Fractures of the supracondylar humerus are frequently recognized as the most prevalent elbow fractures in adolescents globally.¹ The projected annual rate of children presenting with supracondylar fractures is 177.3/100000. This fracture is seen at the supracondylar area or the metaphysis of the distal humerus and is responsible for 65.4% of upper extremity fractures among younger individuals.^1-3 Displaced supracondylar fractures are managed to achieve a complete functional recovery and a normal appearance of the elbow. Currently, closed manipulative reduction and percutaneous fixation are employed for the management of supracondylar fractures of type II and type III based on the modified Gartland classification, all under the control of an image intensifier. Nevertheless, there is disagreement regarding the most effective placement of the pins.

Cross-pinning techniques are biomechanically preferable to lateral double-pinning techniques; however, there is a likelihood of ulnar nerve injury when a medial pin is used. The necessity of a medial suture to avert malunion has not been definitively established.⁴ In managing supracondylar fractures, lateral cross-pinning is a viable alternative. Fixation of both Gartland types II and III (unstable) supracondylar fractures of the humerus in minors is both efficient and secure when performed with only lateral pins. Iatrogenic damage to the ulnar nerve is prevented by employing only lateral sutures.⁵ The null hypothesis is that lateral pin fixation provides equivalent stability compared with conventional cross-pinning with no risk of ulnar nerve injury.⁶

The objective of this investigation is to determine whether lateral pinning is equivalent to crossed pinning in the realm of stability and, if not, superior in terms of functionality. The study aimed to establish a comparison between the functional and radiological evaluation of displaced supracondylar fractures that were treated with percutaneous pinning using K-wire.

The patients were enlisted in this prospective randomized controlled study at a single center from June 2012 to May 2014 using a random sampling technique. The Institutional Ethics Committee (No: IEC/MES/34/2012) approved the investigation. This study was carried out on 40 patients who were enrolled in the Orthopaedic Department of MES Medical College at the time and had closed displaced supracondylar fractures of the extension type. A signed informed consent was collected from all the subjects who were willing to participate in the study. The inclusion criteria were as follows: individuals of both genders, aged less than 12 years, who had displaced extension type supracondylar fractures of the Gartland types II and III, with a recent duration, and a closed fracture with a time frame of less than or equal to 5 days. The study excluded individuals over the age of 12 with a flexion type supracondylar fracture of the humerus and compound fractures, those with severe pediatric co-morbidities that render the patient anesthetically unfit, and fractures that were older than 5 days.

 PREOPERATIVE ASSESSMENT

In the emergency room patients were assessed clinically by checking airway, breathing, and circulation. A local examination of the involved limb was done followed by careful examination to rule out neurovascular complications. Supracondylar fracture of the humerus was confirmed by taking an X-ray of the involved elbow AP and Lateral views. The fracture stabilized temporarily by applying a POP long arm slab. Displaced fractures (Gartland types II and III) were posted for emergency closed reduction and percutaneous K-wire fixation.

PREOPERATIVE WORK UP

The patient kept NPO, secured an IV cannula, and after necessary blood investigations (including HIV, HBsAg, and HCV) and chest X-ray, a pre-anesthetic checkup was done. Preoperatively given one dose of injection antibiotic half an hour before surgery, injection Tetanus Toxoid, and slow IV fluid as maintenance. Xylocaine test was also done to rule out sensitivity to Xylocaine. After completing 6 hours of NPO patient was shifted to the operation theatre for the decided surgical procedure.

SURGICAL TECHNIQUE

Closed manipulative reduction and percutaneous K wire fixation were implemented for each individual. The patients were randomly assigned to either lateral entry or medial and lateral entry K wire fixation. All patients were administered general anesthesia and were positioned in a supine position on the operating table. Fluoroscopy was employed to supervise the reductions. A 1.8-mm Kirschner wire was utilized to treat children weighing less than 20 kg, while a 2.0-mm K wire was used to manage children weighing more than 20 kg. After appropriate painting and draping, closed manipulative reduction was performed under strict aseptic measures then followed by percutaneous K wire fixation.

The lateral entry technique involved inserting two pins from the elbow's lateral side through the lateral cortex and engaging the medial cortex with hyperflexion. The medial and lateral entry technique used a pin from the elbow's lateral side along the lateral cortex to contact the medial cortex in hyperflexion. To prevent injury to an anteriorly subluxating ulnar nerve, the elbow was subsequently extended to a position that was less than 90°. From the medial epicondyle, the medial pin was inserted to engage the lateral cortex. The long arm slab was used with the forearm in neutral rotation, and the elbow flexed to a range of approximately 70° to 90°, and the pins were bent outside the epidermis.

FOLLOW UP

Each patient was evaluated clinically and radiographically at one, three, six, and twelve weeks and six months. The slab and pins were taken out three to four weeks after the surgery. Neurological and vascular examinations of the extremity, and any complications such as pin-track infection, were all part of the clinical assessment, which also included the elbow's appearance: normal or deformed. An anteroposterior and lateral radiograph of the distal aspect of the humerus and the elbow were included in the radiographic assessment. Preoperative radiographs were obtained following fracture reduction, one week postoperatively at the third week, and the three-month and six-month follow-up appointments. Functional assessment employing modified Flynn's criteria and clinical and radiographic assessments were conducted at the six-month follow-up visit. The carrying angle, flexion, and extension loss were evaluated in degrees and categorized as excellent, good, fair, or poor.

Statistical analysis

The Chi-square test was applied to find the association between pin configuration and selected variables. SPSS 17.0 version used for statistical analysis.

This study encompasses 40 closed supracondylar fractures of the humerus that were surgically managed by closed reduction and percutaneous K-wire fixation in either a crossed medial and lateral configuration or a lateral crossed double configuration. The individuals were monitored for a minimum of six months. These kinds of fractures of the humerus were prevalent in the 6-8-year age group in the current study. The patient's age ranged from three years to twelve years. The patient population in the investigation had an average age of 7.4 years.

The majority of affected patients were male (72.5%). Female patients were less affected (27.5%). In this study, 33 were Gartland type III (82.5%) and 7 were Gartland type II (17.5%). In this study, the dominant side was involved in 11 patients (27.5%), and the non-dominant side in 29 patients (72.5%). In our study, one patient presented with the same side bone fractures in the forearm (2.5%), and another one presented with the same side ulna fracture (2.5%). There was good vascular status in 39 patients (97.5%) and only one was presented with a feeble pulse (2.5%). In this study, 32 patients were with posteromedial displacement (80%), 6 were with posterolateral displacement (15%) and 2 were with posterior displacement (5%). The most of sample population were presented with good neurological status at the time of injury (39 patients-97.5%) and only one (2.5%) was presented with radial nerve palsy which was a posteromedially displaced fracture. In this study, 21 (52.5%) were treated with crossed medial and lateral pinning and 19 (47.5%) were treated by lateral double-crossed pinning. 

Table 1 indicates that there was a statistically insignificant difference between pin configurations based on displacement in the current study (p>0.05). Table 2 illustrates that the evaluation of carrying angle loss yielded excellent outcomes in 28 patients, good outcomes in 9 patients, and fair results in 3 patients, with an average of 4±3⁰. The evaluation of flexion loss yielded excellent results in 30 individuals, good results in 9, and fair results in one patient, with a mean of 3.9±2.2⁰. The evaluation of extension loss yielded excellent outcomes in all patients (100%), with a mean loss of 0.7±1.2⁰. Nevertheless, we were unable to establish a correlation between the type of pin configuration and the loss of carrying angle, flexion, and extension (p>0.05). The results of Table 3 indicate that 28 patients had excellent outcomes, 9 patients had good outcome, and 3 patients had fair scores. However, we were unable to establish an association between pin configuration and functional outcome (p>0.05).

Table 1: Comparison of pin configuration based on displacement

p>0.05 – statistically insignificant

Table 2: Comparisons of carrying angle loss, flexion loss and extension loss based on modified Flynn’s Criteria (1974)

p>0.05 – statistically insignificant

Table 3: Distribution of pin configuration based on functional outcome

p>0.05 – statistically insignificant

For the clinicoradiological assessment of displaced supracondylar fractures of the humerus in children, this study compared lateral double-crossed pinning (Group II) to medial and lateral crossed pinning (Group I). In this investigation, supracondylar fractures of the humerus were prevalent among individuals aged 6 to 8. Similar studies by Muslu et al.,⁷ and Fowles and Kassab⁸ documented the mean age as 6.21 years and 7.2 years respectively. Conversely, Aronson and Prager⁹ established the average age as 5.4 years. In the current study, 29 (72.5%) of the 40 patients affected were males, while 11 (27.5%) were females, indicating a male preponderance. In a study, Fowles and Kassab⁸ revealed that the incidence of the condition was 81% in males and 19% in girls. In an additional investigation by Aronson and Prager,⁹ 75% of males and 25% of girls were affected. We exclusively examined closed-type displaced extension supracondylar fractures, of which 33 were Gartland type III (82.5%) and 7 were Gartland type II (17.5%). In a study of 90 extension supracondylar fractures of the humerus in children, by Cekanauskas et al.,¹⁰ there were 25.5% type II Gartland fractures, 70% type III fractures, and 4.5% type I fractures.

In our study, there were 29 (72.5%) patients with non-dominant side involvement and 11(27.5%) patients with dominant side involvement. Fowles and Kassab⁸ noted 43% dominant side and 57% non-dominant side involvement. Another study by Aronson and Prager⁹ showed more non-dominant side involvement (65%) than the dominant side (35%). Pirone et al.¹¹ also got similar results with 63% and 37% involvement of non-dominant and dominant sides respectively. In the present study, associated fractures were present in 2 cases (5%). On the same side forearm both bone fractures upper third middle third junction in one case (2.5%) and same side ulna fracture in the other case (2.5%). Ipsilateral fractures reported by Fowles and Kassab⁸ were 0.9%. Nacht et al.¹² noted 13% of associated ipsilateral bone fractures, while Pirone et al.¹¹ showed 8.7% of ipsilateral fractures.

The present study showed that the most of patients were presented with good neurological status at the time of injury (n=39; 97.5%) and only one (2.5%) was presented with radial nerve palsy in a posteromedially displaced fracture. Sharma et al.¹³ established that without the threat of iatrogenic ulnar nerve damage, lateral pinning offers equivalent stability and improved functional results. Fowles and Kassab⁸ reported 6.36% of nerve injury out of which 57% radial nerve injury and 43% median nerve injury. Nacht et al.¹² reported 11% of nerve injury consisting of equal incidence of radial and median nerve injury. Aronson and Prager found 11% nerve injury including radial and median nerve injury of 50% each. Another study by Pirone et al.¹¹ showed an overall percentage (14%) of nerve injury consisting of 42% radial nerve injury, 47% median nerve injury, and 11% ulnar nerve injury. 

In our study, 32 patients were with posteromedial displacement (80%), 6 were with posterolateral displacement (15%) and 2 were with posterior displacement (5%). In a study, Aronson and Prager⁹ noted 75% of posteromedial displacement and 25% of posterolateral displacement. Pirone et al.¹¹ showed 81% posteromedial and 19% posterolateral displacements. In group I there were 21 children and in group II there were 19 subjects. Regarding displacement in group, I there were 17 patients (81.0%) with posteromedial, 3 (14.3%) with posterolateral, and 1 patient (4.8%) with posterior displacements. In group II there were 15 patients (78.9%) with posteromedial, 3 (15.8%) with posterolateral, and 1 (5.3%) with posterior displacement. We could not establish an association of pin configuration on displacement (p>0.05).

Closed reduction and percutaneous K-wire fixation were implemented in all instances. Twenty-one patients (52.5%) underwent crossed medial and lateral pinning, while 19 patients (47.5%) underwent lateral double-crossed pinning. Closed reduction and percutaneous pin fixation are the benchmark treatments for displaced (Gartland types II and III) extension-type supracondylar fractures of the humerus in individuals of younger age. Nevertheless, there is ongoing debate among authors regarding the most effective strategy for percutaneous pin fixation. Lateral pinning using three K-wires in parallel and divergent configuration was employed by Gopinath et al.¹⁴ Similar to our study findings, Choudhary et al.¹⁵ documented that closed reduction of these fractures with percutaneous K-wire yielded better results. Flynn et al.¹⁶ employed blind pinning of displaced supracondylar fractures of the humerus. The lateral cross-pinning approach under fluoroscopy was implemented by Phan et al.¹⁷

For a minimum of six months, there was consistent follow-up. In the third week, callus formation was observed. Implant fracture or backout were not observed. Implants were extracted during the fourth week. At six months, there was no residual paralysis. Pin track infection was not observed in our investigation. Pirone et al.¹¹ reported a 1% incidence of pin track infection, while Mostafavi et al.¹⁸ found a higher incidence of 2.4%. The crossed pins and the lateral pins did not exhibit any distinction in terms of fracture reduction maintenance. This research was comparable to that of Skaggs et al.,⁵ which did not observe any reduction in either group.

After six months, a functional assessment was conducted using modified Flynn's criteria, which considered carrying angle, flexion loss, and extension loss. The overall functional outcome was excellent in 28 children (70%), good in 9 (22.5%), and fair in 3 subjects (7.5%) in our study. Therefore, the results of our investigation were consistent with those of other studies, such as Naik et al.,¹⁹ and Pavone et al.²⁰ in which the majority of patients in both groups experienced good to excellent results. Skaggs et al.⁵ claimed that the use of lateral pins as the sole method of fixation is both safe and efficacious for type II and III Gartland fractures. 13 (61.9%) excellent, 9 (33.3%) good, and 1 fair (4.8%) were observed among 21 crossed medial and lateral pin configurations. There were 15 (78.9%) excellent, 2 (10.5%) good, and 2 (10.5%) fair results in the 19-lateral double-pinning cases analyzed. Therefore, we could not establish a correlation between the overall functional outcome and the pin configuration. However, this is comparable to the findings of El-Adl et al.,²¹ who utilized percutaneous lateral K-wires and achieved 77.1% excellent and 11.6% good outcomes.

This study examined the clinical, radiological, and functional effects of closed manipulative reduction with percutaneous K-wire fixation. Lateral K-wire fixation is equally stable as crossed K-wire fixation concerning biomechanical stability.

1. Foead A, Penafort R, Saw A, Sengupta S. Comparison of two methods of percutaneous pin fixation in displaced supracondylar fractures of the humerus in children. J Orthop Surg (Hong Kong). 2004;12(1):76-82. doi: 10.1177/230949900401200114.
2. Mulpuri K, Hosalkar H, Howard A. AAOS clinical practice guideline: the treatment of pediatric supracondylar humerus fractures. J Am Acad Orthop Surg. 2012;20:328–30. doi: 10.5435/JAAOS-20-05-328.
3. Shrader MW. Pediatric supracondylar fractures and pediatric physeal elbow fractures. Orthop Clin North Am. 2008;39(2):163-71, v. doi: 10.1016/j.ocl.2007.12.005.
4. Eberhardt O, Fernandez F, Ilchmann T, Parsch K. Cross pinning of supracondylar fractures from a lateral approach. Stabilization achieved with safety. J Child Orthop. 2007;1(2):127-33. doi: 10.1007/s11832-007-0011-y.
5. Skaggs DL, Hale JM, Bassett J, Kaminsky C, Kay RM, Tolo VT. Operative treatment of supracondylar fractures of the humerus in children. The consequences of pin placement. J Bone Joint Surg Am. 2001;83(5):735-40. 
6. Shamsuddin SA, Penafort R, Sharaf I. Crossed-pin versus lateral-pin fixation in pediatric supracondylar fractures. Med J Malaysia. 2001;56 Suppl D:38-44.
7. Muslu O, Cengiz T, Aydın Şimşek Ş, Yurtbay A, Keskin D. Radiological and Clinical Outcomes of Pediatric Patients With a Supracondylar Humerus Fracture Surgically Treated With Closed Reduction and Percutaneous Pinning. Cureus. 2023;15(11):e49358. doi: 10.7759/cureus.49358.
8. Fowles JV, Kassab MT. Displaced supracondylar fractures of the elbow in children. A report on the fixation of extension and flexion fractures by two lateral percutaneous pins. J Bone Joint Surg Br. 1974;56B(3):490-500. 
9. Aronson DD, Prager BI. Supracondylar fractures of the humerus in children. A modified technique for closed pinning. Clin Orthop Relat Res. 1987;(219):174-84
10. Cekanauskas E, Degliūte R, Kalesinskas RJ. Virsgumburiniu zastikaulio lūziu gydymas vaikams remiantis Gartlando klasifikacija [Treatment of supracondylar humerus fractures in children, according to Gartland classification]. Medicina (Kaunas). 2003;39(4):379-83.
11. Pirone AM, Graham HK, Krajbich JI. Management of displaced extension-type supracondylar fractures of the humerus in children. J Bone Joint Surg Am. 1988;70(5):641-50. Erratum in: J Bone Joint Surg [Am] 1988 Aug;70(7):1114. 
12. Nacht JL, Ecker ML, Chung SM, Lotke PA, Das M. Supracondylar fractures of the humerus in children treated by closed reduction and percutaneous pinning. Clin Orthop Relat Res. 1983;(177):203-9.
13. Sharma, D. K., Solanki, M., Solanki, S., & E. P., A. Comparative study of crossed pinning v/s lateral pinning in paediatric supracondylar humerus fractures. International Journal of Research in Orthopaedics. 2024;11(1):73–8. https://doi.org/10.18203/issn.2455-4510.IntJResOrthop20243889.
14. Gopinathan NR, Sajid M, Sudesh P, Behera P. Outcome Analysis of Lateral Pinning for Displaced Supracondylar Fractures in Children Using Three Kirschner Wires in Parallel and Divergent Configuration. Indian J Orthop. 2018;52(5):554-60. doi: 10.4103/ortho.IJOrtho_462_17.
15. Choudhary D, Mayi SC, Ranganath N. Assessment of functional and radiological outcomes of closed reduction and K-wire fixation of supracondylar fracture of humerus in children. Panacea J Med Sci 2023;13(1):98-102. DOI:18231/j.pjms.2023.021.
16. Flynn JC, Matthews JG, Benoit RL. Blind pinning of displaced supracondylar fractures of the humerus in children. Sixteen years' experience with long-term follow-up. J Bone Joint Surg Am. 1974;56(2):263-72. 
17. Phan MD, Vo NQ, Mai TT, Truong QH, Truong KT, Nguyen PD. Management of Pediatric Supracondylar Humerus Fractures Using Lateral Cross-Wiring Technique Under Fluoroscopic Guidance. Cureus. 2024;16(4):e59029. doi: 10.7759/cureus.59029.
18. Mostafavi HR, Spero C. Crossed pin fixation of displaced supracondylar humerus fractures in children. Clin Orthop Relat Res. 2000;(376):56-61. doi: 10.1097/00003086-200007000-00009.
19. Naik L.G., Sharma G.M., Badgire K.S., Qureshi F., Waghchoure C., Jain V. Cross pinning versus lateral pinning in the management of type III supracondylar humerus fractures in children. J Clin Diagn Res: JCDR. 2017;11(8):RC01. doi: 10.7860/JCDR/2017/28481.10351.
20. Pavone V., Riccioli M., Testa G. Surgical treatment of displaced supracondylar pediatric humerus fractures: comparison of two pinning techniques. Journal of Functional Morphology and Kinesiology. 2016;1(1):39–47. https://doi.org/10.3390/jfmk1010039
21. El-Adl WA, El-Said MA, Boghdady GW, Ali AS. Results of treatment of displaced supracondylar humeral fractures in children by percutaneous lateral cross-wiring technique. Strategies Trauma Limb Reconstr. 2008;3(1):1-7. doi: 10.1007/s11751-008-0030-3. 
22. Choudhary D, Mayi SC, Ranganath N. Assessment of functional and radiological outcomes of closed reduction and K-wire fixation of supracondylar fracture of humerus in children. Panacea J Med Sci 2023;13(1):98-102.