Open Reduction of Supracondylar Fractures of the Humerus
Christine M. Goodbody
John M. Flynn
A supracondylar fracture that requires open reduction is one that cannot be treated with closed reduction and percutaneous pinning.
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.
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.
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.
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.
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.
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▪ Open Reduction through an Anterior Approach
Incision and Dissection
Once the patient has been prepared and draped, the tourniquet is inflated.
A transverse incision is made across the antecubital fossa (TECH FIG 1A). Care must be taken in dissecting, as the neurovascular bundle may be in a nonanatomic location—typically immediately subcutaneous and at risk for damage during the initial dissection (TECH FIG 1B).
Dissection proceeds until the metaphyseal spike is encountered. It is often covered by a small amount of tissue and parts of the brachialis muscle that may be torn (TECH FIG 1C).
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