ORIGINAL ARTICLE

Meta-Analysis of Pinning in Supracondylar Fracture of the Humerus in Children

Patarawan Woratanarat, MD, PhD,* Chanika Angsanuntsukh, MD,* Sasivimol Rattanasiri, PhD, John Attia, MD, PhD, FRCPC, FRACP, Thira Woratanarat, MD, MMedSc, and Ammarin Thakkinstian, PhD
Key Words: supracondylar, humerus, children, pinning, metaanalysis (J Orthop Trauma 2012;26:4853)

Objectives: The purpose of this study was to compare the outcomes

of lateral pinning versus cross pinning in pediatric supracondylar humerus fractures.

Data Sources: The Cochrane library, MEDLINE, CINAHL, specic orthopaedic journals, abstracts/papers from conferences and meetings, and reference lists of articles were searched from inception to September 2007. Study Selection: All randomized controlled trials and cohort studies comparing outcomes (ie, loss of xation, iatrogenic ulnar nerve injury, and Flynn criteria) between crossed and lateral pinning were identied. Data Extraction: Two authors independently assessed methodological quality and extracted data by using a standardized data extraction form. Data Synthesis: Heterogeneity among studies was assessed using the Q test. Pooled relative risk was estimated using the MantelHaenszel method. Eighteen of 1829 studies were included with 1615 supracondylar fractures (837 and 778 children with cross and lateral pinning, respectively). The average age was 6.1 6 0.9 years. The risk of iatrogenic ulnar nerve injury was 4.3 (95% condence interval, 2.19.1) times higher in cross pinning compared with lateral pinning. There was no signicant difference for loss of xation, late deformity, or Flynn criteria between the two types of pinning. Conclusions: Lateral pinning is preferable to cross pinning for xation of pediatric supracondylar humerus fractures as a result of decreased risk of ulnar nerve injury.
Accepted for publication February 4, 2011. From the *Department of Orthopaedics and Clinical Epidemiology Unit, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand; Centre for Clinical Epidemiology and Biostatistics, The University of Newcastle, Newcastle, NSW, Australia; and Department of Preventive and Social Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand. Each author certies that he or she has no commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conict of interest in connection with the submitted article. Each author certies that his or her institution has approved the protocol for this investigation and that all investigations were conducted in conformity with ethical principles of research. Reprints: Patarawan Woratanarat, MD, PhD, Department of Orthopaedics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand (e-mail: rapwo@mahidol.ac.th). Copyright 2012 by Lippincott Williams & Wilkins

INTRODUCTION
Supracondylar fractures of the humerus are the most common elbow fractures in children1,2 and the decision to treat operatively depends on the quality of reduction, ability to maintain reduction, the degree of displacement, and fracture stability.36 Cross pinning is biomechanically superior to lateral pinning.79 Although some authors have proposed that divergent lateral pins are comparable in extension, varus, and valgus stability to cross pins, the axial torsional strength was far less.9 However, the primary drawback of cross pinning is iatrogenic ulnar nerve injury.10,11 Various surgical techniques (eg, mini-open approach to the ulnar nerve,1215 elbow extension,14,16 preoperative nerve stimulator,17 or Dorgans technique)18 have been used to prevent this complication with limited success. Previous debates led to a systematic review that concluded there was a 42% reduction in xation failure and deformity with cross pinning, but at the cost of ve times higher risk of iatrogenic ulnar nerve injury.19 However, heterogeneity was not addressed in the review nor were standard meta-analysis methods used to combine studies.20 Thus, variance in pooling might be biased. In addition, there have been three further studies published since the 2007 review.11,12,15 To ll former methodological gaps and obtain the best available evidence, we conducted a new systematic review and formal meta-analysis specically comparing rates of iatrogenic ulnar nerve injury, loss of xation, late deformity, and Flynn criteria between the two types of pinning.

MATERIALS AND METHODS Search Strategies

We searched the Cochrane library, MEDLINE (1966 to September 2007), and CINAHL (1982 to September 2007) using both PubMed and OVID. In addition, specic orthopaedic journals (eg, Journal of Bone and Joint Surgery, Journal of Pediatric Orthopaedics, Clinical Orthopaedics and
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Related Research, Journal of Orthopaedics Trauma, Orthopaedics Clinic of North America), abstracts/papers from conferences and meetings (eg, Pediatric Orthopaedic Society of North America (POSNA), International Pediatric Orthopaedic Symposium (IPOS), European Pediatric Orthopaedic Society (EPOS), American Academy of Orthopaedic Surgeons (AAOS), The Royal College of Orthopaedic Surgeons of Thailand (RCOST)), and reference lists from articles were also explored. The search strategies included combinations of the following terms: supracondylar fracture*, humerus, child*, treatment, operative treatment, pin*, neurovascular injury, results, nerve injury. Search hits were limited to child and age 018 years.

Data Analysis
Characteristics of studies were described using frequency and mean. Only cohort studies were pooled in the main analyses, because the majority of designs were cohort studies with a limited number of RCTs. The risk ratio (RR) and 95% condence interval (CI) were estimated for each study. A continuity correction was performed by adding 0.5 to those studies that had at least one zero cell. Heterogeneity of RRs was assessed using the Q test and I2.24 If heterogeneity was present (as judged by a Q-test P , 0.1 or I2 $ 50%), the random effect model was used for pooling. Otherwise, the xed effect model using Mantel-Haenzel was applied.20 To secure the validity of analytical process, sensitivity analysis was also performed with or without including the randomized control trials or very small studies (ie, less than 10 patients). Furthermore, publication bias was assessed using the Egger test. All analyses were performed by using STATA Version 10.0 (StataCorp 2007, College Station, TX). A P value , 0.05 was considered statistically signicant, except for the test of heterogeneity in which 0.10 was used.

Inclusion Criteria
Follow-up studies, ie, randomized controlled trials (RCTs) and cohort studies, comparing outcomes between cross and lateral pinning in supracondylar humerus fractures were included if they met the following criteria: children aged 0 to 18 years; had at least one of the following outcomes: iatrogenic ulnar nerve injury, loss of xation, late deformity, and/or Flynn criteria21; and sufcient results for data extraction, ie, number of subjects for each outcome group was provided. If eligible papers had insufcient information, we contacted the authors for additional information. The most complete and/or recent results were selected if there were multiple publications from the same study group.

RESULTS
Using multiple databases, 1829 articles were identied, of which 869 were duplicates (Fig. 1). This left 960 abstracts, which were gathered and reviewed; 935 articles were excluded, leaving 25 abstracts for which full papers were retrieved. Seven of the 25 had inadequate reporting of data (eg, number of patients in each type of pinning and/or outcomes were not reported), leaving 18 studies eligible for review.1016,2535 These 18 studies, representing 1615 children, are described in Table 1. Study designs were largely cohorts

Outcomes of Interest
The outcomes of interest were iatrogenic ulnar nerve injury, loss of xation, late deformity, and Flynn criteria for cosmetic and functional outcomes.21 Iatrogenic ulnar nerve injury was dened as ulnar nerve injury caused by surgery. Other iatrogenic nerve injuries (anterior interosseous nerve, median nerve, posterior interosseous nerve, and radial nerve) were also collected. Loss of xation was dened as displacement of the fracture by more than 2 mm, angulation of more than 5, or fracture needing revision surgery. Late deformity would be documented if there were cubitus varus of more than 5 after complete fracture healing 3 to 4 weeks postoperatively. Flynn criteria were categorized as excellent/ good and fair/poor.

Data Extraction
We used a standardized data extraction form, which included outcomes and baseline patient characteristics (ie, age, gender, study setting [country], extension type, completely displaced fracture [Gartland classication; Type III], and ulnar nerve injury before surgery). Two authors independently extracted data. Any disagreement was adjudicated by a third author.

Quality Assessment
Two authors independently assessed quality of studies. Jadads scale for quality rating of randomized control trials was applied.22 Observational studies were assessed based on GRADE (Grading of Recommendations Assessment, Development and Evaluation).23
q 2012 Lippincott Williams & Wilkins FIGURE 1. Study ow diagram demonstrated methods of data retrieval and reasons for exclusion until gathered eligible articles. www.jorthotrauma.com |

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TABLE 1. Characteristics of Included Studies

Mean Age (years) 5.8 6.9 6.0 6.6 6.1 8.6 5.8 6.1 5.7 6.8 4.3 5.0 5.8 5.7 6.0 5.8 5.9 Percent Male 31.0 34.8 65.9 61.7 43.5 68.2 50.0 60.3 52.5 72.9 41.3 55.7 44.2 Percent Extension Type 100.0 100.0 100.0 99.1 77.0 100.0 100.0 100.0 100.0 Percent Gartland Type III 86.2 67.2 100.0 100.0 81.7 77.8 65.0 74.1 76.8 59.1 100.0 63.5 58.8 58.1 100.0 Percent Ulnar Nerve Injury Before Surgery 3.5 1.1 4.3 3.5 4.9 1.5 0 0 0 1.8 0 0 0 No. of Pinnings Cross 2 24 33 8 27 69 19 68 95 26 28 220 35 28 49 65 17 24 Lateral 6 5 14 74 20 35 25 13 43 82 28 125 24 27 55 66 108 28

Year 1978 1992 1992 1995 1995 1996 1998 2000 2001 2001 2001 2001 2003 2004 2004 2006 2007 2007

Author Gjerloff Cramer27 France28 Cheng29 Topping10 Mehlman16 Onwuanyi30 Davis31 Gordon14 Mazda32 Shamsuddin33 Skaggs13 Solak34 Foead25 Ponce35 Sibinski12 Sankar15 Kocher11
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Design Cohort Cohort Cohort Cohort Cohort Cohort Cohort Cohort Cohort Cohort Cohort Cohort Cohort RCT Cohort Cohort Cohort RCT

Setting Denmark USA USA Hong Kong USA USA Saudi Arabia USA USA France Malaysia USA Turkey Malaysia USA UK USA USA

(n = 16) and two were randomized controlled trials. Ten studies were conducted in the United States (55.6%), four in Europe, and four in Asia. Average age ranged from 4.3 to 8.6 years and 31.0% to 72.9% of participants were male. Extension type was between 77% and 100%, and Gartland classication Type III was from 58.1% to 100.0%. Ulnar nerve injury before surgery was 0% to 4.9%. Cross pinning was performed in 837 children, and 778 children underwent xation with lateral pins. The standard cross pinning technique was performed by engaging each pin at the lateral and medial column, respectively, whereas lateral pinning technique engaged each pin at the lateral and central columns. At least two pins were used for each pinning technique to achieve fracture stability. Fixation using less than two pins was considered substandard treatment and therefore excluded from review. Dorgans technique was considered as a subgroup of the cross pinning technique; however, it is not included in this review because it was not included in the surgical methods section of any of the eligible articles. Quality of studies ranged from low to moderate for cohort studies. For RCTs, the Jadad scale for description of randomization, double-blinded, withdrawal, and dropouts was 10025 and 101.11

As shown in Figure 2, estimated RRs across studies were quite similar and there was no evidence of heterogeneity (chisquare = 10.6, df = 12, P = 0.566, I2 = 0). The pooled RR, estimated using the Mantel-Haenzel method, was 4.5 (95% CI, 2.19.7). There was no evidence of publication bias (Egger test: coefcient = 2.5, standard error = 1.6, P = 0.136; Fig. 3). After exclusion of the smallest study,26 sensitivity analysis showed similar results (RR, 4.2; 95% CI, 1.99.4). Pooling the two RCT studies yielded a risk ratio of 2.0 (95%

TABLE 2. Distribution of Ulnar Nerve Injury and Estimated Risk Ratios (RRs)
Cross Pinning Author Cheng Cramer27 Davis31 Gjerloff26 Gordon14 Mazda32 Mehlman16 Ponce35 Shamsuddin33 Skaggs13 Solak34 Topping10 Sibinski12 Summary
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Lateral Pinning NJ+ 0 0 0 0 0 0 0 0 0 0 1 0 0 1 NJ 74 5 13 6 43 82 35 55 28 125 23 20 66 584 RR (95% CI) 25 0.2 0.6 11.7 0.5 3.1 0.5 3.4 7 20.0 1.4 2.3 9.1 4.5 (1.1569.1) (010.9) (014.2) (0.8176.8) (022.7) (0.1151.2) (025.4) (0.180.6) (0.4129.6) (1.2329.0) (0.114.3) (0.152.5) (0.5166.4) (2.19.7)

NJ+ 1 0 1 2 0 0 0 1 3 17 2 1 4 35

NJ 7 24 67 0 95 26 69 48 25 203 33 26 61 703

Ulnar Nerve Injury

Among the eligible 16 cohort studies,10,1216,2635 13 studies10,1214,16,26,27,29,3135 had sufcient data for pooling ulnar nerve injury outcomes (Table 2). There were 716 participants in the cross pinning group and 576 participants in the lateral pinning group. Average age of included studies varied from 4.3 to 6.8 years. Thirty one percent to 72.9% of participants were male and Gartland Type III ranged from 58.8% to 100%.

NJ, nerve injury; NJ+, presence of iatrogenic ulnar nerve injury; NJ, absence of iatrogenic ulnar nerve injury; CI, condence interval.

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TABLE 3. Distribution of Iatrogenic Nerve Injuries

Iatrogenic Nerve Injuries Study Cheng29 Cramer27 Davis31 Foead25 France28 Kocher11 Gerloff26 Gordon14 Mazda32 Mehlman16 Onwuanyi30 Ponce35 Sankar15 Shamsuddin33 Skaggs13 Solak34 Topping10 Sibinski12 Total Median Radial Ulnar Overall 1 0 1 8 NA 0 2 0 0 0 NA 1 NA 4 17 4 1 4 43 0 0 1 0 0 0 0 0 1 0 1 7 NA NA NA 0 0 0 0 0 2 0 0 0 0 0 0 0 0 0 NA NA NA 0 0 1 NA NA NA 0 1 3 NA NA 17 1 0 3 0 0 1 0 0 4 1 2 40 (lateral pin) lateral pin) (2 lateral25, 38 cross pin)

FIGURE 2. A forest plot showed pooling risk ratio of ulnar nerve injury between cross and lateral pinning.

CI, 0.57.6), which was not signicant. In the lateral pinning group, there were two radial nerve and one anterior interosseous nerve34 injuries (Table 3).25,33 However, the pooled relative risk could not be estimated for these injuries as a result of insufcient data (ie, no postoperative nerve injuries, other than ulnar nerve, in the cross pinning group).

Loss of Fixation
Ten cohorts had sufcient data to assess loss of xation as an outcome (Table 4). No evidence of heterogeneity was found (chi-square = 8.7, df = 9, P = 0.470, I2 = 0) and thus the xed effect model was applied for pooling. The pooled relative risk was 0.6 (95% CI, 0.41.0) as shown in Figure 4. There was only one RCT; therefore, the data could not be pooled.
10,1215,28,31,32,34,35

NA, not available.

Flynn Function
Four studies were pooled for Flynn criteria12,28,32,34 (Table 6). With no evidence of heterogeneity (chi-square = 2.9, df = 3, P = 0.398, I2 = 0), the pooled relative risk was 0.9 (95% CI, 0.81.0). There were insufcient RCTs to pool data.

Late Deformity
Seven studies were included for pooling of late deformity10,13,15,3032,34 (Table 5). They were homogeneous (chi-square = 8.6, df = 7, P = 0.285, I2 = 0.2) and the pooled relative risk using a xed effects model was 1.1 (95% CI, 0.6 2.1). Pooling two RCT studies yielded the RR of 0.6 (95% CI, 0.14.3).

DISCUSSION
The purpose of this study was to nd the most appropriate type of pinning for xation of pediatric

TABLE 4. Distribution of Loss of Fixation and Estimated Risk Ratios (RRs)

Cross Pinning Author Davis31 France28 Gordon14 Mazda32 Ponce35 Sankar15 Skaggs13 Solak34 Topping10 Sibinski12 Summary N 68 33 95 26 49 171 220 35 27 65 811 LoF+ 1 1 0 1 0 1 5 9 1 3 22 LoF 67 32 95 25 49 170 215 26 26 62 789 Lateral Pinning N 13 14 43 82 55 108 125 24 20 66 559 LoF+ 2 0 0 3 0 7 4 7 0 2 25 LoF 11 14 43 79 55 101 121 17 20 64 534 RR (95% CI) 0.1 1.3 0.5 1.1 1.1 0.1 0.7 0.9 2.3 1.5 0.6 (01.0) (0.130.7) (022.7) (0.19.7) (055.4) (00.7) (0.22.6) (0.42.0) (0.152.5) (0.38.8) (0.41.0)

FIGURE 3. Funnel plot of pooling ulnar nerve injury. q 2012 Lippincott Williams & Wilkins

LoF, loss of xation; LoF+, presence of loss of xation; LoF, absence of loss of xation; CI, condence interval.

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TABLE 6. Distribution of Functional Outcome According to Flynns Criteria and Estimated Risk Ratios (RRs) of Poor Function Outcome
Cross Pinning Author France28 Mazda32 Solak34 Sibinski12 Summary Lateral Pinning RR (95% CI) 1.0 1.0 1.0 0.9 0.9 (0.81.2) (0.91.1) (0.61.4) (0.71.0) (0.81.0) Poor Good Poor Good N Function Function N Function Function 32 26 35 65 158 29 25 21 49 124 3 1 14 16 34 14 82 24 66 186 13 79 15 57 164 1 3 9 9 22

CI, condenece interval.

FIGURE 4. A forest plot showed pooling risk ratio of loss of xation between cross and lateral pinning.

supracondylar humerus fractures. We conducted a systematic review of all studies published through September 2007 to determine whether cross pinning increased the risk of ulnar nerve injury as compared with lateral pinning in pediatric supracondylar humerus fractures. We found that cross pinning quadrupled the risk of ulnar nerve injury as compared with lateral pinning, whereas late deformity and Flynn criteria risks were similar. Additionally, there was an insignicant trend toward increased stability with cross pinning versus lateral pinning. Differences between data in this review, as compared with the previous review,19 are most likely the result of strict adherence to rigorous methodological principles. Applying the simple pooling method used in the previous review to our data yielded a risk of ulnar nerve injury as high as 25.7% with a very wide and imprecise 95% CI that ranged from 3.5 to 187.8. The included studies were quite homogeneous and results indicated that although cross pinning had a 40% lower risk of loss of xation (P = 0.05); this was offset by a 400% higher risk of ulnar nerve injury with lateral pinning. The risks of developing late deformity or poor function were similar for both pinning groups. To synthesize this information, it is

TABLE 5. Distribution of Late Deformity After Cross and Lateral Pinning and Estimated Risk Ratios (RRs)
Cross Pinning Author Davis31 Mazda32 Onwuanyi30 Sankar15 Skaggs13 Solak34 Topping10 Summary N 68 26 19 171 220 35 27 588 LD+ 3 5 0 0 1 6 1 17 LD 65 21 19 171 219 29 26 571 Lateral Pinning N 13 82 25 108 125 24 20 406 LD+ 1 3 4 1 0 4 0 13 LD 12 79 21 107 125 20 20 393 RR (95% CI) 0.6 5.2 0.1 0.2 1.7 1.0 2.3 1.1 (0.15.1) (1.320.5) (02.5) (05.1) (0.141.7) (0.33.3) (0.152.5) (0.62.1)

LD, late deformity; LD+, presence of late deformity; LD, absence of late deformity; CI, condence interval.

useful to look at absolute risks. For every 100 children treated by cross pinning versus lateral pinning, two extra cases of loss of xation are prevented but ve extra cases of ulnar nerve damage are caused. Hence, the net effect favors lateral pinning. Exclusion from pooling the Skaggs et al study,13 which performed cross pinning in hyperexion (well known to increase the risk of iatrogenic ulnar nerve injury), results in a relative risk of ulnar nerve injury of 3.0 (95% CI, 1.46.4) compared with lateral pinning. It is well documented that the risk of inadvertent ulnar nerve injury is increased when pins are placed from medial to lateral.12,13,19,3335 In this review, inadvertent injury of the medial or radial nerve only occurred when pins are placed lateral to medial. Nevertheless, the included articles did not clearly explain how lateral pins injured those nerves.25,33,34 This is a limitation of systematic reviews based on secondary data. When the additional high-impact consequences of nonrecovered iatrogenic ulnar nerve injury (1% of cross pins only) and loss of xation necessitating revision surgery are evaluated (1.3% of cross and 2.1% of lateral pins), the effects of both pinning techniques are nearly equivalent. After continuity correction, the pooled relative risks were 2.0 (95% CI, 0.94.6) and 0.6 (95% CI, 0.31.2) for iatrogenic ulnar nerve and loss of xation, respectively. The absolute risks per 100 children treated by cross pinning result in one less case of loss of xation requiring revision surgery and one extra case of nonrecovered ulnar nerve injury compared to lateral pinning. The insignicant positive trend toward stability and better Flynn scores in cross pinning may inuence clinical practice in two ways: 1) for surgeons that use lateral pinning, they may increase stability by using divergent pins and/or adding a third pin; and (2) for surgeons that use cross pinning (a technically more difcult procedure), they should use additional techniques to minimize the risk of ulnar nerve damage: careful reduction, identifying the ulnar nerve, and proper pin insertion.34 In summary, cross pinning minimizes the risk of loss of xation but increases the risk of ulnar nerve damage. We estimate that for every 100 children operated on using cross pinning rather than lateral pinning, two fewer cases of loss of xation occur but ve more cases of ulnar nerve injury occur. Hence, lateral pinning is the favored procedure.
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