Gartland classification and mode of treatment of 440 supracondylar humerus fractures Antegrade nailing (n = 264) 97 (37%) 125 (47%) 42 (16%) Crossed pinning (n = 176) 58 (33%) 91 (52%) 27 (15%) 608 Gartland type II Gartland type III Gartland type IV Results Antegrade nailing was performed in 60% of the fractures (264 of the 440 patients) and treatment with crossed pins was per- formed in 40% of the fractures. The distribution of the Gart- land types was similar in both groups (Table). Revision surgery was required in 4 patients following ante- grade nailing (4/264, 2%) and in 3 patients following crossed pinning (3/176, 2%). The reasons for revision surgery were incomplete reduction with remaining displacement of the distal fragment in the 3 patients with crossed pinning, and incorrect implant placement in the 4 patients with antegrade nailing. Iatrogenic injury to the ulnar nerve was found in 6% of the children (28/440). In the group with crossed pinning, the rate of ulnar nerve injury was 15% (27/176) (10 with sensory affection and 17 with sensomotoric affection) whereas the rate of ulnar nerve injury in the group with antegrade nailing was 0.4% (1/264) (sensory affection) (p < 0.001). Total recovery of the nerve occurred in all children after mean 9.3 (6–36) weeks. Follow-up examinations were performed after mean 3.2 (1.6–12) years. All patients had normal motion. None had more than 10° deviation of the elbow axis relative to the unaf- fected side. According to the Linscheid Wheeler score, the results were good in 9% of the patients after antegrade nail- ing (n = 23) and excellent in 91% (n = 241). The results were similar after crossed pinning: good in 8% of the patients (n = 14) and excellent in 92% (n = 162). Discussion The most common technique for operative fixation of dis- placed supracondylar fractures is percutaneous pinning. Dif- ferent configurations of pinning have been proposed. Crossed pinning with radial and ulnar entry points is a widely used method (Babal et al. 2010). An alternative, based on the same principle, is lateral cross-wiring—also known as Dor- gan’s technique (Shannon et al. 2004). Skaggs et al. (2004) have described a series of supracondylar fractures with paral- lel radial stabilization using 2 or 3 pins. While elastic stable intramedullary nailing (ESIN) has become the gold standard for treatment of long bone fractures of the upper and lower limb (Schalamon and Petnehazy 2009), there are few reports Acta Orthopaedica 2011; 82 (5): 606–609 on use of the ESIN technique for treatment of supracondylar fractures (Prevot et al. 1990, Weinberg et al. 2003, Schaffer et al. 2007). Prevention of ulnar nerve injuries is essential for safe supra- condylar fracture management. Due to the immature joint and to the posttraumatic swelling, clear anatomic landmarks are often missing and palpation of the ulnar epicondyle or ulnar nerve may not be possible. Moreover, the pin rarely directly impales the nerve but commonly restricts the nerve within the cubital tunnel by tethering adjacent soft tissue (Rasool 1998, Shannon et al. 2004, Eidelman et al. 2007, Kocher et al. 2007). A routine surgical exploration of the nerve is not rec- ommended, but an incision over the medial epicondyle may to be useful in order to detect the ulnar groove and facilitate correct pin placement (Yen and Kocher 2008). Nevertheless, damage to the ulnar nerve is a well-known complication and affects between 2% and 20% of patients treated with crossed fixation (Lyons et al. 1998). We can confirm the high rate of ulnar nerve injuries after treatment with crossed pinning. By contrast, the rate of ulnar nerve injuries using ESIN was 0.4%. This patient suffered a displaced fracture with a very short distal fragment. During fracture fixation, the descending ulnar nail perforated the distal corticalis and injured the nerve. 2 studies have not found any ulnar nerve injuries using the ESIN technique in 110 patients in total (Weinberg et al. 2003, Schaf- fer et al. 2007). Considering the rates of ulnar nerve injuries, these results together with ours confirm the superiority of ESIN for treatment of displaced supracondylar fractures. Crossed K-wire fixation in cases of supracondylar humeral fracture gives good mechanical stability (Weinberg et al. 2007). In an adult cadaver study, it has been shown that down- ward nailing results in poor rotational stability. These find- ings may be explained by an inadequate relationship between the bone dimensions of adult cadavers and the diameter of implants used in this study (Weinberg et al. 2007). In contrast to the biomechanical results, clinical studies have shown that there is adequate stability using antegrade nailing (Prevot et al. 1990, Weinberg et al. 2003, Schaffer et al. 2007). In the pres- ent study, downward nailing was performed in 264 patients. In highly unstable fractures, a third nail was inserted between the radial and ulnar implant. There was no need for revision surgery due to instability and loss of reduction. The clinical outome was good, and was similar in both treatment groups. In summary, based on our results, intramedullary antegrade nailing of displaced supracondylar humeral fractures can be considered to be an adequate and safe alternative to the widely performed K-wire fixation. In addition, this method is clearly superior to crossed pinning regarding iatrogenic ulnar nerve injury. RE: initiated the study and wrote the manuscript; CE: collected the dara; ES: collected the data; AMW: analyzed the statistics; MEH: reviewed the manu- script; GS: analyzed the data and critically reviewed the manuscript.