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Is Lateral Pin Fixation for Displaced Supracondylar Fractures of the Humerus Better Than Crossed Pins in Children?

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Clinical Orthopaedics and Related Research®

Abstract

Background

Closed reduction and percutaneous pin fixation is considered standard management for displaced supracondylar fractures of the humerus in children. However, controversy exists regarding whether to use an isolated lateral entry or a crossed medial and lateral pinning technique.

Questions/purposes

We performed a meta-analysis of randomized controlled trials (RCTs) to compare (1) the risk of iatrogenic ulnar nerve injury caused by pin fixation, (2) the quality of fracture reduction in terms of the radiographic outcomes, and (3) function in terms of criteria of Flynn et al. and elbow ROM, and other surgical complications caused by pin fixation.

Methods

We searched PubMed, Embase, the Cochrane Library, and other unpublished studies without language restriction. Seven RCTs involving 521 patients were included. Two authors independently assessed the methodologic quality of the included studies with use of the Detsky score. The median Detsky quality score of the included trials was 15.7 points. Dichotomous variables were presented as risk ratios (RRs) or risk difference with 95% confidence intervals (CIs) and continuous data were measured as mean differences with 95% CI. Statistical heterogeneity between studies was formally tested with standard chi-square test and I2 statistic. For the primary objective, a funnel plot of the primary end point and Egger’s test were performed to detect publication bias.

Results

The pooled RR suggested that iatrogenic ulnar nerve injury was higher with the crossed pinning technique than with the lateral entry technique (RR, 0.30; 95% CI, 0.10–0.89). No publication bias was further detected. There were no statistical differences in radiographic outcomes, function, and other surgical complications. No significant heterogeneity was found in these pooled results.

Conclusions

We conclude that the crossed pinning fixation is more at risk for iatrogenic ulnar nerve injury than the lateral pinning technique. Therefore, we recommend the lateral pinning technique for supracondylar fractures of the humerus in children.

Level of Evidence

Level I, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

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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;20:69–77.

    Article  PubMed  Google Scholar 

  2. Anwar W, Rahman N, Iqbal MJ, Khan MA. Comparison of the two methods of percutaneous K-wire fixation in displaced supracondylar fracture of humerus in children. J Postgrad Med Inst. 2011;25:356–361.

    Google Scholar 

  3. Babal JC, Mehlman CT, Klein G. Nerve injuries associated with pediatric supracondylar humeral fractures: a meta-analysis. J Pediatr Orthop. 2010;30:253–263.

    Article  PubMed  Google Scholar 

  4. Bhandari M, Richards RR, Sprague S, Schemitsch EH. The quality of reporting of randomized trials in the Journal of Bone and Joint Surgery from 1988 through 2000. J Bone Joint Surg Am. 2002;84:388–396.

    Article  PubMed  Google Scholar 

  5. 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.

    Article  PubMed  Google Scholar 

  6. Brown IC, Zinar DM. Traumatic and iatrogenic neurological complications after supracondylar humerus fractures in children. J Pediatr Orthop. 1995;15:440–443.

    Article  PubMed  CAS  Google Scholar 

  7. Casiano E. Reduction and fixation by pinning “banderillero” style-fractures of the humerus at the elbow in children. Mil Med. 1960;125:262–264.

    PubMed  CAS  Google Scholar 

  8. Davis RT, Gorczyca JT, Pugh K. Supracondylar humerus fractures in children: comparison of operative treatment methods. Clin Orthop Relat Res. 2000;376:49–55.

    Article  PubMed  Google Scholar 

  9. de las Heras J, Duran D, de la Cerda J, Romanillos O, Martinez-Miranda J, Rodriguez-Merchan EC. Supracondylar fractures of the humerus in children. Clin Orthop Relat Res. 2005;432:57–64.

    Google Scholar 

  10. Detsky AS, Naylor CD, O’Rourke K, McGeer AJ, L’Abbe KA. Incorporating variations in the quality of individual randomized trials into meta-analysis. J Clin Epidemiol. 1992;45:255–265.

    Article  PubMed  CAS  Google Scholar 

  11. Donnelly M, Green C, Kelly IP. An inconvenient truth: treatment of displaced paediatric supracondylar humeral fractures. Surgeon. 2012;10:143–147.

    Article  PubMed  CAS  Google Scholar 

  12. Egger M, Davey Smith G, Schneider M, Minder C. Bias in meta-analysis detected by a simple, graphical test. BMJ. 1997;315:629–634.

    Article  PubMed  CAS  Google Scholar 

  13. 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;56:263–272.

    PubMed  CAS  Google Scholar 

  14. Foead A, Penafort R, Saw A, Sengupta S. Comparison of two methods of percutaneous pin fixation in displaced supracondylar fractures of the humerus in children. J Orthop Surg (Hong Kong). 2004;12:76–82.

    PubMed  CAS  Google Scholar 

  15. Gartland JJ. Management of supracondylar fractures of the humerus in children. Surg Gynecol Obstet. 1959;109:145–154.

    PubMed  CAS  Google Scholar 

  16. Gaston RG, Cates TB, Devito D, Schmitz M, Schrader T, Busch M, Fabregas J, Rosenberg E, Blanco J. Medial and lateral pin versus lateral-entry pin fixation for Type 3 supracondylar fractures in children: a prospective, surgeon-randomized study. J Pediatr Orthop. 2010;30:799–806.

    Article  PubMed  Google Scholar 

  17. Gordon JE, Patton CM, Luhmann SJ, Bassett GS, Schoenecker PL. Fracture stability after pinning of displaced supracondylar distal humerus fractures in children. J Pediatr Orthop. 2001;21:313–318.

    PubMed  CAS  Google Scholar 

  18. Gosens T, Bongers KJ. Neurovascular complications and functional outcome in displaced supracondylar fractures of the humerus in children. Injury. 2003;34:267–273.

    Article  PubMed  Google Scholar 

  19. Gottschalk HP, Sagoo D, Glaser D, Doan J, Edmonds EW, Schlechter J. Biomechanical analysis of pin placement for pediatric supracondylar humerus fractures: does starting point, pin size, and number matter? J Pediatr Orthop. 2012;32:445–451.

    Article  PubMed  Google Scholar 

  20. 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.

    Article  PubMed  Google Scholar 

  21. Gupta N, Kay RM, Leitch K, Femino JD, Tolo VT, Skaggs DL. Effect of surgical delay on perioperative complications and need for open reduction in supracondylar humerus fractures in children. J Pediatr Orthop. 2004;24:245–248.

    Article  PubMed  Google Scholar 

  22. Han QL, Wang YH, Liu F. Comparison of complications and results of early versus delayed surgery for Gartland type III supracondylar humeral fractures in pediatric patients. Orthop Surg. 2011;3:242–246.

    Article  PubMed  Google Scholar 

  23. Hasler CC. Supracondylar fractures of the humerus in children. Eur J Trauma. 2001;27:1–15.

    Google Scholar 

  24. Higgins JP, Thompson SG. Controlling the risk of spurious findings from meta-regression. Stat Med. 2004;23:1663–1682.

    Article  PubMed  Google Scholar 

  25. Higgins JP, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses. BMJ. 2003;327:557–560.

    Article  PubMed  Google Scholar 

  26. Kallio PE, Foster BK, Paterson DC. Difficult supracondylar elbow fractures in children: analysis of percutaneous pinning technique. J Pediatr Orthop. 1992;12:11–15.

    PubMed  CAS  Google Scholar 

  27. Kim WY, Chandru R, Bonshahi A, Paton RW. Displaced supracondylar humeral fractures in children: results of a national survey of paediatric orthopaedic consultants. Injury. 2003;34:274–277.

    Article  PubMed  CAS  Google Scholar 

  28. Kocher MS, Kasser JR, Waters PM, Bae D, Snyder BD, Hresko MT, Hedequist D, Karlin L, Kim YJ, Murray MM, Millis MB, Emans JB, Dichtel L, Matheney T, Lee BM. 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.

    Article  PubMed  Google Scholar 

  29. Lee KM, Chung CY, Gwon DK, Sung KH, Kim TW, Choi IH, Cho TJ, Yoo WJ, Park MS. Medial and lateral crossed pinning versus lateral pinning for supracondylar fractures of the humerus in children: decision analysis. J Pediatr Orthop. 2012;32:131–138.

    Article  PubMed  CAS  Google Scholar 

  30. Lee S, Park MS, Chung CY, Kwon DG, Sung KH, Kim TW, Choi IH, Cho TJ, Yoo WJ, Lee KM. Consensus and different perspectives on treatment of supracondylar fractures of the humerus in children. Clin Orthop Surg. 2012;4:91–97.

    Article  PubMed  Google Scholar 

  31. Lee SS, Mahar AT, Miesen D, Newton PO. Displaced pediatric supracondylar humerus fractures: biomechanical analysis of percutaneous pinning techniques. J Pediatr Orthop. 2002;22:440–443.

    PubMed  Google Scholar 

  32. Li YA, Lee PC, Chia WT, Lin HJ, Chiu FY, Chen TH, Feng CK. Prospective analysis of a new minimally invasive technique for paediatric Gartland type III supracondylar fracture of the humerus. Injury. 2009;40:1302–1307.

    Article  PubMed  Google Scholar 

  33. Loizou CL, Simillis C, Hutchinson JR. A systematic review of early versus delayed treatment for type III supracondylar humeral fractures in children. Injury. 2009;40:245–248.

    Article  PubMed  CAS  Google Scholar 

  34. 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.

    PubMed  CAS  Google Scholar 

  35. Maity A, Saha D, Roy DS. A prospective randomised, controlled clinical trial comparing medial and lateral entry pinning with lateral entry pinning for percutaneous fixation of displaced extension type supracondylar fractures of the humerus in children. J Orthop Surg Res. 2012;7:6.

    Article  PubMed  Google Scholar 

  36. McCarthy SM, Ogden JA. Radiology of postnatal skeletal development: V. Distal humerus. Skeletal Radiol. 1982;7:239–249.

    Article  PubMed  CAS  Google Scholar 

  37. Mostafavi HR, Spero C. Crossed pin fixation of displaced supracondylar humerus fractures in children. Clin Orthop Relat Res. 2000;376:56–61.

    Article  PubMed  Google Scholar 

  38. Mulpuri K, Wilkins K. The treatment of displaced supracondylar humerus fractures: evidence-based guideline. J Pediatr Orthop. 2012;32(suppl 2):S143–152.

    Article  PubMed  Google Scholar 

  39. Nacht JL, Ecker ML, Chung SM, Lotke PA, Das M. Supracondylar fractures of the humerus in children treated by closed reduction and percutaneous pinning. Clin Orthop Relat Res. 1983;177:203–209.

    PubMed  Google Scholar 

  40. Omid R, Choi PD, Skaggs DL. Supracondylar humeral fractures in children. J Bone Joint Surg Am. 2008;90:1121–1132.

    Article  PubMed  Google Scholar 

  41. Otsuka NY, Kasser JR. Supracondylar fractures of the humerus in children. J Am Acad Orthop Surg. 1997;5:19–26.

    PubMed  Google Scholar 

  42. Paradis G, Lavallee P, Gagnon N, Lemire L. Supracondylar fractures of the humerus in children: technique and results of crossed percutaneous K-wire fixation. Clin Orthop Relat Res. 1993;297:231–237.

    PubMed  Google Scholar 

  43. Rasool MN. Ulnar nerve injury after K-wire fixation of supracondylar humerus fractures in children. J Pediatr Orthop. 1998;18:686–690.

    PubMed  CAS  Google Scholar 

  44. Reising K, Schmal H, Kohr M, Kuminack K, Sudkamp NP, Strohm PC. Surgical treatment of supracondylar humerus fractures in children. Acta Chir Orthop Traumatol Cech. 2011;78:519–523.

    PubMed  CAS  Google Scholar 

  45. Reynolds RA, Jackson H. Concept of treatment in supracondylar humeral fractures. Injury. 2005;36(suppl 1):A51–56.

    Article  PubMed  Google Scholar 

  46. Sankar WN, Hebela NM, Skaggs DL, Flynn JM. Loss of pin fixation in displaced supracondylar humeral fractures in children: causes and prevention. J Bone Joint Surg Am. 2007;89:713–717.

    Article  PubMed  Google Scholar 

  47. Sibinski M, Sharma H, Bennet GC. Early versus delayed treatment of extension type-3 supracondylar fractures of the humerus in children. J Bone Joint Surg Br. 2006;88:380–381.

    Article  PubMed  CAS  Google Scholar 

  48. Sibinski M, Sharma H, Sherlock DA. Lateral versus crossed wire fixation for displaced extension supracondylar humeral fractures in children. Injury. 2006;37:961–965.

    Article  PubMed  Google Scholar 

  49. Skaggs DL, Cluck MW, Mostofi A, Flynn JM, Kay RM. Lateral-entry pin fixation in the management of supracondylar fractures in children. J Bone Joint Surg Am. 2004;86:702–707.

    PubMed  Google Scholar 

  50. Skaggs DL, Hale JM, Bassett J, Kaminsky C, Kay RM, Tolo VT. Operative treatment of supracondylar fractures of the humerus in children: the consequences of pin placement. J Bone Joint Surg Am. 2001;83:735–740.

    PubMed  Google Scholar 

  51. Skaggs DL, Kay RM, Tolo VT. Fracture stability after pinning of displaced supracondylar distal humerus fractures in children. J Pediatr Orthop. 2002;22:697; author reply 697–698.

    Google Scholar 

  52. Slobogean BL, Jackman H, Tennant S, Slobogean GP, Mulpuri K. Iatrogenic ulnar nerve injury after the surgical treatment of displaced supracondylar fractures of the humerus: number needed to harm, a systematic review. J Pediatr Orthop. 2010;30:430–436.

    Article  PubMed  Google Scholar 

  53. 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.

    Article  PubMed  CAS  Google Scholar 

  54. Tripuraneni KR, Bosch PP, Schwend RM, Yaste JJ. Prospective, surgeon-randomized evaluation of crossed pins versus lateral pins for unstable supracondylar humerus fractures in children. J Pediatr Orthop B. 2009;18:93–98.

    Article  PubMed  Google Scholar 

  55. Vaidya SM. Percutaneous fixation of displaced supracondylar fracture in children comparing lateral with medial and lateral pin. A thesis submitted to university of Seychelles American institute of medicine. 2009. Available at: http://www.mch-orth.com/pdf/Thesis%20by%20Dr.Sudeep%20Vaidya.pdf. Accessed April 17, 2013.

  56. Wang X, Feng C, Wan S, Bian Z, Zhang J, Song M, Shao J, Yang X. Biomechanical analysis of pinning configurations for a supracondylar humerus fracture with coronal medial obliquity. J Pediatr Orthop B. 2012;21:495–498.

    Article  PubMed  Google Scholar 

  57. Woratanarat P, Angsanuntsukh C, Rattanasiri S, Attia J, Woratanarat T, Thakkinstian A. Meta-analysis of pinning in supracondylar fracture of the humerus in children. J Orthop Trauma. 2012;26:48–53.

    Google Scholar 

  58. Yen YM, Kocher MS. Lateral entry compared with medial and lateral entry pin fixation for completely displaced supracondylar humeral fractures in children: surgical technique. J Bone Joint Surg Am. 2008;90(suppl 2 pt 1):20–30.

    PubMed  Google Scholar 

  59. Zamzam MM, Bakarman KA. Treatment of displaced supracondylar humeral fractures among children: crossed versus lateral pinning. Injury. 2009;40:625–630.

    Article  PubMed  Google Scholar 

  60. 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.

    PubMed  CAS  Google Scholar 

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Acknowledgments

We thank the professional staff of Tianjin Medical Information Center and Tianjin Medical Library for providing assistance. We also thank the patients and clinical researchers who were involved in the publications mentioned in our article.

Author information

Authors and Affiliations

  1. Department of Orthopaedic Surgery, Tianjin Hospital, No. 406 Jiefang South Road, Hexi District, Tianjin, 300211, China

    Jia-Guo Zhao MD

  2. Department of Traumatic Orthopaedics, Tianjin Hospital, Tianjin, China

    Jia Wang MD, PhD

  3. Department of Orthopaedic Surgery, Second Affiliated Hospital of Soochow University, Suzhou, China

    Peng Zhang MD

  4. Department of Orthopaedic Surgery, Clinical College of Orthopaedics, Tianjin Medical University, Tianjin, China

    Jia-Guo Zhao MD & Jia Wang MD, PhD

Authors
  1. Jia-Guo Zhao MD
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  2. Jia Wang MD, PhD
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  3. Peng Zhang MD
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Correspondence to Jia-Guo Zhao MD.

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Appendix 1. Detailed characteristics of included studies

Appendix 1. Detailed characteristics of included studies

Variable

Foead et al. [14]

Kocher et al. [28]

Tripuraneni et al. [54]

Vaidya [55]

Gaston et al. [16]

Anwar et al. [2]

Maity et al. [35]

Year

2004

2007

2009

2009

2010

2011

2012

Design type

RCT

RCT

Quasi-RCT

RCT

Quasi-RCT

RCT

RCT

Populations

 Number

  Lateral group

27

28

20

29

47

25

80

  Crossed group

28

24

20

31

57

25

80

 Age (years)

5.78

    

7.02

 

  Lateral group

 

6.1

4.3

5.8

5.7

 

6.12

  Crossed group

 

5.7

5.5

6.2

6.2

 

6.24

 Male: female

Unclear

 

Unclear

  

33:17

 

  Lateral group

 

10:18

 

21:8

22:25

 

51:29

  Crossed group

 

13:11

 

17:14

31:26

 

48:32

 Gartland type

II and III

III

II and III

III

III

II and III

II and III

 Inclusion criteria

Closed extension fracture; within 72 hours of injury

Closed extension fracture; within 48 hours of injury

No restriction for open, multiple and compound fracture (total 3 patients)

Closed fracture; within 96 hours of injury

Closed extension fracture; within 24 hours of injury

Closed fracture; within 72 hours of injury

Closed extension fracture; within 72 hours of injury

 Exclusion criteria

Multiple fracture; compound fracture; previous fracture

Multiple fracture; compound fracture; previous fracture; open reduction

Revision fixation cases

Multiple fracture; compound fracture; previous fracture; open reduction

Inadequate perioperative radiographs

Neurovascular complications; open reduction and internal fixation

Multiple fracture; compound fracture; previous fracture; open reduction

Interventions

  Lateral group

Closed reduction and two lateral pins

Closed reduction and two lateral pins

Closed reduction and two lateral pins; 8 patients with a third pin

Closed reduction and two or three lateral pins

Closed reduction and two lateral pins; 5 patients with a third pin; 3 open reductions

Closed reduction and two lateral pins

Closed reduction and two lateral pins

  Crossed group

Closed reduction and two crossed pins

Closed reduction and two crossed pins

Closed reduction and two crossed pins; 5 patients with a third pin; one open reduction

Closed reduction with one medial and one or two lateral pins

Closed reduction and two crossed pins; 8 patients with a third pin; 5 open reduction

Closed reduction and two crossed pins

Closed reduction and two crossed pins

Outcomes

 Radiographic outcomes

Change in carrying angle, Baumann angle, and medial epicondylar epiphyseal angle

Baumann, carrying and humerocapitellar angle; change in Baumann and Humerocapitellar angle; loss of reduction

Baumann angle, Humerotrochlear angle

Change in carrying angle, change in Baumann and Humerocapitellar angle; loss of reduction

Humerocapitellar angle; change in Baumann and Humerocapitellar angle; loss of reduction

Change in Baumann angle; loss of carrying angle; loss of metaphyseal diaphyseal angle

Baumann and carrying angle; change in Baumann angle; loss of carrying angle; loss of reduction

 Functional outcomes

Loss of extension and flexion

Range of motion; Flynn criteria; return to function

Range of motion

Range of motion; Flynn criteria; return to function

 

Flynn criteria; loss of extension and flexion

Range of motion; Flynn criteria

 Complications

Iatrogenic nerve injury; infection; vascular injury; compartment syndrome

Iatrogenic nerve injury; infection; reoperation

Iatrogenic nerve injury; infection

Iatrogenic nerve injury; infection; reoperation

Iatrogenic nerve injury; reoperation; compartment syndrome

Iatrogenic nerve injury; compartment syndrome

Iatrogenic nerve injury; infection

Followup

8.9 months

3 months

 

6 months

Unclear

6 months

3 months

  Lateral group

  

65.1 days

    

  Crossed group

  

54.6 days

    
  1. Quasi-RCTs were defined as those in which randomization is inadequately concealed (ie, patients are allocated according to known characteristics such as date of birth, hospital chart number, or day of presentation); RCT = randomized controlled trial.

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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 471, 2942–2953 (2013). https://doi.org/10.1007/s11999-013-3025-4

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