A comparative study of two percutaneous pinning techniques (lateral vs medial-lateral) for Gartland type III pediatric supracondylar fracture of the humerus

Surgical outcomes for Gartland type III supracondylar distal humerus fracture in children: Comparison between flexion and extension types

BACKGROUND

Supracondylar distal humeral (SCH) fractures account for 50-70 % of pediatric elbow fractures, which are divided into extension and flexion type based on the injury mechanism. However, there has been no study comparing the surgical outcome between two types of SCH fractures in terms of radiographic and clinical outcomes. This study aimed to compare the surgical outcomes between the flexion and extension types of Gartland type III SCH fractures in children.

MATERIALS AND METHODS

This retrospective study included the children who underwent surgery for Gartland type III SCH fractures. Radiographic and clinical outcomes were compared between patients who had extension- and flexion-type fractures. Radiographic outcomes were evaluated by measuring the Baumann angle (BA), carrying angle (CA), and lateral capitellohumeral angle (LCHA). Clinical outcomes were assessed using the Flynn criteria. Univariable and multivariable logistic regression analysis was used to assess the risk factors for angular deformities after surgery.

RESULTS

This study included 257 patients (mean age, 6.1 years, 37 flexion-type and 220 extension-type). Pin configuration was significantly different between the two groups (p = 0.001). There were significant differences in radiographic outcomes in terms of BA (p = 0.040) and LCHA (p = 0.001) between the two groups. Flexion-type fractures were a significant risk factor for sagittal deformity, with an odds ratio of 3.225 (p = 0.002). According to the Flynn criteria, a satisfactory outcome (excellent or good) was observed in 158 patients (84.1 %) with the extension type and 25 (67.6 %) with the flexion type, but not statistically significant (p = 0.058).

CONCLUSIONS

In this study, we found that flexion-type supracondylar fractures had poor radiographic outcomes after surgery compared to extension-type fractures although, there was no significant difference between groups in clinical outcomes. Flexion-type fractures were significantly associated with poor sagittal alignment. Clinicians should focus on alignment during surgery, particularly in flexion-type SCH fractures.

Prospective Study of Functional and Radiological Outcome after Operative Management of Supracondylar Fracture Humerus in Children

Introduction

Supracondylar fractures of the humerus are the most frequently encountered injuries around the elbow with predominantly occurring in age group 5-7 years, with a higher incidence among male. Research has indicated that for displaced humeral supracondylar fractures, both closed and open reduction with internal fixation using K-wires results in more stable outcomes.

Objectives

The purpose of this study was to determine the functional and radiological outcome of operative management of supracondylar fracture humerus in children.

Materials and Methods

It was a prospective study from 2022 to 2024. The study included 53 patients with close supracondylar fractures humerus who were surgically managed by either closed reduction and percutaneous pinning (CRPP) or open reduction and internal fixation (ORIF) by K-wire fixation, cross pinning, or lateral pinning fixation. The functional and radiological outcomes were assessed by Flynn's criteria.

Results

Out of 53, according to Flynn criteria out of 53 patients, 14 (26.4%) of the patients had excellent outcomes, 28 (52.83%) had good outcomes, 7 (13.2%) had fair outcomes, and 4 (7.5%) had poor outcomes. Satisfactory results in 49 patients (93.33%) and unsatisfactory results in 4 (7.54%) patients.

Conclusion

CRPP is a preferred method for treating displaced supracondylar humeral fractures in children due to its minimally invasive nature, ability to maintain fracture alignment, and generally favorable outcomes with complete functional range of motion and good pain relief along with fracture union. CRPP and ORIF groups had no significant difference with respect to functional outcome. Neurovascular complications most frequently occur with Gartland type 3 and type 4 extension supracondylar fractures.

Biomechanical assessment of Kirschner wires integrated with a novel external fixation device for treatment of pediatric supracondylar humeral fracture: a finite element analysis

Background

Pediatric supracondylar humeral fractures present considerable surgical challenges due to the difficulty of achieving proper fracture alignment and stable fixation while avoiding injury to the ulnar nerve. This study assesses the biomechanical performance of a novel Kirschner wire (K-wire) fixation device (KFD), designed to enhance stability and reduce complications linked to traditional K-wire configurations.

Methods

Using finite element analysis (FEA), we evaluated four fixation strategies for treatment of pediatric supracondylar humeral simple transverse fractures: crossed pin fixation, crossed pin fixation with KFD, two lateral pin fixation, and two lateral pin fixation with KFD, under various mechanical loads. The analysis focused on the stress and strain experienced by the K-wires at the fracture site during torsional and bending forces.

Results

FEA revealed that the KFD significantly reduced the stress and strain on the K-wires in all configurations. In both crossed pin and two lateral pin fixation methods, the addition of the KFD showed lower stress and strain levels compared to setups without the KFD.

Conclusion

This study demonstrates the potential of the KFD to enhance fracture stability and reduce mechanical stress at the fracture site, suggesting a promising improvement in the treatment of pediatric supracondylar humeral fractures. This innovation may contribute to safer and more reliable outcomes in pediatric orthopedic surgery.

Radiological and biomechanical evaluation of the ulnar nerve after the percutaneous application of the medial K-wire in the extended position on supracondylar humerus fractures: Does the postoperative long arm splint position matter?

Our study aimed to evaluate and compare the changes in ulnar nerve tension and strain at different elbow positions radiologically and mechanically before and after applying the medial K-wire on the supracondylar humerus fracture cadaver model. We used ten fresh frozen cadaver upper extremity specimens to measure strain and tension on the ulnar nerve in 3 different elbow positions: elbow full extension, elbow flexion-forearm supination, and elbow flexion-forearm pronation. We employed Shear wave elastography (Siemens Acuson S3000 USG, 9L4 linear probe) and a microstrain gauge (Microstrain, Inc., Burlington) to obtain our measurements. Minimum, maximum and mean stress and strain values on the nerve and its surroundings were measured and compared statistically. The mean values of elbows with full extension are statistically lower than those in elbows with 90° flexion-forearm supination and those with 90° flexion-forearm pronation positions. Statistical evaluations were performed between all of the groups. Elbow 90° flexion-forearm pronation, both minimum and maximum and mean values were statistically higher in the group, including the specimens with Kirschner applied. The mean values in the elbow full extension and elbow 90° flexion-forearm supination positions were statistically similar in the specimens with and without the K-wire applied. Despite the numerous techniques described in the literature, there is no absolute technical method to prevent ulnar nerve damage. K-wire application to the medial epicondyle with the elbow in a slightly extended position is a technique that can be applied to reduce the risk of ulnar nerve paralysis. However, it has been reported that ulnar nerve damage can be observed in cases where a splint is placed in the 90° flexion position. We hypothesize that the position of the elbow joint in the postoperative period may contribute to ulnar nerve paralysis due to soft tissue tension and strain and as a result of changing the balance of the surrounding tissues. Our findings suggest that the long arm splint applied in elbow 90° flexion and forearm pronation position should not be preferred in the postoperative period. The maximum strain values obtained in the elbow full extension were lower, suggesting that it would be appropriate to stabilize the elbow in the extension position as much as possible postoperatively. Level of evidence: Level V.

[Research progress in the treatment of distal humeral metaphyseal-diaphyseal junction fracture in children]

Objective

To summarize the research progress in the treatment of distal humeral metaphyseal-diaphyseal junction (DHMDJ) fractures in children and to provide reference for clinical practice.

Methods

The characteristics and treatment methods of transverse and comminuted DHMDJ fractures in children were summarized and analyzed by referring to relevant literature at home and abroad.

Results

DHMDJ fractures in children are not uncommon clinically, with high fracture line position, multi-directional instability, difficult closed reduction in treatment, and easy to cause complications such as coronal and sagittal deformity of the elbow. The Kirschner wire technique was effective for DHMDJ fractures with the fracture line at the middle and low levels, but was prone to iatrogenic ulnar nerve injury. Elastic stable intramedullary nail is suitable for higher-position transverse DHMDJ fractures. However, this technique requires a second operation to remove the internal fixator, and may cause iatrogenic epiphysis plate injury in children. External fixator is a new way to treat DHMDJ fractures, and it can show satisfactory results for transverse and comminuted DHMDJ fractures. However, at present, there are few relevant studies, and most of them focus on biomechanical studies, and the efficacy lacks high-quality clinical research support.

Conclusion

The ultimate goal of DHMDJ fracture treatment in children is to restore the anatomical alignment of the fracture and prevent the loss of reduction. The choice of internal fixator depends on the location of the fracture line and the shape of the fracture to provide personalized treatment.

Comparative analysis of pinning techniques for supracondylar humerus fractures in paediatrics: A systematic review and meta-analysis of randomized controlled trials

Purpose

Supracondylar humeral fractures (SCHFs) rank among the frequently observed fractures in children. Nonetheless, there exists a dearth of consensus regarding the optimal surgical approach. This meta-analysis aims to thoroughly evaluate and compare two distinct pinning techniques (cross pinning versus lateral pinning) for SCHFs, using data from Randomized controlled trials (RCTs).

Methods

Literature review was done using PubMed, CINAHL, Scopus, and The Cochrane Library for RCTs comparing the two pinning methods and providing information on at least one of the following: Loss of Baumann's angle, loss of carrying angle, elbow function assessed based on Flynn criteria, pin tract infection, and iatrogenic ulnar nerve injury. Random effect model was used to calculate standardized mean difference or Odds Ratio (OR) for the outcomes. Review Manager 5.4.1. was used to perform quality assessment and statistical analysis.

Results

A total of 22 RCTs were included. 20 studies reported data for iatrogenic ulnar nerve injury, the OR was calculated to be 3.76 (95% CI 1.75-8.06), showing a significantly lower risk of surgical ulnar nerve injury with the lateral technique. However, no significant difference was found between the pinning techniques in regard to the other outcomes.

Conclusion

In comparison to lateral pinning, the utilization of cross pinning technique exposes the patient to a heightened susceptibility of iatrogenic nerve injury. Therefore, it is recommended that surgeons prioritize the implementation of the lateral pinning technique whenever feasible, as it offers greater protection against iatrogenic ulnar nerve injury. For the other intraoperative and postoperative outcomes, both surgical techniques yield comparable results.

Loss of Fixation of a Type IV Supracondylar Humerus Fracture Treated with Three Divergent Lateral Pins

Supracondylar humerus fractures are common injuries encountered by orthopaedic surgeons. Closed reduction and percutaneous pin fixation is classically considered the standard of care treatment for these injuries, as this treatment method minimizes trauma to the soft tissues, are associated with few complications, and have a high rate of success. However, loss of fixation, when occurring, can lead to cosmetic, functional, and neurological complications. We present a case study of a displaced supracondylar humerus fracture initially treated with three lateral divergent pins that lost fixation and underwent subsequent surgical revision. Key Concepts•Failure to engage both the fracture fragment and the intact proximal shaft may lead to loss of fixation.•Rotating the fluoroscopy machine while keeping the elbow fixed allows for obtaining intraoperative imaging while minimizing the risk of fracture displacement or subsequent loss of fixation.•A trans-olecranon pin may be a helpful reduction tool in significantly unstable fracture patterns.•Casting should be considered for postoperative immobilization in Gartland Type III or Gartland IV fractures.

Extra Lateral Pin or Less Radiation? A Comparison of Two Different Pin Configurations in the Treatment of Supracondylar Humerus Fracture

BACKGROUND

Closed reduction and percutaneous fixation are the most commonly used methods in the surgical treatment of supracondylar humerus fractures. The pin configuration changes stability and is still controversial. The aim of this study was to investigate the relationship between surgical duration and radiation dose/duration for different pinning fixations.

METHODS

A total of 48 patients with Gartland type 2, 3, and 4 supracondylar fractures of the humerus were randomized into two groups-2 lateral and 1 medial (2L1M) pin fixation (n = 26) and 1 lateral 1 medial (1L1M) pin fixation (n = 22). A primary assessment was performed regarding surgical duration, radiation duration, and radiation dose. A secondary assessment included clinical outcome, passive range of motion, radiographic measurements, Flynn's criteria, and complications.

RESULTS

There were 26 patients in the first group (2L1M) and 22 patients in the second group (1L1M). There was no statistical difference between the groups regarding age, sex, type of fracture, or Flynn's criteria. The overall mean surgical duration with 1L1M fixation (30.59 ± 8.72) was statistically lower (p = 0.001) when compared to the 2L1M Kirschner wire K-wire fixation (40.61 ± 8.25). The mean radiation duration was 0.76 ± 0.33 s in the 1L1M K-wire fixation and 1.68 ± 0.55 s in the 2L1M K-wire fixation. The mean radiation dose of the 2L1M K-wire fixation (2.45 ± 1.15 mGy) was higher than that of the 1L1M K-wire fixation (0.55 ± 0.43 mGy) (p = 0.000).

CONCLUSIONS

The current study shows that although there is no difference between the clinical and radiological outcomes, radiation dose exposure is significantly lower for the 1L1M fixation method.

Medial-lateral versus lateral-only pinning fixation in children with displaced supracondylar humeral fractures: a meta-analysis of randomized controlled trials

BACKGROUND

Supracondylar humeral fractures (SCHFs) are frequent in children, and closed reduction with percutaneous pin fixation remains the standard surgical treatment for displaced SCHFs. Two pinning configurations, medial-lateral crossed entry pinning (MLP) and lateral-only entry pinning (LP), are widely used, but which one is superior to another one is still debatable. This meta-analysis aimed to compare the efficacy and safety of both pinning fixation methods.

METHODS

Randomized controlled trials (RCTs) were searched on PubMed, EMBASE, Web of Science, Cochrane library and Google Scholar. Relative risk (RR) and mean difference (MD) with corresponding 95% confidence interval (CI) were calculated for radiographical outcomes, functional outcomes and complications.

RESULTS

A total of 19 RCTs comprising 1297 Gartland type II and type III fractures were included. MLP had a decreased risk of loss of reduction (RR = 0.70, 95%CI 0.52-0.94, P = 0.018) but a higher risk of iatrogenic ulnar nerve injury (RR = 2.21, 95%CI 1.11-4.41, P = 0.024) than LP. However, no significant difference was observed for incidence of ulnar nerve injury if applying a mini-open technique in MLP group (RR = 1.73, 0.47-6.31, P = 0.407). There were no differences between both groups in loss of carrying angle (MD = - 0.12, 95%CI - 0.39 to 0.16), loss of Baumann angle (MD = 0.08, 95%CI - 0.15 to 0.30), excellent grading of Flynn criteria (RR = 1.06, 95%CI 0.99-1.14, P = 0.102) and pin tract infection (RR = 0.92, 95%CI 0.50-1.70).

CONCLUSIONS

MLP is more effective in maintaining fixation, while LP is safer with respect to ulnar nerve injury. MLP with a mini-open technique reduces the risk of ulnar nerve lesion and is an effective and safe choice.

Interventions for treating supracondylar elbow fractures in children

BACKGROUND

Elbow supracondylar fractures are common, with treatment decisions based on fracture displacement. However, there remains controversy regarding the best treatments for this injury.

OBJECTIVES

To assess the effects (benefits and harms) of interventions for treating supracondylar elbow fractures in children.

SEARCH METHODS

We searched CENTRAL, MEDLINE, and Embase in March 2021. We also searched trial registers and reference lists. We applied no language or publication restrictions.

SELECTION CRITERIA

We included randomised and quasi-randomised controlled trials comparing different interventions for the treatment of supracondylar elbow fractures in children. We included studies investigating surgical interventions (different fixation techniques and different reduction techniques), surgical versus non-surgical treatment, traction types, methods of non-surgical intervention, and timing and location of treatment.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. We collected data and conducted GRADE assessment for five critical outcomes: functional outcomes, treatment failure (requiring re-intervention), nerve injury, major complications (pin site infection in most studies), and cosmetic deformity (cubitus varus).  MAIN RESULTS: We included 52 trials with 3594 children who had supracondylar elbow fractures; most were Gartland 2 and 3 fractures. The mean ages of children ranged from 4.9 to 8.4 years and the majority of participants were boys. Most studies (33) were conducted in countries in South-East Asia. We identified 12 different comparisons of interventions: retrograde lateral wires versus retrograde crossed wires; lateral crossed (Dorgan) wires versus retrograde crossed wires; retrograde lateral wires versus lateral crossed (Dorgan) wires; retrograde crossed wires versus posterior intrafocal wires; retrograde lateral wires in a parallel versus divergent configuration; retrograde crossed wires using a mini-open technique or inserted percutaneously; buried versus non-buried wires; external versus internal fixation; open versus closed reduction; surgical fixation versus non-surgical immobilisation; skeletal versus skin traction; and collar and cuff versus backslab. We report here the findings of four comparisons that represent the most substantial body of evidence for the most clinically relevant comparisons.  All studies in these four comparisons had unclear risks of bias in at least one domain. We downgraded the certainty of all outcomes for serious risks of bias, for imprecision when evidence was derived from a small sample size or had a wide confidence interval (CI) that included the possibility of benefits or harms for both treatments, and when we detected the possibility of publication bias.  Retrograde lateral wires versus retrograde crossed wires (29 studies, 2068 children) There was low-certainty evidence of less nerve injury with retrograde lateral wires (RR 0.65, 95% CI 0.46 to 0.90; 28 studies, 1653 children). In a post hoc subgroup analysis, we noted a greater difference in the number of children with nerve injuries when lateral wires were compared to crossed wires inserted with a  percutaneous medial wire technique (RR 0.41, 95% CI 0.20 to 0.81, favours lateral wires; 10 studies, 552 children), but little difference when an open technique was used (RR 0.91, 95% CI 0.59 to 1.40, favours lateral wires; 11 studies, 656 children). Although we noted a statistically significant difference between these subgroups from the interaction test (P = 0.05), we could not rule out the possibility that other factors could account for this difference. We found little or no difference between the interventions in major complications, which were described as pin site infections in all studies (RR 1.08, 95% CI 0.65 to 1.79; 19 studies, 1126 children; low-certainty evidence). For functional status (1 study, 35 children), treatment failure requiring re-intervention (1 study, 60 children), and cosmetic deformity (2 studies, 95 children), there was very low-certainty evidence showing no evidence of a difference between interventions. Open reduction versus closed reduction (4 studies, 295 children) Type of reduction method may make little or no difference to nerve injuries (RR 0.30, 95% CI 0.09 to 1.01, favours open reduction; 3 studies, 163 children). However, there may be fewer major complications (pin site infections) when closed reduction is used (RR 4.15, 95% CI 1.07 to 16.20; 4 studies, 253 children). The certainty of the evidence for these outcomes is low. No studies reported functional outcome, treatment failure requiring re-intervention, or cosmetic deformity. The four studies in this comparison used direct visualisation during surgery. One additional study used a joystick technique for reduction, and we did not combine data from this study in analyses. Surgical fixation using wires versus non-surgical immobilisation using a cast (3 studies, 140 children) There was very low-certainty evidence showing little or no difference between interventions for treatment failure requiring re-intervention (1 study, 60 children), nerve injury (3 studies, 140 children), major complications (3 studies, 126 children), and cosmetic deformity (2 studies, 80 children). No studies reported functional outcome. Backslab versus sling (1 study, 50 children) No nerve injuries or major complications were experienced by children in either group; this evidence is of very low certainty. Functional outcome, treatment failure, and cosmetic deformity were not reported.  AUTHORS' CONCLUSIONS: We found insufficient evidence for many treatments of supracondylar fractures. Fixation of displaced supracondylar fractures with retrograde lateral wires compared with crossed wires provided the most substantial body of evidence in this review, and our findings indicate that there may be a lower risk of nerve injury with retrograde lateral wires. In future trials of treatments, we would encourage the adoption of a core outcome set, which includes patient-reported measures. Evaluation of the effectiveness of traction compared with surgical fixation would provide a valuable addition to this clinical field.

Functional and radiological outcomes of different pin configuration for displaced pediatric supracondylar humeral fracture: A retrospective cohort study

BACKGROUND

The most widely accepted treatment for pediatric supracondylar humeral fracture is closed reduction and percutaneous pinning (CRPP). However, there is debate regarding the technique that is utilized, whether crossed or lateral pinning, and the number of pins used.

AIM

To compare the functional and radiological outcomes of lateral and cross pinning in the management of humeral supracondylar fracture.

METHODS

A retrospective analysis was performed on 101 patients who were surgically managed by either one of the CRPP techniques from 2015 to 2019. Several clinical parameters were taken into account, including pre- and post-intervention Baumann angle, as well as scores for pain, range of motion, function, and stability. Statistical analysis was performed to study the outcomes of the utilized techniques.

RESULTS

Amongst our study sample, which included 63 males and 38 females with a mean age of 5.87 years, about one-third of the patients underwent crossed pinning fixation configuration and the remaining two-thirds were managed by lateral pinning configuration. Similar results were obtained in the two groups with no statistical difference regarding Mayo elbow performance scores (MEPS) and Baumann angle. The mean MEPS in the lateral and crossed pinning groups were 93.68 + 8.59 and 93.62 + 9.05, respectively. The mean Baumann angle was 72.5° + 6.46 in the lateral group and 72.3° + 4.70 in the crossed-pinning group (P = 0.878).

CONCLUSION

Both lateral pinning and crossed pinning fixation configuration for displaced pediatric supracondylar humeral fractures provide similar functional and radiological outcomes.

A Mini-Open Approach to Medial Pinning in Pediatric Supracondylar Humeral Fractures May Be Safer Than Previously Thought

BACKGROUND

Displaced pediatric supracondylar humeral fractures (SCHFs) are stabilized after reduction by smooth pins. Although some SCHFs are biomechanically stable after lateral-only entry pinning (lateral pinning), an additional medial entry pin (cross-pinning) confers superior stabilization in some SCHFs. There is a recognized risk of iatrogenic ulnar nerve injury with medial entry pinning. The best existing evidence has estimated an iatrogenic ulnar nerve injury rate of approximately 3.4% in cross-pinning. In similar studies, the rate of iatrogenic nerve injury (all nerves) in lateral pinning is estimated at 1.9%. This study aimed to use a large, single-center, single-technique (mini-open) retrospective case series to determine the rate of iatrogenic ulnar nerve injury in cross-pinning.

METHODS

Patients undergoing percutaneous cross-pinning via the mini-open technique for SCHFs from 2007 to 2017 were retrospectively reviewed. Injury characteristics, operative variables, fixation technique, and complications, such as iatrogenic nerve injury, were recorded. Patients who underwent operative treatment at another hospital, had no postoperative follow-up, or died due to polytrauma were excluded.

RESULTS

In this study, 698 patients undergoing cross-pinning during the study period were identified. Patients treated with cross-pinning had severe fractures, including a total of 198 preoperative neurovascular injuries (28.4%), 32 patients (4.6%) with skin tenting, and 19 patients (2.7%) with open fractures. Iatrogenic nerve injury was reported in 3 cases (0.43%), all of which affected the ulnar nerve. In 2 of 3 cases of iatrogenic nerve injury, the ulnar nerve symptoms resolved at a mean follow-up of 15 weeks.

CONCLUSIONS

The mini-open approach for medial pin insertion is safer than previous estimates. Here, in the largest single-center study of cross-pinning for SCHFs, the iatrogenic ulnar nerve injury rate of 0.43% was nearly 10 times lower than estimated rates from recent meta-analyses. Considering all nerves, the iatrogenic injury rate for this cross-pinning cohort was also lower than the estimated iatrogenic nerve injury rate for lateral pinning.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

The outcome of loose bone fragments in pediatric supracondylar humerus fractures: a retrospective study

We evaluated the clinical and imaging outcomes of loose bone fragments in children with supracondylar humerus fractures after closed reduction with percutaneous pin (CRPP) fixation. A retrospective review was conducted on 12 children with fragments on imaging after closed reduction of displaced humeral supracondylar fractures (Gartland III). Primary radiographic assessment included fragment outcome, postoperative Baumann angle, carrying angle and loss of reduction. Clinical outcome included the elbow range of motion (ROM), Flynn grade and other complications. Between January 2015 and January 2018, 460 children (2-14 years old) with supracondylar humerus fractures were treated at our center, including 12 (2.6%) with loose bone fragments on postoperative X-ray. Union or absorption of fragments was noted in all 12 patients at 1 year postoperatively, with good radiographic and clinical outcomes. The mean Baumann angle was 15.5° ± 4.3° and the mean carrying angle was 11.2° ± 2.8°. All patients had a normal elbow ROM. Ten patients achieved an excellent and two a good result according to the Flynn criteria. Good results were achieved after CRPP fixation in 12 children with supracondylar humerus fractures and loose bone fragments. The fragments were mainly absorbed or achieved union to the humerus within 1 year.

Variables affecting complication rates in type III paediatric supracondylar humerus fractures

PURPOSE

Unstable supracondylar humerus (SCH) fractures may have different outcomes as a result of direction of displacement and pin configuration. This study evaluates the impact of fracture displacement, pin configuration and fellowship training on clinical and radiographic outcomes in unstable fractures.

METHODS

A total of 99 patients with completely displaced type III fractures were identified at an academic centre and a local community hospital. Patient characteristics and the fellowship training of the treating surgeon were recorded, and injury films documented the direction of displacement. Pin configuration, coronal and sagittal alignment were recorded from postoperative radiographs and at healing. Radiographic outcomes including coronal, sagittal and rotational malunion as well as clinical complications were analyzed.

RESULTS

Fractures with direct posterior displacement had a lower composite malunion rate compared with those with posterolateral (PL) or posteromedial (PM) displacement (6.9%, 36.4%, 29.2% respectively; p = 0.019). PM displacement had a higher rate of coronal malunion compared with PL (18.2% versus 0%; post hoc p = 0.024). All-lateral constructs resulted in more rotational malunions (20.9% versus 1.8%; p = 0.002) compared with crossed pinning. PL fractures treated with all-lateral fixation showed a trend toward increased rotational instability or malunion (23.8% versus 1.3%; p = 0.073). Higher composite complication rates were noted in patients treated by surgeons with non-paediatric, non-trauma fellowship training.

CONCLUSION

For displaced SCH fractures, all-lateral fixation is associated with higher rates of rotational instability and malunion. Posteromedially and posterolaterally displaced fractures have higher rates of malunion compared with fractures with straight posterior displacement. Fellowship training other than paediatric or trauma was associated with increased complications.

LEVEL OF EVIDENCE

Level III.

Comparison of lateral entry and crossed entry pinning for pediatric supracondylar humeral fractures: a meta-analysis of randomized controlled trials

Background

Closed reduction and pinning entry fixation have been proposed as treatment strategies for displaced supracondylar humeral fractures (SCHFs) in children. However, controversy exists regarding the selection of the appropriate procedure. Hence, this meta-analysis was conducted to compare the effect of lateral and crossed pin fixation for pediatric SCHFs, providing a reference for clinical treatment.

Methods

Online databases were systematically searched for randomized controlled trials (RCTs) comparing lateral pinning entry and crossed pinning entry for children with SCHFs. The primary endpoints were iatrogenic ulnar nerve injuries, complications, and radiographic and functional outcomes.

Results

Our results showed that iatrogenic ulnar nerve injuries occurred more commonly in the crossed pinning entry group than in the lateral pinning entry group (RR = 4.41, 95% CI 1.97–9.86, P < 0.05). However, its risk between the crossed pinning with mini-open incisions group and the lateral pinning entry group was not significantly different (RR = 1.58, 95% CI 0.008–29.57, P = 0.76). The loss of reduction risk was higher in the lateral pinning entry group than in the crossed pinning entry group (RR = 0.66; 95% CI 0.49–0.89, P < 0.05). There were no significant differences in the carry angle, Baumann angle, Flynn scores, infections, and other complications between these two groups.

Conclusions

The crossed pinning entry with mini-open incision technique reduced the loss of reduction risk, and the risk of iatrogenic ulnar nerve injury was lower than in the lateral pinning entry group. The crossed pinning entry with mini-open incision technique is an effective therapeutic strategy for managing displaced supracondylar humeral fractures in children.

The most stable pinning configurations in transverse supracondylar humerus fracture fixation in children: A novel three-dimensional finite element analysis of a pediatric bone model

PURPOSE

This study aimed at finding out the effect of exit height, trajectory and number of pins on the stability of cross and divergent-lateral pins used in the fixation of extension-type, transverse supracondylar humerus fracture (SHF) in children, based on finite element analysis.

METHODS

Distal humerus model consisting of the ossific nucleus of the capitellum (ONC) and distal cartilage of a 6-year-old boy was developed via three-dimensional finite modeling. Various cross and divergent-lateral pinning models with either two or three pins were simulated on an extension-type, transverse SHF and tested in six loading directions.

RESULTS

Two-cross pins and 2-divergent-lateral pins were more stable against torsional and translation forces respectively, while 3-cross pins were the most stable against all forces. The cross pins exiting at the upper border of the distal metaphyseal-diaphyseal junction (MDJ) had the best stiffness among the 2-cross pins, while the lateral pins with a middle third ONC distal pin provided the best stiffness among the 2-lateral pins. A third olecranon fossa pin greatly enhanced stability of the 2-lateral pins.

CONCLUSION

For typical transverse fractures, 2-cross pins are found to be superior to 2-divergent lateral pins only against torsional forces. Pins exiting at the upper border of the MDJ provides the best mechanical stability with 2-cross pins. Two-divergent-lateral pins with a distal pin going through the middle third of the ONC provides the best mechanical stability against translation forces for these transverse fractures. Three-cross pins however offer the best mechanical stability against both translation and torsional forces. This study offers important clues in the preoperative evaluation and management of extension-type supracondylar fractures in children.

Does Surgeon Subspecialty Training Affect Outcomes in the Treatment of Displaced Supracondylar Humerus Fractures in Children?

INTRODUCTION

The effect of the treating surgeon's subspecialty training on the outcomes of managing displaced supracondylar humerus fractures in the pediatric cohort remains under debate. The objective of this study was to examine patient outcomes and treatment variables for these injuries based on the surgeon subspecialty training.

METHODS

A retrospective study of children who had undergone primary closed reduction and percutaneous fixation for displaced supracondylar humerus fractures was done from January 2012 through May 2019. The following four groups with differing orthopaedic subspecialty training were evaluated: (1) pediatric fellowship trained (2) trauma fellowship trained, (3) sports medicine fellowship trained, and (4) all others. Outcomes examined included time to surgery, surgical time, fluoroscopy usage, postoperative follow-up protocols, radiographic measurements of alignment, and complications between surgeon groups.

RESULTS

Two hundred thirty-one cases were included (mean age 6 ± 2 years). Pediatric fellowship-trained surgeons took patients to surgery in a more delayed fashion (>12 hours, P = 0.02). Surgical time and fluoroscopy usage were significantly shorter for pediatric fellowship-trained surgeons (P < 0.001). No statistical difference was noted in pin configuration constructs between the groups. Pediatric fellowship-trained surgeons, on average, saw patients two times postoperatively within a year with most patients being within 30 days. Complications were not statistically different between the groups.

CONCLUSIONS

Pediatric fellowship-trained orthopaedic surgeons provide more efficient care on a more delayed basis for displaced supracondylar humerus fractures than other subspecialty-trained orthopaedic surgeons. However, if barriers exist that limit the practicality or availability of these specialists, nonpediatric fellowship-trained surgeons achieve similar and satisfactory outcomes.

LEVEL OF EVIDENCE

Level III retrospective cohort study.

Lateral versus cross pinning in paediatric supracondylar humerus fractures: a meta-analysis of randomized control trials

BACKGROUND

Supracondylar humerus fractures are common in children. Percutaneous pinning remains the mainstay in treatment; however, there is lack of consensus on the optimal configuration: lateral-only pinning or cross pinning. This study aims to investigate the differences in clinical and surgical outcomes between lateral-only and cross-pinning paediatric supracondylar humerus fractures.

METHODS

A systematic search was performed using Medline Ovid, Embase and Cochrane databases for relevant randomized control trials comparing lateral and cross pinning of paediatric supracondylar humerus fractures, reporting at least one of the following: rate of iatrogenic ulnar nerve injury, loss of reduction, infection, loss of Baumann's angle and loss of carrying angle. Statistical analysis was performed using STATA 13.0.

RESULTS

Eleven suitable randomized control trials involving 900 patients were reviewed. Loss of reduction was more common with lateral pinning (relative risk 1.44, 95% confidence interval 1.04-2.00, P = 0.027). Iatrogenic ulnar nerve injury was less common in lateral pinning with treatment-based analysis (relative risk 0.36, 95% confidence interval 0.14-0.92, P = 0.032). There was no statistically significant difference in loss of carrying angle, loss of Baumann angle or rate of infection.

CONCLUSION

Cross pinning provides superior stability in the treatment of supracondylar humerus fractures in children; however, it carries greater risk of iatrogenic ulnar nerve injury.

Overview of the contemporary management of supracondylar humeral fractures in children

PURPOSE

Supracondylar fractures are common injuries accounting for approximately 15% of all fractures in children with a large body of literature on this subject.

METHODS

 This article critically appraises the available evidence to provide an overview of the treatment options including the role and timing of surgery, the geometry of wire fixation and the management of nerve and arterial injury.

CONCLUSION

 Management decisions are based on a number of considerations particularly fracture stability. Closed reduction and percutaneous K-wire stabilisation are commonly recommended for an unstable displaced fracture. These techniques are however associated with the potential for iatrogenic neurological injury. Vascular injury is also rare but must be recognised and treated promptly to avoid significant permanent morbidity.

Crossed versus lateral K-wire fixation of supracondylar fractures of the humerus in children: a meta-analysis of randomized controlled trials

BACKGROUND

Supracondylar fractures of the humerus are common in children. Whether fixation should be performed with crossed or lateral wires remains controversial. We performed a meta-analysis of randomized controlled trials to evaluate both techniques in terms of the function of the elbow and the risk of neurologic injury and loss of reduction. We also assessed the quality of the evidence currently available.

METHODS

The MEDLINE, Embase, Cochrane Library, and LILACS (Latin American and Caribbean Health Sciences Literature) databases, as well as ongoing clinical trial databases, were searched until March 2020. The main outcomes were function, measured by the Flynn criteria, and complications (neurologic lesions and loss of reduction). A meta-analysis was conducted using relative risk (RR) analysis for dichotomous variables and difference in means for continuous variables. Heterogeneity was tested using the I² statistic.

RESULTS

Twelve trials, with a total of 930 patients, met the inclusion criteria. Both groups (crossed-wire and lateral-wire fixation) presented satisfactory functional results, with no difference between them (RR, 0.99; 95% confidence interval [CI], 0.96-1.02; P = .44). Patients undergoing crossed-wire fixation had a higher risk of iatrogenic neurologic injury (RR, 0.45; 95% CI, 0.21-0.99; P = .05). The crossed group showed greater fixation stability, with a lower incidence of loss of fracture reduction (RR, 1.39; 95% CI, 1.04-1.85; P = .03). The GRADEpro GDT (Guideline Development Tool) showed that the quality of evidence of the evaluated outcomes was low or very low.

CONCLUSION

There is evidence of very low quality that fixation with lateral wires is safer regarding iatrogenic nerve lesions whereas fixation with crossed wires is more effective at maintaining fracture reduction.

The effect of the angle between fracture line and Kirschner wires on stability in supracondylar humerus fractures treated with Kirschner wire fixation: A finite element analysis

Objectives

This study aims to investigate the effects of the angles created by the Kirschner wires (K-wires), which are applied in the percutaneous fixation of supracondylar humerus fractures with cross K-wire, with the fracture line on fracture stabilization.

Patients and methods

The study was conducted on distal humerus fracture models. Medial and lateral K-wires were placed in the fracture models. The angle between the fracture line and the K-wire inserted from medial was represented by alpha (α), while the angle between the fracture line and the K-wires inserted from lateral was represented by beta (β). A combination of various angles (30°, 45°, and 60°) was used in each model, where no two models had the same combination of α and β, resulting in nine different wire configurations. The simulation program was used to simulate the effects of forces, which were applied on rotation, flexion and extension directions, on these models. We measured and compared the stress on the wires and the displacement of fractures under different force configurations.

Results

When the force was applied in the counterclockwise direction, the stresses were 58 megaPascal (MPa) on medial K-wire, 24 MPa on lower lateral K-wire, and 45 MPa on upper lateral K-wire in (45°, 45°) wire configuration. When the force was applied in the clockwise direction, the stresses were 57 MPa on medial K-wire, 23 MPa on lower lateral K-wire, and 45 MPa on upper lateral K-wire in (45°, 45°) wire configuration. In all models, the increased α and β angles were translated into the decreased stress on K-wires at the fracture level and decreased displacement under rotational deforming forces. Despite having generally lower fracture displacement, the increased α and β angles led to variable changes in the stress on K-wires against flexion and extension forces.

Conclusion

In supracondylar humerus fractures, increasing the insertion angle of both medial and lateral K-wires augments stabilization and reduces displacement, particularly against rotational deforming forces.

Supracondylar Humerus Fractures: Classification Based Treatment Algorithms

Supracondylar humerus fractures are the most common fractures around the elbow in children between 4 and 10 years of age. The treatment of supracondylar humerus fractures can vary from conservative treatment to operative treatment depending on the fracture type. All around the world, the most commonly used classification system is the Wilkins-modified Gartland classification of supracondylar humerus fractures. Currently, the decision to operate or conserve the fracture is taken on basis of this classification system. Non-operative treatment for type I fractures and operative treatment for type III fractures have been well-established in literature. The management of type II supracondylar humerus fracture creates confusion in the minds of numerous orthopaedic surgeons around the world. We have tried addressing this using a classification-based treatment algorithm. Other classification systems like the AO classification, Lagrange and Rigault classification and Bahk classification with special reference to special fracture patterns that require attention and pre-op planning have also been mentioned. It is important to understand that operative management of each supracondylar humerus fracture is unique as regards fixation method and it is important to consider the fracture pattern before internal fixation.

Mid-term Patient-reported Outcomes After Lateral Versus Crossed Pinning of Pediatric Supracondylar Humerus Fractures

BACKGROUND

Closed reduction and percutaneous pinning in a crossed or lateral configuration is the standard treatment for supracondylar humerus (SCH) fractures. We compared mid-term patient-reported outcomes (PROs), radiographic outcomes, and complication rates between patients treated with crossed versus lateral pinning.

METHODS

We reviewed 508 pediatric patients treated surgically for Gartland type-III SCH fractures from 2008 to 2017. We included patients aged 5 to 17 years at the time of telephone interviews, who had available radiographs. We excluded those unable to be reached by telephone; those who declined to be surveyed; and those lost to follow-up. Our sample comprised 142 participants (28%) (mean±SD age at surgery, 5.2±2.0 y), 93 (65%) of whom were treated with lateral pinning and 49 (35%) with crossed pinning. Participants' parents completed the Quick Disabilities of the Arm, Shoulder, and Hand and the Patient-Reported Outcomes Measurement Information System Parent Proxy at a mean 4.4 years (range: 2 to 10 y) postoperatively. Postoperative radiographs were reviewed to assess reduction. Bivariate analysis was performed to determine whether outcomes differed by pinning technique (α=0.05).

RESULTS

The proportions of participants achieving complete reduction were not significantly different between pin configuration groups (P=0.71). At follow-up, the 2 groups did not differ significantly in any PRO scores (all, P>0.05).

CONCLUSION

We found no differences between crossed and lateral pinning of Gartland type-III SCH fractures in terms of radiographic reduction, PROs, or complication rates at mid-term follow-up.

LEVEL OF EVIDENCE

Level III.

Surgical management of delayed Gartland type III supracondylar humeral fractures in children: A retrospective comparison of radial external fixator and crossed pinning

Radial external fixator has been proposed to treat delayed irreducible Gartland type III supracondylar humeral fracture, and this study aims to compare its effects with crossed pinning in a retrospective fashion. Delayed supracondylar humeral fracture is defined as more than 72 hours after injury, 2 or more than 2 times failed attempts of closed reduction can be deemed as irreducible fracture.Between January 2010 and January 2017, patients of Gartland type III supracondylar fractures of the humerus receiving surgery were all selected and reviewed. Overall, 39 patients fitting the inclusion criteria were chosen for the External Fixator Group and patients for control group of crossed pinning with matched age, sex, and clinical parameters (fracture location, injured side, and fracture type) were selected from the database. Surgery duration, number of intraoperative X-ray images, incidence of ulnar nerve injury, postoperative redisplacement, and function of the elbow joint were recorded and analyzed.In this study, 39 patients treated with radial external fixator had significantly shorter surgery duration, fewer intraoperative X-ray images, and lower incidence of ulnar nerve injury, and postoperative redisplacement than those receiving crossed pinning. Patients in 2 groups displayed similar range of motion for elbow joint at follow-up.Radial external fixator is an effective and safe method to treat Gartland type III supracondylar fractures that were diagnosed late.

A two-stage retrospective analysis to determine the effect of entry point on higher exit of proximal pins in lateral pinning of supracondylar humerus fracture in children

BACKGROUND

Kirschner wire fixation remains to be the mainstream treatment modality in unstable or displaced supracondylar humerus fracture in children, with divergent lateral pins being the most preferred due to their sufficient stability and decreased risk of ulnar nerve injury. However, the entry point at which the proximal lateral pin can be inserted to achieve a more proximal exit and maximum divergence has not been reported. This study retrospectively analyzed the characteristics and factors influencing the entry and exit points of the proximal lateral pins.

METHODS

The study was divided into two stages. In stage one, the entry and exit points of the proximal pins of lateral pinning configuration were analyzed from intra-operative radiographs of children treated for extension-type supracondylar humerus fractures. The coronal and sagittal pin angles formed by the proximal pins were also measured. Using the findings of stage one, we intentionally tried to achieve a more proximal exit with the proximal pins in stage two. Comparisons between groups of patients treated by random and intentional pinnings were done statistically.

RESULTS

In the first stage, 47 (29.2%) of the 161 proximal pins exited above the metaphyseal-diaphyseal junction (MDJ) region. Of these, 85.1% entered from lateral and posterior to the ossific nucleus of the capitellum (ONC). The pin angles averaged 58.4° and 90.5° in the coronal and sagittal planes respectively. In the second stage, 47 (65.3%) proximal pins in the intended group exited above the MDJ region, while only 32 (36%) in the random group exited above the MDJ region.

CONCLUSION

While aiming at the upper border of the distal MDJ during pinning, lateral pins can easily achieve a higher, proximal exit above the MDJ if inserted from lateral and posterior to the ONC and parallel to the humeral shaft in the sagittal plane. Higher exit can also be easily achieved in younger patients and patients fixated with smaller diameter pins.

Use of external fixation for juxta-articular fractures in children

In this article, the use of external fixation in the management of juxta-articular fractures in paediatric patients is discussed. Basic principles of Ilizarov technique are described for distal radial, distal femoral, distal humeral and distal tibial fractures. Common indications for external fixation in pediatric fractures are comminuted, complicated, and/or open fractures, particularly at the distal humerus, distal radius, distal femur and distal tibia. There are several benefits of external frame fixation in these type of injuries in children. This method avoids additional injury to the growth plate as K-wires are not placed through it. It enables careful reduction without interfragmentary compression and correct anatomic alignment. There is no soft tissue dissection and periosteal blood supply is preserved. External fixation ensures primary fracture stability even in presence of comminution and high adjustment capability. Immediate joint motion and early weight-bearing are further advantages. Joint bridging is an option in severe bone loss or soft tissue injuries.

Do fluoroscopic and radiographic images underestimate pin protrusion in paediatric supracondylar humerus and distal radius fractures? A synthetic bone model analysis

PURPOSE

Fluoroscopy is commonly used to confirm acceptable position of percutaneously placed pins when treating paediatric fractures. There is a paucity of literature investigating the accuracy of fluoroscopic imaging when determining pin position relative to the far cortex of the fixated bone. The purpose of this study was to evaluate the accuracy of fluoroscopic and radiographic imaging in measuring smooth pin protrusion from the far cortex of a bone model.

METHODS

Eight bone models were implanted with smooth pins and anteroposterior fluoroscopic and radiographic studies were obtained. All images were evaluated by orthopaedic attending physicians, residents and medical students. The length of pin protrusion from the model surface was estimated on fluoroscopic imaging and measured on radiographs and compared with actual lengths measured on the bone models.

RESULTS

20 evaluators took a total of 320 pin measurements on images of 8 models. There was a significant difference between fluoroscopic measurements compared to radiographic measurements and actual pin lengths. There was no significant difference between radiographic measurements and actual pin lengths. Level of training of examiner was not statistically significant. On average, fluoroscopic estimations of pin protrusion were 1.53 mm shorter than the actual measured length.

CONCLUSION

Fluoroscopic images underestimate the length of smooth pins protruding from a bone model surface when compared with radiographs and actual measurements. Orthopaedic surgeons using fluoroscopy should be aware of this discrepancy when assessing intraoperative fluoroscopic images to decide on acceptable implant position.

LEVEL OF EVIDENCE

Level V.

Advantages and disadvantages of the prone position in the surgical treatment of supracondylar humerus fractures in children. A literature review

INTRODUCTION

Supracondylar humerus fractures are the most common elbow injuries in children. The widely adopted approach for Gartland III extension type consists of closed reduction and percutaneous pinning; the pin configuration can be lateral or crossed in relationship with the habit of the surgeons. Iatrogenic injury of the ulnar nerve is the most common risk during the insertion of the medial pin. The aim of this study was to analyze advantages and disadvantages of percutaneous pinning with the patient in prone position.

MATERIALS AND METHODS

A literature review of the period 2005-2017 was carried out; four medical search engine (Pubmed, Cochrane Library, ISI Web of Science and Scopus) were consulted using the review's filter and the key words "Ulnar nerve AND supracondylar humerus fractures". The total number of patients were analyzed for: ulnar nerve injuries, anesthesiologic management, time of surgery.

RESULTS

Twenty-nine papers were read, 23 regarding cross pinning in supine position and 6 in prone position. On one hand, 1529 children were treated with closed reduction and cross pinning in supine position; 69 of these patients (4.5%) suffered from iatrogenic ulnar nerve injury. On the other hand, 579 patients underwent the same treatment in prone position; no ulnar nerve lesions were reported in this group. Only one article compared both groups of children in supine and prone position regarding time of anesthesia which is slightly higher in the prone group. There were no differences between supine and prone positions regarding x-ray exposition, time of surgery, closed reduction manoeuvers, pin positioning, x-ray results, clinical and functional results.

DISCUSSION AND CONCLUSIONS

The ulnar nerve in children is hypermobile in the cubital tunnel and tends to dislocate anteriorly over the medial epicondyle, especially when the elbow is in hyperflexion. This may be the reason of the increased risk of nerve injury during the insertion of the medial pin in supine position and, instead, an advantage of the prone position. The insertion of both pins from the lateral side could reduce this complication. Larger studies need to be carried out regarding the reported higher duration of anesthesia in prone position.

Management of supracondylar fractures of the humerus in children

Supracondylar fractures of the humerus are the most frequent fractures of the paediatric elbow, with a peak incidence at the ages of five to eight years.

Extension-type fractures represent 97% to 99% of cases. Posteromedial displacement of the distal fragment is the most frequent; however, the radial and median nerves are equally affected. Flexion-type fractures are more commonly associated with ulnar nerve injuries.

Concomitant upper-limb fractures should always be excluded. To manage the vascular status, distal pulse and hand perfusion should be monitored. Compartment syndrome should always be borne in mind, especially when skin puckering, severe ecchymosis/swelling, vascular alterations or concomitant forearm fractures are present.

Gartland’s classification shows high intra- and inter-observer reliability. Type I is treated with casting. Surgical treatment is the standard for almost all displaced fractures. Type IV fractures can only be diagnosed intra-operatively.

Closed reduction and percutaneous pinning is the gold standard surgical treatment. Open reduction via the anterior approach is indicated for open fractures, absence of the distal vascular flow for > 10 to 15 minutes after closed reduction, and failed closed reduction.

Lateral entry pins provide stable fixation, avoiding the risk of iatrogenic ulnar nerve injury.

About 10% to 20% of displaced supracondylar fractures present with alterations in vascular status. In most cases, fracture reduction restores perfusion.

Neural injuries occur in 6.5% to 19% of cases involving displaced fractures. Most of them are neurapraxias and it is not routinely indicated to explore the nerve surgically.

Cite this article: EFORT Open Rev 2018;3:526-540. DOI: 10.1302/2058-5241.3.170049

Pediatric and Adolescent T-type Distal Humerus Fractures

Although fractures of the elbow are extremely common in pediatric patients, the T-type distal humerus fracture is rare and offers unique challenges. The mechanism of injury may be similar to the adult counterpart and is usually caused by a fall onto a flexed elbow or from a direct blow. Diagnosing these injuries may be difficult. They often resemble extension-type supracondylar fractures, yet the treatment algorithm is quite different. In younger patients, percutaneous pinning remains a viable option, but for older adolescents, open reduction and internal fixation provides stable fixation at the elbow and the most reliable restoration of the articular surface. Appropriate imaging, careful radiographic diagnosis, and choice of surgical technique are of paramount importance when treating young patients with this injury. Most pediatric and adolescent patients with T-type distal humerus fractures have results better than those of adults but often worse than other elbow fractures in this age group.

A comparative biomechanical study on different fixation techniques in the management of transverse metaphyseal-diaphyseal junction fractures of the distal humerus in children

BACKGROUND

Metaphyseal-diaphyseal junction (MDJ) fractures of the distal humerus are problematic to reduce and more susceptible to post-operative complications. This biomechanical study was designed to compare Kirschner wires (KW), lateral external fixation, and elastic stable intramedullary nails (ESIN) in simulated transverse MDJ fractures of various heights.

METHOD

Sagittally oblique, transverse MDJ fractures were created in fourth-generation composite bone models at three levels: high, mid, and low fractures, respectively, and then fixed with either Kirschner wires, lateral external fixation (EF), or ESIN respectively and tested in extension, flexion, valgus, varus, internal, and external rotations.

RESULTS

In the high fractures, ESIN had better overall stiffness than the other techniques. In the mid groups, three crossed pinning (1-medial and 2-lateral pins) had the best overall stiffness, followed by two crossed pinning (1-medial and 1-lateral pins). In the low fractures, three crossed pinning was superior to all other techniques. Two crossed pinning and three -lateral pinning techniques yielded comparable stiffness in the low fracture model.

CONCLUSIONS

From a biomechanical perspective, ESIN provides the best overall stability for fractures located in the upper region of the MDJ, while percutaneous pinning is superior in stabilizing fractures of the lower region. Two lateral and one medial pins make the most stable crossed pinning construct for these fractures.

Comparison of lateral entry with crossed entry pinning for pediatric supracondylar humeral fractures: a meta-analysis

BACKGROUND

The standard treatment for severe displaced pediatric supracondylar humeral fracture (SCHF) is closed reduction and percutaneous pin fixation. However, controversy persists concerning the optimal pin fixation technique. The purpose of this study was to compare the safety and efficacy on the configuration of lateral entry only with crossed entry pin fixation for SCHF, including Gartland type II and type III fractures in children.

METHODS

Published literatures, including retrospective studies, prospective studies, and randomized controlled trials, presenting the probability of poor functional consequence of elbow and/or loss of reduction and/or iatrogenic ulnar nerve injury and/or superficial infection and/or cubitus varus were included. Statistical analysis was performed with the Review Manager 5.3 software.

RESULTS

Twenty-four studies were included in the present meta-analysis involving 1163 patients with lateral entry pins and 1059 patients with crossed entry pins. An excellent score of Flynn criteria occurred more commonly in patients who treated with crossed pins than in patients with lateral pins only (RR = 0.93; 95% CI 0.87-0.99; P = 0.03). In accordance with previous systematic review, the incidence of iatrogenic ulnar nerve injury in crossed entry group was significantly more than in lateral entry group with statistical difference (RR = 0.26; 95% CI 0.14-0.47; P < 0.0001). And, results of subgroup analysis on iatrogenic ulnar nerve injury based on experimental design of retrospective study (RR = 0.23; 95% CI 0.10-0.52; P < 0.0004) and randomized control trial (RR = 0.29; 95% CI 0.10-0.79; P < 0.02) were similar.

CONCLUSIONS

In consideration of the contradictoriness of lateral entry with two pins only (possible risk of poor functional consequence of elbow) and crossed entry pins (risk of iatrogenic ulnar nerve injury), the recommended strategy for the treatment of SCHF is the lateral entry technique with introducing divergent three pins which can provide a stable configuration and avoid the injury of the ulnar nerve. And additional protective measures for the ulnar nerve should be taken by surgeons that wish for the more stable structure with the crossed entry technique.