Safe cross-pinning of pediatric supracondylar humerus fractures with a flexion-extension-external rotation technique

The issue of pin configuration for fixation of displaced supracondylar humerus fractures continues to be controversial. In this article, we report on a large single-surgeon 12-year series in which a flexion-extension-external rotation technique of cross-pinning was used. We retrospectively reviewed all pediatric extension-type supracondylar humerus fractures treated by a single surgeon. The cases of 214 children (mean age, 5.8 years) and 215 medial-entry pins were reviewed in the final analysis. Surgical technique involved a classic hyperflexion maneuver and placement of lateral-entry pins. Indications for medial-entry pins included instability to intraoperative torsional stress examination or medial column comminution. The elbow was then extended to no more than 60° of flexion. The glenohumeral joint was externally rotated to position the medial epicondyle directly en face to the radiographic beam before placement of a medial-entry Kirschner wire. All reviewed patients had medial-entry pin placement with a flexion-extension-external rotation technique. Mean follow-up was 13 weeks. No ulnar nerve neurapraxias were reported. Consistent protection of the ulnar nerve during percutaneous placement of a medial epicondylar pin for supracondylar humerus fracture can be accomplished with partial elbow extension and glenohumeral external rotation after placement of lateral-entry pins.