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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 54  |  Issue : 1  |  Page : 52-61

Percutaneous cross-pinning versus two lateral entry pinning in Gartland type III pediatric supracondylar humerus fractures


Department of Orthopaedic, Assiut University, Assiut, Egypt

Date of Submission15-Apr-2019
Date of Acceptance13-May-2019
Date of Web Publication24-Sep-2019

Correspondence Address:
MD Hossam M.A Abubeih
Department of Orthopaedic, Assiut University Hospitals, PO Box 71526, Assiut, 71515
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/eoj.eoj_15_19

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  Abstract 

Background Supracondylar humerus fracture is the most common elbow fracture in children aged 5–7 years, affecting boys more than girls and the majority of fractures are of the extension type. These fractures are usually associated with a number of complications including neurovascular injuries, malunion, and elbow stiffness. Gartland type III fractures are usually treated by closed reduction and percutaneous pinning.
Patients and methods A prospective study was carried out on children with Gartland type III extension-type supracondylar humerus fractures. The patients were randomized to undergo fixation either with crossed pinning (group A) or two lateral pinning (group B). We compared both groups with regard to their passive elbow range of motion, Flynn’s criteria, Baumann’s angle, change in Baumann’s angle, and Skaggs method of grading of loss of reduction and complications.
Results Group A included 33 patients with a mean age of 5.4 years and group B included 34 patients with a mean age of 4.9 years. Group B had a statistically significant shorter operative time and radiation time. At final follow-up, there were no statistically significant differences between group A and group B with respect to the average Baumann’s angle, change in the Baumann angle, range of elbow motion, Flynn’s grade, or Skaggs criteria. There were no cases of iatrogenic ulnar nerve injury in both groups.
Conclusion If a standardized operative technique is followed in each method, then the result of both methods will be same in terms of safety and efficacy. Orthopedic surgeons treating unstable pediatric supracondylar humerus fractures should be familiar with both pinning techniqus.

Keywords: crossed pinning, Gartland type III, iatrogenic ulnar nerve palsy, lateral entry pinning, percutaneous pinning, supracondylar humerus fracture


How to cite this article:
Abubeih HM, El-Adly W, El-Gaafary K, Bakr H. Percutaneous cross-pinning versus two lateral entry pinning in Gartland type III pediatric supracondylar humerus fractures. Egypt Orthop J 2019;54:52-61

How to cite this URL:
Abubeih HM, El-Adly W, El-Gaafary K, Bakr H. Percutaneous cross-pinning versus two lateral entry pinning in Gartland type III pediatric supracondylar humerus fractures. Egypt Orthop J [serial online] 2019 [cited 2019 Nov 12];54:52-61. Available from: http://www.eoj.eg.net/text.asp?2019/54/1/52/267733


  Introduction Top


Pediatric supracondylar humerus fracture accounts for 55–80% of elbow fractures in children. It commonly occurs in children of 5–7 years old, boys more than girls and the majority of fractures are of the extension type (98%). Management of these fractures aims at avoiding early and late complications. In fractures associated with an absent radial pulse, emergent reduction, and fixation of the fracture should be undertaken [1],[2],[3],[4],[5],[6],[7],[8],[9],[10].

A high risk of developing compartment syndromes of the forearm occurred in children who undergo vascular repair and those who sustain supracondylar fractures with diaphyseal forearm fractures [1],[6],[11],[12].

Nerve injury commonly affects anterior interosseous nerve injury which is the most common, followed by median, radial, and ulnar nerves and usually the deficit is temporary neuropraxia that resolves within 6–12 weeks. Iatrogenic ulnar nerve injuries may follow percutaneous K-wiring. Cubitus varus is the most frequent complication of supracondylar fractures and usually result from malunion and not growth disturbance [2],[6],[13].

Extension-type pediatric supracondylar humerus fractures are classified according to Gartland into three types: type I, undisplaced; type II, displaced with the posterior cortex intact; this type may be subclassified into type IIA: simple posterior angulation and type IIB: angulation plus malrotation. Type III, completely displaced with no cortical contact, which may be subdivided into posteromedial IIIA or posterolateral IIIB [2],[6],[14],[15].

The recommended method of treatment for displaced Gartland type II and type III fractures is closed reduction and percutaneous pinning. Some authors use two lateral wires and other authors recommend two crossed wires, one through the medial condyle and one laterally. Crossed pinning provides increased biomechanical stability, but it carries the risk of iatrogenic ulnar nerve injury from the placement of the medial pin. Two ‘divergent’ lateral pins or three lateral pins are equivalent in terms of rotational stability to crossed pins [2],[3],[7],[8],[14],[16],[17],[18],[19],[20],[21].

There are certain tricks to avoid ulnar nerve injury during medial K-wire stabilization. A mini-open technique is helpful to localize the medial epicondyle. The medial wire should be inserted with the elbow in extension and intraoperative pin stimulation at 2 mA may assist in the placement of the medial pin [5],[16],[22],[23],[24].

Injuries treated as emergencies include open fractures, fractures with abnormal vascular status, and fractures that are at particularly high risk of compartment syndrome. Open reduction is performed if an adequate reduction cannot be obtained by closed manipulation. Open reduction leads to a longer union time, significantly reduced the range of motion (ROM) of the elbow, and poorer functional outcomes [1],[6],[25],[26],[27],[28],[29].

The aim of our study is to compare the functional and radiological results of crossed medial and lateral entry percutaneous pinning versus two lateral entry percutaneous pinning in the management of Gartland type III extension-type supracondylar fractures of the humerus in children.


  Patients and methods Top


This study was exempt according to the Institutional Review Board (ethics committee) of our institution. Informed consent was obtained from the parents of patients that their data may be published. In the period from June 2013 to October 2015, a randomized, prospective, consecutive clinical follow-up study was carried out on patients with Gartland type III extension-type supracondylar fractures of the humerus in children.

All children with supracondylar fractures of the humerus were included in our study if they had the following inclusion criteria: (a) age between 3 and 9 years, (b) unilateral fracture, (c) Gartland type III extension type, (d) no other associated injury in the same limb, and (e) no previous fracture in the same limb. Patients were excluded if they fulfill the following exclusion criteria: (a) age less than 3 years or greater than 9 years, (b) bilateral fracture, (c) flexion type, (d) associated injury in the same limb, (e) previous fracture in the same limb, (f) open fracture, (g) fracture requiring open reduction, and (h) associated neurovascular injury requiring surgical exploration.

During the study period, 122 children were treated for Gartland type III extension supracondylar fracture of the humerus. Ninety-one patients met the inclusion criteria and were included in our study. The patients were randomized into two groups by the concealed envelope technique: 45 children in group A crossed pinning technique and 46 children in group B two lateral pinning technique. Twelve patients in each group missed the follow-up. Thus, the study population consisted of 67 patients. Group A comprised 33 children and group B comprised 34 patients.

Surgical technique

All procedures were done under general anesthesia. Parenteral first-generation cephalosporins was injected on induction of anesthesia. The child was positioned supine with the fractured elbow on the image intensifier of the fluoroscopy unit as a table. Draping was done in the usual manner. Closed reduction was performed under the image guide. Following a successful reduction, the reduction was checked by image guidance. Markers of satisfactory reduction: (a) the anterior humeral line intersects the capitellum, (b) Baumann’s angle is greater than 10°, (c) the medial and lateral columns are intact on oblique views. The lateral pin was always inserted first in both groups.

In the two lateral entry pin group, the two lateral wire was inserted with the elbow in hyperflexion. The wires were angulated at about 10–15° posteriorly, inserted in the lateral and central columns either in divergent or parallel manner, and engaged both lateral and medial cortices ([Figure 1],[Figure 2],[Figure 3],[Figure 4],[Figure 5],[Figure 6]).
Figure 1 Postoperative radiograph, AP view; crossed wiring. AP, anteroposterior.

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Figure 2 Postoperative radiograph, lateral view; crossed wiring.

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Figure 3 Final follow-up radiograph, AP view; crossed wiring. AP, anteroposterior.

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Figure 4 Final follow-up radiograph, lateral view; crossed wiring.

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Figure 5 Final follow-up, clinical photograph; crossed wiring: full extension.

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Figure 6 Final follow-up clinical photograph; crossed wiring: full flexion.

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In the crossed pin group, after insertion of the lateral pin, the elbow was partially extended to less than a 90° position to avoid injury of anteriorly subluxing ulnar nerve. A small 1.5–3.0 cm incision is made over the medial epicondyle with blunt dissection to the bone and the wire was placed through the medial epicondyle, not the ulnar groove ([Figure 7],[Figure 8],[Figure 9],[Figure 10],[Figure 11]).
Figure 7 Postoperative radiograph, AP and lateral views; lateral wiring. AP, anteroposterior.

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Figure 8 Final follow-up radiograph, AP view; lateral wiring. AP, anteroposterior.

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Figure 9 Final follow-up, radiograph lateral view; lateral wiring.

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Figure 10 Final follow-up, clinical photograph; lateral wiring: full extension.

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Figure 11 Final follow-up, clinical photograph; lateral wiring: full flexion.

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In both groups and after insertion of the wires, the reduction was again checked under fluoroscopy with lateral, oblique, and anteroposterior (AP) views, and stressed in varus and valgus. The wires were bent and cut 1–2 cm from the skin and above-elbow cast was applied in 45–70° elbow flexion and neutral forearm rotation.

Postoperative care

In the immediate postoperative period, the patients were evaluated clinically for the neurovascular state, and radiologically AP and lateral radiograph of the affected elbow. Regular outpatient clinic visits were at the 1st, 3rd, 6th, and 12th week postoperatively. At the 1st week AP and lateral radiographs are obtained to ensure pin fixation and fracture alignment had not changed. At the 3rd week visit, the cast and wire were removed and radiographs were obtained out of the cast. Gentle ROM exercises were started after cast removal. At the 6th week visit, the ROM were checked and advise for physiotherapy was given if there was limited ROM. At the 12th week visit, final evaluation of radiological and functional results were done.

Methods of evaluation

Two authors examined all patients and the following information were recorded: (a) neurologic and vascular examination of the extremity, and determination of any complications, (b) carrying angle on both sides with a goniometer, (c) passive range of elbow motion for both sides with a goniometer, (d) Flynn’s criteria ([Table 1]), which are based on the carrying angle and elbow motion, (e) Baumann’s angle, (f) change in Baumann’s angle between immediate postoperative radiograph and 12th week follow-up radiograph, and (g) grading of loss of reduction, based on the method described by Skaggs et al. [30] ([Table 2]) [7].
Table 1 Flynn’s criteria

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Table 2 Skaggs criteria for grading loss of reduction

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The original Baumann’s angle is subtended by the longitudinal axis of the humerus and a line through the coronal axis of the capitellar epiphysis and has a mean value of 70° (range, 64–81°). The complementary angle is usually used with the normal value being 15–20. Radiological comparison with the opposite limb is recommended ([Figure 12]) [31],[32].
Figure 12 Baumann’s angle; angle A is original Baumann’s angle and angle B is more commonly used currently. Normal is 15–20° and equal to the opposite side.

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Statistical analysis

Statistical tests were done by using parametric and nonparametric analyses as appropriate for the data. The independent sample Student’s t tests, χ2 tests, Mann–Whitney U test were performed with use of SPSS 16.0 software (IBM SPSS, Armonk, NY, USA). A P value of less than 0.05 was considered to be statistically significant.


  Results Top


The crossed entry group A and the lateral entry group B were similar in terms of mean age, sex distribution, and side of the fracture. Group A included 33 patients with an average age of 5.4±1.7 years (range, 3–9 years), 24 were men (72.7%) and the left side was fractured in 23 (69.7%) patients. Group B included 34 patients with an average age of 4.9±1.3 years (range, 3–7.5 years), 21 (61.8%) were men and the left side was fractured in 19 (55.9%) patients. There were no statistically significant differences in the average age (P=0.180), side of fracture (P=0.242), or sex (P=0.339) between our two groups.

Compared with group A, group B had a statistically significant shorter operative time and radiation time. The average operative time was 59.1±7 min in group A versus 50.6±8 min in group B (P=0.000). The average radiation time was 1.2±0.3 s in group A versus 0.8±0.1 s in group B (P=0.000).

At final follow-up, there were no statistically significant differences (P>0.05) between group A and group B with respect to the average Baumann’s angle (P=0.081), change in the Baumann angle (P=0.121), range of elbow motion (P=0.795), Flynn’s grade (P=0.541), or Skaggs criteria (P=0.548).

The final elbow ROM averaged 127.8±2.7° in group A and 127.6±2.6° in group B. In group A, one patient had lost more than 10° flexion, one patient had lost more than 15° of flexion with the average loss of ROM being 3.7±2.9° and no cubitus varus deformity. In group B, two patients had lost more than 10° flexion, with the average loss of ROM being 3.9±2.2° and one patient had cubitus varus (carrying angle, −6°). According to the Flynn criteria, group A had 27 excellent, four good, one fair, and one poor results while group B had 25 excellent, six good, two fair, and one poor results. Overall, group A had a satisfactory outcome in 32 (97%) of the 33 elbows and an unsatisfactory outcome in one (3%) elbow, while group B had a satisfactory outcome in 33 (97.1%) of the 34 elbows and an unsatisfactory outcome in one (2.9%) elbow.

Group A had final Baumann’s angle averaged 16.5±3.8° and the average change in the Baumann angle was 2.8±1.6°, while in group B patients the average Baumann’s angle was 15±3.4° and the average change in the Baumann angle was 3.6±2.4°. According to the Skaggs criteria, in group A, there were 31 (93.9%) patients with no loss of reduction, two (6.1%) patients with mild loss of reduction, and no patient had a major loss of reduction. In group B, there were 30 (88.2%) patients with no loss of reduction, three (8.8%) patients with mild loss of reduction, and one (3%) patient had a major loss of reduction.

There were no cases of iatrogenic ulnar nerve injury in either group and no cases of superficial or deep infections.


  Discussion Top


Supracondylar fracture of the humerus is a common childhood injury and accounts for 55–80% of all fractures around the elbow joint and mostly occurs in children around 7 years of age and usually result from a fall on an outstretched arm [33],[34],[35].

Nerve injuries have been reported in 12–20% and they mainly consist of neurapraxias. Absent radial pulse has been reported in 10–20% of children with a displaced supracondylar humerus fracture. Brachial artery lesion may be due to entrapment, division, spasm, intimal tear, or thrombus formation. Urgent brachial artery exploration is indicated in pale pulseless limb. For pink pulseless hand, some authors recommended observation claiming that the rich collateral circulation is sufficient for the viability of the arm, other authors recommended exploration of the cubital fossa only if intraoperative angiographic evaluation showed a brachial artery injury and some authors preferred surgical exploration in all cases [1],[33],[36],[37],[38],[39],[40],[41],[42],[43],[44].

According to Gartland’s classification, extension pediatric supracondylar fractures of the humerus can be distinguished in three types: type I, incomplete fracture without displacement; type II, moderate displacement with intact posterior cortex; while in type III, there is no contact between the fracture ends. Closed reduction and percutaneous pinnig is the treatment of choice for Gartland type III, but controversy exists for the optimal pin configuration [7],[8],[22],[33].

Crossed pinning had superior biomechanical stability to lateral pinning, but it carries the increased risk of iatrogenic ulnar nerve injury. On the other hand, lateral pinning has less risk of iatrogenic ulnar nerve injury, but with less biomechanical stability. Some authors claimed that three lateral entry pins or two lateral entry pins that are divergent and are located in both the lateral and the central column provide torsional rigidity similar to that achieved with the crossed pinning [16],[17],[18],[19],[20].

Sankar and colleagues identified important technical errors associated with loss of fracture reduction after lateral entry pin fixations. These errors include failure to engage both fragments with at least two pins, failure to achieve bicortical fixation with at least two pins, and failure to achieve more than or equal to 2 mm of pin separation at the fracture site. They advised checking the stability of fixation by stressing the fracture under fluoroscopy at the completion of the procedure and when instability found a third lateral pin or a medial pin was added [48].

In a retrospective review of 622 patients after pinning of supracondylar distal humerus fractures, Bashyal and colleagues found a total of 32 (5.1%) complications. The most common complication was pin migration (1.8%) total infection rate of 1.0%, one (0.2%) patient had a malunion, three (0.5%) patients developed compartment syndromes, and only one (0.3%) postoperative ulnar nerve injury occurred with a medial pin [49].

Cubitus varus deformity developed in 5–10% of children with supracondylar humerus fractures irrespective of the treatment. Most studies attribute the deformity as a result of malunion. However, surgical treatment has had a marked effect on decreasing the incidence of this deformity [50],[51],[52].

The incidence of iatrogenic ulnar nerve injury after medial pinning ranges from 1.4 to 15.6%. Ulnar nerve is vulnerable to injury with elbow flexion because in this position it subluxes over the medial epicondyle. Several precautions are suggested to eliminate the risk of ulnar nerve palsy including fixation from the lateral side only, a small incision over the medial epicondyle for direct visualization, insertion of medial pin with elbow in some extension, and attachment of the nerve stimulator to medial pin to localize the ulnar nerve [22],[23],[45],[53],[54],[55],[56],[57].

Delayed pinning for up to 12 h does not result in unsatisfactory outcomes of closed, displaced suprac condylar humerus fracture (SCHF) in children who present without vascular compromise [27],[28],[29].

Crossed pin fixation has been compared with lateral entry pin fixation in numerous studies. Skaggs and colleagues reported no difference in maintenance of reduction between the two methods, but iatrogenic ulnar nerve injury was seen in 7.7% of cases treated with a medial pin compared with no injuries in their lateral wire group. In a study of 27 patients treated with crossed pins compared with 20 patients treated with lateral pins only, Topping and colleagues found no loss of reduction in either group and one ulnar nerve injury in the group with crossed pins. Similarly, in a study of 56 fractures, Shamsuddin and colleagues found three iatrogenic ulnar nerve injuries associated with crossed pin fixation and two iatrogenic radial or anterior interosseous nerve injuries associated with lateral entry pin fixation, although there was no difference in loss of reduction. Foead and colleagues performed a randomized clinical trial in which 34 fractures were treated with medial and lateral pin fixation and 32 were treated with lateral pin fixation. There were no significant differences in terms of loss of reduction, the Baumann angle, or elbow motion between the two groups. There were five iatrogenic ulnar nerve injuries in the medial and lateral entry group, and there were two iatrogenic ulnar nerve injuries and one iatrogenic radial nerve injury in the lateral entry group [16],[20],[60],[61],[62].

In a systematic review of the literature, Brauer and colleagues reported five times higher risk of ulnar nerve injury, but 0.58 times lower risk of loss of reduction with crossed pinning. Kocher and colleagues compared lateral entry pins (28 patients) with medial and lateral entry pins (24 patients) and found no significant difference between these two pin-fixation techniques in terms of loss of reduction or iatrogenic ulnar nerve injury [20],[63].

We carried a prospective, randomized study to compare the functional and radiological results of crossed medial–lateral K-wire fixation with two lateral entry K-wires fixation in Gartland type III extension supracondylar fractures of the humerus in children. At final follow-up, we found no statistically significant differences between both groups with respect to the average Baumann’s angle, change in the Baumann angle, the range of elbow motion, Flynn’s grade, and Skaggs criteria. We had no case of iatrogenic ulnar nerve injury in our series possibly because the medial pin was inserted with the elbow in some extension through a small skin incision over the medial epicondyle.

In our study, group B had a statistically significant shorter operative time and radiation time. This is quite expected since in lateral pinning both wires were inserted with the elbow in hyperflexion one after each other with no change in position of the elbow. The first wire acts as a guide to the second wire, so minimal radiation was required.


  Conclusion Top


In conclusion, there was no significant difference in complications, the ROM, and radiographic alignment between the crossed pin group A and lateral pin group B. Ulnar nerve palpation, placing the elbow in some degree of extension during pin insertion, and mini-open technique can aid in a safer medial pin placement. If a uniform standardized operative technique is followed in each method, then the result of both the percutaneous fixation methods will be same in terms of safety and efficacy. Orthopedic surgeons treating unstable pediatric supracondylar humerus fractures should be familiar with both medial and lateral pin placement.

Acknowledgements

The idea and design of the study were initiated by Prof Kamal El-Gaafary and Dr Hossam M.A. Abubeih. Prof Wael El-Adly and Dr Hatem Bakr performed the surgical procedures. Writing the draft was done by Dr. Hossam M.A. Abubeih and Dr Hatem Bakr; revising the draft was done by the other three authors. Measurements of angles and analysis of results were done by two authors: Dr Hossam M.A. Abubeih and Prof Kamal El-Gaafary.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Choi PD, Melikian R, Skaggs DL. Risk factors for vascular repair and compartment syndrome in the pulseless supracondylar humerus fracture in children. J Pediatr Orthop 2010; 30:50–56.  Back to cited text no. 1
    
2.
Temple A, Bache CE, Gibbons PJ. Fractures of the elbow: supracondylar fractures. Trauma 2006; 8:123–130.  Back to cited text no. 2
    
3.
Maity A, Saha D, Roy DS. A prospective randomised, controlled clinical trial comparing medial and lateral entry pinning with lateral entry pinning for per-cutaneous fixation of displaced extension type supracondylar fractures of the humerus in children. J Orthop Surg Res 2012; 7:1–8.  Back to cited text no. 3
    
4.
Otsuka NY, Kasser JR. Supracondylar fractures of the humerus in children. J Am Acad Orthop Surg 1997; 5:19–26.  Back to cited text no. 4
    
5.
Shannon FJ, Mohan P, Chacko J, D’Souza LG. ‘Dorgan’s’ percutaneous lateral cross-wiring of supracondylar fractures of the humerus in children. J Pediatr Orthop 2004; 24:376–379.  Back to cited text no. 5
    
6.
Abzug JM, Herman MJ. Management of supracondylar humerus fractures in children: current concepts. J Am Acad Orthop Surg 2012; 20:69–77.  Back to cited text no. 6
    
7.
Flynn JC, Matthews JG, Benoit RL. Blind pinning of displaced supracondylar fractures of the humerus in children.Sixteen years’ experience with long-term follow-up. J Bone Joint Surg Am 1974; 56:263–272.  Back to cited text no. 7
    
8.
Arino VL, Llurch EE, Ramriez AM, Ferrer J, Rodriguez L, Baixauli F. Percutaneous fixation of supracondylar fractures of the humerus in children. J Bone Joint Surg Am 1977; 59:914–916.  Back to cited text no. 8
    
9.
White L, Mehlman CT, Crawford AH. Perfused, pulseless, and puzzling.A systematic review of vascular injuries in pediatric supracondylar humerus fractures and results of a POSNA questionnaire. J Pediatr Orthop 2010; 30:328–335.  Back to cited text no. 9
    
10.
Blakey CM, Biant LC, Birch R. Ischaemia and the pink, pulseless hand complicating supracondylar fractures of the humerus in childhood: Long-term follow-up. J Bone Joint Surg Br 2009; 91:1487–1492.  Back to cited text no. 10
    
11.
Blakemore LC, Cooperman DR, Thompson GH, Wathey C, Ballock RT. Compartment syndrome in ipsilateral humerus and forearm fractures in children. Clin Orthop Relat Res 2000; 376:32–38.  Back to cited text no. 11
    
12.
Bae DS, Kadiyala RK, Waters PM. Acute compartment syndrome in children: contemporary diagnosis, treatment, and outcome. J Pediatr Orthop 2001; 21:680–688.  Back to cited text no. 12
    
13.
Chen RS, Liu CB, Lin XS, Feng XM, Zhu JM, Ye FQ. Supracondylar extension fracture of the humerus in children. J Bone Joint Surg 2001; 83B:883–887.  Back to cited text no. 13
    
14.
Gartland JJ. Management of supracondylar fractures of the humerus in children. Surg Gynecol Obstet 1959; 109:145–154.  Back to cited text no. 14
    
15.
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 Joint Surg Am 2006; 88:980–985.  Back to cited text no. 15
    
16.
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 Joint Surg Am 2001; 83:735–740.  Back to cited text no. 16
    
17.
Lyons JP, Ashley E, Hoffer MM. Ulnar nerve palsies after percutaneous cross pinning of supracondylar fractures in children’s elbows. J Pediatr Orthop 1998; 18:43–45.  Back to cited text no. 17
    
18.
Gordon JE, Patton CM, Luhmann SJ, Bassett GS, Schoenecker PL. Fracture stability after pinning of displaced supracondylar distal humerus fractures in children. J Pediatr Orthop 2001; 21:313–318.  Back to cited text no. 18
    
19.
Lee SS, Mahar AT, Miesen D, Newton PO. Displaced pediatric supracondylar humerus fractures: biomechanical analysis of percutaneous pinning techniques. J Pediatr Orthop 2002; 22:440–443.  Back to cited text no. 19
    
20.
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 Joint Surg Am 2007; 89:706–712.  Back to cited text no. 20
    
21.
Larson L, Firoozbakhsh K, Passarelli R, Bosch P. Biomechnical analysis of pinning techniques for pediatric supracondylar humerus fractures. J Pediatr Orthop 2006; 26:573–578.  Back to cited text no. 21
    
22.
Eidelman M, Hos N, Katzman A, Bialik V. Prevention of ulnar nerve injury during fixation of supracondylar fractures in children by ‘flexion-extension cross-pinning’ technique. J Pediatr Orthop B 2007; 16:221–224.  Back to cited text no. 22
    
23.
Wind WM, Schwend RM, Armstrong DG. Predicting ulnar nerve location in pinning of supracondylar humerus fractures. J Pediatr Orthop 2002; 22:444–447.  Back to cited text no. 23
    
24.
Tripuranenia KR, Boscha PP, Schwendb RM, Yastea JY. Prospective, surgeon-randomized evaluation of crossed pins versus lateral pins for unstable supracondylar humerus fractures in children. J Pediatr Orthop B 2009; 18:93–98.  Back to cited text no. 24
    
25.
Aktekin CN, Toprak A, Ozturk AM, Altay M, Ozkurt B, Tabak AY. Open reduction via posterior triceps sparing approach in comparison with closed treatment of posteromedial displaced Gartland type III supracondylar humerus fractures. J Pediatr Orthop B 2008; 17:171–178.  Back to cited text no. 25
    
26.
Carter CT, Bertrand SL, Cearley DM. Management of pediatric type III supracondylar humerus fractures in the United States: results of a national survey of pediatric orthopaedic surgeons. J Pediatr Orthop 2013; 33:750–754.  Back to cited text no. 26
    
27.
Mehlman CT, Strub WM, Roy DR, Wall EJ, Crawford AH. The effect of surgical timing on the perioperative complications of treatment of supracondylar humeral fractures in children. J Bone Joint Surg Am 2001; 83:323–327.  Back to cited text no. 27
    
28.
Gupta N, Kay RM, Leitch K, Femino JD, Tolo VT, Skaggs DL. Effect of surgical delay on perioperative complications and need for open reduction in supracon- dylar humerus fractures in children. J Pediatr Orthop 2004; 24:245–248.  Back to cited text no. 28
    
29.
Bales JG, Spencer HT, Wong MA, Fong YJ, Zionts LE, Silva M. The effects of surgical delay on the outcome of pediatric supracondylar humeral fractures. J Pediatr Orthop 2010; 30:785–791.  Back to cited text no. 29
    
30.
Skaggs DL, Cluck MW, Mostofi A, Flynn JM, Kay RM. Lateral-entry pin fixation in the management of supracondylar fractures in children. J Bone Joint Surg Am 2004; 86:702–707.  Back to cited text no. 30
    
31.
Baumann E. Contribution to the knowledge of the fractures at the elbow joint. Bruns Bbeitr F Klin Chir 1929; 146:1–50.  Back to cited text no. 31
    
32.
Williamson DM, Coates CJ, Miller RK, Cole WG. Normal characteristics pf the Baumann angle, an aid in assessment of supracondylar fractures. J Pediatr Orthop 1992; 12:636–639.  Back to cited text no. 32
    
33.
Korompilias AV, Lykissas MG, Mitsionis GI, Kontogeorgakos VA, Manoudis G, Beris AE. Treatment of pink pulseless hand following supracondylar fractures of the humerus in children. Int Orthop 2009; 33:237–241.  Back to cited text no. 33
    
34.
Cheng JC, Ng BK, Ying SY, Lam PK. A 10-year study of the changes in the pattern and treatment of 6,493 fractures. J Pediatr Orthop 1999; 19:344–350.  Back to cited text no. 34
    
35.
Landin L, Danielsson L. Elbow fractures in children.An epidemiological analysis of 589 cases. Acta Orthop Scand 1986; 57:309–312.  Back to cited text no. 35
    
36.
Schoenecker PL, Delgado E, Rotman M, Sicard GA, Capelli AM. Pulseless arm in association with totally displaced supracon- dylar fracture. J Orthop Trauma 1996; 10:410–415.  Back to cited text no. 36
    
37.
Culp RW, Osterman AL, Davidson RS, Skirven T, Bora FW. Neural injuries associated with supracondylar fractures of the humerus in children. J Bone Joint Surg Am 1990; 72:1211–1215.  Back to cited text no. 37
    
38.
Gosens T, Bongers KJ. Neurovascular complications and functional outcome in displaced supracondylar fractures of the humerus in children. Injury 2003; 34:267–273.  Back to cited text no. 38
    
39.
Louahem DM, Nebunescu A, Canavese F, Dimeglio A. Neurovascular complications and severe displacement in supracondylar humerus fractures in children: defensive or offensive strategy. J Pediatr Orthop B 2006; 15:51–57.  Back to cited text no. 39
    
40.
Luria S, Sucar A, Eylon S, Pinchas-Mizrachi R, Berlatzky Y, Anner H et al. Vascular complications of supracondylar humeral fractures in children. J Pediatr Orthop B 2007; 16:133–143.  Back to cited text no. 40
    
41.
Omid R, Choi PD, Skaggs DL. Supracondylar humeral fractures in children. J Bone Joint Surg Am 2008; 90:1121–1132.  Back to cited text no. 41
    
42.
Garbuz DS, Leitch K, Wright LG. The treatment of supracondylar fractures in children with an absent radial pulse. J Pediatr Orthop 1996; 16:594–596.  Back to cited text no. 42
    
43.
Malviya A, Simmons D, Vallamshetla R, Bache CE. Pink pulseless hand following supra-condylar fractures: an audit of British practice. J Pediatr Orthop 2006; B15:62–64.  Back to cited text no. 43
    
44.
Sabharwal S, Tredwell SJ, Beauchamp RD, Mackenzie WG, Jakubec DM, Cairns R, LeBlanc JG. Management of pulseless pink hand in pediatric supracondylar fractures of humerus. J Pediatr Orthop 1997; 17:303–310.  Back to cited text no. 44
    
45.
Rasool MN. Ulnar nerve injury after K-wire fixation of supracondylar humerus fractures in children. J Pediatr Orthop 1998; 18:686–690.  Back to cited text no. 45
    
46.
Zionts LE, McKellop HA, Hathaway R. Torsional strength of pin configurations used to fix supracondylar fractures of the humerus in children. J Bone Joint Surg Am 1994; 76:253–256.  Back to cited text no. 46
    
47.
Gottschalk HP, Sagoo D, Glaser D, Doan J, Edmonds EW, Schlechter J. Biomechanical analysis of pin placement for pediatric supracondylar humerus fractures: does starting point, pin size, and number matter?. J Pediatr Orthop 2012; 32:445–451.  Back to cited text no. 47
    
48.
Sankar WN, Hebela NM, Skaggs DL, Flynn JM. Loss of pin fixation in displaced supracondylar humeral fractures in children: causes and prevention. J Bone Joint Surg Am 2007; 89:713–717.  Back to cited text no. 48
    
49.
Bashyal RK, Chu JY, Schoenecker PL, Dobbs MB, Luhmann SJ, Gordon JE. Complications after pinning of supracondylar distal humerus fractures. J Pediatr Orthop 2009; 29:704–708.  Back to cited text no. 49
    
50.
Flynn JM, Sarwark JF, Waters PM, Bae DS, Lemke LP. The operative management of pediatric fractures of the upper extremity. J Bone Joint Surg Am 2002; 84:2078–2089.  Back to cited text no. 50
    
51.
Eren A, Güven M, Erol B, Akman B, Ozkan K. Correlation between posteromedial or posterolateral displacement and cubitus varus deformity in supracondylar humerus fractures in children. J Child Orthop 2008; 2:85–89.  Back to cited text no. 51
    
52.
Theruvil B, Kapoor V, Fairhurst J, Taylor GR. Progressive cubitus varus due to a bony physeal bar in a 4-year-old girl fol- lowing a supracondylar fracture: a case report. J Orthop Trauma 2005; 19:669–672.  Back to cited text no. 52
    
53.
Boyd DW, Aronson DD. Supracondylar fractures of the humerus: a prospective study of percutaneous pinning. J Pediatr Orthop 1992; 12:789–794.  Back to cited text no. 53
    
54.
Karakurt L, Ozdemir H, Yilmaz E, Inci M, Belhan O, Serin E. Morphology and dynamics of the ulnar nerve in the cubital tunnel after percutaneous cross-pinning of supracondylar fractures in children’s elbows: an ultrasonographic study. J Pediatr Orthop B 2005; 14:189–193.  Back to cited text no. 54
    
55.
Beaty JH, Kasser JR. Rockwood and Wilkins’ fractures in children. Vol. 3. 5th ed. Philadelphia, Pennsylvania: Lippincott Willams & Wikins; 2001. 576–624  Back to cited text no. 55
    
56.
Belhana O, Karakurta L, Ozdemirb H, Yilmaz E, Kaya M, Serin E, Inci M. Dynamics of the ulnar nerve after percutaneous pinning of supracondylar humeral fractures in children. J Pediatr Orthop B 2009; 18:29–33.  Back to cited text no. 56
    
57.
Brown IC, Zinar DM. Traumatic and iatrogenic neurological complications after supracondylar humerus fractures in children. J Pediatr Orthop 1995; 15:440–443.  Back to cited text no. 57
    
58.
Carmichael KD, Joyner K. Quality of reduction versus timing of surgical intervention for pediatric supracondylar humerus fractures. Orthopaedics 2006; 29:628–632.  Back to cited text no. 58
    
59.
Leet AI, Frisancho J, Ebramzadeh E. Delayed treatment of type 3 supracondylar humerus fractures in children. J Pediatr Orthop 2002; 22:203–207.  Back to cited text no. 59
    
60.
Topping RE, Blanco JS, Davis TJ. Clinical evaluation of crossed-pin versus lateral-pin fixation in displaced supracondylar humerus fractures. J Pediatr Orthop 1995; 15:435–439.  Back to cited text no. 60
    
61.
Shamsuddin SA, Penafort R, Sharaf I. Crossed-pin versus lateral-pin fixation in pediatric supracondylar fractures. Med J Malaysia 2001; 56(Suppl D):38–44.  Back to cited text no. 61
    
62.
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; 12:76–82.  Back to cited text no. 62
    
63.
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: 181–186.  Back to cited text no. 63
    


    Figures

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    Tables

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