ORIGINAL ARTICLE
Treatment of Displaced Pediatric Supracondylar Humerus
Fracture Patterns Requiring Medial Fixation: A Reliable and
Safer Cross-pinning Technique
Eric W. Edmonds, MD, Joanna H. Roocroft, MA, and Scott J. Mubarak, MD
Introduction: Treatment of displaced Gartland type 3 supra-
condylar humerus fractures in children may include closed re-
duction and percutaneous pinning. The pin configuration may
be all-lateral entry or cross-pin. Despite the improved stability
possible with cross-pinning, there is an inherent iatrogenic risk
to the ulnar nerve of about 6%. As medial fixation may be
necessary for certain fracture patterns, this study was conducted
to evaluate the risk of ulnar neuropathy using a technique here
described and developed to minimize injury to this structure.
Methods: A retrospective review was performed on all children
treated for a supracondylar humerus fracture at our institution
between 2003 and 2010. All the type 3 displaced fractures were
placed into 2 groups: lateral-entry pinning and cross-pinning.
The 2 groups were then compared for risk of ulnar nerve injury,
and a post hoc power analysis was performed.
Results: A total of 381 supracondylar humerus fractures met the
inclusion criteria. Our cross-pinning technique was used in 187
(49%) of the children with a mean age of 5.8 years (range, 0.92
to 13.92 y). There were 4 ulnar nerve injuries in the entire cohort
and 2 sustained as iatrogenic injuries in the cross-pinning group
(1.1%). There was no significant difference between our 2
groups in regard to risk of ulnar nerve injury (P = 0.24). There
is a statistically significant lower risk of ulnar nerve injury in our
cross-pinning technique than previously described techniques
(P = 0.0028), with a post hoc power analysis of 93%.
Conclusions: Despite the inherent risk for iatrogenic nerve injury
with cross-pinning completely displaced supracondylar humerus
fractures, there is often a need to use this technique to improve
fixation and stability of the fracture. Our method of cross-pin-
ning is safe and reproducible for providing fracture stability
with a significant decrease in the risk of iatrogenic ulnar nerve
injury (1 in 94) when a medial pin is required.
Level of Evidence: Level III—therapeutic studies.
Key Words: ulnar neuropathy incidence, medial pin, displaced
supracondylar humerus fracture
(J Pediatr Orthop 2012;32:346–351)
From the Department of Orthopaedic Surgery, Rady Children’s Hos-
pital and Health Center, San Diego, CA.
The authors declare no conflict of interest.
Reprints: Eric W. Edmonds, MD, Department of Orthopaedic Surgery,
Children’s Hospital of San Diego, 3030 Children’s Way, San Diego,
CA 92123. E-mail: ewedmonds@rchsd.org.
Copyright r 2012 by Lippincott Williams & Wilkins
346 | www.pedorthopaedics.com
S upracondylar humerus fractures are the most common
elbow fracture in the pediatric population.1 In dis-
placed pediatric supracondylar fractures, closed reduction
and percutaneous pinning is the most widely accepted
treatment and has been shown to decrease risks asso-
ciated with this fracture.1–4 Despite this consensus, there
remains a disagreement as to the best pin configuration.
Studies have shown that the crossed medial and
lateral pin techniques offer increased stability for unstable
fractures, in particular.5,6 However, the utilization of a
medial pin remains controversial due to the reported in-
crease in incidence of iatrogenic ulnar nerve injury.7–9
Babal et al9 found that in neuropathies associated with
supracondylar humerus fracture fixation, 92.3% of those
associated with the placement of a medial pin were ulnar
nerve palsies. Moreover, reports have ranged from 0% to
12% or 1 in every 28 medial pins placed,10 as to the actual
incidence of ulnar nerve injury after the use of a medial
pin. With such varying results, it is difficult to assess the
benefit to risk ratio of augmented pin construct versus
iatrogenic ulnar nerve injury.
Each fracture pattern is unique, and an algorithm of
always using all-lateral pin fixation to minimize risk of
iatrogenic ulnar neuropathy may not be uniformly pos-
sible. Supracondylar fractures that are more proximal
may not allow the placement of >2 lateral pins, neces-
sitating a cross-pin for stability. Furthermore, supra-
condylar fractures with medial comminution may limit
lateral pin fixation and those fractures with initial cubitus
varus instability may require a medial pin for structural
support for the fixation construct.8
In 1994, Mubarak and Davids first described the
technique of medial pin placement currently used and
taught at our institution. The purpose of this study was to
assess the risk of an iatrogenic nerve injury associated
with using this medial pinning technique compared with
lateral-only pinning for Gartland type 3 supracondylar
humerus fractures.
METHODS
Data Collection
After approval from our Institutional Review
Board, a retrospective review of all children who were
treated for a supracondylar humerus fracture over a
7-year period were identified using the CPT code 24538.
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J Pediatr Orthop  Volume 32, Number 4, June 2012 Cross-pinning With Low Risk of Ulnar Nerve Palsy

A total of 1420 supracondylar humerus fractures were

identified. Inclusion criteria included children with a dis-
placed Gartland type 3 supracondylar fracture who un-
derwent surgical fixation through closed reduction and
percutaneous pinning. Those with insufficient clinical or
radiographic data, an open fracture, or a flexion-type
fracture were excluded.
A chart and radiographic review was performed,
and information concerning demographics, preoperative
and iatrogenic nerve injury, and pin configuration was
collected. Statistical analysis was then performed using a
w2 and power analysis.

Technique
After appropriate surgical time-out and admin-
istration of perioperative antibiotics, the operating table
is positioned 90 degrees from anesthesia so that an image
intensifier can be stationed at the head of the bed. This
allows for unencumbered motion of the C-arm for ante-
roposterior (AP) and lateral views of the humerus. Al-
though rarely needed, a sterile or nonsterile tourniquet
can be placed depending on the size of the arm.
The child’s arm is then prepped and draped in a
sterile manner. A standard technique of supracondylar
humerus fracture reduction is then performed, as de-
scribed by Mubarak and Davids.11 After reduction with
elbow hyperflexion, operative fixation through percuta-
neous pinning is then undertaken (Fig. 1). The first step in
fixation is the placement of lateral pins (Fig. 1). Two
smooth 0.062-inch Kirschner wires are placed through
the capitellar side of the fracture in either a divergent
or parallel manner. Either pin construct is acceptable, as
long as both pins engage the far cortex and preferably
avoid crossing through the center of the olecranon fossa
(Fig. 2).
At this point, the surgeon then assesses the stability
of the fracture. The elbow is extended and the carrying
angle is determined. Both AP and lateral fluoroscopy
FIGURE 1. Step 1: Sagittal line drawing of lateral-entry pin
placement of 2 pins with the elbow hyperflexion to help
maintain fracture reduction.
FIGURE 2. Step 2: Coronal line drawing demonstrating ideal
divergent lateral pinning in a high supracondylar humerus
fracture trying to avoid the olecranon fossa so that elbow
extension can be achieved to assess the carrying angle and
palpate the cubital tunnel.
images should be performed to assess fracture alignment
and pin placement. A third lateral pin can be placed, but
if there is an evidence of medial comminution, varus in-
stability, or placement of a third lateral pin would be of
limited utility based on fracture pattern, then a medial pin
can be placed to augment the construct. The following
steps are then undertaken to place the medial pin.
Extension of the elbow relaxes any tension on the
ulnar nerve and limits the risk of anterior subluxation of
that nerve out of its fossa (Fig. 3). This is particularly
important, because the medial pin is usually placed in a
manner that corresponds to the anatomy of the medial
epicondyle. Specifically, the pin tends to run in a slight
posterior to anterior direction, because the medial epi-
condyle is a posteromedial structure. To further protect
the nerve, the surgeon’s thumb should be placed over the
medial epicondyle and swept posterior over the cubital
tunnel protecting the ulnar nerve. The ulnar nerve and
cubital tunnel are readily palpable in even the most
swollen elbow in this extended position. The third smooth
0.062-inch Kirschner wire can then be placed medially
(Fig. 4). The pin should make almost immediate contact
with bone/cartilage of the medial epicondyle once it is
introduced through the skin. When placement is com-
plete, this pin should engage the opposite far cortex, and

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Edmonds et al J Pediatr Orthop  Volume 32, Number 4, June 2012

Ulnar nerve

FIGURE 3. Line drawing demonstrating the proximity of a

nonsubluxating ulnar nerve to the medial epicondyle of the
humerus in flexion.

it is usually acceptable to violate the olecranon fossa with

this pin.
Ultimately, after appropriate pin placement with
acceptable fracture reduction confirmed using fluoro-
scopy (AP, lateral, internal, and external oblique), the
pins are carefully bent to lie against the skin and cut
leaving approximately 2 to 3 cm to prevent pin migration
and facilitate pin removal at 3-week postoperative
(Fig. 5). A long arm univalved, fiberglass cast is then
placed before extubation and transfer to the recovery
room.

RESULTS
A total of 381 children met the inclusion criteria. A
lateral-only 3-pin configuration was used in 193 children,

Medial epicondyle
Ulnar nerve FIGURE 5. Step 4: Line drawing demonstrating external pin
placement with bending and positioning pins to prevent
migration and facilitate removal in clinic.

whereas a medial/lateral crossed pin configuration was

Thumb
FIGURE 4. Step 3: Demonstration of ulnar nerve relaxation
with elbow extension and thumb palpation of nerve in the
cubital tunnel with subsequent medial pinning through the
medial epicondyle.
used in 187 (49.1%) children. Two of these children had 2
medial pins placed for added stabilization of the fracture.
The mean age of children who underwent surgical fixation
was 5.8 years (range, 0.92 to 13.92 y), with 184 boys and
196 girls, and 222 of the fractures involved the left side.
Four ulnar nerve injuries were found in the entire
cohort. Of those with a medial pin placement, there were
3 reported ulnar nerve palsies: 1 preoperative and 2
(1.1%) postoperative. One case resolved at 5 months and
the second case, although improved, had not resolved
when the child was lost to follow-up at 1-month post-
operative. Of those with a lateral-only pin configuration,
there was a single ulnar nerve palsy that was reported
preoperatively.
Other complications in these 2 cohorts included: 4
infections requiring incision and drainage, 2 delayed un-
ions, 1 Volkmann ischemic contracture, 1 loss of reduction
requiring repeat surgery, and 1 compartment syndrome
with associated median nerve injury. The all-lateral-entry

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J Pediatr Orthop  Volume 32, Number 4, June 2012
pin group had the following perioperative palsies: 16
anterior interosseous nerve, 9 median nerve, and 7 pos-
terior interosseous/radial nerves. The medial pin group
had the following perioperative palsies: 11 anterior
interosseous nerve, 6 median nerve, and 6 posterior
interosseous/radial nerves.
A power analysis was performed to determine the
ability of our cohort to demonstrate a true difference in
ulnar nerve injury between medial and lateral pins. The
incidence of ulnar nerve palsy in the lateral-only group is
0% versus the medial pinning group of 1% (P = 0.24).
The power is 13%, but we would need 2319 patients per
group to have 80% power. Essentially, the effect size is
low in both groups, and, ultimately, there is no difference.
A second power analysis was performed to de-
termine the ability of our cohort to demonstrate a dif-
ference in ulnar nerve injury between our medial pinning
technique and the risk of medial pinning with other
techniques based on past literature. Current literature
suggests an incidence of injury to be 1 in 20, or 5%, com-
pared with our results of 1 in 94, or 1%, (P = 0.0028).
The post hoc analysis was 93%, indicating adequate
power in our study to demonstrate a significant difference
in our technique of medial pinning in regard to lower risk
of iatrogenic ulnar nerve injury.
DISCUSSION
Completely displaced supracondylar humerus frac-
tures require surgical treatment to restore the appropriate
elbow anatomy and reduce the risk of Volkmann
contractures. Whereas the methods of reduction seem to
be universally accepted in the literature, the recom-
mendations for percutaneous pinning constructs seem to
vary. Both biomechanical and clinical comparisons of all-
lateral pin constructs versus cross-pin constructs have
FIGURE 6. Five-year-old boy with a proximal supracondylar humerus fracture and medial comminution. A, Preoperative radio-
graphs, AP and lateral. B, Postoperative images demonstrating pin placement and fracture alignment. AP indicates antero-
posterior
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Cross-pinning With Low Risk of Ulnar Nerve Palsy
been performed comparing the stability of the fixation,
loss of reduction, reoperation, and iatrogenic ulnar nerve
injury.
In a randomized, prospective study by Kocher
et al,12 the medial cross-pin technique demonstrated a
statistically significant decrease in risk of loss of reduction
compared with lateral pins only, 4% compared with 21%.
However, previous studies have also demonstrated a
higher risk of iatrogenic ulnar nerve injury with medial
pinning, as compared with lateral-only pinning.
There are many studies comparing all-lateral fix-
ation constructs with cross-pinning fixation constructs,
and the results indicate that the risk for iatrogenic ulnar
nerve injury with medial pin placement is approximately
6%.7,12–23 However, these same studies indicate that the
ulnar nerve is not entirely safe in all-lateral pin fixation
constructs either. Foead and colleagues reported a 7% risk
with lateral-entry pins. However, when combined with the
remainder of studies previously mentioned, then there is
a 0.53% rate of iatrogenic palsies with lateral-entry
pins.7,12–23 It should be noted that Lyons et al8 followed 17
children with iatrogenic ulnar nerve palsies and all of them
had complete recovery of nerve function at 4 months, even
with pin removal at the 3-week postoperative period.
The previously described techniques of medial pin-
ning involve: maintaining elbow flexion, using radio-
graphic parameters,24 placing a thumb over the medial
epicondyle,25 a mini-open incision to directly visualize the
nerve,8 and using a nerve stimulator to identify the nerve
location.26 Past techniques can result in tethering or
directly penetrating the ulnar nerve within the cubital
tunnel.27 Our results compare favorably with the past
findings in that this technique of elbow extension with
direct manual protection of the ulnar nerve only had an
incidence of iatrogenic injury 1% of the time. Extension
of the elbow is the key to this technique for 2 reasons: (1)
www.pedorthopaedics.com | 349
Edmonds et al
FIGURE 7. Seven-year-old boy with a supracondylar humerus fracture in cubitus varus. A, Preoperative radiographs, AP, and
lateral. B, Postoperative images demonstrating pin placement and fracture alignment. AP indicates anteroposterior.
because the ulnar nerve can subluxate out of the cubital
tunnel with flexion in 16% of all patients (including
children), the extension will relax the nerve and limit the
risk of it being draped over the medial epicondyle28,29 and
(2) the extension of a swollen elbow allows for better
palpation of the bony surfaces and identification of the
medial epicondyle and, more importantly, the cubital
tunnel during pinning.11
The limitations of this study are reflected by its
retrospective design. The surgeon choice for all-lateral
versus medial pin placement may reflect fracture person-
ality or it may reflect a surgeon’s discomfort with using a
medial pin. Of all the surgeons represented in this study,
only one of 29 (including pediatric orthopaedic fellows)
apparently felt uncomfortable using a medial pin, as all
other surgeons had cases in both groups. A randomized
trial would better differentiate between these 2 fixation
choices, but as noted previously, the sample needed to
have adequate power would be over 4600 children with
Gartland type 3 supracondylar humerus fractures. Loss
of follow-up for all our patients, including 1 with ulnar
neuropathy, limits our ability to completely understand
and define the long-term morbidity of iatrogenic ulnar
nerve palsy.
To prevent injury to the ulnar nerve, it would be
easy to plan for all-lateral-entry pin fixation when treating
childhood supracondylar humerus fractures. However,
not every fracture pattern is amenable to all-lateral pin
fixation. There are at least 3 different fracture patterns
that necessitate a medial pin for stability of fixation: (1)
high supracondylar fractures (or those fractures where the
primary fracture line is near the metadiaphyseal junction)
will often not provide adequate cross-sectional area for
>2 useful lateral pins (Fig. 6); (2) the more common
fracture patterns that traverse near the olecranon fossa
may have significant comminution involving the medial
cortex, limiting purchase of the lateral-entry pins on their
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J Pediatr Orthop  Volume 32, Number 4, June 2012
far cortex; and (3) those fractures with initial cubitus
varus and medial instability may require a medial pin to
act as a buttress and structural support for the medial
cortex (Fig. 7). If any of these individual fracture patterns
or combination therein are present, then understanding of
a safe method of medial pin placement is an important
part of a treating surgeon’s armamentarium.
Past literature demonstrates that a cross-pin tech-
nique of fracture fixation in Gartland type 3 supra-
condylar fractures provides more stability, but with
increased risk for iatrogenic ulnar nerve palsy. Our
technique provides a method to minimize the risk to the
ulnar nerve and still provide the augmented cross-pinning
construct. For the specific fracture patterns that require
medial pinning, our technique affords safety in pin
placement and can be used as an adjunct to all-lateral
pinning.
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