The treatment for Humeral Supracondylar fractures in children is percutaneous fixation with Kirschner wires using a unilateral or crossed wire configuration. Capitellar entry point with divergent wires is thought crucial in the lateral entry approach. Crossed wire configuration carries a risk of Ulnar nerve injury. Our department had recorded a number of failures and this required review. A search was conducted for children with this injury and surgical fixation. A two year time frame was allocated to allow for adequate numbers. The hospitals radiography viewing system and patient notes were utilized to gather required information. 30 patients from 2–14 years all underwent surgery on the day of admission or the following day. 18 had sustained Gartland grade 3 or 4 injuries. Unilateral configuration was used in 10 cases; a loss of reduction was noted in 5 of these with one case requiring reoperation. Crossed wires were used in 20 cases with a loss of reduction in 1. Crossed wire configuration provides a more reliable fixation with a lower chance or re-operation. Our DGH policy now advises the use of this configuration. A small “mini-open” ulnar approach is utilized with visualization and protection of the nerve.
Paediatric wrist fractures are routinely managed with closed reduction and a molded cast. Gap(GI) and Cast indices(CI) are useful in predicting re-displacement following application of cast. Over 6 months we audited the efficacy of molded cast application following closed reduction of distal radial fractures in paediatric patients. The standard was that proposed by Malviya et al where GI >0.15 and CI >0.8 indicate an increased risk of re-displacement. Age, date and time of operation and surgeon's grade were collected. Pre-op displacement, post-reduction GI and CI and subsequent re-displacement were measured using imaging. Post audit intended changes to practice were presented to all surgeons, a “one-pager” was placed above scrub sinks. Re-audit was conducted at 1 year. The audit and re-audit included 28 and 24 patients respectively. Cast molding (CI) improved minimally following intervention (32% to 29%). Cast padding (GI) improved significantly (82% to 63%). Loss of reduction decreased slightly (14% to 12%), this was not accurately predicted by GI and CI in the re-audit. Audit demonstrated that casts were loose, over-padded and did not hold reduction adequately. Re-audit demonstrated that tighter, less padded but still inadequately molded casts were being applied with minimal change in loss of reduction.
