Crossed pinning in paediatric supracondylar humerus fractures: a retrospective cohort analysis

Purpose

The aim of this study was to analyse the management of displaced paediatric supracondylar humerus fractures at our Level I Trauma Centre and to determine clinical and radiographic long-term results following operative treatment.

Methods

Clinical and radiological results of 78 paediatric patients (29 female, 49 male; mean age 5.1 years) with supracondylar humerus fractures, treated from 1992 to 2004, were evaluated. Gartland’s classification yielded 32 type II, 44 type III and further two flexion injuries. In all patients the follow-up period exceeded 12 months. Assessment after an average of 8.1 years (1.1–19.5) included neurovascular examination, Flynn’s criteria (elbow function and carrying angle), pain, complications (infections, growth disturbances or iatrogenic nerve injuries) and measurement of the humeroulnar angle.

Results

According to Flynn’s criteria 73 patients (93.5 %) had a satisfactory outcome, while five (6.4 %) were graded as unsatisfactory (two due to cubitus varus and three because of limited elbow motion). The visual analogue scale (VAS) score averaged 0 (range 0–1) and the mean carrying angle measured 8.4° (−8 to 20°), compared to 10.8° on the contralateral side (2–20°). Injury-related complications yielded absent pulses in four (5.1 %), five (6.4 %) primary median, two (2.6 %) primary radial and one (1.3 %) primary ulnar nerve injury. Treatment-related complications included a secondary displacement and one iatrogenic radial nerve palsy. Based on primary nerve lesion as a dependent variable, statistical analysis showed that age had a significant influence revealing that older paediatric patients had a significantly higher risk (p = 0.02). Functional outcome as a dependent variable revealed an indirect proportion to the clinical carrying angle, achieving statistical significance (p < 0.01).

Conclusions

Crossed pinning in paediatric supracondylar humerus fractures is an effective method. Evaluation of the outcome in our study group demonstrated good results with the treatment approach described.     

Biomechanical analysis of pinning techniques for pediatric supracondylar humerus fractures

BACKGROUND: Closed reduction and percutaneous pin fixation is the recommended treatment of displaced (Gartland types 2 and 3) supracondylar humerus fractures. The need for a medial pin for maximal stability remains controversial. The purpose of this study was to develop a model of supracondylar humerus fractures simulating medial column comminution and to evaluate the torsional stability of various pin configurations recommended in the current literature. METHODS: Transverse cuts were made in synthetic humeri with a wedge taken from the medial aspect of the proximal fracture fragment in one half of the specimens to simulate medial column comminution. Each fracture was then reduced and fixed with 1 of 4 pin configurations using 0.062 in K-wires. The fixed specimens were then subjected to a torsional load producing internal rotation of the distal fragment. Rotation in degrees and the corresponding torque was recorded for statistical analysis. RESULTS: Specimens with the medial wedge removed demonstrated less torsional stability than their identically fixed counterparts with the intact medial column. In specimens with the intact medial column, the greatest torsional stability was achieved with the 2 lateral divergent and medial cross pin configuration followed by 3 lateral pins, then standard crossed pins with 2 lateral divergent pins demonstrating the least torsional stability. For the medial comminution group the 2 lateral, 1 medial pin construct again had the greatest torsional stability and 2 lateral pins the least. The standard crossed pin and 3 lateral pin constructs were not significantly different in the presence of medial comminution. CONCLUSIONS: In a synthetic humerus model of supracondylar humerus fractures, medial comminution was shown to reduce torsional stability significantly in all pin configurations. There was no statistical difference in torsional stability between 3 lateral pins and standard crossed pins in specimens with medial comminution.     

Displaced pediatric supracondylar humerus fractures: biomechanical analysis of percutaneous pinning techniques

Supracondylar humerus fractures are a common childhood occurrence. Displaced fractures are typically treated with closed reduction and percutaneous pinning. Controversy continues over the appropriateness of various pinning techniques. The most common include crossed or lateral pins. A biomechanical comparison of crossed pins, "parallel" lateral pins, and "divergent" lateral pins was performed using a pediatric synthetic bone model. Mechanical testing of each pin configuration was performed in extension, varus, valgus, internal rotation, and external rotation. The divergent configuration provided statistically greater stability than parallel pins under varus and valgus loading. Divergent pins had similar stability compared with crossed pins in extension, varus, and valgus testing. In axial rotation testing, crossed pins were more stable. If the surgeon feels confident in the ability of lateral pins to provide satisfactory fracture stability, divergent lateral pins provide greater stability than parallel lateral pins while avoiding ulnar nerve injury (associated with crossed pins).     

A retrospective analysis of loss of reduction in operated supracondylar humerus fractures

Background:

Loss of reduction following closed or open reduction of displaced supracondylar fractures of the humerus in children varies widely and is considered dependent on stability of the fracture pattern, Gartland type, number and configuration of pins for fixation, technical errors, adequacy of initial reduction, and timing of the surgery. This study was aimed to evaluate the factors responsible for failure of reduction in operated pediatric supracondylar fracture humerus.

Materials and Methods:

We retrospectively assessed loss of reduction by evaluating changes in Baumann''s angle, change in lateral rotation percentage, and anterior humeral line in 77 consecutive children who were treated with multiple Kirschner wire fixation and were available for followup. The intraoperative radiographs were compared with those taken immediately after surgery and 3 weeks postoperatively. Multivariate logistic regression analysis was performed by STATA 10.

Results:

Reduction was lost in 18.2% of the patients. Technical errors were significantly higher in those who lost reduction (P = 0.001; Odds Ratio: 57.63). Lateral pins had a significantly higher risk of losing reduction than cross pins (P = 0.029; Odds Ratio: 7.73). Other factors including stability of fracture configuration were not significantly different in the two groups.

Conclusions:

The stability of fracture fixation in supracondylar fractures in children is dependent on a technically good pinning. Cross pinning provides a more stable fixation than lateral entry pins. Fracture pattern and accuracy of reduction were not important factors in determining the stability of fixation.     

Complications and timing of follow-up after closed reduction and percutaneous pinning of supracondylar humerus fractures: follow-up after percutaneous pinning of supracondylar humerus fractures

The purpose of this study was to evaluate the need for clinical evaluation with radiographs within 10 days of closed reduction and percutaneous pinning for the treatment of displaced supracondylar humerus fractures. Between May 1 and December 31, 2001, the authors evaluated the complications with closed reduction and percutaneous pinning of 104 displaced supracondylar humerus fractures. Fifty-two of the patients had the initial follow-up examination with radiographs 10 days or less after pinning; the other 52 patients had the initial follow-up examination with radiographs either after 10 days or on the day of pin removal. The overall complication rate for the series was 7.7% (8/104). All eight complications were in type III fractures. The early follow-up group had six complications; the late follow-up group had two complications. Baumann's angle, lateral humerocapitellar angle, and lateral rotational percentage were not significantly different between the two groups. The only variable tested that was associated with a complication was pin configuration. No association between late follow-up and complications was identified. The authors conclude that clinical and radiographic evaluation of routine displaced supracondylar humerus fractures requiring closed reduction and percutaneous pinning may be safely delayed until pin removal.     

Predicting ulnar nerve location in pinning of supracondylar humerus fractures

Thirty-four consecutive patients with displaced supracondylar humerus fractures were treated with reduction and percutaneous pinning. The precise location of the ulnar nerve to the medial pin was determined by intraoperative nerve stimulation. In 22 of the 34 patients, the authors attempted to predict the location of the ulnar nerve by palpation and placing a mark on the skin. They also recorded the ability to feel the anatomic landmarks for pin fixation, including the medial epicondyle and ulnar nerve. The average distance from the medial pin to the predicted location was 9.3 mm, whereas the actual distance measured 7.6 mm, for a significant difference of 1.7 mm. Statistically, the authors could not accurately predict the location of the ulnar nerve prior to blind percutaneous crossed K-wire fixation of supracondylar humerus fractures. However, clinically they were fairly close in their prediction and documented safe insertion and distance from the nerve. Intraoperative nerve stimulation may assist in localizing the nerve prior to placement of the medial pin. Stimulation of the pin itself following insertion is another technique to ensure safe pin placement and decrease the risk of injury.     

Crossed pin fixation of displaced supracondylar humerus fractures in children

The results of 42 children with displaced supracondylar fractures of the humerus (six Gartland Type II and 36 Gartland Type III) treated with crossed pin fixation are reported. In 37 fractures (88%) the teardrop configuration was restored successfully. All fractures healed without loss of reduction. No patients had iatrogenic ulnar nerve injury. Crossed-pin fixation of supracondylar humeral fractures is a safe and effective way of maintaining skeletal stability in children. Careful technique safeguards against ulnar nerve injury.     

经皮克氏针固定治疗小儿肱骨髁上骨折

自1997～1999年我们采用X线透视下手法复位、闭合经皮克氏针固定治疗小儿肱骨髁上骨折32例,取得满意效果,现报告如下。1 临床资料本组32例中男20例,女12例;平均年龄为7岁5个月（3～13.5岁）。左侧24例,右侧8例。伸直型30例,屈曲型2例。按照Gartland[1]肱骨髁上骨折分型:Ⅰ型为无移位骨折,Ⅱ型骨折有移位,但后侧骨皮质相连;Ⅲ型为完全移位骨折。本组Ⅱ型8例,Ⅲ型24例。伤后至来诊时间最短1小时,最长5天,平均1.5天。     

Treatment of displaced supracondylar humeral fractures among children: Crossed versus lateral pinning

This retrospective study evaluated different pinning configurations used in the treatment of displaced supracondylar humeral fractures among children, mainly regarding maintenance of fracture reduction and avoidance of complications. The fractures (41 type II and 67 type III) of 108 children (mean age 6.48 years) were treated by closed reduction and percutaneous pinning: 37 with crossed pins, 37 with two lateral pins and 34 with two lateral and one medial pin. Mean follow-up period was 7.4 months. Type III fractures fixed by two lateral pins were found significantly prone to postoperative instability, late complications and need for medial pin fixation. There was a significant relation between either delay to surgery or postoperative instability and occurrence of complications. Final outcome was significantly poorer in type III than in type II fractures. Fixation by two lateral pins only is not recommended for treating type III supracondylar humeral fractures, but could be used initially to fix severely unstable fractures to allow extension of the elbow before inserting a medial pin. Every effort should be made to avoid iatrogenic ulnar nerve injury while inserting the medial pin.     

Close reduction and percutaneous pinning in displaced supracondylar humerus fractures in children

BackgroundDisplaced supracondylar fractures of the humerus in children are common pediatric injuries treated by orthopedic surgeons. They also have a high rate of complications if not reduced and stabilized in optimal position which may lead to serious neurovascular injuries and residual deformity. Amongst the various methods used for treating these fractures, closed reduction and percutaneous pinning has shown improved results.MethodBetween March 2005 and April 2010, 277 cases of supracondylar humeral fractures (Gartland grade II and III) with less then 1 week old were included in this study. They were treated with closed reduction and percutaneous pinning with crossed Kirschner wires under image intensifier control. Clinical outcome were assessed according to Flynn's criteria.ResultsThe mean age at the time of operation was 6 years (range 2–10 years) and the average duration of follow-up was 4.6 years (range 2.1–7.2 years). The Flynn's criteria were excellent in 202, good in 68, fair in 5 and only 2 with poor results.ConclusionClosed reduction and percutaneous pinning is a sound and effective treatment for displaced supracondylar fractures.     

Fracture stability after pinning of displaced supracondylar distal humerus fractures in children

Between January 1, 1994 and December 31, 1997, we evaluated 138 children with displaced supracondylar distal humerus fractures treated by closed reduction and percutaneous pinning. There were 49 type II fractures and 89 type III fractures. Three principal pin configurations were used at the surgeon's discretion: 2 lateral pins (42 fractures), 1 medial and 1 lateral pin (37 fractures), and 1 medial and 2 lateral pins (57 fractures). There was no statistically significant difference in clinical stability between these groups. One type III fracture pinned using two lateral pins showed marked rotational instability. We recommend using two lateral pins when treating type II fractures. Type III fractures should be treated using two lateral pins initially and, if the elbow demonstrates significant intraoperative rotational instability, a medial pin should be added. If a medial pin is necessary, and the ulnar nerve cannot be identified by palpation, a small incision should be made and the pin placed under direct vision.     

Reduction and pinning of pediatric supracondylar humerus fractures in the prone position

Supracondylar humerus fractures are common pediatric injuries; the preferred treatment for displaced fractures is closed reduction and percutaneous pin fixation. We present a technique for closed reduction and pinning using prone-patient positioning. Prone positioning facilitates fracture reduction and safe pin placement while avoiding elbow hyperflexion. We prefer this technique to the commonly described method of fracture reduction and pinning with the patient supine.