|Year : 2020 | Volume
| Issue : 1 | Page : 70-74
A randomized controlled trial comparing outcomes of K wire removal at 3weeks vs. 6weeks of lateral condyle fractures of humerus in children
Anand Shankar1, Santosh Kumar2, Raju Rijal3, Shiv Raj Paneru4, Reetesh Roshan5
1 Assistant Professor, Dept. of Orthopaedics, NMCH, Jamuhar, Sasaram, India
2 Professor & Head, Dept. of Orthopaedics, IGIMS, India
3 Professor, B.P. Koirala Institute of Health Sciences, Dharan, Nepal, India
4 Assistant Professor, Dept. of Orthopaedics, B.P. Koirala Institute of Health Sciences, Dharan, Nepal, India
5 PG Student, Dept. of Orthopaedics, IGIMS, India
|Date of Submission||15-Feb-2020|
|Date of Acceptance||22-Feb-2020|
|Date of Web Publication||16-Nov-2020|
Prof. & Head Dept. of Orthopedics, IGIMS, Patna
Source of Support: None, Conflict of Interest: None
Background & objectives: Lateral condyle humerus fractures are the most common distal humeral epiphyseal fracture. They are usually associated with relatively high rate of complications and the results of non-operative management are not always good. So a randomised controlled trial comparing outcomes of K-wire removal at three weeks vs. six weeks for lateral condyle fractures of humerus in children was done.
Methods: All patients aged one to fourteen years with traumatic fractures of the lateral condyle fracture of humerus presenting to the Department of Orthopaedics, BPKIHS giving written consent for the trial were included and randomised in two groups. Fractures duration more than seven days old were excluded. Cases taken were put and randomized according to random excel number generation. After open reduction and internal fixation the k-wire removed at three weeks in one group and at six weeks in another group. The clinic radiological outcomes were evaluated and noted for infection and radiological union. The collected data were evaluated and various statistical tests applied. P value of less than 0.05 was taken as significant.
Results: We found statistically significant difference in comparison of union with different age groups (p<0.05). Other parameters were statistically not significant. Three patients developed skin infection, one in group A and two in group B . Three patients did not show radiological union at the expected time of k-wire removal two in group A one in group B and all the cases were above ten years of age.
Conclusion: Our study has shown that fracture of lateral condyle of humerus united earlier than 6 weeks and shows no significant difference in short term outcome of K-wire and back slab removal at 3 weeks or at 6 weeks regarding union and infection.
|How to cite this article:|
Shankar A, Kumar S, Rijal R, Paneru SR, Roshan R. A randomized controlled trial comparing outcomes of K wire removal at 3weeks vs. 6weeks of lateral condyle fractures of humerus in children. J Indira Gandhi Inst Med Sci 2020;6:70-4
|How to cite this URL:|
Shankar A, Kumar S, Rijal R, Paneru SR, Roshan R. A randomized controlled trial comparing outcomes of K wire removal at 3weeks vs. 6weeks of lateral condyle fractures of humerus in children. J Indira Gandhi Inst Med Sci [serial online] 2020 [cited 2021 Dec 6];6:70-4. Available from: http://www.jigims.co.in/text.asp?2020/6/1/70/300745
| Introduction:|| |
Fracture of the lateral condyle of the humerus constitutes 10% to 15 % of elbow injuries with the peak occurring at the age of 6-7 years,,,,,,,. Pediatric fractures around elbow are different from many other pediatric injuries. They are associated with relatively higher rate of complications and the results of non-operative management are not always good. The child’s elbow is well vascularized and therefore fracture healing takes place very quickly. Such a narrow/small window of opportunity makes it imperative that the fracture be properly managed very quickly.
The attached extensor muscles pulls the fragment from its bed to varying degree causing displacement. The displacement varies from a downward, lateral and usually also backwards with or without rotation of the fragment.
The extent/line of injury may not be appreciated on x-ray because most of the distal humeral epiphysis is still cartilaginous. In such situations it is helpful to make x-ray of the normal elbow and compare the two sides, paying particular attention to the relationship (alignment) of the long axis of radius, the capitular ossific nucleus and humerus.
Some authors/writers have advised non-operative treatment for closed undispalced fractures and open reduction and K-wire fixation for displaced fractures,,,,,,. However in further studies by some other authors emphasized the importance of open reduction and K-wire fixation over closed reduction and Plaster of Paris slab application even in undisplaced fractures,,,,,,,,. They have found better results after operative management instead of non-operative management.
There is controversy in removal of K-wire at 3 weeks or 6 weeks after operative fixation. Few of the authors remove K-wires at 6 weeks,,,,,, and others remove in 3-4 weeks,,,,,. Those authors who remove the K-wires in 3 weeks find that there is less number of infection rates, lesser degree of stiffness and lesser time was required to achieve almost full ROM of elbow joint.
Studies have been done in the West which compare the outcomes of removal of K-wires at 3 and 6 weeks in the fixation of lateral condyle fracture of humerus in children. The authors have found no significant difference. But the general practice by most authors is to remove the K-wires at 6 weeks. If a study here in our setup also shows the same results then we also could remove the K-wires at 3 weeks with the advantage of less infection rates, early mobilization and lesser chance of stiffness.
| Materials and Methods|| |
The study was conducted in the Department of Orthopaedics, B.P. Koirala Institute of Health Sciences, a tertiary care hospital in Eastern Nepal, over a period of twelve months from January 2012 to December 2012.
Inclusion criteria: All patients aged 1 to 14 years with traumatic fractures of the lateral condyle fracture of humerus giving written consent for the trial, fit for anaesthesia, without other distal humeral fracture, without any systemic disease which is likely to affect the outcome were included in the study.
Allocation was randomized using Excel random number generation technique into two groups:- Group A: Removal of K-wire and back slab in 3 weeks Group B: Removal of K- wire and back slab in 6 weeks. Following fitness for anesthesia, patients of this group were taken up for surgery and underwent open reduction by lateral approach to elbow and two cross K-wire fixation.
After the surgery any immediate post-operative complications were taken into account. They were discharged and sent home after 2 days of antibiotics on POP slab, general condition permitting.
After the discharge all patients were recalled after 2 weeks for inspection of surgical site whether there is any infection present or not, if not then sutures were removed. Group A patients were called up again at 3 weeks for checking radiological union, signs of infection, K-wire and back slab removal and physiotherapy. At the end of 6 weeks group B patients were followed up for radiological union, signs of infection, K-wire and back slab removal and physiotherapy. Group A patients were again followed up at the end of 6 weeks to observe any deformity. At the end of 12 weeks both groups were followed to observe any deformity.
A student ‘t’ test and 95 % confidence intervals were used to evaluate the difference between the two treatment groups with respect to numerical variables including age, time from injury to hospital
| Observation and Results|| |
Our study shows that most of the patients are male in both the study groups. There is no significant correlation between age and sex with study group showing success of randomization.
Our study shows that Milch type II fracture is much more common than Milch type I in both the study groups.
There were no intra-op and immediate post-op complication noted/observed. At the end of twelve weeks of follow up, there was no deformity seen/observed in any of the case, all cases regained almost comparable range of motion with normal side.
| Discussion:|| |
Our study shows the mean age of incidence to be 7.05 ± 2.78 years. Our study shows that about 14 % of cases of elbow injuries in children is showing lateral condyle fracture of humerus.
Most of the patients in this study were observed to be male. In one study all of the patients selected were male.
About 37 percent of the total patients had injury by fall from 4-6 feet height which highly corroborates with the mode of injury by fall from monkey bars (usual height is 3-6 feet) in a study. In contrast to this finding/observation one study shows that fall from height (bicycle 33 percent, tree 16 percent and monkey bar 16 percent) is more common mode of injury.
Milch type II fracture was more common than Milch type I fracture in total patients in my study.
Involvement of left side (number of cases 39) of humerus is more than the right side (number of cases 29) out of total sixty eight cases in our study. This observation/finding has also been described in other studies.,,,
In our study out of sixty eight cases more than half of the patients (37 patients 54.4 percent) reached within 24 hours of injury and were treated on the same day on emergency basis. Rest of the patients who reached to hospital after 24 hours but were operated within 7 days. Those patients who came late i.e. after 7 days of injury were excluded from the study. In one of the studies done previously 25 patients (about 24percent) were treated on same day of injury, 62 patients (60 percent) were treated next day, Between 2-7 days 12 patients (11 percent) were treated and only 5 patients (about 5 percent) were treated within the time period of 8-17 days of injury.
One of the studies excluded all the patients who underwent operative fixation after 14 days. In contrast to these studies one study treated 12 patients between 1 to 4 weeks, 5 patients between 5 to 8 weeks and 5 patients between 9 to 12 weeks.
There are other studies in which authors have done fixation of fracture even after 3 weeks of injury.,
Comparison of occurrence of infection has been done in different study groups at the time of suture removal and at the time of K-wire removal. It has been found that only one patient in study group A shows signs of superficial infection at the time of suture removal i.e. 2 weeks. These cases were successfully and effectively treated with wound dressing and intravenous antibiotics successfully. No cases got infected any further in this group.
One of the previous studies in which K-wire and back slab was removed in 3 weeks as our group A had one case of superficial infection which resolved with antibiotics.26 Other studies in which K-wires and back slab/cast was removed at 3 weeks found no infection in their patients., One of the studies who removed K-wire and back slab at 6 weeks as our group B found three cases of pin tract infection which were treated successfully by oral antibiotics. Other studies / authors who preferred to removed K-wire and back slab/cast at or after 6 weeks had no cases of infection.,
In our study there were only two cases in study group A which did not show radiological union at 3 weeks but on further follow up both cases had radiological union at 6th week. There was one case which does not had radiological union at 3rd week in one of the previous studies as our group A. K-wire reinserted for 3 more weeks but still there was no radiological union. Finally the fracture united after fixation with cannulated cancellous screw across the metaphyseal fragment of the lateral condyle into the distal metaphysis of the humerus.
There was only one case which did not show radiological union in study group B at the end of sixth week, on further follow up at 12th week the fracture was radiologically united. All of the cases operated had radiological union at the end of six weeks in other studies., In contrast to above studies the average time period of radiological union in one of the previous studies was 8 weeks.
Our study clearly shows that all the cases that does not had radiological union at the time of K-wire removal according to their respective study group belongs to age group of greater than 10 years. No study was found comparing these two parameters.
| Conclusion|| |
Our study has shown that fracture of lateral condyle of humerus united earlier than 6 weeks and shows no significant difference in short term outcome of K-wire and back slab removal at 3 weeks or at 6 weeks regarding union and infection. Further evaluation of short term as well as long term outcome is needed with more number of cases in various aspects.
| References|| |
Canale ST, Beaty J. Elbow joint fracture and dislocatìon. In: Campbell’s operative Orthopaedics. 11th ed. Memphis(Tennessee): Mosby Elsevier; 2008. p. 1569-1574.
Tamai J, Lou J, Nagda S et al. Pediatric elbow fractures: Pearls and pitfalls. J The Univ of Penn Orthop 2002;15:43-51.
Beaty JH, Kasser JR. The Elbow: Physeal Fractures, Apophyseal Injuries of the Distal Humerus, Osteonecrosis of the Trochlea, and T- Condylar Fractures. In: Rockwood and Green’s Fractures in Adults. 6th ed. Memphis: Lippincott Williams and Wilkins; 2006. p. 592-610.
Wadsworth TG. Premature epiphyseal fusion after injury of capitellum. J Bone Joint Surg 1964;46:46-49.
Wilson JN. Fracture of external condyle of humerus in children. Br J Surg 1936;18:299-316.
Morrissy RT, Wilkins KE. Deformity following distal humeral fracture in childhood. J Bone Joint Surg (Am) 1984;66:557-562.
Jakob R, Fowles JV, Rang M, et al. Observations concerning fractures of the lateral humeral condyle in children. J Bone Joint Surg 1975;57B:430-436.
Hardacre JA, Nahigian SH, Froimson AI, et al. Fractures of the lateral condyle of the humerus in children. J Bone Joint Surg 1971;53:1083- 1095.
McDonnell DP, Wilson JC. Fracture of the lower end of the humerus in children. J Bone Joint Surg 1948;30:347-358.
Foster DE, Sullivan JA, Gross RH. Lateral humeral condylar fractures in children. J Pediatr Orthop 1985;5:16-22.
Major NM, Crawford ST. Elbow effusions in trauma in adults and children: is there an occult fracture. Am J Roentgenol 2002;178:413- 418.
Badelon O, Bensahel H, Mazda K, et al. Lateral humeral condylar fractures in children: a report of 47 cases. J Pediatr Orthop 1988;8:31-34.
Gooi SG, Chee EK, Wong CL et al. Retrospectìve review of Kirschner wire fixation and casting for displaced lateral condyle fracture of the humerus in children. J Malaysian Orthop 2008;2(2):17-20.
Koh KH, Seo SW, Kim KM et al. Clinical and radiographic results of lateral condyle fracture of distal humerus in children. J Pediatr Orthop 2010; 30(5):425-429.
Launay F, Leet AI, Jacopin S et al. lateral humeral condyle fractures in children: A comparison of two approaches to treatment. J Pediatr Orthop 2004;24(4):385-391.
Milbrandt TA, Copley LAB. Common elbow injuries in children: evaluatìon, treatment and clinical outcomes. J Curr Opin Orthop 2004;15:286-294.
Cardona JI, Riddle E, Kumar SJ. Displaced fractures of the lateral humeral condyle: criteria for implant removal. J Pediatr Orthop 2002;22:194-197.
Boz U, Ulusal E, Vuruskaner H, et al. Functìonal results of displaced lateral condyle fractures of the humerus with four weeks K-wire in children. J Acta Orthop Traumatol turc 2005;39(3):193-198.
Conner A, Smith MGH. Displaced fracture of lateral humeral condyle in children. J Bone Joint Surg 1970;52:460-464.
Blount WP, Schalz I, Cassidy RH. Fractures of the elbow in children. J Am Med Assoc 1951;146:699-704.
Jeffrey CC. Nonunion of epiphysis of the lateral condyle of the humerus. J Bone Joint Surg 1958;40:396-405.
Morin B, Fassier F, Poitras B, et al. Results of early surgical treatment of fractures of the lateral humeral condyle in children. J Rev Chir Orthop Reparatrice Appar Mot 1988;74:129-131.
Nielsen FH, Ottsen P. Fractures of the lateral condyle of the humerus in children. J Acta Orthop Scand 1974;45:518-528.
Sial NA, Shaukat MK, Iqbal MJ. Open reductìon and K-wire fixation of displaced unstable lateral condyle fracture of the humerus in children. J Professional Med 2011 jul-sep;18(3):501-509.
Flynn J. Nonunion of slightly displaced fractures of the lateral humeral condyle in children: an update. J Pediatr Orthop 1989;9: 691-696.
Thomas DP, Howard AW, Cole WG et al. Three weeks of Kirschner wire fixatìon for displaced lateral condyle fractures of the humerus in children. J Pediatr Orthop 2001; 21(5):565-569.
Hausman MR, Qureshi S, Goldstein R et al. Arthroscopically-assisted treatment of pediatric lateral humeral condyle fractures. J Pediatr Orthop 2007;27(7):739-742.
Chan LWM, Siow HM: Exposed versus buried wires for fixatìon of lateral humeral condyle fracture in children: a comparison of safety and efficacy. J Child Orthop 2011;5:329-333.
Wattenbarger JM, Gerardi DO, Johnston CE. Late open reductìon internal fixatìon of lateral condyle fracture. J Pediatr Orthop 2002;22:394-398.