Loss of pin fixation in displaced supracondylar humeral fractures in children: Causes and prevention
ABSTRACT Although the results are generally good following pin fixation of supracondylar humeral fractures in children, occasionally there is postoperative displacement. The purposes of the present study were to identify the causes leading to loss of fixation after pin fixation and to present methods for prevention.
We evaluated 322 displaced supracondylar humeral fractures that had been treated with percutaneous pin fixation. We examined fracture classification, pin configuration, intraoperative alignment after fixation, change in alignment after fixation, details of additional procedures, and final radiographic and clinical outcomes.
Adequate radiographs were available for 279 of the 322 fractures. Eight (2.9%) of the 279 fractures were associated with postoperative loss of fixation; all eight were Gartland type-III fractures. Seven of these eight fractures initially had been treated with two lateral-entry pins, and one had been treated with two crossed pins. In patients with Gartland type-III fractures, loss of fixation was successfully avoided more often when three pins were used (with fixation being maintained in thirty-seven of thirty-seven patients) as opposed to when two lateral-entry pins were used (with fixation being maintained in thirty-five of forty-two patients) (p = 0.01). In all cases, loss of fixation was due to technical errors that were identifiable on the intraoperative fluoroscopic images and that could have been prevented with proper technique. We identified three types of pin-fixation errors: (1) failure to engage both fragments with two pins or more, (2) failure to achieve bicortical fixation with two pins or more, and (3) failure to achieve adequate pin separation (>2 mm) at the fracture site.
Postoperative displacement following pin fixation of supracondylar humeral fractures in children is uncommon. In the present series, loss of fixation was most likely to occur when Gartland type-III fractures were treated with two lateral-entry pins. There were no failures when three pins were used. In all cases of failure, there were identifiable technical errors in pin placement.
Therapeutic Level III. See Instructions to Authors for a complete description of levels of evidence.
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ABSTRACT: This study compares clinical and radiographic outcomes of operatively managed pediatric supracondylar humerus fractures between patients treated by pediatric orthopedists (POs) and patients treated by non-pediatric orthopedists (NPOs). A retrospective cohort study of pediatric patients with surgically managed supracondylar humerus fractures was conducted. For clinical outcomes analyses, 3 months of clinical follow-up were required, resulting in a sample size of 90 patients (33 treated by NPOs, 57 by POs). For radiographic outcomes analyses, 3 months of both clinical and radiographic follow-up were required, resulting in a sample size of 57 patients (23 treated by NPOs, 34 by POs). The rate of inadequate fracture fixation was higher for patients treated by NPOs (43.5 %) than for patients treated by POs (14.7 %; p = 0.030), but rates of clinical complications, malreduction, and postoperative loss of reduction did not differ. Treatment with open reduction was more common for patients treated by NPOs (33.3 %) than for patients treated by POs (3.5 %; p < 0.001). Total operating room time was longer for patients treated by NPOs (110.9 min) than for patients treated by POs (82.9 min; p < 0.001). While patients treated by POs differed from patients treated by NPOs with respect to several intermediate outcomes, including having a lower rate of open reduction and a lower rate of inadequate fracture fixation, there were no differences between POs and NPOs in the rates of the more meaningful and definitive outcomes, including clinical complications, malreduction, and postoperative loss of reduction.Journal of Children s Orthopaedics 02/2015; 9(1). DOI:10.1007/s11832-015-0642-3
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ABSTRACT: Loss of reduction following closed or open reduction of displaced supracondylar fractures of the humerus in children varies widely and is considered dependent on stability of the fracture pattern, Gartland type, number and configuration of pins for fixation, technical errors, adequacy of initial reduction, and timing of the surgery. This study was aimed to evaluate the factors responsible for failure of reduction in operated pediatric supracondylar fracture humerus. We retrospectively assessed loss of reduction by evaluating changes in Baumann's angle, change in lateral rotation percentage, and anterior humeral line in 77 consecutive children who were treated with multiple Kirschner wire fixation and were available for followup. The intraoperative radiographs were compared with those taken immediately after surgery and 3 weeks postoperatively. Multivariate logistic regression analysis was performed by STATA 10. Reduction was lost in 18.2% of the patients. Technical errors were significantly higher in those who lost reduction (P = 0.001; Odds Ratio: 57.63). Lateral pins had a significantly higher risk of losing reduction than cross pins (P = 0.029; Odds Ratio: 7.73). Other factors including stability of fracture configuration were not significantly different in the two groups. The stability of fracture fixation in supracondylar fractures in children is dependent on a technically good pinning. Cross pinning provides a more stable fixation than lateral entry pins. Fracture pattern and accuracy of reduction were not important factors in determining the stability of fixation.Indian Journal of Orthopaedics 11/2012; 46(6):690-7. DOI:10.4103/0019-5413.104219 · 0.62 Impact Factor
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ABSTRACT: Supracondylar distal humerus fractures are one of the most common skeletal injuries in children. The current treatment of choice in North America is closed reduction and percutaneous pin fixation. Often surgeons leave the pins exposed beneath a cast but outside the skin. Great variation exists with respect to preoperative skin preparation, and perioperative antibiotic administration. Few data exist regarding the rate of infection and other complications. The purpose of this study is to review a large series of children to evaluate the rate of infection and other complications. A retrospective review was carried out of all patients treated at our institution over an 11-year period. A total of 622 patients were identified that were followed for a minimum of 2 weeks after pin removal. Seventeen patients had flexion-type fractures, 294 had type II fractures, and 311 had type III fractures. Seventy-four fractures (11.9%) had preoperative nerve deficits with anterior interosseous palsies being the most common (33 fractures, 5.3%). Preoperative antibiotics were given to 163 patients (26.2%). Spray and towel draping were used in 362 patients, paint and towel draping were used in 65 patients, alcohol paint and towel draping were used in 146 patients, and a full preparation and draping were used in 13 patients. The pins were left exposed under the cast in 591 fractures (95%), and buried beneath the skin in 31 fractures (5.0%). A medial pin was placed in 311 fractures with a small incision made to aid placement in 18 of these cases. The most common complication was pin migration necessitating unexpected return to the operating room for pin removal in 11 patients (1.8%). One patient developed a deep infection with septic arthritis and osteomyelitis (0.2%). Five additional patients had superficial skin infections and were treated with oral antibiotics for a total infection rate of 6 of 622 patients (1.0%). One patient ultimately had a malunion and 4 others returned to the operating room for repeat reduction and pinning. Three patients developed compartment syndromes. Ulnar nerve injury was rare with only 1 postoperative ulnar nerve injury occurring in 311 patients treated with a medial pin (0.3%). Closed reduction with percutaneous pinning is effective and has a low complication rate with a very low rate of infection even when simple betadine preparation and towel draping are used. Preoperative antibiotics seem to have little effect on infection rate. Level III retrospective comparative study.Journal of pediatric orthopedics 10/2009; 29(7):704-8. DOI:10.1097/BPO.0b013e3181b768ac · 1.43 Impact Factor