What is the best fixation technique for the treatment of supracondylar humerus fractures in children?^☆

ABSTRACT

OBJECTIVE:

To define the best technique for the surgical treatment of supracondylar fracture of the humerus (SFH) in children, evaluating percutaneous pinning with side wires vs. cross-pinning.

METHODS:

Randomized controlled trials using the Medline, CAPES, and BIREME. The criteria for inclusion of articles criteria were: (1) randomized controlled trials (RCTs) comparing percutaneous wire fixation techniques, (2) SFH Gartland II B, III, and IV, and (3) children aged 1-14 years. The following were used as main variables: incidence of iatrogenic injury to the ulnar nerve and loss reduction.

RESULTS:

Eight studies were selected (521 patients) comparing surgical treatment with pinning in supracondylar fracture of the humerus in children Gartland II type B, III or IV. Iatrogenic injury to the ulnar nerve was greater with the cross-pinning technique, with RR 0.28 and p= 0.03, while the mini-open technique presented RR 0.14 and p= 0.2. A statistically significant greater loss of reduction in the lateral pinning was observed in FSU Gartland III and IV(p= 0.04).

CONCLUSION:

Based upon this meta-analysis of prospective randomized clinical trials, the following is recommended: (1) percutaneous pinning with lateral wires in supracondylar fractures of the humerus in children classified as Gartland II type B; (2) use of crossed wires for Gartland type III or IV, using the mini-open technique for the medial wire.

Keywords:
Humeral fractures; Fracture internal fixation; Child; Bone wires

RESUMO

OBJETIVO:

Definir a melhor técnica para o tratamento cirúrgico da fratura supracondilar do úmero (FSU) nas crianças e avaliar a pinagem percutânea com fios laterais vs. cruzados.

MÉTODOS:

Revisão de ensaios clínicos randomizados nas bases de dados Medline, Capes, Bireme. Os critérios de inclusão dos artigos foram: (1) Ensaios clínicos randomizados que comparam técnicas de fixação percutânea com fios, (2) FSU Gartland II tipo B, III e IV e (3) Crianças com um a 14 anos. Usamos como principais variáveis: incidência de lesão iatrogênica do nervo ulnar e perda da redução.

RESULTADOS:

Foram selecionados oito estudos (521 pacientes) que comparam tratamento cirúrgico com pinagem em fratura supracondilar do úmero em crianças classificadas como Gartland II tipo B, III ou IV. A lesão iatrogênica do nervo ulnar foi maior com a técnica de pinagem cruzada, apresentou RR 0,28 e p = 0,03, enquanto que na técnica de mini-open encontraram-se RR 0,14 e p = 0,2. Em casos de FSU Gartland III e IV, evidenciou-se maior perda da redução na pinagem lateral, com significância estatística (p = 0,04).

CONCLUSÃO:

Embasado em nossa metanálise com ensaios clínicos randomizados prospectivos, recomendamos: (1) pinagem percutânea com fios laterais em fraturas supracondilar do úmero em crianças classificadas como Gartland II tipo B (2) Uso de fios cruzados para fraturas Gartland tipo III ou IV, com a técnica de mini-open para o fio medial.

Palavras-chave:
Fraturas do úmero; Fixação interna de fraturas; Crianças; Fios ortopédicos

Introduction

Supracondylar fracture of the humerus (SFH) is frequent in the immature skeleton.¹ There is predominance in the left side or the non-dominant side,² and fractures in elbow extension with posterior deviation represent 97% of cases.^2,3

The most widely used classification is that described by Gartland,⁴ which was proposed for fractures with elbow extension mechanism and based on deviations in the coronal plane in elbow radiographs. Type I: undisplaced or minimally displaced, with the anterior humeral line intact. Type II: small deviation, fragments in contact (intact posterior cortex), Type III: complete displacement of the fragments (posterior cortex injury). In 1996, Wilkins proposed the B-type subdivision for SFH in children with rotational deviation.^5-7 In 2006, Leitch et al.⁸ added type IV, which describes multidirectional instability.

Surgical treatment is indicated in types IIB, III, and IV fractures. Closed reduction and pinning stabilization is the most commonly used technique.^9,10 Fixation can be performed with crossed pins⁸ or lateral pins.⁴ A mini-open technique is an option for medial passage.¹¹ The most common complication is cubitus varus (3-57% of cases),¹¹ and is mainly due to poor reduction or loss of reduction during treatment. The most frequent iatrogenic nerve injury is that of the ulnar nerve, with an incidence of 0-6%.¹²

This study aimed to define the best technique recommended by the contemporary literature for surgical treatment of supracondylar fracture of the humerus in children and to evaluate percutaneous pinning with lateral wires vs. crossed wires.

Materials and methods

A systematic review of randomized clinical trials was performed through literature search of PubMed, CAPES, and BIREME databases. The terms “supracondylar fractures,” “percutaneous fixation,” “k-wire,” “children,” “cross pinning,” and “lateral pinning fixation” were used in different combinations. A direct search of studies listed in the references of the articles retrieved was also performed. There was no restriction regarding language of publication. Titles and abstracts of studies retrieved in the electronic search were evaluated, and full texts of selected articles were obtained.

Inclusion criteria were: (1) randomized controlled trials (RCTs) comparing percutaneous fixation techniques using wires, (2) SFH Gartland II types B, III, and IV, and (3) children aged 1-14 years. Exclusion criteria were: repeated study or surgical technique different from that advocated in this study. The two authors (GSQAP and CAAF) independently assessed the methodological quality of included studies using the Detsky Quality Index score (maximum of 21 points).¹³

Main variables considered were incidence of iatrogenic injury of the ulnar nerve and loss of reduction. Recommended secondary findings were radiographic results (Baumann angle, loading angle, humero-capitellar angle, Baumann angle variation, loss of loading angle). Loss of reduction was determined based on Baumann angle change according to the criteria reported by Skaggs et al.¹⁴: (1) no displacement (loss smaller than 6°), (2) moderate displacement (6°-12°), and (3) large displacement (larger than 12°).

Data were analyzed with Review Manager (Revman) 5.1. Heterogeneity of studies was assessed through a standard chi-squared test (I²), considered statistically significant with p> 0.05, and a I² greater than 50% were considered significant heterogeneity. For groups that presented heterogeneity, random effects were applied to selected data.

Relative risks (RR) and risk differences were calculated for dichotomous outcomes. For continuous outcomes, mean differences and 95% confidence intervals (CI) were calculated.

Results

Initially, 85 clinical trials comparing percutaneous pinning in SFH in children were retrieved. Of these studies, 35 were excluded for not being randomized. Of the 50 RCTs, 42 were excluded for duplication and/or surgical technique used. Finally, this study included eight prospective RCTs, comprising 521 patients (Fig. 1). Regarding assessment of methodological quality, the Detsky Quality Index score ranged from 13 to 20 points (average of 15.7).^15-22

Fig. 1
Study design.

Iatrogenic ulnar nerve injury in the treatment of SFH in children was more commonly observed in patients treated with cross-pinning when compared with lateral-only pinning (RR 0.28; 95% CI 0.09-0.87; p= 0.03). Heterogeneity was non-significant, with I²= 0%. Among the eight RCTs included in the study, 12 patients (4.46%) presented iatrogenic injury of the ulnar nerve in the cross-pinning group, vs. only two patients in the other group (0.78%; Fig. 2).

Fig. 2
Comparative analysis to assess iatrogenic injury of the ulnar nerve in 521 patients who underwent percutaneous pinning with Kirschner wires for treatment of supracondylar fracture of the humerus in children.

When RCTs that used mini-open technique for cross-pinning were analyzed, no statistically significant differences were observed (RR 0.14; 95% CI 0.01-2.79; p= 0.20) regarding ulnar nerve injury when compared with lateral pinning (Fig. 3).

Fig. 3
Comparative analysis to assess iatrogenic injury of the ulnar nerve in 272 patients who underwent percutaneous pinning with exclusively lateral or crossed Kirschner wires (with mini-open technique for medial access) for the treatment of supracondylar humeral fracture.

Patients submitted to lateral percutaneous pinning presented greater loss of reduction (32 cases; 15.84%) when compared with those who underwent cross-pinning (26 cases; 12.87%); the difference was not statistically significant (p= 0.35; Fig. 4).

Fig. 4
Comparative analysis to assess loss of reduction among 404 patients who underwent percutaneous pinning with exclusively lateral or crossed Kirschner wires for treating supracondylar humeral fracture in children.

When analyzing patients with SFH Gartland III and IV, a statistically significant (p= 0.04) greater loss of reduction was observed in patients submitted to lateral pinning (21 cases - 20.19%). Loss of reduction was observed in 12 patients (10.71%) in the cross-pinning group (Fig. 5).

Fig. 5
Comparative analysis to assess loss of reduction from 216 patients with SHF Gartland III or IV who underwent percutaneous pinning with exclusively lateral or crossed Kirschner wires .

No statistically significant difference was observed between the two techniques regarding the Baumann angle, Baumann angle variation, loading angle, loading angle variation, humero-capitellar angle, and humero-capitellar angle variation (Figs. 6-9).

Fig. 6
Baumann angle.

Fig. 7
Variation of Baumann angle.

Fig. 8
Loading angle.

Fig. 9
Variation of loading angle.

Discussion

Iatrogenic injury of the ulnar nerve is an important factor to be analyzed when treating SFH using percutaneous pinning with Kirschner wires in children. The incidence of ulnar nerve injury observed in the present study (4.46%) is in agreement with the results previously found in the literature.^15-22 Babal et al.²³ concluded that medial pinning is the leading cause of iatrogenic ulnar nerve injury. Brauer et al.²⁴ demonstrated that use of medial pin increased the incidence of neurologic injury by 1.84 times.

In this meta-analysis, a statistically significant difference was observed in the incidence of iatrogenic injury of the ulnar nerve when comparing techniques of lateral pins vs. crossed pins (p= 0.03), which confirmed the relationship of iatrogenic injury of the ulnar nerve with the passage of a medial pin. Neural recovery usually occurs after 2-2.5 months of observation, but it can take up to 6 months.¹¹ In the studies included in this review, all patients recovered from the neurological deficit during follow-up.

Previous studies have shown that mini-open technique for medial pin presents a low incidence of ulnar nerve injury.¹¹ In this study, no statistically significant difference was observed in the analysis of ulnar nerve injury when using medial pin with mini-open technique.

Regarding loss of reduction, the literature still presents inconsistent results.^18,23,24 In a retrospective study of 345 children with SFH, Skaggs et al.²⁵ observed no difference in relationship to maintenance of fracture reduction when comparing both surgical techniques. In a clinical and biomechanical study, Omid et al.²⁶ found similar stability using divergent, spaced lateral wires when compared with cross-pinning. In a systematic review, Brauer et al.²⁴ observed residual deformity (secondary to loss of reduction) in 3.4% of patients treated with cross-pinning and in 5.9% of patients treated only with lateral pin, a statistically significant result. They concluded that cross-pinning provides greater stability in the wire configuration (they should cross above fracture) and that the probability of deformity or loss of reduction was 58% lower when compared with lateral pinning.

The present meta-analysis did not find a statistical significant difference for loss of reduction when evaluating the totality of patients involved in the studies included. When groups with fractures type III or IV of Gartland were assessed, incidence of loss of reduction was approximately 10% higher in the group with lateral wires, a statistically significant difference (p= 0.04).

Conclusion

Based on this meta-analysis with prospective randomized clinical trials, the authors recommend: (1) percutaneous pinning with lateral wires for SFH in children with Gartland II type B fractures; (2) crossed wires in Gartland type III or IV fractures, with a mini-open technique for the medial wire.

References

• ¹
  Davis RT, Gorczyca JT, Pugh K. Supracondylar humerus fractures in children. Comparison of operative treatment methods. Clin Orthop Relat Res. 2000;(376):49-55.
• ²
  Wilkins KE. Fractures and dislocations of the elbow region. In: Rockwood CA, King RE, Wilkins KE, editors. Fractures in children. 3rd ed. New York: JB Lippincott; 1991. p. 526-617.
• ³
  Cheng JC, Lam TP, Maffulli N. Epidemiological features of supracondylar fractures of the humerus in Chinese children. J Pediatr Orthop B. 2001;10(1):63-7.
• ⁴
  Gartland JJ. Management of supracondylar fractures of the humerus in children. Surg Gynecol Obstet. 1959;109(2):145-54.
• ⁵
  Wilkins KE. Fractures and dislocations of the elbow region. In: Rockwood CA Jr, Wilkins KE, King RE, editors. Fractures in children. 4th ed. Philadelphia: Lippincott-Raven Publishers; 1996. p. 680.
• ⁶
  O'Hara LJ, Barlow JW, Clarke NM. Displaced supracondylar fractures of the humerus in children. Audit changes practice. J Bone Jt Surg Br. 2000;82(2):204-10.
• ⁷
  Skaggs DL, Mirzayan R. The posterior fat pad sign in association with occult fracture of the elbow in children. J Bone Jt Surg Am. 1999;81(10):1429-33.
• ⁸
  Leitch KK, Kay RM, Femino JD, Tolo VT, Storer SK, Skaggs DL. Treatment of multidirectionally unstable supracondylar humeral fractures in children. A modified Gartland type -IV fracture. J Bone Jt Surg Am. 2006;88(5):980-5.
• ⁹
  Buturovic S. Komparacija rezultata lijeèenja preloma distralnog humerusa kod djece prema indikaciji za konzervativno ili operativno rjesenje:doktorska? disertacija. Sarajevo: Univerzitet u Sarajevu, Medicinski fakultet; 2006.
• ¹⁰
  Madjar-Simic I, Talic- Tanovic A, Hadziahmetovic Z, Sarac- Hadzihalilovic A. Radiographic assessment in the treatment of supracondylar humerus fractures in children. Acta Inform Med. 2012;20(3):154-9.
• ¹¹
  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;19:158-63.
• ¹²
  Krusche-Mandl I, Aldrian S, Köttstorfer J, Seis A, Thalhammer G, Egkher A. Crossed pinning in paediatric supracondylar humerus fractures: a retrospective cohort analysis. Int Orthop. 2012;36(9):1893-8.
• ¹³
  Detsky AS, Naylor CD, O'Rourke K, McGeer AJ, L'Abbé KA. Incorporating variations in the quality of individual randomized trials into meta- analysis. J Clin Epidemiol. 1992;45(3):255-65.
• ¹⁴
  Skaggs DL, Cluck MW, Mostofi A, Flynn JM, Kay RM. Lateral- entry pin fixation in the management of supracondylar fractures in children. J Bone Jt Surg Am. 2004;86(4):702-7.
• ¹⁵
  Anwar W, Rahman N, Iqbal MJ, Khan MA. Comparison of two methods of percutaneous K- wire fixation in displaced supracondylar fracture of humerus in children. J Postgrad Med Inst. 2011;25:356-61.
• ¹⁶
  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(1):76-82.
• ¹⁷
  Gaston RG, Cates TB, Devito D, Schmitz M, Schrader T, Busch M, et al. 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(8):799-806.
• ¹⁸
  Kocher MS, Kasser JR, Waters PM, Bae D, Snyder BD, Hresko MT, et al. Lateral entry compared with medial and lateral entry pin fixation for completely displaced supracondylar humeral fractures in children. A randomized clinical trial. J Bone Jt Surg Am. 2007;89(4):706-12.
• ¹⁹
  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.
• ²⁰
  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(2):93-8.
• ²¹
  Mazda K, Boggione C, Fitoussi F, Penneçot GF. Systematic pinning of displaced extension-type supracondylar fractures of the humerus in children. A prospective study of 116 consecutive patients. J Bone Jt Surg Br. 2001;83(6): 888-93.
• ²²
  Vaidya SM. Percutaneous fixation of displaced supracondylar fracture in children comparing lateral with medial and lateral pin [thesis]. University of Seychelles: American Institute of Medicine; 2009. Available from: http://www.mch-orth.com/ pdf/Thesis%20by%20Dr.Sudeep%20Vaidya.
• ²³
  Babal JC, Mehlman CT, Klein G. Nerve injuries associated with pediatric supracondylar humeral fractures: a meta- analysis. J Pediatr Orthop. 2010;30(3):253-63.
• ²⁴
  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(2):181-6.
• ²⁵
  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 Jt Surg Am. 2001;83(5):735-40.
• ²⁶
  Omid R, Choi PD, Skaggs DL. Supracondylar humeral fractures in children. J Bone Jt Surg Am. 2008;90(5):1121-32.

• ☆
  Study conducted at Hospital Manoel Victorino and Hospital Regional de Santo Antonio de Jesus, Salvador, BA, Brazil.

Publication Dates

• Publication in this collection
  Jul-Aug 2017

History

• Received
  31 May 2016
• Accepted
  05 Aug 2016