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Scientific Articles   |    
Lateral-Entry Pin Fixation in the Management of Supracondylar Fractures in Children
David L. Skaggs, MD1; Michael W. Cluck, MD, PhD1; Amir Mostofi, BS1; John M. Flynn, MD1; Robert M. Kay, MD1
1 Division of Orthopaedic Surgery, Childrens Hospital Los Angeles, Mailstop 69, 4650 Sunset Boulevard, Los Angeles, CA 90027. E-mail address for D.L. Skaggs: dskaggs@chla.usc.edu
View Disclosures and Other Information
The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.
Investigation performed at Childrens Hospital Los Angeles, Los Angeles, California

The Journal of Bone and Joint Surgery, Incorporated
J Bone Joint Surg Am, 2004 Apr 01;86(4):702-707
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Abstract

Background: There has been controversy regarding the optimal pin configuration in the management of supracondylar humeral fractures in children. A crossed-pin configuration may be mechanically more stable than lateral pins in torsional loading, but it is associated with a risk of iatrogenic injury to the ulnar nerve. Previous clinical studies have suggested that lateral pins provide sufficient fixation of unstable supracondylar fractures. However, these studies were retrospective and subject to patient-selection bias.

Methods: A displaced supracondylar humeral fracture was fixed with only lateral-entry pins in 124 consecutively managed children. Medical records and radiographs were reviewed to identify any complications, including loss of fracture reduction, iatrogenic ulnar nerve injury, infection, loss of motion of the elbow, and the need for additional surgery. In addition, eight displaced supracondylar humeral fractures that had been reduced and fixed with lateral pins at other institutions and had lost reduction were analyzed to determine the causes of the failures.

Results: Sixty-nine children had a type-2 fracture, according to Wilkins's modification of Gartland's classification system; forty-three (62%) of those fractures were stabilized with two pins and twenty-six (38%), with three pins. Fifty-five children had a type-3 fracture; nineteen (35%) of those fractures were stabilized with two pins and thirty-six (65%), with three pins. A comparison of perioperative and final radiographs showed no loss of reduction of any fracture. There was also no clinically evident cubitus varus, hyperextension, or loss of motion. There were no iatrogenic nerve palsies, and no patient required additional surgery. One patient had a pin-track infection. Our analysis of the eight clinical and radiographic failures of lateral pin fixation that were not part of the consecutive series showed that the loss of fixation was due to fundamental technical errors.

Conclusions: In this large, consecutive series without selection bias, the use of lateral-entry pins alone was effective for even the most unstable supracondylar humeral fractures. There were no iatrogenic ulnar nerve injuries, and no reduction was lost. The important technical points for fixation with lateral-entry pins are (1) maximize separation of the pins at the fracture site, (2) engage the medial and lateral columns proximal to the fracture, (3) engage sufficient bone in both the proximal segment and the distal fragment, and (4) maintain a low threshold for use of a third lateralentry pin if there is concern about fracture stability or the location of the first two pins.

Level of Evidence: Therapeutic study, Level IV (case series [no, or historical, control group]). See Instructions to Authors for a complete description of levels of evidence.

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    References

    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    Charles T Mehlman, DO, MPH
    Posted on April 14, 2004
    Supracondylar Humeral Fractures in Children
    Cincinnati Children's Hospital Medical Center

    To the Editor:

    We read the recent work of Skaggs and his co-authors(1) with great interest, and commend them for their excellent paper. We agree completely with their main point that lateral-entry pinning is the treatment of choice for nearly all displaced supracondylar humeral fractures. Beyond this we would like to raise two cogent issues prompted by their work.

    First, it has been our contention for quite some time that modern approaches to supracondylar humeral fracture care have dramatically diminished associated complications (2,3). In fact, we feel that the most common complication following the operative care of these injuries is now infection. This is borne out by the present series from Children’s Hospital Los Angeles. In light of this we feel that Skaggs et al. FIGURES 1-A and 1-B deserve further discussion. Each figure depicts one or two intra-articular pins. We acknowledge that at times the personality of the fracture may dictate such pin placement, but when circumstances allow, extra-articular pins are always more desirable. Intra-articular pins make any infection (like the one pin tract infection reported by Skaggs) a possible harbinger of septic arthritis.

    We have some experience with a different lateral pin tactic (4) whereby one of the two lateral pins is started superior to the fracture site and directed from the lateral supracondylar ridge across the fractures site into the medial epicondyle. In selected cases this may achieve fracture stability and avoid intra- articular pin placement.

    Second, Skaggs, et al, have described Baumann’s angle as an angle having a “range of 9 degrees to 26 degrees” (1). This actually represents the complement of Baumann’s angle. Ernst Baumann published his experience with supracondylar fractures in the German literature in 1929 (5). In it he clearly depicts an angle (Figure A) on the AP radiograph formed by the intersection of a line drawn through the long axis of the shaft of the humerus and a second line drawn along the flat metaphyseal region adjacent to the capitellar growth plate, thus it is a humerocapitellar angle.

    Fig. A

    Baumann considered the normal value of his angle to vary from 75 degrees to 80 degrees. Many other authors have studied the utility of this angle (6,7,8,9) including Williamson and his Australian co-authors who studied the Baumann angle in 114 children aged 2-13 years and established that the average measurement was 72 degrees (with a 95% confidence interval from 64 degrees-81 degrees)(10). Recently Acton and McNally dug into the history of the Baumann angle and they found that Baumann was well aware of the complement of the humerocapitellar angle and thought that it roughly corresponded to the anatomic carrying angle of the elbow. (11). We see this second point as a technical one for purposes of clarity and respect for history - as the directly proportional relationship between Baumann’s angle (or the “shaft-physeal angle” as suggested by Acton & McNally) and its complement does not change the main point of Skaggs' important paper.

    1 Skaggs DL, Cluck MW, Mostofi A, et al. Lateral-Entry Pin Fixation in the Management of Supracondylar Fractures in Children. J Bone Joint Surg 2004;86-A:702-707.

    2 Mehlman CT, Crawford AH, McMillion TL, et al. Operative Treatment of Supracondylar Fractures of the Humerus in Children: The Cincinnati Experience. Acta Orthop Belgica 1996;62(Suppl I):41-50.

    3 Mehlman CT, Strub WM, Roy DR, et al. The Effect of Surgical Timing on the Perioperative Complications of Treatment of Supracondylar Humeral Fractures in Children. J Bone Joint Surg 2001;83-A:323-327.

    4 D'Souza, L., et al. Supracondylar Humeral Fractures in Children. J. Bone Joint Surg 1996; 16:678-679.

    5 Baumann E. Contributions to the Knowledge of Fractures About the Elbow Joint. Bietrage Klin Chir (Bruns Bietrage) 1929;146:1-50.

    6 Camp J, Ishizue K, Gomez M, et al. Alteration of Baumann’s Angle by Humeral Position: Implications for Treatment of Supracondylar Humerus Fractures. J Pediatr Orthop 1993;13:521-525.

    7 Dai L. Radiographic Evaluation of Baumann Angle in Chinese Children and Its Clincial Relevance. J Pediatr Orthop (Part B) 1999;8:197-199.

    8 Keenan WNW, Clegg J. Variations of Baumann’s Angle With Age, Sex, and Side: Implications for Its Use in Radiological Monitoring of Supracondylar Fracture of the Humerus in Children. J Pediatr Orthop 1996;16:97-98.

    9 Worlock P. Supracondylar Fractures of the Humerus: Assessment of Cubitus Varus by the Baumann Angle. J Bone Joint Surg-Br 1986;68:755-757.

    10 Williamson DM, Coates CJ, Miller RK, et al. Normal Characteristics of the Baumann (Humerocapitellar) Angle: An Aid in Assessment of Supracondylar Fractures. J Pediatr Orthop 1992;12:636-639.

    11 Acton JD, McNally MA. Baumann’s Confusing Legacy. Injury 2001;32:41- 43.

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