Research progress in the treatment of distal humeral metaphyseal-diaphyseal junction fracture in children_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

SHEN Xiangyang ,  JIA Guoqiang

Department of Orthopedics, Provincial Children’s Hospital of Anhui Medical University, Hefei Anhui, 230051, P. R. China;

Corresponding author：

JIA Guoqiang, Email: jgqdor@126.com

Keywords：

Distal humeral metaphyseal-diaphyseal junction; fracture; media column; treatment; children

DOI：

10.7507/1002-1892.202402044

Video：

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Objective To summarize the research progress in the treatment of distal humeral metaphyseal-diaphyseal junction (DHMDJ) fractures in children and to provide reference for clinical practice. Methods The characteristics and treatment methods of transverse and comminuted DHMDJ fractures in children were summarized and analyzed by referring to relevant literature at home and abroad. Results DHMDJ fractures in children are not uncommon clinically, with high fracture line position, multi-directional instability, difficult closed reduction in treatment, and easy to cause complications such as coronal and sagittal deformity of the elbow. The Kirschner wire technique was effective for DHMDJ fractures with the fracture line at the middle and low levels, but was prone to iatrogenic ulnar nerve injury. Elastic stable intramedullary nail is suitable for higher-position transverse DHMDJ fractures. However, this technique requires a second operation to remove the internal fixator, and may cause iatrogenic epiphysis plate injury in children. External fixator is a new way to treat DHMDJ fractures, and it can show satisfactory results for transverse and comminuted DHMDJ fractures. However, at present, there are few relevant studies, and most of them focus on biomechanical studies, and the efficacy lacks high-quality clinical research support. Conclusion The ultimate goal of DHMDJ fracture treatment in children is to restore the anatomical alignment of the fracture and prevent the loss of reduction. The choice of internal fixator depends on the location of the fracture line and the shape of the fracture to provide personalized treatment.

Citation： SHEN Xiangyang, JIA Guoqiang. Research progress in the treatment of distal humeral metaphyseal-diaphyseal junction fracture in children. Chinese Journal of Reparative and Reconstructive Surgery, 2024, 38(5): 613-617. doi: 10.7507/1002-1892.202402044 Copy

1.	Bahk MS, Srikumaran U, Ain MC, et al. Patterns of pediatric supracondylar humerus fractures. J Pediatr Orthop, 2008, 28(5): 493-499.
2.	Tokyay A, Okay E, Cansü E, et al. Effect of fracture location on rate of conversion to open reduction and clinical outcomes in pediatric Gartland type Ⅲ supracondylar humerus fractures. Ulus Travma Acil Cerrahi Derg, 2022, 28(2): 202-208.
3.	邓银栓, 白静, 刘锐, 等. 肘前横切口治疗儿童闭合复位失败的Gartland Ⅲ型肱骨髁上骨折早期临床疗效. 中国修复重建外科杂志, 2023, 37(5): 566-571.
4.	Marengo L, Canavese F, Cravino M, et al. Outcome of displaced fractures of the distal metaphyseal-diaphyseal junction of the humerus in children treated with elastic stable intramedullary nails. J Pediatr Orthop, 2015, 35(6): 611-616.
5.	Fayssoux RS, Stankovits L, Domzalski ME, et al. Fractures of the distal humeral metaphyseal-diaphyseal junction in children. J Pediatr Orthop, 2008, 28(2): 142-146.
6.	Sen RK, Tripathy SK, Kumar A, et al. Metaphyseo-diaphyseal junction fracture of distal humerus in children. J Pediatr Orthop B, 2012, 21(2): 109-114.
7.	Shah M, Han JH, Park H, et al. Prevalence and treatment outcome of displaced high-long oblique supracondylar humeral fractures in children. Frontiers in Pediatrics, 2021, 9: 739909. doi: 10.3389/fped.2021.739909.
8.	Weinberg AM, Castellani C, Arzdorf M, et al. Osteosynthesis of supracondylar humerus fractures in children: a biomechanical comparison of four techniques. Clin Biomech (Bristol, Avon), 2007, 22(5): 502-509.
9.	Silva M, Knutsen AR, Kalma JJ, et al. Biomechanical testing of pin configurations in supracondylar humeral fractures: the effect of medial column comminution. J Orthop Trauma, 2013, 27(5): 275-280.
10.	Kwak YH, Kim JH, Kim YC, et al. Medial comminution as a risk factor for the stability after lateral-only pin fixation for pediatric supracondylar humerus fracture: an audit. Ther Clin Risk Manag, 2018, 14: 1061-1066.
11.	De Boeck H, De Smet P, Penders W, et al. Supracondylar elbow fractures with impaction of the medial condyle in children. J Pediatr Orthop, 1995, 15(4): 444-448.
12.	Ji X, Kamara A, Wang E, et al. A two-stage retrospective analysis to determine the effect of entry point on higher exit of proximal pins in lateral pinning of supracondylar humerus fracture in children. J Orthop Surg Res, 2019, 14(1): 351. doi: 10.1186/s13018-019-1400-x.
13.	Hohloch L, Konstantinidis L, Wagner FC, et al. Biomechanical evaluation of a new technique for external fixation of unstable supracondylar humerus fractures in children. Technol Health Care, 2015, 23(4): 453-461.
14.	Afaque SF, Singh A, Maharjan R, et al. Comparison of clinic-radiological outcome of cross pinning versus lateral pinning for displaced supracondylar fracture of humerus in children: A randomized controlled trial. J Clin Orthop Trauma, 2020, 11(2): 259-263.
15.	刘祥飞, Allieu Kamara, 刘闯, 等. 儿童肱骨髁上骨折模型克氏针固定构型的三维有限元分析. 中国骨伤, 2020, 33(10): 948-953.
16.	Eguia F, Gottlich C, Lobaton G, et al. Mid-term patient-reported outcomes after lateral versus crossed pinning of pediatric supracondylar humerus fractures. J Pediatr Orthop, 2020, 40(7): 323-328.
17.	Prashant K, Lakhotia D, Bhattacharyya TD, et al. A comparative study of two percutaneous pinning techniques (lateral vs medial-lateral) for Gartland type Ⅲ pediatric supracondylar fracture of the humerus. J Orthop Traumatol, 2016, 17(3): 223-229.
18.	Dekker AE, Krijnen P, Schipper IB. Results of crossed versus lateral entry K-wire fixation of displaced pediatric supracondylar humeral fractures: A systematic review and meta-analysis. Injury, 2016, 47(11): 2391-2398.
19.	Begovic N, Paunovic Z, Djuraskovic Z, et al. Lateral pinning versus others procedures in the treatment of supracondylar humerus fractures in children. Acta Orthop Belg, 2016, 82(4): 866-871.
20.	Na Y, Bai R, Zhao Z, et al. Comparison of lateral entry with crossed entry pinning for pediatric supracondylar humeral fractures: a meta-analysis. J Orthop Surg Res, 2018, 13(1): 68. doi: 10.1186/s13018-018-0768-3.
21.	Chong HH, Qureshi A. Pediatric distal humeral supracondylar fracture—Achievement of optimal pinning configuration. Acta Orthop Belg, 2022, 88(2): 245-254.
22.	Venkatadass K, Maji M, Sangeet G, et al. Factors determining loss of reduction in paediatric supracondylar humerus fractures treated by closed reduction and percutaneous pinning. J Pediatr Orthop B, 2022, 31(3): 289-295.
23.	Wang W, Li Q, Kamara A, et al. Analysis of the location and trajectory of the Kirschner wires in the fixation of extension-type supracondylar fracture of the humerus by 3D computational simulation. J Shoulder Elbow Surg, 2022, 31(7): 1368-1375.
24.	Zionts LE, McKellop HA, Hathaway R. Torsional strength of pin configurations used to fix supracondylar fractures of the humerus in children. J Bone Joint Surg (Am), 1994, 76(2): 253-256.
25.	Banshelkikar S, Sheth B, Banerjee S, et al. Functional outcome of supracondylar humerus fracture in children with the use of pin configuration as per Bahk classification. J Clin Orthop Trauma, 2021, 13: 78-81.
26.	Kamara A, Ji X, Liu C, et al. The most stable pinning configurations in transverse supracondylar humerus fracture fixation in children: A novel three-dimensional finite element analysis of a pediatric bone model. Injury, 2021, 52(6): 1310-1315.
27.	Liu C, Kamara A, Liu T, et al. Mechanical stability study of three techniques used in the fixation of transverse and oblique metaphyseal-diaphyseal junction fractures of the distal humerus in children: a finite element analysis. J Orthop Surg Res, 2020, 15(1): 34. doi: 10.1186/s13018-020-1564-4.
28.	Zhou H, Zhang G, Li M, et al. Closed reduction and percutaneous pinning in the treatment of humeral distal metaphyseal-diaphyseal junction fractures in children: a technique note and preliminary results. Front Pediatr, 2021, 9: 670164. doi: 10.3389/fped.2021.670164.
29.	孙亮, 刘万林, 赵振群, 等. 操纵杆技术在儿童肱骨远端骨干干骺端交界性骨折中的应用. 中华小儿外科杂志, 2020, 41(4): 342-345.
30.	Pogorelić Z, Kadić S, Milunović KP, et al. Flexible intramedullary nailing for treatment of proximal humeral and humeral shaft fractures in children: A retrospective series of 118 cases. Orthop Traumatol Surg Res, 2017, 103(5): 765-770.
31.	Zivanovic DV, Slavkovic AR, Radovanovic ZL, et al. Elastic stable intramedullary nailing of humerus fractures in children. Int J Clin Exp Med, 2018, 11(4): 2950-2964.
32.	董展, 张志群, 唐凯, 等. 逆行弹性髓内钉技术治疗儿童肱骨远端干骺端-骨干交界性骨折的疗效分析. 中华实用儿科临床杂志, 2020, 35(14): 1089-1092.
33.	Ge YH, Wang ZG, Cai HQ, et al. Flexible intramedullary nailing had better outcomes than Kirschner wire fixation in children with distal humeral metaphyseal-diaphyseal junction fracture: a retrospective observational analysis. Int J Clin Exp Med, 2014, 7(10): 3568-3572.
34.	Sénès FM, Catena N. Intramedullary osteosynthesis for metaphyseal and diaphyseal humeral fractures in developmental age. J Pediatr Orthop B, 2012, 21(4): 300-304.
35.	Greve F, Biberthaler P, Castellani C, et al. Beneficial perioperative aspects favor the use of percutaneous crossed pinning over antegrade nailing in pediatric supracondylar fractures—A retrospective comparative study. Children (Basel), 2023, 10(5): 830. doi: 10.3390/children10050830.
36.	李麒麟, Allieu Kamara, 王恩波, 等. 儿童肱骨远端骨干干骺端交界区骨折不同固定方法生物力学的比较. 中国骨与关节损伤杂志, 2020, 35(9): 917-920.
37.	Kamara A, Ji X, Liu T, et al. A comparative biomechanical study on different fixation techniques in the management of transverse metaphyseal-diaphyseal junction fractures of the distal humerus in children. Int Orthop, 2019, 43(2): 411-416.
38.	Slongo T, Schmid T, Wilkins K, et al. Lateral external fixation—A new surgical technique for displaced unreducible supracondylar humeral fractures in children. J Bone Joint Surg (Am), 2008, 90(8): 1690-1697.
39.	Kow RY, Zamri AR, Ruben JK, et al. Humeral supracondylar fractures in children: A novel technique of lateral external fixation and kirschner wiring. Malays Orthop J, 2016, 10(2): 41-46.
40.	Li WC, Meng QX, Xu RJ, et al. Biomechanical analysis between Orthofix^® external fixator and different K-wire configurations for pediatric supracondylar humerus fractures. J Orthop Surg Res, 2018, 13(1): 188. doi: 10.1186/s13018-018-0893-z.
41.	Li J, Rai S, Tang X, et al. Surgical management of delayed Gartland type III supracondylar humeral fractures in children: A retrospective comparison of radial external fixator and crossed pinning. Medicine (Baltimore), 2020, 99(10): e19449. doi: 10.1097/MD.0000000000019449.
42.	Hohloch L, Konstantinidis L, Wagner FC, et al. Biomechanical comparison of different external fixator configurations for stabilization of supracondylar humerus fractures in children. Clin Biomech (Bristol, Avon), 2016, 32: 118-123.
43.	王磊, 万广亮, 左玉明, 等. 外固定架辅助克氏针固定治疗儿童肱骨远干骺交界部骨折. 实用骨科杂志, 2023, 29(6): 542-545.
44.	Reisoglu A, Kazimoglu C, Hanay E, et al. Is pin configuration the only factor causing loss of reduction in the management of pediatric type Ⅲ supracondylar fractures? Acta Orthop Traumatol Turc, 2017, 51(1): 34-38.
45.	Larson L, Firoozbakhsh K, Passarelli R, et al. Biomechanical analysis of pinning techniques for pediatric supracondylar humerus fractures. J Pediatr Orthop, 2006, 26(5): 573-578.
46.	Lee SS, Mahar AT, Miesen D, et al. Displaced pediatric supracondylar humerus fractures: biomechanical analysis of percutaneous pinning techniques. J Pediatr Orthop, 2002, 22(4): 440-443.
47.	Rees AB, Schultz JD, Wollenman LC, et al. Internal rotation stress test reduces cross-pinning and improves outcomes in displaced pediatric supracondylar humeral fractures. JBJS Open Access, 2021, 6(3): e21.00014. doi: 10.2106/JBJS.OA.21.00014.
48.	Kwak-Lee J, Kim R, Ebramzadeh E, et al. Is medial pin use safe for treating pediatric supracondylar humerus fractures? J Orthop Trauma, 2014, 28(4): 216-221.

1. Bahk MS, Srikumaran U, Ain MC, et al. Patterns of pediatric supracondylar humerus fractures. J Pediatr Orthop, 2008, 28(5): 493-499.
2. Tokyay A, Okay E, Cansü E, et al. Effect of fracture location on rate of conversion to open reduction and clinical outcomes in pediatric Gartland type Ⅲ supracondylar humerus fractures. Ulus Travma Acil Cerrahi Derg, 2022, 28(2): 202-208.
3. 邓银栓, 白静, 刘锐, 等. 肘前横切口治疗儿童闭合复位失败的Gartland Ⅲ型肱骨髁上骨折早期临床疗效. 中国修复重建外科杂志, 2023, 37(5): 566-571.
4. Marengo L, Canavese F, Cravino M, et al. Outcome of displaced fractures of the distal metaphyseal-diaphyseal junction of the humerus in children treated with elastic stable intramedullary nails. J Pediatr Orthop, 2015, 35(6): 611-616.
5. Fayssoux RS, Stankovits L, Domzalski ME, et al. Fractures of the distal humeral metaphyseal-diaphyseal junction in children. J Pediatr Orthop, 2008, 28(2): 142-146.
6. Sen RK, Tripathy SK, Kumar A, et al. Metaphyseo-diaphyseal junction fracture of distal humerus in children. J Pediatr Orthop B, 2012, 21(2): 109-114.
7. Shah M, Han JH, Park H, et al. Prevalence and treatment outcome of displaced high-long oblique supracondylar humeral fractures in children. Frontiers in Pediatrics, 2021, 9: 739909. doi: 10.3389/fped.2021.739909.
8. Weinberg AM, Castellani C, Arzdorf M, et al. Osteosynthesis of supracondylar humerus fractures in children: a biomechanical comparison of four techniques. Clin Biomech (Bristol, Avon), 2007, 22(5): 502-509.
9. Silva M, Knutsen AR, Kalma JJ, et al. Biomechanical testing of pin configurations in supracondylar humeral fractures: the effect of medial column comminution. J Orthop Trauma, 2013, 27(5): 275-280.
10. Kwak YH, Kim JH, Kim YC, et al. Medial comminution as a risk factor for the stability after lateral-only pin fixation for pediatric supracondylar humerus fracture: an audit. Ther Clin Risk Manag, 2018, 14: 1061-1066.
11. De Boeck H, De Smet P, Penders W, et al. Supracondylar elbow fractures with impaction of the medial condyle in children. J Pediatr Orthop, 1995, 15(4): 444-448.
12. Ji X, Kamara A, Wang E, et al. A two-stage retrospective analysis to determine the effect of entry point on higher exit of proximal pins in lateral pinning of supracondylar humerus fracture in children. J Orthop Surg Res, 2019, 14(1): 351. doi: 10.1186/s13018-019-1400-x.
13. Hohloch L, Konstantinidis L, Wagner FC, et al. Biomechanical evaluation of a new technique for external fixation of unstable supracondylar humerus fractures in children. Technol Health Care, 2015, 23(4): 453-461.
14. Afaque SF, Singh A, Maharjan R, et al. Comparison of clinic-radiological outcome of cross pinning versus lateral pinning for displaced supracondylar fracture of humerus in children: A randomized controlled trial. J Clin Orthop Trauma, 2020, 11(2): 259-263.
15. 刘祥飞, Allieu Kamara, 刘闯, 等. 儿童肱骨髁上骨折模型克氏针固定构型的三维有限元分析. 中国骨伤, 2020, 33(10): 948-953.
16. Eguia F, Gottlich C, Lobaton G, et al. Mid-term patient-reported outcomes after lateral versus crossed pinning of pediatric supracondylar humerus fractures. J Pediatr Orthop, 2020, 40(7): 323-328.
17. Prashant K, Lakhotia D, Bhattacharyya TD, et al. A comparative study of two percutaneous pinning techniques (lateral vs medial-lateral) for Gartland type Ⅲ pediatric supracondylar fracture of the humerus. J Orthop Traumatol, 2016, 17(3): 223-229.
18. Dekker AE, Krijnen P, Schipper IB. Results of crossed versus lateral entry K-wire fixation of displaced pediatric supracondylar humeral fractures: A systematic review and meta-analysis. Injury, 2016, 47(11): 2391-2398.
19. Begovic N, Paunovic Z, Djuraskovic Z, et al. Lateral pinning versus others procedures in the treatment of supracondylar humerus fractures in children. Acta Orthop Belg, 2016, 82(4): 866-871.
20. Na Y, Bai R, Zhao Z, et al. Comparison of lateral entry with crossed entry pinning for pediatric supracondylar humeral fractures: a meta-analysis. J Orthop Surg Res, 2018, 13(1): 68. doi: 10.1186/s13018-018-0768-3.
21. Chong HH, Qureshi A. Pediatric distal humeral supracondylar fracture—Achievement of optimal pinning configuration. Acta Orthop Belg, 2022, 88(2): 245-254.
22. Venkatadass K, Maji M, Sangeet G, et al. Factors determining loss of reduction in paediatric supracondylar humerus fractures treated by closed reduction and percutaneous pinning. J Pediatr Orthop B, 2022, 31(3): 289-295.
23. Wang W, Li Q, Kamara A, et al. Analysis of the location and trajectory of the Kirschner wires in the fixation of extension-type supracondylar fracture of the humerus by 3D computational simulation. J Shoulder Elbow Surg, 2022, 31(7): 1368-1375.
24. Zionts LE, McKellop HA, Hathaway R. Torsional strength of pin configurations used to fix supracondylar fractures of the humerus in children. J Bone Joint Surg (Am), 1994, 76(2): 253-256.
25. Banshelkikar S, Sheth B, Banerjee S, et al. Functional outcome of supracondylar humerus fracture in children with the use of pin configuration as per Bahk classification. J Clin Orthop Trauma, 2021, 13: 78-81.
26. Kamara A, Ji X, Liu C, et al. The most stable pinning configurations in transverse supracondylar humerus fracture fixation in children: A novel three-dimensional finite element analysis of a pediatric bone model. Injury, 2021, 52(6): 1310-1315.
27. Liu C, Kamara A, Liu T, et al. Mechanical stability study of three techniques used in the fixation of transverse and oblique metaphyseal-diaphyseal junction fractures of the distal humerus in children: a finite element analysis. J Orthop Surg Res, 2020, 15(1): 34. doi: 10.1186/s13018-020-1564-4.
28. Zhou H, Zhang G, Li M, et al. Closed reduction and percutaneous pinning in the treatment of humeral distal metaphyseal-diaphyseal junction fractures in children: a technique note and preliminary results. Front Pediatr, 2021, 9: 670164. doi: 10.3389/fped.2021.670164.
29. 孙亮, 刘万林, 赵振群, 等. 操纵杆技术在儿童肱骨远端骨干干骺端交界性骨折中的应用. 中华小儿外科杂志, 2020, 41(4): 342-345.
30. Pogorelić Z, Kadić S, Milunović KP, et al. Flexible intramedullary nailing for treatment of proximal humeral and humeral shaft fractures in children: A retrospective series of 118 cases. Orthop Traumatol Surg Res, 2017, 103(5): 765-770.
31. Zivanovic DV, Slavkovic AR, Radovanovic ZL, et al. Elastic stable intramedullary nailing of humerus fractures in children. Int J Clin Exp Med, 2018, 11(4): 2950-2964.
32. 董展, 张志群, 唐凯, 等. 逆行弹性髓内钉技术治疗儿童肱骨远端干骺端-骨干交界性骨折的疗效分析. 中华实用儿科临床杂志, 2020, 35(14): 1089-1092.
33. Ge YH, Wang ZG, Cai HQ, et al. Flexible intramedullary nailing had better outcomes than Kirschner wire fixation in children with distal humeral metaphyseal-diaphyseal junction fracture: a retrospective observational analysis. Int J Clin Exp Med, 2014, 7(10): 3568-3572.
34. Sénès FM, Catena N. Intramedullary osteosynthesis for metaphyseal and diaphyseal humeral fractures in developmental age. J Pediatr Orthop B, 2012, 21(4): 300-304.
35. Greve F, Biberthaler P, Castellani C, et al. Beneficial perioperative aspects favor the use of percutaneous crossed pinning over antegrade nailing in pediatric supracondylar fractures—A retrospective comparative study. Children (Basel), 2023, 10(5): 830. doi: 10.3390/children10050830.
36. 李麒麟, Allieu Kamara, 王恩波, 等. 儿童肱骨远端骨干干骺端交界区骨折不同固定方法生物力学的比较. 中国骨与关节损伤杂志, 2020, 35(9): 917-920.
37. Kamara A, Ji X, Liu T, et al. A comparative biomechanical study on different fixation techniques in the management of transverse metaphyseal-diaphyseal junction fractures of the distal humerus in children. Int Orthop, 2019, 43(2): 411-416.
38. Slongo T, Schmid T, Wilkins K, et al. Lateral external fixation—A new surgical technique for displaced unreducible supracondylar humeral fractures in children. J Bone Joint Surg (Am), 2008, 90(8): 1690-1697.
39. Kow RY, Zamri AR, Ruben JK, et al. Humeral supracondylar fractures in children: A novel technique of lateral external fixation and kirschner wiring. Malays Orthop J, 2016, 10(2): 41-46.
40. Li WC, Meng QX, Xu RJ, et al. Biomechanical analysis between Orthofix^® external fixator and different K-wire configurations for pediatric supracondylar humerus fractures. J Orthop Surg Res, 2018, 13(1): 188. doi: 10.1186/s13018-018-0893-z.
41. Li J, Rai S, Tang X, et al. Surgical management of delayed Gartland type III supracondylar humeral fractures in children: A retrospective comparison of radial external fixator and crossed pinning. Medicine (Baltimore), 2020, 99(10): e19449. doi: 10.1097/MD.0000000000019449.
42. Hohloch L, Konstantinidis L, Wagner FC, et al. Biomechanical comparison of different external fixator configurations for stabilization of supracondylar humerus fractures in children. Clin Biomech (Bristol, Avon), 2016, 32: 118-123.
43. 王磊, 万广亮, 左玉明, 等. 外固定架辅助克氏针固定治疗儿童肱骨远干骺交界部骨折. 实用骨科杂志, 2023, 29(6): 542-545.
44. Reisoglu A, Kazimoglu C, Hanay E, et al. Is pin configuration the only factor causing loss of reduction in the management of pediatric type Ⅲ supracondylar fractures? Acta Orthop Traumatol Turc, 2017, 51(1): 34-38.
45. Larson L, Firoozbakhsh K, Passarelli R, et al. Biomechanical analysis of pinning techniques for pediatric supracondylar humerus fractures. J Pediatr Orthop, 2006, 26(5): 573-578.
46. Lee SS, Mahar AT, Miesen D, et al. Displaced pediatric supracondylar humerus fractures: biomechanical analysis of percutaneous pinning techniques. J Pediatr Orthop, 2002, 22(4): 440-443.
47. Rees AB, Schultz JD, Wollenman LC, et al. Internal rotation stress test reduces cross-pinning and improves outcomes in displaced pediatric supracondylar humeral fractures. JBJS Open Access, 2021, 6(3): e21.00014. doi: 10.2106/JBJS.OA.21.00014.
48. Kwak-Lee J, Kim R, Ebramzadeh E, et al. Is medial pin use safe for treating pediatric supracondylar humerus fractures? J Orthop Trauma, 2014, 28(4): 216-221.

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