hospital, the treatment and nursing plan is for- mulated into the nursing path based on the patient’s personal information, medical history, etc. An individual, scientific nursing interven- tion model combined with clinical signs and symptoms is provided to the patients . Many studies have explored the clinical applications of CNP. Loeb et al.  used CNP intervention in patients with pneumonia and other lower respi- ratory tract infections, which improved their clinical treatment and reduced medical care costs. In a study by Johnson et al. , the use of CNP intervention in inpatients with asthma reduced hospital stays and beta-agonist appli- cations. Meanwhile, no adverse consequences occurred within 2 weeks after discharge. However, little is known about the application of CNP in pediatric supracondylarhumerus fractures.
humerus in two patients. No patients in two groups presented vascular injury, compartment syndrome, deep infection and nonunion. Three (12%) patients presented ulnar nerve palsy in K-wires, and medial K-wire was re- moved immediately. The duration of plaster cast increased to 6 weeks, and nerve palsy gradually recovered with completely union of fracture. One (6.7%) patient presented radial nerve palsy instead of ulnar nerve palsy in external fixator with gradual recover at three months follow-up. All patients had symmetrical and normal functions in flexion-extension of elbow. One patient in group of K-wires devel- oped cubitus varus with carrying angle of -10° in varus. The flexion-extension and supination range of motion were normal with less than 20° active pronation. The additional surgery of supracondylarhumerus osteotomy was per- formed to improve the cubitus varus.
Supracondylar fracture of the distal humerus is a common fracture in the pediatric population, accounting for approxi- mately 60% of all fractures of the elbow . Since1948, Swenson firstly described two K-wires of different sizes for closed reduction of supracondylarhumerus fractures . The classical treatment of displaced supracondylar humeral fractures is closed reduction and percutaneous fixation of Kirschner wires (K-wires). Previous studies have shown that medial and lateral crossed-pin fixation provided more sta- bility in biomechanical analysis than two lateral pin fixation . However, crossed K-wire placement is associated with the risk of iatrogenic ulnar nerve injury up to 3 to 4%. Lee et al.  reported that three lateral divergent or parallel pin fixations were effective and safe in avoiding iatrogenic ulnar nerve injury in supracondylar humeral fractures. In Bogdan et al.’ s  study, the humero-ulnar external fixation is a good alternative to lateral or crossed pinning in supracon- dylar humeral fractures. The optional K-wire configuration could provide the adequate stability of fracture without the risk of neurovascular injury.
the lack of support on medial column was related to the reduction loss. We selected cases that thoroughly followed the stable lateral pin fixation rule, and all the Baumann angle differences were below 10 ° . So, we tried to find any factor related to the Baumann angle change of more than average difference, and medial comminution was noted as a risk factor in the logistic regression analysis, although the dif- ference was very small. If supracondylarhumerus fracture with medial comminution was fixed with lateral-only pin fixation, there is a chance of Baumann angle change until bone union. So, more stable fixation than lateral-only pin fixation will be better, and we recommend additional medial pin fixation.
Supracondylarhumerus fractures (SCH) are the most common fractures about the elbow in children and have a peak incidence at the age of 5 to 6 years  . Type I and II are usually treated non- operatively. Type III fractures accounting for approximately 97% to 99% of SCH fractures are usually caused by a fall onto the outstretched hand with the elbow in full extension  . Soft tissue and neurovascular injuries often accompany these
Fixation with K-Wire following supra- condylar fracture reduction toward children was firstly introduced by Casino (1960) it is an effective therapy in maintaining reduct- ion. Since then the fixation with K-Wire post supracondylar fracture reduction has become standard therapy for supracondylarhumerus fracture among children. However research by Otsuka and Kasser (1997) finding there are complication related to K-Wire fixation including iatrogenic injury of ulnar nerve and reduction failure, that lead to cubitus varus deformity. Research by Gordon et al (2001) and Kalenderer et al. (2008) finding there are an optimal K-Wire configuration gives adequate fracture stability following the re- duction and minimizes the risk of reduction failure.
Furthermore, Slongo et al. defined a new technique called lateral external fixation for managing displaced supracondylarhumerus fractures. The researchers used a small lateral external fixator in 31 pediatric patients; three patients had open supracondylarhumerus fractures, one had a Gustilo Type-I, and two had a Gustilo Type-II fractures. In both closed and open supracondylarhumerus fractures, normal range of motion was observed as well as excellent cosmetic results at the elbow. The authors stated that the main indications for this technique were irreducible fractures following use of the traditional closed techniques, oblique fractures that did not seem stabilized with classic methods, comminuted fractures, and open fractures of the humerus. According to this study, this technique may be considered as an alternative method to traditional percutaneous K-wire fixation, which provides to protect against secondary displacement and risk of malunion in cubitus varus . It may be seen that external fixation is a useful treatment modality in the management of open supracondylarhumerus fracture with bone loss. However, to the best of our knowledge,
Introductions: Cross or two lateral pinnings are the most commonly done procedures for displaced supracondylarhumerus fractures in children. A crossed pin is biomechanically stable than lateral pins, but associated with risk of iatrogenic ulnar nerve injury. Recent studies have shown stable fixation with three lateral pin construct. The purpose of this study was to evaluate the efficacy of three lateral divergent pinning for displaced supracondylarhumerus fractures.
Abstract: Objective: A meta-analysis was conducted to compare the effectiveness and safety of open or closed reduction and percutaneous pinning for pediatric displaced supracondylarhumerus fractures. Methods: Embase, Medline and Cochrane Library were searched to identify the relevant studies published from the year of 1992 to 2015. All the controlled clinical trials and random controlled trails published to compare the open and closed reduction and percutaneous pinning (CRPP, ORPP) for pediatric displaced supracondylarhumerus fractures were enrolled in the study. The study included randomized controlled trials (RCTs) and controlled clinical trial (CCT) to compare the effectiveness and safety of CRPP and ORPP for pediatric displaced supracondylarhumerus fractures. Two investigators independently searched articles, extracted data, and assessed the quality of included studies. Cochrane RevMan software version 5.3 was utilized to perform the meta-analysis. Meta-analysis was performed using random-effect model. Results: 1 RCTs and 6 CCTs involving a total number of 502 patients were enrolled in the study, while 273 subjects adopted CRPP and 229 cases adopted ORPP. No significant differences were detected for the results of carrying angel, Bauman angel and complication rate [MD=-1.62, 95% CI (-3.35, 0.10), P=0.07, I 2 =0%; MD=-1.17, (-5.50, 3.15), P=0.6, I 2 =87%; OR=1.23, 95% CI (0.67, 2.28), P=0.5, I 2 =31%]. Less mean hospital
Background: Kirschner wire fixation remains to be the mainstream treatment modality in unstable or displaced supracondylarhumerus fracture in children, with divergent lateral pins being the most preferred due to their sufficient stability and decreased risk of ulnar nerve injury. However, the entry point at which the proximal lateral pin can be inserted to achieve a more proximal exit and maximum divergence has not been reported. This study retrospectively analyzed the characteristics and factors influencing the entry and exit points of the proximal lateral pins.
Immediate complications like compartment syndrome are rare and long-term complications are decreased. Chance of infection and implant failure are minimum with this method of treatment. Basic aim in supracondylarhumerus fractures is to gain full range of motion of elbow and to obtain a normal appearance of elbow. This modality of treatment is associated with excellent functional outcomes by achieving a full range of motion at the elbow joint in majority of cases and no residual deformity due to malunion. Another advantage is that the removal of implant is an outdoor procedure.
Materials and Methods: A prospective study with 57 cases of displaced fracture supracondylarhumerus, treated by lateral (Group A n=28) and cross pinning (Group B n=29), was conducted between May 2013 and May 2015. Independent sample student’s t-test was done to assess the parameters like age, follow-up and duration of surgery. The results were expressed as mean with standard deviation and p<0.05 was considered as statistically significant.
Supracondylar fracture is a fracture of the distal humerus just above the epicondyles that runs transversely through the coronoid and olecranon fossae of the humerus . It constitutes 16.6% of all pediatric fractures and 60% - 70% of all elbow fractures. These fractures are mostly encountered in children who are less than 8 years old. Generally, extension type fractures seen after falling on an outstretched hand (95% - 98%). The major factor that may contribute to the predisposition of these fractures is ligamentous laxity .
A total of 216 patients with supracondylarhumerus fractures were admitted to the orthopedic wards either through the outpatient department or emergency services. Of the 216 patients, 140 were excluded from the present study as they did not fulfill the inclusion criteria. These included compound fractures (10 cases), aged [ 12 years (12 cases), were not fit for surgery/refused surgery (15 cases), were associated with ipsilateral forearm fractures (6 cases), or were being treated conservatively for Gart- land I and II fractures (46 cases). The remaining 76 patients were enrolled in the study. The method of patient selection for lateral entry or medial-lateral entry was random, using a computer-generated randomization table from http://www.randomization.com. The seed for the random number generator was obtained from the clock of the local computer and was printed at the bottom of the randomization plan. Fourteen patients were exclu- ded from the final analysis because of lost to follow-up. Our analysis included 62 patients who were followed up
In type 2 supracondylarhumerus fracture there is incomplete osseous separation. Some part of the posterior cortex is still in contact. The posterior cortex and periosteum provide inherent stability. With closed reduction stability can be obtained and can be maintained in posterior splint. Medial column collapse will lead to varus deformity. In such cases surgical management is necessary. Two lateral pins is sufficient for stability. Cross pinning is not needed. The pins are left outside the skin and supported in posterior splint for 3 to 4 weeks. They are then removed and range of motion exercises are started.
pointed stainless steel nails have better pur- chase in the head of humerus and produce less damage to the growth plate during penetration compared with blunt-ended nails. Blunt-tipped nails may push the proximal fragment instead of penetrating it; thus, the use of sharp-tipped nails was proposed for proximal humeral frac- tures . Of course, additional care must be taken to avoid perforation of the humeral head and penetration of the shoulder joint, which is much easier with sharp-pointed nails. The slow advancement of nails using multiple fluoro- scopic controls in both AP and lateral projection is mandatory until the final impaction of sharp nails to prevent misplacement (Figure 5). Re- trograde nail insertion using lateral and medial entry points was performed in nearly 70% of our cases. This configuration provides better balance of elastic forces and better fracture stability. If care is taken during dissection down the periosteum and good visualization, gentle retraction and soft tissue protection are ensured, the risk of both ulnar and radial nerve damage is minimal. The minimal complication rate that we observed with crossed pin fixation of supracondylarhumerus fractures  has been of great support. The insertion of both nails from the lateral side through a separate hole may be indicated for proximal humeral fractures [15, 27, 28] as the crossing of nails at the fracture site is not essential for the sta- bility of this type of fracture. Some surgeons have used this configuration even for diaphy- seal fractures to minimize the risk of ulnar
Supracondylar fracture of humerus is the most common fracture of elbow in children, and one of the most difficult fractures to treat. While some authors have relied on remodelling capability of distal humerus to compensate for inadequate reduction, most authors agree that accurate reduction with minimum soft tissue trauma is required to achieve the best possible functional results. Many different methods have been suggested for management of supracondylarhumerus fractures. A cast requires the elbow to be kept in acute flexion to maintain reduction. However, this increases the risk of ischemia and its irrevocable sequelae. Treatment by traction may give good cosmetic results but at the expense of function, requires prolonged stay in hospital and constant surveillance by frequent radiographs. Simple closed manipulation has been considered to be adequate in minimally displaced fractures, but with varying displacement, the results may be both cosmetically and functionally unacceptable. Open reduction of supracondylarhumerus fractures has been believed to cause severe stiffness, infection and myositis ossificans, mainly after lateral or posterior approach. Closed percutaneous K-wiring of these fractures has many advocates, but it is difficult in severe swelling and there occurs a probability of pin track infection and injury to nerve, mainly to the ulnar nerve with a placement of medial pin ulnar nerve gets injured.
It is the most common complication of supracondylar fracture of the humerus. Cubitus varus occurs after poor reduction or loss of reduction. Malunion of the fracture occurs in three planes: internal rotation in the horizontal plane, medial rotation in the coronal plane, and extension in the sagittal plane. It is more of a cosmetic deformity than functional. But patients having cubitus varus deformity find difficult in throwing sports, push-ups and swimming. In patients who do not tolerate the deformity corrective osteotomy should be considered,