--Manuscript Draft-- the Humerus in Children in the Hands of Junior Trainees. Walid A Elnahal, M.Sc Tr & Orth

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1 Journal of Orthopaedic Trauma Crossed Wires versus Two Lateral Wires in Management of Supracondylar Fracture of the Humerus in Children in the Hands of Junior Trainees --Manuscript Draft-- Manuscript Number: Full Title: Article Type: Keywords: Corresponding Author: JOT6746R2 Crossed Wires versus Two Lateral Wires in Management of Supracondylar Fracture of the Humerus in Children in the Hands of Junior Trainees Original Article Supracondylar; Humerus; Crossed; Lateral; fracture Mahmoud Abdel Karim Cairo University Cairo, EGYPT Corresponding Author Secondary Information: Corresponding Author's Institution: Cairo University Corresponding Author's Secondary Institution: First Author: Mahmoud Abdel Karim First Author Secondary Information: Order of Authors: Mahmoud Abdel Karim Ahmed Hosny Nasef Abdelatif Mohamed Hegazy Walid Awadallah sherif Khaled Mostafa Azab Hany Mohammady Walid A Elnahal, M.Sc Tr & Orth Order of Authors Secondary Information: Powered by Editorial Manager and ProduXion Manager from Aries Systems Corporation

2 Reply to Reviewers' Comments REVIEWER'S COMMENTS * Well conceived, well-executed and well-written manuscript. The figures unfortunately show inadequate pin spread in the lateral example. Baumann's angles would not be hard to measure to fortify the findings. Pin spread in the lateral pins in Figures seems too narrow which leads the reader to wonder if spread was really adequate in this group. It may detract from the conclusions. Also the authors should state their reasons for not using the Baumann angles. * Concerning Figure 2 : changed Concerning the reasons for not using the Baumann angles: - Measuring the Baumann angles were not among the main outcomes of this study. - We were guided by the studies performed by Devkota et al, Gordon et al, Zamzam et al, Chakraborty et al who used the same outcome measures. - Still, we would have been very glad to measure it, however as we have found that, five out of the six displaced cases which has occurred in the lateral group; were rotational displacements at the fracture site (only one case with translation), and as Baumann s angle is mainly used to assess coronal plane alignment of the distal humerus. (1) In addition; positioning for elbow x-rays can be difficult in children, 1

3 particularly after acute injury.(2) Thus, many radiographs of the elbow in this setting are taken with the x-ray beam at an imperfect angle for optimal measurement. (2) In his study of a cadaveric elbow, Camp et al (3) showed that BA varies with the angle at which the x-ray beam is directed. So we think that due to this rotational displacement in the majority of the displaced cases in lateral group, measuring it wouldn t truly reflect the true magnitude of displacement. (1) Acton JD, McNally MA. Baumann s confusing legacy. Injury. 2001;32: (2) Mohammad S, Rymaszewski LA, Runciman J. The Baumann angle in supracondylar fractures of the distal humerus in children. J Pediatr Orthop. 1999;19: (3) Camp J, Ishizue K, Gomez M, et al. Alteration of Baumann s angle by humeral position: implications for treatment of supracondylar humerus fractures. J Pediatr Orthop. 1993;13: * Ensure that references are formatted according to JOT style: Journal article 1. Rand NS, Dawson JM, Juliao SF, et al. In vivo macrophage recruitment by murine intervertebral disc cells. J Spinal Disord. 2001;14: Book chapter 2. Todd VR. Visual information analysis: frame of reference for 2

4 - Done visual perception. In: Kramer P, Hinojosa J, eds. Frames of Reference for Pediatric Occupational Therapy. Philadelphia, PA: Lippincott Williams & Wilkins; 1999: Entire book 3. Atlas SW. Magnetic Resonance Imaging of the Brain and Spine. Philadelphia: Lippincott Williams & Wilkins, * Do NOT embed images or tables in the manuscript file. - Done 3

5 Unblinded Title Page Crossed Wires versus Two Lateral Wires in Management of Supracondylar Fracture of the Humerus in Children in the Hands of Junior Trainees Authors : - Mahmoud Abdel Karim ; First / Corresponding Author Lecturer Tr & Orth, Cairo University Hospitals M.D. Tr & Orth mabdelkarim@hotmail.com Ahmed Hosny ; Tr & Orth Resident (V) dr.ahmadhosny@yahoo.com M.Sc. Tr & Orth - Nasef Mohamed Nasef Abdelatif; Assoc. Professor Tr & Orth, Bani-Suef University Hospitals docnasef@hotmail.com M.D. Tr & Orth - Mohamed Mahmoud Hegazy; Assoc. Professor Tr & Orth, Cairo University Hospitals Mohamedhegazy1971@gmail.com M.D. Tr & Orth - Walid R Awadallah; Lecturer Tr & Orth, Cairo University Hospitals walidrm@kasrlainy.ed.u.eg M.D. Tr & Orth - Sherif A. Khaled ; Assoc. Professor Tr & Orth, Cairo University Hospitals sherifakhaled@yahoo.com

6 M.D. Tr & Orth - Mostafa A. A. Azab; Lecturer Tr & Orth, Cairo University Hospitals moos @yahoo.com M.D. Tr & Orth - Walid ElNahal Assistant Lecturer Tr & Orth, Cairo University Hospitals Elnahal.w@kasralainy.edu.eg M.Sc. Tr & Orth - Hany Mohammady; Professor Tr & Orth, Cairo University Hospitals mhani@link.net M.D. Tr & Orth Conflict of interests: The Authors has no conflict of interests related to this study to declare. Previous presentation at a conference: This study was presented as oral presentation at the AAOS 2014 annual meeting in New Orleans, US. Funding disclosure: The authors confirm that no funding was received related to this study.

7 Manuscript 1 2 Abstract: Objectives: The objective was to evaluate and compare the outcome of the crossed and the lateral pin configurations in the management of supracondylar (SC) humeral fractures in children in the hands of junior trainees. 6 Design: Prospective Randomized Controlled Trial. 7 Setting: Level I Trauma Center. 8 9 Patients: 60 children with Supracondylar humeral fractures. The mean age was 5.1 (1.5-9) years. The minimum follow up period was 6 months, with no patients lost to follow up Intervention: 30 patients were managed by crossed and 30 by the lateral method. All surgeries were done by junior trainees in their first three years of training Main Outcome Measurements: Postoperative stability, ulnar nerve injury, range of motions and pin tract infection. 14 Results The crossed configuration was stable in all the patients while the lateral method was less stable in 20% of the cases as the distal fragment rotated in five patients and posteriorly displaced in one patient. The difference was statistically significant with a p value of Ulnar nerve neurapraxia occurred in one patient from the lateral group and it recovered in the 4th month while no ulnar nerve injury occurred in the crossed configuration group. Two patients in the lateral group lost approximately 10 0 of elbow flexion. 21 Conclusions: 22 This prospective randomized controlled trial showed that the crossed pin configuration 1

8 method provided more stability than the lateral pin configuration especially in the hands of junior trainees in their first three years of training and the difference was statistically significant. 26 Introduction: Supracondylar fractures of the humerus are the most common fractures about the elbow in children [1,2]. According to Boyd and Altenberg [3], these fractures account for 65.4% of upper extremity fractures in children. There are 2 basic types of supracondylar fracture based on mechanism: flexion and extension types. The extension type fracture comprises up to 96% of supracondylar fractures and can be further sub classified based on the Wilkins-modified Gartland classification. [4] The Gartland classification is based on the x-ray appearance of fracture displacement. Type I is a non-displaced fracture, Type II is a displaced fracture with intact posterior cortex, Type III is a displaced fracture with no cortical contact and the displacement may be posteromedial or posterolateral. [4] In displaced pediatric supracondylar fractures, closed reduction and percutaneous pinning is the most widely accepted treatment and has been shown to decrease risks associated with this fracture. [1] Despite this consensus, there remains a disagreement as to the best pin configuration. Two basic pin configurations exist: a lateral-entry pin technique and a medial and lateral (crossed) pin technique. Though crossed medial-lateral pin fixation provides increased biomechanical stability, but simultaneously it carries the risk of iatrogenic ulnar nerve injury from placement of the medial pin [5-7]. Conversely, the two lateral pin fixation avoids the danger of iatrogenic ulnar nerve injury, but it provides less biomechanical stability [8-12]. 45 Objective: 2

9 The objective of this prospective Randomized Controlled Trial (RCT) was to compare the outcome of the crossed medial and lateral entry pin technique and the lateral entry pin technique in the management of supracondylar humeral fractures in children in the hands of junior trainees in their first three years of training. Patients & Methods: This study was a single center, prospective, randomized controlled clinical trial, conducted in the Department of Orthopaedics and Traumatology of our institute from December 2011 to February Randomization was done after obtaining a written informed consent from the study participants. Randomization was done using opaque sealed envelopes. The study included 60 children with Gartland types II and III supracondylar humeral fractures; They were all treated by closed reduction and percutaneous pinning. The inclusion criteria were: patients scheduled for closed reduction and K wiring of supracondylar fractures of the humerus under general anaesthesia, Type II or III supracondylar humeral fractures, patients below 10 years, unilateral fractures. The exclusion criteria were: Undisplaced Gartland type I fractures, open fractures, fractures with vascular injury, fractures with compartment syndrome, fractures with preoperative ulnar nerve injury or refusal to provide an informed consent. The mean age at presentation was 5.1years (range: years). There were 18 girls and 42 boys. The left elbow was involved in 33 patients and the right in 27 patients. 57 fractures were extension-type injuries; with 3 fractures were flexion type injuries. There were 53 patients Gartland type III and 7 patients Gartland type II. The duration from injury to admission to the hospital ranged from 2 to 72 hours, with a mean of hours. 69 3

10 The mode of trauma was falling to the ground in 38 patients; fall downstairs in 13 patients and fall from height in 9 patients. There were associated fractures in two patients; one of them had a fracture of the ipsilateral distal radius and the second patient had a greenstick fracture of the proximal phalanx of the contralateral thumb. The radial pulse was absent in two patients but the capillary refill was normal and the normal blood flow was restored after reduction in the two patients and no exploration of blood vessels was necessary. The patients were randomized to be managed with either crossed pins or lateral pins configuration through the use of opaque sealed envelopes. There were no significant differences between the two groups regarding age, sex, side, types of displacement, types of fracture, interval from injury to admission and interval from admission to surgery This study was conducted in a level 1 trauma center in a university hospital. All surgeries were done by junior trainees in their first three years of training. The main Surgeon was either a second year or third year resident (in a 3 year residency program), the assistant was a 1 st, 2 nd or 3 rd year resident. They were supervised by an attending surgeon who was present in the operative premises, and who reviewed the intra operative images on the image intensifier before the procedure was completed Surgical Technique: General anesthesia was used for all patients, and all were in a supine position on the operating table. A prophylactic dose of antibiotics was used in all patients at induction. Reductions were performed under the guidance of fluoroscopy. The child s arm was then prepped and draped in a sterile manner. A standard technique of supracondylar humerus fracture reduction was then performed, as described by 4

11 Mubarak and Davids. [13] The fracture was fixed either by the crossed or the lateral method according to the randomization. The surgeon selected the pin size to be used according to the age of the patient and the size of the arm (usually 1.6 mm for younger children and mm for older children). For the lateral entry technique, two pins were inserted from the lateral aspect of the elbow across the lateral cortex to engage the medial cortex with the elbow in hyperflexion. The pins could be placed in a parallel or divergent manner. Our aim was to start the insertion point in the center of the lateral condyle then through the capitellum into the distal humeral physis and then to finally rest along the far cortex; avoiding the olecranon fossa ; generally, the pin was aimed 35 degrees upward and 10 degrees posteriorly. Fig (1) For the medial and lateral entry technique, we usually started with the lateral pin insertion to obtain stability while reduction was evaluated (avoids need to repeatedly insert medial pins if reduction is not adequate). This pin was inserted from the lateral aspect of the elbow across the lateral cortex to engage the medial cortex with the elbow in hyperflexion. The elbow was then extended to less than a 90 position to avoid injury to an anteriorly subluxating ulnar nerve. Extension of the elbow relaxes any tension on the ulnar nerve and limits the risk of anterior subluxation of that nerve out of its fossa. To further protect the nerve, the surgeon s thumb was placed over the medial epicondyle and swept posterior over the cubital tunnel protecting the ulnar nerve. A small medial incision of 1.5 to 3.0 cm was made over the medial epicondyle. Superficial dissection was performed to ensure that the pin was placed in the medial epicondyle and that the ulnar nerve was not subluxated anteriorly over the medial epicondyle. The medial pin was then placed, starting in the medial epicondyle and engaging the lateral cortex, with the elbow extended to <90 and with retraction of soft tissue from the medial epicondyle. Fig (2) 5

12 After appropriate pin placement with acceptable fracture reduction confirmed using fluoroscopy (AP, lateral, internal, and external oblique), the pins are carefully bent to lie against the skin and cut leaving approximately 2 to 3 cm to prevent pin migration and facilitate pin removal when healing occurs. Then above elbow slab was applied with approximately 70 to 90 of elbow flexion and neutral forearm rotation Follow-up: All patients returned for both clinical and radiographic evaluations at one week, three to four weeks, six weeks and three months. The cast and pins were removed in the clinic at five weeks follow-up appointment. Follow-up assessment of each patient was done by the same team throughout the trial (a third year resident together with an attending). Both the surgeons and the patients were not blinded of the treatment received throughout the trial. Throughout the follow up period, the two study groups were compared with regard to: Postoperative stability, ulnar nerve injury, and range of motion as well as pin tract infection. A stable fixation was considered when no fracture displacement occurred in the follow up period. An unstable fixation was considered when fracture displacement occurred in the follow up period. Displacement was considered when there was translation, angulation or rotation at the fracture site. The minimum follow-up period was 6 months. Cases with complications would undergo a more intensive follow-up protocol depending on the nature of the complication Statistical Analysis: Comparison between the study groups was done using Yates corrected Chi squared equation. p values less than 0.05 was considered statistically significant. All statistical 6

13 calculations were done using computer programs SPSS (Statistical Package for the Social Science; SPSS Inc., Chicago, IL, USA) version 15 for Microsoft Windows. Results: All the patients were followed up for postoperative stability, ulnar nerve injury, range of motions and pin tract infection. Concerning stability, radiographic evaluation showed that the crossed pin fixation technique was found to be stable in all the patients while the lateral entry pin fixation technique was found less stable as the distal fragment rotated in five patients and posteriorly displaced in one patient i.e. in 20 % of the group patients. Comparing the postoperative stability; the difference between the two groups was found to be statistically significant with a p value of After strict adherence to the medial pin insertion technique precautions described previously; no ulnar nerve injury occurred in any of the 30 patients of the crossed pin fixation technique group. Ulnar nerve neurapraxia occurred in one patient; this case was actually from the lateral group and it was recovered in the 4 th month postoperatively. The difference between the two groups was found to be statistically insignificant with a p value of The range of motion was restored in all but ten patients two months after wire removal. The remaining ten patients required an extended period of intensive physiotherapy because of persistent elbow stiffness; two of them belonged to the crossed pin technique group and eight patients belonged to the lateral entry pin fixation technique group. Out of those ten patients; eight patients regained full range of motion after physiotherapy, the remaining two patients; both of them belong to the lateral pin group continued to have approximately 10 0 of elbow flexion loss till the end of the follow up period. The difference between the two groups was not statistically significant with a p value of (Table 1) 167 7

14 Pin tract infection was observed in seven patients on the third week ;four of them from the crossed pin fixation technique group and three from the lateral entry pin fixation technique. All cases ultimately resolved by repeated dressing. The difference between the two groups was not statistically significant with a p value of Discussion: The success of the treatment of displaced supracondylar fractures of the humerus in children depends on good reduction, maintenance of the reduction until fracture healing with avoidance of complications and achieving better functional and cosmetic results. [14] The standard treatment for displaced (Gartland type II and type III) supracondylar fractures of the humerus in children is closed reduction and percutaneous pin fixation. But, controversy persists among authors regarding optimal method of percutaneous pin fixation. Swenson [15], Casiano [16] and Flynn et al. [17] used two crossed medial-lateral pins. Arino et al. [18] used two lateral pins. The advantage of medial and lateral entry pin fixation is probably greater fracture stability, although iatrogenic ulnar nerve injury may result from placement of the medial pin. Conversely, the advantage of lateral entry pin fixation is avoidance of iatrogenic ulnar nerve injury, although the construct may be less stable biomechanically. [19] Out of 60 cases enrolled in this study, instability occurred in 6 cases (10%), all were from the lateral entry pin fixation technique group, while all the fractures fixed by the crossed method were found to be stable. In a study done by Devkota et al; [20]; loss of reduction was seen in two patients (1.96%) of the lateral pinning group. In a similar study done by Chakraborty et al; [14]; instability was seen in 16 patients (17.39%),Ten of them were from the lateral and six were from the crossed pin configuration group. Also a study done by 8

15 Zamzam, et al; [21] in which significant instability were observed in nine children (8.33%) who underwent fixation by two lateral pins. In a prospective randomized controlled study done by Kocher et al; [19]; to compare lateral entry pins with medial and lateral entry pin fixation for completely displaced supracondylar humeral fractures in children, there were no patients in either group that had a major loss of reduction. There were no significant differences between the rates of mild loss of reduction, which occurred in six of the twenty-eight patients treated with lateral entry and 200 one of the twenty-four treated with medial and lateral entry (p = 0.107). In another prospective RCT by Maity et al [22]; there were no differences between the two groups with regard to loss of reduction grading. However, in addition to the location of the entry of the pins, the overall strength of these constructs is related to the divergence of the pins in different columns of the distal part of the humerus and to the overall number of pins. [9] Three lateral entry pins or two lateral entry pins that are divergent and are located in both the lateral and the central column provide torsional rigidity that is similar to that achieved with the combination of a medial and a lateral pin.[9] This study described the outcomes of fixation of the supracondylar humeral fractures in children in the hands of the junior trainees regardless of the pin configuration. The trainees were aware of the different mechanical properties of pin configuration, but were not instructed to preferably use one configuration or another. After strict adherence to the medial pin insertion technique precautions described previously, no ulnar nerve injury occurred to all the 30 patients of the crossed pinning group, while ulnar nerve neurapraxia occurred in one patient from the lateral group and it recovered by the 4 th month. Although the etiology of the ulnar nerve injury that occurred in the lateral group remains unclear, the authors attribute it to either over drilling or over traction during 9

16 manipulation. In the study by Devkota et al; [20]; seven patients of the 79 patients in the crossed pinning group (6.86%) developed ulnar nerve injury. In another study done by Chakraborty et al; [14] ; four patients(4.34%) developed ulnar nerve injury, all were from the crossed pinning group, In a study by Zamzam et al ; [21] ; two patients of (1.85%) developed ulnar nerve injury in the crossed pinning group. In a prospective RCT done by Kocher et al; [19], there were no cases of iatrogenic ulnar nerve injury in either group. In another prospective RCT by Maity et al [22]; there was no significant difference between the two groups with regard to iatrogenic ulnar nerve injury. Brauer et al. [23] performed a systematic review using pooled data of 2054 children from 35 previous studies: 2 randomized trials, 6 retrospective studies and 25 case series. They found no significant difference between the two groups in terms of loss of reduction and iatrogenic nerve injury. In this study, all patients regained full range of motion after physiotherapy, except for two boys (3.33%) from the lateral group who lost approximately 10 0 of elbow flexion. In the study by Devkota et al; [20]; there were four patient (3.92%) that developed poor range of motion, three were from the crossed and one was from the lateral pinning group. In the study by Zamzam, et al; [21], one boy lost approximately 20 o of elbow flexion and had an extension lag of <10 o, and one girl also had an extension lag of <10 o (1.85%) Pin tract infection was noticed in seven patients on the third week, all resolved by repeated dressing. In the study by Devkota et al; [20]; eight patients (7.84%) developed pin tract infection. In the study done by Chakraborty et al; [14] 52 patients (56.52%) developed pin tract infection, while only one child (0.92%) developed a pin-track infection in the study done by Zamzam, et al. [21] The strength of this study is its prospective randomized design. All of the patients in each group were operated on according to a uniform standardized technique. Detailed follow- 10

17 up assessment of the study patients was done with the use of various clinical and radiological outcome measures at standardized intervals. Follow-up assessment of each patient was done by the same team throughout the trial. The fact that all surgeries were done by junior trainees in their first three years of training might show that the crossed method might be more stable in the hands of those in their early training years with more predictable results. The limitation of our study is perhaps the need for larger number of patients in each group to increase the power of the study another weakness of our study is that, both the surgeon and the patients were not blinded of the treatment received throughout the trial This study was approved by the Institutional Review Board (IRB), of the trauma and orthopaedic department, faculty of Medicine, Cairo University Conclusion: In Conclusion, we found that the crossed entry pin fixation technique provides more stability than the lateral entry pin fixation technique in management of supracondylar fracture of the humerus in children in the hands of junior trainees in their first three years of training. The risk of ulnar nerve injury can be avoided if adequate care is given during inserting the medial pin by palpating the ulnar nerve at the time of pinning and making a small incision over the medial epicondyle especially in cases of severe elbow swelling References 1. Otsuka NY, Kasser JR. Supracondylar fractures of the humerus in children. J Am Acad Orthop Surg. 1997; 5: Beaty JH, Kasser JR. Fractures about the elbow. Instr Course Lect. 1995; 44: Boyd HB, Altenberg AR. Fractures about the elbow in children. Arch Surg. 1944; 49:

18 Gartland JJ. Management of supracondylar humerus fractures in children. Surg Gynecol Obstet. 1959;109: Skaggs DL, Hale JM, Bassett J, Kaminsky C, Kay RM, Tolo VT. Operative treatment of supracondylar fractures of the humerus in children. The consequences of pin placement. J Bone Joint Surg Am. 2001; 83: Lyons JP, Ashley E, Hoffer MM. Ulnar nerve palsies after percutaneous crosspinning of supracondylar fractures in children s elbows. J Pediatr Orthop. 1998; 18: Rasool MN. Ulnar nerve injury after K-wire fixation of supracondylar humerus fractures in children. J Pediatr Orthop. 1998; 18: Gordon JE, Patton CM, Luhmann SJ, Bassett GS, Schoenecker PL. Fracture stability after pinning of displaced supracondylar distal humerus fractures in children. J Pediatr Orthop. 2001; 21: Lee SS, Mahar AT, Miesen D, Newton PO. Displaced pediatric supracondylar humerus fractures: biomechanical analysis of percutaneous pinning techniques. J Pediatr Orthop. 2002; 22: Zionts LE, McKellop HA, Hathaway R. Torsional strength of pin configurations used to fix supracondylar fractures of the humerus in children. J Bone Joint Surg Am. 1994; 76: Kallio PE, Foster BK, Paterson DC. Difficult supracondylar elbow fractures in children: analysis of percutaneous pinning technique. J Pediatr Orthop 1992; 12: Davis RT, Gorczyca JT, Pugh K. Supracondylar humerus fractures in children. Comparison of operative treatment methods. Clin Orthop Relat Res. 2000; 376:

19 Mubarak SJ, Davids JR. Closed reduction and percutaneous pinning of supracondylar fractures of the distal humerus in the child. In: Morrey BF, ed. Master Techniques in Orthopedic Surgery, The Elbow. New York: Raven Press, Ltd.; 1994: Chakraborty MK, Onta PR, Sathian B, et al. Displaced supracondylar fracture of humerus in children treated with crossed pin versus lateral pin: A hospital based study from Western Nepal. West Nepal J of Clinic Diagn Res. 2011; Swenson AL. The treatment of supracondylar fractures of the humerus by Kirschner-wire transfixion. J Bone Joint Surg Am. 1948; 30: Casiano E. Reduction and fixation by pinning banderillero stylefractures of the humerus at the elbow in children. Mil Med. 1960; 125: 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: Arino VL, Llurch EE, Ramriez AM, et al. Percutaneous fixation of supracondylar fractures of the humerus in children. J Bone Joint Surg Am. 1977; 59: Kocher MS, Kasser JR, Waters PM, et al. Lateral Entry Compared with Medial and Lateral Entry Pin Fixation for Completely Displaced Supracondylar Humeral Fractures in Children. A Randomized Clinical Trial. J Bone Joint Surg Am. 2007; 89(4): Devkota P, Khan J A, Acharya BM, et al. Outcome of Supracondylar Fractures of the Humerus in Children Treated by Closed Reduction and percutaneous pinning. J Nepal Med Assoc. 2008; 47(170): Zamzam MM, Bakarman KA. Treatment of displaced supracondylar humeral fractures among children: Crossed versus lateral pinning. Injury. 2009; 40(6):

20 Maity A, Saha D, Roy DS. A prospective randomised, controlled clinical trial comparing medial and lateral entry pinning with lateral entry pinning for percutaneous fixation of displaced extension type supracondylar fractures of the humerus in children. J Orthop Surg Res. 2012; 7: 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:

21 Figure 1 Fig (1) : B.A., Male patient, 4 years old, Presented with supracondylar fracture of his left humerus, Extension type, Gartland III after fall from a height. Closed reduction and percutaneous pinning were done by the crossed entry pin fixation technique. The patient regained full range of motion within 2 months without complications. (a), (b) Preoperative AP, lateral views. (c), (d) 5 Weeks follow up postoperative AP & Lateral X ray views 1

22 Figure 2 (a) (b) (a) (b) Fig (2) : Male patient, 4 years old, Presented with supracondylar fracture of her left humerus, Extension type, Gartland III after fall to the ground. Closed reduction and percutaneous pinning were done by two lateral entry pin fixation technique. The patient regained full range of motion within 2 months without complications. 1

23 (a), (b) Preoperative AP, lateral views. (c), (d) 6 Weeks follow up postoperative AP & Lateral X ray views. 2

24 Table (1) Table (1) The Range of motion (ROM) as well as the postoperative stiffness in different groups Crossed Lateral Total Full Range Postoperative Stiffness Total

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