Research Article | Volume 5 Issue -2 (July - Dec, 2024) | Pages 1 - 12
Treatment of supracondylar fracture of the humerus, comparison study between percutaneous fixation by lateral pinning and cross pinning in children
1
M.B.Ch.B\D.O.C. (orthopedic), Kirkuk Health Department, Azadi Teaching Hospital, Kirkuk, Iraq.
Under a Creative Commons license
Open Access
Received
Sept. 12, 2024
Revised
Oct. 11, 2024
Accepted
Nov. 17, 2024
Published
Dec. 20, 2024
Abstract

Background: The supracondylar humerus fractures are common elbow fracture for children. Management of these fractures is accompanied with many intra and post operative complications. Aim of study: To compare between percutaneous fixations of supracondylar fractures of humerus in children by lateral pinning or by cross pinning.Patients and methods: A clinical prospective follow up study carried out in Orthopedics Department of Al-Basrah Teaching Hospital in Basrah city during one year period from 1st of September, 2019 to 31st of August, 2020 on sample of 30 children with supracondylar fracture of the humerus were included in present study; 15 children treated with lateral pinning (unilateral) percutaneous fixation and 15 children by cross pinning (bilateral) percutaneous fixation. The decision of each approach unilateral or bilateral was approved by the supervisor depending on Gartland classification.Results: No significant differences between children with unilateral fixation and children with bilateral fixation regarding postoperative outcomes. Mean surgical operation time of patients treated with percutaneous bilateral fixation was significantly longer than operation time for patients treated with percutaneous unilateral fixation (p<0.001). Mean diameter of k-wire for patients treated with percutaneous bilateral fixation was significantly lower than mean diameter of k-wire for patients treated with percutaneous unilateral fixation (p=0.007). The postoperative complications following both unilateral and bilateral percutaneous fixations are infrequent. Conclusions: The unilateral and bilateral percutaneous fixations have same efficacy and safety in management of supracondylar fracture of humerus in children.

Keywords
INTRODUCTION

Supracondylar humerus fractures are the most frequent elbow fractures in the pediatric population and are associated with significant complications, such as neurovascular injuries and malunion. Cubitus varus is the most common residual deformity from supracondylar fractures, usually resulting from malreductions that promote distal fragment rotational displacement. Other causes include medial column comminution leading to reduction loss during follow-up and growth arrests caused by physeal injuries [1-4]. The most common mechanism of injury is a fall on an extended arm, which accounts for over 95% of cases. Another mechanism is direct trauma to the posterior region of a flexed elbow, causing an anterior deviation of the distal fracture fragment. The most widely used classification for these fractures is described by Gartland: type I (undisplaced or minimally displaced), type II (displaced but with intact posterior cortex), and type III (completely displaced with no cortical contact). Nerve damage occurs in about 11.3% of patients, while vascular lesions are seen in less than 1% of these fractures[5-10]. The ulnar nerve is the most commonly injured nerve in flexion fractures and may also be iatrogenically damaged during percutaneous fixation of the medial column of the distal humerus [11,12]. The objective of surgical treatment of displaced and unstable fractures (Gartland types II and III) is to achieve a stable reduction, prevent neurovascular injuries, avoid compartment syndrome [13,14], and minimize the risk of residual deformities, particularly cubitus varus. The standard treatment is closed reduction and percutaneous Kirschner wire (K-wire) fixation, which can be achieved through various configurations; the most common are two crossed wires and fixation in the lateral column [15-18]. Biomechanical trials show that the configuration of two crossed K-wires—one in the lateral column of the distal humerus and the other in the medial end—provides the greatest stability when fixing these fractures [19-22]. However, there is a risk of iatrogenic injury, mainly to the ulnar nerve, due to its proximity to the posterior surface of the medial epicondyle. To minimize this risk, fractures can alternatively be fixed with parallel or divergent K-wires solely at the lateral column of the humerus, but this configuration is less stable and could lead to residual deformities such as cubitus varus. In summary, there is still no consensus on the most effective technique for treating displaced supracondylar humerus fractures [23,24]. Supracondylar fractures of the humerus are the second most frequent type of bone injury in children, accounting for 55% to 75% of elbow fractures [25,26]. Proper management of these fractures is crucial due to the potential for severe complications. While there is a clear consensus on some treatment aspects, controversies remain, such as the lack of a robust classification system that guides treatment or predicts complications, the timing of emergency reduction, the management of Gartland type II fractures, the optimal reduction technique, the risk/benefit ratio of open reduction, the best pin configuration, the use of a medial pin, the management of a pink pulseless hand, the remodeling capacity of the distal humerus, and the long-term consequences of a cubitus varus deformity [27-33]. Supracondylar fractures of the humerus account for 55% to 80% of total elbow fractures in children and up to two-thirds of pediatric elbow injuries requiring hospitalization [8]. These fractures often result from falls from height or during sports or leisure activities, with an estimated incidence of 177 per 100,000 [9,34,35]. Although these fractures can occur throughout childhood, the median age is approximately six years, with a higher incidence between five and eight years. Supracondylar fractures are more common in boys and affect the non-dominant arm 1.5 times more frequently [36-39]. In children, the supracondylar region consists of weak, thin bone located in the distal humerus, bordered posteriorly by the olecranon fossa, anteriorly by the coronoid fossa, and on both sides by respective supracondylar ridges. The medial and lateral supracondylar ridges end at their respective condyles and epicondyles. The trochlea is normally tilted 4° valgus in males and 8° valgus in females (carrying angle) and is also externally rotated by 3-8°, resulting in external rotation of the arm when flexed to 90° [40,41]. Fractures often heal in extension if the reduction is insufficient or if a type II fracture is treated conservatively. An extension malunion increases extension and reduces flexion, which can cause cosmetic problems and hinder daily activities. Functional elbow motion is from 30° to 130°, and careful reduction in the operating room is necessary to avoid extension malunion. It is crucial to remember that the condyle of the humerus is anterior to the humeral shaft and that the anterior humeral line should cross the humeral condyle in its middle third. Extension malunion is the primary cause of reduced flexion following pediatric supracondylar fractures, and scarring rarely contributes to flexion deficits in children. Thus, treatment should be a supracondylar osteotomy rather than a column procedure (capsulotomy) [42,43]. The cause of cubitus varus remains uncertain. Most authors believe it results from fracture malunion rather than growth arrest. Angular and rotational deformities are thought to contribute to cubitus varus. Posteromedial displacement results in a higher Baumann angle, indicating cubitus varus deformity, while posterolateral displacement results in a lower Baumann angle, indicating cubitus valgus [44-50]. The distal humeral physis has limited remodeling potential; children aged eight to ten years have only 10% of the humerus's total growth remaining. While mild sagittal and coronal deformities may remodel in children under four years old, rotational deformities do not [51-53]. Pin track infections are reported in 1% to over 25% of cases. Most infections are superficial and resolve with pin removal and oral antibiotics. In rare cases of deep infection or joint involvement, drainage, debridement, and intravenous antibiotics usually resolve the infection without significant sequelae [54-57].The aim of this study was to compare percutaneous fixation of supracondylar fractures of the humerus in children by lateral pinning or cross pinning.

MATERIALS AND METHODS

This study is a clinical prospective follow-up study conducted at the Orthopedics Department of Al-Basrah Teaching Hospital in Basrah city. The study period spanned one year, from September 1, 2019, to August 31, 2020.

Study Population

The study population included all children who presented to the Orthopedics Department with a supracondylar fracture of the humerus during the study period.

Inclusion Criteria

  • Pediatric age group (1–10 years).

  • Presence of a supracondylar fracture of the humerus.

  • Unilateral fracture.

Exclusion Criteria

  • Age less than 2 years or above 10 years.

  • Open fractures.

  • Pathological fractures.

  • Congenital anomalies.

  • Associated injuries.

  • Previous fracture in the same limb.

  • Refusal of participation by parents.

Sampling

The study sample consisted of 30 children with supracondylar fractures of the humerus. The sample was divided into two groups:

  • 15 children treated with unilateral (lateral) pinning percutaneous fixation.

  • 15 children treated with bilateral (cross) pinning percutaneous fixation.

Data Collection

Data were collected from the children or their relatives using a structured questionnaire designed by the researcher and the supervisor. The questionnaire collected the following information [58-61]:

  1. Demographic Characteristics: Age and gender.

  2. Clinical History: Past medical history, past surgical history, family history, and drug history.

  3. Fracture History: Duration of admission, chief complaint, involved side, and mechanism of injury.

  4. Preoperative Examination Findings: Inspection, palpation, affected side, vascular assessment, and fracture classification.

  5. Operative Measures: Surgical operation time, K-wire diameter, and the number of K-wires used.

  6. Intra-Operative Assessment: Stability assessment of the fracture.

  7. Postoperative Findings:

  • First Postoperative Day: Signs of nerve injury, vascular injury, stability of fixation, fragment rotation, and pin migration.

  • First Postoperative Week: Signs of nerve injury, stability of fixation, and pin tract infection.

  • Third Postoperative Week: Signs of nerve injury, stability of fixation, pin tract infection, and post-removal K-wire stiffness.

Children were admitted to the Orthopedics Department following referral from the Emergency Room and underwent x-ray imaging for diagnosis confirmation. The decision regarding the type of fixation approach (unilateral or bilateral) was determined by the supervisor based on Gartland classification.

Surgical Procedure

For both types of percutaneous fixation, children received general anesthesia and were placed in a supine position, followed by an antibiotic injection. Closed reduction of the fracture was initially performed. The fracture stability was evaluated by the supervisor, while pin tract infection was assessed by the researcher during subsequent visits by examining skin color (redness), skin temperature, swelling, hardness, and pus drainage [62-64].

Follow-Up

Postoperative follow-up of the children was conducted over three periods: the first day, the first week, and the third week postoperatively. Follow-up included scheduled visits for examination, outcome assessment, and complication monitoring. Additionally, phone calls were made during emergency situations to follow up with the children.

Ethical Considerations

Approval for the study was obtained from the Orthopedics Scientific Committee of Al-Basrah Medical College. Oral informed consent was obtained from the parents of the children participating in the study.

Statistical Analysis

Data were entered and analyzed using the Statistical Package for Social Sciences (SPSS) version 20. Descriptive statistics were presented as mean ± standard deviation for continuous variables and frequencies as percentages for categorical variables. Multiple contingency tables were constructed, and appropriate statistical tests, such as the Chi-square test (or Fisher's exact test when applicable), were used to compare categorical variables. A p-value of ≤ 0.05 was considered statistically significant. The statistical analysis was performed by a community medicine specialist.

RESULT

A total of 30 children with supracondylar fracture of the humerus were included in present study; 15 children treated with lateral pinning (unilateral) percutaneous fixation and 15 children by cross pinning (bilateral) percutaneous fixation; no significant differences were observed between children with unilateral fixation and children with bilateral fixation regarding age (p=0.54) and gender (p=1.0). (Table 1)

 

Table 1: Distribution of demographic            characteristics     according to percutaneous fixation mode.

 

Variable

Mode of Fixation

No. Unilateral

% Unilateral

No. Bilateral

% Bilateral

Age

     

<5 years

Unilateral

2

13.3

1

6.7

5-10 years

Bilateral

13

86.7

14

93.3

   

0.54 NS*

 

1.0 NS*

Gender

     

Male

Unilateral

10

66.7

10

66.7

Female

Bilateral

5

33.3

5

33.3

No significant differences were observed between children with unilateral fixation and children with bilateral fixation regarding past medical history, past surgical history, family history and drugs history; as all children with supracondylar fracture of the humerus had negative clinical history. (Table 2)

Table 2: Distribution of clinical history according to percutaneous fixation mode.

 

Variable

Mode of Fixation

No. Unilateral

% Unilateral

No. Bilateral

% Bilateral

Past medical history

     

Positive

Unilateral

0

-

0

-

Negative

Bilateral

15

100.0

15

100.0

Past surgical history

     

Positive

Unilateral

0

-

0

-

Negative

Bilateral

15

100.0

15

100.0

Family history

     

Positive

Unilateral

0

-

0

-

Negative

Bilateral

15

100.0

15

100.0

Drugs history

     

Positive

Unilateral

0

-

0

-

Negative

Bilateral

15

100.0

15

100.0

No significant differences were observed between children with unilateral fixation and children with bilateral fixation regarding duration of admission to hospital (p=0.7), chief complaint (p=0.1) and involved side (p=0.1). A significant difference was observed between children with unilateral fixation and children with bilateral fixation regarding mechanism of injury (p=0.006); children with fall of heavy object were significantly treated with unilateral percutaneous fixation. (Table 3 and Figure 1)

 

Table 3: Distribution of fracture history according to percutaneous fixation mode.

 

Category

No. Group 1

% Group 1

No. Group 2

% Group 2

Duration of admission

    

≤1 day

9

60.0

8

53.3

>1 day

6

40.0

7

46.7

  

0.7 NS*

 

0.7 NS*

Chief complaint

    

Limitation of

9

60.0

5

33.3

Swelling and pain on movement

0

-

4

26.7

Pain on movement

4

26.7

4

26.7

Swelling

2

13.3

2

13.3

  

0.1 NS**

 

0.1 NS**

Involved side

    

Right

13

86.7

10

66.7

Left

2

13.3

5

33.3

  

0.1 NS**

 

0.1 NS**

Mechanism of injury

    

Fall of heavy object

6

40.0

0

-

Fall on ground

9

60.0

15

100.0

  

0.006 S**

 

0.006 S**

 

 

Description: صورة تحتوي على نص, لقطة شاشة, رسم بياني, تخطيط

تم إنشاء الوصف تلقائياً

Figure 1: Mechanism of injury according to fixation mode.

By inspection, there was a significant association between echymosis and children treated with percutaneous bilateral fixation mode (p=0.02). No significant differences were observed between children with unilateral fixation and children with bilateral fixation regarding palpation (p=0.3), affected side (p=0.1) and assessment of vascularity (p=0.7). There was a highly significant association between unilateral fixation and type II fracture, while bilateral fixation was significantly related to type III fractures (p<0.001). (Table 3 and Figure 2)

 

Table 4: Distribution of preoperative examination findings according to percutaneous fixation mode. 

 

Category

No. Group 1

% Group 1

No. Group 2

% Group 2

Inspection

    

Swelling

15

100.0

9

60.0

Echymosis and Echymosis

0

-

2

13.3

  

0.02 S*

 

0.02 S*

Palpation

    

Tender

15

100.0

14

93.3

Tender and firm

0

-

1

6.7

  

0.3 NS*

 

0.3 NS*

Affected side

    

Right

13

86.7

10

66.7

Left

2

13.3

5

33.3

  

0.1 NS*

 

0.1 NS*

Assessment of vascularity

    

Good

6

40.0

5

33.3

Weak pulse

9

60.0

5

33.3

  

0.7 NS**

 

0.7 NS**

Classification of fracture

    

Type II

14

60.0

10

66.7

Type III

1

40.0

13

60.0

  

<0.001 S*

 

<0.001 S*

 

Description: صورة تحتوي على نص, لقطة شاشة, رسم بياني, خط

تم إنشاء الوصف تلقائياً

Figure 2: Inspection findings according to percutaneous fixation modes.

Mean surgical operation time of patients treated with percutaneous bilateral fixation was significantly longer than operation time for patients treated with percutaneous unilateral fixation (p<0.001). Mean diameter of k-wire for patients treated with percutaneous bilateral fixation was significantly lower than mean diameter of k-wire for patients treated with percutaneous unilateral fixation (p=0.007). Mean number of k-wires for patients treated with percutaneous bilateral fixation was not significantly different than mean number of k-wires for patients treated with percutaneous unilateral fixation (p=0.6). (Table 5)

Table 5: Distribution of operative measures according to percutaneous fixation mode

 

Variable

Mode of Fixation

Mean±SD Unilateral

Mean±SD Bilateral

P-value

Operation time

Unilateral

18.3±2.4

28.2±6.9

<0.001* S

Diameter of k-wire

Bilateral

1.8±0.2

1.6±0.2

0.007* S

Number of k-wires

P

2±0.5

2.1±0.6

0.6* NS

 

No significant differences were observed between children with unilateral fixation and children with bilateral fixation regarding intraoperative assessment of stability, sign of nerve injury 1st day postoperatively, vascular injury 1st day postoperatively, stability of fixation by x-ray 1st day postoperatively, fragment rotation 1st day postoperatively and pins migration 1st day postoperatively; as all children with supracondylar fracture of the humerus had good intra and 1st day postoperative outcomes. (Table 6)


 

 

Table 6: Distribution of intra and 1st day postoperative examination findings according to percutaneous fixation mod

 

Variable

Mode of Fixation

No. Unilateral

% Unilateral

No. Bilateral

% Bilateral

Intraoperative assessment of stability

Good

Unilateral

15

100.0

15

100.0

Negative

Bilateral

0

-

0

-

Sign of nerve injury 1st day postoperatively

 

Positive

Unilateral

0

-

0

-

Negative

Bilateral

15

100.0

15

100.0

Vascular injury 1st day postoperatively

Positive

Unilateral

0

-

0

-

Negative

Bilateral

15

100.0

15

100.0

Stability of fixation by x-ray 1st day postoperatively

Good

Unilateral

15

100.0

15

100.0

Negative

Bilateral

0

-

0

-

Fragment rotation 1st day postoperatively

Positive

Unilateral

0

-

0

-

Negative

Bilateral

15

100.0

15

100.0

Pins migration 1st day postoperatively

Positive

Unilateral

0

-

0

-

Negative

Bilateral

15

100.0

15

100.0

No significant differences were observed between children with unilateral fixation and children with bilateral fixation regarding sign of nerve injury 1st week postoperatively, stability of fixation by x-ray 1st week postoperatively and sign of pin tract infection 1st week postoperatively; as all children with supracondylar fracture of the humerus had good intra and 1st week postoperative outcomes. (Table 7)

 

Table 7: Distribution of 1st week postoperative examination findings according to percutaneous fixation mode.

 

Variable

Mode of Fixation

No. Unilateral

% Unilateral

No. Bilateral

% Bilateral

P-value

Sign of nerve injury 1st week postoperatively

 

Positive

Unilateral

0

-

0

-

 

Negative

Bilateral

15

100.0

15

100.0

 
   

-

 

-

 

Stability of fixation by x-ray 1st week postoperatively

Good

Unilateral

15

100.0

15

100.0

 

Week

Bilateral

0

-

0

-

 
   

-

 

-

 

Sign of pin tract infection 1st week postoperatively

 

0.9* NS

Positive

Unilateral

2

13.3

1

6.7

 

Negative

Bilateral

13

86.7

14

93.3

 

No significant differences were observed between children with unilateral fixation and children with bilateral fixation regarding sign of nerve injury 3rd week postoperatively (p=0.06), although, 1 (6.7%) child treated with percutaneous bilateral fixation had positive sign of nerve injury 3rd week postoperatively. No significant differences were observed between children with unilateral fixation and children with bilateral fixation regarding sign of pin tract infection 3rd week postoperatively (p=0.6), although, 4 (26.7%) children treated with percutaneous unilateral fixation had positive sign of pin tract infection 3rd week postoperatively as compared to 2 (13.3%) children treated with percutaneous bilateral fixation. No significant differences were observed between children with unilateral fixation and children with bilateral fixation regarding stability of fixation by x-ray 3rd week postoperatively and post-removal of k-wire stiffness (p=0.2); although, 3 (20%) children treated with percutaneous bilateral fixation had k-wire stiffness. (Table 8)

 

Table 8: Distribution of 3rd week postoperative examination findings according to percutaneous fixation mode.

Variable

Mode of Fixation

No. Unilateral

% Unilateral

No. Bilateral

% Bilateral

Sign of nerve injury 3rd week postoperatively

Positive

Unilateral

0

-

1

6.7

Negative

Bilateral

15

100.0

14

93.3

   

0.9 NS*

 

0.9 NS*

Stability of fixation by x-ray 3rd week postoperatively

     

Good

Unilateral

15

100.0

15

100.0

Week

Bilateral

0

-

0

-

   

-

 

-

Sign of pin tract infection 3rd week postoperatively

Positive

Unilateral

4

26.7

2

13.3

Negative

Bilateral

11

73.3

13

86.7

   

0.6 NS*

 

0.6 NS*

Post-removal of k-wire stiffness

Positive

Unilateral

11

73.3

3

20

Negative

Bilateral

15

100.0

12

80.0

   

0.2 NS*

 

0.2 NS*

DISCUSSION

The supracondylar fractures of the humerus are regarded as the most predominant type of pediatric elbow fractures, representing about 50% to 70% of elbow fractures. Decisions regarding surgical options for supracondylar fractures of the humerus depend on the quality of reduction, reduction maintenance, displacement degree, and stability of fractures [67]. The present study showed no significant differences between children with unilateral fixation and those with bilateral fixation regarding postoperative outcomes. This finding is similar to the results of many studies, such as Sadik's study in Iraq [68] and Abubeih et al.'s study in Egypt [69], which reported that both methods of fixation had the same efficacy and safety in managing supracondylar fractures of the humerus in children. In Brazil, eight randomized controlled trials including 521 children with supracondylar fractures of the humerus were analyzed by Pariota et al. [70], who recommended the use of unilateral fixation for type II fractures and bilateral fixation for type III or IV fractures. A Chinese meta-analysis study, including 6 clinical studies with 581 children with supracondylar fractures of the humerus, showed that both closed reduction and percutaneous pinning and open reduction and internal fixation of supracondylar humeral fractures had equal postoperative outcomes [6].

Despite our study findings and the above literature, a retrospective review study conducted by Khwaja et al. [71] in the UK on 132 children with supracondylar fractures of the humerus, followed for 5 years, found more complications for unilateral fixation, although all nerve injuries were in children treated by bilateral fixation. The current study found better first postoperative day outcomes without any adverse outcomes. This finding is similar to the reports of Vaquero-Picado et al.'s study in Spain [19], which documented that percutaneous fixation management in both approaches had minimal early postoperative complications with higher efficacy. After one week, two children treated by unilateral percutaneous fixation showed signs of pin tract infection, while one child treated by bilateral percutaneous fixation showed signs of pin tract infection, with no statistically significant difference. This finding coincides with the results of El-Adl et al.'s study in Egypt [72], which found minor complications for percutaneous lateral fixation of supracondylar fractures of the humerus in children, specifically pin tract infection. However, Parikh et al.'s study in the USA [73] found that the majority of pin tract infections are superficial and could be treated with pin removal, oral antibiotics, and wound care.

Regarding postoperative third-week outcomes, our study found only one child with signs of nerve injury managed by percutaneous bilateral fixation of a supracondylar fracture of the humerus. This finding is consistent with the results of Sahu's study in India [74], which reported that both unilateral and bilateral approaches of percutaneous fixation of supracondylar fractures of the humerus in children had the same efficacy and safety, except for ulnar nerve injury, which is more common with the bilateral approach as the medial way might affect the nerve. Regarding pin tract infection on the third day postoperatively, 4 children treated by unilateral fixation had infections, while 2 children treated by bilateral fixation had infections with no statistically significant difference. These findings are in agreement with the results of many studies, such as Dawood's study in Iraq [75] and Basaran et al.'s study in Turkey [76], which revealed that although there were no significant differences in efficacy and safety between children with unilateral fixation and those with bilateral fixation, pin tract infection was more obvious among children treated by unilateral fixation.

Our study found post-removal K-wire stiffness among 3 children treated by bilateral percutaneous fixation of a supracondylar fracture of the humerus with no statistically significant difference from children treated by unilateral fixation. This finding is similar to the results of Anvekar et al.'s study in India [77], which stated that post-removal K-wire stiffness was recorded for children treated by bilateral fixation. In the current study, the mean surgical operation time for patients treated with percutaneous bilateral fixation was significantly longer than the operation time for patients treated with percutaneous unilateral fixation (p<0.001). This finding is consistent with the results of Naik et al.'s study in India [78], which found no significant differences between cross pinning and lateral pinning in the management of type III supracondylar fractures of the humerus; however, they found that the operation time for cross pinning was longer than that for lateral pinning. This longer time for bilateral fixation might be attributed to the fact that the medial side requires a mini-open approach that takes longer. Our study also found that the mean diameter of the K-wire for patients treated with percutaneous bilateral fixation was significantly lower than the mean diameter of the K-wire for patients treated with percutaneous unilateral fixation (p=0.007). Similarly, Foead et al.'s study in Malaysia [79] reported that the diameter of K-wires used for unilateral percutaneous fixation of supracondylar fractures of the humerus in children is larger than the diameter of K-wires used for the bilateral approach. This finding may be to avoid ulnar nerve injury.

In the present study, there was a significant association between unilateral fixation of children with supracondylar fractures of the humerus and a fall from a heavy object (p=0.006). Consistently, Carrazzone et al.'s systematic review study in Brazil [80] stated that unilateral fixation of supracondylar fractures of the humerus is highly preferred by surgeons as it has good outcomes with fewer complications, especially with no risk to the ulnar nerve. Our study also found a significant association between ecchymosis and children treated with percutaneous bilateral fixation mode (p=0.02). This finding is similar to the results of Abubeih et al.'s study in Egypt [69]. In the current study, there was a highly significant association between unilateral fixation and type II fractures, while bilateral fixation was significantly related to type III fractures (p<0.001). This finding is similar to the results of Pariota et al.'s study in Brazil [70].

The unilateral and bilateral percutaneous fixations have the same efficacy and safety in the management of supracondylar fractures of the humerus in children. The duration of surgical operation for bilateral percutaneous fixation is longer than that for unilateral fixation. The diameter of K-wires for bilateral percutaneous fixation is higher than that for unilateral fixation. The postoperative complications following both unilateral and bilateral percutaneous fixations are minor, with no obvious difference between both techniques. Surgeons are encouraged to adopt the option of unilateral percutaneous fixation in the management of type II supracondylar fractures of the humerus and the option of bilateral percutaneous fixation in the management of type III or IV fractures. Precautions should be considered when performing bilateral percutaneous fixation to avoid ulnar nerve injury. More research on the outcomes and complications of both unilateral and bilateral percutaneous fixations, which have the same efficacy and safety in the management of supracondylar fractures of the humerus in children, must be supported.

Conflict of Interest:

The authors declare that they have no conflict of interest

 

 

Funding:

No funding sources

Ethical approval:

The study was approved by the Azadi  Teaching Hospital, Kirkuk, Iraq.

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