How Many K Wires do we Need in the Surgical Treatment of Pediatric Type III Supracondylar Humeral Fracture?
Conditions: Supracondylar Humerus Fracture, Pediatric Fractures
Sponsor: Bakirkoy Dr. Sadi Konuk Research and Training Hospital

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Title Page 
How many K wires do we need in the surgical treatment of pediathric type III 
supracondylar humeral fracture?  
The study entitled ‘How many K wires do we need in the surgical treatment of pediathric 
type III supracondylar humeral fracture? was performed in Bakırköy Dr. Sadi Konuk 
Training and Research Hospital, Department of Orthopedics and Traumatology, Istanbul, 
Turkey. 
The manuscript submitted does not contain information about medical device(s)/drug(s). 
No funds were received in support of this work. 
No relevant financial activities outside the submitted work. 
IRB Approval ID:2014/18/05    IRB Approval Date: 29.12.2014 
 
Study Protocol 
After the approval of the local ethics committee (Approval ID: 2014/18/05), medical 
records of patients who underwent surgery between 2010 and 2013 for Gartland type 3 
fracture were retrospectively screened. Patients with pathological fractures, conservative 
follow-up, less than the 1-year follow-up, and patients with incomplete postoperative follow-
up were excluded from the study. In the present study, the patients were divided into 5 groups 
according to the configurations of the K-wires in fixation as Group 1 (crossed 1 lateral 1 
medial), Group 2 (crossed 2 lateral 1 medial), Group 3 (crossed 1 lateral 2 medial), Group 4 
(2 lateral divergent), and Group 5 (3 lateral divergent). Closed reduction and percutaneous 
pinning were initially preferred in all patients. One hundred patients (68 males and 32 
females) who underwent surgery for Gartland type 3 supracondylar humerus fractures were 
included in the study. 98% of the fractures are extension and 2% are flexion type fractures. 
The left humerus was affected by 73% and the right humerus in 27%. While 53% of the 
fractures occurred with a simple fall at home, 47% were outside. The distribution of 
demographic features and injury characteristics of the patients were presented in Table 1.    

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All patients evaluated at the emergency room and peripheral neurovascular 
examination were reported. The SCHF classified according to Gartland classification [5]. A 
long arm plaster used to immobilize the elbow in 1100-1200 of elbow flexion in a comfortable 
position. No closed reduction was attempted in the emergency department. The timing of the 
surgeries was determined by the patients’ condition and operating room availability. Open 
fractures with associated vascular injury were taken to the operating room emergently on 
presentation. Range of motion on the operated and non-operated side was evaluated at all 
controls and at final control measurements were statistically analyzed. 
Surgical technique 
Under general anesthesia, a high-arm tourniquet was placed on the arm, but not 
inflated and prepared for open reduction and fixation if needs. Intravenous cefazolin used for 
appropriate for patients' weight. The upper limb was prepared and dressed. Closed reduction 
was applied via manual traction. Then varus-valgus position checked by the surgeon by 
palpating the epicondyles and discussed with the preoperative images. While gradually 
flexing the elbow in extension type fractures (hyperextension can be used in some flexion 
type fractures), the surgeon pressed the olecranon to push the distal fragment in the sagittal 
plane to anteriorly for reduction. In pronation, we check fluoroscopy images on the coronal 
and sagittal plane (Figure 1). The reduction was considered acceptable when the anterior 
humeral line (AHL) bisected the middle third of the capitellum as observed on the lateral view 
and the humeral capitellar angle (HCA) was normal (range, 90–260) on the AP fluoroscopy 
view [5,6]. 
Under fluoroscopy guidance, the first KW applied on the lateral epicondyle to the 
medially. For cross-wiring medial epicondyle was centered and KW applied medial to lateral. 
KWs were used for the fixation in different configurations such as 2 medial+1 lateral, 2 
lateral+1 medial, 2 lateral, 3 lateral, or 1 medial+1 lateral. Mini-incision at medially to 
prevent iatrogenic ulnar nerve injury was used for the application of medial KW. Lateral KWs 
were preferred at divergent orientation. The surgeons who managed the operation used an 
adequate number of pins to fix the fracture with sufficient stability for all patients. Surgeons 
decided on the number and configuration of pins used in the intraoperative period. After the 
fractures are reduced, the first k-wire is applied laterally. They decided on the other KW in 
the intraoperative period according to the flexion-extension fluoroscopy images after the first 
KW. Most of the patients used cross KW 1L-1M and cross KW 2L-1M (Figure 1, Figure 2, 
and Figure 3). The pin number and orientation were determined entirely according to the 
configuration to achieve fixation stability during surgery. In the fractures where the arm is 

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edematous and the medial epicondyle cannot be palpated, the use of a lateral pin is preferred 
to avoid the risk of ulnar nerve injury. The pin diameter was determined according to the age 
of the patient and the cortical thickness of the humerus seen on the lateral radiograph. All 
patients evaluated clinically and radiologically at 2nth-, 4th- and 6th weeks, 3rd- and 6th 
months, and annually in the postoperative period (Figure 2 and Figure 4). The elbow was 
immobilized with a long arm plaster for 4 to 6 weeks. Plaster and pins were removed in the 
outpatient clinic after callus formation seemed (between 4th and 6th week). The passive range 
of motion exercises was started after the pin and plaster removed. 
Statistical results 
Statistical analysis was performed with NCSS ( Number Cruncher Statistical System) 
2007 (Kaysville, Utah, USA). Many Whitney U test was used for descriptive statistical 
methods evaluation (average, standard deviation, median, frequency, ratio, minımum, 
maximum) and not normally distributed data comparison. Kruskal Wallis test was used for 
not normally distributed three and upper groups quantitative data comparison. Mann Whitney 
U test was used for the definition of the different groups. Friedman test was used for the 
comparison of intragroup not normally distributed parameters and the Wilcoxon Signed 
Ranks test and Marginal Homogeneity test was used for evaluation of binary comparison. 
Fisher-Freeman-Halton test was used for qualitative data comparison.  P values were 
considered statistically significant when p<0.01 and p<0.05.  
Results 
The mean CA was 9,060±3,450 on the operated side and 8,890±2,910 on the uninjured 
side. The mean flexion range was 136,340±7,880 on the operated side and 140,590±5,650 on 
the uninjured side. The mean extension range was 181,350±6,730 on the operated side and 
183,750±4,640 on the uninjured side. No statistically significant difference was found between 
subgroups in terms of age, sex, carrying angle (CA), flexion-extension range in the 
comparison with the uninjured side (p<0.05) (Table 2). Baumann angle (BA) showed a 
statistically significant difference between the groups only on the first postoperative day 
(p=0.015). However, BA did not differ significantly between the groups on the preoperative, 
postoperative final control, and uninjured side (p<0.05). Also, HCA and AHL did not differ 
significantly between the groups on the preoperative, the first postoperative day, postoperative 
final control, and uninjured side (p<0.05). A significant difference was found between 
preoperative measurements and postoperative first day, postoperative final control, and 
uninjured side measurements in the 2L + 1M group for BA (p=0.004), and in the 2L, 1L+1M, 

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and 2L + 1M groups for HCA (p=0.001, p=0.001, and p=0.034; respectively) (Table 3). In 
posthoc binary analyzes of BA, HCA, and AHL, there were significant differences between 
preoperative values, postoperative values, and uninjured side (p<0.05 and p=0.001) (Table 4). 
Preoperative and postoperative measurements showed a significant differences, because after 
reduction the angular measurements changes significantly. Postoperative BA values show no 
statistical difference in postoperative 1st-day control and last control. All of the patients had 
successful healing and there was no non-union. In complete primary reduction and secondary 
displacement was not reported in any patients. The mean HCA averaged 8,9±2,9 (range 3 to 
18) on the uninjured side and 9,06±3,45 (range 3 to 20) on the injured side (p<0.05). Injury-
related complications were seen in three patients, including ulnar nerve damage. Pin tract 
infection occurred in five patients. One patient in the 2M+1L group, one pin has removed in 
the medial side on the 7th day due to pin tract infection. All complications resolved in 
postoperative 8 weeks.