Posted: Apr 19 2020 #(C101437)

Supracondylar Humerus Fx with Pulseless Hand in 9F

HPI

A 9-year-old female fell from a scooter onto her left hand and presents with severe left elbow pain

PMH

Her past medical history is unremarkable.

On physical exam her skin is intact. There is gross deformity, moderate swelling, and tenderness about left elbow, AIN/PIN and ulnar motor function are intact but there is a slight decrease in sensation in the median nerve distribution compared to the contralateral side. The hand is pink and well-perfused but there is no pulse.

Poll

1 of 12

1. Would you obtain additional imaging to guide management?

No - Current xrays are sufficient

75%

1772/2358

Yes - Additional xray views only (e.g., ipsilateral wrist, contralateral elbow)

10%

249/2358

Yes - Angiogram only

156/2358

Yes - MRI only

12/2358

Yes - Additional xrays + MRI

9/2358

Yes - Additional xrays + Angiogram

78/2358

Yes - Additional xrays + Angiogram + MRI

21/2358

Outside my area of expertise - best if I don't vote

61/2358

2. How would you classify this injury?

I would not classify - it does not impact my treatment

143/2258

Gartland Type II

19/2258

Gartland Type III

50%

1145/2258

Gartland Type IV

36%

818/2258

Flexion type

33/2258

Outside my area of expertise - best if I don't vote

100/2258

3. How would you initially manage this injury?

Nonoperative (closed reduction, immobilization, any location)

11%

250/2249

Operative

87%

1973/2249

Outside my area of expertise - best if I don't vote

26/2249

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

17/2272

Emergently (within 2-3 hours)

40%

917/2272

Urgently (that evening, I would NOT wait until following morning)

37%

862/2272

Semi-urgently (first case following morning)

19%

442/2272

Routine (follow-up in clinic to schedule surgery)

3/2272

Outside my area of expertise - best if I don't vote

31/2272

5. If you choose Operative management, what would be your plan going into surgery?

I would not choose Operative management

5/2207

Attempt Closed reduction percutaneous pinning (CRPP), convert to open only if needed

86%

1913/2207

Planned Open reduction percutaneous pinning (ORPP), don't attempt CRPP)

11%

253/2207

Outside my area of expertise - best if I don't vote

36/2207

6. If you choose Operative management and ended up doing an Open reduction percutaneous pinning (ORPP), what approach would you use?

I would not choose ORPP

109/2152

32%

708/2152

Lateral

33%

719/2152

Medial

197/2152

Posterior

14%

309/2152

Outside my area of expertise - best if I don't vote

110/2152

7. If you choose Closed reduction percutaneous pinning (CRPP) or Open reduction percutaneous pinning (ORPP), what fixation construct would you use?

I would not choose CRPP or ORPP

2/2101

Lateral only - 2 pins

13%

275/2101

Lateral only - 3 pins

26%

565/2101

Combined - 1 lateral and 1 medial pin

21%

458/2101

Combined - 2 lateral and 1 medial pins

31%

659/2101

Combined - 3 lateral and 1 medial pins

27/2101

Combined - 1 lateral and 2 medial pins

11/2101

Medial only - 2 pins

5/2101

Medial only - 3 pins

3/2101

Outside my area of expertise - best if I don't vote

96/2101

8. Assuming you performed Closed reduction percutaneous pinning (CRPP), and the patient has a GOOD PULSE postoperativley, how long would you observe this patient as an inpatient?

I would not choose Operative management

0/2078

Discharge immediately

40/2078

Observe 0-12 hours, then discharge

21%

445/2078

Observe 13-24 hours, then discharge

47%

984/2078

Observe 25-48 hours, then discharge

23%

480/2078

Observe > 48 hours, then discharge

99/2078

Outside my area of expertise - best if I don't vote

30/2078

9. Assuming you performed Closed reduction percutaneous pinning (CRPP), and the patient had a PULSELESS PINK hand after pins are placed, how would you manage it?

I would not perform CRPP

25/2017

Obtain intraoperative vascular consult

33%

677/2017

Conclude case, observe inpatient for at least 24 hours - return to OR with vascular if pulse does not return

29%

594/2017

Conclude case, observe inpatient for at least 48 hours - return to OR with vascular if pulse does not return

147/2017

Conclude case, observe inpatient for at least 72 hours - return to OR with vascular if pulse does not return

16/2017

Conclude case, observe inpatient for at least 24, send home as long as hand remains pink and family is reliable

14%

297/2017

Conclude case, observe inpatient for at least 48, send home as long as hand remains pink and family is reliable

173/2017

Conclude case, observe inpatient for at least 72, send home as long as hand remains pink and family is reliable

17/2017

Outside my area of expertise - best if I don't vote

71/2017

10. If you choose Closed reduction percutaneous pinning (CRPP) or Open reduction percutaneous pinning (ORPP) in this 9yoF, when would you remove the pins?

I would not choose CRPP or ORPP

0/1960

at ~ 2 weeks (14 days postop)

14/1960

at ~3 weeks (21 days postop)

26%

511/1960

at ~ 4 weeks (28 days postop)

46%

918/1960

at 5-7 weeks (35 - 49 days postoop)

23%

454/1960

> 7 weeks

24/1960

Outside my area of expertise - best if I don't vote

39/1960

11. If you choose Closed reduction percutaneous pinning (CRPP) with construct seen in xrays below, assuming radiographic union at the time pins and cast removed, when and how would you begin ROM exercises?

I would not choose CRPP

3/1824

No ROM exercise are needed. Motion will come back on its own.

20%

375/1824

I would instruct Family to begin ROM Immediately

50%

916/1824

I would prescribe a Physical therapist to begin ROM immediately

18%

342/1824

I would instruct Family to begin ROM starting in several weeks

88/1824

I would prescribe a Physical therapist to begin ROM starting in several weeks

64/1824

Outside my area of expertise - best if I don't vote

36/1824

12. If you choose Closed reduction percutaneous pinning (CRPP) with construct seen in xrays below, assuming radiographic union at the time pins and cast removed, when would you allow the child to return to sports?

Immediately after the pins and cast removed

11/1850