Operative fixation is indicated for most type-II and III supracondylar humeral fractures in order to prevent malunion. Medial comminution is a subtle finding that, if treated nonoperatively, is likely to lead to unacceptable varus malunion. Angiography is not indicated for a pulseless limb, as it delays fracture reduction, which usually corrects the vascular problem. A high index of suspicion is necessary to avoid missing an impending compartment syndrome, especially when there is a concomitant forearm fracture or when there is a median nerve injury, which may mask symptoms of compartment syndrome. Lateral entry pins have been shown, in biomechanical and clinical studies, to be as stable as cross pinning if they are well spaced at the fracture line, and they are not associated with the risk of iatrogenic ulnar nerve injury.

Supracondylar humeral fractures in children.

Background: There has been controversy regarding the optimal pin configuration in the management of supracondylar humeral fractures in children. A crossed-pin configuration may be mechanically more stable than lateral pins in torsional loading, but it is associated with a risk of iatrogenic injury to the ulnar nerve. Previous clinical studies have suggested that lateral pins provide sufficient fixation of unstable supracondylar fractures. However, these studies were retrospective and subject to patient-selection bias.

Methods: A displaced supracondylar humeral fracture was fixed with only lateral-entry pins in 124 consecutively managed children. Medical records and radiographs were reviewed to identify any complications, including loss of fracture reduction, iatrogenic ulnar nerve injury, infection, loss of motion of the elbow, and the need for additional surgery. In addition, eight displaced supracondylar humeral fractures that had been reduced and fixed with lateral pins at other institutions and had lost reduction were analyzed to determine the causes of the failures.

Results: Sixty-nine children had a type-2 fracture, according to Wilkins's modification of Gartland's classification system; forty-three (62%) of those fractures were stabilized with two pins and twenty-six (38%), with three pins. Fifty-five children had a type-3 fracture; nineteen (35%) of those fractures were stabilized with two pins and thirty-six (65%), with three pins. A comparison of perioperative and final radiographs showed no loss of reduction of any fracture. There was also no clinically evident cubitus varus, hyperextension, or loss of motion. There were no iatrogenic nerve palsies, and no patient required additional surgery. One patient had a pin-track infection. Our analysis of the eight clinical and radiographic failures of lateral pin fixation that were not part of the consecutive series showed that the loss of fixation was due to fundamental technical errors.

Conclusions: In this large, consecutive series without selection bias, the use of lateral-entry pins alone was effective for even the most unstable supracondylar humeral fractures. There were no iatrogenic ulnar nerve injuries, and no reduction was lost. The important technical points for fixation with lateral-entry pins are (1) maximize separation of the pins at the fracture site, (2) engage the medial and lateral columns proximal to the fracture, (3) engage sufficient bone in both the proximal segment and the distal fragment, and (4) maintain a low threshold for use of a third lateralentry pin if there is concern about fracture stability or the location of the first two pins.

Level of Evidence: Therapeutic study, Level IV (case series [no, or historical, control group]). See Instructions to Authors for a complete description of levels of evidence.

Lateral-entry pin fixation in the management of supracondylar fractures in children

Background Closed reduction and percutaneous pin fixation is the treatment of choice for completely displaced (type-III) extension supracondylar fractures of the humerus in children, although controversy persists regarding the optimal pin-fixation technique. The purpose of this study was to compare the efficacy of lateral entry pin fixation with that of medial and lateral entry pin fixation for the operative treatment of completely displaced extension supracondylar fractures of the humerus in children. Methods This prospective, randomized clinical trial had sufficient power to detect a 10% difference in the rate of loss of reduction between the two groups. The techniques of lateral entry and medial and lateral entry pin fixation were standardized in terms of the pin location, the pin size, the incision and position of the elbow used for medial pin placement, and the postoperative course. The primary study end points were a major loss of reduction and iatrogenic ulnar nerve injury. Secondary study end points included radiographic measurements, clinical alignment, Flynn grade, elbow range of motion, function, and complications. Results The lateral entry group (twenty-eight patients) and the medial and lateral entry group (twenty-four patients) were similar in terms of mean age, sex distribution, and preoperative displacement, comminution, and associated neurovascular status. No patient in either group had a major loss of reduction. There was no significant difference between the rates of mild loss of reduction, which occurred in six of the twenty-eight patients treated with lateral entry and one of the twenty-four treated with medial and lateral entry (p = 0.107). There were no cases of iatrogenic ulnar nerve injury in either group. There were also no significant differences (p > 0.05) between groups with respect to the Baumann angle, change in the Baumann angle, humerocapitellar angle, change in the humerocapitellar angle, Flynn grade, carrying angle, elbow flexion, elbow extension, total elbow range of motion, return to function, or complications. Conclusions With use of the specific techniques employed in this study, both lateral entry pin fixation and medial and lateral entry pin fixation are effective in the treatment of completely displaced (type-III) extension supracondylar fractures of the humerus in children. Level of evidence Therapeutic Level I. See Instructions to Authors for a complete description of levels of evidence.

Lateral entry compared with medial and lateral entry pin fixation for completely displaced supracondylar humeral fractures in children. A randomized clinical trial.

Background Supracondylar distal humerus fractures are one of the most common skeletal injuries in children. The current treatment of choice in North America is closed reduction and percutaneous pin fixation. Often surgeons leave the pins exposed beneath a cast but outside the skin. Great variation exists with respect to preoperative skin preparation, and perioperative antibiotic administration. Few data exist regarding the rate of infection and other complications. The purpose of this study is to review a large series of children to evaluate the rate of infection and other complications. Methods A retrospective review was carried out of all patients treated at our institution over an 11-year period. A total of 622 patients were identified that were followed for a minimum of 2 weeks after pin removal. Seventeen patients had flexion-type fractures, 294 had type II fractures, and 311 had type III fractures. Seventy-four fractures (11.9%) had preoperative nerve deficits with anterior interosseous palsies being the most common (33 fractures, 5.3%). Preoperative antibiotics were given to 163 patients (26.2%). Spray and towel draping were used in 362 patients, paint and towel draping were used in 65 patients, alcohol paint and towel draping were used in 146 patients, and a full preparation and draping were used in 13 patients. The pins were left exposed under the cast in 591 fractures (95%), and buried beneath the skin in 31 fractures (5.0%). A medial pin was placed in 311 fractures with a small incision made to aid placement in 18 of these cases. Results The most common complication was pin migration necessitating unexpected return to the operating room for pin removal in 11 patients (1.8%). One patient developed a deep infection with septic arthritis and osteomyelitis (0.2%). Five additional patients had superficial skin infections and were treated with oral antibiotics for a total infection rate of 6 of 622 patients (1.0%). One patient ultimately had a malunion and 4 others returned to the operating room for repeat reduction and pinning. Three patients developed compartment syndromes. Ulnar nerve injury was rare with only 1 postoperative ulnar nerve injury occurring in 311 patients treated with a medial pin (0.3%). Conclusions Closed reduction with percutaneous pinning is effective and has a low complication rate with a very low rate of infection even when simple betadine preparation and towel draping are used. Preoperative antibiotics seem to have little effect on infection rate. Level of evidence Level III retrospective comparative study.

Complications after pinning of supracondylar distal humerus fractures.

Purpose: The Wilkins-modified Gartland classification of pediatric supracondylar humerus fractures does not consider coronal or sagittal obliquity. The purposes of our study were (1) to identify and describe fracture characteristics with unique properties and (2) to propose a fracture classification system that can be reproduced reliably. Methods: We retrospectively studied 203 consecutive displaced pediatric extension-type supracondylar humerus fractures treated operatively from January 1998 to January 2003. Fracture characteristics (eg, coronal and sagittal obliquity, postoperative alignment), type of surgical treatment, outcome, and complications were assessed and analyzed statistically with Student t test and a receiver operating characteristic curve. Significance was defined as P < 0.05. We incorporated significant cutoff values for fracture obliquity into our classification scheme and tested the classification's interobserver and intraobserver reliability. Results: We identified 4 coronal (typical transverse, medial oblique, lateral oblique, and high fractures) and 2 sagittal (low sagittal and high sagittal) subtypes with significantly different characteristics and outcome. Compared with fractures with coronal obliquity of less than 10 degrees, fractures with coronal obliquity of 10 degrees or greater were associated with significantly more comminution and rotational malunion. Compared with fractures with sagittal obliquity of less than 20 degrees, fractures with sagittal obliquity of 20 degrees or greater were associated with a significantly higher incidence of additional injuries and were more likely to result in extension malunion. Analysis of the interobserver and intraobserver reliability for our system identified correlation coefficients ranging from 0.772 to 0.907 and 0.860 to 0.899, respectively. Conclusions: Because pediatric extension-type supracondylar humerus fractures vary significantly in terms of characteristics, identification of sagittal oblique and coronal oblique angles may have an important role in surgical decision making and may impact outcomes.

Patterns of pediatric supracondylar humerus fractures

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).

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

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