Kirschner wire reconstruction of medial and lateral column periosteal hinge in the treatment of multidirectionally unstable supracondylar fracture of the humerus in children

doi:10.21203/rs.3.rs-3346505/v1

Download PDF

Research Article

Kirschner wire reconstruction of medial and lateral column periosteal hinge in the treatment of multidirectionally unstable supracondylar fracture of the humerus in children

https://doi.org/10.21203/rs.3.rs-3346505/v1

This work is licensed under a CC BY 4.0 License

Journal Publication

published 12 Dec, 2023

Read the published version in European Journal of Medical Research →

You are reading this latest preprint version

Background Multidirectionally unstable supracondylar fracture of the humerus often requires open reduction. We present a simple technique for closed reduction using a Kirschner wire reconstruction-based treatment of internal and lateral column periosteal hinge for the treatment of multidirectionally unstable supracondylar fractures of the humerus in children.

Methods A retrospective cohort study was conducted to analyse the clinical data of 43 patients (27 male and 16 female; mean age: 3–13 [7.0±2.5] years old) with multidirectionally unstable supracondylar fractures of the humerus treated in our Hospital from August 2020 to August 2022. They were divided into two groups according to the development of surgical techniques in our hospital. From September 2021 to August 2022,Twenty-one cases were treated with Kirschner wire reconstruction of the internal and lateral columns periosteum hinge assisted by closed reduction and Kirschner wire internal fixation (study group), and from August 2020 to August 2021, Twenty-two cases were treated with closed reduction and Kirschner wire internal fixation (control group). The operation time, intraoperative fluoroscopy times, percentage of patients who underwent open reduction after failure of closed reduction (incision rate), fracture healing time, Baumann Angle, and Flynn score of elbow function at the last follow-up were compared between the two groups. Complications such as infection and irritation of Kirschner wire tail were observed in the two groups 2 months after the operation.

Results All patients were followed-up for 4–18 months ([8.6±4.2] months). The average operation time of the control group was 84.5 min (range: 51.0–111.0 min), which was significantly longer than that of the study group 34.4 min (range: 25.5–41.5 min) (P<0.05). The number of intraoperative fluoroscopy (30.0±8.9) in the control group was significantly higher than that in the study group (16.4±6.2) (P<0.05). The incision rate of the control group was 18% while that of thestudy group was 0 (P<0.05). The fracture healing time of the control group and the study group were 4.6±1.1 weeks and 4.3±0.7 weeks, respectively (P>0.05). Baumann Angle was 71.0±2.1° in the control group and 71.0±2.6° in the study group (P>0.05). According to Flynn score, the excellent and good rates of the elbow joint in the control group was 86.3%(19/21), including 17 excellent, 2 good, 3 fair, and 0 bad cases. The excellent and good rate of the elbow joint in the study group was 95.2%(20/21), including 18 excellent, 2 good, 1 fair, and 0 bad cases (P>0.05). No infection or Kirschner wire tail irritation occurred in the two groups during the 2-month follow-up.

ConclusionReconstruction of internal and lateral periosteal hinges with Kirscher wire has similar effects to closed reduction and Kirschner wire fixation in the treatment of multidirectionally unstable supracondylar fractures of the humerus in children, but it can shorten the operation time, reduce intraoperative fluoroscopy times and incision rate.

child

multidirectionally unstable

supracondylar humeral fractures

closed reduction

percutaneous fixation

The most common elbow fracture in children is supracondylar fracture of the humerus, and the extended fracture is the most common[1-4]. Currently, the Gartland classification is most widely used in clinical practice [5]. For Gartland types I and IIA, outpatient manual reduction and plaster external fixation are used. Gartland types IIB and III more closed reduction and internal fixation is needed. In 2006, Leitch et al. [6] reported a special type of fracture. The complete fracture of the periostium hinge at the broken end, lacking support at the broken end, and showing instability in the extension of the elbow joint. This type accounted for about 3% of all supracondylar fractures of the humerus in children with displaced fractures and was named the modified Gartland type IV fracture, also known as “multidirectionally unstable supracondylar fractures of the humerus”. There is a lot of overlap between Gartland type IV and flexion type supracondylar fractures of the humerus in children [7-8]. Most supracondylar fractures of the humerus in children with flexion type can also be considered as Gartland type IV. The treatment of such fractures is one of the most challenging tasks for orthopaedic surgeons. The goal of treating supracondylar fractures of the humerus in children is to achieve anatomical reduction and reduce the incidence of complications as much as possible. In view of the particularity of this kind of fracture, it is impossible to obtain stable fracture reduction before intraoperative Kirschner wire placement, and the conventional closed reduction method becomes “ineffective,” and may even require repeated intraoperative reduction, thereby making it difficult to achieve satisfactory results. Eventually, open reduction has to be performed. In recent years, new surgical methods have been used to improve the success rate of minimally invasive treatments for this fracture type, but there is still no unified surgical method available. Therefore, we tried a variety of reduction methods during the operation. We found that the fracture was stabilized by using Kirschner wires inserted into the proximal humeral medullary space from both the medial and lateral sides of the distal fracture. We can consider the distal and proximal fracture and Kirschner wires as a whole. By using this technique, the distal and proximal ends of the fracture can be well reduced by relying on the Kirschner wire as the periosteum hinge.

1.1 General information

The inclusion criteria were: (1) multidirectionally unstable supracondylar fractures of the humerus with definite preoperative or intraoperative fluoroscopy imaging diagnosis; (2) ≤14 years old; (3) no manual reduction and non-surgical treatment was performed before surgery; (4) not accompanied by other injuries or underlying diseases; (5) postoperative follow-up time, ≥6 months; and (6) availability of complete medical records. The exclusion criteria were: (1) supracondylar fracture of the humerus diagnosed as non-multidirectionally unstable by preoperative imaging changed to non-multidirectionally unstable owing to the operator’s error; (2) open fracture; (3) pathological fracture; (4) complicated with vascular or nerve injury or osteofascial compartment syndrome; and (5) multiple fractures, craniocerebral injury, or chronic disease.

A total of 43 patients (27 male and 16 female; mean age: 3–13 [7.0±2.5] years old) with multidirectionally unstable supracondylar fractures of the humerus were included. They were divided into two groups according to the development of surgical techniques in our hospital. From September 2021 to August 2022,Twenty-one cases were treated with Kirschner wire reconstruction of the internal and lateral columns periosteum hinge assisted by closed reduction and Kirschner wire internal fixation (study group), and from August 2020 to August 2021, Twenty-two cases were treated with closed reduction and Kirschner wire internal fixation (control group). The comparison of general data between the two groups showed no statistical significance (all P>0.05), indicating comparability (Table 1).

1.2 Surgical methods

The patient was placed in the supine position, and after full anaesthetic conduction combined with static aspiration, the receiver of the mobile C-arm X-ray machine (Siemens Medical Instrument Co., Ltd., Germany) was close to the edge of the operating bed, and the C-arm X-ray machine receiver was used to replace the operating table. Lead clothing was applied to the neck, chest, abdomen, and pelvis of the patient, and semi-aseptic technology was used for routine disinfection [9]. The surgeon and his assistant fully traction the fracture end. If the skin in front of the elbow is depressed, shows ecchymosis, or the fracture tip is inserted, the “milking” method can be tried to restore the inserted fracture end [10].

Study group: With continued traction, the X-ray confirmed that recessed the fracture and bowed the elbow(Figure 1.1). The distal end of the fracture was showed extreme ulnar skew, and a 2.0-mm diameter Kirschner wire was drilled into the proximal medullary cavity with an electric drill from the lateral condyle of the distal humerus (the above procedure can also be performed by the surgeon alone). The C-arm X-ray machine confirmed that the Kirschner wire had entered the proximal medullary cavity(Figure 1.2), and then the distal end of the fracture was extremely radially skewed. A 1.5-mm or 2.0-mm Kirschner wire was drilled using an electric drill from the distal medial epicondyle of the humerus (the ulnar nerve should be protected) into the proximal medullary cavity of the fracture(Figure 1.3). A 2.0-mm Kirschner wire was selected for children ≥6 years old and 1.5-mm Kirschner wire was selected for children <6 years old. At this point, the distal, broken, and proximal ends of the fracture are viewed as a whole with the Kirschner wire as a bridge, so that the Kirschner wire acts as a temporary periosteum hinge to reconstruct the periosteum hinge of the distal internal and lateral pillars of the humerus. The Kirschner wire stabilizes the fracture end and can correct displacement. After cross placement, flexion, and extension of the elbow joint were performed, and fluoroscopy of the C-arm X-ray machine was used to verify the stability of the fracture. The Kirschner wire in the medullary cavity could be either removed or retained.

Control group: Due to the complete instability of the broken end of the fracture, the assistant applied external force from the radio-lateral ulnar side (radio-lateral humerus supracondylar fracture) or ulnar side (ulnar lateral humerus supracondylar fracture) to correct the coronal displacement and maintain the reduction. The surgeon first placed two Kirschner wires from the lateral condyle of the humerus. Anteroposterior and lateral elbow fluoroscopy was performed under the C - arm. If the fracture is well reduced, continue to insert Kirschner wire on the ulnar side. If the reduction of the fracture is unsatisfactory, open reduction should be used instead.

1.3 Postoperative management

All patients were fixed using plaster support after surgery. The degree of swelling, finger sensation, and activity of the affected limb were observed during hospitalization. Regular postoperative dressing changes were carried out, and patients were discharged when no obvious exudation and swelling were observed. After the discharge, the dressing was changed regularly in the outpatient department and the Kirschner wire tail exudation was observed. Four weeks after the surgery, an outpatient review was carried out. At this time, if the positive and lateral radiographs showed rich callus growth, the plaster could be removed, the Kirschner wire pulled out, and the patient advised to follow active functional exercise.

1.4 Observation indices

The operation time, intraoperative fluoroscopy times, proportion of patients who underwent open reduction due to closed reduction failure (hereinafter referred to as the incision rate), fracture healing time, and Flynn score of elbow function at the last follow-up were compared between the two groups [11].(excellent: elbow flexion and extension were normal with lifting angle within 10°–15°; good: limited elbow flexion <5°, reduced lifting angle or elbow varus within 0°–5°; Fair: elbow joint flexion and extension limited in 0°–10°, elbow varus in 6°–10°; Difference: limited flexion and extension of elbow >11°, elbow varus within 11°–15°). Complications such as infection and irritation of Kirschner needle tail were monitored in the two groups 2 months after operation.

1.5 Statistical analysis

SPSS25.0 statistical software (IBM Corporation, Armonk, NY, USA) was used for all statistical analysis. Kolmogorov–Smirnov method was used to test for data normality. Measurement data conforming to the normal distribution were expressed as ±s. For comparison between groups, the t-test of two independent samples was used; for measurement data not conforming to the normal distribution, 95% confidence interval (CI) was calculated to reflect the difference between the two groups. Statistical data were expressed as a percentage and chi-square test was used for comparison between groups. All tests were two-sided, and P<0.05 was considered to indicate statistically significant differences.

All patients were followed up for 4–18 (8.6±4.2) months. The average operation time of the control group was 84.5 min (range: 51.0–111.0 min) and longer than that of the study group 34.4 min (range: 25.5–41.5 min) (P<0.05). Intraoperative fluoroscopy was 30.0±8.9 times in the control group and 16.4±6.2 times in the research study group (P<0.05) (Table 2). The incision rate of the control group was 18.2% (4/22) higher than that of the study group (0) (χ²=4.210, P=0.040). There was no significant difference in fracture healing time between the control and study groups (P>0.05). The Baumann angle of the control group was 71.0±2.1° and that of the study group was 71.0±2.6°. According to Flynn score, the excellent and good rates of the elbow joint in the control group was 86.3%(19/22), including 17 excellent, 2 good, 3 fair, and 0 bad cases. The excellent and good rate of the elbow joint in the study group was 95.2%(20/21), including 18 excellent, 2 good, 1 fair, and 0 bad cases (P>0.05). There was no significant difference in the rate of excellent and good between the two groups (χ2=1.000, P=0.317). After 2 months, no patient in either group showed any infection or Kirschner wire tail irritation. Typical cases are shown in Figure 2(2.1-2,7).

The treatment of multidirectionally unstable supracondylar fractures of the humerus in children is challenging. Due to complete fracture of periosteum hinge, unstable fracture end, prolonged operation time, increased fluoroscopy times, high incision rate, and difficult closed reduction, it is challenging to achieve ideal reduction requirements for conventional closed reduction and Kirschner wire puncture treatment for such fractures [12-14]. To improve the treatment effect of this type of fracture, researchers and clinicians worldwide continue to explore surgical methods such as common lever-assisted reduction technology, prying reduction technology, and joysticks reduction technology, but no consensus has yet been reached [15-16]. The results of this study showed that the reconstruction of internal- and lateral-column periosteum hinges with Kirschner wire–assisted closed reduction and internal fixation with Kirschner wire could effectively reduce the operation time, reduce the number of fluoroscopies, reduce the incision rate, and improve the success rate of minimally invasive surgery.

The results of our study showed that both groups of patients achieved satisfactory efficacy and had no infection or Kirschner wire tail irritation. The main advantage of this method is the shortened operation time. This method increased the stability of the broken end of the fracture. After traction, the Kirschner wire was inserted both into the distal lateral condyle and the medial epicondyle of the fracture, through the fracture end, and into the pulp cavity of the proximal end of the fracture. The distal and proximal ends of the fracture were fixed as a whole with Kirschner wire as the support. This procedure resulted in improved coronal reduction of the fracture. Silva et al. [10] found that multidirectional unstable supracondylar humerus fractures (type IV) in children required longer operation time, averaging 70 min (range: 49–96 min). In this study, the average operation time of the control group was 84.5 min, while that of the study group was 34.4 min, which was significantly less than that of Silva et al. In conclusion, Kirschner wire reconstruction of internal and lateral column periosteal hinges for the treatment of multidirectionally unstable supracondylar humerus fractures in children can shorten the operative time. Another important advantage of this method is the reduced intraoperative fluoroscopy times. Wei et al. [15] found that the number of intraoperative fluoroscopies in the assisted treatment of multidirectionally unstable supracondylar fractures of the humerus in children with olecranon Kirschner wire threading technique was significantly less than that in patients treated with conventional closed reduction. They speculated that the use of joystick technology to assist the reduction of multidirectionally unstable supracondylar humerus fractures in children is a good choice and can reduce the time of fluoroscopy and achieve good reduction effect. However, the disadvantage is that during the operation, the surgeon and his assistant should maintain the reduction state and continue to be exposed to radiation. In this study, the fluoroscopy times were 30.0±8.9 times in the control group and 16.4±6.2 times in the study group. It can be seen that our method can significantly reduce the intraoperative fluoroscopy times; moreover, there is no need to use additional reduction tools or increase X-ray exposure to the surgeon. This method also increase the success rate of closed reduction. It has been reported in the literature that forced and repeated reduction is not recommended for children with multiple intraoperative closed reduction failures, which may lead to iatrogenic soft tissue injury [16], and open reduction should be replaced to the closed reduction. Some scholars believe that there is no significant difference between closed reduction and open reduction internal fixation in fracture stability and functional recovery [17]. However, more scholars believe that closed reduction can achieve better efficacy and lower the occurrence of complications than open reduction [18]. Therefore, to reduce the open reduction rate of fracture, scholars have been exploring better closed reduction techniques. Silva et al. [10] found in the treatment of multidirectionally unstable supracondylar fractures of the humerus in children (type IV) that closed reduction failed in two patients during the operation and open reduction was required, with an open reduction rate of 17% (2/12). In this study, four cases in the control group failed closed reduction and were required to undergo open reduction, with an open reduction rate of 18% (4/22). In the study group, closed reduction was successful, and the open reduction rate was 0%. The results of this study were similar to the surgical reduction effects of Silva et al. [10] and Wei et al. [15]. In addition, there was no difference in elbow joint function between the two groups at the last follow-up, and all of the patients elbow joint function returned to normal.

The surgical technique can be used to treat fractures. These include: (1) flexion type supracondylar fracture of the humerus in children, complete fracture of periosteum hinge; (2) extended supracondylar fracture of the humerus in children, complete fracture of periosteal hinge, multidirectional instability; and (3) fractures of distal metaphyseal humerus in children with multidirectional instability.

The surgical technique has the following operating points. These include: (1) continuous and effective traction by the surgeon and his assistant before fracture reduction is critical; (2) anteroposterior radiographs showed traction separation at both ends of the fracture, and Kirschner wires were inserted into the proximal medullary cavity through the distal epicondyle and lateral condyle of the fracture. When the distal end of the fracture is connected with the proximal end, the distal end of the fracture and the proximal end of the Kirschner wire are a whole, and the Kirschner wire can be regarded as a temporary hinge at the fracture end, stabilize the fracture end, apply external force from the distal end of the fracture to the ulnar side of the radialis supracondylar fracture, correct the radialis deformity, and pronate the forearm to reduce the sagittal plane. For ulnar-deviated humerus supracondylar fracture, the opposite reduction technique can be used. (3) Flexion and extension of elbow joints were performed after the cross placement of Kirschner wires. The fracture was verified by fluoroscopy with C-arm X-ray machine. The medullary nail could be removed or left in the indentation. (4) Special attention should be paid to whether all operations are carried out on the receiver of the C-arm X-ray machine, and the reduction should be careful and gentle to avoid additional damage to peripheral blood vessels, nerves, and soft tissues caused by violent surgical manoeuvres. In addition, thumb pick should be used to shield the ulnar nerve when placing the medial column Kirschner wire, so as to prevent iatrogenic ulnar nerve injury.

In conclusion, for children with multidirectionally unstable supracondylar humerus fractures, Kirschner wire reconstruction with internal and lateral column periosteum hinge-assisted closed reduction and Kirschner wire internal fixation have similar therapeutic effects as closed reduction and Kirschner wire internal fixation, but can shorten the operation time, reduce intraoperative fluoroscopy times, and reduce the incision rate. There are some limitations in this study. For example, different surgeons may lead to differences in operation time. Further, the sample size is small, so future studies should aim to be multi-centric in design and aim to include more patients to further validate this technique and our results. The strength of this study is that it describes a new surgical technique that simplifies this complex fracture reduction technique. In addition, the surgical technique is relatively simple to operate and easy to learn.

Ethical Approval

This is a retrospective study approved by Ethics Committee of Anhui Provincial Children's Hospital.The requirement for informed consent was waived because of the use of completely anonymized data.

Competing interests

I declare that the authors have no competing interests as defined by BMC, or other interests that might be perceived to influence the results and/or discussion reported in this paper.

Authors' contributions

Hai-Long Ma, Si-Cheng Zhang, Xi-Wei Sun, Fang Liu, Zhong-Tuo Hua:Project design, implementation and thesis writing

Hai-Long Ma, Xi-Wei Sun, Fang Liu:Collect, analyze and interpret data

Jun Sun, Si-Cheng Zhang:Writing instruction and paper revision

Jun Sun, :Provide administrative, material and surgical technical support

Funding

Not applicable

Availability of data and materials

All of the material is owned by the authors and/or no permissions are required.

Dineen HA, Stone J, Ostrum RF. Closed reduction percutaneous pinning of a pediatric supracondylar distal humerus fracture. J Orthop Trauma, 2019, 33 Suppl 1:S7-S8.
Carter CT, Bertrand SL, Cearley DM. Management of pediatric type III supracondylar humerus fractures in the United States: results of a national survey of pediatric orthopaedic surgeons. J Pediatr Orthop, 2013, 33:750-754.
Kropelnicki A, Ali AM, Popat R, et al. Paediatric supracondylar humerus fractures. Br J of Hosp Med (Lond), 2019, 80:312-316.
Duffy S, Flannery O, Gelfer Y, et al. Overview of the contemporary management of supracondylar humeral fractures in children. Eur J Orthop Surg Traumatology, 2021, 31:871-881.
Gartland JJ. Management of supracondylar fractures of the humerus in children. Surg Gynecol Obstet, 1959, 109:145-154.
Leitch KK, Kay RM, Femino JD, et al. Treatment of multidirectionally unstable supracondylar humeral fractures in children. A modified Gartland type-Ⅳ fracture. J Bone Joint Surg Am, 2006, 88:980-985.
Mitchell SL, Sullivan BT, Ho CA, et al. Pediatric Gartland type-IV supracondylar humeral fractures have substantial overlap with flexion-type fractures. J Bone Joint Surg Am. 2019, 101:1351-1356.
Flynn K, Shah AS, Brusalis CM, et al. Flexion-type supracondylar humeral fractures: ulnar nerve injury increases risk of open reduction. J Bone Joint Surg Am, 2017, 99: 1485-1487.
Iobst CA, Spurdle C, King WF, et al. Percutaneous pinning of pediatric supracondylar humerus fractures with the semisterile technique: the Miami experience. J Pediatr Orthop, 2007, 27: 17-22.
Silva M, Cooper SD, Cha A. The outcome of surgical treatment of multidirectionally unstable (Type IV) pediatric supracondylar humerus fractures. J pediatr orthop, 2015, 35:600-605.
Flynn JC, Matthews JG, Benoit RL. Blind pinning of displaced supracondylar fractures of the humerus in children. Sixteen years’ experience with long-term follow-up. J Bone Joint Surg Am, 1974, 56:263-272.
Segal D, Cobb L, Little KJ. Fracture obliquity is a predictor for loss of reduction in supracondylar humeral fractures in older children. J Pediatr Orthop B, 2020, 29:105-116.
Green BM, Stone JD, Bruce RW Jr, Fletcher ND. The use of a transolecranon pin in the treatment of pediatric flexion-type supracondylar humerus fractures. J Pediatr Orthop 2017; 37:e347–e352.
LiBrizzi CL, Klyce W, Ibaseta A, et al. Sex-based differences in pediatric supracondylar humerus fractures. Medicine (Baltimore), 2020, 99:e20267.
Wei YS, Liu WL, Bai R, et al. The use of a transolecranon pin joystick technique in the treatment of multidirectionally unstable supracondylar humeral fractures in children. J Pediatr Orthop B, 2020, 29:452-457.
Georgescu I, Gavriliu S, Pârvan A, et al. Burnei’s “double X” internal fixation technique for supracondylar humerus fractures in children: indications, technique, advantages and alternative interventions: Study and Research Group in Pediatric Orthopaedics-2012. J Med Life, 2013, 6:131-139.
Lee HY, Kim SJ. Treatment of displaced supracondylar fractures of the humerus in children by a pin leverage technique. J Bone Joint Surg Br, 2007, 89:646-650.
Aktekin CN, Toprak A, Ozturk AM, et al. Open reduction via posterior triceps sparing approach in comparison with closed treatment of posteromedial displaced Gartland type Ⅲ supracondylar humerus fractures. J Pediatr Orthop B, 2008, 17:171-178.

Table 1 Comparison of general data of patients with multidirectionally unstable supracondylar fracture of the humerus between the two groups

Group	Total (n)	Sex		Age (years,±s）	Cause of injury		Profile		Time from injury to operation (h) OR (95%CI)
Group	Total (n)	Male (n)	Female (n)	Age (years,±s）	Fall injury (n)	Sports injury (n)	Left (n)	Right (n)	Time from injury to operation (h) OR (95%CI)
Control group	22	13	9	6.8±2.6	15	7	13	9	36.6 (26.8 to 48.0)
Study group	21	14	7	7.2±2.4	16	5	12	9	42.3 (27.5 to 48.0)
Statistic value		0.264		-0.554	0.343		0.017		-0.487
P-value		0.607		0.583	0.558		0.897		0.626

Independent-samples t-test.

chi-squared test

CI, confidence interval; OR, odds ratio.

Table 2 Comparison of operative time, intraoperative fluoroscopy times, fracture healing time, and Baumann angle in patients with multidirectionally unstable supracondylar fractures of the humerus between the two groups

Group	Total (n)	Operation time (min) OR (95%CI)	Intraoperative fluoroscopy times	Fracture healing time (weeks)	Baumann angle (°)
Control group	22	84.5 (51.0 to 111.0)	30.0±8.9	4.6±1.1	71.0±2.1
Study group	21	34.4 (25.5 to 41.5)	16.4±6.2	4.3±0.7	71.0±2.6
Statistic value		-4.622	5.829	0.901	0.000
P-value		0.000	0.000	0.373	1.000

Independent-samples t-test.

chi-squared test

CI, confidence interval; OR, odds ratio.

No competing interests reported.

Download PDF

Journal Publication

published 12 Dec, 2023

Read the published version in European Journal of Medical Research →

Editorial decision: Major revision
16 Oct, 2023
Reviews received at journal
27 Sep, 2023
Reviewers agreed at journal
24 Sep, 2023
Reviewers invited by journal
24 Sep, 2023
Editor assigned by journal
13 Sep, 2023
Submission checks completed at journal
13 Sep, 2023
First submitted to journal
11 Sep, 2023

You are reading this latest preprint version

Kirschner wire reconstruction of medial and lateral column periosteal hinge in the treatment of multidirectionally unstable supracondylar fracture of the humerus in children

Status:

Journal Publication

Version 1

Abstract

Figures

Introduction

Clinical data and methods

Results

Discussion

Declarations

References

Tables

Additional Declarations

Status:

Journal Publication

Version 1