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Supracondylar Fractures: Percutaneous Pin Fixation


- Discussion:
    - has become standard technique for stabilizing types II & type III frx;
    - either two lateral pins, or one lateral and one medial pin may be used and both should penetrate the cortex;
           - medial and lateral pin insertion provides better stabilization;
           - 2 lateral pins may not permit full elbow extension, thus preventing full assessment of carrying angle;


- Radiographs:
    - Baumann's Angle
    - radiographs of uninjuried side


- Pinning Technique: 
    - reduction technique:
    - in preparing for crossed pinning, keep elbow hyperflexed to maintain reduction;
          - consider applying sterile "coband" to keep elbow flexed, which then allows arm to be externally rotated to achieve a lateral
                   view w/o moving flouro;
          - pins should cross proximal to the frx at an angle of about 30 deg to the humeral shaft;
    - positioning:
          - w/ posteromedial displacement, place arm in maximum external rotation on flourscopy platform, and insert the medial pin first;
          - w/ posterolateral displacement, place arm in maximum internal rotaiton on the flourscopy platform, and insert the lateral pin first;
    - pin size:
          - pins need to be smooth w/ trochar point;
          - w/ children younger than 5-6 years, use 0.062 smooth K wire;
          - in older children use 5/64 K wires;
    - lateral pin: 
          - avoid directing pins too far anterior or posterior; 
                   - Safe Zone for Superolateral Entry Pin Into the Distal Humerus in Children: An MRI Analysis
          - insertion point is in the center of lateral condyle (capitellum);
          - because the center of the capitellum is in line w/ anterior aspect of humeral shaft, the pin must be directed slightly posteriorly;
          - wire is inserted thru the capitellum, and then the distal humeral physis;
          - generally, the pin is aimed 35 deg upward and 10 deg posterior;
          - pin should avoid the olecranon fossa and should come to rest along the far cortex;
          - insert lateral pin first to obtain stability while reduction is evaluated (avoids need to repeatedly insert medial pins if reduction is
                 not adequate);
                 - consider placing a temporary 2nd pin thru the lateral condyle to achieve even more stability;
          - Skaggs DL, et al:
                 - configuration of the pins did not affect the maintenance of reduction of either type-2 fractures or type-3 fractures;
                 - ulnar nerve injury was not seen in the 125 patients in whom only lateral pins were used;
                 - medial pin was associated w/ ulnar n injury in 4% patients in whom the pin was applied w/o hyperflexion of the elbow
                          and in 15% in whom the medial pin was applied w/ elbow hyperflexed;
                 - 2 years after the pinning, one of the 17 children with ulnar nerve injury had persistent motor weakness and a sensory deficit;
          - crossed pin configuration:
                 - Cross pinning for supracondylar humerus fractures in children carries risk of iatrogenic ulnar nerve injuries
                 - Crossed Wires versus Two Lateral Wires in Management of Supracondylar Fracture of Humerus in Children in Trainees.

          - references:
                 - Loss of Pin Fixation in Displaced Supracondylar Humeral Fractures in Children: Causes and Prevention. 
                 - Prevention of ulnar nerve injury during fixation of supracondylar frx by 'flexion-extension cross-pinning' technique.
                 - Biomechanical Analysis of Supracondylar Humerus Fracture Pinning for Fractures With Coronal Lateral Obliquity 
                 - Analysis of Pin Placement for Pediatric Supracondylar Fractures: Does Starting Point, Pin Size, and Number Matter?
                 - Biomechanical testing of pin configurations in supracondylar humeral fractures: the effect of medial column comminution.
                 - Lateral-Entry Pin Fixation in the Management of Supracondylar Fractures in Children.
                 - 3 Lateral Divergent or Parallel Pin Fixations for the Treatment of Displaced Supracondylar Humerus Fractures in Children.
                 - 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.
                 - Intraoperative Stability Testing of Lateral-Entry Pin Fixation of Pediatric Supracondylar Humeral Fractures

    - posterior intrafocal pin:

          - Treatment of Gartland Type III Pediatric Supracondylar Humerus Fractures with the Kapandji Technique in the Prone Position.
          - Biomechanical Analysis of Posterior Intrafocal Pin Fixation for the Pediatric Supracondylar Humeral Fracture
          - The posterior intrafocal pin improves sagittal alignment in Gartland type III paediatric supracondylar humeral fractures.

    - medial pin:
          - passed obliquely through medial epicondyle, just proximal to olecranon fossa;
          - need to protect ulnar nerve;
                 - note that w/ flexion, the ulnar nerve can sublux over the medial condyle placing it at risk w/ medial pin insertion;
                 - because of ulnar nerve subluxation, some surgeons always place the lateral pin first (w/ elbow hyperflexed) which confers
                         stability; 
                 - once the lateral pin has been inserted, the surgeon can then bring the elbow out to 80-90 deg flexion (decreasing ulnar nerve
                         subluxation) prior to placement of the medial pin; 
                 - surgeon's thumb can milk the ulnar nerve back into its posterior position and hold it there;
                 - if excessive soft tissue swelling is present, then consider making a small incision thru the skin over the medial epicondyle,
                         and then spreading w/ hemostat;
                         - use soft tissue protector from the cannulated screw set inorder to further protect the ulnar nerve; 
                 - references:
                         - Iatrogenic ulnar nerve injury after treatment of supracondylar fractures: number needed to harm, a systematic review.
                         - Treatment of displaced pediatric supracondylar humerus fracture patterns requiring medial fixation: a reliable and safer cross-pinning technique.
                         - Is Medial Pin Use Safe for Treating Pediatric Supracondylar Humerus Fractures?

          - because medial epicondyle is slightly posterior to the shaft, direct the medial pin slightly anterior;
                - also ensure that the medial pin enters straight into the epicondyle rather than distal to the epicondyle;
                - the medial wire will often appear more transverse than the lateral pin;
          - in the report by Skaggs DL, et al:
                  - use of a medial pin was associated w/ ulnar n injury in 4% patients in whom the pin was applied w/o hyperflexion of the
                           elbow and in 15% in whom the medial pin was applied w/ elbow hyperflexed;
                  - 2 years after the pinning, 1 of 17 children with ulnar nerve injury had persistent motor weakness and a sensory deficit;
                  - authors note that if a medial pin is used, the elbow should not be hyperflexed during its insertion; 
                  - Loss of Pin Fixation in Displaced Supracondylar Humeral Fractures in Children: Causes and Prevention. 
    - after pin placement assess carrying angle to r/o cubitus varus
          - Baumann's angle, angle between long axis of humeral shaft & growth plate of capitellum, will suggest final carrying angle after
                   reduction;
          - finally, re-check the radial pulse and the quality of the pulse; 
    - casting:
          - Immobilization After Pinning of Supracondylar Distal Humerus Fractures in Children: Use of the A-frame Cast
          - Factors Affecting Forearm Compartment Pressures in Children with Supracondylar Fractures of the Humerus


- Post Op:
     - pins can usually be removed a 3 weeks post op;

- Case Example:
    - 7-year-old female who presented with a displaced supracondylar fracture 
    - an attempt at closed reduction was carried out, but the reduction was unacceptable;
           - open reduction was carried out via limited medial and lateral incisions 

             

- Example:
    - these pictures show residual displacement following closed reduction and pin fixation 

               



Supracondylar fractures of the humerus in children. A modified technique for closed pinning.

Supracondylar fractures of the humerus. A comparative study of Dunlop's traction versus percutaneous pinning.

Percutaneous fixation of supracondylar fractures of the humerus in children.

Difficult supracondylar elbow fractures in children: analysis of percutaneous pinning technique.

K-wire fixation of supracondylar humeral fractures in children: results of open reduction via a ventral approach in comparison with closed treatment.

Deformity and function in supracondylar fractures of the humerus in children variously treated by closed reduction and splinting, traction, and percutaneous pinning.

Torsional Strength of Pin Configurations Used to Fix Supracondylar Fractures of the Humerus in Children.

Supracondylar fractures of the humerus in children treated by closed reduction and percutaneous pinning.

Clinical evaluation of crossed-pin versus lateral-pin fixation in displaced supracondylar humerus fractures.

Supracondylar fractures of the humerus: a prospective study of percutaneous pinning

Operative Treatment of Supracondylar Fractures of the Humerus in Children. The Consequences of Pin Placement 

Reduction and pinning of pediatric supracondylar humerus fractures in the prone position.

Lateral Entry Compared with Medial and Lateral Entry Pin Fixation for Completely Displaced Supracondylar Humeral Fractures in Children. A randomized clinical trial.

Loss of Pin Fixation in Displaced Supracondylar Humeral Fractures in Children: Causes and Prevention.



Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Wednesday, May 25, 2016 12:08 pm