EL-MINIA MED. BULL. VOL. 21, NO. 2, JUNE, 2010
El-Fouly
PERCUTANEOUS LATERAL CROSS PINNING FOR SUPRACONDYLAR
FRACTURES IN CHILDREN
By
Ezzat El-Fouly, MD
Department of Orthopedic,
Minia Faculty of Medicine, Egypt.
ABSTRACT:
Twenty five children with displaced type II and III supracondylar fractures of
the humerus were managed with percutaneous lateral cross-wiring technique from
April 2009 to May 2010. There were 16 boys and 9 girls with a mean age of 6.5 years.
All patients were operated within 24 h after trauma using the Dorgans percutaneous
lateral cross-wiring technique. Patients were followed up for a mean period of 9
months and assessed radiologically for union, functionally and cosmetically according
to Flynn’s criteria. All patients achieved solid union. Cosmetically, all patients
achieved satisfactory results, while functionally, 96% of patients had satisfactory
results and 4% had fair result. There was no iatrogenic neurological injury either for
the ulnar or for the radial nerves.
KEYWORDS:
Humeral supracondylar fracture
Lateral cross
Percutaneous pinning
Wiring technique
utilizing three lateral diverging pins.
The least stable was fixation with two
lateral pins, which crossed at the
fracture site. While medial–lateral
cross pinning has the greatest
resistance; the disadvantage is the risk
of ulnar nerve injury4,5,6,7 and 8.
INTRODUCTION:
Extension type supracondylar
fracture of the humerus is the most
common fracture around elbow in
children. It is usually treated as an
emergency manner in children. There
has been an argument concerning the
ideal method of treatment of displaced
supracondylar
humeral
fractures.
Closed reduction with percutaneous
crossed K-wires has gained support as
the preferred method of treatment for
supracondylar humerus fractures in
children1,2. There are various options
for the pattern of K-wire fixation of
displaced supracondylar fractures.
The crossed K wire fixation
method was modified to achieve the
same stability and avoid ulnar nerve
injury, so the aim of the present study
is to re-evaluate the results of
percutaneous
lateral
cross-wiring
technique in treatment of unstable
supracondylar humeral fractures in
children.
Zionts et al.3 measured the
biomechanical stability of different
fixations of adult human cadaver
models. They found the greatest
resistance to rotation occurred with
medial–lateral cross pinning. The
second most stable pattern was fixation
PATIENTS AND METHODS:
In this study patients with
operatively treated
supracondylar
fractures of humerus were evaluated.
Gartland’s classification was utilized9.
Between April 2009 and May 2010, 25
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EL-MINIA MED. BULL. VOL. 21, NO. 2, JUNE, 2010
patients with type II and III fractures
were treated with percutaneous lateral
cross-wiring technique in the Orthopedic Department, Minia Faculty of
Medicine, Egypt. Our treatment was to
perform a closed reduction followed by
lateral cross pin fixation. Treatment
was performed as soon as possible
after the initial trauma. On presentation, patients were fully assessed
clinically both generally and locally.
Special attention was paid to peripheral
circulation and neurological status.
El-Fouly
technique, as shown in Fig. [1].
Stabilization of the fracture was
achieved by the introduction of two
lateral Kirschner wires. The first pin
was introduced starting from the lateral
condyle in a retrograde direction
(ascending) to advance to cross the
fracture site until it perforates the
contra-lateral cortex. The second pin
was introduced in an antegrade
(descending) direction passing through
the lateral supracondylar ridge downwards and inwards into the medial
condyle. It is not allowed to project
beyond the far boundary of the condyle
to prevent it from irritating the ulnar
nerve.
Patients are excluded in cases
of failure of closed reduction, open
fracture, and when the patients had
first treatment in another hospital.
Wires were bent, cut and kept
proud to facilitate removal of K wires.
Above elbow plaster splint was applied
for a period of 3 weeks, at the end of
which active assisted mobilization was
started. Patients were examined on 5th
day, 3 weeks, 6 weeks and 3 months
for assessment of nerve injury,
stiffness, deformity, elbow range of
motion. Wires were removed on the
appearance of callus, which was 3-5
weeks. Clinical evaluation of the final
follow-up was based on the carrying
angle and the arc of flexion–extension
of both the injured and uninjured
elbows. Radiographic assessment of
both elbows was performed using the
Baumann’s angle and humero-ulnar
angle for adults. At each follow-up,
patients were assessed both radiologically for union, cosmotically and
functionally according to Flynn’s
criteria5.
The mean age was 6.5 years
(range 2–13 years 8 months). Patients
were 16 males (64%) and 9 females
(36%). There were 19 right and 6 left
elbows. All were extension-type
injuries. There were 4 type II and 21
type III fractures. Most of the injuries
were due to falling during running. The
mean follow-up was 9 months (4– 12
months).
Surgical technique
The patients are placed in a
supine position. The first reduction
maneuver is performed with traction
applied to the forearm. The assistant
applies countertraction at the shoulder.
After the successful reduction maneuver, the pulse and capillary perfusion
of the hand are evaluated. All patients
were operated on within 24h after
trauma, utilizing the ‘‘Dorgan’s’’
percutaneous
lateral
cross-wiring
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EL-MINIA MED. BULL. VOL. 21, NO. 2, JUNE, 2010
El-Fouly
Fig. 1: Pin configuration stabilizing supracondylar humerus fractures.
A) Commonly used crossed pin fixation. B) Lateral crossed pin fixation.
between 10 and 30. The patient with an
increased shaft-condylar angle had an
extension deficit of 20. There were no
cases of secondary displacement. The
three patients with a humeral shaft
angle of less than 30 had a bad initial
reduction.
RESULTS:
The results were separated into
one of three major categories: (1)
radiographic, (2) functional, and (3)
cosmetic, according to Flynn’s
criteria5.
In this study, prompt surgical
treatment was always available. Of the
25 children that were treated
surgically, all had surgery on the day
of the injury. The mean hospital stay
was 2.2 days (range 1–4 days).
Functional results:
The functional results of 25
patients with type II and III were
evaluated using Flynn’s score [3]. From
the 25 patients 20 had an excellent
result, 4 had a good result. One child
had a fair result.
Radiographic results:
All patients had solid union. In
21 of these 25 patients (84%), the
humeral shaft-condylar angle was felt
to be normal, ranging between 30 and
40. Three of the children (12%),
however, had an angle of less than 30.
There was an angle of greater than 40
in one child (4%). One of the three
patients with a diminished shaftcondylar angle had a loss of flexion of
Cosmetic result:
Using Flynn’s score10, the
cosmetic results were better than the
functional results.
A total of 23 out of 25 children
had an excellent result; two had a good
result. There were no patients
developed a cubitus varus
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EL-MINIA MED. BULL. VOL. 21, NO. 2, JUNE, 2010
El-Fouly
b) Vascular problems
One of the patients presented
with a pulseless forearm and hand
following an initial injury. The pulse
was restored following a closed
reduction of the fracture.
Problems
a) Pin problems; Two cases required a
short term antibiotic treatment for
superficial pin infections. There were
no deep pin infections in any of the
cases
Fig. (2) Case: 1 An 11-year-old girl with type II displaced supracondylar fracture of
the left humerus and early post op.
Fig. (3): After 6 months of follow-up both
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EL-MINIA MED. BULL. VOL. 21, NO. 2, JUNE, 2010
El-Fouly
Fig. (4) Case 2: A 5-year-old boy with type III supracondylar fracture
of the left humerus and early postop.
Fig. 5 After 8 months of follow-up
Fig. (6) Case3: A 5-year-old girl with type III displaced supracondylar fracture of the
right humerus and its early follow up
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EL-MINIA MED. BULL. VOL. 21, NO. 2, JUNE, 2010
El-Fouly
Fig. (7) Case 4: A10 years old boy with type III supracondylar fracture of right
humerus and early postop.
Fig. 8: One year follow up
low rate of complications. There has
been no uniformity of opinion
concerning the ideal method of
treatment of displaced supracondylar
fractures.
DISCUSSION:
Displaced supracondylar humeral fractures in children may be
associated with vascular, neurological
and infectious complications in
addition to difficulties in achieving and
maintaining a satisfactory reduction31–
33
. Many authors have expressed the
opinion that emergent treatment of
these fractures is necessary to avoid
such complications35–39.
Although, there are some
reports feel that the optimal anatomic
reconstruction of the fracture could be
achieved with an open reduction [19],
the most current literatures reported
that closed reduction and percutaneous
pinning is the treatment of choice in
most
pediatric
trauma
centers3,11,12,13,14,15,16,17,18. The two-
The treatment of displaced
supracondylar fractures should be
minimally invasive and should have a
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EL-MINIA MED. BULL. VOL. 21, NO. 2, JUNE, 2010
wire cross-fixation is the most
commonly used and good results have
been reported, but injury of the ulnar
nerve when inserting the medial wire
has been documented ranging from 2
to 8%26–30. In the present study, we
studied the recently introduced
Dorgan’s percutaneous lateral crosswiring technique for supracondylar
humeral fractures performed from the
lateral side. The crossed-wire configuration obtained by inserting both wires
from the lateral side is identical to that
obtained via the traditional medial and
lateral technique.
El-Fouly
only 76% were found to be
acceptable25. With this technique a
success rate of more than 90% of
excellent and good results can be
expected.
Ends of the wires I leave
outside the skin wound so that these
can, later, be pulled out without anaesthesia. This does sometimes give me a
little superficial infection at the skin
pin interface but it is harmless. And a
second operation for the removal of the
wires is avoided. In our circumstances,
it is significant as most of our patients
are too poor to afford it.
The descending pin should not
perforate the medial condyle more then
1–2 mm to avoid ulnar nerve injury.
This could be verified by flouroscopy
when drilling the pin. Ulnar nerve
neuropraxia22,23,24 was not encountered
in this series at either the initial
presentation or after the reduction and
pin fixation. This compares to another
large series using exclusively a lateral
approach but in a different pin
configuration17, which was felt to
avoid ulnar nerve damage.
Conclusion
We are of the opinion that
treatment of choice in type II and III
fractures is first a closed reduction
followed by percutaneous pin stabilization.
Within the obtained results of
the present study, we have confirmed
that the lateral crossed pinning technique gives excellent stability achieved
with crossed pins while having the
advantage of avoiding injury to the
ulnar nerve.
The functional results using
Flynn’s score were good to excellent in
24 (96%) of the children treated, these
results were similar to a series from
France, in which 96% excellent and
good results were achieved13.
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complication after K-wire fixation of
supracondylar fractures of the humerus
in children. J Pediatr Orthop 11:191–
194
29. Skaggs DL, Hale JM, Bassett J
et al (2001) Operative treatment of
supracondylar fractures of the humerus
in children. The consequences of pin
placement. J Bone Joint Surg Am
83A:735–740
152
‫‪El-Fouly‬‬
‫‪EL-MINIA MED. BULL. VOL. 21, NO. 2, JUNE, 2010‬‬
‫الملخص العربى‬
‫فى هذا البحث قد تم عالج خمسة وعشرين من األطفال الذذين ياذانون مذن النذوث ال ذان‬
‫وال الث من كسور اسفل عظذم الادذد فذول الة مذة بواسذطة ت نيذة بديذدد باسذتخدام األسذال عذن‬
‫طريق البةد من الناحية الوحشية لةادد من ابريل‪ 2009‬الى مايو ‪.2010‬و قد كان هنا ‪16‬‬
‫من الفتيان و‪ 9‬من الفتيات ف متوسط سن ‪ 6.5‬عام‪ .‬وتذم ابذراا البراحذة لبميذم المردذى فذ‬
‫غدون ‪ 24‬ساعة باد االصابة باستخدام طري ة دوربذان )‪ . )Dorgan‬وتذم متاباذة المردذى‬
‫لمدد متوسطها ‪ 9‬أشذهر عذن طريذق مراباذة االشذاات والوظيفذة والشذكل الاذام لةطذر الاةذو‬
‫وف ا لماذايير‪. Flynn‬وقذد ح ذت نتذامر مردذية لبميذم المردذى ‪ .‬ولذم يكذن هنذا أ صذابات‬
‫لةاصب الزند او الاصب الكابر نتيبة استخدام هذه الت نية‪.‬‬
‫‪153‬‬