The outcome and parents-based cosmetic satisfaction following fixation of paediatric supracondylar humerus fractures treated by closed method with or without small medial incision
© Basaran et al. 2016
Received: 2 October 2015
Accepted: 15 February 2016
Published: 25 February 2016
Supracondylar humerus fractures are common in children. Displaced fractures are usually treated with closed reduction and cross pin fixation. But, medial pinning may cause the ulnar nerve injury. The aim of this study was to compare the parents-based cosmetic satisfaction of the incision scars in children with displaced supracondylar humerus fractures treated by closed reduction and cross pin fixation with or without small medial incision. We retrospectively reviewed the medical records of 72 children with displaced supracondylar humerus fractures treated two different closed reduction and percutaneous pinning methods at our institution from January 2010 through December 2013. A group has 36 patients treated with small medial incision and crossed K-wires fixation after closed reduction. The other group has 36 patients treated with closed reduction and K-wires fixation. At the final follow-up, the patients were evaluated radiologically and clinically with Flynn’s criteria. Furthermore, a visual analogue scale was used to determine of the parents-based cosmetic satisfaction score. All fractures healed without major complications at the final clinical and radiological assessment. Although, between the two groups did not differ in terms of Flynn cosmetic and functional outcomes, there were statistically significant differences between both groups according to the parents-based cosmetic satisfaction scores. The closed reduction and crossed pin fixation without small medial incision should be preferred first because of better the parents-based cosmetic satisfaction.
KeywordsChildren Supracondylar fracture Percutaneous pinning Cosmetic evaluation Ulnar nerve injury
The gold standard treatment of displaced supracondylar humerus fractures in children is the closed reduction and pin fixation (Pretell-Mazzini et al. 2011; Belhan et al. 2009; Sibinski et al. 2006; Kalenderer et al. 2008; Bashyal et al. 2009; Kaewpornsawan 2001). Cross pin fixation is more stable mechanically than any other type of pin configuration (Zionts et al. 1994; Lee et al. 2002). However, this fixation technique may cause iatrogenic ulnar nerve injury during the medial pinning. The probability of ulnar nerve injury in the fixation with crossed pins is higher than the fixation with only lateral entry pins (Brauer et al. 2007; Slobogean et al. 2010).
For eliminating iatrogenic ulnar nerve injury, some surgeons have preferred the fixation from only lateral side (Sibinski et al. 2006; Gaston et al. 2010). Moreover, many surgical techniques such as the fixation of fracture in the prone position (Fowler and Marsh 2006), medial pin placed without hyperflexion of the elbow (Eidelman et al. 2007; Shim and Lee 2002; Skaggs et al. 2001), ulnar nerve stimulation method (Michael and Stanislas 1996) and small medial incision over the medial epicondyle (Sibinski et al. 2006; Bashyal et al. 2009; Green et al. 2005; Khademolhosseini et al. 2013) have been described for reducing iatrogenic ulnar nerve injury. However, the medial mini-open technique causes extra scar formation.
The aim of this study was to compare the parents-based cosmetic satisfaction score of the incision scars in children with displaced supracondylar humerus fractures treated by closed reduction and crossed pin fixation with or without small medial incision. Also, we compared clinically and radiologically these treatment methods.
A retrospective study was performed on patients with a displaced supracondylar fracture of the humerus treated from January 2010 to December 2013. Exclusion criteria were open fractures, fractures required open reduction, fractures with neurological or vascular injuries in admission, presence of any concomitant fractures, bilateral supracondylar humeral fracture, a previous ipsilateral elbow fracture, and loss to follow-up. We reviewed the hospital records in detail including personal data, preoperative clinical examinations, time to surgery, fracture type, time of pin removal and presence of complications.
The patients were evaluated clinically and radiologically at last follow-up visit. The clinical evaluation included assessment of the carrying angle, the passive range of elbow motion, scar formation, neurologic and vascular examinations of the fractured extremity, and determinations of any complications such as infection and the need for a reoperation. The radiographic evaluation included an anteroposterior radiograph of the distal part of the humerus and a lateral radiograph of the elbow. Baumann angle and humerocapitellar angle of fractured side and the differences of these angles between fractured and opposite sides were calculated and compared in both groups. Also, differences of carrying angle and passive range of elbow motion between fractured and opposite sides were calculated and were compared in both groups.
IBM SPSS Statistic Version 20.0 software was used for statistical analysis. The data was evaluated with descriptive statistical methods (mean, standard deviation). Independent groups of quantitative data showing normal distribution was used independent samples test. For crude analysis of independent groups of qualitative data was used Chi Square test. A 95 % confidence interval, significance at p < 0.05 were accepted.
A total of 72 children fulfilled the inclusion criteria of the study, including 49 (68.1 %) boys and 23 (31.9 %) girls. Their mean age was 7.2 years (range 2–13 years); 22 children (30.6 %) had fractures on the right side and 50 (69.4 %) on the left side. All patients had Gartland type 3 fractures. Two study groups were set up from these included patients; the closed reduction percutaneous cross pin fixation was first group, and closed reduction percutaneous cross pin fixation with small medial incision was second group. The surgical methods were determined by the surgeons’ preferences.
Relationship between both treatment groups
Group I (n = 36)
Group II (n = 36)
6.9 ± 2.7
7.4 ± 2.9
Time to surgey (min)
51.7 ± 21.8
59.7 ± 22
Time of the hospitalization (day)
1.9 ± 1
2.1 ± 1.3
Pin removing time (day)
30.2 ± 7.3
30.2 ± 4.5
23.3 ± 7.3
25.5 ± 11.4
All patients healed completely in the final clinical and radiological assessments. None of the patients were seen major complications such as nerve/arterial injury, compartment syndrome, septic arthritis, osteomyelitis or nonunion. Also, none of the patients developed loss of reduction necessitating return to the operating room.
Radiological and clinical comparisons of two treatment groups
Mean ± SS
Mean ± SS
19.6 ± 5.5
19.6 ± 7.5
Difference of Baumann angle
4 ± 4
4.6 ± 4.1
41.9 ± 6.6
40.9 ± 8.1
Difference of humerocapitellar angle
4.6 ± 4.1
5.8 ± 5.6
Difference of carrying angle
2.3 ± 2.3
1.9 ± 2.0
Diffrence of range of elbow motion
4.5 ± 7.4
4.8 ± 8.1
9.6 ± 0.8
8.6 ± 1.1
There are different surgical approaches can be used for displaced supracondylar humerus fractures in children (Ozkoc et al. 2004; Aktekin et al. 2008; Fu et al. 2011; Oh et al. 2003; Kazimoglu et al. 2009; Li et al. 2009; Basaran et al. 2015). Closed reduction and percutaneous pin fixation are a standard surgical treatment in these fractures (Pretell-Mazzini et al. 2011; Belhan et al. 2009; Sibinski et al. 2006). Also, the fixation with crossed pin is commonly preferred to provide greater rotational stability than lateral pin constructs (Lee et al. 2002; Brauer et al. 2007). However, use of the small medial incision causes extra scar formation. We compared mainly the parents-based cosmetic satisfaction scores of the incision scars of the two treatment methods in our study.
Open reduction is usually preferred after the unsuccessful closed reduction attempts. In the literature, both the cosmetic and functional outcomes based on Flynn’s criteria were similar in between closed reduction and open reduction performed through posterior (Ozkoc et al. 2004), anterior (Oh et al. 2003), lateral (Kaewpornsawan 2001) and medial (Fu et al. 2011) approaches. In these studies, cosmetic concerns are described by angular deformity of the upper extremity, whereas scar formation is not taken into consideration. Also, we did not encounter any studies evaluating cosmetically the medial mini-open method in the literature. Because the patients and their parents might be worried about the appearance of their skins, we think extra scar formation plays also an important role over the cosmetic outcomes.
We used VAS for the determination of parents-based cosmetic satisfaction score. The VAS is a quick and easy method of rating a subjective experience such as pain and anxiety (Oakley et al. 2009; Nicolas et al. 2010). Because our patients were children, we gave to the parents-based outcomes. The use of VAS gave to us an idea of how positive or negative about the experience that cosmetic satisfaction of the parents was. In our study, although the cosmetic results of Flynn criteria were similar, the parents-based cosmetic satisfaction score was better in closed reduction and crossed pins fixation without the small medial incision group.
The simplest way to avoid iatrogenic ulnar nerve injury is to not insert a medial pin. However, there is slightly probability of radial or anterior interosseous nerve damage associated with lateral pin fixation (Sibinski et al. 2006; Brauer et al. 2007). Different surgical techniques were used to prevent iatrogenic ulnar nerve injury (Sibinski et al. 2006; Bashyal et al. 2009; Brauer et al. 2007; Eidelman et al. 2007; Shim and Lee 2002; Skaggs et al. 2001; Michael and Stanislas 1996; Gordon et al. 2001; Wind et al. 2002; Shtarker et al. 2014). However, these techniques do not completely prevent ulnar nerve injuries (Brauer et al. 2007; Skaggs et al. 2001; Wind et al. 2002). The medial pin rarely impales directly the ulnar nerve. In addition, ulnar nerve palsy may develop due to entrapment by a stretched retinaculum after medial pin placement. In our opinion, after insertion of one or two lateral pins is temporarily sufficient to secure alignment, and <90° extension of the elbow relaxes the cubital tunnel retinaculum, a medial pin can be safely inserted to stabilize the fracture, and small medial incision was also performed by surgeons’ preference in some patients. In our study was not encountered any nerve palsies in both groups.
The loss of reduction is rarely encountered after crossed pins fixation and it usually occurs due to technical errors (Brauer et al. 2007; Omid et al. 2008). In present study, the reduction quality was same in both groups. Its retrospective nature was the main weak point of the current study. Another weak point was that the surgical techniques were selected by surgeons.
Our study was showed both treatment techniques gave good results clinically and radiologically in treatment of supracondylar humerus fractures at the last follow up. However, the closed reduction and crossed pin fixation without small medial incision should be preferred first because of better the parent-based cosmetic satisfaction. If the ulnar nerve cannot be identified with palpation, a small incision can perform over the medial epicondyle to ensure protection of the ulnar nerve.
SHB, EE and MCA designed the research; SHB, AB, and CK collected data and helped conducting the research; SHB, MGB and UD analyzed data and performed statistical analysis; SHB and EE wrote the paper; and MGB, UD and MCA did critical review and helped drafting the manuscript. All authors read and approved the final manuscript.
No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. The authors declare that they have no competing interests.
Ethics committee approval was received for this study from the ethics committee of Bakırkoy Dr. Sadi Konuk Research and Training Hospital Clinical Studies.
Informed consent was obtained from all individual participants included in the study.
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- Aktekin CN, Toprak A, Ozturk AM, Altay M, Ozkurt B, Tabak AY (2008) Open reduction via posterior triceps sparing approach in comparison with closed treatment of posteromedial displaced Gartland type III supracondylar humerus fractures. J Pediatr Orthop B 17:171–178View ArticleGoogle Scholar
- Basaran SH, Ercin E, Bilgili MG, Bayrak A, Cumen H, Avkan MC (2015) A new joystick technique for unsuccessful closed reduction of supracondylar humeral fractures: minimum trauma. Eur J Orthop Surg Traumatol 25:297–303View ArticleGoogle Scholar
- Bashyal RK, Chu JY, Schoenecker PL, Dobbs MB, Luhmann SJ, Gordon JE (2009) Complications after pinning of supracondylar distal humerus fractures. J Pediatr Orthop 29:704–708View ArticleGoogle Scholar
- Belhan O, Karakurt L, Ozdemir H, Yilmaz E, Kaya M, Serin E et al (2009) Dynamics of the ulnar nerve after percutaneous pinning of supracondylar humeral fractures in children. J Pediatr Orthop B 18:29–33View ArticleGoogle Scholar
- Brauer CA, Lee BM, Bae DS, Waters PM, Kocher MS (2007) A systematic review of medial and lateral entry pinning versus lateral entry pinning for supracondylar fractures of the humerus. J Pediatr Orthop 27:181–186View ArticleGoogle Scholar
- Eidelman M, Hos N, Katzman A, Bialik V (2007) Prevention of ulnar nerve injury during fixation of supracondylar fractures in children by ‘flexion-extension cross-pinning’ technique. J Pediatr Orthop B 16:221–224View ArticleGoogle Scholar
- Flynn JC, Matthews JG, Benoit RL (1974) Blind pinning of displaced supracondylar fractures of the humerus in children: sixteen years’ experience with long-term follow-up. J Bone Joint Surg Am 56:263–272Google Scholar
- Fowler TP, Marsh JL (2006) Reduction and pinning of pediatric supracondylar humerus fractures in the prone position. J Orthop Trauma 20:277–281View ArticleGoogle Scholar
- Fu D, Xiao B, Yang S, Li J (2011) Open reduction and bioabsorbable pin fixation for late presenting irreducible supracondylar humeral fracture in children. Int Orthop 35:725–730View ArticleGoogle Scholar
- Gaston RG, Cates TB, Devito D, Schmitz M, Schrader T, Busch M et al (2010) Medial and lateral pin versus lateral-entry pin fixation for Type 3 supracondylar fractures in children: a prospective, surgeon-randomized study. J Pediatr Orthop 30:799–806View ArticleGoogle Scholar
- Gordon JE, Patton CM, Luhmann SJ, Bassett GS, Schoenecker PL (2001) Fracture stability after pinning of displaced supracondylar distal humerus fractures in children. J Pediatr Orthop 21:313–318Google Scholar
- Green DW, Widmann RF, Frank JS, Gardner MJ (2005) Low incidence of ulnar nerve injury with crossed pin placement for pediatric supracondylar humerus fractures using a mini-open technique. J Orthop Trauma 19:158–163View ArticleGoogle Scholar
- Kaewpornsawan K (2001) Comparison between closed reduction with percutaneous pinning and open reduction with pinning in children with closed totally displaced supracondylar humeral fractures: a randomized controlled trial. J Pediatr Orthop B 10:131–137Google Scholar
- Kalenderer O, Reisoglu A, Surer L, Agus H (2008) How should one treat iatrogenic ulnar injury after closed reduction and percutaneous pinning of paediatric supracondylar humeral fractures? Injury 39:463–466View ArticleGoogle Scholar
- Kazimoglu C, Cetin M, Sener M, Aguş H, Kalanderer O (2009) Operative management of type III extension supracondylar fractures in children. Int Orthop 33:1089–1094View ArticleGoogle Scholar
- Khademolhosseini M, Abd Rashid AH, Ibrahim S (2013) Nerve injuries in supracondylar fractures of the humerus in children: is nerve exploration indicated? J Pediatr Orthop B 22:123–126View ArticleGoogle Scholar
- Lee SS, Mahar AT, Miesen D, Newton PO (2002) Displaced pediatric supracondylar humerus fractures: biomechanical analysis of percutaneous pinning techniques. J Pediatr Orthop 22:440–443Google Scholar
- Li YA, Lee PC, Chia WT et al (2009) Prospective analysis of a new minimally invasive technique for paediatric Gartland type III supracondylar fracture of the humerus. Injury 40:1302–1307View ArticleGoogle Scholar
- Michael SP, Stanislas MJ (1996) Localization of the ulnar nerve during percutaneous wiring of supracondylar fractures in children. Injury 27:301–302View ArticleGoogle Scholar
- Nicolas E, Bessadet M, Collado V, Carrasco P, Rogerleroi V, Hennequin M (2010) Factors affecting dental fear in French children aged 5–12 years. Int J Paediatr Dent 20:366–373View ArticleGoogle Scholar
- Oakley E, Barnett P, Babl FE (2009) Backslab versus nonbackslab for immobilization of undisplaced supracondylar fractures: a randomized trial. Pediatr Emerg Care 25:452–456View ArticleGoogle Scholar
- Oh CW, Park BC, Kim PT, Park IH, Kyung HS, Ihn JC (2003) Completely displaced supracondylar humerus fractures in children: results of open reduction versus closed reduction. J Orthop Sci 8:137–141View ArticleGoogle Scholar
- Omid R, Choi PD, Skaggs DL (2008) Supracondylar humeral fractures in children. J Bone Joint Surg Am 90:1121–1132View ArticleGoogle Scholar
- Ozkoc G, Gonc U, Kayaalp A, Teker K, Peker TT (2004) Displaced supracondylar humeral fractures in children: open reduction vs. closed reduction and pinning. Arch Orthop Trauma Surg 124:547–551View ArticleGoogle Scholar
- Pretell-Mazzini J, Rodriguez-Martin J, Auñon-Martin I, Zafra-Jimenez JA (2011) Controversial topics in the management of displaced supracondylar humerus fractures in children. Strategies Trauma Limb Reconstr 6:43–50View ArticleGoogle Scholar
- Shim JS, Lee YS (2002) Treatment of completely displaced supracondylar fracture of the humerus in children by cross-fixation with three Kirschner wires. J Pediatr Orthop 22:12–16Google Scholar
- Shtarker H, Elboim-Gabyzon M, Bathish E, Laufer Y, Rahamimov N, Volpin G (2014) Ulnar nerve monitoring during percutaneous pinning of supracondylar fractures in children. J Pediatr Orthop 34:161–165View ArticleGoogle Scholar
- Sibinski M, Sharma H, Sherlock DA (2006) Lateral versus crossed wire fixation for displaced extension supracondylar humeral fractures in children. Injury 37:961–965View ArticleGoogle Scholar
- Skaggs DL, Hale JM, Bassett J, Kaminsky C, Kay RM, Tolo VT (2001) Operative treatment of supracondylar fractures of the humerus in children. The consequences of pin placement. J Bone Joint Surg Am 83:735–740Google Scholar
- Slobogean BL, Jackman H, Tennant S, Slobogean GP, Mulpuri K (2010) Iatrogenic ulnar nerve injury after the surgical treatment of displaced supracondylar fractures of the humerus: number needed to harm, a systematic review. J Pediatr Orthop 30:430–436View ArticleGoogle Scholar
- Wind WM, Schwend RM, Armstrong DG (2002) Predicting ulnar nerve location in pinning of supracondylar humerus fractures. J Pediatr Orthop 22:444–447Google Scholar
- Zionts LE, McKellop HA, Hathaway R (1994) Torsional strength of pin configurations used to fix supracondylar fractures of the humerus in children. J Bone Joint Surg Am 76:253–256Google Scholar