Pediatric Floating Elbows … What Is All the Fuss About? A Multicenter Perspective

Abstract

Background: Classic orthopaedic teaching states a high risk of pediatric acute compartment syndrome (PACS) and other adverse outcomes to be associated with pediatric floating elbow injuries. However, more recent data suggest otherwise. This study aims to evaluate treatment approaches and outcomes of pediatric floating elbow injuries and accurately determine the rate of associated PACS.

Methods: A multicenter retrospective database was created to review patients below 18 years old who presented between 2014 and 2019 with floating elbow injuries. Patient demographics, injury characteristics, treatment course, and outcomes were evaluated. A severity classification (Children's Orthopaedic Trauma and Infection Consortium for Evidence-Based Studies) was established: class 1 injuries included Gartland 1 supracondylar fracture, class 2 included Gartland 2 supracondylar fracture, and class 3 included Gartland 3 or 4 supracondylar or t-condylar fracture. Subclasses A and B were based on displacement of the distal fracture.

Results: Four hundred fifty four patients were evaluated across 15 institutions. The cohort was 51% male and a median of 6.8 years old at injury. Thirteen patients (2.9%) presented without a palpable or dopplerable pulse, all having class 3 injuries. Ninety patients (20.0%) presented with nerve injuries, which were more common in class 3 injuries ( P <0.001). Only 14 (3.1%) had persistent nerve injuries at the final follow-up. Displacement largely dictated whether the distal injury was treated with fixation ( P <0.001) or immobilization only. Open reduction rate of the proximal fracture was 7.7% overall. There was 1 case (0.2%) of PACS involving displaced proximal and distal fractures. The median length of follow-up was 2.5 months. Modified Flynn outcomes at the last clinical visit were excellent/good in 315 patients (70%). More severe injuries had less good/excellent outcomes than less severe injuries ( P =0.030).

Conclusions: This multicenter study of a large cohort of pediatric floating elbow injuries identified a low rate of PACS (0.2%). Closed treatment of the distal fracture was more frequently performed for nondisplaced fractures. Nerve and vascular injury rates were consistent with those of isolated component fractures and were associated with fracture displacement. The Children's Orthopaedic Trauma and Infection Consortium for Evidence-based Studies classification was an effective predictor of outcomes.

Level of evidence: Level IV.