|MISSION HOSPITAL SECTION
|Year : 2017 | Volume
| Issue : 1 | Page : 43-48
Functional and radiological correlation in surgically managed severe supracondylar humerus fracture in a pediatric cohort using pediatric outcomes data collection instrument upper extremity scale: A report from a level V trauma center in rural Central India
Deeptiman James, Manjulata Gajendran, Tapan Kumar Paraseth
Department of Orthopedics, Christian Hospital Mungeli, Mungeli, Chhattisgarh, India
|Date of Web Publication||19-Dec-2016|
Department of Orthopedics, Christian Hospital Mungeli, Lormi Road, Mungeli, Chhattisgarh - 495 334
Source of Support: None, Conflict of Interest: None
Context: This study highlights the correlation between functional and radiological outcome in a pediatric cohort who were surgically managed for displaced supracondylar humerus fractures at a level V trauma center. Settings: Surgically managed pediatric Gartland type III supracondylar humerus fracture patients were retrospectively assessed. All patients were managed at the level V trauma center from 2011 to 2015. Patients with regular follow-up were included in the study. Methodology: Baumann's angle and pediatric outcomes data collection instrument (PODCI) upper extremity and physical function core scale administered at 6 months follow-up were used to assess the radiological and functional outcomes. Results: Thirty-seven children with supracondylar humerus fracture were treated at our center. Fifteen patients underwent surgical management for Gartland type III fracture. One patient presented with open fracture. Three patients with delayed presentation underwent open reduction and K-wire fixation. Ten patients underwent closed reduction under fluoroscopy guidance and K-wire fixation. Fourteen patients were followed up for 6 months and underwent radiological evaluation and functional assessment. One patient was lost to follow-up. Two patients had median nerve palsy, one patient had complete recovery at 6 months follow-up, and the other patient had partial recovery. Average Baumann's angle was 72.97 (standard deviation [SD] =8.5), ranging from 57.8 to 84.86. The average PODCI outcome was 50.5 (SD = 6.16), ranging from 36 to 57. A weak Pearson's correlation coefficient (r = 0.476) was observed between radiological and functional outcomes. Conclusions: Satisfactory outcomes were observed in most patients who underwent surgical management of severe Gartland type III supracondylar fracture. Low PODCI score was observed with partial median nerve recovery. A weak linear correlation between Baumann's angle and PODCI score suggests multifactorial determinants of functional outcomes in pediatric supracondylar fracture.
Keywords: Baumann′s angle, pediatric outcomes data collection instrument scale, supracondylar fracture
|How to cite this article:|
James D, Gajendran M, Paraseth TK. Functional and radiological correlation in surgically managed severe supracondylar humerus fracture in a pediatric cohort using pediatric outcomes data collection instrument upper extremity scale: A report from a level V trauma center in rural Central India. CHRISMED J Health Res 2017;4:43-8
|How to cite this URL:|
James D, Gajendran M, Paraseth TK. Functional and radiological correlation in surgically managed severe supracondylar humerus fracture in a pediatric cohort using pediatric outcomes data collection instrument upper extremity scale: A report from a level V trauma center in rural Central India. CHRISMED J Health Res [serial online] 2017 [cited 2021 Apr 17];4:43-8. Available from: https://www.cjhr.org/text.asp?2017/4/1/43/196066
| Introduction|| |
Supracondylar fracture is the most common elbow injury observed in the pediatric population.  Unstable fracture anatomy and short lever arm in severe Gartland type III supracondylar fracture make accurate reduction challenging and increase risk of loss of reduction. , While consensus eludes to which configuration gives best fracture stability, closed reduction with crossed K-wire configuration is commonly advocated, but iatrogenic injury to ulnar nerve must be avoided. , Failed closed reduction and neglected severely displaced supracondylar fractures require open reduction. 
Baumann's angle is used as a universal guide to assess fracture reduction in pediatric humerus supracondylar fracture. , Variation in Baumann's angle directly affects the cosmetic outcome.  Flynn's criteria use the loss of carrying angle and loss of motion to grade outcome. ,, However, limited data exist regarding correlation between functional and radiological outcomes in severe supracondylar humerus fractures. No outcome data for pediatric supracondylar fracture are available from rural India. This study attempts to evaluate outcome of severe supracondylar humerus fracture treated surgically at a level V trauma center in rural Central India and objectively assess correlation between radiological and functional outcomes in a pediatric cohort with severe supracondylar humerus fracture.
| Methodology|| |
A retrospective outcome analysis study was designed. Radiological outcome and functional outcome were designated as the two independent variables. To facilitate objective assessment, Baumann's angle and pediatric outcomes data collection instrument (PODCI) upper extremity and physical function core scale were assigned as radiological and functional outcome scores, respectively.  Information about all pediatric supracondylar fractures managed at the level V trauma center from 2011 to 2015 was obtained from the orthopedic department database. The inclusion criteria were (1) patients up to 14 years of age, (2) displaced type III Gartland humerus supracondylar fracture, (3) patients with regular outpatient physiotherapy and occupational therapy follow-up. All patients were followed up for 6 months. Baumann's angle was calculated with Medsynapse PACS software measurement tools (Medsynaptic Pvt Ltd). PODCI upper extremity and physical function core scale was administered at 6 months outpatient follow-up. The outcome was also graded according to Flynn's criteria. Data were tabulated and analyzed with Microsoft Excel 2007 software.
All reductions were carried out under image intensifier guidance [Figure 1],[Figure 2],[Figure 3],[Figure 4],[Figure 5] and [Figure 6]. Crossed K-wire configuration was used for postreduction fracture stabilization in all patients, except in one, where two divergent lateral K-wires were used to stabilize the fracture. An above elbow posterior slab was applied at 90° elbow flexion for a period of 2 weeks. Posterior slab was discontinued after 2 weeks of immobilization, and active-assisted elbow range of movement exercises, activities of daily living, and play activities were initiated. Home therapy was encouraged with weekly visit to the outpatient physiotherapy and occupational therapy clinic for evaluation and supervision. K-wire exit was done at 6 weeks follow-up. Orthogonal elbow radiographs were taken on the 2 nd postoperative day and at 6 weeks before K-wire exit was done. In some cases, radiographs were taken after K-wire exits on request. All patients were followed up at 3 months and 6 months. Patients with elbow stiffness were followed up more frequently.
|Figure 1: Case 1: Displaced Gartland III supracondylar fracture (anteroposterior view)|
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|Figure 2: Case 1: Displaced Gartland III supracondylar fracture (lateral view)|
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|Figure 3: Case 2: Displaced Gartland III supracondylar fracture (lateral view)|
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|Figure 4: Case 2: Displaced Gartland III supracondylar fracture (anteroposterior view)|
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|Figure 5: Closed reduction and internal fixation (crossed K-wire fixation) (anteroposterior view)|
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Linear correlation between the two variables was analyzed with scatter diagram [Figure 7]. Pearson's correlation coefficient was calculated to measure the degree of association between Baumann's angle and PODCI upper extremity and physical functional core scale, respectively.
|Figure 7: Scatter diagram for linear correlation between Baumann's angle and pediatric outcomes data collection instrument score|
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| Results|| |
Thirty seven children with supracondylar fracture were managed at the level V trauma center, out of which 15 patients were classified as severely displaced Gartland type III fracture based on radiological evaluation [Table 1]. Four patients underwent open reduction and K-wire fixation, and 11 patients underwent closed reduction and K-wire fixation under fluoroscopy guidance. One patient presented with open fracture. Three patients presented late with maluniting supracondylar fractures. They underwent open reduction, osteoclasis or "calloclasis," and K-wire fixation. One patient was lost to follow-up. Six female and eight male patients with average age of 7.2 years (ranging from 2 to 12 years) were followed up for 6 months. Two patients had right elbow injury and 12 patients had left elbow injury. Clinical and radiological evidence of bony union was confirmed in all patients at 6 weeks [Figure 8]. PODCI upper extremity and physical function core scale questionnaire was administered to 14 patients.
Average Baumann's angle was 72.97° (standard deviation [SD] =8.5), ranging from 57.8° to 84.86°. The average PODCI outcome was 50.5 (SD = 6.16), ranging from 36 to 57. The outcome was graded as excellent in nine patients, good in four patients, and fair in one patient. Two patients had median nerve palsy, one had complete recovery at 6 months follow-up, and the other patient had partial recovery. Three patients with pin tract infections were treated successfully with antibiotics and K-wire removal. One patient with 15° loss of elbow motion was graded as fair outcome. A weak Pearson's correlation coefficient (r = 0.476) was observed between radiological and functional outcomes.
| Discussion|| |
Children commonly present with extension type supracondylar humerus fracture, following fall on outstretched hand. , Tertiary centers have reported good outcome in severely displaced supracondylar humerus fracture in children. ,, However, outcome report for supracondylar humerus fracture from remote and rural areas of India is not available. To the best of our knowledge, we are the first to report outcome in pediatric supracondylar fracture managed surgically at a level V trauma center in rural Central India.
Accurate reduction of severely displaced supracondylar fracture is essential for good cosmetic outcome. Baumann's angle is universally accepted measurement tool for assessment of reduction of supracondylar humerus fracture both intraoperatively as well as postoperatively. , The normal range of the humerocapitellar angle varies from 64° to 81°. ,, The mean Baumann's angle (72.97°) in our study is comparable to other published data. , This study was conducted with the aim to investigate if accuracy of radiological reduction of severely displaced supracondylar fracture alone is sufficient to ensure excellent outcome. We assessed the correlation between Baumann's angle and functional outcome in patients with severely displaced pediatric supracondylar humerus fracture.
The outcome in severely displaced Gartland type III pediatric supracondylar humerus fracture have traditionally been graded in terms of cosmetic and functional parameters. ,, Excellent to good outcome was observed in our patients including the four patients who underwent open reduction, with osteoclasis or "calloclasis" and crossed K-wire fixation. One patient with residual elbow stiffness had fair outcome. This result is comparable to most published supracondylar humerus fracture outcome data. However, Flynn's outcome grading has been criticized for ignoring neurological assessment in assessing supracondylar fracture outcome.  Outcome analysis scales for objective assessment of supracondylar fracture outcome have been used sparingly. ,, The outcome was evaluated by administering "PODCI upper extremity and physical function core scale." None of the patients in our cohort had any musculoskeletal deformity or deficit prior to the injury. The PODCI scale was administered to all patients at 6 months follow-up in the outpatient physiotherapy and occupational therapy clinic. The average PODCI score was 50.5, ranging from 36 to 57. High PODCI score was observed in all patients with excellent outcome. However, the lowest PODCI score was observed in patient with partial median nerve recovery, who was graded as a good outcome based on Flynn's grading. Due to this fallacy in Flynn's grading, we chose PODCI scale as the measurement parameter for functional outcome in our study.
The study was able to establish a weak correlation between Baumann's angle and PODCI upper extremity and physical function core scale scores in our cohort. Lack of absolute linear correlation between the two variables suggests that radiological accuracy of reduction is not the sole factor that ensures good functional outcome in severely displaced Gartland III supracondylar humerus fracture. Other factors such as injury velocity, soft tissue contusion, perioperative manipulation, duration of immobilization, postoperative physiotherapy and occupational therapy, and neurological status may influence functional outcome in severely displaced Gartland III supracondylar fracture in children. Further investigation into these factors may be necessary to ensure a holistic approach to the management of such injury.
| Conclusions|| |
Pediatric supracondylar humerus fractures are commonly seen in rural orthopedic practice. Excellent outcome is achievable with accurate reduction and stable fixation. However, radiological accuracy of reduction is not the sole factor that determines functional outcome in severe supracondylar humerus fracture. Data investigating the role of physiotherapy and occupational therapy in supracondylar humerus fracture outcome are inadequate.  Hence, more investigation is needed to identify factors that may influence outcome in severe supracondylar humerus fracture. Identification of these factors is essential to ensure good outcome in severe supracondylar fractures, irrespective of the level of trauma center.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]
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