Nagelkerke R2 = 0.574 and Hosmer & Lemeshow chi-square (p = 0.739). Area Under Curve of the ROC curve was C = 0.919 (SE = 0.035, 95% CI 0.850 – 0.988). Using Youden's Index, a cut-off for probability of follow up was set at 0.094 with the overall sensitivity and specificity maximized to 86.2% and 88% respectively. Using this model and cohort, 194 three month clinic visits would have been deemed medically unnecessary. Preliminary blind prospective testing against the 22 patient cohort demonstrates a model sensitivity and specificity at 100% and 75% respectively, correctly deeming 15 visits unnecessary. Virtual clinics and automated clinical decision making can improve healthcare inefficiencies, unclog clinic wait times, and ultimately enhance quality of care delivery. Our regression model is highly accurate in determining medical necessity for physician examination at the three month visit following supracondylar fracture closed reduction and percutaneous pinning. When applied correctly, there is potential for significant reductions in health care expenditures and in the economic burden on patient families by removing unnecessary visits. In light of positive patient and family receptiveness toward technology, our promising findings and predictive model may pave the way for remote health care delivery, virtual clinics, and automated clinical decision making

Purpose: The aim of this retrospective study was to assess the correlation between the occurance of iatrogenic ulnar nerve injury and frontal and saggital angular insertion of the medial pin in pediatric type 3 supracondylar humerus fractures treated with closed reduction and percutaneous fixation using a crossed-pin configuration. Method: Among 164 patients with type 3 supracondylar humerus fractures, treated with closed reduction and percutaneous fixation using a crossed-pin configuration while the elbow was in hyperflexion, between 1999 and 2003, ninety patients (54 male and 36 female, mean age 6.1 years) with complete clinical and radiological records and follow-up period of at least 6 months were included the study. Frontal humerus-pin angle (FHPA) was the angle between the long axis of humerus and the axis of the medial pin measured on an anteroposterior radiograph. Saggital humerus-pin angle (SHPA) was the angle between the long axis of humerus and the axis of the medial pin measured on a lateral radiograph and expressed as a positive value if the medial pin direction was anteroposterior and as a negative value if the direction was posteroanterior. All the mesurements were made by the same observer blinded to the clinical records of the patients. Results: Postoperative ulnar nerve injury was observed in 18 patients. The ulnar nerve injury group and control group were similar with respect to age and gender. Mean FHPA was 36.6 and 33.8 degrees in ulnar nerve injury and control groups respectively (p=0.270). Mean SHPA was 12.1 and 1.6 degrees in ulnar nerve injury and control groups respectively, and the difference was significant (p=0.001). All the patients with ulnar nerve injury had complete recovery within 3 months following surgery. Conclusion: There are several methods to avoid iatrogenic ulnar nerve injury in supracondylar fractures such as insertion of two or three lateral pins, insertion of the medial pin while the elbow is less than 90 degrees of flexion. The findings of this retrospective study revealed that there was a considerable correlation between the occurence of iatrogenic ulnar nerve injury and sagittal angular insertion of the medial pin. We suggest that if a crossed-pin figuration is desired, it is better to insert the medial pin neutral or posteroanterior direction in the sagittal plane if the elbow is in hyperflexion

All supracondylar humeral fractures managed with closed or open reduction and pin fixation at the Hospital for Sick Children between 1995 and 2002 were retrospectively reviewed. Time from injury to treatment, post reduction complications and need for open reduction were recorded. Fractures treated ≥ 8 hours from injury were considered in the early treatment group while > 8 hours were considered in the late treatment group. Fractures presenting with a cold hand (four patients) were taken to the operating room as quickly as possible and were excluded from the study. There were 431 patients with a Gartland grade 3 and 141 patients with a Gartland grade 2b. The time from injury to surgery ranged from 2 hours to 13 days. The average time to reduction was 12 hours for grade 3 injuries and 21 hours for grade 2b injuries. None of the patients had an initial closed reduction in the emergency department. The early treatment group consisted of 230 patients with two compartment syndromes, six ulnar-, one superficial radial-, one median- and one radial nerve palsy, one septic arthritis, one pin site infection, six open reductions and one re-manipulation was required for loss of reduction. The late treatment group consisted of 342 patients with six ulnar-, three median-, one radial nerve palsy and one lateral cutaneous nerve of the forearm palsy, three pin site infections, five open reductions and re-manipulation was required in one patient. All nerve palsies recovered post-operatively. Conclusion: There was no significant difference in the proportion of complications between the early and late treatment group, but the most severe complication, the development of a compartment syndrome was only seen in the early group. Delayed treatment of supracondylar humeral fractures seems to be safe in a large number of patients, and in fact, most of our patients were treated more than eight hours from the injury. Early operation of fractures not associated with a neurovascular compromise also does not seem to reduce the complication rate. Nevertheless the decision when to operate needs to be decided for each patient individually

The treatment of supracondylar humeral fractures in children continues to evolve. The currently fashionable treatment for displaced fractures is closed reduction and the insertion of at least two K-wires. This usually requires the patient to have a second surgery to remove the K-wires, and may result in significant scarring. The senior author has used the straight arm method to treat displaced supracondylar fractures. We have reviewed the long term results of seven children treated by the straight arm method. No patient had a scar, no patient had a cubitus varus and all children regained a full range of movement. This method offers excellent results with no risk of iatrogenic nerve injury, scarring, or second surgery

Aim. Differing reports about the surgical management of the supracondylar humeral fracture make evidence-based practice very difficult, so knowledge of the contemporary practices and opinions of an expert body can provide a useful benchmark for appraisal; the aim of this study was to obtain this information. Methods. An electronic 18 item, single response multiple-choice questionnaire was designed to investigate various aspects of the surgical management of supracondylar fractures, with particular focus on areas that remain controversial in the literature. Members of BSCOS were invited by email, on three occasions, to complete the questionnaire, which was posted on the web-based SurveyMonkey™ platform (. www.surveymonkey.com. , California, USA). The survey was available for completion for a period of 10 weeks. Results. 102 responses were received (response rate 56.7%); all respondents completed the entire questionnaire. There was almost complete agreement (>90%) in only three areas: -The preferred management of Gartland 3 fractures; The management of the fracture with an absent radial pulse and impaired digital perfusion; An ulnar nerve palsy detected four weeks post-operatively. Majority agreement (>60%) was found regarding: - Possible consequences of delay in performing closed reduction; Management of the pink, perfused hand with an absent radial pulse; Necessity of anatomical reduction. There was no consensus regarding: - K-wiring of Gartland 2 fractures; Management of ulnar nerve palsy detected one week post-operatively; Open insertion of the medial K-wire. Conclusion. Reflecting current trends and attitudes, this survey provides information against which an individual surgeon can appraise their own practice. Strong consensus existed in areas in which clear evidence is available to inform practice. This highlights the importance of good-quality research, and identifies areas requiring further investigation

Aim. Our aim was to compare the Wilkins'-modified Gartland classification and AO classifications of supracondylar humeral fracture with respect to: -Inter-observer reliability; Association of fracture-grade with radiological quality of reduction; Association of fracture-grade with complications. Methods. The unit database was interrogated to identify all operated supracondylar fractures between 2007–2011. Radiographs from each case were evaluated by four observers (three consultants, one trainee) and classified according to Gartland and the AO system. Inter-observer reliability was calculated using Cohen's Kappa coefficient. Radiological quality of reduction was evaluated using a new scoring system, combining the anterior humeral line, the lateral capitello-humeral angle (LCHA) and Baumann's angle, (compared to reference values). Analysis of variance (ANOVA) was performed to determine whether there was a statistically significant difference in scores between the fracture grades. Case notes were reviewed for pre- and post-operative complication, and chi-squared test performed to compare the incidence between different fracture grades. Results. 83 cases were identified for fracture classification and 66 for assessment of reduction and complications. Inter-observer reliability was 0.58 for Gartland (moderate agreement), and 0.70 for the AO classification (good agreement). ANOVA demonstrated no significant difference in the overall reduction scores between the different grades of either classification. Mean scores for LCHA were lower for Gartland-2b (p=0.02) and AO-3 (p=0.007) groups (compared to Gartland-3 and AO-4). Complications were more frequent with the higher grades of fracture in both classifications (p<0.05). Conclusion. The AO classification has greater reliability and should be considered as an alternative to the Gartland classification. A higher grade of fracture is not associated with inferior radiographic outcomes. Surgeons should be aware that restoration of the LCHA is more difficult with the Gartland-2b and AO-3 fractures, probably because of the intact posterior cortex. A greater rate of complications should be expected with higher grades of fracture

Cubitus varus following paediatric supra-condylar humeral fracture represents a complex three-dimensional malunion. This affects cosmesis, function and subsequent distal humeral fracture risk. Operative correction is however difficult with high complication rates. We present the 40-year Yorkhill experience of managing this deformity. From a total of 3220 supracondylar humeral fractures, 40 cases of post-traumatic cubitus varus were identified. There were ten undisplaced fractures, treated in cast, and thirty displaced fractures. Five were treated in cast, thirteen manipulated (MUA), four MUA+k-wires, seven ORIF (six k-wire, one steinman pin) and one in skeletal-traction. Sixteen malunions were treated operatively. The mean pre-operative varus was 19°. All had cosmetic concerns, three mild pain, one paraesthesia/weakness and three reduced movement (ROM). The operative indication was cosmetic in fifteen and functional in one (concern about instability). Twelve patients had lateral closing-wedge osteotomies; three complex/3D osteotomies (dome, unspecified rotational, antero-lateral wedge) and two had attempted 8-plate guided-growth correction. Complications occurred in eight patients (50 %): Fixation was lost in three (two staples, one k-wiring), incomplete correction in six (both 8-plates, both staples, two standard plates) and one early wound infection requiring metalwork removal resulting in deformity recurrence. One patient underwent revision lateral wedge osteotomy with full deformity correction but marked ROM restriction (20–100°) secondary to loose bodies. Those without complications were satisfied (50 %). All patients with residual deformity were unsatisfied. 1 patient with keloid scarring was unsatisfied despite deformity correction. Varus malunion is uncommon (1 %) but needs to be guarded against. It tended to occur in displaced fractures treated with MUA and cast alone. We therefore recommend additional pin fixation in all displaced fractures. Deformity correction should only be attempted in those with significant symptomatic deformity due to the high complication/dissatisfaction rates. Staple osteotomy fixation and 8-plate guided growth correction are not recommended

The aims of this study were (1) to assess whether rotational stability testing in Gartland III supracondylar fractures can be used intra-operatively in order to assess fracture stability following fixation with lateral-entry wires and (2) to quantify the incidence of rotational instability following lateral-entry wire fixation in Gartland type III supracondylar humeral fractures in children. Twenty-one consecutive patients admitted with Grade III supracondylar fractures at the Children's Hospital at Westmead were surgically treated according to a predetermined protocol. Following closed fracture reduction, 2 lateral-entry wires were inserted under radiographic control. Stability was then assessed by comparing lateral x-ray images in internal and external rotation. If the fracture was found to be rotationally unstable by the operating surgeon, a third lateral-entry wire was inserted and images repeated. A medial wire was used only if instability was demonstrated after the insertion of three lateral wires. Rotational stability was achieved with two lateral-entry wires in 6 cases, three lateral-entry wires in 10 cases and with an additional medial wire in 5 cases. Our results were compared to a control group of 24 patients treated at our hospital prior to introduction of this protocol. No patients returned to theatre following introduction of our protocol as opposed to 6 patients in the control group. On analysis of radiographs, the protocol resulted in significantly less fracture position loss as evidenced by change in Baumann's angle (p<0.05) and lateral rotational percentage (p<0.05). We conclude that the introduction of rotational stability testing allows intra-operative assessment of fracture fixation. Supracondylar fractures that are rotationally stable intra-operatively following wire fixation are unlikely to displace post-operatively. Only a small proportion (26%) of these fractures were rotationally stable with 2 lateral-entry wires. This may be a reflection of either the fracture configuration or inability to adequately engage the medial column