JBJS | Operative Treatment of Supracondylar Fractures of the Humerus in Children : The Consequences of Pin Placement

The Journal of Bone & Joint Surgery, Volume 83, Issue 5

Articles | May 01, 2001

Operative Treatment of Supracondylar Fractures of the Humerus in Children : The Consequences of Pin Placement

David L. Skaggs, MD; Julia M. Hale, MHS, PAC; Jeffrey Bassett, BA; Cornelia Kaminsky, MD; Robert M. Kay, MD; Vernon T. Tolo, MD

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Investigation performed at Childrens Hospital, Los Angeles, California
David L. Skaggs, MD Julia M. Hale, MHS, PAC Jeffrey Bassett, BA Robert M. Kay, MD Vernon T. Tolo, MD Division of Orthopedic Surgery, Childrens Hospital, Mailstop 69, 4650 Sunset Boulevard, Los Angeles, CA 90027. E-mail address for D.L. Skaggs: dskaggs@chla.usc.edu
Cornelia Kaminsky, MD Department of Radiology, Childrens Hospital, 4650 Sunset Boulevard, Los Angeles, CA 90027
In support of their research or preparation of this manuscript, one or more of the authors received grants or outside funding from The Desert Golf Classic at Rancho Mirage. None of the authors received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

The Journal of Bone & Joint Surgery. 2001; 83:735-740

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Abstract

Background: The commonly accepted treatment of 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, the ulnar nerve can be injured with the use of a medial pin. It has not been proved that the added stability of a medial pin is clinically necessary since, in young children, pin fixation is always augmented with immobilization in a splint or cast.

Methods: We retrospectively reviewed the results of reduction and Kirschner wire fixation of 345 extension-type supracondylar fractures in children. 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 (a partially intact posterior cortex), seventy-four were treated with lateral pins only and sixty-seven were treated with crossed pins. Of 204 children who had a Gartland type-3 (unstable) fracture, fifty-one were treated with lateral pins only and 153 were treated with crossed pins.

Results: There was no difference with regard to maintenance of fracture reduction, as seen on anteroposterior and lateral radiographs, between the crossed pins and the lateral pins. The configuration of the pins did not affect the maintenance of reduction of either the Gartland type-2 fractures or the Gartland 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 was associated with ulnar nerve injury in 4% (six) of 149 patients in whom the pin was applied without hyperflexion of the elbow and in 15% (eleven) of seventy-one in whom the medial pin was applied with the elbow hyperflexed. Two years after the pinning, one of the seventeen children with ulnar nerve injury had persistent motor weakness and a sensory deficit.

Conclusions: Fixation with only lateral pins is safe and effective for both Gartland type-2 and Gartland type-3 (unstable) supracondylar fractures of the humerus in children. The use of only 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 in the treatment of supracondylar fractures of the humerus in children. If a medial pin is used, the elbow should not be hyperflexed during its insertion.

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Introduction

Introduction | Materials and Methods | Results | Discussion | References

Fracture reduction and percutaneous fixation is the most commonly accepted treatment of displaced supracondylar humeral fractures in children. There is, however, controversy about the optimal pin configuration^1-5. Treatment based on the modified version of the Gartland classification⁶ consists of closed reduction and percutaneous pinning of type-2 and type-3 fractures. Type-1 fractures are nondisplaced; type-2 fractures are displaced in extension, with a fracture of the anterior cortex, a partially intact posterior cortex, and rotation of the distal fragment; and type-3 fractures do not have an intact cortex and are completely unstable.

One study of cadaver elbows suggested that the torsional strength of crossed pins is greater than that of two lateral pins but similar to that of three lateral pins⁷. The reported prevalence of ulnar nerve injury with the use of crossed pins has ranged from 0% (of 105) to 6% (nineteen of 331)^2,8-12. A review of two clinical studies involving a total of ninety-three patients showed that lateral pins alone were clinically as effective as crossed pins and also that the ulnar nerve was protected from injury^13,14.

Flexion of the elbow to more than 90° in the presence of hypermobility of the ulnar nerve leads to anterior subluxation of the nerve, placing it on the medial epicondyle¹². Using a small medial incision to define the location of the ulnar nerve may help to avoid injury to the nerve¹⁵.

We performed this study to evaluate the hypotheses that the risk of injury to the ulnar nerve is (1) decreased with the use of only lateral pins, (2) increased when the medial pin is placed with hyperflexion of the elbow, (3) more frequent in younger children, and (4) avoided by the use of a small medial incision to identify a safe point of entry for the pin.

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TABLE I: Change in Baumann Angle16 from Postoperative Radiographs to Radiographs Made at Time of Fracture-Healing

*The values are given as the mean and standard deviation in degrees.

Gartland⁶ Fracture Type and Patient Age	Lateral Pins*	Crossed Pins*		Combined
No Hyperflexion	Hyperflexion
Type 2
£5 yr	?0.53 4.6	?1.33 ± 5.6	1.17 ± 6.2	?0.31 ± 5.3
>5 yr	-1.57 7.5	-0.57 ± 10.7	3.83 ± 6.7	-0.34 ± 8.2
Combined	?0.09 5.6	?0.90 ± 6.9	-0.13 ± 6.5	?0.14 ± 6.1
Type 3
£5 yr	?2.14 5.5	?0.62 ± 5.9	?0.60 ± 5.3	?1.06 ± 5.7
>5 yr	-2.54 9.4	-1.47 ± 6.4	-0.14 ± 7.0	-1.36 ± 7.0
Combined	?0.82 7.1	-0.22 ± 6.2	?0.24 ± 6.1	?0.12 ± 6.3

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TABLE I: Change in Baumann Angle16 from Postoperative Radiographs to Radiographs Made at Time of Fracture-Healing

*The values are given as the mean and standard deviation in degrees.

Gartland⁶ Fracture Type and Patient Age	Lateral Pins*	Crossed Pins*		Combined
No Hyperflexion	Hyperflexion
Type 2
£5 yr	?0.53 4.6	?1.33 ± 5.6	1.17 ± 6.2	?0.31 ± 5.3
>5 yr	-1.57 7.5	-0.57 ± 10.7	3.83 ± 6.7	-0.34 ± 8.2
Combined	?0.09 5.6	?0.90 ± 6.9	-0.13 ± 6.5	?0.14 ± 6.1
Type 3
£5 yr	?2.14 5.5	?0.62 ± 5.9	?0.60 ± 5.3	?1.06 ± 5.7
>5 yr	-2.54 9.4	-1.47 ± 6.4	-0.14 ± 7.0	-1.36 ± 7.0
Combined	?0.82 7.1	-0.22 ± 6.2	?0.24 ± 6.1	?0.12 ± 6.3

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TABLE II: Prevalence of Fractures Displaced on Lateral Radiographs

Gartland⁶ Fracture Type and Patient Age	Lateral Pins	Crossed Pins		Combined
No Hyperflexion	Hyperflexion
Type 2
£5 yr	?1/45 = 2%	0/24 = 0%	0/23 = 0%	?1/92 = 1%
>5 yr	?1/19 = 5%	?0/7 = 0%	?0/6 = 0%	?1/32 = 3%
Type 3
£5 yr	?1/28 = 4%	?3/53 = 6%	0/15 = 0%	?4/96 = 4%
>5 yr	?1/11 = 9%	?1/36 = 3%	1/14 = 7%	?3/61 = 5%
Combined	4/103 = 4%	4/120 = 3%	1/58 = 2%	9/281 = 3%

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TABLE II: Prevalence of Fractures Displaced on Lateral Radiographs

Gartland⁶ Fracture Type and Patient Age	Lateral Pins	Crossed Pins		Combined
No Hyperflexion	Hyperflexion
Type 2
£5 yr	?1/45 = 2%	0/24 = 0%	0/23 = 0%	?1/92 = 1%
>5 yr	?1/19 = 5%	?0/7 = 0%	?0/6 = 0%	?1/32 = 3%
Type 3
£5 yr	?1/28 = 4%	?3/53 = 6%	0/15 = 0%	?4/96 = 4%
>5 yr	?1/11 = 9%	?1/36 = 3%	1/14 = 7%	?3/61 = 5%
Combined	4/103 = 4%	4/120 = 3%	1/58 = 2%	9/281 = 3%

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TABLE III: Prevalence of Ulnar Nerve Injury

Gartland⁶ Fracture Type and Patient Age	Lateral Pins	Crossed Pins		Combined
No Hyperflexion	Hyperflexion
Type 2
£5 yr	0/48 = 0%	?0/26 = 0%	2/27 = 7%	?2/101 = 2%
>5 yr	0/26 = 0%	??0/7 = 0%	?0/7 = 0%	??0/40 = 0%
Combined	0/74 = 0%	?0/33 = 0%	2/34 = 6%	?2/141 = 1%
Type 3
£5 yr	0/38 = 0%	?3/73 = 4%	?2/20 = 10%	?5/131 = 4%
>5 yr	0/13 = 0%	?3/43 = 7%	?7/17 = 41%	??10/73 = 14%
Combined	0/51 = 0%	6/116 = 5%	?9/37 = 24%	15/204 = 7%

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TABLE III: Prevalence of Ulnar Nerve Injury

Gartland⁶ Fracture Type and Patient Age	Lateral Pins	Crossed Pins		Combined
No Hyperflexion	Hyperflexion
Type 2
£5 yr	0/48 = 0%	?0/26 = 0%	2/27 = 7%	?2/101 = 2%
>5 yr	0/26 = 0%	??0/7 = 0%	?0/7 = 0%	??0/40 = 0%
Combined	0/74 = 0%	?0/33 = 0%	2/34 = 6%	?2/141 = 1%
Type 3
£5 yr	0/38 = 0%	?3/73 = 4%	?2/20 = 10%	?5/131 = 4%
>5 yr	0/13 = 0%	?3/43 = 7%	?7/17 = 41%	??10/73 = 14%
Combined	0/51 = 0%	6/116 = 5%	?9/37 = 24%	15/204 = 7%

Materials and Methods

Introduction | Materials and Methods | Results | Discussion | References

we examined the medical records and radiographs of 382 children who had a supracondylar fracture of the humerus that had been treated operatively by one of eleven staff pediatric orthopaedic surgeons. The children were seen consecutively between January 1990 and December 1995. At our institution, Gartland type-2 or type-3 supracondylar fractures of the humerus were treated operatively¹⁵. Thirty-seven children were excluded from the study: twenty-one had inadequate documentation of the type of fracture, thirteen were not followed until fracture-healing had occurred, and three had a flexion-type fracture. The mean age of the remaining 345 children at the time of the operation was four years and four months (range, one to twelve years). All fractures were treated within twenty-four hours after presentation at our hospital; however, because of the tertiary referral pattern the mean time from injury to treatment was 1.4 days (range, zero to seventeen days; median, one day).

The information recorded for all patients included the nature of the injury (open or closed), neurovascular status, type of reduction (open or closed), name of the operating surgeon, number and site of pins, use of a medial incision and position of the elbow when a medial pin was used, postoperative neurovascular status, postoperative loss of fracture reduction requiring another operation, and details of additional procedures. The treatment provided and the time to recovery were recorded for patients who had clinical evidence of a postoperative injury to the ulnar nerve.

Maintenance of reduction was assessed in 281 patients for whom radiographs made postoperatively and at the time of fracture union were available for review. The radiographs of sixty-four children could not be retrieved, as they had been returned to the referring facilities. One of us (D.L.S.) reviewed all available radiographs.

The maintenance of fracture reduction in the coronal plane was determined on an anteroposterior radiograph by measuring the angle described by Baumann¹⁶. This angle is formed by the intersection of a line perpendicular to the humeral shaft and a line parallel to the lateral portion of the distal humeral metaphysis. The difference, if any, between the measurements made postoperatively and those made at the time of fracture union was recorded. Maintenance of fracture reduction in the sagittal plane was confirmed when the anterior humeral line intersected the ossified part of the capitellum; an absence of this relationship indicated loss of reduction.

Multivariate linear regression analysis was used to determine the effect, if any, of the use of lateral pins or crossed pins, hyperflexion of the elbow when a medial pin was applied, Gartland fracture type, and age of the patient on the maintenance of fracture reduction in the frontal plane as indicated by the angle of Baumann. The Fisher exact test was used to evaluate the effect, if any, of the same variables on the maintenance of fracture reduction in the sagittal plane as indicated by the position of the capitellum relative to the anterior humeral line. Logistic regression analysis was used to estimate the risk of ulnar nerve injury relative to the same variables.

Results

Introduction | Materials and Methods | Results | Discussion | References

There were 141 Gartland type-2 fractures. Lateral pins were used in seventy-four of them; crossed pins without hyperflexion of the elbow, in thirty-three; and crossed pins with hyperflexion, in thirty-four. There were 204 Gartland type-3 fractures. Lateral pins were used in fifty-one of them; crossed pins without hyperflexion, in 116; and crossed pins with hyperflexion, in thirty-seven. Crossed pins were used in 48% (sixty-seven) of the 141 type-2 fractures and in 75% (153) of the 204 type-3 fractures.

Closed reduction and percutaneous pinning was performed in 331 patients, and open reduction with pinning was done in fourteen (with six open and eight closed fractures). One of the eight patients who had a closed fracture and an open reduction sustained an ulnar nerve injury.

With the numbers available, there was no association between the mean change (and standard deviation) in the Baumann angle as measured on the anteroposterior radiograph and the use of crossed pins or lateral pins (0.06° ± 6.31° and 0.25° ± 6.19°; p = 0.806), pin placement with or without hyperflexion of the elbow (0.05° ± 6.2° and 0.15° ± 6.2°; p = 0.913), or Gartland type-2 or type-3 fracture (0.14° ± 6.1° and 0.12° ± 6.3°; p = 0.974). The mean change in the Baumann angle in children who were five years old or younger was significantly smaller (p = 0.013) than the mean change in children who were more than five years old (0.07° ± 5.5° and -1.01° ± 7.44°). There was no association between the mean change in the Baumann angle and the use of crossed pins or lateral pins when type-2 (p = 0.657) and type-3 (p = 0.430) fractures were analyzed independently (Table I).

With the numbers available, fracture reduction in the sagittal plane was not affected by age, fracture type, pin configuration, or hyperflexion of the elbow during medial pin placement. No significant difference was found between crossed pins and lateral pins when the analysis involved all 345 fractures (p = 0.729), type-2 fractures only (p = 0.497), type-3 fractures only (p = 0.999), or patients more or less than five years old (p = 0.484). The difference between type-2 and type-3 fractures with regard to maintenance of reduction in the sagittal plane was not significant (p = 0.307) (Table II).

The loss of reduction of the fracture in two patients in whom crossed pins had been used had clinical implications. One patient, a four-year-old girl, had a type-2 fracture. One week after the initial reduction, the distal fragment was found to be in a varus position and a second closed reduction with pin fixation was performed. The fracture healed uneventfully with a good functional result. The second child, a six-year-old boy, had fixation of a type-3 fracture with one medial pin and two lateral pins. One year later, he had 15° of cubitus varus of the affected extremity and 15° of cubitus valgus of the contralateral extremity. The patient could hyperextend the injured elbow to 20° compared with 10° on the unaffected side. A corrective osteotomy was recommended.

Seventeen (4.9%) of the 345 patients had an iatrogenic ulnar nerve injury. None of the 125 patients in whom only lateral pins were used had a nerve injury. Six (4%) of the 149 patients in whom a medial pin was placed without hyperflexion of the elbow and eleven (15%) of the seventy-one patients who had placement of the medial pin with hyperflexion of the elbow had an ulnar nerve injury. The difference among the three groups was significant (p < 0.001) .

Ulnar nerve injury occurred more frequently when crossed pins were used than it did when only lateral pins were used (a 7.7% prevalence [seventeen of 220] compared with a 0% prevalence [zero of 125]; p < 0.001). The difference in the prevalence of ulnar nerve injury between crossed pins and lateral pins was greater for type-3 fractures (10% [fifteen of 153] compared with 0% [of fifty-one]; p = 0.025) than it was for type-2 fractures (3% [two of sixty-seven] compared with 0% [of seventy-four]; p = 0.224). Ulnar nerve injury was not seen with lateral or crossed pins in the 107 type-2 fractures that were pinned without hyperflexion of the elbow. When crossed pins were used for type-3 fractures, the risk of ulnar nerve injury was 24% (nine of thirty-seven) when the elbow was taped in hyperflexion and 5% (six of 116) when the elbow was not hyperflexed (p = 0.002) (Table III). The risk of nerve injury with the use of crossed pins for a type-3 fracture was greater in children who were more than five years old (17% [ten of sixty]) than it was in children who were five years old or less (5% [five of ninety-three]) (p = 0.027). A multivariate logistic regression analysis showed that age (p = 0.009), fracture type (p = 0.044), and placement of a medial pin with the elbow in hyperflexion (p = 0.001) were independently related to an increased risk of ulnar nerve injury. Ulnar nerve injury was seen in two (6%) of the thirty-three patients in whom the point of pin entry had been exposed with a medial incision and in fifteen (8%) of the 187 patients in whom the incision was not used (p = 0.697).

Fourteen of the seventeen children with ulnar nerve injury had both sensory and motor deficits, two had a motor deficit, and one had a sensory deficit. The pins were removed after the fracture had healed. Exploration of the ulnar nerve or reconstructive procedures were not required in any patient. Nine children received occupational therapy, and six wore a splint to prevent deformity. Eleven children were followed until complete neurological recovery. The average time to recovery was eighteen weeks (range, six to fifty-four weeks). When interviewed by telephone, the families of five of the remaining patients stated that there was no residual nerve deficit. Two years after the operation, one child who had been treated with crossed pins had residual motor and sensory deficits.

In summary, the predictors of ulnar nerve injury were found to be related to the operative technique. The use of crossed pins (p < 0.001) and pinning with the elbow in hyperflexion (p = 0.001) were associated with the greatest risk.

Discussion

Introduction | Materials and Methods | Results | Discussion | References

Fracture reduction and percutaneous fixation is the most commonly accepted treatment of displaced supracondylar fractures of the humerus in children; however, the optimal pin configuration continues to be the subject of debate^1-5. Casiano¹⁷ and Flynn et al.¹⁸ recommended the use of crossed pins, and contemporary textbooks describe this as the preferred technique except when the medial epicondyle cannot be palpated³.

Fowles and Kassab¹⁹ reviewed the results of treatment of 110 children and recommended the use of two lateral pins. Arino et al.²⁰ also used two lateral pins, in 189 patients. Aronson and Prager²¹ reported injury to the ulnar nerve in the first patient in whom they used crossed pins. Subsequently they used only lateral pins in the remaining nineteen patients in their study. Royce et al.¹¹ recommended the use of two lateral pins when the reduction was stable and the use of crossed pins when the reduction was unstable. Boyd and Aronson²² reported ulnar nerve injury in two of seventy-one patients treated with crossed pins. Lyons et al.¹⁰ suggested that lateral pins are sufficient in most patients but crossed pins may be required in younger children in whom the distal part of the humerus has a small cross-sectional area, especially when there is comminution of the medial humeral cortex.

Kallio et al.²³ reported loss of fixation in eleven of eighty patients in whom only two lateral pins had been used. The loss of fixation was attributed to technical errors, such as failure to engage the proximal and distal cortices and crossing of the pins at the fracture site. The authors concluded that, although the use of two lateral pins eliminates the risk of injury to the ulnar nerve, it is technically very demanding. However, the technical errors that they described are not specific to the placement of lateral pins in the distal part of the humerus but are errors that would result in poor fixation of any type of fracture.

Topping et al.¹⁴ evaluated the association of pin configuration with nerve injury during the fixation of type-3 fractures by comparing the results of the use of crossed pins in twenty-seven children with those of the use of two lateral pins in twenty patients. Crossed pins had been used in the only patient who had an ulnar nerve injury. These authors noted that the patients treated with crossed pins had a greater degree of change in the Baumann and humeral-capitellar angles at the time of fracture union but the difference was not clinically relevant. France and Strong¹³ compared the use of two lateral pins in thirty-two patients with the use of crossed pins in fourteen patients, all of whom had a type-3 fracture, and found no difference in the maintenance of reduction. The conclusions in these two studies were that crossed pins did not provide any advantage over two lateral pins in the treatment of displaced supracondylar fractures of the humerus and that the risk of ulnar nerve injury with crossed pins was not acceptable.

Zionts et al.⁷ investigated the torsional strength of various pin configurations in adult human cadavera with simulated supracondylar fractures. They noted that two crossed pins were 25% more rigid than three lateral pins; however, this difference was not significant. The authors also noted that two crossed pins were 37% stronger than two parallel lateral pins and 80% stronger than two lateral pins that crossed at the fracture site; these differences were significant (p < 0.05 for both).

It is believed that joint infection can develop after the use of multiple lateral pins, as the distal pin may cross the olecranon fossa. The only report of joint infection that we found was by Fowles and Kassab¹⁹, who performed a study in Tunisia. The authors believed the infection to be related to the working environment rather than to operative technique.

Zaltz et al.¹² noted that when the elbow was flexed more than 90° the ulnar nerve migrated anterior to the medial epicondyle in 18% of children less than five years of age and over the epicondyle in 43%. In children six to ten years old the rates were 8% and 21%, respectively, and in children eleven to eighteen years old the rates were 6% and 20%, respectively. These authors suggested that the lateral pin should be inserted first so that the medial pin can be inserted with the elbow in less flexion, thereby decreasing tension on the ulnar nerve and allowing it to fall posteriorly. Our results support this concept.

The prevalence of ulnar nerve injury was 5% (seventeen of 345) in our study, which was similar to the 6% prevalence (nineteen of 331) reported by Lyons et al.¹⁰. Our hypothesis that nerve injury was a consequence of placement of pins and not of manipulation during reduction was validated. There were no nerve injuries in the 125 patients in whom only lateral pins were used, whereas there were seventeen injuries in the 220 patients in whom crossed pins were used (p < 0.001).

The hypothesis that hyperflexion of the elbow during placement of the medial pin increases the risk of nerve injury was also validated. Eleven of the seventy-one patients whose elbow was hyperflexed had an injury to the ulnar nerve compared with only six of 149 patients who did not have hyperflexion of the elbow. In addition, seven of seventeen patients, older than five years of age, who had a type-3 fracture stabilized with a medial pin placed with the elbow in hyperflexion had an ulnar nerve injury.

Our hypothesis that ulnar nerve injury was more common in younger children was not validated. Ten of 113 children older than five years of age had a nerve injury, whereas only seven of 232 children five years old or less had an injury (p = 0.027). The mean age of the children who had a nerve injury was 6.5 years compared with 4.3 years for the children who did not have an injury. It is possible that we failed to recognize nerve injury in very young children, as clinical changes may be very subtle and difficult to detect.

Our hypothesis that ulnar nerve injury could be avoided with a small medial incision to guide accurate placement of the pin was also not validated. However, other reports^1,11, including a study of fifty-two patients by Weiland et al.¹⁵, demonstrated no nerve injuries after open reduction and fixation with crossed pins. We noted nerve injury in two of thirty-three patients in whom a small incision had been used compared with fifteen of 187 patients in whom an incision had not been used (p = 0.697).

To overcome bias related to the surgeon’s preference to use crossed pins for unstable fractures, we evaluated maintenance of fracture reduction in relation to fracture type and pin configuration. The configuration of the pins did not appear to influence the change in the Baumann angle in either type-2 fractures or type-3 (unstable) fractures. The position of the capitellum relative to the anterior humeral line changed more frequently in type-3 fractures than in type-2 fractures; however, there was no difference in relation to pin configuration when type-2 and type-3 fractures were analyzed independently.

Our conclusion, based on this study, reinforces the conclusions of other authors^13,14: lateral pins alone provide adequate fixation of unstable supracondylar fractures of the humerus and avoid injury to the ulnar nerve.

Note: The authors thank Fred Dorey, PhD, for statistical guidance and Nina Lebron for editorial assistance.

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Introduction | Materials and Methods | Results | Discussion | References

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Boyd DW, and Aronson DD: Supracondylar fractures of the humerus: a prospective study of percutaneous pinning. J Pediatr Orthop,1992.12: 789-94, 12789 1992 [PubMed]

Kallio PE; Foster BK; and Paterson DC: Difficult supracondylar elbow fractures in children: analysis of percutaneous pinning technique. J Pediatr Orthop,1992.12: 11-5, 1211 1992 [PubMed]

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TABLE I: Change in Baumann Angle16 from Postoperative Radiographs to Radiographs Made at Time of Fracture-Healing

*The values are given as the mean and standard deviation in degrees.

Gartland⁶ Fracture Type and Patient Age	Lateral Pins*	Crossed Pins*		Combined
No Hyperflexion	Hyperflexion
Type 2
£5 yr	?0.53 4.6	?1.33 ± 5.6	1.17 ± 6.2	?0.31 ± 5.3
>5 yr	-1.57 7.5	-0.57 ± 10.7	3.83 ± 6.7	-0.34 ± 8.2
Combined	?0.09 5.6	?0.90 ± 6.9	-0.13 ± 6.5	?0.14 ± 6.1
Type 3
£5 yr	?2.14 5.5	?0.62 ± 5.9	?0.60 ± 5.3	?1.06 ± 5.7
>5 yr	-2.54 9.4	-1.47 ± 6.4	-0.14 ± 7.0	-1.36 ± 7.0
Combined	?0.82 7.1	-0.22 ± 6.2	?0.24 ± 6.1	?0.12 ± 6.3

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TABLE I: Change in Baumann Angle16 from Postoperative Radiographs to Radiographs Made at Time of Fracture-Healing

*The values are given as the mean and standard deviation in degrees.

Gartland⁶ Fracture Type and Patient Age	Lateral Pins*	Crossed Pins*		Combined
No Hyperflexion	Hyperflexion
Type 2
£5 yr	?0.53 4.6	?1.33 ± 5.6	1.17 ± 6.2	?0.31 ± 5.3
>5 yr	-1.57 7.5	-0.57 ± 10.7	3.83 ± 6.7	-0.34 ± 8.2
Combined	?0.09 5.6	?0.90 ± 6.9	-0.13 ± 6.5	?0.14 ± 6.1
Type 3
£5 yr	?2.14 5.5	?0.62 ± 5.9	?0.60 ± 5.3	?1.06 ± 5.7
>5 yr	-2.54 9.4	-1.47 ± 6.4	-0.14 ± 7.0	-1.36 ± 7.0
Combined	?0.82 7.1	-0.22 ± 6.2	?0.24 ± 6.1	?0.12 ± 6.3

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TABLE II: Prevalence of Fractures Displaced on Lateral Radiographs

Gartland⁶ Fracture Type and Patient Age	Lateral Pins	Crossed Pins		Combined
No Hyperflexion	Hyperflexion
Type 2
£5 yr	?1/45 = 2%	0/24 = 0%	0/23 = 0%	?1/92 = 1%
>5 yr	?1/19 = 5%	?0/7 = 0%	?0/6 = 0%	?1/32 = 3%
Type 3
£5 yr	?1/28 = 4%	?3/53 = 6%	0/15 = 0%	?4/96 = 4%
>5 yr	?1/11 = 9%	?1/36 = 3%	1/14 = 7%	?3/61 = 5%
Combined	4/103 = 4%	4/120 = 3%	1/58 = 2%	9/281 = 3%

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TABLE II: Prevalence of Fractures Displaced on Lateral Radiographs

Gartland⁶ Fracture Type and Patient Age	Lateral Pins	Crossed Pins		Combined
No Hyperflexion	Hyperflexion
Type 2
£5 yr	?1/45 = 2%	0/24 = 0%	0/23 = 0%	?1/92 = 1%
>5 yr	?1/19 = 5%	?0/7 = 0%	?0/6 = 0%	?1/32 = 3%
Type 3
£5 yr	?1/28 = 4%	?3/53 = 6%	0/15 = 0%	?4/96 = 4%
>5 yr	?1/11 = 9%	?1/36 = 3%	1/14 = 7%	?3/61 = 5%
Combined	4/103 = 4%	4/120 = 3%	1/58 = 2%	9/281 = 3%

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TABLE III: Prevalence of Ulnar Nerve Injury

Gartland⁶ Fracture Type and Patient Age	Lateral Pins	Crossed Pins		Combined
No Hyperflexion	Hyperflexion
Type 2
£5 yr	0/48 = 0%	?0/26 = 0%	2/27 = 7%	?2/101 = 2%
>5 yr	0/26 = 0%	??0/7 = 0%	?0/7 = 0%	??0/40 = 0%
Combined	0/74 = 0%	?0/33 = 0%	2/34 = 6%	?2/141 = 1%
Type 3
£5 yr	0/38 = 0%	?3/73 = 4%	?2/20 = 10%	?5/131 = 4%
>5 yr	0/13 = 0%	?3/43 = 7%	?7/17 = 41%	??10/73 = 14%
Combined	0/51 = 0%	6/116 = 5%	?9/37 = 24%	15/204 = 7%

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TABLE III: Prevalence of Ulnar Nerve Injury

Gartland⁶ Fracture Type and Patient Age	Lateral Pins	Crossed Pins		Combined
No Hyperflexion	Hyperflexion
Type 2
£5 yr	0/48 = 0%	?0/26 = 0%	2/27 = 7%	?2/101 = 2%
>5 yr	0/26 = 0%	??0/7 = 0%	?0/7 = 0%	??0/40 = 0%
Combined	0/74 = 0%	?0/33 = 0%	2/34 = 6%	?2/141 = 1%
Type 3
£5 yr	0/38 = 0%	?3/73 = 4%	?2/20 = 10%	?5/131 = 4%
>5 yr	0/13 = 0%	?3/43 = 7%	?7/17 = 41%	??10/73 = 14%
Combined	0/51 = 0%	6/116 = 5%	?9/37 = 24%	15/204 = 7%