Iatrogenic Ulnar Nerve Injury After the Surgical Treatment of Displaced Supracondylar Fractures of the Humerus: Number Needed to Harm, A Systematic Review

Slobogean, Bronwyn; Jackman, Heather; Tennant, S; Slobogean, Gerard P.; Mulpuri, Kishore

doi:10.1097/bpo.0b013e3181e00c0d

Cited by 111 publications

(85 citation statements)

References 59 publications

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“…The pooled result of iatrogenic ulnar nerve injury in the current study is in agreement with previous reviews [1,3,5,38,40,52]. Babal et al [3] performed a meta-analysis which was derived almost exclusively from retrospective studies and concluded that the medial pin carried the greater overall risk of nerve injury as compared with a lateral-pin-only construct, and that the ulnar nerve was at risk of injury in patients who had medial pins.…”

Section: Discussionsupporting

confidence: 91%

“…Pin tract infection, superficial infection, reoperation, and compartment syndrome also were compared. Previous systematic reviews were aimed mainly at iatrogenic nerve injury, deformity, or loss of reduction [3,5,29,38,52]. Few meta-analyses or systematic reviews compared the postoperative functional outcomes.…”

Section: Discussionmentioning

confidence: 99%

“…Although several meta-analyses or systematic reviews of lateral entry versus crossed medial and lateral entry pinning for supracondylar fractures of the humerus have been reported [3,5,29,38,52,57], the conclusions drawn are based largely on results from nonrandomized controlled trials (nRCTs), which increases the likelihood that bias has affected those analyses. Randomized controlled trials (RCTs) are considered to be the most reliable form of scientific evidence in the hierarchy of evidence because they reduce spurious inferences of causality and bias.…”

Section: Introductionmentioning

confidence: 99%

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Is Lateral Pin Fixation for Displaced Supracondylar Fractures of the Humerus Better Than Crossed Pins in Children?

Zhao

Wang

Zhang

2013

Clinical Orthopaedics &Amp; Related Research

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Background Closed reduction and percutaneous pin fixation is considered standard management for displaced supracondylar fractures of the humerus in children. However, controversy exists regarding whether to use an isolated lateral entry or a crossed medial and lateral pinning technique. Questions/purposes We performed a meta-analysis of randomized controlled trials (RCTs) to compare (1) the risk of iatrogenic ulnar nerve injury caused by pin fixation, (2) the quality of fracture reduction in terms of the radiographic outcomes, and (3) function in terms of criteria of Flynn et al. and elbow ROM, and other surgical complications caused by pin fixation.Methods We searched PubMed, Embase, the Cochrane Library, and other unpublished studies without language restriction. Seven RCTs involving 521 patients were included. Two authors independently assessed the methodologic quality of the included studies with use of the Detsky score. The median Detsky quality score of the included trials was 15.7 points. Dichotomous variables were presented as risk ratios (RRs) or risk difference with 95% confidence intervals (CIs) and continuous data were measured as mean differences with 95% CI. Statistical heterogeneity between studies was formally tested with standard chi-square test and I 2 statistic. For the primary objective, a funnel plot of the primary end point and Egger's test were performed to detect publication bias. Results The pooled RR suggested that iatrogenic ulnar nerve injury was higher with the crossed pinning technique than with the lateral entry technique (RR, 0.30; 95% CI,. No publication bias was further detected. There were no statistical differences in radiographic outcomes, function, and other surgical complications. No significant heterogeneity was found in these pooled results. Conclusions We conclude that the crossed pinning fixation is more at risk for iatrogenic ulnar nerve injury than the lateral pinning technique. Therefore, we recommend the lateral pinning technique for supracondylar fractures of the humerus in children.

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Section: Discussionsupporting

confidence: 91%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Is Lateral Pin Fixation for Displaced Supracondylar Fractures of the Humerus Better Than Crossed Pins in Children?

Zhao

Wang

Zhang

2013

Clinical Orthopaedics &Amp; Related Research

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“…The patient's age at the time of fracture was also equally similar: 5.9 years (2,4,(26)(27)(28)(29) . The development of compartment syndrome is the most feared complication of this type of injury.…”

Section: Discussionmentioning

confidence: 83%

Fratura supracondiliana de úmero em crianças: fixação com dois fios de Kirschner cruzados

Carvalho¹,

Filho²,

Neto³

et al. 2012

Rev. bras. ortop.

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Objective: To analyze and present the surgical results from unstable supracondylar fractures of the humerus in children, treated by means of reduction and percutaneous fixation using two crossed Kirschner wires. Methods: A cross-sectional study was conducted on 20 children, taking into consideration sex, age at the time of the fracture, age at the time of the assessment, side affected, type and mechanism of trauma, postoperative complications and radiographic and clinic variables. Results: Ten fractures were observed in the left arm and ten in the right arm. The age at the time of the fracture ranged from 2 to 13 years (mean: 5.9 ± 2.48 years). Three fractures were classified as type II and 17 as type III. The length of follow-up ranged from four months to three years. Baumann's angle ranged from 69 to 100 (mean: 78.3) and cubitus varus was observed in four patients (values ranging from 84 to 100). According to the modified Flynn's criteria, 20 cases presented satisfactory outcomes: 17 excellent (85%), two good (10%) and one regular (5%). Two patients presented limited range of motion, two had paresthesia in the cubital region and one had transient neuropraxia of the ulnar nerve for six weeks. Conclusion: Percutaneous fixation with two crossed Kirschner wires leads to good results when carried out under direct viewing and with isolation of the ulnar nerve.

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“…Although a medial KW may improve stability, it also increases the risk of iatrogenic ulnar nerve injury, with the reported incidence of post-operative ulnar nerve injury ranging from 0 to 15 % [1,5,9,11]. In their recent review of the literature, Slobogean et al concluded that when compared with lateral entry KW, the crossed KW configuration is associated with an increased risk of injuring the ulnar nerve [4].…”

Section: Introductionmentioning

confidence: 99%

Pediatric supracondylar humerus fractures: Effect of bone–implant interface conditions on fracture stability

Lamdan

Liebergall

Gefen

et al. 2013

Journal of Children's Orthopaedics

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Background Closed reduction and percutaneous fixation with Kirschner wires (KWs) is the standard of care of pediatric supra-condylar humerus fractures (SCHFs). Failure modes leading to loss of reduction are not clear and have not been quantified. Multiple factors may weaken the KW-bone interface bonding conditions. To the best of our knowledge, the possible effect of this decrease on different KW configurations and fracture stability has never been studied. Purpose To investigate the effect of bone-KW friction conditions on SCHF post-operative mechanical stability and to formulate clinical guidelines for KW configuration under different conditions. Methods Finite element-based model of a fixated SCHF was used to simulate structure stability for two lateral divergent versus crossed lateral and medial KW configurations under varying KW-bone friction conditions. Results Finite element simulations demonstrated that crossed KWs provide superior stability compared with the divergent configuration when KW-bone bonding is compromised. When KW-bone bonding conditions are adequate, crossed and divergent KW configurations provide similar, sufficient fracture stability. Conclusions Under normal bone-implant interface conditions, the two diverging lateral KW configuration offers satisfactory mechanical stability and may be the preferred choice of SCHF fixation. When KW-bone bonding is suboptimal, as when one or more of the lateral KWs are redrilled, addition of a medial KW should be considered in order to improve stability despite risk to ulnar nerve.

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Iatrogenic Ulnar Nerve Injury After the Surgical Treatment of Displaced Supracondylar Fractures of the Humerus: Number Needed to Harm, A Systematic Review

Abstract: Level III.

Cited by 111 publications

References 59 publications

Is Lateral Pin Fixation for Displaced Supracondylar Fractures of the Humerus Better Than Crossed Pins in Children?

Is Lateral Pin Fixation for Displaced Supracondylar Fractures of the Humerus Better Than Crossed Pins in Children?

Fratura supracondiliana de úmero em crianças: fixação com dois fios de Kirschner cruzados

Pediatric supracondylar humerus fractures: Effect of bone–implant interface conditions on fracture stability

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