Humeral Supracondylar Fractures in Children: A Novel Technique of Lateral External Fixation and Kirschner Wiring

Abstract

Introduction: Supracondylar fracture of the humerus is the most common fracture around the elbow in children. Pinning with Kirschner wires (K-wires) after open or closed reduction is generally accepted as the primary treatment modality. However, it comes with the risk of persistent instability and if the K-wire is not inserted properly, it may cause displacement and varus deformity. We present our two-year experience with a new technique of lateral external fixation and K-wiring of the humeral supracondylar fracture. Materials and Methods: A total of seven children with irreducible Gartland Type III supracondylar humeral fracture were treated with closed reduction and lateral external fixation and lateral Kirschner wiring. Patients with ipsilateral radial or ulnar fracture, open fracture and presence of neurovascular impairment pre-operatively were excluded. All the patients were followed up at one, three and six weeks and three and six months. The final outcomes were assessed based on Flynn's criteria. Results: All the patients achieved satisfactory outcomes in terms of cosmetic and functional aspects. All patients except one (85.5%) regained excellent and good cosmetic and functional status. One patient (14.3%) sustained pin site infection which resolved with oral antibiotic (Checketts- Otterburn grade 2). There was no neurological deficit involving the ulnar nerve and radial nerve. Conclusion: The introduction of lateral external fixation and lateral percutaneous pinning provide a promising alternative method for the treatment of humeral supracondylar fracture. This study demonstrates that it has satisfactory cosmetic and functional outcomes with no increased risk of complications compared to percutaneous pinning.

Keywords: Kirschner wire; Supracondylar fracture; external fixator; humerus.

Fig. 1

Show intra-operative photographs of the patient. (A) The first 3.5 mm Schanz pin was inserted at the distal fragment at the metaphysis (DP) and a temporary 4 mm Schanz pin (TP) was inserted at the proximal 1/3rd of the humerus, just distal to the insertion site of the deltoid tendon(Del). Acting as a joystick, the temporary Schanz pin can be internally or externally rotated to correct any rotational deformity of the proximal fragment. (B) TP was removed after a proximal Schanz pin (PP) was inserted, parallel to the TP. (C) location of the PP and DP in the imaging intensifier monitor. (D) Acute distraction of 1-3mm was done using the T-handle bar to correct the coronal deformity. (E) A retractor was used to correct the sagittal deformity. (F) A cross K-wire was inserted to maintain the reduction. (G) Range of motion was checked at the end of the surgery.

Fig. 2

Shows the schematic diagram of the surgery. (A) temporary Schanz pin (blue bar) was used to correct the rotational deformity. (B) Acute distraction of 1-3mm to correct the coronal deformity. (C) A retractor (yellow) was used to correct the sagittal deformity.

Fig. 3

Serial radiographs of a left humeral supracondylar fracture Gartland type III successfully treated with lateral external fixation and Kirschner wiring.

Fig. 4

Left elbow of a patient three weeks post-operative shows a combination of external fixator and Kirschner wire providing a stable fixation of the fracture site.

Fig. 5

The patient with good results, both functionally and cosmetically six months post-operatively. The pin site scars were barely visible (black arrows).