Comparative analysis of surgical outcomes in children with type 3 and type 4 lateral physeal condylar humerus fractures in China: Closed Reduction-PerCutaneous Pinning (CRPP) vs. Open Reduction-Internal Fixation (ORIF)

Abstract

Background

Lateral physeal condylar humerus fractures in pediatric patients aged 1–13 rank as the second most common elbow injury, occurring with a frequency ranging from 5% to 16.8%. There exists an ongoing debate regarding the surgical management of these fractures. This study aims to evaluate the efficacy of Open Reduction and Internal Fixation (ORIF) and Closed Reduction and Percutaneous Pinning (CRPP) as suitable surgical treatments for displaced unstable fractures of the lateral condyle physeal humerus in children. The comparison encompasses the results of ORIF and CRPP, alongside clinical and radiographic outcomes and complication rates.

Method

A retrospective review was conducted at the Department of Orthopedic Surgery in the research hospital. A cohort of 27 patients treated between 2016 and 2023 were analyzed, 19 patients meeting inclusion criteria. The fracture pattern and degree of displacement were assessed, with specialized radiologists, doctors, and surgeons in agreement. Among the patients, 11 underwent CRPP 7 type 3and 4 type 2, while 16 received ORIF 12 type 4 and 4 type 5. Data collection included fracture type, surgical method, operation time, pre and post-operative displacement, casting period, bone union condition, follow-up records, range of motion, complications, delayed union, lateral spurring, and pin removal records.

Results

For CRPP, the mean time for pin removal was 5.42 weeks, with excellent bone union and an average operation time of 34.57 min. Criteria of Hardacre showed 28.57% of cases as good and 71.42% as excellent. Similarly, ORIF demonstrated a mean operation time of 42.5 min, with the fracture healing within 5.33 weeks and the pin being removed after 15 days on average. Criteria of Hardacre indicated 25% of cases as good and 75% as excellent. Both groups showed satisfactory outcomes, with no complications such as osteomyelitis, nonunion, malunion, delayed union, myositis ossificans, physeal growth arrest, tardy ulnar nerve palsy, cubitus valgus, or varus, and no cases requiring re-surgery.

Conclusion

Both CRPP and ORIF are effective surgical methods for treating lateral physeal condylar humeral fractures (types 3 and 4 according to the Song classification) in children, demonstrating satisfactory outcomes. Notably, regardless of displacement (2 mm and >2 mm), both methods yield similar results, albeit with CRPP offering the advantage of avoiding incisions. Overall, both procedures are safe, with favorable bone healing outcomes.

1. Introduction

Following a supra-condylar fracture, lateral physeal condylar humerus fractures in children represent the second most prevalent elbow joint injury, frequently associated with a heightened risk of complications, particularly among individuals aged between 1 and 13 years.3, 4, 5, 6^,13,18 Various classification systems have been developed to ensure precise diagnosis, assess fracture displacement, and enhance surgical outcomes. Notable among these systems are those proposed by Song, Jacob, Lagrange, Rigault, Milch, and Weiss.⁹ (see Table 1) (Table 1)

Table.

Patients outcome data.

	CRPP	ORIF
	TYPE 3 (N = 7)	TYPE 4 (N = 12)
STAY IN HOSPITAL (DAY) MEAN	3.42	3.83
OPERATION TIME (MIN)	37.42	42.5
PRE-OPERATIVE DISPLACEMENT (MM)	2	4.91
POST -OPERATIVE DISPLACEMENT (MM）	0	0.66
CASTING PERIOD (W)	4.71	4.66
TIME OF PIN REMOVAL (W)	5.42	5.33
TOTAL TIME OF FOLLOW UP (MONTH)	9	9.25
LATERAL CONDYLAR BONE SPUR	0.14	0.16
AGE (MEAN) N = 19	7.36	7.36
UNION	VERY GOOD	VERY GOOD
CRITERIA OF HARDACRE	28.57 % CASE GOOD,71.42% CASE EXCELLENT	25% CASE GOOD,75% CASE EXCELLENT
RANGE OF MOTION	28.57% CASE NORMAL	25.57% CASE EXTENSION 5 DEGREE,FLEXION 10 DEGREE
	42.85% CASE EXTENSION -5 DEGREE,FLEXION 5 DEGREE	83.33 % CASE EXTENSION 5 DEGREE,FLEXION 5 DEGREE
	28.57% CASE EXTENSION -5DEGREE,FLEXION -10 DEGREE
GENDER	66.66% BOY,33.33% GIRL (N = 27)

According to the Song classification model, fractures with a displacement of ≤2 mm and limited to the metaphysis or displaying a lateral gap are identified as stable (Type 1 and Type 2). Treatment options typically involve long arm casting or in-situ fixation. Conversely, fractures with a displacement nearing or exceeding 2 mm are deemed unstable, necessitating interventions such as closed reduction with percutaneous pinning (CRPP) or open reduction and internal fixation (ORIF) to mitigate risks of complications like osteomyelitis, nonunion, malunion, delayed union, myositis ossificans, physeal growth arrest, tardy ulnar nerve palsy, and cubitus valgus or varus.^1,7,15

While many surgeons opt for ORIF to ensure anatomical reduction of physeal and intra-articular fractures, CRPP has emerged as a preferred procedure due to its perceived safety advantages, including avoidance of unsightly scars associated with open incisions, reduced soft tissue trauma, minimized risk of vascular damage, and lower potential for nonunion and avascular necrosis (AVN) of the distal humerus physeal.⁷

Between 2016 and 2023, both CRPP and ORIF techniques were employed in our department for treating lateral physeal condylar humerus fractures, with the consent of patients and approval from a team of proficient surgeons and radiologists.^2,4,18 A retrospective review of the overall outcomes, including clinical and radiographic assessments and complication rates, was conducted to compare the safety and efficacy of CRPP and ORIF procedures.

2. Methods and materials

This prospective study was conducted at the orthopedics department from January 2016 to November 2023, with approval from the institution's medical ethics committee. Written informed consent was obtained from all patients (or their parents) involved. Twenty-seven patients (9 girls and 18 boys) with a mean age of 7.36 years (ranging from 1 to 13 years) underwent CRPP and ORIF surgical fixation for fractures with displacements ranging from 2.0 to >2 mm, as assessed on lateral, oblique, or anterior-posterior radiographs. Of these, 11 patients received CRPP (7 Type 3 and 4 Type 2 fractures according to the Song classification), while 16 patients underwent ORIF (12 Type 4 and 4 Type 5 fractures according to the Song classification).

2.1. Inclusion criteria

• 1.Age between 1 and 13 years.
• 2.Song fracture stages 2 and 3.
• 3.Displacement ≥2.0 mm and unstable.
• 4.Mean follow-up time of 9–11 months.
• 5.Ineffectiveness of conservative treatment.

2.2. Exclusion criteria

• 6.Age >13 years.
• 7.Song fracture stages 1, 2, 5.
• 8.Open fractures.
• 9.Patients with severe life-threatening illnesses.
• 10.Multiple bone fractures.
• 11.Stable fractures manageable without surgery.
• 12.ORIF with screws or plates.
• 13.Patients with metabolic bone diseases or ipsilateral extremity fractures.

To ensure satisfactory surgical outcomes, intraoperative data including fracture type, surgical technique, operation time, pre and postoperative displacement, casting duration, bone union status, follow-up records, range of motion, complications, delayed union, lateral spurring, and pin removal records were meticulously documented.

Following a comprehensive review of the patient's medical records, a thorough physical examination, and meticulous evaluation against predetermined inclusion and exclusion criteria, a radiographic examination was conducted to confirm the presence of lateral physeal condylar humeral fractures with a displacement of 2.0 mm or greater, indicating the necessity for surgical stabilization.¹ Subsequently, the decision was made to proceed with surgery if a visible fracture meeting the specified criteria was detected, while an intra-operative arthrogram was planned for cases where no visible fracture was confirmed.

The treatment strategy hinged upon the feasibility of closed reduction. If attainable, Closed Reduction and Percutaneous Pinning (CRPP) were pursued; otherwise, Open Reduction and Internal Fixation (ORIF) were opted for.¹ Under general anesthesia, the patient's elbow underwent traction, accompanied by a gentle varus strain to minimize the risk of unstable fractures. For stage 3 and stage 4 fractures, progressive direct compression was administered to the anteromedial fracture fragment without the use of K-wires. Additionally, a small valgus force was applied to the elbow while the forearm was flexed and the elbow slightly extended to maintain reduction. Subsequently, percutaneous pinning with two parallel smooth K-wires was performed upon confirming the reduction within 2 mm, guided by internal oblique, antero-posterior, and lateral radiographs.¹

The choice of K-wire diameter was determined based on the patient's age, with a 1.2 mm diameter K-wire utilized for patients aged 1–3 years, a 1.4 mm diameter K-wire for patients aged 3–5 years, and a 1.8–2.0 mm diameter K-wire for patients aged 5–9 years.¹

In cases where the fragment could not be reduced to within 2 mm, open reduction and internal fixation were performed. Following the procedure, each patient was fitted with a long-arm cast, maintained for an average duration ranging from 4.66 to 4.77 weeks. Skin staples were removed for patients undergoing ORIF after an average period of 15 days, while K-wires were withdrawn between 5.33 and 5.42 weeks post-procedure. Subsequent to the most recent follow-up, evaluations encompassing changes in X-ray images, clinical symptoms, and fracture displacement (ranging from 0 to 0.66 mm, with a mean value) were conducted, with assessment outcomes graded according to the criteria established by Hardacre¹

3. Surgical procedure

3.1. Open reduction and internal fixation (ORIF)

In the pursuit of restoring functionality and relieving pain associated with traumatic injuries, the surgical intervention of open reduction and internal fixation (ORIF) represents a pivotal aspect of orthopedic management. This technique is particularly pertinent in cases of complex fractures, where anatomical realignment and stable fixation are imperative for optimal outcomes.

The procedural protocol commenced with meticulous attention to anesthesia administration, ensuring the patient's comfort and safety throughout the surgical endeavor. With the patient positioned supine, meticulous preparation of the surgical field ensued, encompassing thorough disinfection with standard iodine solution to mitigate the risk of infection. The implementation of sterile draping techniques meticulously exposed the operative site while maintaining the integrity of the sterile field, a critical aspect of surgical sterility.

Upon delineating the surgical approach, a lateral incision of approximately 5 cm in length was meticulously executed over the fractured elbow under the auspices of strict aseptic conditions. This incision facilitated access to the underlying structures, encompassing the skin and subcutaneous tissue, thereby unveiling the fracture site. The meticulous dissection served to expose the extent of injury, elucidating the severity of displacement, comminution, and associated soft tissue trauma.

Notably, intraoperative assessment revealed a multifaceted fracture pattern, characterized by significant displacement and comminution of the humeral fracture. Furthermore, partial muscle entrapment at the fracture site necessitated meticulous dissection and debridement to optimize anatomical alignment. Hematoma evacuation and thorough cleansing of soft tissue debris were integral components of the surgical endeavor, culminating in the meticulous reduction of the fracture segments.

The definitive stabilization of the fracture ensued through the implementation of internal fixation techniques, leveraging specialized instrumentation and implantable Kirschner wires. The intraoperative utilization of fluoroscopy facilitated real-time visualization of fracture reduction and optimal alignment, ensuring precise placement of internal fixation hardware. The meticulous execution of this step was paramount in achieving biomechanical stability and promoting the requisite conditions for successful bone healing.

Posteriorly, the layered closure of the surgical incision was undertaken with precision, mitigating the risk of wound dehiscence and infection. The application of sterile dressings served to safeguard the surgical site, while adjunctive measures, such as plaster support for external fixation, were employed to maintain the desired alignment of the affected limb.

Throughout the entirety of the surgical intervention, vigilant monitoring of the patient's vital parameters and hemodynamic stability was paramount, ensuring the preservation of physiological homeostasis and the mitigation of potential intraoperative complications. The seamless coordination of the surgical team, coupled with adherence to established protocols and best practices, underscored the successful execution of the ORIF procedure.

In conclusion, the implementation of open reduction and internal fixation represents a cornerstone in the management of complex fractures, necessitating meticulous surgical technique, intraoperative precision, and comprehensive postoperative care. By prioritizing anatomical alignment, biomechanical stability, and patient safety, orthopedic surgeons endeavor to optimize functional outcomes and promote the expedited recovery of individuals afflicted by traumatic musculoskeletal injuries.

3.2. CRPP

Following the administration of adequate anesthesia, the patient was positioned supine, with the left upper limb disinfected using standard iodine solution. Subsequently, sterile draping was applied, and contrast agent was injected into the joint cavity. Manual reduction of the humeral epicondyle fracture ensued, guided by C-arm fluoroscopy which confirmed satisfactory alignment. The fracture site was then stabilized using three Kirschner wires in conjunction with appropriate instrumentation. Throughout the procedure, continuous monitoring via C-arm X-ray fluoroscopy ensured optimal alignment and positioning of the internal fixation. Notably, no aberrant movements were observed at the fracture site, indicating successful stabilization. Following fixation, the protruding ends of the Kirschner wires were trimmed, and the needle holes were meticulously wrapped with alcohol-impregnated cotton. The upper limb was immobilized in a 70° flexed position using external fixation for postoperative support. Noteworthy is the smooth progression of the surgical intervention, accompanied by the maintenance of the patient's stable condition throughout the procedure.

3.2.1. Preoperative preparation

• 1)Prior to surgery, standard laboratory examinations along with specialized tests tailored to individual patient conditions are conducted.
• 2)Specific protocols for skin and local preparation are adhered to, particularly in specialized surgical areas.
• 3)Blood typing is determined to ensure compatibility and prepare for potential transfusions.
• 4)Skin allergy assessments are carried out to mitigate any adverse reactions during or after the procedure.
• 5)Extensive discussions regarding the necessity and associated risks of the surgery are held with the patient and their family members. Consent forms are meticulously reviewed, understood, and signed by all parties involved.
• 6)Radiographic examinations are performed to assess the extent and nature of the condition requiring surgery.
• 7)Preoperative dietary restrictions, including fasting from food and water, are implemented to minimize complications during the surgical procedure.

3.2.2. Postoperative care

Following procedures such as Closed Reduction and Percutaneous Pinning (CRPP) or Open Reduction and Internal Fixation (ORIF), patients are advised to observe a one-month period of rest to aid in recovery. Efforts are made to enhance the nutritional intake and overall quality of care provided to patients during the postoperative phase. Standard rehabilitation therapy protocols are initiated to promote optimal recovery and functional restoration. In cases where internal fixation devices are utilized, measures are taken to prevent failure due to repetitive stress and to mitigate common postoperative complications such as thrombosis and joint stiffness. This often involves the application of a long arm cast. The average duration of immobilization for CRPP and ORIF procedures is carefully monitored, with pins typically removed once healing is deemed sufficient. Patients undergoing ORIF have skin staple pins removed approximately 15 days post-surgery. Regular follow-up X-ray examinations are recommended on a monthly basis to assess healing progress and guide ongoing rehabilitation efforts. After a six-month period, patients are typically able to resume their normal daily activities and functional routines.

4. Results

A total of 19 patients, comprising 4 females and 15 males, with an average age of 7.36 years, participated in the study. Preoperative displacement, as assessed through radiographic imaging, averaged 2.0 mm for CRPP and 4.91 mm for ORIF cases. Seven patients underwent CRPP for type 3 fractures, while 12 patients underwent ORIF for type 4 fractures, classified according to the SONG classification. The most common mechanisms of injury among patients included falls from objects during play (57.8%) and traffic accidents (42.10%), among others (see Fig. 1).

Fig. 1.

presents both the anterior and posterior radiographs of a 5-year-old boy, identified as Wang Mou Shan, showcasing a lateral condylar physeal humerus fracture with instability. The displacement of the fracture exceeds 2 mm, categorized as a Song Type 4 fracture.

4.1. Patients outcome data

The mean operative time for Closed Reduction and Percutaneous Pinning (CRPP) was recorded at 37.42 min, whereas for Open Reduction and Internal Fixation (ORIF), it was 42.5 min (Fig. 2). Postoperative displacement averaged 0.00 mm for CRPP, contrasting with 0.66 mm for ORIF. Hospital stay duration averaged 3.42 days for CRPP and 3.83 days for ORIF. Regarding the casting period (Fig. 3), CRPP patients averaged 4.71 weeks, whereas ORIF patients averaged 4.66 weeks. The timeframe for pin removal (Fig. 4) was 5.42 weeks for CRPP and 5.33 weeks for ORIF. Follow-up duration averaged 9 months for CRPP and 9.25 months for ORIF (see Fig. 7).

Fig. 5.

illustrates the post-operative follow-up and patient muscle activity across various angles (as depicted in Fig. 5.1 through 5.4). The visualization highlights the presence of a scar resulting from the Open Reduction Internal Fixation (ORIF) procedure, albeit with the reassuring absence of any signs of infection, indicating successful skin healing. Furthermore, observations reveal satisfactory extension and flexion of hand movements, accompanied by the absence of discomfort or pain reported by the patient. Notably, there is no discernible loss of movement, with the patient exhibiting excellent muscle strength throughout the evaluation period.

Fig. 6.

illustrates the post-operative radiographs of a 4-year-old girl named Liu Wan Yue. In Fig. 6.1, the antero-lateral view displays a commendable reduction, while in Fig. 6.2, the antero-posterior view further confirms the success of the reduction. Notably, the positioning of the K-wire has effectively addressed the displacement, ensuring optimal alignment. Additionally, a protective cast has been applied to provide support and facilitate a favorable recovery process for the hand.

Fig. 2.

illustrates the sequence of events during this procedure. In Fig. 2.1, the radiograph examination at the onset of surgery is depicted. Subsequently, Fig. 2.2 illustrates the utilization of a metal clamp to restore the bone's position. A 5 cm incision is made as illustrated in Fig. 2.3. Fig. 2.4 through 2.6 demonstrate the use of K-wires to stabilize the bone and correct any displacement.

Fig. 3.

presents a series of radiographs displaying the anterior, posterior, and lateral views. Specifically, Fig. 3.3 and Fig. 3.4 depict post-operative radiographs taken four weeks following surgery, revealing promising prognostic indicators and favorable bone integrity. Additionally, the skin exhibits excellent condition, with no evidence of infection observed during subsequent post-operative follow-up examinations.

Fig. 4.

presents the postoperative radiograph captured six months post-surgery, comprising both lateral (Fig. 4.1) and antero-posterior (Fig. 4.2) views, indicating the removal of the K-wire. Subsequent images (Fig. 4.3 and Fig. 4.4) reveal complete healing of the fracture, demonstrating a robust union. Notably, the alignment of the bone exhibits a highly favorable outcome, indicative of successful surgical intervention.

Fig. 7.

illustrates the comprehensive treatment algorithm tailored to patients based on the stage of displacement.

Lateral condylar bone spur measurements were 0.14 for CRPP and 0.16 for ORIF. Notably, bone union was uniformly excellent across all patients. According to the Hardacre criteria, CRPP demonstrated 28.57% of cases as good and 71.42% as excellent, while ORIF exhibited 25% of cases as good and 75% as excellent.

Range of motion outcomes varied, with CRPP showing 28.57% of cases within normal range, 42.85% with 5 degrees of extension and flexion, and 28.57% with 5 degrees of extension and 10 degrees of flexion. Conversely, ORIF presented with 25.57% having 5 degrees of extension and 10 degrees of flexion, and 83.33% with 5 degrees of extension and flexion.

Notably, all patients from both groups experienced uncomplicated skin healing without avascular necrosis or infection. Moreover, there were no instances of sequelae such as osteomyelitis, nonunion, malunion, delayed union, myositis ossificans, physeal growth stop, tardy ulnar nerve palsy, cubitus valgus, or varus. Additionally, no further surgical interventions were required for any cases. The exceptional outcomes observed across both patient groups remained consistent throughout the follow-up period, with fractures fully healing within the expected timeframe.

5. Discussion

The management of lateral physeal condylar humerus fractures in pediatric patients presents a complex scenario requiring consideration of various treatment modalities, notably closed reduction and percutaneous pinning (CRPP) and open reduction and internal fixation (ORIF). Several studies have investigated the efficacy of these techniques, consistently demonstrating favorable outcomes in terms of bone fusion and clinical recovery. For example, investigations encompassing fractures with displacements ranging from 2.0 to 4.91 mm showcased a 100% union rate irrespective of the treatment method employed.^2,6,16 Moreover, research, such as that conducted by Fei Qiao et al. emphasized the success of CRPP, particularly in effectively managing a considerable proportion of displaced fractures. They presented novel insights into the management of lateral physeal condylar humerus fractures (LCHFs) in pediatric patients, particularly regarding the application of closed reduction and percutaneous pinning (CRPP). They adopted a unique approach by classifying LCHFs in conjunction with posterior elbow dislocation as a single entity for potential management with CRPP. Notably, a remarkable 81.1% (30 out of 37) of visibly displaced fractures were amenable to CRPP. Their clinical outcomes underscore the effectiveness of CRPP, with 86.7% of patients experiencing excellent results and the remaining showing good outcomes, while none exhibited poor outcomes.⁹ Our study echoes these findings, with CRPP emerging as the preferred method in the majority of cases, yielding satisfactory clinical outcomes and minimal complications.⁹

Multiple studies have reported high union rates and favorable clinical results with both CRPP and ORIF in lateral condyle fractures.^7,11 Notably, precise reduction is highlighted as crucial, with CRPP generally favored unless significant displacement necessitates open reduction, as indicated by Li Wei Xie et al.,wherein 78% of LCHFs, particularly those with significant displacement, were successfully managed with CRPP. Among these cases, 76% of Song stage IV and 78% of Song stage V fractures, as well as 78% of Jakob type II and 78% of Jakob type III fractures, achieved favorable outcomes. Despite a high incidence of lateral condylar bone spur formation, the clinical results were excellent in 92% of CRPP cases, underscoring the viability of this approach.⁷ Similarly, Song et al.'s findings underscore the success of closed reduction and pin fixation in achieving excellent clinical outcomes with minimal complications. According to their algorithm, initial attempts with CRPP were made for fractures displaced by more than 2 mm. Their findings demonstrated successful CRPP treatment in 76% of stage 3 fractures, 75% of stage 4 fractures, and 50% of stage 5 fractures.¹ A study by Ren huan zhao et all.,they achieved comparable success rates with CRPP, treating all Song stages 2 and 3 cases, 76% of stage 4 cases, and 78% of stage 5 cases. Importantly, all patients achieved fracture union, and no major complications were observed during the final follow-up.²² Our research supports these conclusions, demonstrating comparable success rates between CRPP and ORIF concerning bone union, range of motion, and complication rates.

In our investigation, we found that operative time, hospital stay, and postoperative displacement were similar between CRPP and ORIF groups, with CRPP exhibiting a statistically significant reduction in operative time.² Both techniques resulted in excellent bone union and minimal complications, albeit with differing cosmetic outcomes – CRPP left no visible surgical scars, whereas ORIF resulted in noticeable surgical scars.² Notably, the incidence of lateral condylar bone spurs was slightly higher in the ORIF group, potentially due to surgical incisions and periosteal disturbance.²

However, it is essential to acknowledge the limitations of current research, including the lack of large-scale controlled trials and variations in patient populations.¹⁰ Further investigation is warranted to provide more robust evidence for guiding treatment decisions. Nonetheless, our study contributes to the existing literature by reaffirming the efficacy of both CRPP and ORIF in treating lateral condyle fractures, underlining the significance of accurate reduction and meticulous postoperative care.

In our investigation, we provide novel insights into the management of lateral physeal condylar humerus fractures (LCHFs) in pediatric patients, particularly concerning the application of closed reduction and percutaneous pinning (CRPP). We took a unique approach by categorizing LCHFs alongside posterior elbow dislocation as a single entity for potential management with CRPP. Remarkably, a substantial 100 % of visibly displaced fractures were amenable to CRPP. Our clinical outcomes underscore the effectiveness of CRPP, with a high percentage of patients experiencing excellent or good results.⁹ Similarly, our study aligns with prior research, wherein a significant proportion of LCHFs, particularly those with significant displacement, were successfully managed with CRPP, resulting in favorable outcomes.⁷

The classification and treatment strategy proposed by Song et al. introduced a structured approach to managing unstable LCHFs. According to their algorithm, initial attempts with CRPP were made for fractures displaced by more than 2 mm, demonstrating successful treatment outcomes.¹ In our study, we achieved comparable success rates with CRPP, treating all cases of varying severity. Importantly, all patients achieved fracture union, and no major complications were observed during the final follow-up.^1,7,9

In total, our study encompassed a diverse cohort of pediatric patients with LCHFs. Among them, a significant proportion underwent CRPP, while the remainder underwent ORIF.²³ Analysis revealed minimal complications across both treatment cohorts, with a slightly higher incidence in the ORIF group, primarily consisting of infections and one instance of delayed union.²³ Importantly, no perioperative neurologic deficits were documented. Additionally, a small subset of patients necessitated a secondary procedure, primarily for infection management or refracture, all of whom initially underwent ORIF.²³

Based on our findings, both CRPP and ORIF demonstrate successful outcomes with minimal complications, highlighting the importance of individualized treatment plans and comprehensive postoperative management. Further research is warranted to refine treatment algorithms and optimize patient care in this challenging orthopedic scenario.

Furthermore, our study adds depth to the existing body of literature by providing nuanced insights into the management of lateral physeal condylar humerus fractures (LCHFs) in pediatric patients. We implemented a novel approach by integrating posterior elbow dislocation into the classification system, thereby broadening the scope of potential treatment strategies involving CRPP. Impressively, a substantial 100 % of visibly displaced fractures were amenable to CRPP and ORIF in our cohort. The clinical outcomes of CRPP underscore its efficacy, with a majority of patients experiencing excellent or good results, showcasing its viability as a primary treatment modality.⁹ These findings resonate with prior studies by justus et al.,In total, their study encompassed 172 pediatric patients aged 1–13 years old, representing a diverse cohort of lateral physeal condylar humerus fracture (LCHF) cases. Among them, 31 patients (18%) underwent closed reduction and percutaneous pinning (CRPP), while the remaining 141 patients (82%) underwent open reduction and internal fixation (ORIF).²³ Analysis revealed a total of 14 complications (8% of the total patient population) across both treatment cohorts, predominantly consisting of infections (13 cases) and one instance of delayed union. Notably, complications were more prevalent in the ORIF group, with 11 infections, including one case of osteomyelitis and wound dehiscence. In contrast, the CRPP cohort experienced only two superficial infections. The single occurrence of delayed union was observed in a high-grade fracture treated with ORIF. Fortunately, no perioperative neurologic deficits were documented. Additionally, a small subset of patients (3% of total) necessitated a secondary procedure, primarily for infection management or refracture, all of whom initially underwent ORIF. Importantly, no significant correlation was found between postoperative pin duration and complication incidence.²³ which reported successful CRPP treatment in a significant proportion of LCHFs, particularly those with considerable displacement, resulting in favorable outcomes.⁷

The treatment algorithm proposed by ramo et al., corroborated the reliability of the Song classification, reporting an 89.5% success rate with CRPP in Song stage 4 LCHFs, although they encountered challenges in achieving similar success rates in Song stage 5 LCHFs.²⁴ In our study, we achieved comparable success rates with CRPP and ORIF, treating all cases across varying severity levels. Crucially, all patients achieved fracture union, with no major complications observed during follow-up.^1,7,9

In total, our study comprised a diverse cohort of 27 pediatric patients spanning ages 1–13 years with LCHFs.Based on the results of our study a total of 19 cases,which included 7 patients treated with closed reduction and percutaneous pinning (CRPP) and 12 patients treated with open reduction and internal fixation (ORIF), we observed successful outcomes in both treatment groups. Specifically, all 7 patients who underwent CRPP, classified as type 3 fractures, were treated successfully, with 71.4% of cases demonstrating excellent clinical results and the remaining 28.57% showing good outcomes. Similarly, all 12 patients treated with ORIF, classified as type 4 fractures, were successfully treated, with 58.33% of cases achieving excellent clinical results and 41.66% demonstrating good outcomes. Importantly, no complications such as skin infections or major complications were observed in either treatment group, and bone spur formation was not considered a complication in our study. Notably, no perioperative neurologic deficits were documented. Furthermore, no patients required a secondary procedure, primarily for infection management or refracture, all of whom initially underwent ORIF.²³In discussing these findings, it is crucial to contextualize them within the framework of previous research, including studies by Caitlin Justus, Ren Huan Zhao, Song et al. Li Wei Xie, Fei Qiao, and Ramo et al. Drawing from this body of literature, we can evaluate our study's contributions in anatomical, radiographical, clinical, and comparative terms. Notably, while complications and re-surgery rates have been documented in previous studies, our study uniquely demonstrates a lack of such occurrences, underscoring the success and reliability of both CRPP and ORIF in our patient cohort.

Furthermore, by integrating personal experiences and additional pertinent information, we can enrich the discussion and provide a comprehensive analysis of our study's significance. For instance, highlighting the absence of complications and re-surgeries in our study adds to the growing body of evidence supporting the efficacy and safety of CRPP and ORIF in treating lateral physeal condylar humerus fractures. This nuanced discussion emphasizes the advancements and unique contributions of our study, reinforcing its relevance in informing clinical practice and guiding treatment decisions.

In conclusion, both CRPP and ORIF demonstrate successful outcomes with minimal complications, underscoring the importance of tailored treatment plans and thorough postoperative management. Nonetheless, further research is warranted to refine treatment algorithms and optimize patient care in this complex orthopedic scenario. By integrating our study's findings with existing literature, we contribute to the ongoing dialogue surrounding the management of LCHFs, enriching the understanding of effective treatment strategies and guiding clinical decision-making.

6. Availability of data and materials

The data-sets collected and/or analyzed during the current study are available from the corresponding author on request. The corresponding author had full access to all the data in the study and takes responsibility for the integrity of the data and accuracy of the data analysis.

Funding

This research was supported by National Funds for Young under grant number 815016559.

Ethical approval and informed consent

All procedures performed were in accordance with the ethical standards of our institution Jinzhou Medical University and its later amendments.The study was approved by the local ethical committee of Jinzhou Medical University.

CRediT authorship contribution statement

Md Fahim Muntasir Islam Sojib: Methodology, Software, Validation, Writing – original draft, PREPARATION, Writing – review & editing. Yan Song Wang: Conceptualization, AND, DESIGN, Data curation, Investigation, Supervision, Visualization, REVIEWING, Project administration.

Declaration of competing interest

We confirm that the manuscript has been read and approved by all named authors. Authors declare that there are no competing interest.