Three-wire Technique for Irreducible Extension Type Supracondylar Humeral Fracture in Children.

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Mahmoud Badawy, Sami Ibrahim Sadek, Mohammad Hassan, Ahmed Mostafa Elnagar, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7424376/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 15 Dec, 2025 Read the published version in Journal of Orthopaedic Surgery and Research → Version 1 posted 17 You are reading this latest preprint version Abstract Introduction: Irreducible extension type supracondylar humeral fracture [ESCHF] accounts for 3–15% of cases and often requires open reduction, which carries risks of complications. This study describes and reports the outcomes of the three-wire technique in treating irreducible ESCHF. Patients and methods: Twenty patients with irreducible ESCHF (8 girls and 12 boys) were operated on using the three-wire technique. We inserted two K-wires in an unreduced position in the distal fragment and one proximal wire just above the olecranon fossa and used these three wires for manipulation and correction of sagittal, coronal, and rotational deformities at the fracture site. Results: All fractures achieved acceptable closed reduction, with a mean operation time of 32.65 minutes. Radiological assessments showed favorable outcomes: the mean Baumann angle was 19.95 degrees, the carrying angle averaged 12.95 degrees, and the anterior humeral line dissected the capitellum at the middle third in 16 cases and at the anterior third in 4 cases. Complications included mild pin tract infections in five cases, all resolved within a week after K-wire removal. Conclusion: The three-wire technique is effective for managing irreducible ESCHF, providing good outcomes while avoiding the risks associated with open reduction. extension type supracondylar humeral fracture irreducible supracondylar humeral fracture closed reduction techniques for supracondylar humeral fracture Figures Figure 1 Figure 2 Introduction Extension type supracondylar humeral fracture [ESCHF] accounts for about 97% of all supracondylar humeral fractures [SCHF] in children. 1 Gartland classified these fracture into three types based on the degree of the displacement. 2 Leitch and coworkers 3 later added type IV SCHF, which represents a multidirectional unstable fracture that lacks any periosteal hinge. Most displaced ESCHF cases are treated with closed reduction and percutaneous pinning. However, a minority of cases where closed reduction fails necessitate open reduction. 4 Failed closed reduction is reported in the literature to be between 3–15% of cases. This has been attributed to many factors such as the severity of the injury, the fracture type, and soft tissue interposition. 5 – 8 Both repeated attempts at closed reduction and open reduction have their own complications. Repeated trials of closed reduction can increase the risk of compartment syndrome, neurovascular damage, and myositis ossificans. 9 Open reduction is associated with worse functional outcomes compared to closed reduction, including longer anesthesia time, scar formation, and poorer cosmetic results. 7 Patient and methods This retrospective study was conducted from March 2021 to March 2024, involving twenty patients with irreducible ESCHF (8 girls and 12 boys). The three-wire technique was used to facilitate the fracture reduction. The mean age of the patients was 10.2 ± 1.39 years (ranging from 6-13 years). Informed consent was obtained from each child's parent, and the study was approved by our Institutional Review Board (IRB) [ZU-IRB# 269/1-4-2024]. Among the cases, there were 11 right-sided and 9 left-sided fractures, with a mean follow-up period of 7 months (ranging from 4 to 9 months). There was one case of preoperative anterior interosseous nerve injury. The eligibility criteria required that patients had failed closed reduction of ESCHF after two to three trials using traditional closed reduction methods. Patients with ESCHF for more than 10 days since the time of the injury, open fractures, and fractures associated with vascular injury were excluded from the study. Demographic data indicated that 70% of the patients were either overweight or obese, 90% were either Gartland grade III or IV, and in 70% of the cases, high-energy trauma (such as sport participation and fall from height) was identified as the mechanism of injury [Table 1]. Table 1 Distribution of patients according to demographic data: variable N=20 % p-value Sex Female Male 8 12 40% 60% 0.503 Side of lesion Left Right 9 11 45% 55% 0.824 Age (year) 6 - 8 years >8 – 13 years Mean ± SD 9 11 10.2 ± 1.39 45% 55% 0.824 Obesity Normal Overweight Obese 6 7 9 30% 35% 35% 0.387 Time from injury to surgery 8 - 48 hours 9 11 45% 55% 0.263 Fracture type IIb III IV 2 14 4 10% 70% 20% 0.002* Mechanism of trauma High energy Low energy 14 6 70% 30% 0.004* Continuous variables were expressed as mean ± standard deviation (SD), Categorical variables were expressed as number (percentage) and One sample Chi-square test; p-value<0.05 is significant. Surgical technique; With the patient positioned supine and under general anesthesia, the affected upper extremity was sterilized and draped. Initially, two to three closed reduction trials were done for all cases. For those that remained irreducible, the three-wire technique was used (Figure 1A). This technique followed the same principles described by the first author for facilitating closed reduction of flexion type SCHF. 10 In the unreduced position, two appropriately sized K-wires (1.2 – 1.8 mm) were inserted into the distal fracture fragment; one in the lateral column and one in the medial column, both positioned short of the fracture line. A third K-wire was inserted into the proximal fracture fragment, approximately 1 cm above the olecranon fossa from a lateral to medial direction (Figure 1B). To prevent injury to the radial nerve, the proximal wire was introduced posterior to the lateral edge of the humerus. The reduction process began with traditional traction and countertraction, maintaining the elbow in 30 degrees of flexion. This was followed by correcting the coronal plane deformity and flexing the elbow while pushing the distal fragment anteriorly. 11 The three-wire technique facilitated the correction of the residual fracture deformities (Figure 1C). Disimpaction of the fracture fragments was achieved by pulling the distal wires distally and the proximal wire proximally. The technique effectively corrected the frontal and sagittal plane angulation, but not the translation. Rotational deformity was corrected by rotating the proximal fragment medially or laterally using the proximal joystick wire. The accuracy of the reduction was verified under the image intensifier, with the lateral view obtained by rotating the image intensifier itself. Once an acceptable reduction was achieved, the lateral wire was advanced through the fracture site to engage the medial cortex proximally, while maintaining the reduction with the proximal and medial wires. Subsequently, the medial wire was advanced through the fracture site in a cross direction to the lateral wire to engage the lateral cortex proximally, again ensuring that the reduction was preserved with the aid of the proximal and lateral wires (Figure 1D). Finally, an additional lateral K-wire was introduced to secure the fixation of this unstable fracture (Figure 1E). The accuracy and stability of the reduction were confirmed by gently stressing the fracture under the image intensifier in all directions. Distal pulsation was checked, and a back slab was applied with the elbow in 90 degrees of flexion and the forearm in neutral rotation. Figure 2 illustrates the preoperative, intraoperative, and postoperative follow-up of a male patient with irreducible ESCHF. Postoperative care and follow-up Clinically, we assessed the neurovascular status of the limb. There was one case of preoperative anterior interosseous nerve injury, which improved during the follow-up period. Radiologically, plain radiographs in both anteroposterior and lateral views were performed at the immediate postoperative period to assess the accuracy of the reduction. Follow-up radiographs were taken at the 4th and 6th weeks to assess fracture union, with additional imaging conducted at the final follow-up to evaluate the carrying angle, Baumann’s angle, and the anterior humeral line. Data analysis Data analysis was performed using the software SPSS (Statistical Package for the Social Sciences) version 27. Categorical variables were described using their absolute frequencies. Shapiro-Wilk test was used to verify assumptions for use in parametric tests. Quantitative variables were described using their means and standard deviations. Pearson (for normally distributed data) and Spearman rank correlation coefficient ((for not normally distributed data) were used to measure strength and association of correlation between two continuous variables. One sample chi square test to measure goodness of fit between observed and expected data The level statistical significance was set at P <0.05. Results At the final follow-up of the current study, all fractures were united in an acceptable position. The time to union ranged from 4 to 6 weeks, with a mean of 5.15 ± 0.81 weeks. The evaluation of radiological parameters for fracture reduction included the Baumann angle, the anterior humeral line, and the carrying angle. The mean Baumann angle was 19.95 ± 1.7 [ranging from 17 to 23] degrees. The anterior humeral line intersected the capitellum at the middle third in 16 cases and at the anterior third in 4 cases. The carrying angle ranged from 6 to 15 degrees, with a mean of 12.95 ± 3.85 degrees. According to Flynn clinical criteria, 12 15 patients achieved excellent outcomes, while five patients were rated as having good outcomes. In this study, the mean operation time was 32.65 ± 4.38 minutes, and the average number of C-arm images used during the procedures was 25.3 ± 5.75 [Table 2]. Regarding complications, there were five cases of mild pin tract infection, all of which resolved within one week following the removal of the K-wires. Additionally, one patient experienced preoperative anterior interosseous nerve neuropraxia, which showed improvement during the follow-up period. Table 2 The final follow-up results of the current study. N=20 % Time till union 4 weeks 5 weeks 6 weeks Mean ± SD 5 7 8 5.15 ± 0.81 25% 35% 40% Flynn criteria Excellent Good 15 5 75% 25% Mean ± SD Range Operation time 32.65 ± 4.38 25 – 40 Baumann angle 19.95 ± 1.7 17 – 23 Carrying angle 12.95 ± 3.85 6 – 15 C-arm images 25.3 ± 5.75 13 – 31 Continuous variables were expressed as mean ± standard deviation (SD), Categorical variables were expressed as number (percentage) Discussion Closed reduction and percutaneous pinning is the primary treatment for displaced ESCHF. However, achieving an acceptable reduction using traditional closed reduction methods is not always feasible. 13 According to Sun and coworkers, the fracture type, mechanism of the injury, and timing between injury and surgery are independent risk factors for failed closed reduction. The fracture type-Gartland type III fractures- are particularly associated with a higher rate of open reduction. This is due to the complete loss of cortical contact, the absence of a periosteal hinge, and the potential for soft tissue entrapment. The mechanism of injury is another independent risk factor for failed closed reduction. High-energy trauma can lead to increased swelling of the elbow, marked fracture displacement, and comminution, complicating the reduction process. Lastly, the time between injury and surgery, Sun et al. reported that the rate of open reduction increased from 10.2–29.1% if surgery was delayed beyond 8 hours. Furthermore, if surgery was performed between 8 hours and 5 days post-injury, the rate of open reduction rose to 65%. This increase is attributed to swelling at the fracture site, which obscures bony landmarks and makes fracture reduction more challenging. 14 In the current study, we observed similar trends in our patient analysis. We found that 70% of the irreducible cases were classified as Gartland type III fractures, and 70% of the cases resulted from high-energy trauma. However, there was no significant statistical difference between patients who presented for treatment within 8 hours of injury and those who presented after 8 hours. Additionally, we noted that 70% of our irreducible cases involved patients who were either overweight or obese. Obesity obscures the bony landmarks during the reduction process, making it more challenging to achieve a successful closed reduction. Therefore, we recommend further investigation into overweight and obesity as potential independent risk factors for failed closed reduction. Leitch and his colleagues described the multidirectional unstable SCHF and classified it as grade IV SCHF. This fracture is unstable in both flexion and extension due to the complete loss of the periosteal hinge both anteriorly and posteriorly. They recommended inserting two lateral K-wires in the unreduced position and rotating the image intensifier rather than the patient's arm to achieve an acceptable closed reduction. 3 We had four cases of irreducible type IV, all of which were successfully reduced using the three-wire technique. Heffernan and his colleagues reported the reversed oblique SCHF, where the fracture line in the sagittal plane extends from anterior and proximal to posterior and distal. This type of fracture is challenging to reduce using traditional closed methods due to the presence of an anterior spike in the distal fragment, which faces a posterior metaphyseal spike in the proximal fragment. They recommended maintaining the distal fragment in its displaced posterolateral position while translating it anteriorly to disimpact the proximal fragment. 15 In the current study, we had two reversed oblique ESCHFs. With the assistance of the three-wire technique, we were able to achieve posterior angulation with the apex anterior and manipulate the fragments until they were off-ended, facilitating the reduction. Many studies reported the use of posterior intrafocal K-wire for the correction of sagittal plane deformity. They used the posterior wire solely for reduction 16 , 17 or for both reduction and fixation. 18 However, this technique is not recommended for fractures with posterior comminution or suspected neurovascular entrapment. Additionally, it is ineffective for correcting coronal or rotational deformities. Basaran et al. 19 utilized a proximal K-wire as a joystick to facilitate the correction of rotational deformities. They initially corrected the coronal plane deformity, then inserted a lateral K-wire for the fixation of the fracture fragments, and subsequently used the proximal joystick wire to address the rotational deformity. However, the positioning of the proximal wire just distal to the deltoid insertion, far from the fracture site, resulted in less control over the proximal fragment. Additionally, if there is a residual sagittal plane deformity, it will be difficult to correct in the presence of the lateral K-wire. Ma and coworkers described a technique using K-wires for the reconstruction of the medial and lateral column periosteal hinges in type IV SCHF. In their approach, two K-wires were inserted—one into the medial column and the other into the lateral column of the distal fragment—extending into the medullary canal of the proximal fragment. They concluded that this technique reduced operation time, fluoroscopy exposure, and the rate of incisions required. 20 Lin and coworkers described the use of de-sharpened K-wire introduced at the lateral column of the distal fragment to enter the medullary cavity. They noted that as the K-wire advanced deeper into the medullary canal, it facilitated the correction of lateral coronal plane displacement. They concluded that the use of de-sharpened K-wires provided satisfactory reductions comparable to traditional methods, while also reducing operation time and minimizing exposure to radiation from the image intensifier. 21 In this study, the three-wire technique effectively facilitated the reduction of irreducible cases and helped avoid potential complications associated with both repeated closed reduction trials and open reduction. The mean operation time was 32.65 ± 4.38 minutes, which is comparable to the findings of Ma et al. 20 (32.32 ± 10.25 minutes) and Lin et al. 21 (32.88 ± 3.69 minutes). The average number of intraoperative fluoroscopies was 25.3 ± 5.75, slightly higher than that reported by Ma et al. (15.24 ± 6.25) and Lin et al. 21 (20.62 ± 5.41). This increase may be attributed to the fact that our study focused exclusively on irreducible cases. Conclusion: The three-wire technique is a straightforward and effective method for the closed reduction of irreducible ESCHF. This technique gives good to excellent results while avoiding the potential complications associated with open reduction. However, the current study has limitations, including a small sample size. Additionally, we did not investigate the risk factors for failed closed reduction due to the absence of a controlled group. Declarations Disclosure The author(s) report no conflicts of interest in this work. Funding This research received no external funding. Author Contribution A,B,D,F performed surgeriesA, C,E reviewed the literatureA,B, C prepared and wrote the main manuscriptA, C, F prepared the figures All authors reviewed the manuscript. References Houshian S, Mehdi B, Larsen MS. The epidemiology of elbow fracture in children: analysis of 355 fractures, with special reference to supracondylar humerus fractures. J Orthop Sci. 2001;6:312–5. Gartland JJ. Management of supracondylar fractures of the humerus in children. Surg Gynecol Obstet. 1959;109:145–54. Leitch KK, Kay RM, Famino JD, et al. Treatment of multidirectionally unstable supracondylar humeral fractures in children. A modified Gartland type-IV fracture. J Bone Joint Surg Am. 2006;88:980–5. Shim JS, Lee YS. Treatment of completely displaced supracondylar fractures of the humerus in children by cross-fixation with three Kirschner wires. J Pediatr Orthop. 2002;22:12–6. Omid R, Choi PD, Skaggs DL. Supracondylar humeral fractures in children. JBone Joint Surg Am. 2008;90:1121–32. Ozkoc G, Gonc U, Kayaalp A, Teker K, Peker TT. Displaced supracondylarhumeral fractures in children: open reduction vs. closed reduction and pinning. Arch Orthop Trauma Surg. 2004;124:547–51. Aktekin CN, Toprak A, Ozturk AM, Altay M, Ozkurt B, Tabak AY. Open reduction via posterior triceps sparing approach in comparison with closed treatment of posteromedial displaced Gartland type III supracondylar humerus fractures. JPediatr Orthop B. 2008;17:171–8. Mazzini JP, Martin JR, Esteban EMA. Surgical approaches for open reduction and pinning in severely displaced supracondylar humerus fractures in children: asystematic review. J Child Orthop. 2010;4:143–52. Abzug JM, Herman MJ. Management of supracondylar humerus fractures in children: current concepts. J Am Acad Orthop Surg. 2012;20:69–77. Badawy M, Amin HED, Abdel-Ghani H, Abdelaal AH, Yasin E. Technique for facilitating closed reduction of difficult flexion type supracondylar humeral fracture in children. J Pediatr Orthop B. 2023;32(6):565–8. Skaggs DL. Closed reduction and pinning of supracondylar humerus fractures. In: Tolo VT, Skaggs DL, editors. Master Techniques in Orthopaedic Surgery: Pediatrics. Philadelphia, PA: Lippincott Williams & Wilkins; 2008. pp. 1–15. 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;56:263–72. Mahan ST, May CD, Kocher MS. Operative management of displaced flexion supracondylar humerus fractures in children. J Pediatr Orthop. 2007;27:551–6. Sun LJ, Wu ZP, Yang J, Tian NF, Yu XB, Hu W, Chen H. Factors associated with a failed closed reduction for supracondylar fractures in children. Volume 100. Orthopaedics & Traumatology: Surgery & Research; 2014. pp. 621–4. 6. Heffernan MJ, Lucak T, Igbokwe L, Yan J, Gargiulo D, Khadim M. The reverse oblique supracondylar humerus fracture: description of a novel fracture pattern. J Pediatr Orthop. 2020;40(2):e131–7. 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;89:646–50. Sawaizumi T, Takayama A, Ito H. Surgical technique for supracondylar fracture of the humerus with percutaneous leverage pinning. J Shoulder Elb Surg. 2003;12:603–6. Fahmy MA, Hatata MZ, Al-Seesi H. Posterior intrafocal pinning for extension-type supracondylar fractures of the humerus in children. J Bone Joint Surg Br. 2009;91:1232–6. Basaran SH, Ercin E, Bilgili MG, Bayrak A, Cumen H, Avkan MC. A new joystick technique for unsuccessful closed reduction of supracondylar humeral fractures: minimum trauma. Eur J Orthop Surg Traumatol. 2015;25(2):297–303. Ma HL, Sun XW, Liu F, Hua ZT, Sun J, Zhang SC. Kirschner wire reconstruction of medial and lateral column periosteal hinge in the treatment of multidirectionally unstable supracondylar fracture of the humerus in children. Eur J Med Res. 2023;28(1):585. Lin Y, Hua Z, Zhou C, Chen S, Sun X, Liu F, Meng G, Zhang S, Sun J. A new technique of intramedullary elastic reduction of the de-sharpened Kirschner wire for the treatment of Gartland type III posterolateral displaced supracondylar fracture of the humerus in children. Eur J Med Res. 2024;29(1):87. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 15 Dec, 2025 Read the published version in Journal of Orthopaedic Surgery and Research → Version 1 posted Editorial decision: Revision requested 08 Sep, 2025 Reviews received at journal 06 Sep, 2025 Reviews received at journal 02 Sep, 2025 Reviews received at journal 02 Sep, 2025 Reviewers agreed at journal 01 Sep, 2025 Reviewers agreed at journal 30 Aug, 2025 Reviews received at journal 29 Aug, 2025 Reviewers agreed at journal 29 Aug, 2025 Reviewers agreed at journal 29 Aug, 2025 Reviewers agreed at journal 29 Aug, 2025 Reviewers agreed at journal 28 Aug, 2025 Reviewers agreed at journal 27 Aug, 2025 Reviewers agreed at journal 27 Aug, 2025 Reviewers invited by journal 27 Aug, 2025 Editor assigned by journal 21 Aug, 2025 Submission checks completed at journal 21 Aug, 2025 First submitted to journal 21 Aug, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7424376","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":509248485,"identity":"c72a5932-4b74-4abf-93ac-6c52e9d8ebd5","order_by":0,"name":"Mahmoud Badawy","email":"data:image/png;base64,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","orcid":"","institution":"Zagazig University","correspondingAuthor":true,"prefix":"","firstName":"Mahmoud","middleName":"","lastName":"Badawy","suffix":""},{"id":509248486,"identity":"4959d678-64c4-4ac3-9df5-b868b4c864b2","order_by":1,"name":"Sami Ibrahim Sadek","email":"","orcid":"","institution":"Zagazig University","correspondingAuthor":false,"prefix":"","firstName":"Sami","middleName":"Ibrahim","lastName":"Sadek","suffix":""},{"id":509248487,"identity":"06efa5ee-b857-4098-a439-6328b9deeb6c","order_by":2,"name":"Mohammad Hassan","email":"","orcid":"","institution":"Zagazig University, El Husseiniya","correspondingAuthor":false,"prefix":"","firstName":"Mohammad","middleName":"","lastName":"Hassan","suffix":""},{"id":509248488,"identity":"a31f7cbf-1700-4020-a0db-bf5d319b0742","order_by":3,"name":"Ahmed Mostafa Elnagar","email":"","orcid":"","institution":"Zagazig University","correspondingAuthor":false,"prefix":"","firstName":"Ahmed","middleName":"Mostafa","lastName":"Elnagar","suffix":""},{"id":509248489,"identity":"54003de6-849e-46e1-9ae1-d69c848d0aef","order_by":4,"name":"Elsayed Shaheen","email":"","orcid":"","institution":"Alazhar University, Cairo","correspondingAuthor":false,"prefix":"","firstName":"Elsayed","middleName":"","lastName":"Shaheen","suffix":""},{"id":509248490,"identity":"97b64a4e-7679-4c34-a157-18efc04316f4","order_by":5,"name":"Ibrahim Abdellatif Algohiny","email":"","orcid":"","institution":"Zagazig University","correspondingAuthor":false,"prefix":"","firstName":"Ibrahim","middleName":"Abdellatif","lastName":"Algohiny","suffix":""}],"badges":[],"createdAt":"2025-08-21 09:08:46","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7424376/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7424376/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s13018-025-06543-z","type":"published","date":"2025-12-15T15:57:16+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":90544881,"identity":"95f72509-b590-4577-9aa3-29ade5d6b1b6","added_by":"auto","created_at":"2025-09-04 00:22:42","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":186853,"visible":true,"origin":"","legend":"\u003cp\u003eA; irreducible ESCHF after 2 trials of closed reduction. B; the three wires were inserted. C; correction of the rotational and sagittal deformity using the three-wire technique. D; the lateral K-wire was advanced to the proximal medial cortex. E; the medial wire was then advanced and a second lateral K-wire was inserted.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7424376/v1/494ee817c2bcf41ba07bedcf.png"},{"id":90543834,"identity":"a7c9f518-3bb3-4c3f-9df7-232199f2197a","added_by":"auto","created_at":"2025-09-04 00:14:42","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":1101697,"visible":true,"origin":"","legend":"\u003cp\u003eA; 13 years old boy with displaced right-sided ESCHF. B; after 2 trials of closed reduction with the traditional method. C-E Intra-operative images showing reduction of the fracture using the three-wire technique. F; Follow-up plain X-rays antero-posterior and lateral views showing fracture union in acceptable position\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7424376/v1/95fbae00f43e6bee5be1293b.jpeg"},{"id":98813848,"identity":"96c43d7d-30e5-428b-9f7a-6553f4cc4c5c","added_by":"auto","created_at":"2025-12-22 16:05:12","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1769631,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7424376/v1/c983e5be-1e7e-4e49-8138-85e8c715d7e5.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Three-wire Technique for Irreducible Extension Type Supracondylar Humeral Fracture in Children.","fulltext":[{"header":"Introduction","content":"\u003cp\u003eExtension type supracondylar humeral fracture [ESCHF] accounts for about 97% of all supracondylar humeral fractures [SCHF] in children.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e Gartland classified these fracture into three types based on the degree of the displacement.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e Leitch and coworkers \u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e later added type IV SCHF, which represents a multidirectional unstable fracture that lacks any periosteal hinge.\u003c/p\u003e\u003cp\u003eMost displaced ESCHF cases are treated with closed reduction and percutaneous pinning. However, a minority of cases where closed reduction fails necessitate open reduction.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eFailed closed reduction is reported in the literature to be between 3\u0026ndash;15% of cases. This has been attributed to many factors such as the severity of the injury, the fracture type, and soft tissue interposition.\u003csup\u003e\u003cspan additionalcitationids=\"CR6 CR7\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eBoth repeated attempts at closed reduction and open reduction have their own complications. Repeated trials of closed reduction can increase the risk of compartment syndrome, neurovascular damage, and myositis ossificans.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e Open reduction is associated with worse functional outcomes compared to closed reduction, including longer anesthesia time, scar formation, and poorer cosmetic results.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e"},{"header":"Patient and methods","content":"\u003cp\u003eThis retrospective study was conducted from March 2021 to March 2024, involving twenty patients with irreducible ESCHF (8 girls and 12 boys). The three-wire technique was used to facilitate the fracture reduction. The mean age of the patients was 10.2 \u0026plusmn; 1.39 years (ranging from 6-13 years). Informed consent was obtained from each child\u0026apos;s parent, and the study was approved by our Institutional Review Board (IRB) [ZU-IRB# 269/1-4-2024]. Among the cases, there were 11 right-sided and 9 left-sided fractures, with a mean follow-up period of 7 months (ranging from 4 to 9 months). There was one case of preoperative anterior interosseous nerve injury. The eligibility criteria required that patients had failed closed reduction of ESCHF after two to three trials using traditional closed reduction methods. Patients with ESCHF for more than 10 days since the time of the injury, open fractures, and fractures associated with vascular injury were excluded from the study. Demographic data indicated that 70% of the patients were either overweight or obese, 90% were either Gartland grade III or IV, and in 70% of the cases, high-energy trauma (such as sport participation and fall from height) was identified as the mechanism of injury [Table 1].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 1 Distribution of patients according to demographic data:\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 32.1101%;\"\u003e\n \u003cp\u003evariable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.8532%;\"\u003e\n \u003cp\u003eN=20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22.0183%;\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22.0183%;\"\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 32.1101%;\"\u003e\n \u003cp\u003eSex\u003c/p\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003cp\u003eMale\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.8532%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22.0183%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e40%\u003c/p\u003e\n \u003cp\u003e60%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22.0183%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.503\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 32.1101%;\"\u003e\n \u003cp\u003eSide of lesion\u003c/p\u003e\n \u003cp\u003eLeft\u003c/p\u003e\n \u003cp\u003eRight\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.8532%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22.0183%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e45%\u003c/p\u003e\n \u003cp\u003e55%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22.0183%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.824\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 32.1101%;\"\u003e\n \u003cp\u003eAge (year)\u003c/p\u003e\n \u003cp\u003e6 - 8 years\u003c/p\u003e\n \u003cp\u003e\u0026gt;8 \u0026ndash; 13 years\u003c/p\u003e\n \u003cp\u003eMean \u0026plusmn; SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.8532%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003cp\u003e10.2 \u0026plusmn; 1.39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22.0183%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e45%\u003c/p\u003e\n \u003cp\u003e55%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22.0183%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.824\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 32.1101%;\"\u003e\n \u003cp\u003eObesity\u003c/p\u003e\n \u003cp\u003eNormal\u003c/p\u003e\n \u003cp\u003eOverweight\u003c/p\u003e\n \u003cp\u003eObese\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.8532%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22.0183%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e30%\u003c/p\u003e\n \u003cp\u003e35%\u003c/p\u003e\n \u003cp\u003e35%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22.0183%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.387\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 32.1101%;\"\u003e\n \u003cp\u003eTime from injury to surgery\u003c/p\u003e\n \u003cp\u003e\u0026lt;8 hours\u003c/p\u003e\n \u003cp\u003e\u0026gt;8 - 48 hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.8532%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22.0183%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e45%\u003c/p\u003e\n \u003cp\u003e55%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22.0183%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.263\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 32.1101%;\"\u003e\n \u003cp\u003eFracture type\u003c/p\u003e\n \u003cp\u003eIIb\u003c/p\u003e\n \u003cp\u003eIII\u003c/p\u003e\n \u003cp\u003eIV\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.8532%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22.0183%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e10%\u003c/p\u003e\n \u003cp\u003e70%\u003c/p\u003e\n \u003cp\u003e20%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22.0183%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.002*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 32.1101%;\"\u003e\n \u003cp\u003eMechanism of trauma\u003c/p\u003e\n \u003cp\u003eHigh energy\u003c/p\u003e\n \u003cp\u003eLow energy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.8532%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22.0183%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e70%\u003c/p\u003e\n \u003cp\u003e30%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22.0183%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.004*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eContinuous variables were expressed as mean \u0026plusmn; standard deviation (SD), Categorical variables were expressed as number (percentage) and One sample Chi-square test; p-value\u0026lt;0.05 is significant.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSurgical technique;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWith the patient positioned supine and under general anesthesia, the affected upper extremity was sterilized and draped. Initially, two to three closed reduction trials were done for all cases. For those that remained irreducible, the three-wire technique was used (Figure 1A). This technique followed the same principles described by the first author for facilitating closed reduction of flexion type SCHF.\u003csup\u003e10\u003c/sup\u003e In the unreduced position, two appropriately sized K-wires (1.2 \u0026ndash; 1.8 mm) were inserted into the distal fracture fragment; one in the lateral column and one in the medial column, both positioned short of the fracture line. A third K-wire was inserted into the proximal fracture fragment, approximately 1 cm above the olecranon fossa from a lateral to medial direction (Figure 1B). To prevent injury to the radial nerve, the proximal wire was introduced posterior to the lateral edge of the humerus. The reduction process began with traditional traction and countertraction, maintaining the elbow in 30 degrees of flexion. This was followed by correcting the coronal plane deformity and flexing the elbow while pushing the distal fragment anteriorly.\u003csup\u003e11\u003c/sup\u003e The three-wire technique facilitated the correction of the residual fracture deformities (Figure 1C). Disimpaction of the fracture fragments was achieved by pulling the distal wires distally and the proximal wire proximally. The technique effectively corrected the frontal and sagittal plane angulation, but not the translation. Rotational deformity was corrected by rotating the proximal fragment medially or laterally using the proximal joystick wire. The accuracy of the reduction was verified under the image intensifier, with the lateral view obtained by rotating the image intensifier itself. Once an acceptable reduction was achieved, the lateral wire was advanced through the fracture site to engage the medial cortex proximally, while maintaining the reduction with the proximal and medial wires. Subsequently, the medial wire was advanced through the fracture site in a cross direction to the lateral wire to engage the lateral cortex proximally, again ensuring that the reduction was preserved with the aid of the proximal and lateral wires (Figure 1D). Finally, an additional lateral K-wire was introduced to secure the fixation of this unstable fracture (Figure 1E). The accuracy and stability of the reduction were confirmed by gently stressing the fracture under the image intensifier in all directions. Distal pulsation was checked, and a back slab was applied with the elbow in 90 degrees of flexion and the forearm in neutral rotation. Figure 2 illustrates the preoperative, intraoperative, and postoperative follow-up of a male patient with irreducible ESCHF.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePostoperative care and follow-up\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eClinically, we assessed the neurovascular status of the limb. There was one case of preoperative anterior interosseous nerve injury, which improved during the follow-up period.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRadiologically, plain radiographs in both anteroposterior and lateral views were performed at the immediate postoperative period to assess the accuracy of the reduction. Follow-up radiographs were taken at the 4th and 6th weeks to assess fracture union, with additional imaging conducted at the final follow-up to evaluate the carrying angle, Baumann\u0026rsquo;s angle, and the anterior humeral line.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData analysis was performed using the software SPSS (Statistical Package for the Social Sciences) version 27. Categorical variables were described using their absolute frequencies. Shapiro-Wilk test was used to verify assumptions for use in parametric tests. \u0026nbsp;Quantitative variables were described using their means and standard deviations. Pearson (for normally distributed data) and\u0026nbsp;Spearman rank correlation coefficient ((for not normally distributed data)\u0026nbsp;were used to measure strength and association of correlation between two continuous variables. One sample chi square test to measure goodness of fit between observed and expected data The level statistical significance was set at \u003cem\u003eP\u003c/em\u003e\u0026lt;0.05.\u0026nbsp;\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eAt the final follow-up of the current study, all fractures were united in an acceptable position. The time to union ranged from 4 to 6 weeks, with a mean of 5.15 \u0026plusmn; 0.81 weeks. The evaluation of radiological parameters for fracture reduction included the Baumann angle, the anterior humeral line, and the carrying angle. The mean Baumann angle was 19.95 \u0026plusmn; 1.7 [ranging from 17 to 23] degrees. The anterior humeral line intersected the capitellum at the middle third in 16 cases and at the anterior third in 4 cases. The carrying angle ranged from 6 to 15 degrees, with a mean of 12.95 \u0026plusmn; 3.85 degrees. According to Flynn clinical criteria,\u003csup\u003e12\u003c/sup\u003e 15 patients achieved excellent outcomes, while five patients were rated as having good outcomes. In this study, the mean operation time was 32.65 \u0026plusmn; 4.38 minutes, and the average number of C-arm images used during the procedures was 25.3 \u0026plusmn; 5.75 [Table 2]. Regarding complications, there were five cases of mild pin tract infection, all of which resolved within one week following the removal of the K-wires. Additionally, one patient experienced preoperative anterior interosseous nerve neuropraxia, which showed improvement during the follow-up period.\u003c/p\u003e\n\u003cp\u003eTable 2 The final follow-up results of the current study.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 39.6226%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.5597%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eN=20\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30.8176%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 39.6226%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTime till union\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e4 weeks\u003c/p\u003e\n \u003cp\u003e5 weeks\u003c/p\u003e\n \u003cp\u003e6 weeks\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eMean \u0026plusmn; SD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.5597%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003cp\u003e5.15 \u0026plusmn; 0.81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30.8176%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e25%\u003c/p\u003e\n \u003cp\u003e35%\u003c/p\u003e\n \u003cp\u003e40%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 39.6226%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFlynn criteria\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eExcellent\u003c/p\u003e\n \u003cp\u003eGood\u003cstrong\u003e\u0026nbsp; \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.5597%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30.8176%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e75%\u003c/p\u003e\n \u003cp\u003e25%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 39.6226%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.5597%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean \u0026plusmn; SD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30.8176%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRange\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 39.6226%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOperation time\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.5597%;\"\u003e\n \u003cp\u003e32.65 \u0026plusmn; 4.38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30.8176%;\"\u003e\n \u003cp\u003e25 \u0026ndash; 40\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 39.6226%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBaumann angle\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.5597%;\"\u003e\n \u003cp\u003e19.95 \u0026plusmn; 1.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30.8176%;\"\u003e\n \u003cp\u003e17 \u0026ndash; 23\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 39.6226%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCarrying angle\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.5597%;\"\u003e\n \u003cp\u003e12.95 \u0026plusmn; 3.85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30.8176%;\"\u003e\n \u003cp\u003e6 \u0026ndash; 15\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 39.6226%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eC-arm images\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.5597%;\"\u003e\n \u003cp\u003e25.3 \u0026plusmn; 5.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30.8176%;\"\u003e\n \u003cp\u003e13 \u0026ndash; 31\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eContinuous variables were expressed as mean \u0026plusmn; standard deviation (SD), Categorical variables were expressed as number (percentage)\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eClosed reduction and percutaneous pinning is the primary treatment for displaced ESCHF. However, achieving an acceptable reduction using traditional closed reduction methods is not always feasible.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eAccording to Sun and coworkers, the fracture type, mechanism of the injury, and timing between injury and surgery are independent risk factors for failed closed reduction. The fracture type-Gartland type III fractures- are particularly associated with a higher rate of open reduction. This is due to the complete loss of cortical contact, the absence of a periosteal hinge, and the potential for soft tissue entrapment. The mechanism of injury is another independent risk factor for failed closed reduction. High-energy trauma can lead to increased swelling of the elbow, marked fracture displacement, and comminution, complicating the reduction process. Lastly, the time between injury and surgery, Sun et al. reported that the rate of open reduction increased from 10.2\u0026ndash;29.1% if surgery was delayed beyond 8 hours. Furthermore, if surgery was performed between 8 hours and 5 days post-injury, the rate of open reduction rose to 65%. This increase is attributed to swelling at the fracture site, which obscures bony landmarks and makes fracture reduction more challenging.\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e In the current study, we observed similar trends in our patient analysis. We found that 70% of the irreducible cases were classified as Gartland type III fractures, and 70% of the cases resulted from high-energy trauma. However, there was no significant statistical difference between patients who presented for treatment within 8 hours of injury and those who presented after 8 hours. Additionally, we noted that 70% of our irreducible cases involved patients who were either overweight or obese. Obesity obscures the bony landmarks during the reduction process, making it more challenging to achieve a successful closed reduction. Therefore, we recommend further investigation into overweight and obesity as potential independent risk factors for failed closed reduction.\u003c/p\u003e\u003cp\u003eLeitch and his colleagues described the multidirectional unstable SCHF and classified it as grade IV SCHF. This fracture is unstable in both flexion and extension due to the complete loss of the periosteal hinge both anteriorly and posteriorly. They recommended inserting two lateral K-wires in the unreduced position and rotating the image intensifier rather than the patient's arm to achieve an acceptable closed reduction.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e We had four cases of irreducible type IV, all of which were successfully reduced using the three-wire technique.\u003c/p\u003e\u003cp\u003eHeffernan and his colleagues reported the reversed oblique SCHF, where the fracture line in the sagittal plane extends from anterior and proximal to posterior and distal. This type of fracture is challenging to reduce using traditional closed methods due to the presence of an anterior spike in the distal fragment, which faces a posterior metaphyseal spike in the proximal fragment. They recommended maintaining the distal fragment in its displaced posterolateral position while translating it anteriorly to disimpact the proximal fragment.\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e In the current study, we had two reversed oblique ESCHFs. With the assistance of the three-wire technique, we were able to achieve posterior angulation with the apex anterior and manipulate the fragments until they were off-ended, facilitating the reduction.\u003c/p\u003e\u003cp\u003eMany studies reported the use of posterior intrafocal K-wire for the correction of sagittal plane deformity. They used the posterior wire solely for reduction\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e or for both reduction and fixation.\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e However, this technique is not recommended for fractures with posterior comminution or suspected neurovascular entrapment. Additionally, it is ineffective for correcting coronal or rotational deformities.\u003c/p\u003e\u003cp\u003eBasaran et al.\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e utilized a proximal K-wire as a joystick to facilitate the correction of rotational deformities. They initially corrected the coronal plane deformity, then inserted a lateral K-wire for the fixation of the fracture fragments, and subsequently used the proximal joystick wire to address the rotational deformity. However, the positioning of the proximal wire just distal to the deltoid insertion, far from the fracture site, resulted in less control over the proximal fragment. Additionally, if there is a residual sagittal plane deformity, it will be difficult to correct in the presence of the lateral K-wire.\u003c/p\u003e\u003cp\u003eMa and coworkers described a technique using K-wires for the reconstruction of the medial and lateral column periosteal hinges in type IV SCHF. In their approach, two K-wires were inserted\u0026mdash;one into the medial column and the other into the lateral column of the distal fragment\u0026mdash;extending into the medullary canal of the proximal fragment. They concluded that this technique reduced operation time, fluoroscopy exposure, and the rate of incisions required.\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eLin and coworkers described the use of de-sharpened K-wire introduced at the lateral column of the distal fragment to enter the medullary cavity. They noted that as the K-wire advanced deeper into the medullary canal, it facilitated the correction of lateral coronal plane displacement. They concluded that the use of de-sharpened K-wires provided satisfactory reductions comparable to traditional methods, while also reducing operation time and minimizing exposure to radiation from the image intensifier.\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eIn this study, the three-wire technique effectively facilitated the reduction of irreducible cases and helped avoid potential complications associated with both repeated closed reduction trials and open reduction. The mean operation time was 32.65\u0026thinsp;\u0026plusmn;\u0026thinsp;4.38 minutes, which is comparable to the findings of Ma et al.\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e (32.32\u0026thinsp;\u0026plusmn;\u0026thinsp;10.25 minutes) and Lin et al. \u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e (32.88\u0026thinsp;\u0026plusmn;\u0026thinsp;3.69 minutes). The average number of intraoperative fluoroscopies was 25.3\u0026thinsp;\u0026plusmn;\u0026thinsp;5.75, slightly higher than that reported by Ma et al. (15.24\u0026thinsp;\u0026plusmn;\u0026thinsp;6.25) and Lin et al.\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e (20.62\u0026thinsp;\u0026plusmn;\u0026thinsp;5.41). This increase may be attributed to the fact that our study focused exclusively on irreducible cases.\u003c/p\u003e\u003cp\u003eConclusion: The three-wire technique is a straightforward and effective method for the closed reduction of irreducible ESCHF. This technique gives good to excellent results while avoiding the potential complications associated with open reduction.\u003c/p\u003e\u003cp\u003eHowever, the current study has limitations, including a small sample size. Additionally, we did not investigate the risk factors for failed closed reduction due to the absence of a controlled group.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003ch2\u003eDisclosure\u003c/h2\u003e\u003cp\u003eThe author(s) report no conflicts of interest in this work.\u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e\u003cp\u003eThis research received no external funding.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eA,B,D,F performed surgeriesA, C,E reviewed the literatureA,B, C prepared and wrote the main manuscriptA, C, F prepared the figures All authors reviewed the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eHoushian S, Mehdi B, Larsen MS. The epidemiology of elbow fracture in children: analysis of 355 fractures, with special reference to supracondylar humerus fractures. J Orthop Sci. 2001;6:312\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGartland JJ. Management of supracondylar fractures of the humerus in children. Surg Gynecol Obstet. 1959;109:145\u0026ndash;54.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLeitch KK, Kay RM, Famino 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\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eShim JS, Lee YS. Treatment of completely displaced supracondylar fractures of the humerus in children by cross-fixation with three Kirschner wires. J Pediatr Orthop. 2002;22:12\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eOmid R, Choi PD, Skaggs DL. Supracondylar humeral fractures in children. JBone Joint Surg Am. 2008;90:1121\u0026ndash;32.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eOzkoc G, Gonc U, Kayaalp A, Teker K, Peker TT. Displaced supracondylarhumeral fractures in children: open reduction vs. closed reduction and pinning. Arch Orthop Trauma Surg. 2004;124:547\u0026ndash;51.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAktekin CN, Toprak A, Ozturk AM, Altay M, Ozkurt B, Tabak AY. Open reduction via posterior triceps sparing approach in comparison with closed treatment of posteromedial displaced Gartland type III supracondylar humerus fractures. JPediatr Orthop B. 2008;17:171\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMazzini JP, Martin JR, Esteban EMA. Surgical approaches for open reduction and pinning in severely displaced supracondylar humerus fractures in children: asystematic review. J Child Orthop. 2010;4:143\u0026ndash;52.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAbzug JM, Herman MJ. Management of supracondylar humerus fractures in children: current concepts. J Am Acad Orthop Surg. 2012;20:69\u0026ndash;77.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBadawy M, Amin HED, Abdel-Ghani H, Abdelaal AH, Yasin E. Technique for facilitating closed reduction of difficult flexion type supracondylar humeral fracture in children. J Pediatr Orthop B. 2023;32(6):565\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSkaggs DL. Closed reduction and pinning of supracondylar humerus fractures. In: Tolo VT, Skaggs DL, editors. Master Techniques in Orthopaedic Surgery: Pediatrics. Philadelphia, PA: Lippincott Williams \u0026amp; Wilkins; 2008. pp. 1\u0026ndash;15.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFlynn JC, Matthews JG, Benoit RL. Blind pinning of displaced supracondylar fractures of the humerus in children. Sixteen years\u0026rsquo; experience with long-term follow-up. J Bone Joint Surg Am. 1974;56:263\u0026ndash;72.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMahan ST, May CD, Kocher MS. Operative management of displaced flexion supracondylar humerus fractures in children. J Pediatr Orthop. 2007;27:551\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSun LJ, Wu ZP, Yang J, Tian NF, Yu XB, Hu W, Chen H. Factors associated with a failed closed reduction for supracondylar fractures in children. Volume 100. Orthopaedics \u0026amp; Traumatology: Surgery \u0026amp; Research; 2014. pp. 621\u0026ndash;4. 6.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHeffernan MJ, Lucak T, Igbokwe L, Yan J, Gargiulo D, Khadim M. The reverse oblique supracondylar humerus fracture: description of a novel fracture pattern. J Pediatr Orthop. 2020;40(2):e131\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLee 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\u0026ndash;50.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSawaizumi T, Takayama A, Ito H. Surgical technique for supracondylar fracture of the humerus with percutaneous leverage pinning. J Shoulder Elb Surg. 2003;12:603\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFahmy MA, Hatata MZ, Al-Seesi H. Posterior intrafocal pinning for extension-type supracondylar fractures of the humerus in children. J Bone Joint Surg Br. 2009;91:1232\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBasaran SH, Ercin E, Bilgili MG, Bayrak A, Cumen H, Avkan MC. A new joystick technique for unsuccessful closed reduction of supracondylar humeral fractures: minimum trauma. Eur J Orthop Surg Traumatol. 2015;25(2):297\u0026ndash;303.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMa HL, Sun XW, Liu F, Hua ZT, Sun J, Zhang SC. Kirschner wire reconstruction of medial and lateral column periosteal hinge in the treatment of multidirectionally unstable supracondylar fracture of the humerus in children. Eur J Med Res. 2023;28(1):585.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLin Y, Hua Z, Zhou C, Chen S, Sun X, Liu F, Meng G, Zhang S, Sun J. A new technique of intramedullary elastic reduction of the de-sharpened Kirschner wire for the treatment of Gartland type III posterolateral displaced supracondylar fracture of the humerus in children. Eur J Med Res. 2024;29(1):87.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-orthopaedic-surgery-and-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"josr","sideBox":"Learn more about [Journal of Orthopaedic Surgery and Research](http://josr-online.biomedcentral.com)","snPcode":"13018","submissionUrl":"https://submission.nature.com/new-submission/13018/3","title":"Journal of Orthopaedic Surgery and Research","twitterHandle":"@MSKmedBMC","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"extension type supracondylar humeral fracture, irreducible supracondylar humeral fracture, closed reduction techniques for supracondylar humeral fracture","lastPublishedDoi":"10.21203/rs.3.rs-7424376/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7424376/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eIntroduction: Irreducible extension type supracondylar humeral fracture [ESCHF] accounts for 3\u0026ndash;15% of cases and often requires open reduction, which carries risks of complications. This study describes and reports the outcomes of the three-wire technique in treating irreducible ESCHF.\u003c/p\u003e\u003cp\u003ePatients and methods: Twenty patients with irreducible ESCHF (8 girls and 12 boys) were operated on using the three-wire technique. We inserted two K-wires in an unreduced position in the distal fragment and one proximal wire just above the olecranon fossa and used these three wires for manipulation and correction of sagittal, coronal, and rotational deformities at the fracture site.\u003c/p\u003e\u003cp\u003eResults: All fractures achieved acceptable closed reduction, with a mean operation time of 32.65 minutes. Radiological assessments showed favorable outcomes: the mean Baumann angle was 19.95 degrees, the carrying angle averaged 12.95 degrees, and the anterior humeral line dissected the capitellum at the middle third in 16 cases and at the anterior third in 4 cases. Complications included mild pin tract infections in five cases, all resolved within a week after K-wire removal.\u003c/p\u003e\u003cp\u003eConclusion: The three-wire technique is effective for managing irreducible ESCHF, providing good outcomes while avoiding the risks associated with open reduction.\u003c/p\u003e","manuscriptTitle":"Three-wire Technique for Irreducible Extension Type Supracondylar Humeral Fracture in Children.","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-04 00:14:37","doi":"10.21203/rs.3.rs-7424376/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-09-08T05:26:12+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-06T16:40:51+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-02T17:18:49+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-02T15:10:11+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"123980463742928635963810240706613348734","date":"2025-09-01T14:31:43+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"49764008633774956844226438315626732254","date":"2025-08-30T23:17:02+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-29T17:59:52+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"108345592385005481410485350794785347594","date":"2025-08-29T15:06:20+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"23871868659189523047634823707154050579","date":"2025-08-29T13:50:18+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"33467413515153774507653070905055623343","date":"2025-08-29T13:35:15+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"151233881303936080381831756226707916776","date":"2025-08-28T05:01:22+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"73231868545052625916510531593071017626","date":"2025-08-28T00:52:27+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"212304762510722334897618832750368941087","date":"2025-08-27T15:27:16+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-27T13:15:00+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-08-22T01:40:53+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-22T01:08:32+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Orthopaedic Surgery and Research","date":"2025-08-21T09:06:51+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-orthopaedic-surgery-and-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"josr","sideBox":"Learn more about [Journal of Orthopaedic Surgery and Research](http://josr-online.biomedcentral.com)","snPcode":"13018","submissionUrl":"https://submission.nature.com/new-submission/13018/3","title":"Journal of Orthopaedic Surgery and Research","twitterHandle":"@MSKmedBMC","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"1261e94c-e894-4b9e-90d4-2fb6aec62970","owner":[],"postedDate":"September 4th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-12-22T15:59:50+00:00","versionOfRecord":{"articleIdentity":"rs-7424376","link":"https://doi.org/10.1186/s13018-025-06543-z","journal":{"identity":"journal-of-orthopaedic-surgery-and-research","isVorOnly":false,"title":"Journal of Orthopaedic Surgery and Research"},"publishedOn":"2025-12-15 15:57:16","publishedOnDateReadable":"December 15th, 2025"},"versionCreatedAt":"2025-09-04 00:14:37","video":"","vorDoi":"10.1186/s13018-025-06543-z","vorDoiUrl":"https://doi.org/10.1186/s13018-025-06543-z","workflowStages":[]},"version":"v1","identity":"rs-7424376","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7424376","identity":"rs-7424376","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}