Journal Reading 2

Dr. Yoyos Dias Ismiarto, dr., SpOT (K)., M.Kes., CCD

Fathurachman, dr., SpOT., M.Kes

Bangkit Primayudha
 Introduction
• Extension type supracondylar humeral fracture
is most common injury around elbow in
pediatric
• Classified based on direction & degree
displacement (Gartland criteria)
• Immobilization in a cast for undisplaced fracture
• Goal of treatment in displaced fracture: achieve
& maintain a near anatomical reduction 
union
 Introducation
• CRPP has become a standard method of
treatment, together with a difference of opinion
about optimum pin configuration
• Two main options:
– Crossed fixation: one/ more wire from each
epicondyles to cross above fracture
– Parallel or divergent fixation: two/ more from lateral
epicondyle
• Biomechanical studies suggested superiority of
crossed pin design over pararel pin in maintaining
fracture stability
 Purpose
• to describe the surgical technique along with
the precautions needed during the procedure
and also to present the outcomes of a
biplanar crossed pin construct achieved by
two Kirschner wires in two planes for Gartland
type III pediatric supracondylar humerus
fractures.
 Materials and Methods
• Prospective study, 64 children with Gartland
type III extension type SCH fracture from
january 2008 to June 2013, 3-10 years old and
within 5 days of injury

• Exclusion criteria: open fractures, associated

neurological and/or vascular injury, fracture
with multdirectional intability requiring open
reduction, previous fracture same elbow,
ipsilateral fracture
Surgical Technique and Follow-up
• General anesthesia, supine with shoulder of
injured close to edge operating table with
adequate supports
• Prophylaxis with cefuroxime
• Closed reduction is performed under
fluoroscopy, followed by antiseptic skin scrub
and draping
• Two K-Wire equal diameter (1.5 mm diameter if
< 15 kg, 1.8 or 2 mm if > 15 kg)
 Surgical Technique and Follow-up
• First wire from posterolateral corner of lateral
condyle, across fracture site in oblique direction,
to anteromedial metaphyseal cortex
• Second wire from anteromedial corner of medial
epicondyle, cross lateral wire above fracture site,
to posterolateral metaphyseal cortex
• Biplanar crossed pin construct is achived in
coronal & sagittal plane
• Avoided: repeated attempts of pin insertion,
overshooting into soft tissue
 Surgical Technique and Follow-up
• Lateral pin fixation in full flexion, medial fixation
in 60°-70° flexion
• Assessed in AP, lateral, oblique fluoroscopy view
with gentle stress in varus, valgus, internal and
external rotation
• Wire are cut outside skin without bending them,
protruding 2 cm
• Well-padded above elbow back slab with forearm
in neutral position and elbow flexed 60°-70°
Surgical Technique and Follow-up
• K-wire and back slab are removed after 3
weeks after documentation fracture healing
(periosteal reaction & callus crossing fracture
site)  active mobilization of elbow
• Evaluated at 3 weeks, 6 weeks, 3 months & 6
months postop (clinical evaluation: ROM
elbow & carrying angle, radiological
evaluation: Baumann’s Angle)
3 Weeks

1 Year
3 Months
 Results
• Mean follow-up of 62 patients was 14.5
months (range 6-24 months)
• 41 boys and 21 girls, mean age: 6.2 y.o. (range
3.3- 10.2 y.o.)
• 42 fracture at dominant side/ hand
• Mean interval between injury& operative:
16.9 h (rangen 6-80 h)
 Results
• Anatomical reduction was achieved in all cases
• Mean Radiological union 3.2 weeks (range 2.5-
3.8 weeks)
• No posoperative neural or vascular
complications
• 2 children: pin tract infection, successfully
treated with local dressing and short course
oral antibiotic.
 Results
• 3 parameters were compared to uninjured
side:
– Baumann angle (radiological): mean 76.84° (range
70°-100°)
– Carrying angle (Clinical): 56 (90.3%) patients had
0°-5° reduction, 4 patient had 6°-10° reduction, 2
patients had 20°& 25° reduction
– ROM (functional): 50 (80.6%) patients lost less
than 5° in flexion-extension, 8 patients lost 6°-10°
of flexion and 4 (6.5%) lost 11°-15° of flexion
Results
 Discussion
• Treatment of displaced SCH fracture in
children by CRPP has consistenly given
satisfactory results
• Crossed pin (by Swenson) has the advantage
of better biomechanical stability, although
iatrogenic ulnar nerve injury is possible.
• Lateral pinning entry method has advantage of
avoiding ulnar nerve injury, but less stable
 Discussion
• Cross pin is 25% more rigid than three lateral
pin and 37% stronger than two paralele lateral
pin
• >> of wires inserted in each of the epicondyles
 more stability, but multiple entry points over
a small cartilaginous area  chances of skin
nipping, nerve entrapment, and pin-tract
infections.
• Biplanar Cross pin provide adequate stability
 Discussion
• Prevent ulnar nerve injury in medial/ cross
pinning, when inserting k-wire, elbow position
in 60°-70° flexion, it is possible to feel medial
condyle and Anatomically, the ulnar nerve in
native groove behind the medial epicondyle at
this particular angle of elbow flexion and
becomes prominent with increasing flexion
 Discussion
• Overprojecting into soft tissues would
endanger the surrounding vital structures and
pulling the wire back might compromise its
purchase strength.
• We believe that the bending would create
motion transmission and may weaken the
purchase strength of the Kirschner wires.
Despite this, no patient had internal wire
migration in our series.
 Discussion
• Limitation: the lack of direct comparison with
other forms of reduction and fixation.
• In the future, further larger series and
biomechanical comparison studies may
validate the study.
 Conclusion
• a biplanar crossed pin construct achieved by
two Kirschner wires, crossed in two planes, is
efficient for stabilizing a displaced extension
type supracondylar humeral fracture in
children and provided a safe and effective
surgical technique.
Thank You