SUPRAKONDİLLER HUMERUS KIRIKLARININ TEDAVİSİNDE MEDİAL VE LATERAL ÇAPRAZ PİNLEME VE SADECE LATERAL PİNLEME RETROSPEKTİF KARŞILAŞTIRMALI KLİNİK BİR ÇALIŞMA

Öz

AMAÇ: Bu çalışmadaki amacımız suprakondiler humerus kırığı (SHK) sebebiyle opere edilen pediatrik hastalarda çapraz pinleme tekniği (ÇP) ile lateral pinleme tekniğinin (LP) klinik ve radyolojik sonuçlarını karşılaştırmaktır.
GEREÇ VE YÖNTEM: 2017 - 2019 yılları arasında hastanemizde ÇP yada LP ile SHK ameliyatı geçiren hastalar retrospektif olarak incelendi. Yaş, cinsiyet, redüksiyon şekli, Gartland sınıfı, ameliyat süresi, pin sayısı, postop nöro-vasküler durum, postop ilk Baumann açısı ve son takip Baumann açısı, lateral kapitello-humeral açı, pin çıkarma süresi, takip süresi, Flyinn kriterleri ve komplikasyonlar (fiksasyon yetmezliği, infeksiyon, sinir yaralanması, kaynamama, avasküler nekroz, revizyon cerrahisi) değerlendirildi.
BULGULAR: 77 hasta çalışmaya dahil edildi. 51 hastaya ÇP, 26 hastaya LP gerçekleştirildi. Çapraz pinlenen hastaların 24’üne medial açık redüksiyon uygulandı. Her iki grup arasında; kullanılan pin sayısı, postoperatif erken ve son kontrol baumann açısı, lateral capitello humeral açı, pin çıkarma süresi, takip süresi, Fly’in kriterleri ve komplikasyonlar açısından anlamlı bir fark görülmedi (p>0,005). Hiçbir hastada kaynamama, gecikmiş kaynama veya avasküler nekroz saptanmadı. Ameliyat süresi LP grubunda daha kısa idi (p = 0,038). ÇP grubunda 4 hastada iyatrojenikulnar sinir felci, LP grubunda 1 hastada fiksasyon hatası saptandı.
SONUÇ: Çalışmamız her iki grubun fonksiyonel sonuçlarının benzer olduğunu ortaya koymuştur. Bununla birlikte, ulnar sinir hasarı kapalı redüksiyon ve perkütançapraz-pinleme yapılan hastalarda daha yaygındı. İstatistiksel olarak komplikasyonlar açısından iki grup arasında anlamlı fark olmamakla birlikte, sınırlı medial açık prosedür ile çapraz pinleme veya sadece lateral pinleme suprakondiler humerus kırıklarının tedavisi için daha güvenli olabilir.

Anahtar Kelimeler

• Pediatrik
• humerus
• suprakondiler kırık
• çapraz pinleme
• lateral pinleme

MEDIAL AND LATERAL CROSSED-PINNING VERSUS ONLY LATERAL PINNING IN THE TREATMENT OF SUPRACONDYLAR FRACTURES OF HUMERUS A RETROSPECTIVE COMPARATIVE CLINICAL STUDY

Öz

OBJECTIVE: In this study, we aimed to compare the clinical and radiological results of cross-pinning technique (CP) and lateral pinning technique (LP) in pediatric patients operated for supracondylar humerus fracture (SHF).
MATERIAL AND METHODS: The medical records of patients undergoing operations for an SFH either with crossed-pinning technique or only lateral pining technique between the years 2017 and 2019 at the same institution were retrospectively reviewed. Age, gender, reduction type, Gartland class, duration of surgery, number of pins, postop neuro-vascular status, postoperative initial Baumann’s angle and Baumann’s angle at last follow-up visit, Lateral capitellohumeral angle, pin removal time, follow-up time, Flynn's criteria and complications (revision for fixation failure, infection, nerve palsy. nonunion, avascular necrosis ) were evaluated for all patients.
RESULTS: 77 patients were included in the study. Of these, crossed-pinning (CP) technique was performed on 51 patients while only lateral pinning technique (LP) was performed on 26 patients. Among the CP group, 24 of the cross-pinned patients had undergone a medial open reduction. There was no significant difference between the groups ; in terms of the number of pins used, postoperative initial Baumann’s angle and Baumann’s angle at last follow-up visit, Lateral capitellohumeral angle, pin removal time, follow-up time, Flynn's criteria and complications(p>0,005). Nonunion, delayed union or avascular necrosis was not detected in any of the patients. However, the duration of the surgery was shorter in the LP group (p= 0,038). Iatrogenic ulnar nerve palsy was detected in four patients in the CP group and 1 fixation failure was detected in the LP group.
CONCLUSIONS: Our study revealed that the results of both groups were comparable in terms of functional results. However, ulnar nerve injury was more common in patients undergoing closed reduction and percutaneous crossed-pinning. Although threre was no statistically difference in terms of complications among the groups, only lateral pinning or crossed-pinning with a limited medial open procedure may be safer for treatment of supracondylar humerus fractures.

Anahtar Kelimeler

• Pediatric
• humerus
• supracondylar fracture
• crossed-pinning
• lateral pinning

Kaynakça

1. 1. Li M, Xu J, Hu T, Zhang M, Li F. Surgical management of Gartland type III supracondylar humerus fractures in older children: a retrospective study. J Pediatr Orthop B 2019; 28(6): 530-5.
2. 2. Hasler CC, von Laer L. Prevention of growth disturbances after fractures of the lateral humeral condyle in children. J Pediatr Orthop B 2001;10(2):123-30.
3. 3. Gartland JJ. Management of supracondylar fractures of the humerus in children. Surg Gynecol Obstet 1959 ;109(2):145-54.
4. 4. Wilkins KE. Fractures and dislocation of the elbow region. In: Anonymous. Fractures in children. Lippincott Raven, Philadelphia, 1996: 653-904.
5. 5. Beaty JH, KasserJR. (Editor).Rockwood and Wilkin's Fractures in Children. 5th EditionLippincott, Williams & Wilkins, New York 2010:1-1076.
6. 6. Flynn JC, Matthews JG, Benoit RL. Blind pinning of displaced supracondylar fractures of the humerus in children. Sixteen years' experience with long-term follow-up. J Bone Joint Surg Am 1974;56(2):263-72.
7. 7. Joshi T, A Koder, M Herman. Staying Out of Trouble: Complications of Supracondylar Humerus Fractures. Instructional course lectures, 2019. 68: p. 357.
8. 8. Afaque SF, Singh A, Maharjan R, Ranjan R, Panda AK, Mishra A. Comparison of clinic-radiological outcome of cross pinning versus lateral pinning for displaced supracondylar fracture of humerus in children: A randomized controlled trial. J Clin Orthop Trauma 2020;11(2):259-63.

9. 9. Lee SS, Mahar AT, Miesen D, Newton PO. Displaced pediatric supracondylar humerus fractures: biomechanical analysis of percutaneous pinning techniques. J Pediatr Orthop 2002 ;22(4):440-3.
10. 10. Silva M, Knutsen AR, Kalma JJ, et al. Biomechanical testing of pin configurations in supracondylar humeral fractures: the effect of medial column comminution. J Orthop Trauma. 2013 ;27(5):275-80.
11. 11. Babal JC, Mehlman CT, Klein G. Nerve injuries associated with pediatric supracondylar humeral fractures: a meta-analysis. J Pediatr Orthop 2010;30(3):253-63.
12. 12. Larson L, Firoozbakhsh K, Passarelli R, Bosch P. Biomechanical analysis of pinning techniques for pediatric supracondylar humerus fractures. J Pediatr Orthop 2006;(5):573-8.
13. 13. Wang X, Feng C, Wan S, et al. Biomechanical analysis of pinning configurations for a supracondylar humerus fracture with coronal medial obliquity. J Pediatr Orthop 2012 ;21(6):495-8.
14. 14. Feng C, Guo Y, Zhu Z, Zhang J, Wang Y. Biomechanical analysis of supracondylar humerus fracture pinning for fractures with coronal lateral obliquity. J Pediatr Orthop 2012 ;32(2):196-200.
15. 15. Chen TL, He CQ, Zheng TQ, et al. Stiffness of various pin configurations for pediatric supracondylar humeral fracture: a systematic review on biomechanical studies. J Pediatr Orthop B 2015;24(5):389-99.
16. 16. Brauer CA, Lee BM, Bae DS, Waters PM, Kocher MS. A systematic review of medial and lateral entry pinning versus lateral entry pinning for supracondylar fractures of the humerus. J Pediatr Orthop 2007;27(2):181-6.
17. 17. Zhao JG, Wang J, Zhang P. Is lateral pin fixation for displaced supracondylar fractures of the humerus better than crossed pins in children? Clin Orthop Relat Res 2013;471(9):2942-53.
18. 18. Foead A, Penafort R, Saw A, Sengupta S. Comparison of Two Methods of Percutaneous Pin Fixation in Displaced Supracondylar Fractures of the Humerus in Children. J Orthop Surg 2004:76-82.
19. 19. Yen YM, Kocher MS. Lateral entry compared with medial and lateral entry pin fixation for completely displaced supracondylar humeral fractures in children. Surgical technique. J Bone Joint Surg (Suppl 2) 2008;90:20–30.
20. 20. Dost A, Yilmaz B, Komur B, et al. Middle and long term radiologic and functional results of childhood supracondylar humeral fractures operated in first 24 hours with limited medial approach. JPMA. The Journal of the Pakistan Medical Association 2016;66(4):393-8.
21. 21. Lee KM, Chung CY, Gwon DK, et al. Medial and lateral crossed pinning versus lateral pinning for supracondylar fractures of the humerus in children: decision analysis. J Pediatr Orthop 2012 ;32(2):131-8.
22. 22. Langenskiold A, Kivilaakso R. Varus and valgus deformity of the elbow following supracondylar fracture of the humerus. Acta Orthop Scand 1967;38:313–20.
23. 23. Saeed A, Zafardar U, Awais M, Akram M. Outcome of neurolysis combined with anterior submuscular transfer of ulnar nerve in McGowan Grade II and III tardy ulnar nerve palsy. J Pak Med Assoc 2014; 64: 167-72.
24. 24. Taniguchi Y, Matsuzaki K, Tamaki T. Iatrogenic ulnar nerve injury after percutaneous cross-pinning of supracondylar fracture in a child. J Shoulder Elb Surg 2000;9:160-2.
25. 25. Lyons JP, Ashley E, Hoffer M. Ulnar nerve palsies after percutaneous cross-pinning of supracondylar fractures in children’s elbows. J Pediatr Orthop 1998;18(1):43-5.
26. 26. Kalenderer O, Reisoglu A, Surer L, Agus H. How should one treat iatrogenic ulnar injury after closed reduction and percutaneous pinning of paediatric supracondylar humeral fractures? Injury 2008; 39(4):463-6.
27. 27. Slobogean BL, Jackman H, Tennant S, Slobogean GP, Mulpuri K. Iatrogenic ulnar nerve injury after the surgical treatment of displaced supracondylar fractures of the humerus: number needed to harm, a systematic review. J Pediatr Orthop 2010;30(5):430-6.