33.1 Introduction

Supracondylar humerus fractures are one of the most common fractures in the pediatric population (▶Fig. 33.1). ¹ Gartland’s classification of supracondylar humerus fractures was developed in 1959, and it helped guide the management of these complex injuries. Prior to his classification, displaced supracondylar fractures often resulted in malalignment and Volkmann’s contracture of the injured extremity. ² Non-displaced supracondylar fractures (Gartland type I) are managed non operatively, with cast immobilization. Displaced fractures (Gartland types II through IV) are typically managed operatively. ¹ Displaced fractures with a pulseless extremity or neurological deficit require emergent operative treatment. Displaced fractures without neurovascular compromise should be closed reduced in the emergency department followed by definitive closed reduction and percutaneous pinning in the operating room. Rarely do these fractures require open reduction prior to pinning.

33.2 Preop

• 
  

  Surgical table. Surgeon-specific flat table with radiolucent hand table

  
  
• 
  

  Patient position. Supine. Position the patient as close to the hand table as possible, ensuring that the elbow can be fully visualized with intraoperative fluoroscopy. For small children, move the patient’s shoulder and head onto the hand table.

  
  
• 
  

  Operating room setup. The surgical table should be rotated 90 degrees with the C-arm perpendicular to the hand table.

  
  
• 
  

  Surgical prep. Sterilely prep the entire arm, from the shoulder to the hand.

  
  
• 
  

  Patient exam. Perform a complete neurovascular and motor exam, which includes the assessment of sensation and motor function of the median nerve (specifically, the anterior interosseous), ulnar nerve, and radial nerve. Evaluate distal radial pulse, hand perfusion, and capillary refill time. Assess the carrying angle of the contralateral un-injured extremity, and use it as a template for anatomic reduction of the fractured extremity.

33.3 Closed Reduction Percutaneous Pinning

Closed reduction and percutaneous pinning is the preferred treatment for most pediatric displaced supracondylar humerus fractures. ¹

33.3.1 Fracture Reduction

• 
  

  Pull gentle axial traction with the elbow in 20 to 30 degrees of flexion. Avoid pulling traction with the arm in full extension, as you risk injury to the neurovascular structures that lie over the anteriorly displaced proximal fracture fragment. ³

  
  
• 
  

  If length cannot be restored with gentle axial traction, the proximal fracture fragment is likely to be entrapped in the brachialis muscle. In this scenario, use the “milking maneuver” to manipulate and free the soft tissue interposition in a proximal to distal direction. ⁴ Ensure that anesthesia has provided maximal pharmacologic muscle relaxation as it will aid in fracture manipulation and reduction.

  
  
• 
  

  After the length is restored, address the coronal fracture deformity. Hold the humeral shaft with the surgeon’s non-dominant hand and the forearm with the dominant hand. Apply varus and valgus stress to restore the medial and lateral columns. The restoration of coronal alignment is confirmed using anteroposterior (AP) fluoroscopy. It is important to ensure the coronal alignment is restored prior to addressing the sagittal alignment.

  
  
• 
  

  The flexion reduction maneuver is then used to address the sagittal fracture deformity. The elbow is gradually flexed into a hyperflexed position, while using your thumb, to create an anterior directed force on the distal fracture fragment and the olecranon.

  
  
  
  
  • 
    

    For fractures that are displaced posteromedially, the forearm is held in pronation.

    
    
  • 
    

    For fractures that are displaced posterolaterally, the forearm is held in supination. ³

  
  
• 
  

  Maintain the elbow in flexion, and confirm the reduction with fluoroscopy (▶Fig. 33.2):

  
  
  
  
  • 
    

    The anterior humeral line crosses the central third of the capitellum.

    
    
  • 
    

    Baumann’s angle is restored.

    
    
  • 
    

    The medial and lateral columns are aligned on oblique fluoroscopic views.

  
  
• 
  

  If help is limited in the operating room, an elastic bandage or Coban wrap can be used to keep the elbow in hyperflexion, by wrapping it around the arm and forearm. This allows the surgeon’s hands to be free while pinning.

Stay updated, free articles. Join our Telegram channel

Join