Nerve deficit: overall most common is AIN; PL - median 75%, PM - radial 77%, flexion - ulnar
If vascular: emergent CR under conscious sedation then definitive K wire fixation (pulseless pale = emergent OT; pulseless pink = urgent same day, Skaggs JBJS 2015)
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
Q5What is the theatre setup and aim of surgery for a supracondylar fracture?▸
Supine with arm board, image intensifier from the end of the bed parallel to the bed; setup and a good assistant are key
Aim: restore alignment in all three planes
Prevents late complications such as cubital varus deformity
Q6Describe the closed reduction manoeuvre for supracondylar fracture.▸
Traction in line with humerus in 20 degrees elbow flexion +/- milking manoeuvre +/- hyperextension to disengage
Correct valgus/varus and rotation by rotating forearm: supination tenses BR in PL displacement, pronation closes gap in PM displacement
Direct pressure on distal fragment to correct translational deformity
Thumb over olecranon to reduce extension deformity while maintaining traction
Q7How is the reduction assessed?▸
Clinically if the hand can touch the shoulder
XR: AP, lateral, IO and EO views; oblique views to look at the respective columns
Anterior humeral line cutting middle 1/3 of capitellum
Baumann's angle: angle between humeral long axis and proximal edge of lateral condyle epiphysis; normal 75-80, compare with normal side (<5 degrees difference)
Q8Describe the pinning technique and post-operative monitoring.▸
AAOS: 2 divergent 1.6mm lateral guide pins, maximum spread at fracture site, bicortical fixation, avoid cross at fracture site
If unstable add 1 lateral or medial pin; 3 divergent lateral pins at least as stable as crossed pins (Larson JPO2006)
Cut and bend K wires, cast; monitor perfusion, neurology and pain (compartment syndrome) for 24-48hrs (Robb JBJS 2009)
If ulnar nerve palsy develops: likely neuropraxia, observe, most return by 3 weeks
Q9What are the indications for emergency open reduction after pinning?▸
Extend elbow and wait 15mins after pinning before deciding
Still white; pink but pulseless + no anatomical reduction; pre-CR pulse present but post-CR pulse absent
If hand remains perfused, cast in 40-60deg of flexion to avoid vascular compromise
Pulseless hand postop: assess reduction and XR; if perfect and pink may observe; if not, release backslab, extend, contact vascular team for exploration +/- repair
Q10How are nerve injuries managed after a supracondylar fracture?▸
CR for all
Post CR: anatomical reduction -> observe
Post CR: suboptimal reduction -> explore
Q11Describe the open reduction approach for a supracondylar fracture.▸
Lazy S incision: proximal medial to biceps, distal between PT and BR
Watch out for the lateral cutaneous nerve of the forearm (2cm lateral to biceps tendon)
Release bicipital aponeurosis (lateral to medial, risk of AVN); full supination to protect the PIN
Retract biceps and brachialis medially and brachioradialis laterally
Q12What wound management is needed in a paediatric supracondylar fracture?▸
Inside-out wound
Gustilo 1 in paediatric cases: debridement/antibiotics not necessary
Q13How do you avoid ulnar nerve palsy when medial pinning, and what are the indications for a medial pin?▸
Avoid: extend elbow, direct visualisation, oscillating mode, protect with drill sleeve
Indications (Skaggs JBJS 2001): unstable after 2 lateral pins (relative)
Medial comminution
Fracture site proximal medial to distal lateral
Q14What are the indications for exploration of the AIN?▸
Postoperative (iatrogenic)
Fracture site gap
Open fracture
Q15What is the evidence for managing a pink pulseless hand after pinning?▸
Pink pulseless hand can be managed with observation after pinning
Carbonell, EPOSNA annual meeting 2017: no long-term sequelae at 20 years
Q16What are the AAOS 2015 recommendations of Moderate strength for paediatric supracondylar humerus fractures?▸
Nonsurgical immobilization for acute non-displaced fractures (e.g. Gartland Type I)
Closed reduction with pin fixation for displaced fractures (Type II and III, and displaced flexion)
Strength of Recommendation: Moderate
Q17What are the AAOS 2015 recommendations of Weak strength?▸
Use two or three laterally introduced pins
Considerations of potential harm indicate that the physician might avoid the use of a medial pin
Physician might perform open reduction for displaced fractures with varus or other malposition after closed reduction
Strength of Recommendation: Weak
Q18Which AAOS 2015 recommendations were rated Inconclusive?▸
Using an open incision to introduce a medial pin
Time threshold for reduction of displaced fractures without neurovascular injury
Open exploration of the antecubital fossa in patients with absent wrist pulses but a perfused hand after reduction
Optimal time for removal of pins and mobilization; routine supervised physical or occupational therapy; optimal time for unrestricted activity after injury
Optimal timing/indications for electrodiagnostic studies or nerve exploration in nerve injuries; open reduction and stable fixation for adolescent supracondylar fractures
Q19Which AAOS 2015 recommendations are Consensus-based?▸
Emergent closed reduction for patients with decreased perfusion of the hand
Open exploration of the antecubital fossa for patients who have absent wrist pulses and are underperfused after reduction and pinning
Q20What is the incidence and aetiology of cubital varus deformity?▸
Incidence: 3% pinning vs 14% with casting
Malreduction of supracondylar fracture
Malunion of trochlear in lateral condyle fracture (type I fishtail); trochlear AVN (type II fishtail)