Session VI - Pediatrics

Pin Configuration in the Operative Treatment of Supracondylar Humerus Fractures in Children: A Review of 345 Cases

David L. Skaggs, MD; Julia M. Hale, MNS, PA-C; Jeffrey Basset, MB; Cornelia Kaminsky, MD; Robert M. Kay, MD; Vernon T. Tolo, MD, Children's Hospital Los Angeles, Los Angeles, CA

Background: The commonly accepted treatment for displaced supracondylar fractures of the humerus in children is fracture reduction and percutaneous pin fixation; however, there is controversy about the optimal placement of the pins. A crossed-pin configuration is believed to be mechanically more stable than lateral pins alone; however, injury to the ulnar nerve can occur with the use of a medial pin. It has not been proven that the added stability of a medial pin is clinically necessary because, in the young child, pin fixation is always augmented with immobilization in a splint or cast.

Methods: We retrospectively reviewed the results of 345 extension-type supracondylar fractures in children treated with reduction and Kirschner-wire fixation. Maintenance of fracture reduction and evidence of ulnar nerve injury were evaluated in relation to pin configuration and fracture pattern. Of 141 children who had a Gartland type-2 fracture (partially intact posterior cortex), lateral pins only were used in 74, and crossed pins were used in 67. Lateral pins only were used in 51 of 204 children who had an unstable Gartland type-3 fracture, and crossed pins were used in 153 children.

Results: There was no difference in maintenance of fracture reduction between the use of crossed pins and only lateral pins, as seen on anteroposterior and lateral radiographs. The configuration of the pins did not affect the maintenance of reduction when Gartland type-2 fractures were compared with type-3 fractures. Ulnar nerve injury was not seen in the 125 patients in whom only lateral pins were used. The use of a medial pin without hyperflexion of the elbow was associated with ulnar nerve injury in 4% of 149 patients (n = 6), and in 17% of 71 patients (n = 11) pinned medially with the elbow hyperflexed. Two years after the pinning one of the 17 children had persistent motor weakness and a sensory deficit.

Conclusions: Fixation of supracondylar fractures of the humerus in children with only lateral pins is safe and effective for both Gartland type-2 and unstable Gartland type-3 fractures. The use of lateral pins prevents iatrogenic injury to the ulnar nerve. On the basis of our findings, we do not recommend the routine use of crossed pins for treatment of supracondylar fractures of the humerus in children. If a medial pin is used, the elbow should not be hyperflexed during its insertion.