ORIGINAL ARTICLE
Fixation of Type 2a Supracondylar Humerus Fractures in Children With a Single Pin Alexander J. Kish, BS and William L. Hennrikus, MD
Background: The AAOS guidelines suggest operative fixation of all type 2 supracondylar humerus fractures. Not all type 2 fractures are the same. Wilkins type 2a fractures have intrinsic stability. The purpose of this paper is to report closed reduction and single-pin fixations for Wilkins 2a fractures. Methods: Fifteen consecutive type 2a fractures treated with single-pin fixation were prospectively evaluated. Procedure notes, age, sex, side involved, duration of immobilization, and complications were recorded. Radiographs were measured for the lateral humerocapitellar line and the humeral ulna angle. At final follow-up the carrying angle, range of motion, and the Flynn criteria were recorded. Results: The average age of patients was 5 years (age range, 1 to 9 y). Three females and 12 males were studied. Eight right elbows and 7 left elbows were injured. A 0.0625 K-wire was used in 2 cases and a 2 mm K-wire was used in 13 cases. On preoperative lateral radiographs, the anterior humeral line did not intersect the capitellum. On postoperative radiographs, the anterior humeral line intersected the middle third of the capitellum. Following pinning, the elbow was immobilized in a long-arm cast in pronation with elbow at 75 degrees of flexion. The cast and pin were removed at an average of 27 days (range, 25 to 31 d). One patient was lost to follow-up. The remaining 14 patients were followed for at least 3 months. At final follow-up, the carrying angle was within 2 degrees of the opposite elbow and ROM was within 3 degrees of the opposite elbow in all cases. Final Flynn criteria were excellent in all 14 patients. There were no complications. Conclusions: Treatment of supracondylar fractures has evolved from selective pinning of type 2 fractures to pinning all type 2 fractures. The results of the current study demonstrate the efficacy of using a single lateral entry pin for stabilization of type 2a fractures in children. Level of Evidence: Level III. Key Words: supracondylar fracture, humerus, percutaneous pinning, fracture, closed reduction, pediatric (J Pediatr Orthop 2014;34:e54–e57)
From the Department of Orthopaedics, Penn State College of Medicine, Hershey, PA. The authors declare no conflicts of interest. Reprints: William L. Hennrikus MD, Department of Orthopaedics, Penn State College of Medicine, 30 Hope Drive, Hershey, PA 17033. E-mail: [email protected]. Copyright r 2014 by Lippincott Williams & Wilkins
e54 | www.pedorthopaedics.com
S
upracondylar humerus fractures are one of the most common fracture patterns observed in the pediatric population, making up nearly 60% of fractures about the elbow region and 30% of all fractures seen in pediatrics.1–3 Gartland classifies supracondylar fractures into 3 types. Type 2 fractures have been further subclassified by Wilkins4 into 2a: posterior hinge intact without rotation and 2b: posterior hinge intact with rotation. Treatment of type 2 fractures is controversial. Some authors recommend operative fixation of all type 2 fractures, including the recent AAOS guidelines.5–8 Previous authors have suggested selective treatment of type 2 fractures. For example, Parikh et al9 recommended performing closed reduction and casting first, then only pinning the type 2 fractures that lost reduction. The purpose of this study is to report the clinical and radiographic outcomes of Wilkins type 2a supracondylar humerus fractures treated with a technique of closed reduction and a single lateral entry pin fixation.
METHODS The records and radiographs of 15 consecutive patients who sustained a Wilkins type 2a supracondylar fracture of the humerus treated with reduction and a single smooth pin fixation were studied. Each pin was placed from the lateral side and obtained bicortical fixation. Age at the time of fracture, sex, side involved, duration of immobilization, and complications were recorded. Radiographic assessment included the lateral humerocapitellar line and the humeral ulna angle. At final follow-up the carrying angle, range of motion, and the Flynn criteria were recorded.
RESULTS The average age of patients was 5 years (range, 2 to 9 y). Three females and 12 males were studied. Eight right elbows and 7 left elbows were injured. A 0.0625 K-wire was used in 2 cases (ages 2 and 3 y) and a 2 mm K-wire was used in 13 cases (age range, 4 to 9 y)—all through a lateral entry. On preoperative lateral radiographs, the anterior humeral line did not intersect the capitellum in any cases. On postoperative radiographs, the anterior humeral line intersected the middle third of the capitellum in all cases. Following pinning, the elbow was immobilized in a long-arm cast with the elbow at 75 degrees of flexion and the forearm in pronation. Pronation helps to lock in the periosteum and stabilize the fracture in most J Pediatr Orthop
Volume 34, Number 8, December 2014
J Pediatr Orthop
Volume 34, Number 8, December 2014
Fixation of Type 2a Supracondylar Humerus Fractures
TABLE 1. Flynn Criteria for Fracture Assessment Excellent Good Fair Poor
Cosmetic Factor Loss of Carrying Angle (deg.)
Functional Factor Loss of Motion (deg.)
No. Patients
0-5 6-10 11-15 > 15
0-5 6-10 11-15 > 15
14 0 0 0
cases. The cast and pin were removed at an average of 27 days after reduction. One patient moved out of the state after pin removal and was lost to follow-up. The remaining 14 patients were followed for at least 3 months. At final follow-up, the carrying angle was within 2 degrees of the opposite elbow and ROM was within 3 degrees of the opposite elbow in all cases. Final Flynn criteria were excellent in all 14 patients. There were no malunions, loss of reduction, cubitus varus, hyperextension, loss of flexion, nerve palsies, pin tract infections, iatrogenic nerve injuries, pin migration, or compartment syndromes (Table 1).
DISCUSSION Wilkins and Rang classify type 2 supracondylar humerus fractures into 2 groups. Type 2a supracondylar humerus fractures are extension-type fractures that have an intact posterior cortex with no rotation. Type 2b extension fractures still have some posterior cortex contact but have a rotational component as well.4,10 The purpose of this study is to report the clinical and radiographic outcomes of Wilkins type 2a supracondylar fractures treated with closed reduction, a single lateral entry pin, and a cast in pronation (Fig. 1). Debate still exists regarding the necessity of pinning of Gartland type 2 supracondylar humerus fractures after a
closed reduction. The sentinel study by Pirone et al6 on the management of displaced extension-type supracondylar fractures suggested that closed reduction and pinning was superior to closed reduction and casting. Additional studies support Pirone’s conclusion.6,11,12 For example, Moraleda et al’s12 study demonstrated that one fourth of patients who had cast treatment alone resulted in cubitus varus deformity. Parikh et al9 reported that about one third of his series of type 2 fractures initially treated with closed reduction and casting alone subsequently lost reduction and needed surgical intervention.6 However, if all patients were initially treated with surgery in his study, then 2/3 of patients would have undergone unnecessary surgery. In contrast, other authors suggested that pinning all type 2 fractures might be unnecessary. For example, Hadlow and colleagues have reported that up to three quarters of patients undergoing pinning for type 2 fractures increases their risk of adverse outcomes such as nerve injury, infection, and anesthetic complications compared with casting alone.12–15 There is also debate on the number of pins, pin size, and entry technique used in the treatment of type 2 supracondylar fractures.4,7 Multiple studies have shown that lateral entry pin fixation is as clinically effective as crossed pin configuration.7,16,17 Pradhan and colleagues demonstrated that increased pin diameter increased fracture stability.18–20 Sorenson and colleagues studied
FIGURE 1. Prereduction AP (A), prereduction lateral (B), postreduction lateral (C), images utilizing a single percutaneous pin. r
2014 Lippincott Williams & Wilkins
www.pedorthopaedics.com |
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Kish and Hennrikus
pin removal from the elbow in the office in children. They demonstrated that pain increased in direct proportion to number of pins removed. For example, removing 1 pin resulted in the least pain and anxiety.21 Currently, the trend is to treat all type 2 supracondylar humerus fractures with closed reduction and percutaneous pinning with 2 or 3 laterally based pins.6,7 Reports of percutaneous pinning for supracondylar humerus fractures began as early as 1948 by Swenson.22 In the 1990s, Wilkins4 recommended treatment of type 2 supracondylar fractures to be cast immobilization with the arm held in flexion and pronation because the intact posterior cortex provides sufficient stability to prevent loss of reduction when the cast is applied. Pring et al10 also suggest that pronation locks in the periosteum and increases fracture stability. Not all type 2 fractures are the same. Type 2a fractures have intrinsic stability due to the lack of rotation about the posterior cortex. In the past, many authors including Wilkins, Parikh, and Hadlow would treat these fractures with closed reduction but no pinning. However, today, the AAOS guidelines suggest pinning all type 2 fractures. The current study using only 1 pin is a technique that fulfills the spirit of the AAOS guidelines but in a simplified manner. The current study demonstrates that closed reduction of the fracture, fixation with a single, well placed, smooth, lateral entry pin and casting in pronation resulted in excellent outcomes by the Flynn criteria in 14 consecutive patients. In addition, this technique also streamlines pin removal in the office. Prior studies report complication rates following pinning of supracondylar fractures up to 13.8%.23 These complications include infection, pin migration, loss of reduction, compartment syndrome, iatrogenic nerve injury, malunion, and deformity.2,12,13,24–27 In the current study, the complication rate was 0% and all patients achieved Flynn Criteria results of excellent. Specifically, we report no loss of reduction as compared with rates of up to 0.6%,6 and no pin infections as compared with rates of 1% to 6.8%13,24 when using 1 pin for fixation (Table 2). Limitations of this study include the retrospective design and small sample size. The keys to success in using single-pin fixation for type 2a supracondylar fractures are: (1) Proper selection of Wilkins 2a fractures. (2) Near-anatomic closed reduction. (3) Bicortical lateral entry smooth pinning. (4) Brief intraoperative fluoro examination to confirm stability. For example, once the pin is in place, performing a few seconds of continuous fluoro while flexing and extending the elbow allows the physician to be certain the fracture reduction is stable.
TABLE 2. Comparison of Complication Rates Infection (%) Loss of reduction (%) No. patients
Pirone et al6
Bashyal et al13
This Study
2.1 1.3 230
1 0.6 622
0 0 15
e56 | www.pedorthopaedics.com
Volume 34, Number 8, December 2014
(5) Casting in pronation to lock in the medial periosteum and increase stability.
CONCLUSIONS Treatment of supracondylar fractures has evolved from selective pinning of type 2 fractures to pinning all type 2 fractures. The results of the current study demonstrate the efficacy of using a single lateral entry pin for stabilization after reduction of type 2a supracondylar humerus fractures in children. REFERENCES 1. Lee YH, Lee SK, Kim BS, et al. Three lateral divergent or parallel pin fixations for the treatment of displaced supracondylar humerus fractures in children. J Pediatr Orthop. 2008;28:417–422. 2. Memisoglu K, Cevdet Kesemenli C, Atmaca H. Does the technique of lateral cross-wiring (Dorgan’s technique) reduce iatrogenic ulnar nerve injury? Int Orthop. 2011;35:375–378. 3. Silva M, Wong TC, Bernthal NM. Outcomes of reduction more than 7 days after injury in supracondylar humeral fractures in children. J Pediatr Orthop. 2011;31:751–756. 4. Wilkins KE. The operative management of supracondylar fractures. Orthop Clin North Am. 1990;21:269–289. 5. Omid R, Choi PD, Skaggs DL. Supracondylar humeral fractures in children. J Bone Joint Surg Am. 2008;90a:1121–1132. 6. Pirone AM, Graham HK, Krajbich JI. Management of displaced extenstion-type supracondylar fractures of the humerus in children. J Bone Joint Surg. 1988;70A:641–650. 7. Skaggs DL, Hale JM, Bassett J, et al. Operative treatment of supracondylar fractures of the humerus in children. The consequences of pin placement. J Bone Joint Surg. 2001;83A:735–740. 8. Mulpuri K, Hosalkar H, Howard A. AAOS clinical practice guideline: the treatment of pediatric supracondylar humerus fractures. J Am Acad Orthop Surg. 2012;20:328–330. 9. Parikh SN, Wall EJ, Foad S, et al. Displaced type II extension supracondylar humerus fractures: do they all need pinning? J Pediatr Orthop. 2004;24:380–384. 10. Pring ME, Rang M, Wenger DR. Elbow-distal humerus. Chapter 8. In: Rang M, Pring ME, Wenger DR, eds. Rang’s Children’s Fractures. 3rd ed. Philadelphia: Lippincott Williams & Wilkins; 2005;104. 11. Camus T, MacLellan B, Cook PC, et al. Extension type II pediatric supracondylar humerus fractures: a radiographic outcomes study of closed reduction and cast immobilization. J Pediatr Orthop. 2011; 31:366–371. 12. Moraleda L, Valencia M, Barco R, et al. Natural history of unreduced Gartland type-II supracondylar fractures of the humerus in children. J Bone Joint Surg. 2013;95A:28–34. 13. Bashyal RK, Chu JY, Schoenecker PL, et al. Complications after pinning of supracondylar distal humerus fractures. J Pediatr Orthop. 2009;29:704–708. 14. Brauer CA, Lee BM, Bae DS, et al. A systematic review of medial and lateral entry pinning versus lateral entry pinning for supracondylar fractures of the humerus. J Pediatr Orthop. 2007;27:181–186. 15. Hadlow AT, Devane P, Nicol RO. A selective treatment approach to supracondylar fracture of the humerus in children. J Pediatr Orthop. 1996;16:104–106. 16. Skaggs DL, Cluck MW, Mostofi A, et al. Lateral-entry pin fixation in the management of supracondylar fractures in children. J Bone Joint Surg. 2004;86A:702–707. 17. Topping RE, Blanco JS, Davis TJ. Clinical evaluation of crossed-pin versus lateral-pin fixation in displaced supracondylar humerus fractures. J Pediatr Orthop. 1995;15:435–439. 18. Pradhan AK, Hennrikus WL, Armstrong AD, et al. Torsional strength of pin configuration in supracondylar fractures: does pin diameter matter? J Child Orthop. 2014. (In press). 19. Srikumaran U, Tan EW, Erkula G, et al. Pin size influences sagittal alignment in percutaneously pinned pediatric supracondylar humerus fractures. J Pediatr Orthop. 2010;30:792–798. r
2014 Lippincott Williams & Wilkins
J Pediatr Orthop
Volume 34, Number 8, December 2014
20. Gottschalk HP, Sagoo D, Glaser D, et al. Biomechanical analysis of pin placement for pediatric supracondylar humerus fractures: does starting point, pin size, and number matter? J Pediatr Orthop. 2012;32:445–451. 21. Sorenson SM, Hennrikus WL, Slough JM, et al. Pain during office removal of K wires in children. J Pediatr Orthop. 2014. (In press). 22. Swenson AL. The treatment of supracondylar fractures of the humerus by Kirschner wire fixation. J Bone Joint Surg. 1948; 30A:993–997. 23. Yaokreh JB, Gicquel P, Schneider L, et al. Compared outcomes after percutaneous pinning versus open reduction in paediatric supracondylar elbow fractures. Orthop Traumatol Surg Res. 2012;98:645–651.
r
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Fixation of Type 2a Supracondylar Humerus Fractures
24. El-Adl WA, El-Said MA, Boghdaddy GW, et al. Results of treatment of displaced supracondylar humeral fractures in children by percutaneous lateral cross-wiring technique. Strategies Trauma Limb Reconstr. 2008;3:1–7. 25. Mai MC, Beck R, Gabriel K, et al. Posterior arm compartment syndrome after a combined supracondylar humeral and capitellar fractures in an adolescent: a case report. J Pediatr Orthop. 2011;31:16–19. 26. Eberl R, Eder C, Smolle E, et al. Iatrogenic ulnar nerve injury after pin fixation and after antegrade nailing of supracondylar humeral fractures in children. Acta Orthop. 2011;82:606–609. 27. Babal JC, Mehlman CT, Klein G. Nerve injuries associated with pediatric supracondylar humeral fractures: a meta-analysis. J Pediatr Orthop. 2010;30:253–263.
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e57
Fixation of Type 2a Supracondylar Humerus Fractures in Children With a Single Pin Alexander J. Kish, BS and William L. Hennrikus, MD
Background: The AAOS guidelines suggest operative fixation of all type 2 supracondylar humerus fractures. Not all type 2 fractures are the same. Wilkins type 2a fractures have intrinsic stability. The purpose of this paper is to report closed reduction and single-pin fixations for Wilkins 2a fractures. Methods: Fifteen consecutive type 2a fractures treated with single-pin fixation were prospectively evaluated. Procedure notes, age, sex, side involved, duration of immobilization, and complications were recorded. Radiographs were measured for the lateral humerocapitellar line and the humeral ulna angle. At final follow-up the carrying angle, range of motion, and the Flynn criteria were recorded. Results: The average age of patients was 5 years (age range, 1 to 9 y). Three females and 12 males were studied. Eight right elbows and 7 left elbows were injured. A 0.0625 K-wire was used in 2 cases and a 2 mm K-wire was used in 13 cases. On preoperative lateral radiographs, the anterior humeral line did not intersect the capitellum. On postoperative radiographs, the anterior humeral line intersected the middle third of the capitellum. Following pinning, the elbow was immobilized in a long-arm cast in pronation with elbow at 75 degrees of flexion. The cast and pin were removed at an average of 27 days (range, 25 to 31 d). One patient was lost to follow-up. The remaining 14 patients were followed for at least 3 months. At final follow-up, the carrying angle was within 2 degrees of the opposite elbow and ROM was within 3 degrees of the opposite elbow in all cases. Final Flynn criteria were excellent in all 14 patients. There were no complications. Conclusions: Treatment of supracondylar fractures has evolved from selective pinning of type 2 fractures to pinning all type 2 fractures. The results of the current study demonstrate the efficacy of using a single lateral entry pin for stabilization of type 2a fractures in children. Level of Evidence: Level III. Key Words: supracondylar fracture, humerus, percutaneous pinning, fracture, closed reduction, pediatric (J Pediatr Orthop 2014;34:e54–e57)
From the Department of Orthopaedics, Penn State College of Medicine, Hershey, PA. The authors declare no conflicts of interest. Reprints: William L. Hennrikus MD, Department of Orthopaedics, Penn State College of Medicine, 30 Hope Drive, Hershey, PA 17033. E-mail: [email protected]. Copyright r 2014 by Lippincott Williams & Wilkins
e54 | www.pedorthopaedics.com
S
upracondylar humerus fractures are one of the most common fracture patterns observed in the pediatric population, making up nearly 60% of fractures about the elbow region and 30% of all fractures seen in pediatrics.1–3 Gartland classifies supracondylar fractures into 3 types. Type 2 fractures have been further subclassified by Wilkins4 into 2a: posterior hinge intact without rotation and 2b: posterior hinge intact with rotation. Treatment of type 2 fractures is controversial. Some authors recommend operative fixation of all type 2 fractures, including the recent AAOS guidelines.5–8 Previous authors have suggested selective treatment of type 2 fractures. For example, Parikh et al9 recommended performing closed reduction and casting first, then only pinning the type 2 fractures that lost reduction. The purpose of this study is to report the clinical and radiographic outcomes of Wilkins type 2a supracondylar humerus fractures treated with a technique of closed reduction and a single lateral entry pin fixation.
METHODS The records and radiographs of 15 consecutive patients who sustained a Wilkins type 2a supracondylar fracture of the humerus treated with reduction and a single smooth pin fixation were studied. Each pin was placed from the lateral side and obtained bicortical fixation. Age at the time of fracture, sex, side involved, duration of immobilization, and complications were recorded. Radiographic assessment included the lateral humerocapitellar line and the humeral ulna angle. At final follow-up the carrying angle, range of motion, and the Flynn criteria were recorded.
RESULTS The average age of patients was 5 years (range, 2 to 9 y). Three females and 12 males were studied. Eight right elbows and 7 left elbows were injured. A 0.0625 K-wire was used in 2 cases (ages 2 and 3 y) and a 2 mm K-wire was used in 13 cases (age range, 4 to 9 y)—all through a lateral entry. On preoperative lateral radiographs, the anterior humeral line did not intersect the capitellum in any cases. On postoperative radiographs, the anterior humeral line intersected the middle third of the capitellum in all cases. Following pinning, the elbow was immobilized in a long-arm cast with the elbow at 75 degrees of flexion and the forearm in pronation. Pronation helps to lock in the periosteum and stabilize the fracture in most J Pediatr Orthop
Volume 34, Number 8, December 2014
J Pediatr Orthop
Volume 34, Number 8, December 2014
Fixation of Type 2a Supracondylar Humerus Fractures
TABLE 1. Flynn Criteria for Fracture Assessment Excellent Good Fair Poor
Cosmetic Factor Loss of Carrying Angle (deg.)
Functional Factor Loss of Motion (deg.)
No. Patients
0-5 6-10 11-15 > 15
0-5 6-10 11-15 > 15
14 0 0 0
cases. The cast and pin were removed at an average of 27 days after reduction. One patient moved out of the state after pin removal and was lost to follow-up. The remaining 14 patients were followed for at least 3 months. At final follow-up, the carrying angle was within 2 degrees of the opposite elbow and ROM was within 3 degrees of the opposite elbow in all cases. Final Flynn criteria were excellent in all 14 patients. There were no malunions, loss of reduction, cubitus varus, hyperextension, loss of flexion, nerve palsies, pin tract infections, iatrogenic nerve injuries, pin migration, or compartment syndromes (Table 1).
DISCUSSION Wilkins and Rang classify type 2 supracondylar humerus fractures into 2 groups. Type 2a supracondylar humerus fractures are extension-type fractures that have an intact posterior cortex with no rotation. Type 2b extension fractures still have some posterior cortex contact but have a rotational component as well.4,10 The purpose of this study is to report the clinical and radiographic outcomes of Wilkins type 2a supracondylar fractures treated with closed reduction, a single lateral entry pin, and a cast in pronation (Fig. 1). Debate still exists regarding the necessity of pinning of Gartland type 2 supracondylar humerus fractures after a
closed reduction. The sentinel study by Pirone et al6 on the management of displaced extension-type supracondylar fractures suggested that closed reduction and pinning was superior to closed reduction and casting. Additional studies support Pirone’s conclusion.6,11,12 For example, Moraleda et al’s12 study demonstrated that one fourth of patients who had cast treatment alone resulted in cubitus varus deformity. Parikh et al9 reported that about one third of his series of type 2 fractures initially treated with closed reduction and casting alone subsequently lost reduction and needed surgical intervention.6 However, if all patients were initially treated with surgery in his study, then 2/3 of patients would have undergone unnecessary surgery. In contrast, other authors suggested that pinning all type 2 fractures might be unnecessary. For example, Hadlow and colleagues have reported that up to three quarters of patients undergoing pinning for type 2 fractures increases their risk of adverse outcomes such as nerve injury, infection, and anesthetic complications compared with casting alone.12–15 There is also debate on the number of pins, pin size, and entry technique used in the treatment of type 2 supracondylar fractures.4,7 Multiple studies have shown that lateral entry pin fixation is as clinically effective as crossed pin configuration.7,16,17 Pradhan and colleagues demonstrated that increased pin diameter increased fracture stability.18–20 Sorenson and colleagues studied
FIGURE 1. Prereduction AP (A), prereduction lateral (B), postreduction lateral (C), images utilizing a single percutaneous pin. r
2014 Lippincott Williams & Wilkins
www.pedorthopaedics.com |
e55
J Pediatr Orthop
Kish and Hennrikus
pin removal from the elbow in the office in children. They demonstrated that pain increased in direct proportion to number of pins removed. For example, removing 1 pin resulted in the least pain and anxiety.21 Currently, the trend is to treat all type 2 supracondylar humerus fractures with closed reduction and percutaneous pinning with 2 or 3 laterally based pins.6,7 Reports of percutaneous pinning for supracondylar humerus fractures began as early as 1948 by Swenson.22 In the 1990s, Wilkins4 recommended treatment of type 2 supracondylar fractures to be cast immobilization with the arm held in flexion and pronation because the intact posterior cortex provides sufficient stability to prevent loss of reduction when the cast is applied. Pring et al10 also suggest that pronation locks in the periosteum and increases fracture stability. Not all type 2 fractures are the same. Type 2a fractures have intrinsic stability due to the lack of rotation about the posterior cortex. In the past, many authors including Wilkins, Parikh, and Hadlow would treat these fractures with closed reduction but no pinning. However, today, the AAOS guidelines suggest pinning all type 2 fractures. The current study using only 1 pin is a technique that fulfills the spirit of the AAOS guidelines but in a simplified manner. The current study demonstrates that closed reduction of the fracture, fixation with a single, well placed, smooth, lateral entry pin and casting in pronation resulted in excellent outcomes by the Flynn criteria in 14 consecutive patients. In addition, this technique also streamlines pin removal in the office. Prior studies report complication rates following pinning of supracondylar fractures up to 13.8%.23 These complications include infection, pin migration, loss of reduction, compartment syndrome, iatrogenic nerve injury, malunion, and deformity.2,12,13,24–27 In the current study, the complication rate was 0% and all patients achieved Flynn Criteria results of excellent. Specifically, we report no loss of reduction as compared with rates of up to 0.6%,6 and no pin infections as compared with rates of 1% to 6.8%13,24 when using 1 pin for fixation (Table 2). Limitations of this study include the retrospective design and small sample size. The keys to success in using single-pin fixation for type 2a supracondylar fractures are: (1) Proper selection of Wilkins 2a fractures. (2) Near-anatomic closed reduction. (3) Bicortical lateral entry smooth pinning. (4) Brief intraoperative fluoro examination to confirm stability. For example, once the pin is in place, performing a few seconds of continuous fluoro while flexing and extending the elbow allows the physician to be certain the fracture reduction is stable.
TABLE 2. Comparison of Complication Rates Infection (%) Loss of reduction (%) No. patients
Pirone et al6
Bashyal et al13
This Study
2.1 1.3 230
1 0.6 622
0 0 15
e56 | www.pedorthopaedics.com
Volume 34, Number 8, December 2014
(5) Casting in pronation to lock in the medial periosteum and increase stability.
CONCLUSIONS Treatment of supracondylar fractures has evolved from selective pinning of type 2 fractures to pinning all type 2 fractures. The results of the current study demonstrate the efficacy of using a single lateral entry pin for stabilization after reduction of type 2a supracondylar humerus fractures in children. REFERENCES 1. Lee YH, Lee SK, Kim BS, et al. Three lateral divergent or parallel pin fixations for the treatment of displaced supracondylar humerus fractures in children. J Pediatr Orthop. 2008;28:417–422. 2. Memisoglu K, Cevdet Kesemenli C, Atmaca H. Does the technique of lateral cross-wiring (Dorgan’s technique) reduce iatrogenic ulnar nerve injury? Int Orthop. 2011;35:375–378. 3. Silva M, Wong TC, Bernthal NM. Outcomes of reduction more than 7 days after injury in supracondylar humeral fractures in children. J Pediatr Orthop. 2011;31:751–756. 4. Wilkins KE. The operative management of supracondylar fractures. Orthop Clin North Am. 1990;21:269–289. 5. Omid R, Choi PD, Skaggs DL. Supracondylar humeral fractures in children. J Bone Joint Surg Am. 2008;90a:1121–1132. 6. Pirone AM, Graham HK, Krajbich JI. Management of displaced extenstion-type supracondylar fractures of the humerus in children. J Bone Joint Surg. 1988;70A:641–650. 7. Skaggs DL, Hale JM, Bassett J, et al. Operative treatment of supracondylar fractures of the humerus in children. The consequences of pin placement. J Bone Joint Surg. 2001;83A:735–740. 8. Mulpuri K, Hosalkar H, Howard A. AAOS clinical practice guideline: the treatment of pediatric supracondylar humerus fractures. J Am Acad Orthop Surg. 2012;20:328–330. 9. Parikh SN, Wall EJ, Foad S, et al. Displaced type II extension supracondylar humerus fractures: do they all need pinning? J Pediatr Orthop. 2004;24:380–384. 10. Pring ME, Rang M, Wenger DR. Elbow-distal humerus. Chapter 8. In: Rang M, Pring ME, Wenger DR, eds. Rang’s Children’s Fractures. 3rd ed. Philadelphia: Lippincott Williams & Wilkins; 2005;104. 11. Camus T, MacLellan B, Cook PC, et al. Extension type II pediatric supracondylar humerus fractures: a radiographic outcomes study of closed reduction and cast immobilization. J Pediatr Orthop. 2011; 31:366–371. 12. Moraleda L, Valencia M, Barco R, et al. Natural history of unreduced Gartland type-II supracondylar fractures of the humerus in children. J Bone Joint Surg. 2013;95A:28–34. 13. Bashyal RK, Chu JY, Schoenecker PL, et al. Complications after pinning of supracondylar distal humerus fractures. J Pediatr Orthop. 2009;29:704–708. 14. Brauer CA, Lee BM, Bae DS, et al. A systematic review of medial and lateral entry pinning versus lateral entry pinning for supracondylar fractures of the humerus. J Pediatr Orthop. 2007;27:181–186. 15. Hadlow AT, Devane P, Nicol RO. A selective treatment approach to supracondylar fracture of the humerus in children. J Pediatr Orthop. 1996;16:104–106. 16. Skaggs DL, Cluck MW, Mostofi A, et al. Lateral-entry pin fixation in the management of supracondylar fractures in children. J Bone Joint Surg. 2004;86A:702–707. 17. Topping RE, Blanco JS, Davis TJ. Clinical evaluation of crossed-pin versus lateral-pin fixation in displaced supracondylar humerus fractures. J Pediatr Orthop. 1995;15:435–439. 18. Pradhan AK, Hennrikus WL, Armstrong AD, et al. Torsional strength of pin configuration in supracondylar fractures: does pin diameter matter? J Child Orthop. 2014. (In press). 19. Srikumaran U, Tan EW, Erkula G, et al. Pin size influences sagittal alignment in percutaneously pinned pediatric supracondylar humerus fractures. J Pediatr Orthop. 2010;30:792–798. r
2014 Lippincott Williams & Wilkins
J Pediatr Orthop
Volume 34, Number 8, December 2014
20. Gottschalk HP, Sagoo D, Glaser D, et al. Biomechanical analysis of pin placement for pediatric supracondylar humerus fractures: does starting point, pin size, and number matter? J Pediatr Orthop. 2012;32:445–451. 21. Sorenson SM, Hennrikus WL, Slough JM, et al. Pain during office removal of K wires in children. J Pediatr Orthop. 2014. (In press). 22. Swenson AL. The treatment of supracondylar fractures of the humerus by Kirschner wire fixation. J Bone Joint Surg. 1948; 30A:993–997. 23. Yaokreh JB, Gicquel P, Schneider L, et al. Compared outcomes after percutaneous pinning versus open reduction in paediatric supracondylar elbow fractures. Orthop Traumatol Surg Res. 2012;98:645–651.
r
2014 Lippincott Williams & Wilkins
Fixation of Type 2a Supracondylar Humerus Fractures
24. El-Adl WA, El-Said MA, Boghdaddy GW, et al. Results of treatment of displaced supracondylar humeral fractures in children by percutaneous lateral cross-wiring technique. Strategies Trauma Limb Reconstr. 2008;3:1–7. 25. Mai MC, Beck R, Gabriel K, et al. Posterior arm compartment syndrome after a combined supracondylar humeral and capitellar fractures in an adolescent: a case report. J Pediatr Orthop. 2011;31:16–19. 26. Eberl R, Eder C, Smolle E, et al. Iatrogenic ulnar nerve injury after pin fixation and after antegrade nailing of supracondylar humeral fractures in children. Acta Orthop. 2011;82:606–609. 27. Babal JC, Mehlman CT, Klein G. Nerve injuries associated with pediatric supracondylar humeral fractures: a meta-analysis. J Pediatr Orthop. 2010;30:253–263.
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