Joystick reduction benefits operative efficiency in pediatric supracondylar humeral Fx

Study Type: Therapy
OE Level of Evidence: 2
Journal Level of Evidence: N/A
68 pediatric patients with displaced supracondylar humeral fractures were randomized to one of two methods of closed reduction. In one group, if closed manipulation did not yield acceptable reduction, the joystick technique was used to facilitate reduction. In the other Please login to view the rest of this report. Please login to view the rest of this report.
Funding: Non-funded
Conflicts: None disclosed
Why was this study needed now?
Supracondylar humeral fractures are a relatively common childhood injury, usually resulting from a fall. Many of these fractures require fixation, most commonly using percutaneous pinning. Obtaining an adequate closed reduction of the fracture can be challenging with many cases converted to open reduction following failed attempts at closed reduction. The joystick technique, using either a Kirschner wire or a Shanz pin, has been reported to aid reduction, though whether there is any significant advantage of this technique over manual traction in obtaining reduction has yet to be tested in a randomized controlled trial.
What was the principal research question?
In the closed reduction of pediatric supracondylar humeral fractures, is there a significant difference in operative outcomes, including operative time, fluoroscopy time, reduction success, and postoperative radiographic outcome between reduction by joystick technique versus traditional manual traction?
Population: 68 children, aged 4-12 years, with a displaced (>2mm), closed supracondylar humeral fracture who were scheduled for percutaneous pin fixation.
Intervention: Joystick group: Initially, closed manipulation of the fracture was attempted. If unsuccessful, a Kirschner wire was inserted through a 1-cm incision made at the distal third of the humerus and used as a joystick to facilitate antero-posterior, varus-valgus, and rotational correction. Once stabilized, the fracture was fixed using 2-3 Kirschner wires. (n=34; Mean age: 7.6+/-2.6)
Comparison: Manual traction group: Closed reduction was attempted using axial traction, varus-valgus manipulation, hyperflexion or hyperextension to address extension or flexion deformity, and forearm rotation. Once stabilized, the fracture was fixed using 2-3 Kirschner wires. If unsuccessful after three attempts, reduction method was converted to the joystick technique for assistance. Cases requiring conversion to the joystick technique were excluded from the analysis (n=34; Mean age: 8.0+/-2.5)
Outcomes: Perioperative outcomes included operative time, intraoperative fluoroscopy time, the rate of successful reduction intraoperatively, and the length of hospital stay. The reduction was acceptable intraoperatively when the anterior humeral line was in line with the middle third of the humeral capitulum on lateral radiographs, and the capitulum angle was between 9-26 degrees on antero-posterior radiographs (AP). Postoperative outcomes included fracture healing status (union, nonunion, malunion) on radiographs, hyperextension/hyperflexion deformity on lateral radiographs, capitulum angle on AP radiographs, complication rate, and the Flynn criteria for elbow function (rated as either Excellent, Good, Fair, or Poor).
Methods: RCT; single-center
Time: Mean postoperative follow-up was >2.5 years in both groups (33.8+/-12.6mo and 30.9+/-9.5mo, respectively).
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The authors responsible for this critical appraisal and ACE Report indicate no potential conflicts of interest relating to the content in the original publication.