Abstract
Amaç: Deplese pediatrik suprakondiler humerus kırıklar da kapalı redüksiyon ve pinleme altın standart olarak tedavide yer alır. Pinleme birçok şekilde yapılmakla birlikte iyatrojenik sinir hasarı en sık görülen komplikasyonlardandır. Ultrasound (USG) eşliğinde lateral çapraz pinleme tekniği ile radial sinir hasarının önlenebilirliliği test edilmesi amaçlanmıştır.
Materyal-yöntem: Eylül 2019- Eylül 2020 yılları arasında kliniğimize başvuran çocuk humerus suprakondiler kırık tanısı konan ve USG eşliğinde lateral çapraz pinleme yapılan 30 hasta ile çalışma yapıldı. Her hastanın dosyası geriye dönük olarak tarandı ve hastaların demografik ve klinik bilgileri toplandı. Hastaların yas, cinsiyet, taraf, kırık tipi, ameliyat süresi, kırık ve contralateral kol çapı, lateral kondil sinir mesafesi ve proximal K teli radial sinir mesafesi, postoperatif sinir yaralanma durumu hastaların geçmişe yönelik dosya taramalarından bulunarak kayıt altına alındı.
Bulgular: Çalışmaya alınan 30 hastanın 15 (%50.0) ı kız çocuktan oluşmakta olup ortalama yaş 59.2±33.9 ay idi. 18 hasta (%60.0) sol extremiteden kırık geçirmişti. Hastaların %3,3 ü flexiyon tip, %30,0 tip 2 , %40,0 tip3 , %26,7 si tip4 yaralanma mevcuttu.
Kırık tipi ile contralateral/Kırık extremite çap farkı oranı karşılaştırıldığında tip4 kırıkların çap farkı ortalamalarının daha yüksek olduğu bulunmuş (17.1±5.5) olup istatistiksel olarak anlamlıdır (p=0.013). Kırık tipleri ile Wire-Radial/Condyle-Radial sinir mesafe farkı oranı karşılaştırıldığında tip 2 kırıklarında wire-sinir oranı arasındaki mesafenin en uzun olduğu bulunmuştur (23.3±8.0). Bu sonuç istatistiksel olarak anlamlıdır (p=0.027). Hiçbir hastada postoperatif iyatrojenik radial sinir yaralanması görülmemiştir.
Sonuç: pediatrik Suprakondiler humerus kırıklı hastaların kırık tipi ile extremite şişlik oranının arttığı görülmektedir. Bu arttış proximal K telinin radial sinir ile olan mesafesi ile ters oranda azalmaktadır. USG eşliğinde lateral çapraz pinleme tekniği uygulama kolaylığı ve özellikle aşırı şişlik gözlenen dirsek yaralanmalarında sinir hattının belirlenip güvenli bir alan oluşturması açısından güvenilir bir yöntem olarak karşımıza çıkmaktadır.
References
- 1. Cheng JC, Shen WY. Limb fracture pattern in different pediatric age groups: a study of 3,350 children. J Orthop Trauma. 1993;7(1):15–22.
- 2. Brubacher JW, Dodds SD. Pediatric supracondylar fractures of the distal humerus. Curr Rev Musculoskelet Med. 2008;1(3-4):190-196.
- 3. Prashant K , Lakhotia D , Bhattacharyya TD , Mahanta AK , Ravoof A . A comparative study of two percutaneous pinning techniques (lateral vs medial-lateral) for Gartland type III pediatric supracondylar fracture of the humerus. J Orthop Traumatol. 2016;17(3):223-229.
- 4. Woratanarat P , Angsanuntsukh C , Rattanasiri S et al. Meta-analysis of pinning in supracondylar fracture of the humerus in children. J Orthop Trauma. 2012;26(1):48-53.
- 5. Rizk AS, Kandil MI. Conventional versus lateral cross-pinning (Dorgan’s technique) for fixation of displaced pediatric supracondylar humeral fractures: a randomized comparative study. Egypt Orthop J. 2018;53:348-58.
- 6. Dekker AE, Krijnen P, Schipper IB. Results of crossed versus lateral entry K-wire fixation of displaced pediatric supracondylar humeral fractures: A systematic review and meta-analysis. Injury. 2016 Nov;47(11):2391-2398.
- 7. Altay MA, Erturk C, Isikan UE. Comparison of traditional and Dorgan’s lateral cross-wiring of supracondylar humerus fractures in children. Saudi Med J. 2010; 31:793–796.
- 8. Brighton B , Abzug JM , Ho CA , Ritzman TF . Current strategies for the management of pediatric supracondylar humerus fractures: tips and techniques for successful closed treatment. Instr Course Lect. 2016;65:353-360
- 9. Gartland JJ. Management of supracondylar fractures of the humerus in children. Surg Gynecol Obstet. 1959 Aug;109(2):145-54.
- 10. Leitch KK, Kay RM, Femino JD, Tolo VT, Storer SK, Skaggs DL. Treatment of multidirectionally unstable supracondylar humeral fractures in children. A modified Gartland type-IV fracture. J Bone Joint Surg Am. 2006 May;88(5):980-5.
- 11. S.S. Lee, A.T. Mahar, D. Miesen, P.O. Newton. Displaced pediatric supracondylar humerus fractures: biomechanical analysis of percutaneous pinning techniques. J Pediatr Orthop. 2002;22; 440-443.
- 12. Feng, Chao MD; Guo, Yuan MD; Zhu, Zhenhua MD; Zhang, Jianli MD; Wang, Yukun MD. Biomechanical Analysis of Supracondylar Humerus Fracture Pinning for Fractures With Coronal Lateral Obliquity, Journal of Pediatric Orthopaedics. 2012; 32(2);196-200.
- 13. Vanderhave KL, Brighton B, Casey V, Montijo H, Scannell B. Applications of musculoskeletal ultrasonography in pediatric patients. J Am Acad Orthop Surg. 2014 Nov;22(11):691-8.
- 14. Altay MA, Erturk C, Altay M, Belhan O, Isikan UE. Ultrasonographic examination of the radial and ulnar nerves after percutaneous cross-wiring of supracondylar humerus fractures in children: a prospective, randomized controlled study. J Pediatr Orthop B. 2011 Sep;20(5):334-40.
- 15. Soldado F, Knorr J, Haddad S, et al. Ultrasound-guided Percutaneous Medial Pinning of Pediatric Supracondylar Humeral Fractures to avoid Ulnar Nerve Injury. Arch Bone Jt Surg. 2015;3(3):169-172.
- 16. Gangadharan S, Rathinam B, Madhuri V. Radial nerve safety in Dorgan's lateral cross-pinning of the supracondylar humeral fracture in children: a case report and cadaveric study. J Pediatr Orthop B. 2014 Nov;23(6):579-83.
- 17. Bloom T, Zhao C, Mehta A, Thakur U, Koerner J, Sabharwal S. Safe zone for superolateral entry pin into the distal humerus in children: an MRI analysis. Clin Orthop Relat Res. 2014 Dec;472(12):3779-88.
- 18. Nielsen E, Andras LM, Skaggs DL. Quantifying the Location of the Radial Nerve in Children for Intraoperative Use. J Pediatr Orthop. 2018 May/Jun;38(5):292-5.
- 19. Queally JM, Paramanathan N, Walsh JC, Moran CJ, Shannon FJ, D'Souza LG . Dorgan's lateral cross-wiring of supracondylar fractures of the humerus in children: a retrospective review. Injury. 2010;41:568–571
- 20. Vaquero-Picado A, González-Morán G, Moraleda L. Management of supracondylar fractures of the humerus in children. EFORT Open Rev. 2018;3(10):526-540.
- 21. 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;1:127–133.
Abstract
Background: Closed reduction and pinning is the gold standard in the treatment of displaced pediatric supracondylar humerus fractures. With different methods of pinning available, iatrogenic nerve damage is one of the most common complications of this technique. In our study, we aimed to test the preventability of radial nerve injury in the ultrasound-guided lateral cross pinning technique.
Methods: The study included 30 patients who were admitted to our clinic between September 2019 and September 2020 due to supracondylar humerus fractures and underwent closed reduction with the lateral cross pinning technique under ultrasonography. Demographic and clinical data of the patients including age, gender, fracture type and side, arm diameters of the fractured and contralateral sides, the distance between the lateral condyle and the radial nerve (LCRN), the distance between the proximal K-wire and the radial nerve (PWRN), duration of surgery, and postoperative complications of the nerve were retrieved from the patient files and recorded.
Results: Fifteen (50%) of the 30 patients included in the study were girls. The patients’ mean age was 59.2±33.9 months. While 3.3% of the patients had flexion-type injuries, 30.0% had Gartland Type 2, 40.0% had Type 3, and 26.7% had Type 4 injuries. Eighteen patients (60%) had fractures in their left extremities. Type 4 fractures exhibited the biggest difference among all fracture types in comparison of the arm diameters of the fractured and contralateral sides (17.1%±5.5%; p=0.013). In the comparison of the PWRN to LCRN distance ratio, the difference was the highest in Type 2 fractures (23.3%±8.0%; p=0.027). None of the patients encountered postoperative iatrogenic radial nerve injury.
Conclusion: In pediatric patients with supracondylar humerus fractures, the swelling of the extremity increases with the severity of the fracture. This situation decreases inversely with the distance of the proximal K wire from the radial nerve. The ultrasound-guided lateral cross pinning technique is a reliable method in terms of ease of application and the determination of the nerve line to create a safe zone, especially in elbow injuries with excessive swelling.
References
- 1. Cheng JC, Shen WY. Limb fracture pattern in different pediatric age groups: a study of 3,350 children. J Orthop Trauma. 1993;7(1):15–22.
- 2. Brubacher JW, Dodds SD. Pediatric supracondylar fractures of the distal humerus. Curr Rev Musculoskelet Med. 2008;1(3-4):190-196.
- 3. Prashant K , Lakhotia D , Bhattacharyya TD , Mahanta AK , Ravoof A . A comparative study of two percutaneous pinning techniques (lateral vs medial-lateral) for Gartland type III pediatric supracondylar fracture of the humerus. J Orthop Traumatol. 2016;17(3):223-229.
- 4. Woratanarat P , Angsanuntsukh C , Rattanasiri S et al. Meta-analysis of pinning in supracondylar fracture of the humerus in children. J Orthop Trauma. 2012;26(1):48-53.
- 5. Rizk AS, Kandil MI. Conventional versus lateral cross-pinning (Dorgan’s technique) for fixation of displaced pediatric supracondylar humeral fractures: a randomized comparative study. Egypt Orthop J. 2018;53:348-58.
- 6. Dekker AE, Krijnen P, Schipper IB. Results of crossed versus lateral entry K-wire fixation of displaced pediatric supracondylar humeral fractures: A systematic review and meta-analysis. Injury. 2016 Nov;47(11):2391-2398.
- 7. Altay MA, Erturk C, Isikan UE. Comparison of traditional and Dorgan’s lateral cross-wiring of supracondylar humerus fractures in children. Saudi Med J. 2010; 31:793–796.
- 8. Brighton B , Abzug JM , Ho CA , Ritzman TF . Current strategies for the management of pediatric supracondylar humerus fractures: tips and techniques for successful closed treatment. Instr Course Lect. 2016;65:353-360
- 9. Gartland JJ. Management of supracondylar fractures of the humerus in children. Surg Gynecol Obstet. 1959 Aug;109(2):145-54.
- 10. Leitch KK, Kay RM, Femino JD, Tolo VT, Storer SK, Skaggs DL. Treatment of multidirectionally unstable supracondylar humeral fractures in children. A modified Gartland type-IV fracture. J Bone Joint Surg Am. 2006 May;88(5):980-5.
- 11. S.S. Lee, A.T. Mahar, D. Miesen, P.O. Newton. Displaced pediatric supracondylar humerus fractures: biomechanical analysis of percutaneous pinning techniques. J Pediatr Orthop. 2002;22; 440-443.
- 12. Feng, Chao MD; Guo, Yuan MD; Zhu, Zhenhua MD; Zhang, Jianli MD; Wang, Yukun MD. Biomechanical Analysis of Supracondylar Humerus Fracture Pinning for Fractures With Coronal Lateral Obliquity, Journal of Pediatric Orthopaedics. 2012; 32(2);196-200.
- 13. Vanderhave KL, Brighton B, Casey V, Montijo H, Scannell B. Applications of musculoskeletal ultrasonography in pediatric patients. J Am Acad Orthop Surg. 2014 Nov;22(11):691-8.
- 14. Altay MA, Erturk C, Altay M, Belhan O, Isikan UE. Ultrasonographic examination of the radial and ulnar nerves after percutaneous cross-wiring of supracondylar humerus fractures in children: a prospective, randomized controlled study. J Pediatr Orthop B. 2011 Sep;20(5):334-40.
- 15. Soldado F, Knorr J, Haddad S, et al. Ultrasound-guided Percutaneous Medial Pinning of Pediatric Supracondylar Humeral Fractures to avoid Ulnar Nerve Injury. Arch Bone Jt Surg. 2015;3(3):169-172.
- 16. Gangadharan S, Rathinam B, Madhuri V. Radial nerve safety in Dorgan's lateral cross-pinning of the supracondylar humeral fracture in children: a case report and cadaveric study. J Pediatr Orthop B. 2014 Nov;23(6):579-83.
- 17. Bloom T, Zhao C, Mehta A, Thakur U, Koerner J, Sabharwal S. Safe zone for superolateral entry pin into the distal humerus in children: an MRI analysis. Clin Orthop Relat Res. 2014 Dec;472(12):3779-88.
- 18. Nielsen E, Andras LM, Skaggs DL. Quantifying the Location of the Radial Nerve in Children for Intraoperative Use. J Pediatr Orthop. 2018 May/Jun;38(5):292-5.
- 19. Queally JM, Paramanathan N, Walsh JC, Moran CJ, Shannon FJ, D'Souza LG . Dorgan's lateral cross-wiring of supracondylar fractures of the humerus in children: a retrospective review. Injury. 2010;41:568–571
- 20. Vaquero-Picado A, González-Morán G, Moraleda L. Management of supracondylar fractures of the humerus in children. EFORT Open Rev. 2018;3(10):526-540.
- 21. 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;1:127–133.
Details
| Primary Language | English |
|---|---|
| Subjects | Implementation Science and Evaluation |
| Journal Section | Research Article |
| Authors | |
| Publication Date | September 30, 2024 |
| Submission Date | August 29, 2024 |
| Acceptance Date | September 10, 2024 |
| Published in Issue | Year 2024 |