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 Table of Contents  
ORIGINAL ARTICLE
Year : 2013  |  Volume : 6  |  Issue : 1  |  Page : 78-83

Percutaneous lateral Kirschner wire fixation in pediatric supracondylar fractures of humerus


Department of Orthopedics, SMS and RI Sharda University, Greater Noida, Uttar Pradesh, India

Date of Web Publication23-Sep-2013

Correspondence Address:
Ramji Lal Sahu
11284, Laj Building No. 1, Doriwalan, New Rohtak Road, Karol Bagh, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0975-7341.118749

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  Abstract 

Aim: This prospective study was conducted to know the outcome of percutaneous lateral pinning in the management of displaced supracondylar fracture of humerus in children. Settings and
Designs:
Prospective study. Materials and Methods: Eighty five patients with displaced supracondylar fractures admitted between July 2005 and July 2010 were recruited into the study. All patients were operated under general anesthesia within 24 h after trauma using the percutaneous 2-lateral pin fixation (n = 85). Results were analyzed using Flynn's criteria. All patients were followed up to 6 months post-operatively. Results: Eighty five displaced supracondylar fractures of humerus, aged between 1½ year and 13 years, were treated using close reduction and percutaneous Kirschner (K) wire fixation under the c-arm image intensifier. Above elbow plaster of paris back slab was applied in all cases for at least 4 weeks. The slab and K-wires were removed after 4 weeks and elbow range of motion exercise was started. 68.23% had excellent, 29.40% good, 1.17% fair and 1.17% had poor results at 8 th weeks, which was improved to 91.75% excellent, 7.05% good, 1.17% fair and no poor result at final follow-up. There was no iatrogenic neurological injury either for the ulnar or for the radial nerves. Five patients developed superficial pin tract infection post-operatively and were treated conservatively with good healing and no long-term sequelae. Conclusion: Closed reduction and percutaneous lateral pinning proved an efficient, reliable, and safe method in the treatment of displaced supracondylar fractures of the humerus in children.

Keywords: Close reduction, humerus, percutaneous pinning, supracondylar fracture


How to cite this article:
Sahu RL. Percutaneous lateral Kirschner wire fixation in pediatric supracondylar fractures of humerus. J Orthop Traumatol Rehabil 2013;6:78-83

How to cite this URL:
Sahu RL. Percutaneous lateral Kirschner wire fixation in pediatric supracondylar fractures of humerus. J Orthop Traumatol Rehabil [serial online] 2013 [cited 2019 Jul 21];6:78-83. Available from: http://www.jotr.in/text.asp?2013/6/1/78/118749


  Introduction Top


Supracondylar fractures of the humerus represent 50-70% of all elbow fracture in children in the first decade of life. [1] Current method of treatment of this fracture is based on Gartland classification. Flynn et al. reported the incidence of cubitus varus deformity after treatment was 5% whereas Ariño et al. reported that it was almost 21%, ulner nerve deficit was found in 15% of patients who were treated with medial and lateral pin as per the report of chai. [2],[3],[4],[5] Many different methods are described such as close reduction and long arm cast or slab, Dunlop skin traction, olecranon traction, but all of these methods had large complication rate. [1],[2],[6],[7],[8],[9],[10],[11],[12] The current preferred method of treatment for displaced supracondylar fracture has been close reduction and percutaneous pin fixation. This method has given excellent results reported by various authors. [10],[11],[12],[13],[14],[15] This prospective study was conducted to know the outcome of percutaneous lateral pinning in the management of displaced supracondylar fracture of humerus in children, at the same time to see the possibility of complication like iatrogenic ulner nerve palsy. [16],[17],[18]


  Materials and Methods Top


This prospective study was carried out at Orthopedics Department of M.M. Medical College from July 2005 to July 2010. It was approved by institutional medical ethics committee. A written informed consent was obtained from all the patients (by their parents). [19],[20] A total of 85 children with fractures supracondylar of humerus Grade III, closed were included in this study. The patients were aged between 1½ year and 13 years with the mean age of 7.76 years. We excluded Grade I and Grade II fractures and open fractures. Type III fractures are completely displaced and lack cortical contact. With the patient in the supine position, we measured the carrying angle pre- and post-operatively at the shoulder in 0° flexion and 0° extension, full extension of the elbow, and the supinated position of the forearm at the lesion side. The carrying angle also was measured on the patients' unaffected side. The axis of the arm was defined distally at the midpoint between the medial and lateral epicondyles of the humerus and proximally at the lateral border of the cranial surface of the acromion. The axis of the forearm was defined distally at the midpoint between the distal radial and ulnar styloid processes and proximally at the midpoint between the medial and lateral epicondyles of the humerus. The carrying angle was measured with a manual goniometer with two drawing axes of the arm and forearm. To verify the carrying angles measured with the goniometer, radiographic examinations of the acromion-elbow-wrist axis were performed with the patients' elbows supinated and with patients in a supine position. All patients were operated under general anesthesia within 24 h after trauma using the percutaneous 2-lateral pin fixation (n = 85). The patients were evaluated as described by Flynn and the results compared with the contra lateral normal elbow. [2] Under general anesthesia, using c-arm image intensifier, closed reduction was done. The forearm was then pronated and the elbow acutely flexed and held temporarily by adhesive tape. Pronation de-rotates the distal fragment from its frequently medially rotated position and locks it in correct alignment. [21] When satisfactory reduction had been achieved then fixation was done by two parallel or divergent lateral K-wires of 1.5 or 2.0 mm size [Figure 1], [Figure 2], [Figure 3], [Figure 4]. In the lateral fixation technique, two pins were inserted from the lateral aspect of elbow across the lateral cortex to engage the medial cortex keeping the elbow in hyperflexion. Pins were placed either in parallel or divergent configuration with the adequate separation at the fracture site. Fracture stability was assessed by screening the fracture under varus/valgus, flexion/extension and rotational stresses and carrying angle was checked by extending the elbow. During this study, five children required medial pinning due to comminution at medial condyle. I had not included these children in the study.
Figure 1: Pre-operative anterior-posterior and lateral radiograph showing supracondylar fracture of humerus of 6-year-old child

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Figure 2: Post-operative anterior-posterior radiographs of supracondylar fracture of humerus showing with two lateral K-wire fixations

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Figure 3: Post-operative lateral radiographs of supracondylar fracture of humerus showing with 2 lateral K-wire fixations

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Figure 4: Follow-up radiographs of supracondylar fracture of humerus

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The pins were bent and cut off outside the skin and a well-padded, above-elbow, posterior back-slab was applied. The elbow could be held in any position without losing the reduction, and the optimum position, usually 60-90° of elbow flexion, allowed free blood flow. The patient was carefully observed for 12-72 h (average 58 h) and then discharged. The above-elbow plaster of paris (POP) back slab was kept for 4 weeks and pins and slab were removed in the outpatient department clinic. Elbow range of motion (ROM) was started after removing the POP back slab. The follow-up was arranged as follows: the first follow-up on the 7 th day to inspect the wound; the second follow-up on the 2 nd week for wound inspection or suture removal and to see the pin configuration; the 3 rd follow-up on the 4 th week for the removal of plaster slab and pins and to start physiotherapy; the 4 th follow-up on the 8 th week post-operatively to see the ROM and carrying angle of the elbow; and the final follow-up on the 6 months post-operatively to see the final result of the study.


  Results Top


There were 85 children in this study, 67 children were male and 18 children were females. The children were aged 1.5 years to 13 years. There were 45 left sided and 40 right-sided fractures. 54 children had injury during playing, 24 children had met with a road traffic accident and 7 had a fall from a height. All were closed fractures. The extension type was 72 (84.70%) and flexion type 13 (15.29%). All the cases were treated by two lateral parallel or divergent K-wires. In three cases, we were unable to reduce the fracture by close means due to displacement and rotation of the fragment. Therefore, we reduced the fracture by opening the fracture site. Pre-operatively, five cases had nerve injuries (median nerve two, ulnar nerve two and radial nerve one) and there were no cases of vascular injuries. During follow-up, we did not found secondary displacement of wires and loss of reduction. Post-operatively, five (5.88%) patients got pin tract infection, which was superficial and healed after removing pins and oral antibiotic administration. Post-operatively there was no ulnar nerve injury in any patients. All nerve injuries (pre-operative) recovered within 3½ months post-operatively. Callus formation was seen in all patients at the 4 th week post-operatively before removing the K-wires. The fracture united in all cases at the 4 th week post-operatively. Results were analyzed using Flynn's criteria. [2] All patients were followed at 8 th week, 16 week and the 24 weeks post-operatively. 68.23% had excellent, 29.40% good, 1.17% fair and 1.17% poor results at 8 weeks, which was improved to 91.75% excellent, 7.05% good, 1.17% fair and no poor result at the final follow-up [Table 1] and [Table 2]. In my study, there was an inappropriate fixation in one case where two pins, which is too close and work as one pin, though reduction was maintained and the union had occurred without deformity. Child was kept in close follow-up. During this study, complications like vascular injury, compartment syndrome, myositis ossifications, significant mal-union and non-union were not seen. No loss of carrying angle or varus deformity was noted clinically [Figure 1], [Figure 2], [Figure 3], [Figure 4].
Table 1: Flynn et al. criteria for grading


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Table 2: Final results of lateral K-wire fixation of supracondylar fracture humerus


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  Discussion Top


Management of displaced extension Type III supracondylar fracture of humerus treated by close reduction and percutaneous pin fixation has consistently given satisfactory result compared to other method of treatment. However, controversy persists regarding the adequate pin fixation technique comparing lateral pin fixation with medial and lateral pin fixation. In this study, we found fracture fixation was stable and there was no ulnar nerve injury. The medial and lateral pin fixation method supposed to have the advantage of better fracture stability, although iatrogenic ulnar injury can occur with this technique. Conversely, lateral pin entry has the advantage of avoiding ulnar nerve injury but this construct has been thought to be biomechanically less stable. Lee et al. and Zionts et al. reported that medial and lateral entry provides greater torsional rigidity than lateral entry pin fixation does. [19],[20] The total strength of this construct is not only related to pin entry but mainly to divergence of the pins in a different column and number of pins. The greater strength seen with the divergence of the pins was related to the location of the interaction of the two pins and the fact that the greater amount of divergence between the two pins allow for some purchase in the medial and lateral column. [19],[20] There are some authors who advocated the use of the third wire to prevent the displacement of the distal fragment. [22],[23] The use of a third pin requires the medial pin to enter the joint and thus increases the risk of joint penetration and infection. We preferred the use of two pins laterally to decrease the risk of infection. Skaggs

et al. [13] found no ulnar nerve palsy and no reduction was lost in 124 children managed with only lateral-entry pins. In another study of Skaggs et al. [14] Of 204 children who had a Gartland Type III fracture, 51 were treated with lateral pins only and 153 were treated with crossed pins. The configuration of the pins did not affect the Baumann's angle in Gartland Type III fractures. Reynolds and Jackson [24] found no differences in results between the two different methods. The most common complication in the treatment of closed reduction and percutaneous pinning of displaced supracondylar fractures of the humerus is iatrogenic ulnar nerve palsy with the use of medial pin. [18],[25],[26],[27],[28] The rate of ulnar nerve injuries varies in different studies. Lyons et al. [18] have reported this number as 6%, Royce et al. [26] as 3%, Agus et al. [27] as 58%. It is found that post-operative nerve palsies after percutaneous pinning was with direct injury to the nerve, not after manipulation of closed reduction. [11],[25],[26],[29] Skaggs et al. [14] Noted the incidence of ulnar nerve injury as 4% in patients whom the pins were applied without hyper flexion of the elbow and as 15% in whom the medial pin was applied with the elbow hyperflexed. Different techniques are performed to decrease the rate of ulnar nerve injury. It is also showed that lateral-pins decrease the rate of ulnar nerve injury when compared with medial-pins. In the present study, there was no incidence of ulnar nerve injury where pinning was done from the lateral side; and we did not find delayed union and malunion. Skaggs found that the use of lateral-entry pins alone was effective for even the most unstable supracondylar humeral fractures and they saw no iatrogenic ulnar nerve injuries and no reduction was lost. [13],[14] Although most of the ulnar nerve injuries recover spontaneously between 4 months and 6 months, permanent damage has been reported in the literature. [26],[27] Lyons et al. [18] Observed spontaneous functional recovery after the removal of medial pin. However, Rasool [30] advocated the early exploration of the nerve. Clawing of the fingers may occur rarely after ulnar nerve injuries. Pathological electromyographic measurements can be detected in most of the ulnar nerve injuries during the early post-operative period. In this study, the results of lateral pin insertion at 8 th post-operative week showed excellent results in around 70% of patients. At the final follow-up, these excellent results were seen in around 90% of the cases. In post-operative period, physiotherapy plays a significant role in increasing the ROM of the elbow joint. Those patients who had good or fair results were having severe soft tissue injuries or repeated closed reduction. Khan obtained 88% excellent, 4% good and 4% poor results in his study. [31] Tiwari observed 88% satisfactory results, among which 42% were excellent, in his series of late-presenting supracondylar fractures of humerus in children. [32] These two studies are comparable to our study. Cubitus varus deformity is the most common problem seen after the treatment of supracondylar fractures. The cause of the deformity is coronal rotation, or tilting of the distal fragment. [33] Some investigators believed that varus deformity is due to epiphyseal growth disturbance or rotation of the distal fragment. [34] Smith suggested that residual medial tilt after reduction is the most important factor in varus angulations, with isolated rotational deformities being corrected by compensatory rotation at the shoulder. [35] This concept has become popular in understanding the sequel of alteration in carrying angle. [36] In this series, five patients (5.88%) had nerve injury pre-operatively, out of which two had median, two ulnar and one radial. Not any patients got ulnar nerve injuries post-operatively. All the nerve injuries (pre-operative) recovered within 14 weeks post-operatively. The incidence of post-operative has been estimated to range from 5% to 19%. [37] Culp recommends that initial observation and supportive therapy for neural injury associated with a closed, displaced, supracondylar fracture of the humerus; and that if there is no clinical or electromyography evidence of return of neural function at 5 months after injury, exploration and neurolysis should be performed. If the nerve is in continuity, the prognosis after neurolysis is excellent. [38] In the present series, five (5.88%) patients developed pin-tract infections, which were superficial and healed after removing pins and administration of oral antibiotics. No deep infection or septic arthritis was found. Pirone found superficial pin-tract infection in 2% of cases with no deep infection and septic arthritis. [39] In the present series, the distal pin migration was not seen in any patients. Gordon observed pin-tract migration in 6% of cases and Lee noticed the loss of reduction in 7% of cases. [12],[19] Lee et al. [40] stated that the lateral pinning technique was found to be more beneficial than the medial and lateral crossed pinning technique for supracondylar fractures of the humerus in children, on the basis of current evidences. However, the results were sensitive to the data of ulnar nerve injury. Avoiding the worst clinical scenario (permanent ulnar nerve palsy) might be more important and affordable than obtaining favorable clinical results (stable fixation) at the potential cost of disastrous complications. Dua et al. [41] proposed that Closed reduction and crossed pinning of displaced supracondylar fractures of humerus in children is a safe and effective method even with delayed presentation. Erpelding et al. [42] stated that open treatment of distal humeral fractures with an extensor mechanism-on approach results in excellent healing, a mean elbow flexion-extension arc exceeding 100°, and maintenance of 90% of elbow extension strength compared with that of the contra lateral, normal elbow. Woratanara et al. [43] stated that Lateral pinning is preferable to cross pinning for fixation of pediatric supracondylar humerus fractures as a result of decreased risk of ulnar nerve injury. A potential limitation of our study was the absence of a control group treated by a different modality. Thus, we cannot actually determine if any other method of treatment would have led to different results. Nevertheless, our results are better than those of the previous studies in which medial-lateral pin fixation have been used. None of the patients in our series lost to follow-up. In my study, there was an inappropriate fixation in one case where two pins, which is too close and work as one pin, though reduction was maintained and the union had occurred without deformity. Child was kept in close follow-up. The main goal of the treatment of displaced pediatric supracondylar humerus fractures is to achieve an anatomic reduction. This reduction should be supported by a fixation with a good stability and less morbidity. When all these are taken into consideration, we believe that closed reduction and percutaneous lateral pinning is an efficient, reliable and safe method.

 
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