Clean FRCS notes with inline figures
Supracondylar fracture
Radiographic description
•Age by CRMTOL (around 2-3 y.o.)
•Pattern of fracture (extension, flexion, Gartland → 1 minimal deformity, 2 anterior cortex broken, posterior cortex intact, 3 posterior cortex not intact)
•Direction of displacement
Gartland classification: type III
•ATLS
Ample history
•r/o fracture in same limb (esp distal radius)
Examination
•Local: Wound, pucker sign, neurological deficit (overall most common is AIN. PL – median, PM – radial, flexion - ulnar), vascular status (radial pulse CR), compartment
•[Nerve inj [OB]: AIN then radial; ulnar most common in flexion type. nearly all cases of neurapraxia following SCH fractures resolve spontaneously → further diagnostic studies are not indicated in the acute setting]
•Systemic: HI, secondary survey
•If any vascular, try emergent CR under conscious sedation, need definitive K wire fixation
•Aim of surgery is restore the alignment in all three planes to prevent late complications such as cubital varus deformity
Most common scenario:
•Pulseless, CR <2sec (Perfusion of UL is well) [I would inform the vascular surgeon on call to be on standby in case the hand perfusion becomes worse after reduction]
•Consent parent for CR +/- OR + KFW as emergent OT (pulseless, pale), urgent – within same day, not to wait overnight (pulseless, pink) JBJS 2015 Skaggs
•In the theatre, the set up of the II and the help of a good assistant is key
•Supine with arm board, II from the end of the bed parallel to the bed
CR maneuver:
•Traction in line with humerus in 20 degrees elbow flexion +/- milking maneuver +/- hyperextension to disengage fracture
•Correct valgus/ varus and rotation by rotating forearm (Supination to relax BR in PL displacement, pronation to close up fracture gap for PM displacement)
•Direct pressure on distal fragment to correct translational deformity
•Thumb over olecranon to reduce extension deformity while maintaining traction
•Assessment of reduction: clinically if hand can touch the shoulder, XR → (need AP, lateral, IO and EO views)
•Anterior humeral line cutting middle 1/3 of capitellum
•Baumann’s angle (angle between long axis of humerus and proximal edge of lateral condyle epiphysis, compare with normal side <5deg difference, N 75 to 80)
•Oblique views to look at the respective columns
Pinning:
•According to AAOS guideline, will insert 2 divergent 1.6mm lateral pins, with maximum spread at fracture site, bicortical fixation, and avoid cross at fracture site
•If still unstable will add 1 more lateral pin / medial pin with mini open wound, dissection down bone, insert K Wire under direct vision with elbow in extension (Larson showed that 3 divergent lateral pins are at least as stable as standard crossed pins JPO 2006)
•(If develop ulnar nerve palsy: likely neuropraxia, closely observe, most return by 3 weeks)
•Cut and bend k wires
•Cast
•Postop monitor perfusion of hand, neurology and also pain (compartment syndrome) for 24-48hrs (Robb JBJS 2009)
•After pinning, wait for circulation to return
•- Extend elbow and wait 15mins after pinning before deciding on OR
Indication of emergency OR:
•Still white
•Pink but pulseless + no anatomical reduction
•Pre CR pulse+, post CR pulse-
•- if hand remains perfused, then slab the arm in 40-60deg of flexion to avoid further vascular compromise
•For nerve injury
•CR for all
Post CR:
•Anatomical reduction → observe
•Suboptimal → explore (check if nerve jamming within fracture site)
Open reduction:
•Lazy S incision, proximal medial to bicep, distal between PT and BR→ watch out for lateral cutaneous nerve of forearm (2cm lateral to bicep tendon) → release bicipital aponeurosis (lat → med, AVN), full supination to protect PIN → retract biceps and brachialis medially and BR laterally
•Post reduction monitor overnight, Q1H charting
•Inside out wound, gustilo 1 in paediatric cases: debridement/ Abx not necessary
•Pink pulseless even after pinning – can be managed with observation
•Most actually still have brachial artery thrombosis in pink pulseless, but no long term sequalae due to adequate collaterals
•(Carbonell et al EPOSNA annual meeting 2017) – no long term sequelae at 20yrs
Postop developed pulseless hand, what to do?
•Complete the rest of vascular examination, assess CR, colour and warmth
Assess intraop XR, reduction, any gap?
•If reduction perfect, pink pulseless, may observe as it may be from vascular spasm
•If reduction not perfect, or white pulseless hand, release backslab and extend arm. Still no improvement, contact vascular team for urgent exploration +/- repair
How to avoid ulnar nerve palsy when medial pinning?
•Extend elbow
•Direct visualization
•Oscillating mode
•Protect with drill sleeve
Indications for medial pinning? (Skaggs JBJS 2001)
•Unstable after 2 lateral pins – relative
•Medial comminution
•Fracture pattern (proximal medial to distal lateral)
Indications for exploration of AIN
•Postop (iatrogenic)
•Fracture site gap
•Open fracture