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

In combined high median and ulnar nerve injury, transfer of extensor digiti minimi (EDM) and extensor carpi ulnaris (ECU) nerve branches to restore intrinsic hand function is previously described. A segment of nerve graft is required in this operation. The aim of this study was to evaluate the feasibility of using the sensory branch of radial nerve (SRN) as an “in situ vascular nerve bridge'” (IVNB) instead of sural nerve graft. Twenty fresh cadavers were dissected. In proximal forearm incision, the feasibility of transferring the EDM/ECU branches to the distal stump of transected SRN was evaluated. In distal forearm incision, the two distal branches of the SRN were transected near the radial styloid process to determine whether transfer of the proximal stumps of these branches to the motor branches of the median (MMN) and ulnar (MUN) nerves is possible. The number of axons in each nerve was determined. The size of the dissected nerves and their location demonstrate that tension free nerve coaptation is easily possible in both proximal and distal incisions. Utilisation of the SRN as an IVNB instead of the conventional sural nerve graft has some advantages. Firstly, the sural nerve graft is a single branch and could be sutured to either the MMN or MUN, whereas the SRN has two terminal branches and can address both of them. Secondly, the IVNB has live Schwann cells and may accelerate the regeneration. Finally, this IVNB does not require leg incision and could be performed under regional anesthesia. The SRN as an IVNB is a viable option which can be used instead of conventional nerve graft in some brachial plexus or high median and ulnar nerve injuries when restoration of intrinsic hand function by transfer of EDM/ECU branches is attempted

Aim. To investigate the effectiveness of a decision-based protocol designed to minimise the use of medial incisions when performing crossed-wire fixation of supracondylar fractures of the distal humerus whilst minimising ulnar nerve injury. Method. We have employed a protocol for placing the medial wire during crossed k-wire fixation of supracondylar fractures dependent upon the medial epicondyle. When this is palpable, the wire is introduced percutaneously; when it is not, a mini-incision is made. All cases of closed reduction and crossed K-wiring of supracondylar fracture over a three year period (2008–2011) were identified from our department database. Cases with a neurological injury identified pre-operatively, and those in which the protocol had not been followed were excluded. Casenotes were reviewed to determine the incidence and outcomes of post-operative ulnar nerve deficit. Results. A total of 106 cases were identified, from which 36 cases were excluded, leaving 70 cases in the study. The mean age was 5 (range 1–11). 68 were extension-type injuries, of which 29 (41%) were type 2 and 39 (56%) type 3 according to the classification of Gartland. 2 were flexion-type. A mini-incision for placement of the medial K-wire was required in only 3 cases (4.3%), with percutaneous placement in all other cases. There was clinical evidence of partial ulnar nerve injury in 1 case (1.4%) which recovered spontaneously within 11 months. Conclusion. The results of this study demonstrate our protocol to be effective. Careful percutaneous placement of the medial wire can be performed in the majority of cases with little risk of significant or permanent injury to the ulnar nerve. Open placement of the medial wire is indicated in only a small proportion of cases. We suggest that the routine use of a medial mini-incision should be re-considered

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

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

Supra-condylar humerus fractures (SCHF) are amongst the most common fractures requiring surgical stabilisation in the pediatric age group (1). Closed reduction and percutaneous fixation with Kirschner wires (KW) is currently the standard of care (2). The number of KW used and their configuration has been the subject of much research (3, 4). The failure modes leading to loss of fracture reduction are not clear and have not been quantified. The aim of this study is to compare the mechanical stability of the opt-used configurations for various loading modes and contact interactions at the KW/bone interface. A Gartland type-III SCHF was introduced to a fourth generation composite saw bone (Sawbones®, Vashon, Washington, USA). The model was CT scanned with a slice spacing of 0.5mm and pixel size 0.3×0.3mm. The CT data set was imported into AmiraDev (AmiraDev 5.2 Visage Imaging, Inc). A uniaxial mechanical test was conducted in order to measure the KW pullout forces from the distal humerus. A model of the fractured humerus was constructed with the following steps: 1) manual segmentation; 2) surface generation of each fragment, and; 3) automatic volumetric grid generation for each fragment. The fracture was then virtually reduced and KWs were placed at the desired configurations (Fig 1a-b). For each configuration, a separate model was generated. Material properties were assigned to the bone-model elements according to the manufacturer's data sheet; Young's modulus E = 16GPa and E = 150MPa for the cortical and cancellous bone respectively. The KW were assigned a Young's modulus of 200GPa. Each of the models created in Amira was imported to a finite element application (Abaqus 6.9, DS-Simula) for structural analysis. For each of KW configuration four different torque forces load types were simulated (Fig 1c left): 1) a clockwise and counterclockwise torque with a magnitude of 1.5 NM (Newton/Meters); 2) a translational force with a magnitude of 30 N (Newtons) in the direction of the humerus shaft, and; 3) a shear force with a magnitude of 30 N in the direction parallel to the fracture plane. The results were normalised such that the maximum displacement for the crossed pin configuration with a coefficient of friction equal to zero (μ = 0) was used as unity for each load configuration. Similarly, for each of KW configuration four different translational forces load types were simulated (Fig 1c right): 1) a clockwise and counter clock-wise torque with a magnitude of 1.5 NM (Newton/Meters); 2) a translational force with a magnitude of 30N in the direction of the humerus shaft, and; 3) a shear force with a magnitude of 30N in the direction parallel to the fracture plane. The results were normalised as described above. Results. Torque forces: the crossed configuration was found to be almost independent of the bone-implant friction and was symmetric in terms of direction of the applied torque. The diverging configuration exhibited larger dependency on the bone-implant interface. This is especially noticed as the coefficient of friction (COF) reduced to values below μ = 0.2. Translational forces: the diverging configuration exhibited high sensitivity to reduction of the COF μ = 0. Displacement of the fracture for μ = 0 was substantially larger for the diverging configuration relative to the crossed configuration: 13.5 times and 19 times for the transverse and pullout directions, respectively. As the COF increased to values above μ = 0.5, both fixation configurations performed in a similar manner. Stabilisation of SCHF has been the subject of numerous studies. Relative stability of the different configurations and the risk for iatrogenic ulnar nerve injury has been in the center of the debate. Crossed KW configuration was shown in some clinical studies to be more stable than two lateral KW while others demonstrated no significant difference in stability. As ulnar nerve injury may occur in up to 15.4% of surgeries even if insertion of a medial KW is performed under direct vision, utilisation of two lateral KW configurations offers the advantage of reducing this risk significantly. The main finding of this study is that for a COF exceeding a threshold level (µ = 0.2) the crossed KW configuration did not offer any mechanical advantage over the diverging lateral KW configuration. However, for very low COF values (µ<0.2) the crossed configuration exhibited improved performance when compared with divergent lateral KW (figure 1d). The data demonstrates that the KW-bone bonding has a profound effect on the stability of the fixated bone construct. This is mostly evident when distraction forces are applied but also occurs, to a lesser degree, with rotational or translational forces. This may be a clinically important consideration in the rare SCHF in children with abnormal bones and possibly more commonly, when the KW-bone bonding was compromised after multiple attempts of passing the KW through the same entry point. We have conducted a combined in-vitro mechanical test and finite element-based simulations of a fixated SCHF with different KW configurations, under various friction conditions. Under normal bone-implant interface bonding conditions, the two diverging lateral KW configuration offers adequate mechanical stability and may be the preferred choice of SCHF fixation

Introduction

In response to the COVID-19 pandemic, there was a rapidly implemented restructuring of UK healthcare services. The The Royal National Orthopaedic Hospital, Stanmore, became a central hub for the provision of trauma services for North Central/East London (NCEL) while providing a musculoskeletal tumour service for the south of England, the Midlands, and Wales and an urgent spinal service for London. This study reviews our paediatric practice over this period in order to share our experience and lessons learned. Our hospital admission pathways are described and the safety of surgical and interventional radiological procedures performed under general anaesthesia (GA) with regards to COVID-19 in a paediatric population are evaluated.