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Excerpt
We congratulate Dr. Skaggs et al. (2) on the excellent results that they obtained in the treatment of 345 extension-type supracondylar fractures. As the studies were published nearly simultaneously in the Journal of Pediatric Orthopaedics and the Journal of Bone and Joint Surgery, we, of course, could not cite them in the reference section. We agree that the fracture shown in Figure 2 in our paper is rotationally unstable and this is shown postoperatively as it did, indeed, rotate within the cast. In retrospect, the pins probably can be judged to be too close together, although I don't think that they are substantially closer together than most surgeons would accept. We believe that loss of reduction after operative pinning of supracondylar fractures is a rare event and, indeed, Skaggs et al. (2) reported loss of reduction of the fracture in only two patients, in both of whom crossed pins were used. Most authors have agreed that the initial stage in loss of reduction leading to a change in Bowman's angle with varus or hyperextension involves rotation of the distal fragment. We attempted to measure this with our lateral rotational percentage as, perhaps, a more sensitive measure of the beginnings of loss of reduction in identifying fractures that were more at risk for developing varus (1). Unfortunately, both our study and that of Skaggs et al. (2) suffer from a common problem of being of a retrospective nature. It is difficult to discern, retrospectively, what led to the placement of a medial pin, whether that was a perception of instability on the part of the treating surgeon or whether it was simply a routine maneuver. We concur with Skaggs et al. (2) that placement of a medial pin, because it does have some element of risk to the ulnar nerve, should not be a routine measure. We believe also, however, there is a subgroup of type III supracondylar distal humerus fractures that, either through the presence of greater periosteal stripping or other factors, have a greater element of instability. Whether that should be treated by the addition of a divergent lateral pin or could be treated safely with a medial pin, we believe should be left to the treating surgeon in the absence of any more definitive information about this small group of unstable fractures.
