Comparative analysis of pinning techniques for supracondylar humerus fractures in paediatrics: A systematic review and meta-analysis of randomized controlled trials

Abstract

Purpose: Supracondylar humeral fractures (SCHFs) rank among the frequently observed fractures in children. Nonetheless, there exists a dearth of consensus regarding the optimal surgical approach. This meta-analysis aims to thoroughly evaluate and compare two distinct pinning techniques (cross pinning versus lateral pinning) for SCHFs, using data from Randomized controlled trials (RCTs).

Methods: Literature review was done using PubMed, CINAHL, Scopus, and The Cochrane Library for RCTs comparing the two pinning methods and providing information on at least one of the following: Loss of Baumann's angle, loss of carrying angle, elbow function assessed based on Flynn criteria, pin tract infection, and iatrogenic ulnar nerve injury. Random effect model was used to calculate standardized mean difference or Odds Ratio (OR) for the outcomes. Review Manager 5.4.1. was used to perform quality assessment and statistical analysis.

Results: A total of 22 RCTs were included. 20 studies reported data for iatrogenic ulnar nerve injury, the OR was calculated to be 3.76 (95% CI 1.75-8.06), showing a significantly lower risk of surgical ulnar nerve injury with the lateral technique. However, no significant difference was found between the pinning techniques in regard to the other outcomes.

Conclusion: In comparison to lateral pinning, the utilization of cross pinning technique exposes the patient to a heightened susceptibility of iatrogenic nerve injury. Therefore, it is recommended that surgeons prioritize the implementation of the lateral pinning technique whenever feasible, as it offers greater protection against iatrogenic ulnar nerve injury. For the other intraoperative and postoperative outcomes, both surgical techniques yield comparable results.

Keywords: Elbow; Elbow fractures; Meta-analysis; Orthopedic surgery; Randomized controlled trial; Supracondylar distal humeral fracture; Ulnar nerve.

Fig. 1

PRISMA Flowchart. The PRIMSA diagram describes our search and selection process applied during the overview.

Fig. 2

Forest Plot (A) A Forest plot showing a comparison of the excellent outcome of Flynn's criteria between the cross entry and lateral entry groups. Odds Ratio was 1.14 (95% CI 0.79–1.63) showing no significant difference between the techniques. (B) A Forest plot showing a comparison of the poor outcomes of Flynn's criteria between cross entry and lateral entry groups. Odds Ratio was calculated as 0.93 (95% CI 0.53–1.63) showing no significant difference between the techniques.

Fig. 3

Forest Plot (A) A Forest plot showing a comparison of the ulnar nerve injury between the cross entry and the lateral entry groups. Odds Ratio was 3.76 (95% CI 1.75–8.06) showing a significant difference between the techniques (B) A Forest plot showing a comparison of the pin tract infection between the cross entry and the lateral entry groups. Odds Ratio was 0.88 (95% CI 0.49–1.57) showing a significant difference between the techniques.

Fig. 4

Forest Plot (A) A Forest plot showing a comparison of the postoperative Baumann's angle between cross entry and lateral entry groups. Odds Ratio was 0.12 (95% CI -0.07-0.30) showing a significant difference between the techniques (B) A Forest plot showing a comparison of the postoperative loss of angle between cross entry and lateral entry groups. Odds Ratio was −0.04 (95% CI -0.22-0.14) showing a significant difference between the techniques.

Fig. 5

Risk of bias graph. The risk of bias item estimation in all included studies is presented in percentage form.

Fig. 6

The risk of bias in the included randomized controlled trials. +: no bias; −: bias; ? unknown bias.

Fig. 7

Funnel plot of pooling ulnar nerve injury.