Prospective, surgeon-randomized evaluation of crossed pins versus lateral pins for unstable supracondylar humerus fractures in children

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.

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.

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.

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.

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.

Risk of ulnar nerve injury during cross-pinning in supine and prone position for supracondylar humeral fractures in children: a recent literature review

Aim of this review article is to evaluate the percentage of ulnar nerve lesion during cross-pinning considering the patient's position (supine or prone) on the surgical bed. Comprehensive research was performed by searching in PUBMED, Cochrane Library, ISI Web of Science, SCOPUS and Clinicaltrials.gov from 2005. Children with extension type supracondylar humeral fractures without clinical signs of ulnar nerve lesion at presentation were included. A total of 28 papers were examined including 2147 patients; 1541 underwent a closed reduction and cross-pinning in supine position and 606 in prone position. Among 1541 patients in supine position, 69 (4.5%) suffered from a ulnar nerve injury while among the 606 patients treated in prone position none ulnar nerve lesions were reported. Despite the apparent safety of prone position, further larger studies, comparing the patient's position on the surgical bed, need to be carried out in order to confirm this likelihood.

Internal Rotation Stress Testing Improves Radiographic Outcomes of Type 3 Supracondylar Humerus Fractures

BACKGROUND

The purpose of this study was to determine if routine use of an intraoperative internal rotation stress test (IRST) for type 3 supracondylar humerus fractures will safely improve maintenance of reduction.

METHODS

An intraoperative protocol for type 3 supracondylar humerus fractures was adopted at our institution, consisting of fracture reduction, placement of 2 laterally based divergent pins, and then an IRST to determine the need for additional fixation with a medial column pin placed through a small open approach. Fractures treated with the prospective IRST protocol were compared with a retrospective cohort before adoption of the protocol (pre-IRST). The primary outcomes were differences in Baumann's angle, lateral humerocapitellar angle, and the rotation index between final intraoperative fluoroscopic images and radiographs at final follow-up. Secondary outcomes were complications such as iatrogenic nerve injury, loss of fixation, or need for reoperation.

RESULTS

There were 78 fractures in the retrospective cohort (pre-IRST) and 49 in the prospective cohort (IRST). Overall rotational loss of reduction (>6%), measured by lateral rotation percentage, and major rotational loss of reduction (>12%) were less common in the IRST cohort (6/49 vs. 27/78, P=0.007 overall; 0/49 vs. 8/78, P=0.02 major loss). There were no major losses of reduction for Baumann's angle (>12 degrees) in either cohort. There were 5 subjects in the pre-IRST cohort (6.4%) with a major loss of reduction of the humerocapitellar angle (>12 degrees) and none in the IRST cohort (P=0.16) Loss of proximal fixation with need for reoperation occurred in 3 fractures in the pre-IRST cohort, and none in the IRST cohort (P=0.28). There were no postoperative nerve injuries in either group.

CONCLUSIONS

Intraoperative IRST after placement of 2 lateral pins assists with the decision for additional fixation in type 3 supracondylar humerus fractures. This method improved the final radiographic rotational alignment, and was safely performed using a mini-open approach for medial pin placement.

LEVEL OF EVIDENCE

Level III-prospective cohort compared with a retrospective cohort.

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.

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.

Surgical Interventions for the Treatment of Supracondylar Humerus Fractures in Children: Protocol of a Systematic Review

Background

The treatment of supracondylar humerus fracture in children (SHFC) is associated with complications such as functional deficit, residual deformity, and iatrogenic neurological damage. The standard treatment is closed reduction and percutaneous Kirschner wire fixation with different configurations. Despite this fact, there is still no consensus on the most effective technique for the treatment of these fractures.

Objective

The aim of this systematic review will be to evaluate the effect of surgical interventions on the treatment of Gartland type II and III SHFC by assessing function, complications, and error as primary outcomes. Clinical outcomes such as range of motion and pain and radiographic outcomes will also be judged.

Methods

A systematic review of randomized controlled trials or quasi-randomized controlled trials evaluating the surgical treatment of SHFC will be carried out in the Cochrane Central Register of Controlled Trials, PubMed, Literatura Latino-Americana e do Caribe em Ciências da Saúde, and Excerpta Medica Database. The search will also occur at ongoing and recently completed clinical trials in selected databases. Data management and extraction will be performed using a data withdrawal form and by analyzing the following: study method characteristics, participant characteristics, intervention characteristics, results, methodological domains, and risk of bias. To assess the risk of bias of the included trials, the Cochrane Risk of Bias Tool will be used. Dichotomous outcome data will be analyzed as risk ratios, and continuous outcome data will be expressed as mean differences, both with 95% confidence intervals. Also, whenever possible, subgroup analysis, sensitivity analysis, and assessment of heterogeneity will be performed.

Results

Following the publication of this protocol, searches will be run and included studies will be deeply analyzed. We hope to obtain final results in the next few months and have the final paper published by the end of 2018. This study was funded by a government-based noncommercial agency, Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP).

Conclusions

This study may provide surgical treatment effects evidence for SHFC. The results will assist clinical practice by demonstrating the effectiveness and potential complications of these interventions and might serve as a reference for future clinical trials on the topic.

Trial Registration

PROSPERO CRD42014009304; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=9304 (Archived by WebCite at http://www.webcitation.org/6usiDHzD7)

A Retrospective Study Comparing Crossed and Lateral Wire Configurations in Paediatric Supracondylar Fractures

Background:

Supracondylar fractures are common in children and are associated with significant morbidity.

The purpose of our study was to assess and compare the clinical and radiological outcome of management of supracondylar fractures by both wire configurations, along with identifying factors that predispose to complications.

Materials & Methods:

We retrospectively reviewed all paediatric cases admitted with a supracondylar fracture over a five year period. We reviewed case notes, theatre records and radiographs to determine the age of the patient, classification of fracture, treatment method, delay to theatre, duration of surgery, wire configuration, Baumann´s angle, radiocapitellar alignment, anterior humeral alignment and complications.

Results:

During the five year period we admitted 132 patients and complete notes were available for 123 patients for analyses. For all the patients managed with wire stabilisation 23% developed complications, including 13% with significant complications including nerve injuries and fracture displacements. All five nerve injuries had crossed wires, whereas all for fracture displacements had lateral wires. Baumann´s angle was 76.7 degrees in the group with no complication and 72.2 degrees in the significant complication group (p=0.02). Radiocapitellar line and anterior humeral line were not satisfactory in 5% and 15% of the group with no complications, and 17% and 33% of the group with significant complications.

Conclusion:

We found more complications in lateral pinning configurations, although all nerve injuries were in patients with crossed wire configurations. The factors we believe are associated with a higher likelihood of complications are inadequate post-operative radiological appearance.

What is the best fixation technique for the treatment of supracondylar humerus fractures in children?

Objective

To define the best technique for the surgical treatment of supracondylar fracture of the humerus (SFH) in children, evaluating percutaneous pinning with side wires vs. cross-pinning.

Methods

Randomized controlled trials using the Medline, CAPES, and BIREME. The criteria for inclusion of articles criteria were: (1) randomized controlled trials (RCTs) comparing percutaneous wire fixation techniques, (2) SFH Gartland II B, III, and IV, and (3) children aged 1–14 years. The following were used as main variables: incidence of iatrogenic injury to the ulnar nerve and loss reduction.

Results

Eight studies were selected (521 patients) comparing surgical treatment with pinning in supracondylar fracture of the humerus in children Gartland II type B, III or IV. Iatrogenic injury to the ulnar nerve was greater with the cross-pinning technique, with RR 0.28 and p = 0.03, while the mini-open technique presented RR 0.14 and p = 0.2. A statistically significant greater loss of reduction in the lateral pinning was observed in FSU Gartland III and IV(p = 0.04).

Conclusion

Based upon this meta-analysis of prospective randomized clinical trials, the following is recommended: (1) percutaneous pinning with lateral wires in supracondylar fractures of the humerus in children classified as Gartland II type B; (2) use of crossed wires for Gartland type III or IV, using the mini-open technique for the medial wire.

Results of crossed versus lateral entry K-wire fixation of displaced pediatric supracondylar humeral fractures: A systematic review and meta-analysis

PURPOSE

Supracondylar humeral fractures (SCHF) are among the most common injuries in children. The aim of this systematic review was to investigate functional and radiographic outcome after crossed and lateral K-wire fixation for displaced extension-type SCHF, and complications related to the type of K-wire construction used.

METHODS

RCTs and prospective comparative cohorts on the functional outcome and complications after fracture reduction and K-wire fixation were identified in MEDLINE, Embase, Web of Science and the Cochrane Library.

RESULTS

Thirteen studies were identified, including 1158 patients in seven RCTs and six prospective comparative cohorts. According to the Flynn criteria, there was no difference in outcome between the K-wire configurations (Relative Risk 1.07). Loss of reduction occurred in 27 (11.6%) of 232 patients treated with crossed K-wires, and in 35 (12.4%) of 282 patients treated with lateral entry K-wires. Twenty (4.1%) of 493 patients in the crossed group were diagnosed with iatrogenic ulnar nerve injury, compared with 2 (0.3%) of 666 patients in the lateral entry group. The overall incidence of persistent ulnar nerve related complaints was 3.5/1000.

CONCLUSIONS

Crossed and lateral entry pin fixation of SCHF result in similar construct stability and functional outcome. Although ulnar nerve injury was three times more likely in the crossed K-wire group, the overall incidence of this complication was very low. The available evidence does not support the use of either approach for daily practice. If the surgeon wishes to avoid all potential risk of iatrogenic ulnar nerve injury, the lateral K-wire approach is safest.

Quality of research and quality of reporting in elbow surgery trials

BACKGROUND

Randomized controlled trials (RCTs) are high in the hierarchy of scientific evidence, but possible sources of bias should be identified or even excluded. This systematic review assessed the methodologic quality and the quality of reporting of the RCTs on the treatment of elbow pathology.

METHODS

A systematic review of RCTs was performed on the treatment of elbow pathology. PubMed/MEDLINE, Embase, and the Cochrane Library were searched for relevant trials. Thirty-five of the initial 540 articles being an (pseudo) RCT on invasive treatment of elbow pathology in humans were included. These were scored with the use of an adapted Checklists to Evaluate A Report of a Nonpharmacologic Trial (CLEAR-NPT). To assess quality of reporting, points were administered to the articles based on the results from CLEAR-NPT list. The highest possible score for quality is 26 points.

RESULTS

The average quality score was 18.1 points (range, 10-25 points). The mean scores were 19.5 for trials published in the American Journal of Sports Medicine, 19.8 for those published in the Journal of Bone and Joint Surgery, and 20.3 for those published in the Journal of Shoulder and Elbow Surgery.

CONCLUSIONS

The most important finding was that the overall quality and the quality of reporting has not improved over the years and that the overall quality of the selected studies and the quality of reporting in these trials is not related to the journal they are published in.

Stiffness of various pin configurations for pediatric supracondylar humeral fracture: a systematic review on biomechanical studies

To compare the biomechanical stability of various pin configurations for pediatric supracondylar humeral fractures under varus, internal rotation, and extension conditions. After electronic retrieval, 11 biomechanical studies were included. Stiffness values of pin configurations under different loading conditions were extracted and pooled. There were no statistically significant differences between two cross pins and two divergent lateral pins on the basis of the 'Hamdi method' (P=0.249-0.737). An additional pin did not strengthen two-pin construct (P=0.124-0.367), but better stabilized fractures with medial comminution (P<0.01). Isolated lateral pins are preferable because of a better balance of a lower risk of nerve injury and comparable fixation strength. Limitations such as differences in experimental setup among recruited studies and small sample size may compromise the methodologic power of this study.

Is medial pin use safe for treating pediatric supracondylar humerus fractures?

OBJECTIVES

We present a group of pediatric supracondylar humerus fractures in whom a medial pin was inserted, in addition to lateral-entry pins, and compared it with a group that was treated with lateral-only entry pins. We evaluated differences in the rate of complications related to the insertion of the medial pin.

DESIGN

Prospective nonrandomized.

SETTING

Level II academic center.

METHODS

The data on 291 pediatric was analyzed. Patients in group 1 (n = 47) were treated with a combination of 2 lateral-entry pins and 1 medial-entry pin, whereas patients in group 2 (n = 244) were treated with lateral-only entry pins alone. Information related to the injury and surgical procedure was prospectively collected. The length of surgery, amount of pin separation at the fracture site, presence of neurological complications, pin tract infection, loss of fixation, final carrying angle, and range of motion were recorded.

RESULTS

Fracture severity was similar in both groups (P = 0.6). Medial column comminution was identified preoperatively in all fractures in group 1 and in 10% of fractures in group 2. Length of surgery was a mean of 21 minutes longer for patients in group 1 (P < 0.00001). There were no iatrogenic nerve injuries, vascular complications, or compartment syndromes in either group. The use of a medial-entry pin significantly increased the amount of pin separation at the fracture site (P < 0.00001). The percentage of satisfactory results was similar in both groups (P = 0.6).

CONCLUSIONS

The results of this study suggest that the use of a medial-entry pin for the treatment of pediatric supracondylar humerus fractures is safe, if an adequate technique is followed. Although insertion of medial pins leads to longer surgeries, it does not seem to result in higher incidence of complications.

Is lateral pin fixation for displaced supracondylar fractures of the humerus better than crossed pins in children?

BACKGROUND

Closed reduction and percutaneous pin fixation is considered standard management for displaced supracondylar fractures of the humerus in children. However, controversy exists regarding whether to use an isolated lateral entry or a crossed medial and lateral pinning technique.

QUESTIONS/PURPOSES

We performed a meta-analysis of randomized controlled trials (RCTs) to compare (1) the risk of iatrogenic ulnar nerve injury caused by pin fixation, (2) the quality of fracture reduction in terms of the radiographic outcomes, and (3) function in terms of criteria of Flynn et al. and elbow ROM, and other surgical complications caused by pin fixation.

METHODS

We searched PubMed, Embase, the Cochrane Library, and other unpublished studies without language restriction. Seven RCTs involving 521 patients were included. Two authors independently assessed the methodologic quality of the included studies with use of the Detsky score. The median Detsky quality score of the included trials was 15.7 points. Dichotomous variables were presented as risk ratios (RRs) or risk difference with 95% confidence intervals (CIs) and continuous data were measured as mean differences with 95% CI. Statistical heterogeneity between studies was formally tested with standard chi-square test and I(2) statistic. For the primary objective, a funnel plot of the primary end point and Egger's test were performed to detect publication bias.

RESULTS

The pooled RR suggested that iatrogenic ulnar nerve injury was higher with the crossed pinning technique than with the lateral entry technique (RR, 0.30; 95% CI, 0.10-0.89). No publication bias was further detected. There were no statistical differences in radiographic outcomes, function, and other surgical complications. No significant heterogeneity was found in these pooled results.

CONCLUSIONS

We conclude that the crossed pinning fixation is more at risk for iatrogenic ulnar nerve injury than the lateral pinning technique. Therefore, we recommend the lateral pinning technique for supracondylar fractures of the humerus in children.

Biomechanical testing of pin configurations in supracondylar humeral fractures: the effect of medial column comminution

OBJECTIVES

We measured biomechanical stability in simulated supracondylar humeral fractures fixed with each of 6 pin configurations, 2 with associated medial comminution, and developed a technique for reproducible pin placement and divergence.

METHODS

A transverse supracondylar osteotomy was performed on 36 biomechanical humerus models. Of these, 24 (4 groups of 6 specimens each) were fixed with pins in 1 of 4 lateral entry configurations. The remaining 12 (2 groups of 6 specimens each) had a 30-degree medial wedge removed from the distal humerus and were fixed with 1 of 2 configurations. Half of each group was tested under axial rotation and the other half under varus bending. The distal humerus was divided into 4 equal regions from lateral to medial (1-4). Lateral entry pins were inserted through regions 1-3, whereas the medial pin was inserted through region 4.

RESULTS

Without comminution, 3 widely spaced, divergent lateral entry pins resulted in higher torsional stiffness (0.36 Nm/degree) than 2 pins in adjacent regions (P < 0.055), but similar to 2 pins in nonadjacent regions (P = 0.57). Three lateral entry pins had higher bending stiffness (79.6 N/mm) than 2 pins, which ranged from 46.7 N/mm (P < 0.01) to 62.5 N/mm (P = 0.21). With comminution, adding a third medial entry pin increased torsional stiffness (0.13-0.24 Nm/degree, P < 0.01) and increased bending stiffness (38.7-44.7 N/mm, P = 0.10).

CONCLUSIONS

For fractures without medial column comminution, fixation using 3 lateral entry pins may provide the greatest combination of torsional and bending stiffness. With medial comminution, adding a third medial pin increased torsional stiffness (P < 0.01) and bending stiffness (P = 0.10).

Ultrasound evaluation of ulnar nerve anatomy in the pediatric population

BACKGROUND

Ulnar nerve instability has been reported in up to 17% of children. Accurate assessment is important to achieve because of potential nerve complications that can arise from treatment of common pediatric fractures, including supracondylar humerus fractures. The objective of our study was to evaluate our ability to use ultrasonography to determine the extent of ulnar nerve dislocation in the normal pediatric population and to determine if there is a relationship between ulnar nerve instability and ligamentous laxity.

METHODS

We conducted a prospective ultrasound evaluation of 51 children, examining the excursion of the ulnar nerve through full range of motion. On the basis of its movement during flexion, the ulnar nerve was categorized as stable, subluxating, or dislocating. In addition, we assessed all subjects for ligamentous laxity using the Wynne-Davies signs of joint laxity. The subjects were then divided into groups based on age or ligamentous laxity, and statistical analysis was performed.

RESULTS

Most of the elbows evaluated had stable ulnar nerves (64/102, 62.7%), 27.5% (28/102) had subluxating nerves, and 9.8% (10/102) had dislocating nerves. Patients aged between 6 and 10 showed the highest rate of dislocating or subluxating nerves, with 50%, and also the highest average laxity score, 2.0. When grouped according to ligamentous laxity, patients who had multiple signs of ligamentous laxity had statistically higher numbers of subluxating and dislocating nerves (91.6%, 11/12) than those with lower laxity scores (25.6%, 10/39).

CONCLUSIONS

There are a substantial number of subluxating or dislocating ulnar nerves in children, and the incidence is often bilateral. Patients with ligamentous laxity are more likely to possess unstable ulnar nerves. Ultrasound evaluation and assessment of ligamentous laxity are additional tools that can be used to assess elbow anatomy and identify children at risk for iatrogenic nerve injury.

LEVEL OF EVIDENCE

Level III, diagnostic study.

Treatment of displaced pediatric supracondylar humerus fracture patterns requiring medial fixation: a reliable and safer cross-pinning technique

INTRODUCTION

Treatment of displaced Gartland type 3 supracondylar humerus fractures in children may include closed reduction and percutaneous pinning. The pin configuration may be all-lateral entry or cross-pin. Despite the improved stability possible with cross-pinning, there is an inherent iatrogenic risk to the ulnar nerve of about 6%. As medial fixation may be necessary for certain fracture patterns, this study was conducted to evaluate the risk of ulnar neuropathy using a technique here described and developed to minimize injury to this structure.

METHODS

A retrospective review was performed on all children treated for a supracondylar humerus fracture at our institution between 2003 and 2010. All the type 3 displaced fractures were placed into 2 groups: lateral-entry pinning and cross-pinning. The 2 groups were then compared for risk of ulnar nerve injury, and a post hoc power analysis was performed.

RESULTS

A total of 381 supracondylar humerus fractures met the inclusion criteria. Our cross-pinning technique was used in 187 (49%) of the children with a mean age of 5.8 years (range, 0.92 to 13.92 y). There were 4 ulnar nerve injuries in the entire cohort and 2 sustained as iatrogenic injuries in the cross-pinning group (1.1%). There was no significant difference between our 2 groups in regard to risk of ulnar nerve injury (P=0.24). There is a statistically significant lower risk of ulnar nerve injury in our cross-pinning technique than previously described techniques (P=0.0028), with a post hoc power analysis of 93%.

CONCLUSIONS

Despite the inherent risk for iatrogenic nerve injury with cross-pinning completely displaced supracondylar humerus fractures, there is often a need to use this technique to improve fixation and stability of the fracture. Our method of cross-pinning is safe and reproducible for providing fracture stability with a significant decrease in the risk of iatrogenic ulnar nerve injury (1 in 94) when a medial pin is required.

LEVEL OF EVIDENCE

Level III-therapeutic studies.

The treatment of pediatric supracondylar humerus fractures

Based on the best current evidence and a systematic review of published studies, 14 recommendations have been created to guide clinical practice and management of supracondylar fractures of the humerus in children. Two each of these recommendations are graded Weak and Consensus; eight are graded Inconclusive. The two Moderate recommendations include nonsurgical immobilization for acute or nondisplaced fractures of the humerus or posterior fat pad sign, and closed reduction with pin fixation for displaced type II and III and displaced flexion fractures.

Ultrasonographic examination of the radial and ulnar nerves after percutaneous cross-wiring of supracondylar humerus fractures in children: a prospective, randomized controlled study

In this prospective study, we aimed to find out whether there is a change in the ultrasonographic features of the radial and ulnar nerves as well as clinical outcomes after traditional and lateral percutaneous cross-wiring of the supracondylar humerus fractures in children. Twenty-nine consecutive children with completely displaced Gartland type III supracondylar humerus fractures were treated with the traditional (group T) or lateral (group L) cross-wiring technique. Our findings showed that ultrasonographic features of the radial nerve were not changed in both groups but the ulnar nerve movement was reduced, and the diameter of major axis of the ulnar nerve during elbow flexion was larger (P=0.040) than in elbow extension in the traditional cross-wiring technique but not in the lateral cross-wiring technique. Lateral cross-wiring technique does not change the ultrasonographic features of the radial and ulnar nerves, and provides satisfactory results.

Controversial topics in the management of displaced supracondylar humerus fractures in children

The aim of our study was to review the literature looking for the up to date information regarding these controversial topics. An electronic literature search was performed using the Medline/PubMed database. A closed reduction attempt should always be done first. It is more important to engage both columns as well as divergence of the pins no matter whatever configuration is applied. Time to surgery seems to be not an important factor to increase the risk of complications as well as open reduction rate. Usually neurological injuries present a spontaneous recovery. If there is absent pulse, we should follow the algorithm associated with the perfusion of the hand.

The treatment of upper limb fractures in children and adolescents

BACKGROUND

The treatment of fractures in children and adolescents must be based on an adequate knowledge of the physiology of the growing skeleton. Treatment failures usually do not result from technical deficiencies, but rather from a misunderstanding of the special considerations applying to the treatment of fractures in this age group.

METHODS

We selectively reviewed recent publications on the main types of long bone fracture occurring in the period of skeletal development.

RESULTS

Alleviating pain is the first step in fracture management, and due attention must be paid to any evidence of child abuse. The goals of treatment are to bring about healing of the fracture and to preserve the function of the wounded limb. The growth that has yet to take place over the remaining period of skeletal development also has to be considered. Predicting the growth pattern of fractured bones is a basic task of the pediatric traumatologist. During the period of skeletal development, conservative and surgical treatments are used in complementary fashion. Particular expertise is needed to deal with fractures around the elbow, especially supracondylar humeral fractures, displaced fractures of the radial condyle of the humerus, radial neck fractures, and radial head dislocations (Monteggia lesions). These problems account for a large fraction of the avoidable cases of faulty fracture healing leading to functional impairment in children and adolescents.

CONCLUSION

The main requirements for the proper treatment of fractures in children and adolescents are the immediate alleviation of pain and the provision of effective treatment (either in the hospital or on an outpatient basis) to ensure the best possible outcome, while the associated costs and effort is kept to a minimum. Further important goals are a rapid recovery of mobility and the avoidance of late complications, such as restriction of the range of motion or growth disorders of the fractured bone. To achieve these goals, the treating physician should have the necessary expertise in all of the applicable conservative and surgical treatment methods and should be able to apply them for the proper indications.