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Supracondylar Fracture - Pediatric
Posted: Apr 19 2020 #(C101438)
A

Supracondylar Humerus Fx with Ulnar Nerve Palsy in 7M

HPI

This is a 7-year-old male who sustained a witnessed fall from the monkey bars and landed directly onto his right elbow. He had immediate pain and swelling to the right elbow. His mother brought him into the emergency department immediately for evaluation. He is evaluated by Orthopedics at 8pm, and his last PO (full meal) was at 7pm.

PMH

Healthy, no significant past medical history

PE

Focused examination of the right upper extremity reveals obvious swelling of the elbow with inability to tolerate any range of motion, posterior ecchymosis proximal to olecranon, and a medial elbow abrasion. There is no tenderness to palpation of the forearm or wrist. He is able to make a thumbs up and "ok" sign. He has difficulty crossing his 2nd and 3rd fingers over. Sensation is intact to the back of the thumb and finger pads of the index and middle fingers. Diminished sensation (feels "asleep") along ulnar border of the small finger is present. He has 2+ radial pulse with all fingers warm and well perfused.

Poll
1 of 14
1. In addition to the plain radiographs above, would you obtain any additional imaging to guide treatment?
No - Current radiographs are sufficient
79%
725/910
Yes - additional radiographs of the ipsilateral extremity
7%
68/910
Yes - additional radiographs of the contralateral elbow
3%
35/910
Yes - additional radiographs of the ipsilateral extremity AND contralateral elbow
2%
21/910
Yes - advanced imaging (CT or MRI)
3%
34/910
Yes - additional radiographs and advanced imaging (CT or MRI)
1%
14/910
Outside my area of expertise - best if I don't vote
1%
13/910
2. How would you classify this injury?
I would not use a classification system - it does not change my management
9%
88/905
Gartland Type I
0%
3/905
Gartland Type II
4%
39/905
Gartland Type III
28%
255/905
Gartland Flexion type
54%
491/905
Outside my area of expertise - best if I don't vote
3%
29/905
3. How would you initially manage this injury?
Nonoperative (closed reduction, immobilization)
5%
51/887
Operative
93%
826/887
Outside my area of expertise - best if I don't vote
1%
10/887
4. If you choose Operative management, assuming you saw the patient in the ER at 8 pm, and they ate a full meal at 7 pm, when would you perform surgery?
I would not choose Operative management
0%
2/764
Emergently (within 2-3 hours)
19%
146/764
Urgently (that evening, I would NOT wait until following morning)
36%
276/764
Semi-urgently (first case following morning)
42%
326/764
Routine (follow-up in clinic to schedule surgery)
0%
5/764
Outside my area of expertise - best if I don't vote
1%
9/764
5. If you choose Operative management, how would you setup the OR?
I would not choose Operative management
0%
1/885
Semi sterile setup - image intensifier (C-arm) as the arm board
3%
30/885
Semi sterile setup - radiolucent arm board and C-arm draped separately
4%
36/885
Full sterile setup - C-arm as the arm board
28%
256/885
Full sterile setup - radiolucent arm board and C-arm draped separately
61%
541/885
Outside my area of expertise - best if I don't vote
2%
21/885
6. If you choose Operative management, what would be your INITIAL surgical plan going into the OR?
I would not choose Operative management
0%
4/897
Attempt Closed reduction percutaneous pinning (CRPP)
79%
709/897
Planned Open reduction percutaneous pinning (ORPP)
19%
173/897
Outside my area of expertise - best if I don't vote
1%
11/897
7. If you choose Attempt Closed reduction percutaneous pinning (CRPP), non-anatomic reduction in which of the following planes would most likely influence your decision to convert to open?
I would not choose Attempt CRPP
2%
25/834
Sagittal
14%
122/834
Coronal
9%
77/834
Axial/Rotational
18%
157/834
Coronal or Axial/Rotational
25%
215/834
Any of the above
24%
208/834
Outside my area of expertise - best if I don't vote
3%
30/834
8. If you choose Attempt Closed reduction percutaneous pinning (CRPP) and have an unsatisfactory reduction, WHEN would you make the decision to convert to open?
I would not choose Attempt CRPP
3%
27/796
After closed reduction, but before pinning
31%
250/796
After closed reduction and provisional pinning
16%
131/796
After percutaneous manipulation of the fracture fragments, but before pinning
19%
153/796
After percutaneous manipulation of the fracture fragments and provisional pinning
27%
218/796
Outside my area of expertise - best if I don't vote
2%
17/796
9. If you choose Planned Open reduction percutaneous pinning (ORPP), what approach would you use?
I would not choose Planned ORPP
8%
67/795
Anterior (Antecubital fossa)
16%
131/795
Lateral
29%
237/795
Medial
23%
188/795
Posterior
18%
147/795
Outside my area of expertise - best if I don't vote
3%
25/795
10. If you choose Attempt Closed reduction percutaneous pinning (CRPP) or Planned Open reduction percutaneous pinning (ORPP), what fixation construct would you use?
I would not choose CRPP or ORPP
0%
1/791
Lateral only - 2 pins
12%
102/791
Lateral only - 3 pins
22%
175/791
Combined - 1 lateral and 1 medial pin
25%
199/791
Combined - 2 lateral and 1 medial pins
34%
272/791
Combined - 3 lateral and 1 medial pins
1%
12/791
Combined - 1 lateral and 2 medial pins
0%
4/791
Medial only - 2 pins
0%
4/791
Medial only - 3 pins
0%
1/791
Outside my area of expertise - best if I don't vote
2%
21/791
11. If you choose to place Medial pins, what would be your preferred technique?
I would not choose medial pins
7%
56/761
Percutaneously through skin (no scalpel)
13%
101/761
Mini open - small scalpel incision and bluntly spread down to bone
59%
451/761
Open - make a full, medial incision and identify/protect all important structures
18%
138/761
Outside my area of expertise - best if I don't vote
1%
15/761
12. If you choose Planned or Converted Open reduction percutaneous pinning (ORPP), considering the patient has a nerve palsy, would you explore and perform neurolysis?
I would not choose ORPP
0%
6/742
No - I would not explore the nerve
35%
267/742
Yes - I would explore the nerve if potentially blocking fracture reduction
41%
307/742
Yes - I would explore the nerve regardless
17%
129/742
I would consult a hand or nerve surgeon for assistance
2%
18/742
Outside my area of expertise - best if I don't vote
2%
15/742
13. If you choose Planned or Converted Open reduction percutaneous pinning (ORPP), how long would you observe this patient in the hospital after surgery?
I would not choose ORPP
0%
1/729
Discharge immediately
0%
2/729
Observe 0-12 hours, then discharge
15%
111/729
Observe 13-24 hours, then discharge
51%
374/729
Observe 25-48 hours, then discharge
27%
199/729
Observe > 48 hours, then discharge
4%
31/729
Outside my area of expertise - best if I don't vote
1%
11/729
14. If you choose Closed reduction percutaneous pinning (CRPP) or Open reduction percutaneous pinning (ORPP), when would you remove the pins?
I would not choose CRPP or ORPP
0%
1/726
at 1-2 weeks (7-14 days postop)
0%
6/726
at ~3 weeks (21 days postop)
30%
219/726
at ~ 4 weeks (28 days postop)
46%
339/726
at 5- 7 weeks (35 - 49 days postop)
19%
141/726
> 7 weeks
1%
10/726
Outside my area of expertise - best if I don't vote
1%
10/726
PROCEDURE #1

Closed (Converted to Open) Reduction and Percutaneous Pinning of right supracondylar humerus fracture

Intra-procedure P1
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OUTCOMES
Post-procedure P1
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