Paediatric supracondylar humeral fractures: a technique for safe medial pin passage with zero incidence of iatrogenic ulnar nerve injury

Woo, Chin Yee; Ho, Han; Zainuddin, Mohammad Ashik; Lim, Kwanghui

doi:10.11622/smedj.2017094

Cited by 10 publications

(14 citation statements)

References 19 publications

Supporting

Mentioning

Contrasting

Unclassified

Order By: Relevance

“…Because of the size of our case series, these meta-analyses offer the only studies of comparable size. This case series (to our knowledge, the largest single-technique series) adds substantial support to the growing evidence that the mini-open technique is a safe method of cross-pinning 8,21,24,[40][41][42][43] . The mini-open technique allows for direct visualization of the pin entry site, allowing for much more confident placement than blind placement with palpation.…”

Section: The True Rates Of Iatrogenic Ulnar Nerve Injurysupporting

confidence: 60%

A Mini-Open Approach to Medial Pinning in Pediatric Supracondylar Humeral Fractures May Be Safer Than Previously Thought

Rees

Schultz

Wollenman

et al. 2021

Journal of Bone and Joint Surgery

View full text Add to dashboard Cite

Background: Displaced pediatric supracondylar humeral fractures (SCHFs) are stabilized after reduction by smooth pins. Although some SCHFs are biomechanically stable after lateral-only entry pinning (lateral pinning), an additional medial entry pin (cross-pinning) confers superior stabilization in some SCHFs. There is a recognized risk of iatrogenic ulnar nerve injury with medial entry pinning. The best existing evidence has estimated an iatrogenic ulnar nerve injury rate of approximately 3.4% in cross-pinning. In similar studies, the rate of iatrogenic nerve injury (all nerves) in lateral pinning is estimated at 1.9%. This study aimed to use a large, single-center, single-technique (mini-open) retrospective case series to determine the rate of iatrogenic ulnar nerve injury in cross-pinning.Methods: Patients undergoing percutaneous cross-pinning via the mini-open technique for SCHFs from 2007 to 2017 were retrospectively reviewed. Injury characteristics, operative variables, fixation technique, and complications, such as iatrogenic nerve injury, were recorded. Patients who underwent operative treatment at another hospital, had no postoperative follow-up, or died due to polytrauma were excluded.Results: In this study, 698 patients undergoing cross-pinning during the study period were identified. Patients treated with cross-pinning had severe fractures, including a total of 198 preoperative neurovascular injuries (28.4%), 32 patients (4.6%) with skin tenting, and 19 patients (2.7%) with open fractures. Iatrogenic nerve injury was reported in 3 cases (0.43%), all of which affected the ulnar nerve. In 2 of 3 cases of iatrogenic nerve injury, the ulnar nerve symptoms resolved at a mean follow-up of 15 weeks. Conclusions:The mini-open approach for medial pin insertion is safer than previous estimates. Here, in the largest single-center study of cross-pinning for SCHFs, the iatrogenic ulnar nerve injury rate of 0.43% was nearly 10 times lower than estimated rates from recent meta-analyses. Considering all nerves, the iatrogenic injury rate for this cross-pinning cohort was also lower than the estimated iatrogenic nerve injury rate for lateral pinning.

show abstract

Section: The True Rates Of Iatrogenic Ulnar Nerve Injurysupporting

confidence: 60%

A Mini-Open Approach to Medial Pinning in Pediatric Supracondylar Humeral Fractures May Be Safer Than Previously Thought

Rees

Schultz

Wollenman

et al. 2021

Journal of Bone and Joint Surgery

View full text Add to dashboard Cite

show abstract

“…Green et al [22]suggested an open medial incision, while Shim et al [23] proposed a subjective technique, putting their thumb over the cubital tunnel. A complex adjustment of the elbow' position combined with repetitive uoroscopy was mentioned in some other studies [28,29]. Michael et al [24] and Shtarker et al [25] applied the nerve stimulator in the medial K-wire insertion.…”

Section: Discussionmentioning

confidence: 99%

Pediatric supracondylar humeral fractures： a safe entry zone of medial pinning based on intraoperative fluoroscopy to avoid iatrogenic ulnar nerve injury

Zhu

et al. 2023

Preprint

View full text Add to dashboard Cite

Background For children with supracondylar humeral fractures (SHFs), iatrogenic ulnar nerve injury resulting from medial pinning remains a challenge for orthopedic surgeons. This study aims to explore a safe medial pinning zone and assess its efficacy. Methods First, the radiographic images of a healthy elbow were reconstructed and mapped by E3d software to display the safe medial pinning zone we summarized. Second, all the pediatric SHF cases treated by our team between May 2014 to May 2020 were retrospectively reviewed to evaluate the safety and efficacy of the pinning zone. Furthermore, we proposed a hand gesture to fast locate the safe medial pin insertion point. Results On the anteroposterior (AP) view, the upper 1/2 part of the slope line segment we defined was safe since the ulnar nerve traversed the ulnar groove at the lower 1/2 part. On the lateral view, the diamond zone we defined was a safe entry zone. In the retrospective study, 134 SHF cases were included and divided into two groups. In group A (74 cases), the medial Kirschner wire (K-wire) was inserted from the safe zone at both AP and lateral views, while in group B (60 cases) the medial pinning point was beyond the safe entry zone. The incidence of iatrogenic ulnar nerve injury in group A was significantly lower than in group B (P < 0.01). Moreover, the exploration and neurolysis of the ulnar nerve were performed in patients involving postoperative ulnar nerve dysfunction. A left-hand gesture by the surgeon during operations could help to fast locate the safe insertion point of medial pins. Conclusion Medial pinning from the safe entry zone based on intraoperative fluoroscopy is an easy, reliable, and reproducible technique to avoid iatrogenic ulnar nerve injury in children with SHFs.

show abstract

“…We also followed these steps while passing the medial pin. Edmonds et al and Woo et al followed the steps given in Tachdjian's Pediatric Orthopaedics textbook by Herring JA regarding safe pin holding, the position of the elbow, and insertion of a medial pin in order to minimize ulnar nerve injury [ 12 , 13 ]. In the year 2018, Woo et al treated 125 children with supracondylar fractures by medial pin fixation first with good results [ 13 ].…”

Section: Introductionmentioning

confidence: 99%

“…Edmonds et al and Woo et al followed the steps given in Tachdjian's Pediatric Orthopaedics textbook by Herring JA regarding safe pin holding, the position of the elbow, and insertion of a medial pin in order to minimize ulnar nerve injury [ 12 , 13 ]. In the year 2018, Woo et al treated 125 children with supracondylar fractures by medial pin fixation first with good results [ 13 ]. There is no study in the literature regarding which K-wire should be placed first so that the reduction stays during fracture fixation with minimal anesthesia time.…”

Section: Introductionmentioning

confidence: 99%

The Outcome of Placing the Medial K-wire First and Then the Lateral K-wire in Treating Supracondylar Humerus Fractures in Children Treated by Closed Reduction

Gupta¹,

Sanjay²,

Kale³

et al. 2022

Cureus

View full text Add to dashboard Cite

BackgroundDisplaced Gartland type III and IV supracondylar fractures are difficult to reduce and invariably require closed pining. After closed reduction, taking the anteroposterior (AP) view does not present any problem but when the elbow is placed in flexion and the limb is rotated internally to take a lateral view, the reduction is invariably lost. However, the reduction stays when the arm is rotated outwards, keeping the medial condyle up. This stimulates the idea of whether the medial pin can be placed first and then the two lateral pins to stabilize the fracture.It is very frustrating for young orthopedic surgeons to see reduction getting lost during internal rotation after first doing lateral pinning. There is no clear guideline on which side should be fixed first. HypothesisWe hypothesized that placing the medial pin first maintains the reduction and facilitates the subsequent placing of lateral pins without the loss of reduction. Materials and methodsA total of 170 children with displaced supracondylar humerus fractures were included in the study. A total of 120 children were grouped in the medial wire first group, and 50 were placed in the lateral wire first group, which was the control group. The mean age of the children was 7.5 years (range 2-13 years). The gender ratio (M: F) was 5:3; the left elbow was involved in 68% of the injuries, whereas the right elbow was involved in 32% of the injuries. All 170 children had an extension-type injury, with 91 (53.5%) fractures being Gartland type III and 79 (46.45%) fractures being type IV. ResultsResults were recorded as per Flynn's criteria. At the end of two years of follow-up, the children in the medial wire first group 117 (97.5%) showed excellent results and three (2.5%) children showed good results, whereas, in the lateral wire first group, 48 (96%) children showed excellent results and two (3.8%) children showed good results. There was a significant difference in the mean surgical time of 20.11±15.43 minutes in the medial wire first group vs 41.23±19.65 minutes in the lateral first group (p = 0.0021). None of the children developed permanent ulnar nerve palsy. ConclusionsPlacing the medial K-wire first rather than the conventional placing of the lateral wire first helps in maintaining the reduction and allows for the subsequent placement of lateral K-wires without losing the reduction, thus minimizing fixation time and producing good results.

show abstract

Paediatric supracondylar humeral fractures: a technique for safe medial pin passage with zero incidence of iatrogenic ulnar nerve injury

Abstract: This safe method of medial pin placement for surgical stabilisation of paediatric supracondylar humeral fractures is easily learnt and reproducible, and produces excellent results.

Cited by 10 publications

References 19 publications

A Mini-Open Approach to Medial Pinning in Pediatric Supracondylar Humeral Fractures May Be Safer Than Previously Thought

A Mini-Open Approach to Medial Pinning in Pediatric Supracondylar Humeral Fractures May Be Safer Than Previously Thought

Pediatric supracondylar humeral fractures： a safe entry zone of medial pinning based on intraoperative fluoroscopy to avoid iatrogenic ulnar nerve injury

The Outcome of Placing the Medial K-wire First and Then the Lateral K-wire in Treating Supracondylar Humerus Fractures in Children Treated by Closed Reduction

Contact Info

Product

Resources

About