Preoperative Patient Care A 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 B 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 C 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 Operative Techniques E 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 F 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 G 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 H 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 I 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 J 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 K 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 Postoperative Patient Care O 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 R Managing the Complex Patient with Postoperative Complications 1 Develops unique, complex post-operative management plans
A 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 B 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 C 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
E 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 F 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 G 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 H 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 I 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 J 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 K 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
O 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 R Managing the Complex Patient with Postoperative Complications 1 Develops unique, complex post-operative management plans