Effect of minimally invasive surgery guided by arthrography on surgical progress, postoperative recovery and long-term prognosis of lateral humeral condyle fractures in children: a retrospective cohort study

Abstract

Background

In recent years, arthrography-assisted fixation techniques have become more common in pediatric orthopedic surgery because they provide real-time intraoperative assessment of fracture alignment and overall joint congruency. This study aimed to descriptively analyze outcomes in two groups of patients: patients with Jakob type IIA lateral humeral condyle fractures (LHCF) treated with closed reduction and internal fixation (CRIF) using intraoperative arthrography (arthrography group, AG); and patients with Jakob type IIB LHCF treated with open reduction and internal fixation (ORIF) (control group, CG). Caution is used when interpreting outcomes due to the differences in fracture severity.

Methods

A total of 190 pediatric patients diagnosed with Jakob type II LHCF and treated between 2021 and 2023 were analyzed retrospectively. Jakob type IIA fractures (n=101) underwent CRIF with assistance from arthrography, and Jakob type IIB fractures (n=89) underwent ORIF. The outcomes evaluated included operation time (OT), intraoperative blood loss (IBL), length of hospitalization (LOH), pain (Visual Analog Scale; VAS), elbow function (Mayo Elbow Performance Score; MEPS), complications, and long-term prognosis. Postoperative imaging was obtained to confirm anatomic reduction.

Results

The AG had significantly shorter OT, less IBL, and less LOH than the CG (P<0.05), along with lower VAS scores on postoperative day 1 and higher MEPS on day 28. Long-term functions were similar between groups, and the rate of complications was similarly low, with a lower rate of poor prognosis in the AG. As the differences in severity of fracture between groups were intrinsic reasons for differences between the groups, they can be followed descriptively and cannot imply the superiority of treatment.

Conclusions

Arthrography-assisted CRIF may be a safe and feasible method to assist with treating some selected Jakob type IIA LHCF and offers some short-term reductions in pain. These findings are limited in their ability to be interpreted due to retrospective design, failures of group comparability, and no objective imaging confirmation, so caution should be taken into account. Further prospective controlled studies are warranted to validate these results.

Highlight box.

Key findings

• Arthrography-guided closed reduction and internal fixation (CRIF) for Jakob type IIA lateral humeral condyle fractures in children showed shorter operative time, reduced intraoperative blood loss, and shorter hospital stays compared with open reduction and internal fixation (ORIF) for Jakob type IIB fractures.

• Early postoperative pain and functional recovery (Mayo Elbow Performance Score) were better in the arthrography group, though long-term outcomes and complication rates were comparable between both techniques.

• Arthrography provided real-time visualization of joint congruity and fracture alignment, enhancing intraoperative assessment during minimally invasive procedures.

What is known and what is new?

• Traditionally, ORIF is the standard approach for displaced lateral humeral condyle fractures, whereas CRIF has been limited by challenges in assessing articular surface reduction.

• This study introduces the use of intraoperative arthrography to assist CRIF, demonstrating its feasibility and potential to improve short-term recovery in less severe fracture patterns.

What is the implication, and what should change now?

• Arthrography-assisted CRIF appears to be a safe, minimally invasive option for selected Jakob type IIA fractures, potentially reducing operative trauma and enhancing early recovery.

• However, due to intrinsic differences in fracture severity and retrospective design, these findings should be interpreted descriptively.

• Prospective randomized studies with imaging validation are warranted before recommending arthrography-assisted CRIF as a standard of care.

Introduction

Lateral humeral condyle fractures (LHCFs) are common injuries in children, usually aged 5–12 years, and comprise approximately 12% to 20% of all pediatric elbow fractures (1,2). The lateral condyle of the humerus is a bony prominence located on the lateral aspect of the distal humerus. It articulates with the radial head and contributes to the stability and mobility of the elbow joint. Its anatomical position renders it particularly susceptible to fracture following the application of external forces. These fractures are characterized as intra-articular injuries and are prone to displacement because of the traction exerted by the forearm extensor muscles attached to the lateral condyle (3). The most common mechanisms of injury include falls from furniture or standing height, trampoline-related injuries, and direct blows to the elbow (4). Because children’s bones are still developing and the epiphyseal–metaphyseal junction is relatively weak, fractures are more likely to occur when external forces are applied. Furthermore, the high level of physical activity in children further increases the risk of injury. Certain underlying conditions, such as hemophilic arthropathy, may further predispose children to condylar fractures (5). Current diagnostic challenges include ensuring timely and accurate identification of these fractures, which primarily relies on radiographic evaluation. Management strategies range from conservative approaches to surgical intervention, depending on the degree of displacement and joint involvement (6).

There are many classifications available to assist with treatment protocols, but the Jakob classification is the most common and widely used in the literature and practice, which is categorized by general displacement and involvement of the joint surface as: Type I: non-displaced or minimally displaced fracture with an intact articular surface; Type II: fracture with involvement of the articular surface, however, the fragment is partially displaced with some cortical contact; Type III: complete displacement, often a rotational displacement of fragment, with no cortical contact and loss of joint surface (7,8).

In general, type I is treated conservatively; type II and type III are rarely stable, and surgical intervention is required (9). The aim of surgery for types II and III is anatomical reduction and fixation of the articular surface to minimize the long-term sequelae of joint incongruence, growth disturbance, and elbow dysfunction (10,11).

Treatment options typically consist of open reduction and internal fixation (ORIF) or closed reduction and internal fixation (CRIF) aided by Kirschner wires.

At our centre, we also subdivide Jakob type II fractures into type IIA and type IIB based on the extent of displacement and rotational deformity. Type IIA fractures have partial cortical discontinuity and no rotation, while type IIB fractures exhibit significant displacement or rotational deformity. This subdivision is applied at our institution and is not part of the original Jakob classification but is solely used for internal purposes to aid decision-making and surgical planning. This is further supported by the preoperative radiographic review, which includes the use of internal oblique view radiographs, which form part of the completion process for all patients at initial clinical evaluation to assess for cortical disruption and the extent of articular involvement.

In contrast to Jakob’s original description of Type III fractures, which require being reduced and fixed surgically with ORIF due to complete displacement and rotational malalignment (10), some mildly displaced or stable Jakob II fractures may be reduced and fixed with CRIF as long as intraoperative imaging modality (intraoperative arthrography) is used to be able to see the cartilaginous surface, and also help to confirm the reduction is adequate (12-15). Intraoperative arthrography improves the ability to visualize intra-articular structures and adequately assess the congruency within the joint, and whether the fracture alignment is still intact with percutaneous fixation. Additionally, it is non-invasive and safe, and these modalities are becoming more common in pediatric orthopaedic surgery.

In clinical practice, the use of medial K-wire fixation in addition to lateral pins often enhances fixation stability. The use of medial K-wire fixation is not common practice in most situations and relies on anecdotal institutional practice. The intention is to minimize secondary displacement. Similarly, the length of time that patients remain in hospital for post-operative care may also seem longer than other institutions based on discharge protocol and the fact that parents feel more comfortable waiting for an extended period within the hospital rather than going home (16,17).

Despite the increased usage of arthrography-assisted CRIF, there remains limited evidence comparing its clinical value to traditional ORIF, particularly in the pediatric population. Available studies have primarily published case series and do not include comparisons (16,18).

In order to address this gap, we performed a descriptive retrospective cohort study comparing children with Jakob type II LHCF in two groups: type IIA, which was managed with arthrography-assisted CRIF, and type IIB, which was managed with ORIF. We aimed to assess our surgical progress, early recovery, complication rates, and long-term outcomes, acknowledging the limitations due to the inherent differences in fracture severity. We present this article in accordance with the STROBE reporting checklist (available at https://tp.amegroups.com/article/view/10.21037/tp-2025-aw-748/rc).

Methods

Study subjects and participants

This study was a retrospective descriptive cohort study of pediatric patients with diagnosed LHCF with treatment at the Orthopedic Department of our institution between January 2021 and December 2023. A total of 235 children with radiologically confirmed LHCF were screened, and 190 of those children met eligibility criteria. Inclusion criteria were fresh closed Jakob type II LHCF with X-ray confirmed radiological assessment, being 14 years of age or younger, no systemic infection at the time of admission, treatment within 7 days of injury, and at least 12 months of follow-up. Exclusion criteria included other types of fractures, other concurrent fractures or neurovascular injuries, open or pathological or multiple fractures, congenital deformity of the affected side, prior fracture or surgery of the affected side, and/or incomplete imaging or clinical data. Fracture types were identified through the Jakob classification system. In our practice, Jakob type II fractures were further classified into type IIA and type IIB fractures based on the displacement and rotation features of the fracture. If there was any displacement and/or rotation identified on the preoperative imaging, we would identify the fracture as type IIB. Preoperative imaging typically included internal oblique views of the humerus for all patients at the time of diagnosis to assess the disorder. Jakob type IIA fractures ruptured the inner cortical surface of the humerus and did not show a rotation of fracture components, while Jakob type IIB fractures exhibited greater degree of displacement and/or rotation of the fracture components.

Of the 190 children, 101 with Jakob type IIA fractures underwent minimally invasive CRIF using intraoperative arthrography guidance (arthrography group, AG), while 89 with Jakob type IIB fractures underwent ORIF (control group, CG). This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. This study was approved by the Ethics Committee of Honghui Hospital, Xi’an Jiaotong University (No. 2021092809). Informed consent was obtained from the guardians of all individual participants included in the study. The study followed guidelines based on the Sex and Gender Equity in Research (SAGER) reporting guide, using the term “sex” rather than “gender” to describe characteristics of patients in the study.

Surgical procedures

All children in the CG who sustained Jakob type IIB fractures that presented with a complete pattern of cortex disruption combined with displacement or rotation underwent ORIF. Children were placed in the supine position with a combination of intravenous and inhalation anesthetic agents. A 3-cm longitudinally lateral incision at the elbow was made, and the fracture was exposed. Any hematoma and soft tissue were debrided. Fragments were anatomically reduced. Two 1.5-mm Kirschner wires were percutaneously inserted at 35–40° to the humeral shaft and 10° posteriorly. In accordance with our institutional protocol, a supplemental medial K-wire was routinely inserted to enhance fracture stability and reduce the risk of secondary displacement. The ulnar nerve was carefully identified and protected during this step. Fluoroscopic C-arm imaging was used to confirm satisfactory reduction, and the wires were bent and left externalized. A long-arm posterior splint was applied with the elbow flexed to 90°.

Children in the AG with Jakob type IIA fracture, a modifiable or partial pattern of cortical discontinuity in the absence of rotational deformity, were CRIF with arthrography. After sterile preparation and draping, a 1:1 mixture of iodinated contrast and saline was injected into the elbow joint via the posterior olecranon fossa using a 22-gauge spinal needle, angled proximally along the humeral shaft. A slow and gentle flexion and rotation allowed the contrast to distribute, and the fracture position and articular surface were visualized and monitored live through C-arm fluoroscopy. The closed reduction was achieved with careful traction, and the wires were inserted percutaneously for provisional fixation. Once assured there was congruity in the joint, supplementary K-wires were inserted as proposed by the CG. Open reduction and fixation were performed if anatomic reduction could not be obtained.

Postoperative care

Postoperative care protocols were consistent throughout both groups. Intravenous antibiotics were used perioperatively, and pain was treated with appropriate weight-based doses of acetaminophen or ibuprofen. Anti-edema measures and neurovascular checks were performed as standard care for at least 24 hours postoperatively. Randomized anteroposterior and lateral X-rays were performed on day one postoperatively to verify hardware location and fracture reduction. Patients returned for clinical and X-ray follow-up at 4, 24, and 48 weeks postoperatively. Fracture healing was documented by the radiographic presence of callus formation and bridging trabeculae prior to removal of splints or wires. The duration of hospitalization and discharge were unique to the individual patient and depended not only on medical criteria for discharge, but also on institutional norms and caregiver preference; several parents opted for additional time in the hospital until their child had completely passed all tests prior to heading back home.

Evaluation metrics

Surgical progress was assessed by operation time (OT), length of hospitalization (LOH), IBL, and external fixation time. For assessment of intra-operative blood loss for CRIF, irrigation fluids and the extent of surgery drapes were measured. Minimal bleeding was expected with percutaneous approaches. Pain was measured using a Visual Analog Scale (VAS) on a 0–10 cm scale before surgery, 1 day postoperatively, and at 4 weeks and 6 weeks. Elbow function was assessed using the Mayo Elbow Performance Score (MEPS) at 4, 24, and 48 weeks, which assessed pain, range of motion, and stability (0–100 points). The minimal clinically important difference (MCID) for MEPS in this pediatric population had yet to be firmly established. Radiographic remodeling was assessed at 48 weeks, including the carrying angle and shaft-condylar angle (SCA). Complications, including infection, elbow valgus, displacement of the stable fracture, malunion, and nonunion, were also assessed.

Flow chart

A total of 235 patients with lateral humeral condyle fractures were initially identified. After excluding patients who did not meet the eligibility criteria, 190 patients with Jakob II type lateral humeral condyle fractures were enrolled. These patients were allocated to the arthrography group (n=101) and the control group (n=89) (Figure 1).

Figure 1.

Study flowchart.

Statistical analysis

Statistical analyses were conducted with SPSS 22.0 for hypothesis testing and GraphPad Prism 9 for the visualization of data. Continuous variables were presented as mean ± standard deviation and were compared by independent samples t-tests. Within-group comparisons over time were evaluated by paired t-tests. Repeated measures analysis of variance (ANOVA) with least significant difference (LSD) post hoc was used for VAS and MEPS scores to measure the change over time. Categorical data, such as rates of complication and poor prognosis, were evaluated using chi-squared tests. Two-tailed P<0.05 was considered statistically significant.

Results

Comparison of general characteristics between the two groups

In the study, a cumulative 190 children were eligible based on inclusion/exclusion criteria. Every child in the CG had Jakob type IIB LHCFs, while every child in the AG had Jakob type IIA fractures. The basic characteristics for both groups, such as age, sex distribution, fracture side, time from injury to surgery, body mass index (BMI), and mechanism of injury, were not statistically significant (P>0.05) across groups (Table 1).

Table 1. Comparison of general data between the two groups.

Characteristics	Control group (n=89)	Arthrography group (n=101)	t/χ2	P
Age (years)	5.32±1.24	5.18±1.20	0.790	0.43
Gender			0.664	0.42
Male	67 (75.28)	81 (80.20)
Female	22 (24.72)	20 (19.80)
Fracture side			1.161	0.28
Left	56 (62.92)	71 (70.30)
Right	33 (37.08)	30 (29.70)
Time from injury to surgery (days)	2.38±1.20	2.43±1.25	0.280	0.78
Body mass index (kg/m2)	15.23±1.29	15.17±1.27	0.323	0.75
Cause of injury			1.706	0.19
Fall injury	84 (94.38)	90 (89.11)
Car accident	5 (5.62)	11 (10.89)

Data are presented as n (%) or mean ± standard deviation.

However, it is important to highlight that these two groups fundamentally differ in regard to fracture severity and configuration. The AG group had fewer displaced, more stable, Jakob type IIA fractures. The CG group had more complicated Jakob-type IIB fractures with displacement or rotational deformity. Thus, any differences in outcomes between the two groups should be descriptively interpreted and do not represent superiority or inferiority of one treatment versus the other due to this selection bias.

Comparison of surgical progress

OT was significantly shorter for the AG than the CG (P<0.001), as were IBL and length of stay (P<0.001) (Table 2, Figure 2). These differences should be interpreted as descriptive cross-sectional data only with limitations, and further recognizing that Jakob type IIA fractures (AG) are less severe than Jakob type IIB fractures (CG). External fixation time was similar between groups (P=0.12) (Figure 2D).

Table 2. Comparison of surgical progress between the two groups.

Characteristics	Control group (n=89)	Arthrography group (n=101)	t	P
Operation time (min)	69.38±7.63	40.28±5.38	30.650	<0.001
Intraoperative blood loss (mL)	65.37±6.36	12.48±1.24	81.856	<0.001
External fixation time (days)	41.27±3.80	42.13±3.85	1.546	0.12
Length of hospital stay (days)	14.82±2.74	5.82±1.12	30.273	<0.001

Data are presented as mean ± standard deviation.

Figure 2.

Comparison of surgical progress results between the two groups. (A) Operation time. (B) Intraoperative blood loss. (C) Length of hospitalization. (D) External fixation time. AG, arthrography group; CG, control group.

These data probably reflect the lower surgical complexity with the Jakob IIA fracture-treated patients in the AG group and should not be interpreted as a treatment effect per se. In the AG group, the utilization of intraoperative arthrography allowed us to assess the fragment alignment and joint congruity in real time. However, in our approach, we might have compromised follow-up standards since we did not use a postoperative computed tomography (CT) or any validated scoring system to objectively confirm anatomical reduction upon termination of surgery. As such, the interpretation of the outcomes remains imperfect. The position of a medial K-wire was executed with special care to avoid injury to the ulnar nerve. A schematic showing safe medial pin trajectory and anatomical landmarks was illustrated in Figure S1.

Comparison of postoperative pain intensity

Pain ratings on the VAS had a consistent decrease over time for each group (P<0.05). The AG had significantly lower VAS scores on postoperative day 1 compared with the CG (4.32±0.97 vs. 5.32±1.11; P<0.05), but the groups had no significant differences in VAS scores at the other time points (P>0.05; Figure 3A). This early postoperative difference should be interpreted with caution. The lower pain in the AG may be attributable to the less invasive CRIF technique and the less serious injury (Jakob IIA) rather than any specific advantage of the procedure. Therefore, these observations were primarily descriptive and likely confounded by the severity of fracture.

Figure 3.

Line graphs showing changes in pain and elbow joint functional recovery over time between the arthrography and control groups. (A) VAS results; (B) MEPS score. ***, P<0.001 vs. control. Within group comparison: (A): a, P<0.05 vs. preoperative; b, P<0.05 vs. postoperative day 1; c, P<0.05 vs. postoperative week 4. (B): a, P<0.05 vs. week 4; b, P<0.05 vs. week 24. MEPS, Mayo Elbow Performance Score; VAS, Visual Analog Scale.

Comparison of elbow joint function recovery

MEPS improved significantly with time in both groups. At 4 weeks postoperative, the MEPS score for AG was significantly greater than that of CG (69.48±4.57 vs. 63.22±4.23, P<0.001; Table 3, Figure 3). However, at 24 weeks and 48 weeks, the MEPS scores were similar in both groups, and there were no significant differences (P=0.13 and 0.41, respectively).

Table 3. Comparison of elbow joint function recovery between the two groups of children.

MEPS score	Control group (n=89)	Arthrography group (n=101)	t	P
4 weeks after surgery	63.22±4.23	69.48±4.57	9.755	<0.001
24 weeks after surgery	71.28±5.38*	72.47±5.49*	1.505	0.13
48 weeks after surgery	90.38±7.37*#	91.27±7.48*#	0.824	0.41

Data are presented as mean ± standard deviation. Compared with the same group 4 weeks after surgery, *P<0.05; compared with the same group 24 weeks after surgery, ^#P<0.05. MEPS, Mayo Elbow Performance Score.

These findings suggested that early functional recovery was faster in the AG group, which may reflect the lower complexity of the fractures that they presented with. Overall, the long-term outcomes were similar, reinforcing the concept of both techniques leading to a satisfactory functional outcome when appropriately used. However, since these were two different fracture types, these differences do not permit establishment of superiority, and conclusions need to be descriptive.

Comparison of elbow joint remodeling

Both groups achieved acceptable radiographic outcomes at the 48-week follow-up. Neither group significantly differed in carrying angle or SCA, as shown in Table 4 and Figure 4. The radiographic parameters demonstrate that joint alignment was restored and proper remodeling of the elbow joint occurred following either surgical technique.

Table 4. Comparison of elbow joint shaping after surgery between the two groups.

Characteristics	Control group (n=89)	Arthrography group (n=101)	t	P
Carrying angle (°)	12.48±1.84	12.37±1.79	0.038	0.97
SCA (°)	42.83±3.47	43.21±3.52	0.747	0.46

Data are presented as mean ± standard deviation. SCA, shaft-condylar angle.

Figure 4.

Comparison of elbow joint shaping remodeling results between the two groups. (A) Carrying angle; (B) shaft-condylar angle. AG, arthrography group; CG, control group.

Comparison of complications and long-term prognosis

There were no significant differences in complication rates (pin tract infection and elbow valgus) between groups (P>0.05). The rate of poor prognosis (malunion, nonunion, re-displacement) was lower in the AG compared to CG (4.95% vs. 13.48%, P=0.040; Table 5).

Table 5. Comparison of complications and long-term prognosis between the two groups.

Characteristics	Control group (n=89)	Arthrography group (n=101)	χ2	P
Complication	6 (6.74)	2 (1.98)	2.659	0.10
Infection of the incision or needle tract	5 (5.62)	2 (1.98)
Elbow valgus	1 (1.12)	0 (0.00)
Poor prognosis	12 (13.48)	5 (4.95)	4.228	0.04
Fracture re-displacement	5 (5.62)	4 (3.96)
Malunion	1 (1.12)	0 (0.00)
Nonunion of fractures	6 (6.74)	1 (0.99)

Data are presented as n (%). “Fracture re-displacement” is defined as a postoperative loss of fracture alignment as determined on follow-up radiographs. In both groups, all of the re-displaced fractures eventually united; however, no instances required any additional surgical intervention. No cases of nonunion were seen in the arthrography group.

Importantly, of the 9 cases of fracture re-displacement recorded, 5 occurred in the CG group and 4 in the AG group. Of these, 3 in the CG group and 1 in the AG group had malunion, and 1 in the CG group and none in the AG group had nonunion. All patients with re-displacement were treated non-operatively and achieved subsequent healing, albeit with varied functional and cosmetic results.

Again, the differences in the prognosis observed are likely a reflection of the pre-existing severity of the fractures and not the result of a benefit of one surgical procedure over the other. The results corroborate the descriptive feasibility of using arthrography-assisted CRIF in select patients but do not allow us to make conclusions regarding its superiority in general.

Discussion

The elbow is a commonly injured area in pediatric trauma, with LHCF being a common type. Jakob type II LHCF is an unstable fracture because it involves the articular surface, likely requires surgical intervention to restore joint congruity, and to prevent chronic dysfunction (18,19). Simply relying on plain radiographs, it is often difficult to define and characterize fracture displacement or determine if there was cartilage integrity. Intraoperative arthrography provides an opportunity to visualize the cartilaginous articular surface in a dynamic (real-time) way, giving additional information to clinicians during percutaneous fixation (20-22). Intraoperative arthrography may provide value to surgeons by improving intraoperative decision-making, such as providing confirmation of the reduction, improving Kirschner wire placement, and reducing joint penetration (23-27).

In the present study, children with Jakob type IIA fractures that underwent arthrography-guided CRIF (AG group) had shorter operative time, less intraoperative blood loss, and shorter length of stay than children with Jakob type IIB fractures treated by ORIF (CG group).

While these differences may seem meaningful in a clinical context at first glance, we must reiterate that the two groups had very different fracture severities. The AG group had less displaced fracture patterns and more stable fractures, while the CG group had more complicated injuries with rotational displacement. Therefore, the two cohorts cannot be compared, and the differences should be viewed only as descriptive trends and not as groups in treatment superiority (28).

One of the major limitations in this study is the lack of objective representation of anatomic reduction with imaging. Specifically, there were no postoperative CT scans or calibrated radiographic scoring systems, thereby limiting our ability to validate our intraoperative findings (29). Although satisfactory outcomes were achieved clinically and radiographically, we recognize that we were unable to objectively verify joint congruity, which affects our interpretations.

The pain outcomes on postoperative day 1 were less in the AG group, which may be due to less disruption to soft-tissue structures associated with CRIF. However, this could also be due to other mitigating factors, including that CRIF could rank as a less invasive procedure, and therefore, a Jakob IIA fracture is likely the least complex fracture type to treat, more likely due to the impact of arthrography (27,30). Furthermore, while further early MEPS scores were greater in the AG group, there was no difference in functional outcomes at 24 or 48 weeks, suggesting that outcomes should be similar whenever a surgeon uses appropriate intervention based on fracture type (31).

In our center, we routinely used a supplemental medial K-wire with internal fixation for improved stability. While this practice has uncommon literature detail, we believe that it helps limit secondary displacement in certain fracture patterns. All ulnar nerves were described and protected at the time of medial wire placement. There were no nerve injuries in our series. We emphasize, though, that this may not apply to every surgical setting and must be further evaluated prospectively.

Although the AG group reported a lower rate of poor outcome (malunion, nonunion, and re-displacement), this likely represents more favorable baseline fracture morphology and not an explicit advantage of the surgical skill (32). Further, all re-displacement cases were managed with no reoperation and acceptable final healing outcomes, albeit with some cosmetic or functional deficiencies associated with their malunion.

This study has a lot of limitations. First, this was a retrospective, non-randomized study comparing two different approaches to two different fracture types, which results in selection bias and classification bias. The results should not be generalized to all LHCF, particularly more complex types, or other settings with different skills and expertise in surgery or examining imaging. The study was also performed at a single center, and each case was done by the same surgical team, limiting the external validity (33). Lastly, there was no postoperative CT or objective imaging assessment to definitively establish the accuracy of the fracture reduction.

For the advancement of this area of research, we would advise prospective randomized controlled trials with similar fracture patterns to be conducted comparing arthrography-assisted CRIF and standard CRIF with objective radiography and functional outcome measures in patients. Other studies should also examine the process of medial pin insertion and whether there could be any safety, reproducibility, and biomechanical implications of this process in a larger patient population (33,34).

In summary, CRIF using arthrography may be appropriate for select Jakob type IIA fractures in situations where live imaging can enhance the surgical precision of the procedure. However, due to the disparity in fracture severity, retrospective nature of this project, and absence of physical imaging, this work should be viewed as descriptive observations rather than comparative judgments. Further high-quality research is required to confirm our preliminary observations and determine the role of arthrography in the management of pediatric elbow fractures.

Conclusions

Arthrography-assisted CRIF could be a viable treatment option for less severe Jakob type IIA LHCFs in children. Though our study suggests some potential short-term benefits, including decreased operative time, blood loss, and recovery time, these results are observed and need to be interpreted with caution because of the retrospective design and frequent non-equivalence of fracture types between groups. These findings do not show superiority over other techniques, and future randomized controlled trials comparing arthrography-assisted with standard CRIF in the same fracture types with objective imaging evidence are necessary to substantiate these findings.

Supplementary

The article’s supplementary files as

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. This study was approved by the Ethics Committee of Honghui Hospital, Xi’an Jiaotong University (No. 2021092809). Informed consent was obtained from the guardians of all individual participants included in the study.

Data Sharing Statement

Available at https://tp.amegroups.com/article/view/10.21037/tp-2025-aw-748/dss

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DOI: 10.21037/tp-2025-aw-748