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Pinning of supracondylar fractures in children – Strategies to avoid complications
Accepted Manuscript Title: Pinning of Supracondylar Fractures in Children – Strategies to avoid Complications Authors: Markus Rupp, Christoph Sch¨afer, Christian Heiss, Volker Alt PII: DOI: Reference:
S0020-1383(19)30160-3 https://doi.org/10.1016/j.injury.2019.03.042 JINJ 8117
To appear in:
Injury, Int. J. Care Injured
Received date: Accepted date:
5 February 2019 28 March 2019
Please cite this article as: Rupp M, Sch¨afer C, Heiss C, Alt V, Pinning of Supracondylar Fractures in Children – Strategies to avoid Complications, Injury (2019), https://doi.org/10.1016/j.injury.2019.03.042 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Pinning of Supracondylar Fractures in Children –
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Strategies to avoid Complications
Markus Rupp, MD Christoph Schäfer, MD
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Christian Heiss, MD
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From the: Department of Trauma Surgery University Hospital Giessen-Marburg GmbH Campus Giessen 35385 Giessen Germany
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Volker Alt, MD, PhD*
Corresponding author:
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Prof. Dr. med. Dr. biol. hom. Volker Alt Department of Trauma Surgery University Hospital Giessen-Marburg, Campus Giesen Rudolf-Buchheim-Str. 7 35392 Giessen Germany
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email: [email protected]
Highlights
This paper
reviews current treatment principles for paediatric supracondylar fractures
gives treatment recommendations for this frequent injury
helps to avoid complications, particularly to avoid re-operations and to avoid ulnar
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nerve injury
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Abstract
In the pediatric population supracondylar humerus fracture (SHF) is one of the most common injuries. Diagnosis is based on inspection and conventional radiography. SHFs should be
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classified according to the modified Gartland classification, which guides treatment. Nondisplaced or minimally displaced fractures (Gartland type-I) should be treated non-
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operatively, completely displaced type III fractures require closed reduction and K-wire
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fixation. In type-II fractures, important landmarks, such as the anterior humeral line (Roger´s
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line), the shaft-physeal angle (Baumann´s angle) and the shaft condylar angle should be considered to guide treatment. Special attention has to be paid for potential rotational
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dislocation, which is indicated by a ventral spur. In such cases surgery is necessary. The degree of acceptable extension malpositioning depends on patient´s age. In 10-year-old children fractures with a shaft condylar angle of more than 15° are still suitable for nonoperative therapy. Timing for surgery is controversially discussed. Postponing surgery to the
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next day seems reasonable if absence of pain, intact soft tissue and normal neurovascular status are present. Neurovascular complications are not uncommon, especially in Gartland
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type-III fractures and in cases with additional forearm injuries. A white hand without palpable pulse needs emergency surgery, the management of the pulseless pink hand is still
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controversially discussed. Different operative techniques exist for surgical treatment. The golden standard is closed reduction and percutaneous K-wire pinning. Crossed pinning seems to achieve best biomechanical stability. Since ulnar nerve injuries are reported to occur in 6% after medially inserting K-wires, lateral divergent insertion of two K-wires has been compared to crossed pinning fixation in several randomized controlled trials. Meta-analysis demonstrated a higher risk for ulnar nerve injury for the crossed pinning technique while risk for loss of fixation was higher in lateral only pinning. In both cases, K-wires should be removed 3-6 weeks after surgery with consolidation of the fracture. Clinical and radiological
follow-up should be carried out at 3 weeks post fracture fixation to rule out loss of reduction. If this should occur, early revision surgery has been demonstrated beneficial.
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Keywords: supracondylar humerus fracture, K-wire, ulnar nerve, pinning
Background
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Supracondylar humerus fracture (SHF) is the most common fracture of the elbow in the pediatric population. While distal humeral fractures account for about 16% of all fractures in
long bones during skeletal development 1, 50-70% of all elbow fractures in children are SHF . SHF are usually the result of falls on outstretched hands. This mechanism is widely known
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as FOOSH (fall on out-stretched hand) mechanism. Patients suffering from SHF are usually
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within their first decade of life with an age peak in the 5th and 6th year of life. This makes
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examination and diagnosis challenging especially in not obvious case3. To avoid unnecessary
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pain, clinical examination concentrates on inspection of the injured site. It is obligatory to check peripheral circulation, motor function and sensitivity. However, the essential cornerstone of diagnosis is conventional radiography. X-ray images of the elbow are taken in
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two planes by default. If there is any suspicion of additional forearm fracture, further X-rays
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of the forearm in two planes should be initiated (Figure 2) as 5% of SHF are associated with additional forearm fractures. Higher rates of neuropraxia up to 23% and pulselessness of the
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hand in 6%-9% underline the value of limited physical examination in association with radiography 4. In these injuries, successful therapy depends on depicting a growth prognosis. Spontaneous correction but also growth disorders are both possible if the remaining growth period is long enough. Thus, fracture characteristics have to be considered together with age, sex and development status for estimation of remaining growth potential. For the elbow and thus for
SHF, both the distal humeral growth plates and the proximal forearm growth plates are only responsible for 20% of longitudinal growth in their segment 5. Therefore, the risk of growth disorders around the elbow is low as well as the potential of spontaneous correction. Hence, compared to the proximal upper arm and distal forearm, even a small degree of displacement usually requires surgical therapy with appropriate anatomical reduction.
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The Gartland three staged classification system of SHF has been widely used in pediatric trauma care 6. The modified version, which was proposed by Wilkins in 1981, has prevailed
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in the Anglo-American community: type-I: undisplaced fracture, type-IIa: greenstick fracture
with posterior angulation (Figure 1), type-IIb: greenstick fracture with malrotation and
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posterior angulation (Figure 2), type-III: completely displaced fracture (Figure 3) 7. Its major
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advantage is its low intra-observer and interobserver variability 8. In 2006, Leitch et al.
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proposed a fourth type modifying Gartland´s classification. They described type-IV as a rare
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multidirectional unstable fracture due to a lack of posterior periosteal hinge. Instability results in displacement into flexion and/or extension 9. The most used classification system in the
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German speaking sphere is the four staged classification system of von Laer, which is quite similar to the modified Gartland classification: type-I: non displaced, type-II: displaced
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without rotation, type-III: displaced with rotation, type-IV: completely displaced 5.
Anatomical landmarks and radiological assessment
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Correct assessment of radiographs is the cornerstone of successful therapy. Knowledge of anatomical landmarks of both lateral and anterior-posterior projections is a basic prerequisite. Trauma surgeons should be aware of the appearance of secondary ossification centers to evaluate the pediatric elbow on X-rays. CRITOE (capitellum, radial head, internal [medial] epicondyle, trochlea, olecranon, external [lateral] epicondyle) has been established as
mnemonic. The ossification center of the capitellum appears at the age of one. Afterwards, each ossification center appears about 2 years after another (Figure 4) 3. The most important lateral landmark is the anterior humeral line, which is also called Roger´s line. It should pass through the middle third of the ossification center of the capitellum. The second important line is the coronoid line. The anterior border of the coronoid process should barely touch the
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anterior portion of the lateral condyle (Figure 5). A further landmark on lateral X-rays is the shaft condylar angle (SCA). This angle measures 40 degrees between the long axis of the
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humerus and the long axis of the lateral condyle. The teardrop, which is seen on lateral radiographs, is formed by the posterior margin of the coronoid fossa, the anterior margin of the olecranon fossa and the superior border of the ossification center of the capitellum (Figure
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6). For all projections, lateral, oblique and anterior-posterior (AP), the line down the middle
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of the radial neck and shaft should intersect the capitellum at its middle third. The “shaft-
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physeal” angle (or Baumann´s angle) is a further important AP landmark. It is formed
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between the line parallel to the humerus shaft and a line parallel to the lateral physis.
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Baumann´s angle normally measures 72 degrees (range 64 to 81 degrees) (Figure 7). In subtle cases with unapparent fractures, the posterior fat pad sign is indicative for elbow fractures (76% of all cases). In such cases, SHF are the most common elbow fractures as well (53% of
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. For correct assessment of radiography, the outstanding significance of rotation
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though
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all fractures). The anterior fat pad is a normal feature of lateral X-rays of flexed elbows,
displacement in SHF must be understood. In 1979, Lutz von Laer described the importance of
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rotational dislocation in supracondylar fractures. In a retrospective case series of supracondylar fractures, he could demonstrate that lateral tilting was in any case the result of rotation displacement, whereas lateral compression was not the reason for that. Thus, von Laer concluded that it is mandatory to identify fractures with rotational errors since rotational stable surgical correction is necessary
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. A ventral spur is the best radiological feature to
detect rotational dislocation (Figure 2A). Keeping this in mind, the modification of Gartland´s
classification by Wilkins and von Laer, are of practical relevance and well comprehensible. The physiological cubitus valgus measures 5-15° and is called carrying angle. In case of posttraumatic sequelae cubitus varus is possible. This “gunstock deformity” may result in poor cosmesis and in rare but serious cases in functional deficiencies. Then, hitting the hips
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with the swinging arms while walking hampers the patients in everyday life.
Indication and timing for surgery
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Type-I SHF are undisplaced or only minimally displaced (<2mm). For those fractures non
operative treatment is ideal. Injuries which are classified as type-III fractures have to be treated surgically. The posterior cortex has lost its integrity in such fractures. Malpositioning
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in extension in the sagittal and rotation in the transverse plane needs surgical correction
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(Figure 2). In addition, the multidirectional instability staged in the modified Gartland
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classification as type-IV fracture needs surgical therapy as well. Nonetheless, a wide range of
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fractures fall under the category of type-II fractures. These range from fractures with mild
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extension without rotational and coronal malalignment to fractures with cortical contact but severe dislocation. Thusly, treatment indications differ within this category. Non-operative treatment is an option if no rotational deformity, coronal malalignment and significant 12
. The degree of acceptable extension
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extension of the distal fragment is detectable
malpositioning depends on the age of the patients. In toddlers, which are under 3-years-old,
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remodeling potential allows for non-operative treatment when the humeral line brushes the
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anterior capitellum. Eight to ten-year-old patients only still have 10% growth of their distal humerus
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. Fractures with isolated extension and an SCA of >15 degrees are regarded
suitable for conservative treatment 12. Fractures with more isolated extension malpositioning require at least closed reduction. Afterwards, immobilization with either a cast or a cuff and collar is necessary. A radiological follow-up after 7 days is obligatory. If loss of reduction occurs, surgery with reduction and percutaneous pinning of the fracture can be performed.
Within 7 days after trauma, reduction and percutaneous pinning do not affect long-term alignment
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. In case of above-mentioned radiological criteria for conservative treatment and
additional soft tissue swelling and hematoma, immobilization in flexion larger than 90° may not be reasonable. Flexion larger than 90° results in increased compartment pressure in the forearm
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. Thus, surgical treatment which enables immobilization in 90° or less flexion
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should be considered early to avoid compartment syndrome. Finally, knowledge of factors
associated with successful non-operative therapy of Gartland type-II fractures enable
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conservative treatment. Consequently, unnecessary surgeries in up to 72% of all SHF type-II fractures as well as associated operative and iatrogenic complications can be avoided 16.
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If surgery is indicated, the question raises, when it is the best time. Higher complication rates
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. For after-hours surgery in supracondylar humerus fractures, poorer
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other surgical fields
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for surgeries at nighttime are controversially discussed in orthopedic trauma care as well as in
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. However, a higher
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fixation rates compared to daytime procedures were demonstrated
conversion rate to open reduction and internal fixation was reported if surgery was delayed 21
. Experience and high volume surgery are crucial factors for
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for more than 12 hours
successful operative management of supracondylar fractures
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. Thus, as long as no
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prospective multicentered study enlightens our knowledge on this subject, we recommend that timing of surgery should be individually determined. Absence of pain after immobilization,
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intact soft tissue and normal neurovascular status allow postponing surgery to the next day.
Concomitant vascular and neurological injuries – surgical emergencies? Vascular and neurological complications most frequently occur in type-III fractures. Neurological injuries can be found in 10% to 20%
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whereas vascular injuries occur in up to
20% 24. Assessment of motor function and sensation is very difficult in injured, pain-troubled children. Nevertheless, correct assessment prior to surgery is essential since postoperative
neurological deficits are more common than initially on admission
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. Visible soft tissue
injury is associated with neurovascular injury. Elbow swelling, tenting, puckering and ecchymoses are significantly associated with nonpalpable pulses and neurological injury
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.
Additional ipsilateral forearm fracture should prompt the surgeon to assess the neurovascular status even more carefully since neurovascular injuries are almost twice as often with
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associated forearm fractures compared to isolated SHF 4. Color of the hand (pink vs. white), temperature and edema are characteristics to assess peripheral circulation. Palpation of the
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radial pulse as well as testing of the capillary refill (<2 seconds) are obligatory. An increase in
pain medication may be a sign of ischemia and emerging compartment syndrome. Additional diagnostics such as doppler ultrasonography and prereduction angiography are not
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recommended and should not delay surgical treatment. Placing the arm in 30-40 degrees
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flexion and application of gentle traction may help to improve circulation
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. A white hand
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without palpable pulse needs emergency surgery. Acute ischemia requires open reduction and
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identifying of the brachial artery. However, the management of pulseless pink hands is
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controversially discussed due to lack of high-quality clinical studies. Interestingly, no guidelines exist in relation to this matter. There is agreement that urgent, but non-emergency surgery in terms of closed reduction and internal fixation is necessary 27. Several studies and
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reviews demonstrate that radial pulses usually occur after closed reduction during 24, 28-30
. A spasm of the brachial artery rather than a structural injury
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postoperative follow-up
is regarded as reason of the success of watchful waiting in those cases 24. In contrast to those
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findings, White et al. reported 70% brachial artery injuries in “pink pulseless hands” after SHF and not surprisingly he recommended a more aggressive vascular exploration and repair 31
. If the circulation deteriorates and forearm compartment occurs in the course of the
treatment, surgical exploration of the brachial artery becomes inevitable. Neurological impairment can be a result of an injury of one or more of the three major nerves. The median nerve and the anterior interosseous nerve are most often involved in Gartland type-III
fractures. They account for over 60% of all neurological injuries. However, the involvement depends on fracture dislocation. Posterolateral dislocation predisposes median nerve injury, whereas posteromedial dislocation is related to radial nerve injury 23. Injury of the ulnar nerve is most often iatrogenic. Ulnar nerve injuries result in up to 6% by medially inserted k-wires 25
. If postoperative ulnar nerve damage occurs, revision of the k-wire and neurolysis seems
ulnar nerve palsies
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logical. However, spontaneous recovery was demonstrated in a case series of postoperative
. Complete remission after forty-nine days (range, two to 224 days) for 33
. Spontaneous recovery of median and
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the anterior interosseous nerve was demonstrated
radial nerve is observed as well. Median time to nerve recovery was 2.3 months (range 1.3 to 3.7 months). After 3 months, 60% and after 6 months 90% of the affected patients
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experienced recovery of the affected nerves. Shore et al. could demonstrate that median nerve
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recovery was fastest and radial nerve recovery lasts 30% longer than the one of the median
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nerve. Multiple nerve injuries take 54% longer to recover than single median nerve injuries34.
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Reports of complete resolution of injuries of all 3 major nerves in patients with closed SHF
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and consecutive closed reduction and k-wire fixation, underline the need of patience of
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surgeons, parents and patients to await nerve recovery 35.
Operative techniques
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Closed reduction and percutaneous pinning are the golden standard of any displaced SHF in
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children. However, techniques of percutaneous pinning are controversially discussed. On the one hand primary stability has to be achieved to avoid loss of reduction. On the other hand, iatrogenic damage with associated long-term impairment has to be minimized. Crossed pinning provides the biomechanically most stable construct using to k-wires (Figure 1)
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.
However, iatrogenic ulnar nerve injury due to the medially inserted k-wires appears in up to 6%
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. While ulnar nerve injury in lateral pinning technique appears about 5 times rarer
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,
the “lateral only” technique resulted in 3.4% in median nerve neuropraxia (Figure 2)
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. The
latest meta-analysis of Dekker and colleagues included seven randomized control trials (RCT) and six prospective comparative cohorts including in total 1158 patients. All studies were published between 2000 and 2014. They found similar loss of reduction rates in both groups (crossed pinning 11.6% vs lateral pinning 12.4%). Ulnar nerve injury was more often in the 39
. In their meta-
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crossed k-wire group (4.1%) compared to lateral entry pin fixation (0.3%)
analysis from 2012, Woratanarat et al. analyzed 18 studies published through September 2007
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representing 1615 children. Cross pinning had a 40% lower risk of loss of fixation, but a 400% higher risk of ulnar nerve injury. Late deformity and poor function were similar for
both pinning groups. Median or radial nerve injury was observed only in lateral to medial pin
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insertion. Revision surgery for loss of fixation (1.3% for crossed and 2.1% for lateral pinning)
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and non-recovered ulnar nerve injury (1% for crossed pins only) were similar
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. Zhao et al.
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performed a meta-analysis of RCTs from 1966 to 2012. Based on 7 RCTs with 512 patients,
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they concluded that crossed pinning fixation was more at risk for iatrogenic ulnar nerve injury
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than lateral pinning technique. No difference in radiographic outcomes, function and other complications were found, though
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. Not surprising, the fracture morphology plays a major
role for stability. Kwak et al. postulated a loss of stability due to lesser separation of lateral
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entry pins in case of medial wall comminution 42. Reisoglu et al. came to the same conclusion 43
. The adaption of pin configuration
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and postulated crossed entry pin fixation in such cases
to fracture characteristics seems reasonable. Bauer and coworkers describe intraoperative
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internal rotation stress testing after insertion of two lateral entry pins. If rotational instability is determined intraoperatively, an additional medially inserted k-wire was applied in a miniopen approach. Thus, ulnar nerve injury as well as reoperation due to loss of reduction could be avoided in Gartland type-III SHF 44. In our opinion, this mini-open approach for displaying the ulnar nerve is essential for crossed pinning techniques. In 2005, Green could demonstrate that no ulnar nerve injuries are to be expected with this approach, either 45. However, safe and
reliable closed techniques in elbow extension 46, elbow flexion with a thumb placed over the medial epicondyle
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and even nerve monitoring during pin insertion
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are reported in
literature. Hitherto, meta-analyses summarizing ulnar nerve injuries did not differ between medial entry pin fixation techniques. The classical crossed and lateral two pin techniques have undergone several modifications to improve biomechanical stability and reduce risk of
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iatrogenic nerve injury. Modification of crossed pinning with lateral insertion of both k-wires is possible. Dorgan´s lateral percutaneous cross-wiring of supracondylar fractures could
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demonstrate the same functional outcome as in standard cross-wiring without ulnar nerve injuries 49, 50_ENREF_50. However, the radial nerve could be injured by inserting the proximal k-wire
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. Hamdi et al. examined different lateral pin configurations in an experimental
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biomechanical setting. Their group could demonstrate that a lateral pin parallel to the humeral
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cortex and a diverging pin crossing the fracture level at the medial edge of the coronoid fossa
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result in the optimum fixation using two lateral entry pins52. Biomechanical studies could not
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demonstrate a difference of crossed pin fixation and the lateral pin fixation, which was
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recommended by Hamdi et al. unless medial column comminution is present. In such cases, a three lateral pin construct was not significantly different compared to the standard crossed pin
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construct in the presence of medial comminution 53. For high metaphyseal-diaphyseal junction fractures, elastic stable intramedullary nail (ESIN)
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insertion is an elegant way of treatment. ESINs provide the best biomechanical stiffness in an experimental setup and allow cast free aftercare in the clinical setting. In more distal SHF,
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Kamara et al. could demonstrate that three crossed pinning (one medial and two lateral pins) could achieve best biomechanical stability (Figure 3), whereas two crossed and three lateral pinning techniques yielded comparable stiffness 54. Regarding infection rates, it does not seem to matter if k-wires are buried under the skin or not
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. However, non-buried pins avoid a
second surgery and pin removal is possible during postoperative aftercare without additional general anaesthesia. When stability is not achieved by closed reduction and percutaneous
pinning, external fixation is an option to overcome problems associated with type-III SHF. Rigid stability allows elbow motion and ulnar nerve injury is unlikely through a lateral approach. Perpendicular application of the Schanz pins is recommended. Thus, a joystick technique is possible for closed reduction. A further advantage is the possibility to compress the lateral condylar column which prevents secondarily medial column collapse 56. Initially, a
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retrograde k-wire which was inserted from the radial side was recommended by Slongo 56. An additional ulnar-sided k-wire has been shown to be superior to a radially inserted k-wires for 57
. Again, a mini open technique is
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anti-rotation purposes with external fixation
recommended. When open reduction is necessary, medial, lateral and ventral approaches are possible. A dorsal approach should be obviated since the blood supply for the epiphysis 58
. A major benefit of the ventral approach is the exploration of the
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comes from dorsal
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transverse incision of the elbow crease.
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brachial artery and the median nerve. A cosmetically appealing result is achieved by a
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Aspects of aftercare
K-wires are removed 3-6 weeks after surgery with consolidation of the fracture.
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Immobilization of the elbow is necessary for this period. If k-wires are not buried, daily pin site care should be avoided. It is associated with higher infection rates, especially during
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summer months
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. The postoperative follow-up should assess potential loss of reduction.
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Clinically malalignment is hard to assess when the arm is placed in a cast with the elbow flexed at 90 degrees. Therefore, X-ray postoperative control is recommended. If a coronal or sagittal plane deformity of more than 10 degrees is determined, revision surgery should be considered. Or and colleagues demonstrated that early revision within 3 weeks of initial reduction and fixation is a sound option if malalignment is realized during this period of postoperative aftercare. Thus, malunion and consecutive corrective osteotomies can be
avoided by early revision surgery
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. However, the weakness of this study is the lack of a
comparative group and small volume in numbers. Nevertheless, a clinical and radiological 3
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weeks follow-up examination is reasonable against this background.
Conclusion
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SHF are common fractures and surgeons have to deal with best treatment strategies. Clinical
and radiological assessment are the mainstay of non-operastive and surgical treatment.
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Indication for surgery in SHF type-II should be based on radiological characteristics,
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especially rotational displacement must not be overlooked. Percutaneous pinning is possible
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in many different ways. Ulnar nerve injury is a major risk in traditional crossed pinning
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technique. A mini-open approach is an established way to avoid ulnar nerve injury. Lateral entry pin fixation needs divergent pin placement. Additional pinning, either lateral or medial,
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improves biomechanical stability. External fixators, ESINs and open reduction are further
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treatment possibilities in rare but challenging cases.
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30. Matuszewski Ł. Evaluation and management of pulseless pink/pale hand syndrome coexisting with supracondylar fractures of the humerus in children. Eur J Orthop Surg Traumatol. 2014;24:14011406. 31. White L, Mehlman CT, Crawford AH. Perfused, pulseless, and puzzling: a systematic review of vascular injuries in pediatric supracondylar humerus fractures and results of a POSNA questionnaire. J Pediatr Orthop. 2010;30:328-335. 32. Kalenderer O, Reisoglu A, Surer L, Agus H. How should one treat iatrogenic ulnar injury after closed reduction and percutaneous pinning of paediatric supracondylar humeral fractures? Injury. 2008;39:463-466. 33. Barrett KK, Skaggs DL, Sawyer JR, Andras L, Moisan A, Goodbody C, et al. Supracondylar humeral fractures with isolated anterior interosseous nerve injuries: is urgent treatment necessary? J Bone Joint Surg Am. 2014;96:1793-1797. 34. Shore BJ, Gillespie BT, Miller PE, Bae DS, Waters PM. Recovery of Motor Nerve Injuries Associated With Displaced, Extension-type Pediatric Supracondylar Humerus Fractures. J Pediatr Orthop. 2017. 35. Khademolhosseini M, Rashid AHA, Ibrahim S. Nerve injuries in supracondylar fractures of the humerus in children: is nerve exploration indicated? J Pediatr Orthop B. 2013;22:123-126. 36. Feng C, Guo Y, Zhu Z, Zhang J, Wang Y. Biomechanical analysis of supracondylar humerus fracture pinning for fractures with coronal lateral obliquity. J Pediatr Orthop. 2012;32:196-200. 37. Brauer CA, Lee BM, Bae DS, Waters PM, Kocher MS. 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. 38. Babal JC, Mehlman CT, Klein G. Nerve injuries associated with pediatric supracondylar humeral fractures: a meta-analysis. J Pediatr Orthop. 2010;30:253-263. 39. Dekker A, Krijnen P, Schipper I. Results of crossed versus lateral entry K-wire fixation of displaced pediatric supracondylar humeral fractures: A systematic review and meta-analysis. Injury. 2016;47:2391-2398. 40. Woratanarat P, Angsanuntsukh C, Rattanasiri S, Attia J, Woratanarat T, Thakkinstian A. Metaanalysis of pinning in supracondylar fracture of the humerus in children. J Orthop Trauma. 2012;26:48-53. 41. Zhao J-G, 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;471:2942-2953. 42. Kwak YH, Kim J-h, Kim Y-C, Park K-B. Medial comminution as a risk factor for the stability after lateral-only pin fixation for pediatric supracondylar humerus fracture: an audit. Ther Clin Risk Manag. 2018;14:1061. 43. Reisoglu A, Kazimoglu C, Hanay E, Agus H. Is pin configuration the only factor causing loss of reduction in the management of pediatric type III supracondylar fractures? Acta Orthop Traumatol Turc. 2017;51:34-38. 44. Bauer JM, Stutz CM, Schoenecker JG, Lovejoy SA, Mencio GA, Martus JE. Internal Rotation Stress Testing Improves Radiographic Outcomes of Type 3 Supracondylar Humerus Fractures. J Pediatr Orthop. 2016. 45. Green DW, Widmann RF, Frank JS, Gardner MJ. Low incidence of ulnar nerve injury with crossed pin placement for pediatric supracondylar humerus fractures using a mini-open technique. J Orthop Trauma. 2005;19:158-163. 46. Edmonds EW, Roocroft JH, Mubarak SJ. Treatment of displaced pediatric supracondylar humerus fracture patterns requiring medial fixation: a reliable and safer cross-pinning technique. J Pediatr Orthop. 2012;32:346-351. 47. Shim JS, Lee YS. Treatment of completely displaced supracondylar fracture of the humerus in children by cross-fixation with three Kirschner wires. J Pediatr Orthop. 2002;22:12-16. 48. Shtarker H, Elboim-Gabyzon M, Bathish E, Laufer Y, Rahamimov N, Volpin G. Ulnar nerve monitoring during percutaneous pinning of supracondylar fractures in children. J Pediatr Orthop. 2014;34:161-165.
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49. Dučić S, Radlović V, Bukva B, Radojičić Z, Vrgoč G, Brkić I, et al. A prospective randomised nonblinded comparison of conventional and Dorgan’s crossed pins for paediatric supracondylar humeral fractures. Injury. 2016;47:2479-2483. 50. Queally JM, Paramanathan N, Walsh JC, Moran CJ, Shannon FJ, D'Souza LG. Dorgan's lateral crosswiring of supracondylar fractures of the humerus in children: A retrospective review. Injury. 2010;41:568-571. 51. Gangadharan S, Rathinam B, Madhuri V. Radial nerve safety in Dorgan’s lateral cross-pinning of the supracondylar humeral fracture in children: a case report and cadaveric study. J Pediatr Orthop B. 2014;23:579-583. 52. Hamdi A, Poitras P, Louati H, Dagenais S, Masquijo JJ, Kontio K. Biomechanical analysis of lateral pin placements for pediatric supracondylar humerus fractures. J Pediatr Orthop. 2010;30:135-139. 53. Chen TL-w, He C-q, Zheng T-q, Gan Y-q, Huang M-x, Zheng Y-d, et al. Stiffness of various pin configurations for pediatric supracondylar humeral fracture: a systematic review on biomechanical studies. J Pediatr Orthop B. 2015;24:389-399. 54. Kamara A, Ji X, Liu T, Zhan Y, Li J, Wang E. A comparative biomechanical study on different fixation techniques in the management of transverse metaphyseal-diaphyseal junction fractures of the distal humerus in children. Int Orthop. 2018:1-6. 55. Wormald J, Park C, Eastwood D. A systematic review and meta-analysis of adverse outcomes following non-buried versus buried Kirschner wires for paediatric lateral condyle elbow fractures. J Child Orthop. 2017;11:465-471. 56. Slongo T, Schmid T, Wilkins K, Joeris A. Lateral external fixation—a new surgical technique for displaced unreducible supracondylar humeral fractures in children. J Bone Joint Surg Am. 2008;90:1690-1697. 57. Hohloch L, Konstantinidis L, Wagner FC, Strohm PC, Südkamp NP, Reising K. Biomechanical comparison of different external fixator configurations for stabilization of supracondylar humerus fractures in children. Clin Biomech. 2016;32:118-123. 58. Yang Z, Wang Y, Gilula LA, Yamaguchi K. Microcirculation of the distal humeral epiphyseal cartilage: implications for post-traumatic growth deformities. J Hand Surg Am. 1998;23:165-172. 59. Kao H-K, Chen M-C, Lee W-C, Yang W-E, Chang C-H. Seasonal temperature and pin site care regimen affect the incidence of pin site infection in pediatric supracondylar humeral fractures. Biomed Res Int. 2015;2015. 60. Kao H-K, Chen M-C, Lee W-C, Yang W-E, Chang C-H. A prospective comparative study of pin site infection in pediatric supracondylar humeral fractures: daily pin care vs. no pin care. Arch Orthop Trauma Surg. 2014;134:919-923. 61. Or O, Weil Y, Simanovsky N, Panski A, Goldman V, Lamdan R. The outcome of early revision of malaligned pediatric supracondylar humerus fractures. Injury. 2015;46:1585-1590.
IP T SC R U N A M TE D EP CC A Figure 1. Gartland type IIa/von Laer type II fracture in a 6-year-old boy after fall from a climbing frame (A), (B). Extension malpositioning was not acceptable (B). After closed reduction internal fixation was performed with crossed 1.8mm k-wires (C), (D).
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Figure 2. (A) X-rays of the elbow and wrist of a 7-year-old boy after a fall from a sofa with a Gartland type-IIb/von Laer type-III SHF with a ventral spur at the distal humerus on the lateral image and additional forearm fracture (A),(B), (E). Metaphyseal radius fracture could be treated conservatively. After closed reduction, fixation was performed by two laterally placed K-wires.
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Figure 3. (A) AP and (B) lateral radiographs of a Gartland type III/ von Laer type IV SHF in a 6-year-old girl after fall from a trampoline. Postoperative AP (C) and lateral radiographs (D): one medial and two lateral K-wires were used to achieve best biomechanical stability.
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Figure 4. Ossification centers of the elbow in order of appearance and approximate age of ossification. Reproduced with permission from Mark D. Miller and Stephen R. Thompson. Miller's review of orthopaedics. Elsevier Health Sciences, 2016.
Figure 5. (A) The anterior humeral line should pass through the middle third of the ossification center of the capitellum. (B) Coronoid line. The anterior border of the coronoid process should barely touch the anterior portion of the lateral condyle.
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Figure 6. (A) The tear-drop formed by the posterior margin of the coronoid fossa, anterior margin of the olecranon fossa and superior border of the ossification center of the capitellum. (B) Shaft condylar angle (SCA), 40 degrees angulation between the long axis of the humerus and lateral condyle.
Figure 7. Baumann angle also known as “shaft-physeal” angle. It is a good measurement of any deviation of the angulation of the distal humerus (normal: 72 degrees (range 64 to 81 degrees).
S0020-1383(19)30160-3 https://doi.org/10.1016/j.injury.2019.03.042 JINJ 8117
To appear in:
Injury, Int. J. Care Injured
Received date: Accepted date:
5 February 2019 28 March 2019
Please cite this article as: Rupp M, Sch¨afer C, Heiss C, Alt V, Pinning of Supracondylar Fractures in Children – Strategies to avoid Complications, Injury (2019), https://doi.org/10.1016/j.injury.2019.03.042 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Pinning of Supracondylar Fractures in Children –
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Strategies to avoid Complications
Markus Rupp, MD Christoph Schäfer, MD
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Christian Heiss, MD
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From the: Department of Trauma Surgery University Hospital Giessen-Marburg GmbH Campus Giessen 35385 Giessen Germany
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Volker Alt, MD, PhD*
Corresponding author:
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Prof. Dr. med. Dr. biol. hom. Volker Alt Department of Trauma Surgery University Hospital Giessen-Marburg, Campus Giesen Rudolf-Buchheim-Str. 7 35392 Giessen Germany
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email: [email protected]
Highlights
This paper
reviews current treatment principles for paediatric supracondylar fractures
gives treatment recommendations for this frequent injury
helps to avoid complications, particularly to avoid re-operations and to avoid ulnar
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nerve injury
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Abstract
In the pediatric population supracondylar humerus fracture (SHF) is one of the most common injuries. Diagnosis is based on inspection and conventional radiography. SHFs should be
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classified according to the modified Gartland classification, which guides treatment. Nondisplaced or minimally displaced fractures (Gartland type-I) should be treated non-
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operatively, completely displaced type III fractures require closed reduction and K-wire
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fixation. In type-II fractures, important landmarks, such as the anterior humeral line (Roger´s
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line), the shaft-physeal angle (Baumann´s angle) and the shaft condylar angle should be considered to guide treatment. Special attention has to be paid for potential rotational
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dislocation, which is indicated by a ventral spur. In such cases surgery is necessary. The degree of acceptable extension malpositioning depends on patient´s age. In 10-year-old children fractures with a shaft condylar angle of more than 15° are still suitable for nonoperative therapy. Timing for surgery is controversially discussed. Postponing surgery to the
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next day seems reasonable if absence of pain, intact soft tissue and normal neurovascular status are present. Neurovascular complications are not uncommon, especially in Gartland
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type-III fractures and in cases with additional forearm injuries. A white hand without palpable pulse needs emergency surgery, the management of the pulseless pink hand is still
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controversially discussed. Different operative techniques exist for surgical treatment. The golden standard is closed reduction and percutaneous K-wire pinning. Crossed pinning seems to achieve best biomechanical stability. Since ulnar nerve injuries are reported to occur in 6% after medially inserting K-wires, lateral divergent insertion of two K-wires has been compared to crossed pinning fixation in several randomized controlled trials. Meta-analysis demonstrated a higher risk for ulnar nerve injury for the crossed pinning technique while risk for loss of fixation was higher in lateral only pinning. In both cases, K-wires should be removed 3-6 weeks after surgery with consolidation of the fracture. Clinical and radiological
follow-up should be carried out at 3 weeks post fracture fixation to rule out loss of reduction. If this should occur, early revision surgery has been demonstrated beneficial.
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Keywords: supracondylar humerus fracture, K-wire, ulnar nerve, pinning
Background
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Supracondylar humerus fracture (SHF) is the most common fracture of the elbow in the pediatric population. While distal humeral fractures account for about 16% of all fractures in
long bones during skeletal development 1, 50-70% of all elbow fractures in children are SHF . SHF are usually the result of falls on outstretched hands. This mechanism is widely known
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as FOOSH (fall on out-stretched hand) mechanism. Patients suffering from SHF are usually
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within their first decade of life with an age peak in the 5th and 6th year of life. This makes
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examination and diagnosis challenging especially in not obvious case3. To avoid unnecessary
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pain, clinical examination concentrates on inspection of the injured site. It is obligatory to check peripheral circulation, motor function and sensitivity. However, the essential cornerstone of diagnosis is conventional radiography. X-ray images of the elbow are taken in
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two planes by default. If there is any suspicion of additional forearm fracture, further X-rays
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of the forearm in two planes should be initiated (Figure 2) as 5% of SHF are associated with additional forearm fractures. Higher rates of neuropraxia up to 23% and pulselessness of the
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hand in 6%-9% underline the value of limited physical examination in association with radiography 4. In these injuries, successful therapy depends on depicting a growth prognosis. Spontaneous correction but also growth disorders are both possible if the remaining growth period is long enough. Thus, fracture characteristics have to be considered together with age, sex and development status for estimation of remaining growth potential. For the elbow and thus for
SHF, both the distal humeral growth plates and the proximal forearm growth plates are only responsible for 20% of longitudinal growth in their segment 5. Therefore, the risk of growth disorders around the elbow is low as well as the potential of spontaneous correction. Hence, compared to the proximal upper arm and distal forearm, even a small degree of displacement usually requires surgical therapy with appropriate anatomical reduction.
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The Gartland three staged classification system of SHF has been widely used in pediatric trauma care 6. The modified version, which was proposed by Wilkins in 1981, has prevailed
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in the Anglo-American community: type-I: undisplaced fracture, type-IIa: greenstick fracture
with posterior angulation (Figure 1), type-IIb: greenstick fracture with malrotation and
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posterior angulation (Figure 2), type-III: completely displaced fracture (Figure 3) 7. Its major
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advantage is its low intra-observer and interobserver variability 8. In 2006, Leitch et al.
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proposed a fourth type modifying Gartland´s classification. They described type-IV as a rare
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multidirectional unstable fracture due to a lack of posterior periosteal hinge. Instability results in displacement into flexion and/or extension 9. The most used classification system in the
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German speaking sphere is the four staged classification system of von Laer, which is quite similar to the modified Gartland classification: type-I: non displaced, type-II: displaced
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without rotation, type-III: displaced with rotation, type-IV: completely displaced 5.
Anatomical landmarks and radiological assessment
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Correct assessment of radiographs is the cornerstone of successful therapy. Knowledge of anatomical landmarks of both lateral and anterior-posterior projections is a basic prerequisite. Trauma surgeons should be aware of the appearance of secondary ossification centers to evaluate the pediatric elbow on X-rays. CRITOE (capitellum, radial head, internal [medial] epicondyle, trochlea, olecranon, external [lateral] epicondyle) has been established as
mnemonic. The ossification center of the capitellum appears at the age of one. Afterwards, each ossification center appears about 2 years after another (Figure 4) 3. The most important lateral landmark is the anterior humeral line, which is also called Roger´s line. It should pass through the middle third of the ossification center of the capitellum. The second important line is the coronoid line. The anterior border of the coronoid process should barely touch the
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anterior portion of the lateral condyle (Figure 5). A further landmark on lateral X-rays is the shaft condylar angle (SCA). This angle measures 40 degrees between the long axis of the
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humerus and the long axis of the lateral condyle. The teardrop, which is seen on lateral radiographs, is formed by the posterior margin of the coronoid fossa, the anterior margin of the olecranon fossa and the superior border of the ossification center of the capitellum (Figure
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6). For all projections, lateral, oblique and anterior-posterior (AP), the line down the middle
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of the radial neck and shaft should intersect the capitellum at its middle third. The “shaft-
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physeal” angle (or Baumann´s angle) is a further important AP landmark. It is formed
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between the line parallel to the humerus shaft and a line parallel to the lateral physis.
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Baumann´s angle normally measures 72 degrees (range 64 to 81 degrees) (Figure 7). In subtle cases with unapparent fractures, the posterior fat pad sign is indicative for elbow fractures (76% of all cases). In such cases, SHF are the most common elbow fractures as well (53% of
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. For correct assessment of radiography, the outstanding significance of rotation
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though
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all fractures). The anterior fat pad is a normal feature of lateral X-rays of flexed elbows,
displacement in SHF must be understood. In 1979, Lutz von Laer described the importance of
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rotational dislocation in supracondylar fractures. In a retrospective case series of supracondylar fractures, he could demonstrate that lateral tilting was in any case the result of rotation displacement, whereas lateral compression was not the reason for that. Thus, von Laer concluded that it is mandatory to identify fractures with rotational errors since rotational stable surgical correction is necessary
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. A ventral spur is the best radiological feature to
detect rotational dislocation (Figure 2A). Keeping this in mind, the modification of Gartland´s
classification by Wilkins and von Laer, are of practical relevance and well comprehensible. The physiological cubitus valgus measures 5-15° and is called carrying angle. In case of posttraumatic sequelae cubitus varus is possible. This “gunstock deformity” may result in poor cosmesis and in rare but serious cases in functional deficiencies. Then, hitting the hips
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with the swinging arms while walking hampers the patients in everyday life.
Indication and timing for surgery
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Type-I SHF are undisplaced or only minimally displaced (<2mm). For those fractures non
operative treatment is ideal. Injuries which are classified as type-III fractures have to be treated surgically. The posterior cortex has lost its integrity in such fractures. Malpositioning
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in extension in the sagittal and rotation in the transverse plane needs surgical correction
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(Figure 2). In addition, the multidirectional instability staged in the modified Gartland
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classification as type-IV fracture needs surgical therapy as well. Nonetheless, a wide range of
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fractures fall under the category of type-II fractures. These range from fractures with mild
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extension without rotational and coronal malalignment to fractures with cortical contact but severe dislocation. Thusly, treatment indications differ within this category. Non-operative treatment is an option if no rotational deformity, coronal malalignment and significant 12
. The degree of acceptable extension
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extension of the distal fragment is detectable
malpositioning depends on the age of the patients. In toddlers, which are under 3-years-old,
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remodeling potential allows for non-operative treatment when the humeral line brushes the
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anterior capitellum. Eight to ten-year-old patients only still have 10% growth of their distal humerus
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. Fractures with isolated extension and an SCA of >15 degrees are regarded
suitable for conservative treatment 12. Fractures with more isolated extension malpositioning require at least closed reduction. Afterwards, immobilization with either a cast or a cuff and collar is necessary. A radiological follow-up after 7 days is obligatory. If loss of reduction occurs, surgery with reduction and percutaneous pinning of the fracture can be performed.
Within 7 days after trauma, reduction and percutaneous pinning do not affect long-term alignment
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. In case of above-mentioned radiological criteria for conservative treatment and
additional soft tissue swelling and hematoma, immobilization in flexion larger than 90° may not be reasonable. Flexion larger than 90° results in increased compartment pressure in the forearm
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. Thus, surgical treatment which enables immobilization in 90° or less flexion
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should be considered early to avoid compartment syndrome. Finally, knowledge of factors
associated with successful non-operative therapy of Gartland type-II fractures enable
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conservative treatment. Consequently, unnecessary surgeries in up to 72% of all SHF type-II fractures as well as associated operative and iatrogenic complications can be avoided 16.
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If surgery is indicated, the question raises, when it is the best time. Higher complication rates
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. For after-hours surgery in supracondylar humerus fractures, poorer
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other surgical fields
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for surgeries at nighttime are controversially discussed in orthopedic trauma care as well as in
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. However, a higher
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fixation rates compared to daytime procedures were demonstrated
conversion rate to open reduction and internal fixation was reported if surgery was delayed 21
. Experience and high volume surgery are crucial factors for
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for more than 12 hours
successful operative management of supracondylar fractures
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. Thus, as long as no
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prospective multicentered study enlightens our knowledge on this subject, we recommend that timing of surgery should be individually determined. Absence of pain after immobilization,
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intact soft tissue and normal neurovascular status allow postponing surgery to the next day.
Concomitant vascular and neurological injuries – surgical emergencies? Vascular and neurological complications most frequently occur in type-III fractures. Neurological injuries can be found in 10% to 20%
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whereas vascular injuries occur in up to
20% 24. Assessment of motor function and sensation is very difficult in injured, pain-troubled children. Nevertheless, correct assessment prior to surgery is essential since postoperative
neurological deficits are more common than initially on admission
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. Visible soft tissue
injury is associated with neurovascular injury. Elbow swelling, tenting, puckering and ecchymoses are significantly associated with nonpalpable pulses and neurological injury
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Additional ipsilateral forearm fracture should prompt the surgeon to assess the neurovascular status even more carefully since neurovascular injuries are almost twice as often with
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associated forearm fractures compared to isolated SHF 4. Color of the hand (pink vs. white), temperature and edema are characteristics to assess peripheral circulation. Palpation of the
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radial pulse as well as testing of the capillary refill (<2 seconds) are obligatory. An increase in
pain medication may be a sign of ischemia and emerging compartment syndrome. Additional diagnostics such as doppler ultrasonography and prereduction angiography are not
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recommended and should not delay surgical treatment. Placing the arm in 30-40 degrees
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flexion and application of gentle traction may help to improve circulation
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. A white hand
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without palpable pulse needs emergency surgery. Acute ischemia requires open reduction and
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identifying of the brachial artery. However, the management of pulseless pink hands is
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controversially discussed due to lack of high-quality clinical studies. Interestingly, no guidelines exist in relation to this matter. There is agreement that urgent, but non-emergency surgery in terms of closed reduction and internal fixation is necessary 27. Several studies and
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reviews demonstrate that radial pulses usually occur after closed reduction during 24, 28-30
. A spasm of the brachial artery rather than a structural injury
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postoperative follow-up
is regarded as reason of the success of watchful waiting in those cases 24. In contrast to those
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findings, White et al. reported 70% brachial artery injuries in “pink pulseless hands” after SHF and not surprisingly he recommended a more aggressive vascular exploration and repair 31
. If the circulation deteriorates and forearm compartment occurs in the course of the
treatment, surgical exploration of the brachial artery becomes inevitable. Neurological impairment can be a result of an injury of one or more of the three major nerves. The median nerve and the anterior interosseous nerve are most often involved in Gartland type-III
fractures. They account for over 60% of all neurological injuries. However, the involvement depends on fracture dislocation. Posterolateral dislocation predisposes median nerve injury, whereas posteromedial dislocation is related to radial nerve injury 23. Injury of the ulnar nerve is most often iatrogenic. Ulnar nerve injuries result in up to 6% by medially inserted k-wires 25
. If postoperative ulnar nerve damage occurs, revision of the k-wire and neurolysis seems
ulnar nerve palsies
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logical. However, spontaneous recovery was demonstrated in a case series of postoperative
. Complete remission after forty-nine days (range, two to 224 days) for 33
. Spontaneous recovery of median and
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the anterior interosseous nerve was demonstrated
radial nerve is observed as well. Median time to nerve recovery was 2.3 months (range 1.3 to 3.7 months). After 3 months, 60% and after 6 months 90% of the affected patients
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experienced recovery of the affected nerves. Shore et al. could demonstrate that median nerve
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recovery was fastest and radial nerve recovery lasts 30% longer than the one of the median
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nerve. Multiple nerve injuries take 54% longer to recover than single median nerve injuries34.
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Reports of complete resolution of injuries of all 3 major nerves in patients with closed SHF
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and consecutive closed reduction and k-wire fixation, underline the need of patience of
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surgeons, parents and patients to await nerve recovery 35.
Operative techniques
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Closed reduction and percutaneous pinning are the golden standard of any displaced SHF in
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children. However, techniques of percutaneous pinning are controversially discussed. On the one hand primary stability has to be achieved to avoid loss of reduction. On the other hand, iatrogenic damage with associated long-term impairment has to be minimized. Crossed pinning provides the biomechanically most stable construct using to k-wires (Figure 1)
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.
However, iatrogenic ulnar nerve injury due to the medially inserted k-wires appears in up to 6%
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. While ulnar nerve injury in lateral pinning technique appears about 5 times rarer
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,
the “lateral only” technique resulted in 3.4% in median nerve neuropraxia (Figure 2)
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. The
latest meta-analysis of Dekker and colleagues included seven randomized control trials (RCT) and six prospective comparative cohorts including in total 1158 patients. All studies were published between 2000 and 2014. They found similar loss of reduction rates in both groups (crossed pinning 11.6% vs lateral pinning 12.4%). Ulnar nerve injury was more often in the 39
. In their meta-
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crossed k-wire group (4.1%) compared to lateral entry pin fixation (0.3%)
analysis from 2012, Woratanarat et al. analyzed 18 studies published through September 2007
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representing 1615 children. Cross pinning had a 40% lower risk of loss of fixation, but a 400% higher risk of ulnar nerve injury. Late deformity and poor function were similar for
both pinning groups. Median or radial nerve injury was observed only in lateral to medial pin
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insertion. Revision surgery for loss of fixation (1.3% for crossed and 2.1% for lateral pinning)
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and non-recovered ulnar nerve injury (1% for crossed pins only) were similar
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. Zhao et al.
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performed a meta-analysis of RCTs from 1966 to 2012. Based on 7 RCTs with 512 patients,
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they concluded that crossed pinning fixation was more at risk for iatrogenic ulnar nerve injury
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than lateral pinning technique. No difference in radiographic outcomes, function and other complications were found, though
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. Not surprising, the fracture morphology plays a major
role for stability. Kwak et al. postulated a loss of stability due to lesser separation of lateral
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entry pins in case of medial wall comminution 42. Reisoglu et al. came to the same conclusion 43
. The adaption of pin configuration
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and postulated crossed entry pin fixation in such cases
to fracture characteristics seems reasonable. Bauer and coworkers describe intraoperative
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internal rotation stress testing after insertion of two lateral entry pins. If rotational instability is determined intraoperatively, an additional medially inserted k-wire was applied in a miniopen approach. Thus, ulnar nerve injury as well as reoperation due to loss of reduction could be avoided in Gartland type-III SHF 44. In our opinion, this mini-open approach for displaying the ulnar nerve is essential for crossed pinning techniques. In 2005, Green could demonstrate that no ulnar nerve injuries are to be expected with this approach, either 45. However, safe and
reliable closed techniques in elbow extension 46, elbow flexion with a thumb placed over the medial epicondyle
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and even nerve monitoring during pin insertion
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are reported in
literature. Hitherto, meta-analyses summarizing ulnar nerve injuries did not differ between medial entry pin fixation techniques. The classical crossed and lateral two pin techniques have undergone several modifications to improve biomechanical stability and reduce risk of
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iatrogenic nerve injury. Modification of crossed pinning with lateral insertion of both k-wires is possible. Dorgan´s lateral percutaneous cross-wiring of supracondylar fractures could
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demonstrate the same functional outcome as in standard cross-wiring without ulnar nerve injuries 49, 50_ENREF_50. However, the radial nerve could be injured by inserting the proximal k-wire
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. Hamdi et al. examined different lateral pin configurations in an experimental
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biomechanical setting. Their group could demonstrate that a lateral pin parallel to the humeral
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cortex and a diverging pin crossing the fracture level at the medial edge of the coronoid fossa
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result in the optimum fixation using two lateral entry pins52. Biomechanical studies could not
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demonstrate a difference of crossed pin fixation and the lateral pin fixation, which was
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recommended by Hamdi et al. unless medial column comminution is present. In such cases, a three lateral pin construct was not significantly different compared to the standard crossed pin
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construct in the presence of medial comminution 53. For high metaphyseal-diaphyseal junction fractures, elastic stable intramedullary nail (ESIN)
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insertion is an elegant way of treatment. ESINs provide the best biomechanical stiffness in an experimental setup and allow cast free aftercare in the clinical setting. In more distal SHF,
A
Kamara et al. could demonstrate that three crossed pinning (one medial and two lateral pins) could achieve best biomechanical stability (Figure 3), whereas two crossed and three lateral pinning techniques yielded comparable stiffness 54. Regarding infection rates, it does not seem to matter if k-wires are buried under the skin or not
55
. However, non-buried pins avoid a
second surgery and pin removal is possible during postoperative aftercare without additional general anaesthesia. When stability is not achieved by closed reduction and percutaneous
pinning, external fixation is an option to overcome problems associated with type-III SHF. Rigid stability allows elbow motion and ulnar nerve injury is unlikely through a lateral approach. Perpendicular application of the Schanz pins is recommended. Thus, a joystick technique is possible for closed reduction. A further advantage is the possibility to compress the lateral condylar column which prevents secondarily medial column collapse 56. Initially, a
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retrograde k-wire which was inserted from the radial side was recommended by Slongo 56. An additional ulnar-sided k-wire has been shown to be superior to a radially inserted k-wires for 57
. Again, a mini open technique is
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anti-rotation purposes with external fixation
recommended. When open reduction is necessary, medial, lateral and ventral approaches are possible. A dorsal approach should be obviated since the blood supply for the epiphysis 58
. A major benefit of the ventral approach is the exploration of the
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comes from dorsal
A
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transverse incision of the elbow crease.
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brachial artery and the median nerve. A cosmetically appealing result is achieved by a
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Aspects of aftercare
K-wires are removed 3-6 weeks after surgery with consolidation of the fracture.
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Immobilization of the elbow is necessary for this period. If k-wires are not buried, daily pin site care should be avoided. It is associated with higher infection rates, especially during
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summer months
59, 60
. The postoperative follow-up should assess potential loss of reduction.
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Clinically malalignment is hard to assess when the arm is placed in a cast with the elbow flexed at 90 degrees. Therefore, X-ray postoperative control is recommended. If a coronal or sagittal plane deformity of more than 10 degrees is determined, revision surgery should be considered. Or and colleagues demonstrated that early revision within 3 weeks of initial reduction and fixation is a sound option if malalignment is realized during this period of postoperative aftercare. Thus, malunion and consecutive corrective osteotomies can be
avoided by early revision surgery
61
. However, the weakness of this study is the lack of a
comparative group and small volume in numbers. Nevertheless, a clinical and radiological 3
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weeks follow-up examination is reasonable against this background.
Conclusion
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SHF are common fractures and surgeons have to deal with best treatment strategies. Clinical
and radiological assessment are the mainstay of non-operastive and surgical treatment.
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Indication for surgery in SHF type-II should be based on radiological characteristics,
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especially rotational displacement must not be overlooked. Percutaneous pinning is possible
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in many different ways. Ulnar nerve injury is a major risk in traditional crossed pinning
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technique. A mini-open approach is an established way to avoid ulnar nerve injury. Lateral entry pin fixation needs divergent pin placement. Additional pinning, either lateral or medial,
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improves biomechanical stability. External fixators, ESINs and open reduction are further
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treatment possibilities in rare but challenging cases.
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IP T SC R U N A M TE D EP CC A Figure 1. Gartland type IIa/von Laer type II fracture in a 6-year-old boy after fall from a climbing frame (A), (B). Extension malpositioning was not acceptable (B). After closed reduction internal fixation was performed with crossed 1.8mm k-wires (C), (D).
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Figure 2. (A) X-rays of the elbow and wrist of a 7-year-old boy after a fall from a sofa with a Gartland type-IIb/von Laer type-III SHF with a ventral spur at the distal humerus on the lateral image and additional forearm fracture (A),(B), (E). Metaphyseal radius fracture could be treated conservatively. After closed reduction, fixation was performed by two laterally placed K-wires.
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Figure 3. (A) AP and (B) lateral radiographs of a Gartland type III/ von Laer type IV SHF in a 6-year-old girl after fall from a trampoline. Postoperative AP (C) and lateral radiographs (D): one medial and two lateral K-wires were used to achieve best biomechanical stability.
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Figure 4. Ossification centers of the elbow in order of appearance and approximate age of ossification. Reproduced with permission from Mark D. Miller and Stephen R. Thompson. Miller's review of orthopaedics. Elsevier Health Sciences, 2016.
Figure 5. (A) The anterior humeral line should pass through the middle third of the ossification center of the capitellum. (B) Coronoid line. The anterior border of the coronoid process should barely touch the anterior portion of the lateral condyle.
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Figure 6. (A) The tear-drop formed by the posterior margin of the coronoid fossa, anterior margin of the olecranon fossa and superior border of the ossification center of the capitellum. (B) Shaft condylar angle (SCA), 40 degrees angulation between the long axis of the humerus and lateral condyle.
Figure 7. Baumann angle also known as “shaft-physeal” angle. It is a good measurement of any deviation of the angulation of the distal humerus (normal: 72 degrees (range 64 to 81 degrees).