Burnei’s “double X" internal fixation technique for supracondylar humerus fractures in children: indications, technique, advantages and alternative interventions : Study and Research Group in Pediatric Orthopaedics-2012

Background. The Study and Research Group in Pediatric Orthopedics-2012 initated this retrospective study due to the fact that in Romania and in other countries, the numerous procedures do not ensure the physicians a definite point of view related to the therapeutic criteria in the treatment of supracondylar fractures. That is why the number of complications and their severity brought into notice these existent deficiencies. In order to correct some of these complications, cubitus varus or valgus, Prof. Al. Pesamosca communicated a paper called "Personal procedure in the treatment of posttraumatic cubitus varus" at the County Conference from Bacău, in June 24, 1978. This procedure has next been made popular by Prof. Gh. Burnei and his coworkers by operating patients with cubitus varus or valgus due to supracondylar humeral fractures and by presenting papers related to the subject at the national and international congresses. The latest paper regarding this problem has been presented at the 29th Annual Meeting of the European Pediatric Orthopedic Society in Zagreb, Croatia, April 7-10, 2010, being titled “Distal humeral Z-osteotomy for posttraumatic cubitus varus or valgus", having as authors Gh. Burnei, Ileana Georgescu, Ştefan Gavriliu, Costel Vlad and Daniela Dan. As members of this group, based on the performed studies, we wish to make popular this type of osteosynthesis, which ensures a tight fixation, avoids complications and allows a rapid postoperative activity. Introduction. The acknowledged treatment for these types of fractures is the orthopedic one and it must be accomplished as soon as possible, in the first 6 hours, by reduction and cast immobilization or by closed or open reduction and fixation, using one of the several methods (Judet, Boehler, Kapandji, San Antonio, San Diego, Burnei’s double X technique). The exposed treatment is indicated in irreducible supracondylar humeral fractures, in reducible, but unstable type, in polytraumatized patients with supracondylar fractures, in supracondylar fractures with vascular injury, in late presenting fractures, in case of loss of reduction under cast immobilization or in case of surgery with other types of fixation that is deteriorated. We have been using Burnei’s osteosynthesis for about 10 years. Aim. This paper aims to present the operative technique, its results and advantages. Materials and methods. 56 cases were treated with Burnei’s "double X" osteosynthesis in "Alexandru Pesamosca" Surgery Clinics, from 2001 to 2011. We used the Kocher approach and the aim of surgery was to obtain a fixation that does not require cast immobilization and that allows motion 24 hours after the surgery. The wires placed in "double X" must not occupy the olecranon fossa. The reduction must be anatomical and the olecranon fossa free. Flexion and extension of the elbow must be in normal range after surgery without crackles or limitations. This surgery was performed on patients with: • Loss of reduction after 10 days with cast immobilization; • Surgery with other types of fixation, deteriorated; • Polytraumatized patients with supracondylar fracture; • After neglected or late presenting fractures, without the orthopedic reduction made in emergency; • Fractures with edema and blistering. Results and complications. The patients’ ages ranged 3 to12 years old, the mean age for girls was 7,3 years and 6,8 for boys. The hospitalization ranged 3 to 7 days, the average period being of 5 days. The wires had been pulled out after 21 days. The total recovery of the flexion and extension motion of the elbow was, depending on the age, between 21 and 40 days with an average period of 30 days. There were 5 cases of minor complications: in 3 cases the wires migrated outwards up to the 10th day and in 2 cases the wires were found in the olecranon fossa. The CT exam highlighted the impingement effect and the wire that passed through the olecranon fossa had to be removed between the 7th and the 9th day. No reported cases of cubitus varus or valgus were reported. Conclusion. The Burnei’s "double X" osteosynthesis does not require cast immobilization. In oblique fractures, the stability is more difficult to obtain and by using other methods, elbow stiffness or ulnar nerve palsy may appear. The Burnei’s "double X" osteosynthesis ensures stability of these types of fractures and avoids complications. This technique allows early motion after surgery and, in case of polytrauma, ensures comfort both to the patient and the physician, allowing repetitive examinations, preferential positions or the nursing of the extensive skin lesions.