7: Supracondylar Humeral Fractures

PROCEDURE 7 Supracondylar Humeral Fractures

Sahal Altamimi, Michael D. McKee

image

The Role of Arthroplasty

PITFALLS

• Young active patients with high functional demands
• High-grade (Gustilio II and III) open fractures
• Poor soft tissue coverage or skin lesions
• Presence of active infection
• Lack of familiarity with the technique of TEA

Controversies

• Type I Gustilio open fractures seen within 12 hours of injury can be treated by early incision and drainage and primary TEA. Alternatively, a two-stage procedure with early incision and drainage and insertion of an antibiotic spacer followed by TEA can be done.

Indications

image Total elbow arthroplasty (TEA) provides good to excellent results in carefully selected patients with comminuted distal humeral fractures.
image Poor bone quality and osteoporosis, which are often found in elderly patients, can lead to inadequate fixation and mechanical failure following open reduction and internal fixation (ORIF). In addition, articular comminution and cartilage fragmentation may preclude anatomic reduction. The ideal candidate for TEA is an elderly patient with a comminuted intra-articular distal humeral fracture.
image Distal humeral fractures in patients with underlying rheumatoid arthritis or pre-existing arthrosis are best managed with primary TEA.
image Several factors play an important role in decision making for primary TEA versus ORIF. These include:
• Intra-articular comminution and cartilage fragmentation
• Physiologic age and functional demands of the patient
• Pre-existing joint arthrosis or underlying rheumatoid arthritis
• Bone quality and degree of osteoporosis
• Surgeon experience and familiarity with TEA

Examination/Imaging

Treatment Options

• Nonoperative (“bag of bones” technique)
• Open reduction and internal fixation
• Primary TEA
• Distal humeral hemiarthroplasty

image A common pitfall is to focus immediately on the obvious injury. Examination of the shoulder and wrist is a must.
image The skin should be visualized circumferentially, so that an open fracture is not missed.
image Ecchymosis and deformity are usually apparent.
image A careful neurologic evaluation that includes motor and sensory functions of the ulnar, radial, and median nerves is critical.
image The vascular status of the arm should be evaluated by palpation of the distal pulses and assessment of capillary refill.
image The forearm compartments should be assessed as well.
image Plain radiographs are universally the initial study of choice.
• Standard anteroposterior and lateral radiographs of the elbow are adequate in most cases.
• Figure 1 shows the preoperative anteroposterior (Fig. 1A) and lateral (Fig. 1B) radiographs of a 68-year-old woman with a comminuted intra-articular distal humerus fracture.
• It is important to note the degree of displacement, angulation, intra-articular comminution, and bone quality.
image Additional traction views or computed tomography maybe obtained in selected cases. Typically, when TEA is chosen, advanced imaging studies are not required.
image

FIGURE 1

Surgical Anatomy

image The ulnar nerve is derived from the C8 and T1 nerve roots (Fig. 2).
image The nerve runs down the anterior compartment of the arm medial to the brachial artery and gives off no branches in the upper arm.
image At the middle of the arm, it pierces the intermuscular septum and travels along the medial head of the triceps.
image At the elbow, the nerve passes posterior to the medial epicondyle.
image Before entering the forearm, the ulnar nerve gives off capsular branches to the elbow joint, the first motor branch to the flexor carpi ulnaris (FCU), and branches to the ulnar half of the flexor digitorum profundis.
image In the proximal forearm, the nerve runs between the two heads of the FCU.
image

FIGURE 2

Positioning

PEARLS

• Ensure that the elbow can be moved through a full range of motion over the bolster before beginning the procedure

PITFALLS

• A foam pad should be place under the lower leg to protect the common peroneal nerve.

Equipment

• Beanbag
• Arm bolster
• Axillary roll
• Foam pads or gel
• Sterile tourniquet

Controversies

• Alternatively, TEA can be done in the supine position. The injured arm can be placed across the patient’s chest or, with the shoulder flexed, beside the patient’s head.

image We prefer to place the patient in the lateral decubitus position with the injured arm up (Fig. 3). The affected elbow is supported over a bolster.
• This position facilitates extensile exposure of the humerus and allows the elbow to flex beyond 90°.
image A deflatable beanbag is used to secure the patient in place. Great care is taken to pad all bony prominences.
image The arm is prepped and draped to the shoulder so that a sterile tourniquet can be applied as high as possible.
image After the extremity is exsanguinated, the tourniquet is inflated. The pressure is set at 250 mm Hg, or 275 mm Hg for an obese arm.
image

FIGURE 3

Portals/Exposures

PEARLS

• A Hohmann retractor can be used on either side of the humeral shaft to “lift up” the shaft for exposure, rather than levering on the soft tissue excessively. This is especially important on the lateral side where the radial nerve courses proximally.
• In most cases, the radial head will be left intact. However, in the setting of a distal humeral fracture in a joint afflicted with pre-existing inflammatory arthritis, the radial head should be resected. This helps improve exposure.

image A straight posterior midline skin incision is made (see Fig. 3).
• Dissection is carried down to the triceps fascia proximally and subcutaneous border of the ulna distally.
• Full-thickness medial and lateral fasciocutaneous flaps are elevated.

Related posts:

16: Perilunate Injuries 29: Proximal Tibia Fractures: Intramedullary Nailing 11: Open Reduction and Internal Fixation of Olecranon Fractures 18: Femoral Neck Fractures: Arthroplasty 8: Terrible Triad Injuries of the Elbow 5: Humeral Shaft Fractures

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Jun 7, 2016 | Posted by in ORTHOPEDIC | Comments Off on 7: Supracondylar Humeral Fractures

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