RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,
KARNATAKA, BANGALORE
ANNEXURE - II
PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION
1. Name of the candidate : and address / DR. GIRISH KUMAR K P.G. IN ORTHOPEDICS ROOM NO. 107, PG & INTERNS HOSTEL FOR MEN, MYSORE MEDICAL COLLEGE AND RESEARCH INSTITUTE, MYSORE-5700212. Name of the institution : / MYSORE MEDICAL COLLEGE AND RESEARCH INSTITUTE, MYSORE
3. Course of study and : Subject / POST GRADUATE M.S ORTHOPAEDICS
4. Date of admission to : course / 6th MARCH 2009
5. Title of topic : / STUDY ON SURGICAL MANAGEMENT
OF DISPLACED SUPRACONDYLAR FRACTURE OF HUMERUS IN CHILDREN
6. Brief resume of the intended work :
6.1 Need for the study:
Supracondylar fractures are the most frequent elbow injuries in children reported to occur in 55% to 75% of patients with elbow fractures, most frequent before age of seven years (with incidence of 16.6% of all the fractures in children).
Supracondylar fractures of humerus which are displaced & communited in children when accompanied by marked swelling present with formidable challenge. Many of these displaced fractures are unstable after reduction. Immobilsation in right angle position will frequently allow the fragment to slip and the necessity of repeated manipulations causing elbow stiffness & myositis ossificans and physeal damage in which varus deformity is most frequent problem with mean incidence of 30% as reviewed in a series by Smith.
Internal stabilization can be achieved using two crossed kirschner wires. Jones & Swinson were early advocates of this technique.
So we decided to study & evaluate the results of internal fixation with Kirschner wires to confirm its present day relevance.
6.2 REVIEW OF LITERATURE:
Supracondylar fracture were described in writing of Hippocrates during third & fourth century A.D. Supracondylar fractures are known to mankind since longtime. In late 1800’s, Desault who is chief of surgery at Notel Diew Hospital in Paris reported this type of fracture. Proper position and immobilization of this fracture has always been matter of controversy among the ancient writers, while the flexion was most accepted method of treatment. At the beginning of 20th century treatment began to change from these simple passive methods to more aggressive & active methods.
In 1960, Smith Lyman observed that many fractures cannot be reduced to hairline apposition by closed methods & of the few that can, some become displaced subsequently and they also observed that it is difficult to assess the rotation and alignment of distal fragment on X-ray. Hence, internal fixation with ‘K’ wires after reduction is necessary.
In 1960, T.S. Mann and Robert D Ambrosia (1972) concluded that medial and lateral tilt of distal fragment was important cause of cubitus varus or valgus deformity.
In 1974, Joseph C.Flynn, Joseph G Mathews and Royer L.Benoit studied blind pinning of displaced supracondylar fractures of humerus in children and found that reduction and percutaneous pinning of these troublesome fractures provided stability, vascular safety, simplified management, reduced hospital stay and consistently satisfactory appearance and function of elbow in 72 patients. Their long term study showed that the fixation pins do not disturb the growth potential of the distal end of humerus. Cubitus varus, when it occurred was a result of imperfect reduction rather than growth disturbance. In fifty two fractures on long term follow up, satisfactory results were recorded in 98%.Vascular and neural complication were minor and no Volkmann’s contracture were seen.
In 1994, L.E. Zionts [E] agreed that two crossed pins placed from the medial and lateral condyles provided the greatest resistance to rotational displacement of the fracture fragments. This configuration may be preferred for most fractures, but three lateral pins or two lateral pins also provided good stability and these configuration may be treatment options for patients in whom marked swelling of the elbow increases the risk of injury to ulnar nerve during medial placement of pin. The low resistance to rotational displacement provided by two lateral crossed pins suggested that this configuration should not be used.
In JBJS March 2000, L.T. O’ Hora, J.W. Barlow NMP Clarke conducted an audit and reported that Indication for open reduction and pin fixation include a fracture which is irreducible by closed methods, an open fracture and fractures associated with vascular injury.
In 2007, Wudbhav N.Shankar, Nader M.Hebera, David L.Skaggs and John M.Flynn evaluated 322 displaced supracondylar humeral fractures that had been treated with percutaneous pin fixation. They examined fracture classification, pin configuration, change in alignment after fixation, details of additional procedures and final radiological outcomes. They found that 2.9% were associated with postoperative loss of fixation.
Loss of fixation was due to technical errors and the identified three pin-fixation errors.
1. Failure to engage both fragments with two pins and more
2. Failure to achieve cortical fixation with two pins or more
3. Failure to achieve pins separation.
Gurkan V, Orhun H, Akca OS et al evaluated the results of surgical treatment for pediatric displaced supracondylar humerus fractures. The study included 98 pediatric patients. All fractures were approached posteriorly. Reduction was achieved by cutting the triceps muscle in a reverse V-shape, followed by fixation using two cross-k wires from the epicondyles.
The mean follow up was 42.6 months. According to the criteria of Flynn et al, 95 patients (96.9%) had perfect or good cosmetic results, 84 patients (85.7%) had perfect or good functional results.
Elbow angles, elbow range of motion and the strength of triceps muscle were similar to those measured on normal side (P>0.05).
Three patients (3.4%) developed cubitus varus deformity. They concluded that reduction of pediatric displaced supracondylar humerus fracture may be achieved easily by the posterior approach.
6.3 OBJECTIVES OF THE STUDY:
1) Preoperative assessment and evaluating the age group affected, type of fracture, the mechanism of injury and associated neurovascular injuries in supracondylar fractures of humerus in children.
2) To evaluate the results of treatment of displaced supracondylar fracture of humerus treated by internal fixation with ‘Kirschner’ wires.
3) To note intraoperative and postoperative complication.
4) To assess the efficacy and advantage of this treatment.
7. MATERIALS AND METHODS :
7.1 Source of data :
The proposed study is a hospital based prospective study centered in K.R.Hospital attached to the MMC&RI, Mysore during the term between January 2010 to October 2011.
7.2 Method of collection of data (including sampling procedures if any) :
Sample size: Minimum of 25 cases meeting criteria for the present study
Inclusion Criteria
o Age group :- 3 years – 12 years
o Both male and female patients
o Gartland type II and type III fractures scheduled for percutaneous pinning and open reduction
o Consent to participate in the study
Exclusion Criteria
o Gartland type I fractures
o Supracondylar fracture with compartment syndrome needing fasciotomy.
o Supracondylar fracture needing vascular repair
o Supracondylar fracture associated with distal radius/ulna, proximal humerus fracture.
o Refusal to provide informed consent.
7.3 Sampling Procedure:-
· History
· Clinical examination
· Radiological examination
7.4 Investigations:
Blood : Hb, BT, CT, TC, DC, ESR,Blood grouping and Rh typing.
Blood : RBS, BU, & SC
ECG : In all leads
HIV, HBSAg
Plain radiograph AP and lateral view of affected elbow joint.
Patients subjected to surgery will be followed up at regular intervals with clinical and radiological data. Assessment will be done based on a proforma containing all necessary information regarding.
· Personal details age, sex, address and occupation
· Type of fracture
· Surgical procedure carried out
· Duration of hospital stay
· Initiation of mobilization
· Physiotherapy
· Development of surgical complications
. Post-operative evaluation
Postoperative Evaluation
The results will be evaluated with the help of Joseph Flynn criteria, considering two factors, cosmetic and functional factor. The cosmetic appearance of elbow is graded in 5 degree interval of loss of carrying angle, if any varus deformity it would result in poor grade. In functional one the intervals of 5 degrees loss of total arc of flexion and extension is measured.
Joseph Flynn Criteria
Results Cosmetic factors-loss of Functional loss of
Carrying angle (degree) motion (degree)
Excellent 0-5 0-5
Good 6-10 6-10
Fair 11-15 11-15 Poor more than 15 more than 15
7.3 Does the study require any investigations or interventions to be conducted on patients or other humans or animals? If so, please describe briefly.
NO
7.4 Has Ethical clearance been obtained from your institution?
YES
Copy enclosed
7.5 Duration of study?
22 months
8. LIST OF REFERENCES :
1. Chang J.C, Sher W.Y: Limb fractures in different pediatric age groups, a study of
3350 children with ortho trauma 1993:7:15-22.
2. Smith L: Deformity following supracondylar fractures of humerus. J Bone and
Joint Surgery 1960; 42-A 235-52
3. Mann T.S, Perth: Prognosis of supracondylar fractures JBJS 1963 vol 45B, page
761-777
4. Robert D. Ambrosia: Supracondylar fracture of humerus prevention of cubitus
varus JBJS 1972, vol 54:60-66
5. Dannielson, Petterson Holger: Open reduction and pin fixation of severely
displaced supracondylar fracture in children (Acta Ortho vol. 57, 1980 page 249-
55)
6. Zionts LE: Torsional strength pin configuration used to fix supracondylar
fracture of humerus JBJS Vol 76A, 1994 page 253-256
7. Flynn Joseph, Mathews. J, Beboitt J. Rojev: Blind pinning of displaced
supracondylar fractures of humerus in children (JBJS Vol 56A 1974 page 263-
272)
8. Reja Omid, Paul D. Choi, and Davil: Supracondylar humeral fracture in children JBJS, May 2008 Vol 90: page 1121-1132
9. Royce Ro, Dutkowsky JP, Kasser JR, Rand FR Neurologic complications after K-wire fixation of supracondylar humerus fractures in children. JBJS Vol/90 2008 page 1121-1132.
10. Wudbhav N. Shankar, Nader M. Hebela, Davil L. Skagges, John M. Flynn. Loss of pin fixation in displaced supracondylar humerus fractures in children causes and prevention. JBJS (American) 2007; 89, 713-717.
11. Gurkan V, Orhun H, Akca O, Ercan T, Ozel. S. Treatment of pediatric displaced supracondylar humerus fractures by fixation with two cross K-wires following reduction achieved after cutting the triceps muscle in a reverse V-shape. Acta Orthop traumatol Turc; 2008 May-July; 42(3) 154-160.
12. Beaty, James H; Kasser, James R Tittle: Rockwood and Wilkins’ fractures in children 6th edition.
9. Signature of the candidate :
Dr. GIRISH KUMAR. K
10. Remarks of the guide :
11.Name and designation of (in block letter)
11.1 Guide /
Dr. KIRAN KALAIAH
Professor, Department of Orthopaedics
K.R. Hospital, MMC&RI ,Mysore
11.2 Signature
11.3 Head of Department / Dr.KALADAGI.P.S
Professor & HOD, Department of Orthopaedics
K.R. Hospital, MMC&RI, Mysore
11.4 Signature
11.5 Co-Guide / Dr.BELLAD.S.H
Lecturer,department of orthopaedics,
K.R. Hospital, MMC&RI, Mysore
11.6 Signature of co-guide:
12. 12.1 Remarks of Dean and Director:
12.2 Signature :
ETHICAL COMMITTEE CLEARANCE
1. Title of Dissertation / “STUDY ON SURGICAL MANAGEMENT OF DISPLACED SUPRACONDYLAR FRACTURE OF HUMERUS IN CHILDREN”
2. Name of the candidate / Dr.GIRISH KUMAR.K
3. Subject / MS IN ORTHOPAEDICS
4. Name of the guide / Dr. KIRAN KALAIAH
Professor, Department of Orthopaedics
K.R. Hospital, MMC&RI ,Mysore
5. Approved/Not approved (If not approved, suggestion)
MEDICAL SUPERINTENDENT KR Hospital, Mysore / MEDICAL SUPERINTENDENT Cheluvamba Hospital, Mysore
PROFESSOR AND HOD DEPARTMENT OF MEDICINE, MYSORE MEDICAL COLLEGE AND RESEARCH INSTITUTE, MYSORE / PROFESSOR AND HOD DEPARTMENT OF SURGERY MYSORE MEDICAL COLLEGE AND RESEARCH INSTITUTE, MYSORE
MEDICAL SUPERINTENDENT P.K.T.B AND CHEST DISEASES HOSPITAL, MYSORE / LAW EXPERT
DEAN AND DIRECTOR MYSORE MEDICAL COLLEGE AND RESEARCH INSTITUTE, MYSORE