Open Reduction of Supracondylar Fractures of the Humerus

Christine M. Goodbody

John M. Flynn

ANATOMY

The neurovascular anatomy to consider for an open reduction includes the following:
- The ulnar nerve passes behind the medial epicondyle.
- The radial nerve courses from posterior to anterior just above the olecranon fossa.
- The brachial artery and median nerve pass through the antecubital fossa and are often immediately subcutaneous anteriorly because of fracture displacement, putting them at risk during the skin incision.

PATIENT HISTORY AND PHYSICAL FINDINGS

The patient history is the same for supracondylar fractures being treated by closed methods.
A careful neurovascular examination must also be performed.

SURGICAL MANAGEMENT

Indications for open treatment of a supracondylar fracture include an open fracture, a fracture that proves irreducible by closed techniques, and a compromised vascular supply to the hand that does not reconstitute with closed reduction.
The timing for surgical intervention has been a matter of debate. Many surgeons believe that prompt reduction is optimal. Other studies show no significant increase in complication rates with delayed treatment.²,³

Preoperative Planning

For children with a severe, potentially irreducible fracture, it is helpful to make a provisional attempt at fracture reduction immediately after the induction of anesthesia.
After milking the fracture from its entrapment in the brachialis muscle, standard reduction maneuvers are performed to reduce the distal fragment into generally good alignment.
Although time should not be spent perfecting the reduction (which will likely be lost during prepping and draping), this provisional reduction of severe fractures after induction can alert the surgical team that open reduction may be necessary, allowing time to gather equipment (such as a sterile tourniquet) and to obtain and place a radiolucent table to facilitate open reduction.

Positioning

The patient is placed supine on the operating table. A hand table attachment is valuable when open reduction is needed.
A sterile tourniquet is placed on the child’s arm after preparation and draping.
The surgeon should make sure that the portable image intensifier can be moved easily into and out of the operative field to assist with pinning of the fracture.

Approach

In general, a transverse anterior incision through the antecubital fossa is the most useful and cosmetic.
If more visualization is needed, this incision can be extended medially or laterally based on displacement, but this is rarely necessary.
Extension of the incision on the opposite side of the displacement of the distal fragment allows for removal of soft tissue obstacles to reduction.
If there is a suspicion of neurovascular compromise, the anterior approach provides the best extensile exposure to explore these structures.
An inability to reduce the fracture may indicate that the proximal fragment has buttonholed through the brachialis muscle. Again, an anterior approach provides the most useful exposure to reduce this deformity.