What to do with K-wires in displaced upper extremity fractures in children – where to bury or not

Abstract Kirschner wires (K-wires) are the standard fixation method for displaced pediatric upper extremity fractures, yet no consensus exists on whether wire ends should be buried subcutaneously or left exposed epicutaneously. While epicutaneous K-wires offer cost-effectiveness and avoid second anesthesia, concerns remain regarding infection risk and psychological distress. To systematically review and compare complication rates between buried and exposed K-wire fixation in pediatric upper extremity fractures, including infection, refracture, skin erosion, and secondary implant displacement. We conducted a systematic review following PRISMA guidelines, searching Cochrane, PubMed, EmBase, and Ovid databases. Inclusion criteria were: modified Coleman Methodology Score (mCMS) > 60, upper extremity fractures treated with K-wire fixation, and age < 16 years. Studies including adult patients and biomechanical studies were excluded. Meta-analysis compared outcomes across 12 studies encompassing 1,977 patients. Buried K-wires demonstrated significantly lower overall infection rates (OR = 1.74; 95% CI: 1.19–2.56; p = 0.004). However, no significant difference was observed in deep surgical siteinfections ( OR = 1.56; 95% CI: 0.60–4.0; p = 0.36 ). Exposed wires showed significantly lower skin irritation rates (OR = 0.09; 95% CI: 0.04–0.21; p < 0.00001). No significant differences were found in secondary implant displacement (OR = 1.26; 95% CI: 0.10–15.75; p = 0.86) or refracture rates (OR = 1.90; 95% CI: 0.91–3.96; p = 0.09). Geographic subgroup analysis revealed significant regional differences: infection rate differences were significant in Asia/Africa (OR = 2.90; 95% CI: 1.61–5.22; p = 0.0004) but not in Europe/USA (OR = 1.16; 95% CI: 0.69–1.95; p = 0.57). Epicutaneous K-wire fixation shows higher overall infection rates than buried wires but does not increase deep surgical site infections requiring operative revision. Considering the avoidance of additional anesthesia, favorable cost-benefit profile, and geographic variation in infection risk, epicutaneous K-wires are recommended when no patient-specific contraindications exist, particularly in temperate climates. Level III (Systematic Review of Level II-III Studies).