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CRPP of Supracondylar Humerus Fractures

Planning

B

Preoperative Plan

1

Evaluate 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) may be more likely to require ORIF
  • verify that reduction is required
  • anterior humeral line not centered on capitellum (except in <3 yo- may be physiologic)
  • Baumann's angle less than 10 degrees/medial comminution present
  • 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
  • examine or X-ray 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

P

1

Surgical instrumentation

  • smooth k-wires usually .062 or larger for older children

2

Room setup and equipment

  • setup OR with standard operating table
  • turn table 45- 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
Pearls
  • using a larger K-wire will give more stability, one can usually use a .062 K-wire in even the smallest child

3

Patient positioning

  • arm board centered at level of patient’s shoulder
  • can add arm tourniquet placed high on upper arm with webril underneath
  • for very small children may need to place head on armboard to allow for elbow to be in center of fluoroscopy
  • check AP/Lat radiographs prior to draping
Pearls
  • for open reductions a sterile tourniquet is generally preferred

Technique

D

Approach

1

Palpate and mark out medial and lateral epicondyles of elbow, location and course of ulnar nerve

2

Plan pin placement

  • if comminuted, severely displaced fracture need to prepare anterior approach to elbow through brachialis and brachioradialis proximally and brachioradialis and pronator teres distally
E

Fracture Reduction

P
P

1

Use the milking maneuver proximal to distal to free up soft tissue interposition

  • this step is generally only needed if proximal fragment has been driven into/through brachialis

2

Follow with gentle traction with elbow in slight flexion

Pitfalls
  • do not pull traction with arm in extension
  • (may stretch the neuromuscular bundle over the displaced fracture and put those structures at risk)

3

Perform coronal reduction first by applying varus/valgus and translation stress with arm in slight flexion

  • surgeon nondominant hand secures humeral shaft, dominant hand holds forearm
Pearls
  • make sure you are satisfied with fracture reduction in coronal plane before performing flexion maneuver
  • varus/valgus alignment is sometimes worsened by flexion maneuver but never improved

4

Address sagittal deformity

  • Reduction is a combination of hyper flexion of patients elbow, while surgeons thumb pushes distal fragment anteriorly
  • for posteromedial fragments pronate forearm, for posterolateral fragments supinate forearm to place intact periosteum under tension
  • for flexion injuries extend elbow to achieve reduction (consider placing pins into distal fragment before fracture reduction)
  • type IV fractures are unstable in flexion and extension- in those cases may need to adjust flexion/extension until appropriate alignment with capitellum is obtained
Pearls
  • for type 4 fracture, consider placing pins in distal fragment prior to reduction
  • for type 4 fracture, rotate C-arm to obtain lateral, as rotating the arm frequently causes loss of reduction

5

Confirm adequate reduction

  • anterior humeral line centered on capitellum
  • Baumann's angle restored
  • if the fingers cannot reach the shoulder, sagittal reduction is unlikely to be adequate
Pearls
  • in children <5yo ossification of the capitellum is not always in the center, so the anterior humeral line may be off center
F

Pinning

P

1

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

  • smooth k-wires (0.062 or larger for most kids) placed from lateral condyle in superomedial direction x2
  • Pins with maximal spread at fracture site
  • first pin (more medial of 2 pins) enters through capitellum for bicortical fixation and goes from anterior to posterior for more fixation
  • Check first kwire placement, needs to be in humeral canal on lateral xray
  • diverge/spread wires so that there is capture of both medial and lateral columns
  • All pins need to be bicortical
Pearls
  • In general, need 2 K-wires for a type 2 SCH fx and 3 or more for a type 3 or 4

2

In unstable fractures place a 3rd or even 4th lateral pins

3

In rare cases in which fracture is unstable after lateral pins,

  • need to watch out for ulnar nerve if using medial kwire
  • making a small incision to visualize the nerve or moving the nerve posterior with the thumb may decrease the risk of injury
  • if crossed medial and lateral pins used they need to cross above fracture site for increased stability, not below or at fracture site
  • if placing a medial pin, first place lateral pins, then extend elbow so ulnar nerve moves posteriorly

4

Bend wires at least 1cm off skin to allow for swelling, then cut with 1-2cm exposed

  • protect skin from pins with felt, Xeroform or other
G

Confirm Hardware Position Recheck Clinical Exam

P

1

Check dynamic live exam with various/valgus stress on AP and flexion/extension on lateral

Pearls
  • Check that all pins are bicortical
  • Unicortical pins are a common source of failed fixation in CRPP of SCH
  • when pins are in olecranon fossa, elbow cannot fully extend - this is not a problem

2

save final ap, lateral and oblique images

3

Check carrying angle compared to contralateral side

4

Check forearm compartments and pulses

H

Wound Closure

P
P

1

Irrigation and Hemostasis

Pearls
  • authors prefer placing foam directly on the skin with a cast to allow for swelling

2

long-arm posterior splint or use uni- or bi-valved cast at approximately 75 degrees or less flexion to accommodate swelling

  • sling to prevent external rotation (especially important to use in small children)
Pitfalls
  • Too much flexion increases compartment pressure and decreases arterial flow.
  • Be sure there is a good pulse in the position of immobilization

Patient Care

K

Preoperative H & P

P

1

Obtains history and performs basic physical exam

  • injury mechanism
  • radial pulse assessment
  • assess Medial, Radial and Ulnar nerve sensation
  • assess AIN, PIN and Ulnar nerve motor function
  • assess soft tissue swelling, check for ecchymosis
  • identify medical co-morbidities that might impact surgical treatment
Pearls
  • Emergent treatment if: pulseless, sensory nerve injury, ecchymosis, severe swelling, skin puckering or forearm fx
  • if sensory exam difficult, may wrap hand in wet washcloth and look for wrinkles - insensate regions do not wrinkle

2

Obtains appropriate imaging

  • 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 1 week
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: 1-2 week postoperative visit
  • wound check/cast change if suspicious for cast/pin issue
  • check radiographs
  • diagnose and management of early complications
  • postop: 3-4 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 ~6-8 wks post injury

6

Capable of diagnosis and early management of complications

  • compartment syndrome
  • pin tract infection
  • cast problems
N

Advanced Evaluation and Managment

1

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

  • abnormal vascular examination
  • neurological deficits
  • brachial "pucker" 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

Managing the Complex Patient with Postoperative Complications

1

Develops unique, complex post-operative management plans

 

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