Cutting edge Orthopedics

20 • CUTTING EDGE - ORTHOPEDICS and/or an increasing need for analgesia [9]. Increasing pain control requirements, along with other clinical signs, is the most sensitive indicator of compartment syndrome in children [41]. If the child’s pain is controlled and the neurovascular exam remains normal and unchanged, the child may be discharged home on the first postoperative day [9]. Postoperative antibiotics do not decrease the rate of pin site infections [77]. Radiographs may be taken approximately 1 week after the procedure to ensure the reduction has been maintained; however, according to a study performed by Tuomilehto and colleagues (2016), postoperative radiographs did not affect management or outcome [78]. The original splint or cast may be left in place, or a long-arm cast may be applied. Three weeks following the proce- dure, the splint or cast is removed for radiographs. If abundant callous formation is demonstrated, the pins may be removed [8, 9, 19]. In the absence of sufficient callous formation, a new cast is applied, and the pins are left in place for another week. After 4 weeks, if abundant callous forma- tion is still not present, the pins are removed and a cast is reapplied. Inadequate healing in a child for more than 6 weeks raises concern for infection [9]. After the pins are removed, a sling may be used for comfort, but active elbow motion is initiated. Children may be seen in the office 2–3 weeks later for a range of motion check [8, 9, 19]. Normal activities are generally sufficient for return of range of motion within approximately 4–9 weeks [51, 52]. Comparable range of motion outcomes are expected at 1 year with or without physical therapy [53], and formal therapy is rarely required [8, 9, 52, 53]. Alternative Pin Constructs The optimal pin configuration for fixation of supracondylar humerus fractures remains controver- sial. Both lateral-entry pins alone and cross pin constructs are utilized [79]. In the 2011 Clinical Practice Guideline of the American Academy of Orthopaedic Surgeons, a weak recommendation stated that “the practitioner might use two or three laterally introduced pins to stabilize the reduc- tion of displaced pediatric supracondylar fractures of the humerus. Considerations of potential harm indicate that the physician might avoid the use of a medial pin” [49]. Factors generally asso- ciated with achieving a stable pin construct include: pins diverging across the fracture site, at least 2 mm of separation between the pins at the fracture site, bicortical fixation with all pins, and pins that are bent and cut outside the skin. Typically, two lateral-entry pins are used for Gartland Type II fractures, and three lateral-entry pins are recommended for Type III fractures. A medial-entry pin may be utilized for fractures with medial comminution or persistent instability. Additionally, the fracture stability should be assessed with live fluoroscopy after pin placement (Video 3) [8, 14]. Traditionally, a cross pin configuration was recommended [55], with studies indicating that a cross pin construct is more stable than lateral pins alone [80–83]. However, Skaggs and colleagues (2004) suggested that lateral pin placement was too close together in the biomechanical study per- formed by Zionts and colleagues (1994), making the results of the study inapplicable to standard practice [61, 80]. A concern with cross pin constructs is potential risk of ulnar nerve injury. Two series with greater than 300 patients each found rates of iatrogenic ulnar nerve injury of approxi-