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Children's Orthopaedics: A. Gadgil, C. Hayhurst, N. Maffulli, and J. S. M. Dwyer Elevated, straight-arm traction for supracondylar fractures of the humerus in children J Bone Joint Surg Br 2005; 87-B: 82-87 [Abstract] [Full text] [PDF]

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Response to the letter from Mr Kakarala and Mr Lahoti

Jonathan S.M. Dwyer, A. Gadgil   (6 September 2005)

Response to the letter from Dr Papavasiliou and Mr Isaac

Jonathan S.M. Dwyer, Gadgil A.   (5 September 2005)

Response to Mr Chirputkar

Jonathan S.M. Dwyer, A. Gadgil   (5 September 2005)

Elevated, straight-arm traction for supracondylar fractures of the humerus in children

Athanasios V. Papavasiliou, David Isaac MRCS(Ed)   (12 May 2005)

Letter from Mr Kakarala

Gopikrishna Kakarala, Om Lahoti, Consultant Orthopadic Surgeon, King's College Hospital, London   (10 March 2005)

Letter from Mr Chirputkar

Kedar V Chirputkar   (18 January 2005)

Response to the letter from Mr Kakarala and Mr Lahoti 6 September 2005
Jonathan S.M. Dwyer, Consultant Orthopaedic Surgeon North Staffs University Hospital, A. Gadgil Send letter to journal: Re: Response to the letter from Mr Kakarala and Mr Lahoti abragadabra13{at}yahoo.com Jonathan S.M. Dwyer, et al.	Sir, We thank Messrs Kakarala and Lahoti for their interest in our study. The majority of studies that have examined the management of supracondylar fractures of the humerus in children have demonstrated that manipulative reduction followed by splintage produces the highest rate of post-traumatic malunion. Our pilot study revealed this feature and we have discontinued this form of management for grade 2b and 3 fractures. Grade 1 and 2a fractures were admitted for observation while in elevated, straight-arm traction where there was significant concern that early elbow flexion in the presence of marked swelling might increase the risk of forearm flexor compartment ischaemia. Once this risk had passed, these elbows were flexed to just beyond 90°, supported in a collar and cuff and the patients were discharged home within 48 hours of injury. We found that these fractures were accurately classified and healed without complication, rapidly returning to normal function. We disagree with Mr Kakarara’s statement that elevated, straight-arm traction does not control medial or lateral displacement. It does indeed prevent further medial or lateral displacement and will allow some degree of control of coronal plane axial alignment by moving the traction point towards the foot or the head of the bed. With movement towards the head of the bed there is an increased valgus moment created about the elbow and conversely, when moving a traction point towards the foot, there is an increased varus moment created about the elbow, and one can see on inspection in the first few days after injury, that the carrying angle can be adjusted. As the child becomes more mobile in bed, this becomes less important as the fracture is stabilised and at this point it is probably reasonable to compare the treatment with the skilful neglect referred to by Mr Kakarara as once swelling is reduced and forearm flexor compartment ischaemia is no longer at risk, management in a long arm cast would become possible. We are aware of publications reporting this form of management. My concern would be that prolonged immobilisation of the elbow may give rise to a greater degree of stiffness in the joint and prevent rapid remodelling as the children, once treated in elevated, straight-arm traction begin to flex the elbow during the second week of treatment and we recognise that once flexion against the traction weight has been achieved to an angle beyond 45°, which in some of the more severely displaced fractures does indeed represent their initial maximum flexion arc, that the fracture is sufficiently stable for the child to be mobilised and discharged from hospital. The child is discharged free from support at this point, and allowed to continue elbow movement. However, the parents are advised to keep the child in a protected environment to prevent recurrence of injury. As regards prolonged in-patient management of children and the psychological implications, we did initially begin to study this but found no evidence of psychological injury to any patient, or indeed associated family members and therefore discontinued this part of the study, as many families felt that it was overly intrusive. There were several children in the series who benefited from in-patient admission, as this allowed significant social problems, including non-accidental injury to be addressed, and by comparison with other patients in my clinics receiving operative management of their injuries, one has to say that this group of patients readily and happily attend the Out-Patient Department, are comfortable in the company of medical and nursing staff and are almost universally co-operative and compliant during examination. They have no surgical scars and no surgical complications, and we have no cases of phobic anxiety states in relation to hypodermic needles or injections, or other medical interventions in this group. Since our study we now offer surgical management to patients ten years of age or older with Gartland grade 2b or 3 fractures, using closed manipulative reduction and percutaneous crossed Kirschner wire stabilisation of an anatomically reduced fracture undertaken on the first available operating list after injury and under paediatric consultant orthopaedic supervision. We advise families and patients who are particularly concerned about surgery that it is possible to manage fracture conservatively, but that they may suffer a post-traumatic deformity, although this is unlikely to produce any significant longer-term functional deficit. Interestingly, we still have patients in this age group who therefore opt for conservative management in elevated, straight-arm traction. In the under ten age group we advise on the range of surgical managements available. We advise against closed manipulative reduction with splintage. We advise that the only benefit from operative intervention is that of social convenience, and clearly we are obliged to discuss the potential risk of complication and almost without exception these patients and families opt for conservative management. This form of management affords an opportunity to provide a process of truly informed consent as to the range of treatments available, a safe environment for the child, evolution of a secure doctor-patient relationship, which leads to a far more realistic evaluation of outcome than surgical management performed as an emergency. Despite deliberately choosing the most exacting standards to assess our outcomes we have demonstrated that conscientious conservative management will produce results equivalent to surgical management without the associated risks. The results of this treatment in real terms are therefore to be considered superior. A. GADGIL, FRCS C. HAYHURST, MRCS N. MAFFULLI, FRCS(Orth) J.S.M. DWYER, FRCS(Orth) University Hospital of North Staffordshire and Keele University, Stoke on Trent, UK.
Response to the letter from Dr Papavasiliou and Mr Isaac 5 September 2005
Jonathan S.M. Dwyer, Consultant Orthopaedic Surgeon North Staffs University Hospital, Gadgil A. Send letter to journal: Re: Response to the letter from Dr Papavasiliou and Mr Isaac abragadabra13{at}yahoo.com Jonathan S.M. Dwyer, et al.	Sir, We would like to thank Dr Papavasiliou and Mr Isaac for the interest they have shown in our paper. All fractures in our series were grade 2B or 3 according to Gartland’s modified classification. As regards unsatisfactory reduction, the important point is to identify this common childhood injury as of the periosteal sleeve type, which occurs almost exclusively in patients below ten years of age. After ten a more adult fracture pattern occurs and this accounts for the less successful results with a higher rate of post-traumatic deformity. For the purpose of our study, serial radiographs were undertaken to demonstrate re-formation of the distal humerus within the periosteal sleeve and modelling/resorption of the anteriorly extruded proximal fragment. The important feature of elevated, straight-arm traction is that rotational malreductions are self-resolving. Axial malreductions, by controlling the degree of abduction of the shoulder, are providing either a slight varus or valgus stress for the majority to correct deformity, which is best managed by inspection. There is, therefore, only malunion of the distal fragment in the sagittal plane / extension. This remodels in the plane of movement of the humero-ulnar articulation over a two year period. The child is mobilised under supervision in the ward to ensure stability while walking. This is usually achieved on the first day following removal of skin traction. The parents are then advised to keep the child under close supervision and avoid vigorous physical activities. Children were then seen one week after discharge in the fracture clinic for assessment, both clinically and radiographically, and then further follow-up assessments were undertaken at six month periods until restoration of range of movement and radiographic evidence of completion of remodelling were established. We now consider this degree of follow-up to be unnecessary as the fractures behave in an entirely predictable manner, and the rate of re-fracture is no greater than that shown in studies applying surgical management to these fractures. During our pilot study options for manipulative reduction followed by splintage, with or without percutaneous Kirschner wiring, were discussed. Once we had established that there were problems associated with splintage following manipulative reduction with a high rate of malunion, particularly rotational, and the risks associated with surgical management, usually iatrogenic peripheral nerve injury, we advised parents of our concept of treatment and had no acceptance of offers of surgical management. This process was undertaken after consent had been given following the child’s admission and was recorded in the clinical notes, but no formal written consent documents were filled out for conservative management, which would represent standard NHS practice, both at the time of the study and in current management. A. GADGIL, FRCS C. HAYHURST, MRCS N. MAFFULLI, FRCS J.S. M. DWYER, FRCS(Orth) University Hospital of North Staffordshire and Keele University, Stoke on Trent, UK.
Response to Mr Chirputkar 5 September 2005
Jonathan S.M. Dwyer, Consultant Orthopaedic Surgeon North Staffs University Hospital, A. Gadgil Send letter to journal: Re: Response to Mr Chirputkar abragadabra13{at}yahoo.com Jonathan S.M. Dwyer, et al.	Sir, We thank Mr Chirputkar for his interest in our paper. All neurological injuries documented were the result of fractures of the distal humerus and all resolved completely without the need for further intervention. The longest period of recovery was a radial nerve palsy that persisted for six months. The child was managed in a wrist extension splint and occupational therapy advice and support was given to avoid stiffness during the period of weakness of the extensors. Function was normal two years after injury. This is in contrast with the iatropathic injuries recently reported by Miss Eastwood and Professor Birch to the British Society of Children’s Orthopaedic Surgery, where peripheral nerves injured surgically produce persisting symptoms, requiring operative intervention. There was not a complete resolution of the nerve injury in all cases. J.S.M. DWYER A.G. GADGIL University of North Staffordshire and Keele University, Stoke on Trent, UK.
Elevated, straight-arm traction for supracondylar fractures of the humerus in children 12 May 2005
Athanasios V. Papavasiliou, Research Sp R in T&O Eastbourne DGH, David Isaac MRCS(Ed) Send letter to journal: Re: Elevated, straight-arm traction for supracondylar fractures of the humerus in children PpvslA{at}aol.com Athanasios V. Papavasiliou, et al.	Sir, We read this article with interest. In studies using straight-arm traction by Piggot et al1 and Dodge2 the authors emphasise the importance of initial manipulation prior to the application of skin traction and the necessity of serial radiographs to check the maintenance of the reduction, and the adjustment of the traction if necessary. In his article Dodge2 states that 'skin traction alone will not always reduce the fracture, and when reduction does not occur with traction the golden opportunity for closed reduction of the fracture has passed' and that 'unacceptable reduction or inability to maintain an acceptable reduction after a few days in traction' is a contra-indication for this method of treatment, requiring surgical intervention. The authors of this article do not find initial manipulation or adjustment of the traction crucial, which makes the elevated straight-arm traction as proposed equal to 'skilful neglect'. We would be interested to know the following. Firstly, the number of type IIb and III supracondylar fractures. Secondly, the management of any cases of unsatisfactory reduction during the initial few days in traction or prior to discharge. Thirdly, the management after discharge. Also whether or not the surgical option was discussed with the parents and informed consent obtained for conservative treatment. Finally, at what point the final outcome was measured (a similar result to that shown in Fig. 2 will be obtained more rapidly with surgical treatment). A. PAPAVASILIOU BSc, MD, PhD D. Isaac, MRCS(Ed) Eastbourne District and General Hospital, Eastbourne, UK. 1. Piggot J, Graham HK, McCoy GF. Supracondylar fractures of the humerus in children: treatment by straight lateral traction. J Bone Joint Surg [Br] 1986;68-B:577-83. 2. Dodge HS. Displaced supracondylar fractures of the humerus in children: treatment by Dunlop’s traction. J Bone Joint Surg [Am] 1972;54-A:1408-18.
Letter from Mr Kakarala 10 March 2005
Gopikrishna Kakarala, Junior Clinical fellow King's College Hospital, Om Lahoti, Consultant Orthopadic Surgeon, King's College Hospital, London Send letter to journal: Re: Letter from Mr Kakarala kakaralagk{at}yahoo.com Gopikrishna Kakarala, et al.	Sir, We read with interest the article by Gadgil, Hayhurst, Maffulli, and Dwyer1 in the January 2005 issue entitled “Elevated, straight-arm traction for supracondylar fractures of the humerus in children”. We would like to know from the authors: 1. Why did manipulation under anaesthesia gave them unsatisfactory results? 2. Elevated straight-arm traction, as shown in the photograph, does not control medial, lateral displacement. So how different is it from treating these fractures by "skilful neglect" in a long arm cast. Although not well reported this latter method is used by under developed nations. 3. Furthermore, prolonged inpatient management of children (in this series an average of 22 days) has its own psychological implications2. G. KAKARALA, MRCS Ed O. LAHOTI, FRCS (Orth) King’s College Hospital, London, UK. 1. Gadgil A, Hayhurst C, Maffuuli N, Dwyer JSM. Elevated, straight-arm traction for supracondylar fractures of the humerus in children. J Bone Joint Surg [Br] 2005;87-B:82-87. 2. Campbell IR, Scaife JM, Johnstone JM. Psychological effects of day case surgery compared with inpatient surgery. Arch Dis Child 1988,63;4:415-7
Letter from Mr Chirputkar 18 January 2005
Kedar V Chirputkar, Orthopaedic registrar Dumfries and Galloway Royal Infirmary,Scotland. Send letter to journal: Re: Letter from Mr Chirputkar kchirputkar{at}hotmail.com Kedar V Chirputkar	Sir, I read your article with interest. The article concludes that results of management of younger children with displaced suprecondylar fractures of the humerus without vascular deficit using straight-arm traction, are comparable with those of closed/open K wire fixation for similar group of patients. The article states that there were 17 patients who had neurological involvement (two radial nerve, six anterior interosseous nerve, seven median nerve and two ulnar nerve involvements), at the time of presentation. I would be interested to know more about these patients in terms of method of management, extent of neurological recovery and necessity for any further intervention. K.V CHIRPUTKAR, SpR Dumfries and Galloway Royal Infirmary, Dumfries, UK.