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Preoperative Patient Care
Operative Techniques

Preoperative Plan


Evaluate fracture displacement

  • <2mm treat nonoperatively
  • 2-4mm treat with closed reduction percutaneous pinning and arthrogram to evaluate articular surface (open treatment if articular surface not aligned)
  • >4mm treat with open reduction and pin fixation


Execute surgical walkthrough

  • describe key steps of the operation verbally to attending prior to beginning of case.
  • describe potential complications and the steps to avoid them

Room Preparation



Surgical instrumentation

  • smooth k-wires (usually 0.062" K-wires)
  • can use 0.08" K-wire or small cannulated screw (3.5mm) in larger children
  • We recommend using at least 0.062 K-wires even in very small children (smaller k-wires do not provide as stable of fixation)


Room setup and equipment

  • setup OR with standard operating table and radiolucent arm board
  • c-arm in from foot of bed


Patient positioning

  • supine with shoulder at edge of bed
  • place sterile tourniquet
  • abduct 90 degrees and internally rotate the arm

Lateral Approach


Mark out the anatomy

  • identify and mark out the lateral condyle. identifies fracture fragment as origin of common extensor tendon.


Mark out the incision

  • draw an approximately 5 cm incision with two thirds of the incision proximal to the elbow joint and one third distal to the elbow joint
  • this incision should be directly over lateral condyle (if arm is very swollen confirm with c-arm)


Make the incision


Deep Dissection


Expose the lateral condyle

  • incise fascia on anterior aspect of lateral condyle at level of fracture.
  • There will often be a large egress of fracture hematoma. Bulb irrigation at this point can help with visualizing the anatomy and fracture


Expose the articular surface

  • expose the anterior articular surface of the elbow by developing the tear in the brachioradialis and elevating soft tissue off of the anterior aspect of the fracture fragment
  • keep the dissection anterior because the blood supply of the lateral condyle is posterior
  • A chandler retractor can be slid across the anterior aspect of the distal humerus to aid in visualization
  • elevate the soft tissue (brachioradialis and joint capsule) from proximal to distal until the fracture is well visualized
  • continue exposure until the trochlea or the medial extent of the fracture can be identified anteriorly

Fracture Reduction



Inspect the articular surface

  • lift the anterior soft tissues with a retractor (usually chandler or army-navy) to visualize the articular surface
  • remove any blocks to reduction in the fracture site


Reduce the fracture

  • can place a kirschner wire into the distal fragment to use as a joystick to control the reduction
  • reduce the fracture
  • the fracture can in many cases be maintained in a reduced position with a pointed towel clip on the lateral aspect of the fracture fragment and metaphysis of the distal humerus
  • can use K-wire joystick or pointed dental tool to align fracture fragment

Fracture Fixation



Confirm the reduction

  • visually evaluate the reduction (intraarticular surface, metaphysis anteriorly, metaphysis laterally)
  • It is also often possible (and beneficial) to feel the articular surface and have tactile confirmation that this is smooth without any stepoff
  • In cases of severe displacement the fragment may have plastic deformation so it won't completely key in at lateral metaphysis
  • This is alright as long as the articular surface is anatomically reduced


Stabilize with K wires

  • 0.062 " K- wires are then placed in either a parallel or divergent fashion
  • If placing divergently: one K- wire is placed up the lateral column, and one parallel to the joint but this pin should be in bone and not cartilage to maximize stability
  • all pins should engage the medial cortex
  • In older/larger children one can use either 0.08" K-wires or a small cannulated screw (3.5mm) up the lateral column
  • If using a screw this is placed in the metaphysical spike (avoiding the physis), across the fracture site and up the lateral column
  • Care should be taken to avoid the olecranon fossa if using a screw
  • The advantage of screw is that it may allow earlier mobilization; disadvantage is the need for later screw removal
  • the authors prefer smooth guide wires if using cannulated screws as we are aware of cases of ulnar nerve injury from threaded guide wires advanced too far medially in this location
  • Care should be taken to avoid the olecranon fossa if using a screw


Check K wire placement with fluoroscopy

  • 2 or more pins crossing the fracture site
  • placed in a parallel or divergent manner
  • all pins engage cortex medially
  • Confirm pins are in bone not cartilage for better stability


Cut K wires

  • bend the K wires 90 degrees outside of the skin and cut
  • cover cut K wire tips or use felt to cover the whole area

Wound Closure


If possible, try to close the lateral periosteum with 0-vicryl

  • this may reduce spur formation and help speed healing


Close deep fascia with 0-vicryl


Close superficial fascia with 3- vicryl


Close skin with running monocryl



  • Immobilize with a long arm cast with the elbow flexed to 90-120 degrees (depending on swelling) and the forearm in neutral
Postoperative Patient Care
Private Note

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