|

Open Reduction and Internal Fixation of Supracondylar Humerus Fractures

Planning

B

Preoperative Plan

1

Template fracture

  • identify fracture pattern (extension vs. flexion), displacement (Gartland classification), comminution, angulation, and rotation based on initial xrays
  • gartland III and IV completely displaced fractures may have interposed brachialis muscle (skin puckering anteriorly on exam) requiring ORIF
  • evaluate anterior humeral line (should traverse capitellum) and integrity of posterior cortex on Lat xray, coronal angulation and rotation on AP
  • critical to determine if lateral condyle vs. medial condyle vs. supracondylar fracture is present as these can be confused with each other
  • determine if posteromedial or posterolateral fragment present as this will affect reduction and potential nerve injury
  • take radiographs of forearm to evaluate for possible forearm fractures (“floating elbow”)

2

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
C

Room Preparation

1

Surgical instrumentation

  • smooth k-wires: .062 or .08

2

Room setup and equipment

  • setup OR with standard operating table
  • turn table 90° so that operative extremity points away from Anesthesia machines
  • c-arm in from foot of bed
  • monitor in surgeon direct line of site on opposite side of OR table

3

Patient positioning

  • arm board centered at level of patient’s shoulder
  • take care not to pull arm into full extension when prepping and draping
  • after draping, apply sterile tourniquet

Technique

D

Anterior Incision

1

depending on surgeon preference, inflate tourniquet (vs only inflate after exposing if needed for significant bleeding)

2

Make an anterior incision

  • make a transverse incision over the antecubital fossa
  • this can be extended if needed either proximally or distally
E

Deep Dissection

1

Perform blunt dissection

  • perform blunt dissection through the subcutaneous and fatty tissue
  • be aware of the neurovascular structures as they might not be in the normal anatomic position
  • dissect down until the metaphyseal spike is identified
  • it is often buttonholed through the brachialis
  • once spike is encountered remove periosteum that may interfere with reduction

2

Identify neurovascular structures (brachial artery and median nerve)

  • Retract neurovascular structures to allow visualization and reduction of the fracture
F

Fracture Reduction

1

Define the outline of the distal fragment

  • this can be one of the most challenging aspects of the procedure
  • it is posterior and lateral with the periosteum folded over its surface

2

Perform the reduction

  • reach the fracture site with a hemostat to get a hold of the cut edge of the periosteum
  • extend the cut edge with scissors to increase the size of the buttonhole and to help free up the distal fragment
  • bring the distal fragment anteriorly and reduce the shaft fragment
  • maneuver the shaft fragment back through the buttonhole into its resting position posterior to the brachialis
  • another option for reduction is to use your thumb on the proximal fragment and push downward while an assistant applies traction to the forearm with the elbow flexed at 90 degrees
G

Pinning

1

After fracture reduced, check on AP/Lat fluoro (rotate C-arm instead of arm if gross fracture instability)

  • smooth .062” kwires (if patient <20 kg) placed from lateral condyle in superomedial direction x2
  • consider .045" kwires if age <2 years, .08" kwires if patient >20 kg
  • want divergent pins spaced ~1.5-2cm apart with elbow flexed
  • first pin (more medial of 2 pins) enters through capitellum for bicortical fixation and goes from anterior to posterior for more fixation

2

Check first kwire placement, needs to be in center of humeral canal on lateral xray, second wire divergent on AP

  • if crossed medial and lateral pins used they need to cross above fracture site for increased stability, not below or at fracture site
  • higher risk of ulnar nerve injury if medial pin placed with elbow in flexion or hyperflexion
  • pins need to be bicortical

3

In highly unstable fractures place a 3rd kwire lateral

  • need to watch out for ulnar nerve if using medial kwire

4

Bend kwires at base using pliers, use fraiser tip suction to bend kwires, then cut with 2cm exposed

  • cover bent k wire tips
H

Confirm Hardware Position Recheck Clinical Exam

1

Check dynamic live exam then final AP/oblique/lat radiographs

  • Check carrying angle compared to contralateral side
  • Check forearm compartments and pulses
I

Wound Closure

1

Irrigation and Hemostasis

  • irrigate pin sites
  • close skin with absorbable sutures

2

Dressing and Immediate immobilization

  • xeroform around base of kwires
  • padded gauze around base of kwires
  • long-arm postmold splint for immobilization at 75°or use uni- or bi-valved cast to reduce swelling
  • sling for comfort

Patient Care

K

Preoperative H & P

1

Obtains history and performs basic physical exam

  • injury mechanism
  • radial and ulnar pulse assessment
  • identify medical co-morbidities that might impact surgical treatment

2

Order basic imaging studies

  • AP and lateral elbow radiographs
  • oblique views if concern for condylar component

3

Prescribe nonoperative treatments

  • long arm cast for garland type I fractures

4

Perform operative consent

  • describe complications of surgery including
  • pin site infection
  • pin site migration
  • cubitus varus deformity
  • neurovascular injury
  • AIN palsy
  • delayed union
  • nonunion
L

Perioperative Inpatient Management

1

Discharge patient appropriately

  • pain meds
  • cast care
  • non weightbearing
  • manage swelling
  • monitor neurological and vascular status
  • schedule follow up in 2 weeks
M

Intermediate Evaluation and Management

1

Recognize vascular, nerve or other associated injuries

  • document neurovascular status
  • document radial and ulnar pulses along with median, radial, and ulnar nerve function
  • AIN neuropraxia (test A-OK sign) most common followed by radial nerve (thumb/wrist extension) palsy and ulnar nerve (hand intrinsics) depending on fracture pattern
  • vascular insufficiency at presentation 5-17% of cases and emergent surgical intervention typically necessary
  • differentiate anterior interosseous nerve versus complete median nerve palsy

2

Appropriately interprets basic imaging studies and recognizes fracture patterns

  • interpret radiographs of the elbow

3

Makes informed decision to proceed with operative treatment

  • describes accepted indications and contraindications for surgical intervention

4

Splints or casts fracture appropriately

  • flexion less than 90 degrees
  • accommodates for swelling potential

5

Provides post-operative management and rehabilitation

  • postop: 2-3 week postoperative visit
  • wound check
  • change splint/cast and continue non-weight bearing
  • check radiographs
  • diagnose and management of early complications
  • postop: 4-6 week postoperative visit
  • check xrays for callus formation out of splint/cast
  • can remove kwires with heavy needle driver in clinic
  • begin range of motion exercises to wrist, hand, and elbow
  • return to activity at ~8 wks

6

Capable of diagnosis and early management of complications

  • compartment syndrome
  • pin tract infection
  • cast problems
N

Advanced Evaluation and Management

1

Recognizes factors that could predict difficult reduction and post-operative complication risk

  • abnormal vascular examination
  • neurological deficits
  • brachialis sign or severe soft tissue swelling
  • associated forearm fracture

2

Appropriately orders and interprets advanced imaging studies

3

Completes comprehensive pre-operative planning with alternatives

  • recognizes fracture patterns that may preclude lateral entry only pinning or necessitate ORIF

4

Modifies and adjusts post-operative treatment plan as needed

  • recognize deviations from typical postoperative course
O

Complex Patient Care

1

Develops unique, complex post-operative management plans

 

Please rate topic.

Average 5.0 of 5 Ratings

Topic COMMENTS (0)
Private Note