Abstract
Introduction: Closed reduction with percutaneous pin fixation remains mainstay treatment for displaced supracondylar fractures. Because of documented iatrogenic ulnar nerve injury from medial pin, predilection for placement of lateral pins exist. There has been wide variation in actual starting points. Some studies favour direct lateral epicondyle, extra-articular entry, whereas others advocate capitellar or paraolecranon starting point. We studied the influence of entry point in lateral pinning on the outcome of fractures.
Materials and Methods: We studied 100 patients of Gartland type-3 supracondylar fracture humerus in children treated between March-2014 to March-2017. Patients were divided into two groups of 50 each based on K-wire entry. Group-1 included cases with direct lateral epicondyle entry and group-2 included those with capitellar entry. Radiographic outcomes were assessed based on change in Baumann angle, humerocapitellar angle. The functional results were graded as per Flynn’s criteria.
Results: There was no statistically significant difference between the groups with respect to immediate post-operative Baumann and humerocapitellar angle. But at 4wks follow up group-2 patients showed significantly better Baumann, Humerocapitellar angle (p<0.005). Mean carrying angle at final follow up was 3.4 in group-1 and 7.8 in group-2. As per Flynn criteria, 31 of 50 patients in group-1 had good to excellent results and 46 of 50 patients had good to excellent results.
Discussion: Patients in group-2 with capitellar entry of K-wires showed lesser loss of reduction, significantly better elbow range of motion and carrying angle than those with direct lateral K-wire entry. This is due to the fact that the capitellum acts as a middle column and a wire through it specifically maximizes the spread across the fracture site and engages sufficient bone in both proximal and distal fragments.
Conclusion: The capitellar starting point has stiffer construct compared with direct lateral construct hence lesser chances of loss of reduction, malunion and gives good to excellent functional outcome.
Keywords: Supracondylar, Fracture, humerus, Pinning.
References
- Otsuka NY, Kasser JR. Supracondylar fractures of the humerus in children. J Am Acad Orthop Surg. 1997;5:19–26
- Gartland JJ. Management of supracondylar fractures of the humerus in children. Surg Gynecol Obstet. 1959;109:145–154.
- France J, Strong M. Deformity and function in supracondylar fractures of the humerus in children variously treated by closed reduction and splinting, traction, and percutaneous pinning. J Pediatr Orthop. 1992;12:494–498.
- Bloom T, Robertson C, Mahar AT, et al. Biomechanical analysis of supracondylar humerus fracture pinning for slightly malreduced fractures. J Pediatr Orthop. 2008;28:766–772.
- Hamdi A, Poitras P, Louati H, et al. Biomechanical analysis of lateral pin placements for pediatric supracondylar humerus fractures. J Pediatr Orthop. 2010;30:135–139.
- Kocher MS, Kasser JR, Waters PM, et al. Lateral entry compared with medial and lateral entry pin fixation for completely displaced supracondylar humeral fractures in children. A randomized clinical trial. J Bone Joint Surg Am. 2007;89:706–712.
- Larson L, Firooz bakhsh K, Passarelli R, et al. Biomechanical analysis of pinning techniques for pediatric supracondylar humerus fractures. J Pediatr Orthop. 2006;26:573–578.
- Zionts LE, McKellop HA, Hathaway R. Torsional strength of pin configurations used to fix supracondylar fractures of the humerus in children. J Bone Joint Surg Am. 1994;76:253–256.
- Lee SS, Mahar AT, Miesen D, et al. Displaced pediatric supracondylar humerus fractures: biomechanical analysis of percutaneous pinning techniques. J Pediatr Orthop. 2002;22:440–443.
- Lyons JP, Ashley E, Hoffer MM. Ulnar nerve palsies after percutaneous cross-pinning of supracondylar fractures in children’s elbows. J Pediatr Orthop. 1998;18:43–45
- Lee YH, Lee SK, Kim BS, et al. Three lateral divergent or parallel pin fixations for the treatment of displaced supraco-ndylar humerus fractures in children. J Pediatr Orthop. 2008;28:417–422.
- 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 Am. 2001;83-A:735–740.
- Pirone AM, Graham HK, Krajbich JI. Management of displaced extension-type supracondylar fractures of the humerus in children. J Bone Joint Surg Am. 1988;70:641–650.
- Skaggs DL, Cluck MW, Mostofi A, et al. Lateral-entry pin fixation in the management of supracondylar fractures in children. J Bone Joint Surg Am. 2004;86-A:702–707.
- Herzenberg J, Koreski J, Carroll N, et al. Biomechanical testing of pin fixation techniques for pediatric supracondylar elbow fractures. Orthop Trans. 1988;12:678–679.
- 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.
- Gordon JE, Patton CM, Luhmann SJ, et al. Fracture Stability after Pinning of Displaced Supracondylar Distal Humerus Fractures in Children. J Pediatr Orthop. 2001;21:313–318.
- Shannon FJ, Mohan P, Chacko J, et al. Dorgan’s percutaneous lateral cross-wiring of supracondylar fractures of the humerus in children. J Pediatr Orthop. 2004;24: 376–379.
- Sankar WN, Hebela NM, Skaggs DL, et al. Loss of pin fixation in displaced supracondylar humeral fractures in children: Causes and prevention. J Bone Joint Surg Am. 2007;89:713–717.
- Flynn JC, Matthews JG, Benoit RL. Blind pinning of displaced supracondylar fractures of the humerus in children. Sixteen years’ experience with long-term follow-up. J Bone Joint Surg Am. 1974;56:263-72.
Corresponding Author
Dr Swetha Purohit
Dept of Anaesthesiology, Subbaiah Institute of Medical Sciences,
Purle, NH-13, Shimoga-577222, Karnataka, India
Mob: +91 8151065298, Email: This email address is being protected from spambots. You need JavaScript enabled to view it.
DOI: https://dx.doi.org/10.18535/jmscr/v5i12.131
