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TECHNIQUE STEPS
Preoperative Patient Care
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
 

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