PEDİATRİK SUPRAKONDİLER HUMERUS KIRIKLARININ CERRAHİ TEDAVİSİNDE MEDİAL PİN İLE STABİLİTE ARZUSU ULNAR SİNİR İATROJENİK YARALANMASINI GÖZE ALMAYA DEĞER Mİ?

AMAÇ:Suprakondiler humerus kırıkları pediatrik yaş grubukırıklarının %10’u oluşturur. Cerrahi tedavisinde en seçkin yöntemkapalı redüksiyon ve peruktan pinlemedir. Cerrahiye bağlı enönemli komplikasyonlarından biri medialden yerleştirilen pinnedeniyle iyatrojenik ulnar sinir yaralanmasıdır. Çalışmamızda,çocuk yaş Gartland tip 3 suprakondiler humerus kırıklarınıntedavisinde, izole lateral pinlerle fiksasyon ve bu osteosenteze ekstabilite sağlaması için yerleştirilen medial pin konfigurasyonukarşılaştırılarak, takipteki korreksiyon kaybı ve kaynama sonrasıpin çıkarım süreleri açısından üstünlüklerinin değerlendirilmesiamaçlanmıştırGEREÇ VE YÖNTEM: 2014-2015 yıllarında Gartland tip 3suprakondiler humerus kırığı nedeniyle çapraz pin (iki lateral birmedial) uygulanan 30 hasta (22 erkek 8 kadın yaş ortalaması 8,1 ±2,6) ve lateral pin (iki lateral) uygulanan 10 hasta (5 erkek 5 kadınortalama yaş 7,1 ± 2,1) çalışmaya dahil edildi. Hastaların ameliyatsonrası ilk radyografilerindeki ve pin çıkarımı esnasında çekilenradyografilerinde Baumann açıları ölçüldü. Açılardaki değişim, ilkkallus dokusunun görünür olma zamanı ve pin çıkarımına kadargeçen süreler karşılaştırıldı.BULGULAR: Cerrahi sonrası ilk dönemde ve tel çıkartılmasıesnasındaki Baumann açılarında değişim sırasıyla; çapraz pingrubunda 4,7 ± 2,2 derece lateral pin grubunda 5,0 ± 2,3 dereceidi ve gruplar arasında anlamlı bir fark yoktu. Hastaların ilk kallusoluşum süreleri sırasıyla 19,7 ± 3,0 ve 20,0 ± 3,1 gün; pin çıkartılmasüreleri sırasıyla 35,3 ± 3,7 ve 35,9 ± 3,6 gün olarak ölçüldü vegruplar arasında anlamlı bir fark yoktu.SONUÇ: Medialden pin yerleştirilmesi korreksiyonu korumak içinşart değildir, sadece lateral pinler ile uygulanan stablizasyon, yeterlikırık kaynamasını sağlaması açısından güvenilir bir yöntemdir.

IS DEMAND OF STABILITY WITH MEDIAL PIN WORTH THE IATROGENIC INJURY OF THE ULNAR NERVE IN SURGICAL TREATMENT OF PEDIATRIC SUPRACONDYLAR HUMERUS FRACTURES?

INTRODUCTION: Supracondylar humerus fractures are 10% of the fractures in children. The preferred treatment of displaced supracondylar humerus fractures in hildren is immediate closed reduction and percutaneous fixation with pins. One of the most important complications of the surgery is the iatrogenic ulnar nerve injury due to the pin placed medially. In our study, we aimed to evaluate Gartland type 3 supracondylar humerus fractures were treated with isolated lateral pinning and medial pin placed configuration for additional stability in the osteosynthesis and superiority of configurations about correction loss and time to pin removal. MATERIAL AND METHODS: 30 patients (22 males, 8 females, mean age 8,1 ± 2,6) who applied cross pin ( two lateral one medial) and 10 patients (5 males, 5 females, mean age 7,1 ± 2,1) who applied lateral pin (two lateral) in pediatric supracondylar humeral fractures between 2014-2015 were included in the study. Baumann’s angle was measured on first radiographs after surgery and the radiographs after pin removal. The differences in the angles, the time of appearance of the first callus tissue and the time to pin removal were compared. RESULTS: The differences in the Baumann’s angles in the cross pin group was 5.0 ± 2.3 degrees and in the lateral pin group of 4.7 ± 2.2 degrees and there was no significant difference between the groups. In terms of initial callus formation and times to pin removal there was no significant difference between the groups. CONCLUSION: Medial pin placement is not necessary to preserve the correction, stabilization applied with only lateral pins is a reliable method for adequate fracture healing.

PDF

___

Farnsworth, C.L., P.D. Silva, and S.J. Mubarak, Etiology of supracondylar humerus fractures. J Pediatr Orthop, 1998. 18(1): p. 38-42.
Mulpuri, K. and K. Wilkins, The treatment of displaced supracondylar humerus fractures: evidence-based guideline. J Pediatr Orthop, 2012. 32 Suppl 2: p. S143-52.
Baratz, M., C. Micucci, and M. Sangimino, Pediatric supracondylar humerus fractures. Hand Clin, 2006. 22(1): p. 69-75.
Omid, R., P.D. Choi, and D.L. Skaggs, Supracondylar humeral fractures in children. J Bone Joint Surg Am, 2008. 90(5): p. 1121-32.
Lee, K.M., 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): p. 131-8.
Marsland, D. and S.M. Belkoff, Biomechanical analysis of posterior intrafocal pin fixation for the pediatric supracondylar humeral fracture. J Pediatr Orthop, 2014. 34(1): p. 40-4.
Wang, X., et al., Biomechanical analysis of pinning configurations for a supracondylar humerus fracture with coronal medial obliquity. J Pediatr Orthop B, 2012. 21(6): p. 495-8.
Silva, M., et al., Biomechanical testing of pin configurations in supracondylar humeral fractures: the effect of medial column comminution. J Orthop Trauma, 2013. 27(5): p. 275-80.
Chen, T.L., 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): p. 389-99.
France, J. and M. Strong, 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): p. 494-8.
Edmonds, E.W., J.H. Roocroft, and S.J. Mubarak, Treatment of displaced pediatric supracondylar humerus fracture patterns requiring medial fixation: a reliable and safer cross-pinning technique. J Pediatr Orthop, 2012. 32(4): p. 346-51.
Brauer, C.A., et al., 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): p. 181-6.
Eberl, R., et al., Iatrogenic ulnar nerve injury after pin fixation and after antegrade nailing of supracondylar humeral fractures in children. Acta Orthop, 2011. 82(5): p. 606-9.
Rose, R.E. and W. Phillips, Iatrogenic ulnar neuropathies post-pinning of displaced supracondylar humerus fractures in children. West Indian Med J, 2002. 51(1): p. 17-20.
Ozcelik, A., A. Tekcan, and H. Omeroglu, Correlation between iatrogenic ulnar nerve injury and angular insertion of the medial pin in supracondylar humerus fractures. J Pediatr Orthop B, 2006. 15(1): p. 58-61.
Garg, S., et al., Clinical characteristics of severe supracondylar humerus fractures in children. J Pediatr Orthop, 2014. 34(1): p. 34-9.
Mehserle, W.L. and P.L. Meehan, Treatment of the displaced supracondylar fracture of the humerus (type III) with closed reduction and percutaneous cross-pin fixation. J Pediatr Orthop, 1991. 11(6): p. 705-11.
Topping, R.E., J.S. Blanco, and T.J. Davis, Clinical evaluation of crossed-pin versus lateral-pin fixation in displaced supracondylar humerus fractures. J Pediatr Orthop, 1995. 15(4): p. 435-9.
Lee, S.S., et al., Displaced pediatric supracondylar humerus fractures: biomechanical analysis of percutaneous pinning techniques. J Pediatr Orthop, 2002. 22(4): p. 440-3.
Zionts, L.E., H.A. McKellop, and R. Hathaway, Torsional strength of pin configurations used to fix supracondylar fractures of the humerus in children. J Bone Joint Surg Am, 1994. 76(2): p. 253-6.
Gottschalk, H.P., et al., Biomechanical analysis of pin placement for pediatric supracondylar humerus fractures: does starting point, pin size, and number matter? J Pediatr Orthop, 2012. 32(5): p. 445-51.
Aarons, C.E., et al., Repair of supracondylar humerus fractures in children: does pin spread matter? J Pediatr Orthop B, 2012. 21(6): p. 499-504.
Skaggs, D.L., et al., Lateral-entry pin fixation in the management of supracondylar fractures in children. J Bone Joint Surg Am, 2004. 86-a(4): p. 702-7.