Advantages and disadvantages of the prone position in the surgical treatment of supracondylar humerus fractures in children. A literature review
Introduction
Supracondylar humerus fractures are the most frequent fractures of the elbow in children [1]. The classification used is Gartland’s classification modified by Wilkins [2] (Type I: undisplaced or minimal displacement, Type II: angulation of the distal fragment and one intact cortex, Type IIIA: completely displaced fracture with the distal fragment dislocated postero-medially, Type IIIB: completely dislocated fracture with the distal fragment dislocated postero-laterally). The most frequent fracture mechanism is represented by a force in extension; usually a fall on the outstretched hand. As a matter of fact, supracondylar fractures in extension correspond to approximately 95–98% of all lesions. In the rarer lesions caused by a flexion force (2–5%) the distal fragment dislocates anteriorly and laterally.
Closed reduction and percutaneous osteosynthesis with Kirschner (K) wires with the patient in supine position is a common and diffusely accepted procedure for type III fractures [2,3]. The most frequent complication associated to percutaneous osteosynthesis is the ulnar nerve lesion [[4], [5], [6], [7], [8], [9]]. Instead, closed reduction and percutaneous osteosynthesis in prone position is less common and there are few articles which report this technique [[10], [11], [12], [13], [14], [15], [16]].
Aim of the study was to evaluate, on the basis of the authors’ (MDP, DF) personal experience [11,16] and on the basis of literature data [[10], [11], [12], [13], [14], [15]], advantages and disadvantages of closed reduction and osteosynthesis of pediatric supracondylar humerus fractures in prone position.
Section snippets
Materials and Methods
A literature review of the period 2005–2017 was carried out; four medical search engine (Pub Med, Cochrane Library, ISI Web of Science and Scopus) were consulted using the review’s filter and the key words “Ulnar nerve AND supracondylar humeral fractures”. This filter was used based on the fact that ulnar nerve injury is the most frequent and quoted complication of the surgical treatment of supracondylar humerus fractures in children. Only papers with cross pinning technique were included.
Surgical technique: Percutaneous crossed pinning in prone position
Under general anaesthesia, the patient is positioned prone with the fractured upper limb at 90° abduction, with the elbow flexed and free forearm. A rigid support, such as folded blankets, is positioned beneath the arm; this support is mandatory in order to avoid the compression of the neuro-vascular bundle and to facilitate the fracture’s reduction by allowing the rotation and translation of the distal fragment. Reduction and osteosynthesis are favoured by gravity, as the distal humerus places
Results
Twenty-nine papers, 23 regarding cross pinning in supine position and 6 in prone position, were considered. In both groups cross pinning was performed with a lateral and a medial pin crossing proximally the fracture line. The lateral pin was introduced through the radial epicondyle with a medial-proximal direction. The medial pin was introduced through the ulnar epicondyle with a lateral-proximal direction. On one hand, 1529 children were treated with closed reduction and cross pinning in
Discussion
Closed reduction and percutaneous osteosynthesis of supracondylar humerus fractures in children in supine position is the most diffusely reported technique, whilst there are few articles which report reduction and osteosynthesis in prone position. Treatment in supine position of the supracondylar fracture in extension, firstly requires, other than a traction, a reduction force at the olecranon level in order to reduce the distal fragment on the proximal fragment; secondly the elbow has to be
Conclusions
Supracondylar humeral fractures are the most common elbow injuries in children. The widely adopted approach for Gartland III extension type fractures consists of closed reduction and percutaneous pinning; the pin configuration can be lateral or crossed (lateral-medial). The ulnar nerve injury is the most common risk during the insertion of the medial pin according to literature. The ulnar nerve in children is hypermobile and tends to dislocate anteriorly over the medial epicondyle, especially
Conflict of interest
The authors have no conflict of interest to declare
Each author certifies that he or she has no commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article.
The study has been performed in accordance with the ethical standards in the 1964 Declaration of Helsinki.
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