Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

Users Online : 86601

AbstractMaterial and MethodsResultsDiscussionConclusionKey MessageReferencesDOI and Others
Article in PDF How to Cite Citation Manager Readers' Comments (0) Audio Visual Article Statistics Link to PUBMED Print this Article Send to a Friend
Advertisers Access Statistics Resources

Dr Mohan Z Mani

"Thank you very much for having published my article in record time.I would like to compliment you and your entire staff for your promptness, courtesy, and willingness to be customer friendly, which is quite unusual.I was given your reference by a colleague in pathology,and was able to directly phone your editorial office for clarifications.I would particularly like to thank the publication managers and the Assistant Editor who were following up my article. I would also like to thank you for adjusting the money I paid initially into payment for my modified article,and refunding the balance.
I wish all success to your journal and look forward to sending you any suitable similar article in future"

Dr Mohan Z Mani,
Professor & Head,
Department of Dermatolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018

Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."

Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018

Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."

Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018

Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."

Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
On Sep 2018

Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."

Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata

Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
On Aug 2018

Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".

Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
On Aug 2018

Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".

Dr. Mamta Gupta
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018

Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.

Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."

Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
On May 11,2011

Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."

Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
On April 2011

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.

Dr. Anuradha
On Jan 2020

Important Notice

Original article / research
Year : 2011 | Month : November | Volume : 5 | Issue : 6 | Page : 1260 - 1263 Full Version

Displaced supracondylar fracture of humerus in children treated with crossed pin versus lateral pin: A Hospital based Study from Western Nepal

Published: November 1, 2011 | DOI:
Chakraborty M K, Onta P R, Sathian B

Prof & HOD, Orthopaedics Department, Manipal College of Medical Sciences, Pokhara, Nepal. Senior Resident, Orthopaedics Department, Manipal College of Medical Sciences, Pokhara, Nepal. Assistant Professor, Department of Community Medicine, Manipal College of Medical Sciences, Pokhara, Nepal

Correspondence Address :
Manoj Kumar Chakraborty,
Prof & HOD, Orthopedics Department,
Manipal College of Medical Sciences, Pokhara, Nepal.
Ph.: 00977-9726155900
Email :


Background: The supracondylar fracture of the humerus is the second most common fracture in children and the most frequent one in the first decade of life. Close reduction with percutaneous pin fixation has become the treatment of choice. The success of the treatment depends on the strength of the fixation and the avoidance of complications. Crossed pin (medial and lateral pin) and two lateral parallel pin fixations after the reduction of the fracture are recommendable.

Objective: To compare the efficacy of the two recommended methods of internal fixation of the displaced supracondylar fractures, Gartland’s Type II and Type III of the humerus in children. Material and Methods: This was a hospital based retrospective study which was conducted in Nepal between January 2010 and June 2011.

Results: Out of the 92 patients, 56 (60.9%) were fixed with a medial lateral cross pin and 36 (39.1%) were fixed with lateral two parallel pins. The average age of the patients who were fixed with the medial lateral cross pin was 7.5± SD 2.3 years and that of those who were fixed with the lateral two parallel pins was 7.6± SD 3.0 years. 24 (26.1%) patients had type II and 68 (73.9%) had type III fractures.

Conclusion: In our study, crossed pining was found to be superior to the two parallel lateral pinning; because crossed pinning had more stability.


Supracondylar fracture, crossed pin, lateral pin

The supracondylar fracture of the humerus occurs most commonly in children under seven years of age and it is more common in boys than in girls (1), (2). Injuries are involved in the left or the nondominant sites. The extension type of fracture is the most common one which is found in children (3).

The displaced supracondylar fracture of the humerus, after reduction, is fixed with pins and is immobilized in a plaster slab. The two principal configurations which have been reported in the literature for displaced supracondylar fractures are two lateral parallel pin fixation and cross (medial and lateral) pin fixation.

The functional and cosmetic outcome is closely related to a successful close reduction and percutaneous pin fixation. Iatrogenic ulnar nerve injury (4), instability, redisplacement and late malunion with varus deformity are the known complications. In displaced supracondylar fracture of the humerus in children who were treated with cross pin versus lateral pin, crossed pinning was found to be biomechanically more stable (5).

Material and Methods

This was a hospital based, retrospective study which was conducted in the Orthopaedic Department of Manipal College of Medical Sciences, Pokhara, Nepal, between January 2010 and June 2011. The variables which were collected were age, gender, crossed pin versus lateral pin, the mode of injury and the affected side. The displaced extension type supracondylar fractures in children were treated at our institute by closed reduction and percutaneous pinning.

The exclusion criteriae were open fractures, fractures that required open reduction, previous epsilateral elbow fracture and the presence of any concomitant fractures in the epsilateral limb. We reviewed the hospital records of the study cohort for details which included pre-operative clinical examinations, operative note, postoperative evaluation, duration of the immobilization and the time of the pin removal. When there were complications, there was a need for further surgeries and clinical assessment at the follow up visit.

A total of 92 children fulfilled the inclusion criteriae of the study,including 72 boys and 20 girls. Their mean age was 7.5 years; 44 were right sided and 48 were left sided. There were 24 Gartland’s type II fractures and 68 Gartland’s type III fractures. All the children underwent closed reduction and percutaneous pinning. The pin size was selected according to the age of the child and the size of the arm, which was usually 1.5 mm for the younger children and 2.0 mm for the older children. The pin configuration was based on the testing post reduction and the fracture stability intraoperatively, with the image intensifier and considering the severity of the elbow swelling.

While placing the medial pins, we followed the flexion-extension cross pinning technique which was described by Eidelman et al (6). The pin ends were bent outside the skin, and an above elbow POP slab was applied, with approximately 90 degree of elbow flexion and neutral forearm rotation. All the children were discharged to go home on the post-operative day three and were again reviewed 1 week after the surgery, by checking their orthogonal plain radiographs. If these were acceptable, the child was seen again after 3 weeks when the cast was removed and the check-up X rays were taken. Whenever an acceptable healing was confirmed, the pins were removed at six weeks in the OPD and motion was encouraged.

Physiotherapy was rarely indicated. The follow-up was continued until the full range of the motion was regained. The average followup period was 7.4 (5),(4),(3),(6) months. The clinical and radiological assessments were analyzed at the final visit. The clinical assessment included the range of motion, the carrying angle, neurological and vascular examination and return to the full function. A radiological assessment was made by comparing the Baumann’s angle in the initial post-operative and in the final follow-up radiographs. The analysis was done by using descriptive statistics and the testing of the hypothesis. The data was analyzed by using Excel 2003, the Statistical Package for the Social Sciences (SPSS) for Windows Version 16.0 (SPSSInc; Chicago, IL, USA) and the EPI Info 3.5.1 Windows Version. The Chi-square test was used to examine the association between the different variables. A p-value of < 0.05 (two-tailed) was used to establish the statistical significance.


Out of the 92 patients, 56 (60.9%) were fixed with a medial lateral cross pin and 36 (39.1%) were fixed with lateral two parallel pins. The average age of the patients who were fixed with the medial lateral cross pin was 7.5± SD 2.3 years and that of those who were fixed with the lateral two parallel pins was

7.6±SD3.0 years. 24 (26.1%) fractures were of type II and 68 (73.9%) were of type III.

The average immobilisation time in the present study was 5.1 +1.04 (4–8) weeks.

(Table/Fig 1): Shows cross pinning A-P and the lateral of the pre and post-op views with the type 3 fracture.

In 10% of the cases, we noticed irritability of ulnar nerve which resolved spontaneously and there was a mild degree of secondary varus deformity.

(Table/Fig 2): Shows lateral pinning A-P and the lateral of the pre and post-op views. The chance of the varus deformity and the 20 degree rotational deformity had only little clinical and functional significance. The varus deformity was the only cosmetic problem. The deformity of the ulnar canal could cause irritation of the ulnar nerve in 10% of the cases. After 3 weeks, it was noticed that all thecases were stable enough for motion.

(Table/Fig 3),(Table/Fig 4): AP and lateral pre and post op views of lateral pinning by divergent methods; biomechanically it is not as strong as cross pinning.


The success of the treatment of displaced supracondylar fractures of the humerus in children depends on good reduction, maintenance of the reduction until fracture healing with avoidance of complications and achieving better functional and cosmetic results.

The pin fixation technique is always controversial. It involves the use of two lateral pins which are placed in either a parallel or a divergent pattern. The latter is more biomechanically stable and therefore it is more popular, with a minimal risk of ulnar nerve injury (7).

Adult cadavers and synthetic paediatric bone models have suggested that lateral pins fixation is not stabile enough against torsional forces (8), and that an additional lateral pin must be added whenever necessary, to control rotational instability (7). Zoints et al showed that the torque which was required to produce 10% rotation was 40% less for two lateral pins than for a two cross pin (7).

In type II fractures, the rotational stability was better, because of the intact bone or the periosteum, posteriorly. The type III fractures developed rotational instability and the cubitus varus deformity due to tilting. The posterior displacement, coronal tilt and the horizontal rotation of the distal fragment were evaluated radiologically to overcome the cubitus varus deformity.

In our study on a total number of 92 cases, a cross pin was fixed in 56 cases and a lateral pin was fixed in 36 cases. The mode of injury was mostly falling while playing. There were 12 cases (33.33%) of pin tract infection in lateral pinning and 40 cases (71.42%) in cross pinning which were tackled with antibiotics. The incidence of the pin tract infection was superficial, may be because of poor hygiene and scratching due to post op irritability, which was treated adequately with oral antibiotics and it was resolved completely. So, it was not a problem.

Radial nerve injury was found in 4 (11.11%) cases in lateral pinning and 4 (7.14%) cases of ulnar nerve palsy in cross pinning. Mild cubitus varus deformity (Baumann’s angle 5 to 8 degree) was found in 4 cases (7.14%) in cross pinning and in 10 cases (27.78%) in lateral pinning. Four iatrogenic ulnar nerve injuries were explored and healed up without any residual palsy. Four radial nerve injuries in the lateral pinning group also healed up. In cases of severely swollen elbow, we preferred to make a small incision over the medial epicondyle to explore the ulnar nerve, to avoid injury to it.

The incidence of iatrogenic ulnar nerve injury in medial pinning was 1.4 to 15.6% (9). The incidence of ulnar nerve injury in our study was 7.14%, which is comparatively low and insignificant because it healed up completely without any residual complications. In our study, only 7.14% cases of ulnar nerve injury were found. There were only four radial nerve injuries among the lateral injuries. Only four iatrogenic ulnar nerve injuries were explored, which healed without any residual palsy. Only in cases of severe swelling, we made a small medial incision because it was very difficult to find the location. Manipulation and hardware insertion may be partially responsible for such injuries.

Biomedical studies have shown that cross pinning was 25% more rigid and 37% more stronger than the two lateral parallel pins (5).

In lateral two parallel pin fixation, the occurrence of intraoperative instability and redisplacement may not allow the full extension of the elbow. Mild cubitus varus deformities are more and not adequate enough for intraoperative stability for torsional forces, more over 4 (11.11%) radial nerve injury. The lateral pins are more close to the epiphysis of the distal humerus and they may disturb the growth plate and may cause mild cubitus varus deformity.

To avoid iatrogenic ulnar nerve damage while inserting the medial pin, a relative extension of the elbow at a maximum of 60 degrees of flexion was done after inserting the lateral pin. The technique of extending the elbow before the placement of the medial pin may have been responsible for avoiding an incidental injury to the ulnar nerve in our cases.

The choice of the pin configuration was based on the intraoperative stability and the severity of the elbow swelling. In the current concept of Bloom et al, they reported that three lateral pins were biomechanically equivalent to two cross pins; but that the cross pins were stronger than the two lateral pins.


Cross pinning has been recommended in the Gartland’s type III fractures. In case of severe swelling, a medial incision to see the entry point of the medial pin is required to prevent the iatrogenic ulnar nerve injury.

Two lateral pin fixations may be suitable only for the type II fractures, where the rotational stability is better because of the intact bone and the periosteum, posteriorly.

In the type III fractures, it may be redisplaced due to lack of enough stability and so we recommended cross pinning.

The final outcome of the low iatrogenic ulnar nerve injury in the type III fractures is possible if adequate care is taken by proper medial pin fixation in cross pinning. The initial ulnar and radial nerve injuries and the pin tract infection were usually resolved without anyresidual complications

In our experience, in cross pinning, the lateral pin should be fixed first, followed by the medial pin, with the elbow in extension. Most of the ulnar nerve injuries may be avoided by this technique, with the advantage of a strong and stable fixation.

Key Message

In cases of displaced supracondylar fractures of the humerus in children who were treated with crossed pin versus lateral pin, crossed pinning was found to be biomechanically more stable. n Pin fixation is always controversial; lateral pin fixation is not stable enough against tortional forces. To avoid iatrogenic ulnar nerve injury in case of medial pinning, the relative extension of the elbow is done after the lateral pinning fixation. Cross pinning has been recommended in Gartland’s Type III fractures. In cases of severe swelling, a medial incision to see the entry point of the medial pin is required to prevent the iatrogenic ulnar nerve injury.


Morris S, McKenna J, Cassidy N, McCormack D. Elbow injuries in the paediatric population: fractures of the distal humerus. Irish J Orthop Surg Trauma 2001;4:189–93.
Cheng JC, Lam TP, Maffulli N. Epidemiological features of the supracondylar fractures of the humerus in Chinese children.J Paediatr Orthop B 2001;10:63-7.
Gordon JE, Patton CM, Luhmann SJ, et al. Fracture stability after the pinning of the displaced supracondylar distal humerus fractures in children. J Paediatr Orthop 2001;21:313–8.
Devkota P, Khan JA, Acharya BM, Pradhan NM, Mainali LP, Singh M, Shrestha SK, Rajbhandari AP, et al. Outcome of the supracondylar fractures of the humerus in children who were treated by closed reduction and percutaneous pinning. JNMA J Nepal Med Assoc. 2008 ;47(170):66-70.
Brauer CA, Lee BM, Bae DS. A systematic review of medial and lateral entry pinning versus lateral entry pinning for the supracondylar fractures of the humerus. J Paediatr Orthop 2007;27:181–6.
Eldelman M, Hos N, Katzman A, Bialik. V. Prevention of ulnar nerve injury during the fixation of supracondylar fractures in children by the “flexion- extension cross pinning” technique. J Paediatrorthop B 2007;16:221-4.
Zionts LE, McKellop HA, Hathaway R.The torsional strength of pin configurations which was used to fix supracondylar fractures of the humerus in children. J Bone Joint Surg (Am) 1994; 76:253-6.
Yen YM, Kocher MS. Lateral entry compared with medial and lateral entry pin fixation for completely displaced supracondylar humeral fractures in children. A surgical technique. J Bone Joint Surg Am. 2008 Mar;90 (Suppl 2 Pt 1):20-30.
Kalenderer O, Reisoglu A, Surer L, Agus H. How should one treat an iatrogenic ulnar injury after the closed reduction and percutaneous pinning of paediatric supracondylar humeral fractures? Injury 2008; 39:463–6.

DOI and Others


JCDR is now Monthly and more widely Indexed .
  • Emerging Sources Citation Index (Web of Science, thomsonreuters)
  • Index Copernicus ICV 2017: 134.54
  • Academic Search Complete Database
  • Directory of Open Access Journals (DOAJ)
  • Embase
  • EBSCOhost
  • Google Scholar
  • HINARI Access to Research in Health Programme
  • Indian Science Abstracts (ISA)
  • Journal seek Database
  • Google
  • Popline (reproductive health literature)