The practitioner might use two or three laterally introduced pins to stabilize the reduction of displaced pediatric supracondylar fractures of the humerus. Considerations of potential harm indicate that the physician might avoid the use of a medial pin.

Rationale
Pin configuration and the potential complications related to instability and iatrogenic ulnar nerve injury are recognized concerns in this population. Therefore the work group deemed it important to examine the technique of pin stabilization. 

Critical outcomes investigated were iatrogenic ulnar nerve injury, loss of reduction, malunion, and reoperation rate. This recommendation is based on data on 65 outcomes from 15 studies comparing pinning technique using lateral only pin entry to lateral and medial crossed pin technique.

Two of the six studies that were sufficiently powered for loss of reduction were statistically significant in favor of medial pins. The remaining four studies reported no statistically significant difference between lateral and medial pins. 

One randomized, prospective study by Kocher, et al., examined loss of reduction and found a loss of reduction rate of 21% (6/28) in lateral only pins. Medial and lateral pins had a statistically significant lower loss of reduction rate of 4% (1/24). This loss of reduction was not clinically significant enough to warrant re-operation in either group. Meta-analysis of low and moderate quality studies found no statistically significant difference between lateral and medial pin configurations with respect to Baumann’s angle, Baumann’s angle change, Flynn’s Criteria and infection.

The ulnar nerve was injured in 3 of 557 (0.53%) cases with laterally introduced pins. Medially introduced pins resulted in 49 of 808 (6%) cases of ulnar nerve injury. Iatrogenic ulnar nerve injury was noted to be statistically significant in favor of lateral pinning in 6 of 11 studies. A meta-analysis of these studies and three additional underpowered studies (1 moderate quality and 13 low quality) also demonstrated a statistically significant effect in favor of lateral pinning (Number Needed to Harm = 22, Odds ratio = 0.27).  This suggests a 1 in 22 chance of harm resulting from the medial pinning techniques used in these studies. Based on limited evidence, the practitioner might use two or three laterally introduced pins to stabilize the reduction of displaced pediatric supracondylar fractures of the humerus. The risk of potential harm from a medial pin must be weighed against the potential advantages.   
  1. (26) France J, Strong M. Deformity and function in supracondylar fractures of the humerus in children variously treated by closed reduction and splinting, traction, and percutaneous pinning. J Pediatr Orthop 1992;12(4):494-498.
  2. (34) 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(7):793-796.
  3. (35) Bombaci H, Gereli A, Kucukyazici O, Gorgec M. A new technique of crossed pins in supracondylar elbow fractures in children. Orthopedics 2005;28(12):1406- 1409.
  4. (36) Devkota P, Khan JA, Acharya BM et al. Outcome of supracondylar fractures of the humerus in children treated by closed reduction and percutaneous pinning. JNMA J Nepal Med Assoc 2008;47(170):66-70.
  5. (37) 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 (Hong Kong) 2004;12(1):76-82.
  6. (38) 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(3):313-318.
  7. (39) 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):706-712.
  8. (40) Memisoglu K, Cevdet KC, Atmaca H. Does the technique of lateral cross-wiring (Dorgan's technique) reduce iatrogenic ulnar nerve injury? Int Orthop 2010.
  9. (41) Shamsuddin SA, Penafort R, Sharaf I. Crossed-pin versus lateral-pin fixation in pediatric supracondylar fractures. Med J Malaysia 2001;56 Suppl D:38-44.
  10. (42) Sibinski M, Sharma H, Sherlock DA. Lateral versus crossed wire fixation for displaced extension supracondylar humeral fractures in children. Injury 2006;37(10):961-965.
  11. (43) 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-A(5):735-740.
  12. (44) Solak S, Aydin E. Comparison of two percutaneous pinning methods for the treatment of the pediatric type III supracondylar humerus fractures. J Pediatr Orthop B 2003;12(5):346-349.
  13. (45) Topping RE, Blanco JS, Davis TJ. Clinical evaluation of crossed-pin versus lateral-pin fixation in displaced supracondylar humerus fractures. J Pediatr Orthop 1995;15(4):435-439.
  14. (46) Tripuraneni KR, Bosch PP, Schwend RM, Yaste JJ. Prospective, surgeon randomized evaluation of crossed pins versus lateral pins for unstable supracondylar humerus fractures in children. J Pediatr Orthop B 2009;18(2):93- 98.
  15. (47) Zamzam MM, Bakarman KA. Treatment of displaced supracondylar humeral fractures among children: crossed versus lateral pinning. Injury 2009;40(6):625- 630.
  16. (48) Fahmy MA, Hatata MZ, Al-Seesi H. Posterior intrafocal pinning for extension type supracondylar fractures of the humerus in children. J Bone Joint Surg Br 2009;91(9):1232-1236.
  17. (49) Lee YH, Lee SK, Kim BS et al. Three lateral divergent or parallel pin fixations for the treatment of displaced supracondylar humerus fractures in children. J Pediatr Orthop 2008;28(4):417-422.