In Children with Supracondylar Humeral Fractures, Crossed Pins Increased Fracture Stability Compared with Lateral Pins

Otsuka, Norman Y. MD

Journal of Bone & Joint Surgery - American Volume:
doi: 10.2106/JBJS.16.00884
Evidence-Based Orthopaedics
Author Information

1The Children’s Hospital at Montefiore, Bronx, New York

Article Outline

Abdel Karim M, Hosny A, Nasef Abdelatif NM, Hegazy MM, Awadallah WR, Khaled SA, Azab MA, A ElNahal W, Mohammady H. Crossed wires versus 2 lateral wires in management of supracondylar fracture of the humerus in children in the hands of junior trainees. J Orthop Trauma. 2016 Apr;30(4):e123-8.

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Question:

In children requiring closed reduction and percutaneous pinning for supracondylar humeral fractures, what is the relative effectiveness of a crossed-pin configuration compared with 2 lateral pins?

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Design:

Randomized (allocation concealed), unblinded, controlled trial with 6 months of follow-up.

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Setting:

Level-I trauma center of a university hospital in Cairo, Egypt.

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Patients:

60 children (mean age, 5.1 years; 70% boys) who were <10 years of age had unilateral type-II or III supracondylar humeral fractures (57 extension-type and 3 flexion-type injuries; 53 Gartland type-III and 7 type-II injuries) and were scheduled for closed reduction and Kirschner wiring under general anesthesia. Exclusion criteria were undisplaced Gartland type-I fractures; open fractures; or fractures associated with vascular injury, compartment syndrome, or preoperative ulnar nerve injury. All patients completed follow-up.

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Intervention:

Percutaneous pinning with use of a crossed configuration of a medial-entry pin and a lateral-entry pin (n = 30) or 2 lateral-entry pins (n = 30). Standard fluoroscopy-guided fracture reduction techniques were used. Surgical procedures were performed by junior trainees (in Year 2 or 3 of a 3-year residency program), assisted by a Year-1, 2, or 3 resident and supervised by an attending surgeon. Once pins were placed and the fracture was reduced, the pins were bent to lie against the skin and were cut, leaving 2 to 3 cm exposed, to prevent pin migration and aid in removal after healing.

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Main outcome measures:

The outcomes were postoperative fracture stability on radiographs, range of motion, ulnar nerve injury, and pin-track infection.

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Main results:

The crossed-pin configuration improved postoperative fracture stability and full range of motion at 2 months and did not differ from the lateral-pin configuration in terms of full range of motion at 6 months, ulnar nerve damage, or pin-track infection (Table).

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Conclusion:

In children who were managed with closed reduction and percutaneous pinning by junior trainees for the treatment of supracondylar humeral fractures, a crossed-pin configuration improved fracture stability compared with the use of 2 lateral-entry pins.

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Source of funding:

Not stated.

For correspondence: Dr. M. Abdel Karim, Cairo University Hospitals, Egypt. E-mail address: mabdelkarim@hotmail.com

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Commentary

The treatment of supracondylar humeral fractures is relevant to all orthopaedic surgeons and continues to be refined as research studies are published1, including the randomized controlled trial by Abdel Karim and colleagues. The Appropriate Use Criteria developed by the American Academy of Orthopaedic Surgeons include pin configuration for the treatment of such fractures2.

There are several concerns with the trial by Abdel Karim and colleagues. The procedures were performed by junior trainees assisted by junior trainees; the extent of supervision and guidance by the attending surgeons is unknown. The level of experience of junior trainees in the treatment of supracondylar humeral fractures was unclear; inexperienced trainees may perform a number of passes for pin placement. The authors noted that the crossed-pin configuration may be more stable than lateral placement when the procedure is performed by less-experienced junior trainees. Other confounding factors that may affect the pinning technique, such as time to procedure, swelling, and time of procedure, were not mentioned.

One outcome of pinning was displacement, which included translation, angulation, or rotation at the fracture site. Although the stability of the fracture was discussed, no criteria for stability (such as displacement) were reported.

Other studies have compared lateral-pin fixation with crossed-pin fixation for the treatment of displaced supracondylar humeral fractures in children, with a meta-analysis demonstrating an increased risk for ulnar nerve injury in association with crossed pins3. The value of the trial by Abdel Karim and colleagues is limited by the participation of junior trainees and the lack of a clear definition of the outcome. As such, the findings of this trial have limited implications for the treatment of supracondylar humeral fractures.

Disclosure: The author indicated that no external funding was received for any aspect of this work. The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article.

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References

1. Abzug JM, Herman MJ. Management of supracondylar humerus fractures in children: current concepts. J Am Acad Orthop Surg. 2012 ;20(2):69–77.
2. Ibrahim T, Hegazy A, Abulhail SI, Ghomrawi HM. Utility of the AAOS Appropriate Use Criteria (AUC) for pediatric supracondylar humerus fractures in clinical practice. J Pediatr Orthop. 2015 . [Epub ahead of print].
3. Zhao JG, Wang J, Zhang P. Is lateral pin fixation for displaced supracondylar fractures of the humerus better than crossed pins in children? Clin Orthop Relat Res. 2013 ;471(9):2942–53. Epub 2013 May 8.
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