Prone versus supine position during surgery for supracondylar humeral fractures

The Role of Patient Position in the Surgical Treatment of Supracondylar Fractures of the Humerus: Comparison of Prone and Supine Position

Background and Objectives: Supracondylar fractures of the humerus (SCHF) make up about one-third of pediatric fractures and are the most common elbow fractures in children. Reduction and fixation of SC fractures can be performed with the patient in the prone or supine position. However, the role of the patient's position during surgery is still unclear. The purpose of this systematic review is to evaluate, based on data from the literature, the role of patient position during closed reduction and fixation of pediatric SCHFs. Materials and Methods: A systematic review of the current literature from 1951 to 2021 was conducted according to PRISMA guidelines. Articles were identified from 6 public databases. Articles were screened and abstracted by two investigators and the quality of included publications (n = 14) was assessed (MINORS criteria). Statistical analyses were performed using R studio 4.1.2. Results: The systematic literature review identified 114 articles, from which, according to inclusion and exclusion criteria, 14 studies were identified. A total of 741 children were treated in the prone position and 538 in the supine position. The results of the systematic review showed that there were no statistical differences between the two positions with regard to clinical, radiographic, and complication outcomes. Conclusions:: The functional and radiographic outcome of displaced SCHFs is generally excellent regardless of the position, prone or supine, in which the patient is positioned for surgery. The choice of how to position the patient depends on the habit and experience of the surgeon and anesthesiologist performing the surgery.

Is Supine Position Superior to Prone Position in the Surgical Pinning of Supracondylar Humerus Fracture in Children?

BACKGROUND

Supracondylar humerus fracture (SCHF) is a frequent injury in pediatric ages. Closed reduction and percutaneous pin fixation is a common treatment of displaced SCHF. Surgery is usually performed in the supine position; otherwise the prone position allows an easier fracture reduction and a safe placement of pins. The aim of study is to compare the clinical and radiographic results of the treatment of displaced SCHF, comparing two different intra-operative positionings.

METHODS

59 SCHF affected children were retrospectively divided into supine (Group 1; n = 34) and prone (Group 2; n = 25), according to intraoperative position. All treated subjects were clinically evaluated according to Flynn's criteria and Mayo Elbow Performance Score, and radiographically, including the measurement of the Baumann angle.

RESULTS

Clinically, Group 1, according Flynn's criteria, had excellent cosmetic outcome in 32 subjects (94.1%). Mean MAYO Score was 96.0 ± 3.8. Group 2, according Flynn's criteria, had excellent cosmetic outcomes in 23 subjects (92.0%). Mean MAYO Score was 97.8 ± 3.3. Radiographically, mean difference of Baumann's angle between the injured limb and the normal limb was 5.5° ± 1.0° in Group 1 and 5.1° ± 1.1° in Group 2.

CONCLUSION

Both supine and prone positioning achieved a satisfying outcome with similar results in joint function recovery and complications.

Arm Board Technique for Closed Reduction Percutaneous Pinning of Displaced Supracondylar Fractures of Humerus in Children: Technical Note

Introduction

Closed reduction percutaneous pinning (CRPP) is the current standard of treatment for displaced supracondylar fractures of humerus in children. This technical note describes a simple method of CRPP using a radiolucent arm board and simpler handling of the C-arm. This technique is a simple method and easy to reproduce, can be adapted to any standard operating table, and gives predictable results.

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.

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.