Elbow fractures are among the most common types of fractures observed in children, and supracondylar fractures constitute 50% of all elbow fractures [1,2]. Although supracondylar fractures are frequently observed, intercondylar fractures of the distal humerus are rare [3–5]. For example, in the study by Maylahn and Fahey  which involved 300 pediatric patients with elbow trauma, intercondylar fractures were detected in only six (2%) patients.
It has been shown that during a high-energy trauma such as a fall from a height, the olecranon enters between the humerus condyles like a wedge, splitting the condyles apart. Given their intra-articular involvement, intercondylar fractures are more complex than supracondylar fractures [7–9].
Treatment options for pediatric T-type distal humerus fractures include conservative or surgical management. Although some of these fractures can be treated with conservative methods, ~ 85% require surgical treatment [1,2]. However, optimum timing of surgery still remains a controversial issue. Although some studies advocate early surgery, others suggest delayed intervention. For example, Ağuş et al.  studied the outcomes of skeletal traction and delayed percutaneous fixation on patients whose fractures could not be treated by closed reduction and reported that no complications occurred with delayed percutaneous pinning. They emphasized that in case of a failed reduction, skeletal traction and delayed percutaneous pinning may be a good treatment alternative. Although most studies on the treatment of pediatric T-condylar fractures consist of small case series, the commonly accepted view is to treat these fractures by open reduction and rigid internal fixation [8,11,12]. However, previous studies have shown that open reduction may lead to iatrogenic injuries such as peripheral soft tissue damage and result in postoperative joint stiffness [13,14]. Therefore, some surgeons tend to avoid open reduction.
On the contrary, there are studies reporting complications such as nonunion, avascular necrosis, and epiphyseal growth arrest in patients receiving conservative treatment . Therefore, to prevent the development of deformities, surgical methods are preferred over conservative methods for the treatment of displaced and comminuted fractures. The most commonly used surgical techniques are open or closed reduction and percutaneous pinning. There are numerous studies reporting successful outcomes with these methods [10,16–18].
Studies have shown that open reduction and pinning yield good functional outcomes in T-type of fractures . In addition to these methods, there are also studies describing closed reduction and percutaneous screw fixation in pediatric patients for T-type fractures [9,20].
The generally accepted treatment protocol for intercondylar fractures of the humerus is open reduction with screw or pin fixation, because it is easier to ensure the stable anatomical reconstruction of the intra-articular fracture with this method . However, studies have shown that 22% of patients who undergo open reduction experience complications such as wound site problems, union-related problems owing to periosteal injury, heterotopic ossification, and iatrogenic nerve injury . In addition, the large soft tissue dissection performed during open reduction may result in vascular complications and elbow stiffness [9,20,21]. It has been shown that the posterior periosteal stripping performed during the triceps-splitting and triceps-sparing techniques may result in the devascularization of the fractured bone fragments and may compromise fracture union [5,22]. Moreover, it has been reported that the intact periosteum should be protected because it can assist with fracture stability and facilitate the closed reduction of the fracture . In light of the aforementioned data, closed reduction with percutaneous pinning seems to be a reasonable alternative. However, literature regarding this subject is still scarce, and it is hard to draw a definitive conclusion. We aimed to evaluate the outcomes of pediatric T-condylar fractures treated by closed reduction and percutaneous pinning (Kirschner wire fixation) in terms of stability, joint range of motion, union rate, and complications.
Patients and methods
Among pediatric patients who were diagnosed with supracondylar humerus fractures in the emergency department between 2010 and 2017, 15 patients who had T-condylar fractures and who underwent closed reduction and percutaneous pinning were retrospectively evaluated. The study was approved by the institutional ethics committee. Patients older than 18 years, patients with open fractures, and those with neurovascular pathologies were not included in the study. Seven patients whose follow-up records were missing were excluded. As a result, eight patients were included in the study. Preoperative assessment was performed with the anteroposterior and lateral radiographs taken in the emergency department. None of the patients underwent computed tomography imaging for diagnostic purposes because the fractures could be clearly interpreted on plain radiographs.
All patients received a single-dose broad-spectrum antibiotic before the surgery. The surgery was performed under general anesthesia. A tourniquet was applied but not inflated. First, the closed reduction of the intercondylar parts of the fracture was obtained, and the reduction was checked under a C arm. Then, the epicondyles were compressed mediolaterally with a bone holding clamp. The reduction and stability of the distal fragments were checked using medial and lateral images obtained under the C arm. Then, for fracture fixation, a transverse pin was passed as perpendicular as possible to the intercondylar fracture line and as parallel as possible to the joint surface. We used cortical continuity and radiologically ossified articular surface continuity in the anterior–posterior and lateral fluoroscopy images. Cortical continuity in the anterior–posterior views and anterior humeral line passing through the capitellum in the lateral view were considered as appropriate reduction criteria. We compare these criteria with the contralateral elbow. The criteria for acceptable reduction were defined as the absence of varus or valgus deformities, anterior humeral line transecting capitellum, minimal rotation, and minimal translation. Then, crossed pins were passed through the medial and the lateral epicondyles into the proximal fragment for fixation. Thus, the fracture was first converted into a supracondylar fracture through the fixation of the condylar fragments and then treated like a simple supracondylar fracture of the humerus. The quantity and positions of the pins used were determined according to the configuration of the fracture (Fig. 1). At the end of the procedure, a long arm splint was applied with the elbow in 90° flexion.
All patients were discharged on the first postoperative day after a control radiograph was taken. Two weeks after the surgery, the patients were reevaluated with anteroposterior and lateral radiographs in terms of reduction loss. The splint was removed on the fourth week, and the patients were instructed to start active and passive exercises. The pins were removed on the sixth week. At 1-year follow-up, the affected extremity was compared with the healthy extremity in terms of rotation, angulation, and joint range of motion. In addition, patient satisfaction was assessed subjectively using visual analogue scale (VAS) scores (Fig. 2a–d). Early postoperative and late postoperative Baumann angles were measured on the anteroposterior and lateral radiographs retrieved from the hospital database.
The mean age was 10.8 ± 4.6 (5–18) years, and all patients were male. The trauma mechanism was a fall from a height (2–6 m) in all patients. The fractured side was the dominant arm in three patients and nondominant arm in five patients.
All patients had type 3 fractures according to the Gartland classification, and the mean follow-up duration was 16.5 ± 7.2 months. The mean union duration was 7.4 ± 2.3 weeks. At the end of the follow-up period, two patients had an extension deficit of 10° and one patient had an extension deficit of 40°. At the end of follow-up period, two patients had 5° of varus, and one patient had 5° of valgus. Compared with the other arm, no growth disturbance was observed in the operated arm in any of the patients. One patient developed pin-tract infection but was treated successfully with antibiotics without the need for debridement. The mean Baumann angles were 74.3° ± 9.6° and 75.4° ± 9.4° on postoperative day 1 and on the third month, respectively. At 1-year follow-up, patient satisfaction was evaluated using the VAS score. The mean VAS score was found to be 9.3 ± 1 (Table 1) .
Treatment methods used for T-condylar humerus fractures may be listed as skeletal traction, long arm casting after closed reduction, closed reduction with percutaneous pinning, and open reduction with internal fixation [16,17]. However, as these types of fractures are uncommon, there is no consensus regarding their treatment .
One of the accepted treatment methods for preventing joint stiffness and enabling early mobilization in intercondylar fractures of the humerus is open reduction with plate and/or screw fixation . There are also studies reporting good outcomes after conservative treatment in pediatric fractures with no/minimal intra-articular displacement and comminution [9,24]. In the literature, there are complications including ulnar nerve injury, pin-tract infection, pin migration, reduction loss, and nonunion or malunion [25,26]. In the 77 patient series by Kundel et al. , the complications reported were iatrogenic nerve injury (16%), heterotopic ossification (49%), deep tissue infection (8%), and implant-related problems requiring revision surgery (5%). It has been reported that open surgery may result in joint stiffness owing to iatrogenic soft tissue damage [13,14]. Given the reported complications of open reduction, the closed reduction and percutaneous pinning method has started to gain ground in the treatment of T-condylar pediatric fractures.
In the study of Papavasiliou and Beslikas , it has been shown that flexion contractures and valgus deformities are more common after open reduction compared with closed reduction with percutaneous pinning.
In this study, three patients had an extension deficit. On the contrary, none of the patients included in the study experienced nonunion/malunion, nerve damage, or heterotopic ossification. It may be difficult to relate the limitation of movement of these three patients to the technique, because T-type fractures occur as a result of high-energy trauma with extensive soft tissue injury, which is generally the reason of limited range of motion. Compared with the literature, fewer complications were observed in our study group, but this may be owing to the small size of our series, given the fact that T-condylar fractures are a rare entity.
Ruiz et al.  described a method in which one of the supracondylar columns was first stabilized with pinning. Then, the other distal fragment was fixed to this restored part using a transverse pin. Kanellopoulos and Yiannakopoulos  reported successful results with pin fixation of the distal fragments followed by osteosynthesis to stabilize the supracondylar component of the fracture using two (medial and lateral) elastic titanium nails. As a different method, Abraham et al.  reported successful results in a 19-patient series in which the integrity of the lateral and medial columns was restored using crossed pins. In this study, first, a transverse pin was passed parallel to the elbow joint to convert the fracture into a simple supracondylar fracture. Then, two crossed pins were passed through the medial and the lateral epicondyles into the proximal fragment, to achieve the remaining fixation. Although the number of cases in our series was limited, the outcomes were found to be favorable.
Given the rarity of T-condylar humerus fractures, our study has some limitations. The most important limitation is the small number of cases in our series. On the contrary, the fact that all surgical procedures were carried out in the same clinic, which is a center that frequently accepts pediatric trauma patients, is a strength of our study.
We believe that closed reduction and percutaneous pinning is a surgical method that may be used for the treatment of pediatric T-condylar fractures, because it is less invasive than open techniques, has fewer complications, and is easily applicable. Prospective studies with wider series and longer follow-up durations are needed for a better understanding of the results of closed reduction and percutaneous pinning in such fractures.
The authors thank Filiz Ölmez Eltez for the images and photo editing.
Conflicts of interest
There are no conflicts of interest.
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