Supracondylar Humerus Fractures: Operative Treatment

Indications

Displaced fracture (Figure 5-1)
Open fracture
Neurovascular compromise
Floating elbow

Options for Fracture Reduction and Fixation

Closed reduction percutaneous pinning (CRPP)
- 2 to 3 lateral entry pins (Figure 5-2)
- Crossed pin fixation
  - Beware of ulnar nerve with medial pin
Open reduction internal fixation (ORIF)

Special Concerns

Vascular compromise
- Avascular hand
- Dysvascular hand
- Pink pulseless hand
Nerve impairment
- Media
  - Complete
  - Anterior interosseous nerve only (AIN motor)
- Radial
- Ulnar
- Combined injuries

Extension Type Supracondylar Humerus

Closed Reduction Percutaneous Pinning

Equipment

0.45°C wires if <20 kg
0.625°C wires if >20 kg

Figure 5-1 ▪ A, Lateral radiograph displaced type II supracondylar humerus fracture into extension. B, AP radiograph of the same fracture noting lateral valgus displacement.
Operative instruments on standby in room if ORIF needed
Fluoroscopy
Image intensifier as operative table for CRPP
Radiolucent hand table for open reduction

Figure 5-2 ▪ A, AP radiograph of CRPP with three lateral entry divergent pins. B, Lateral radiograph of lateral entry divergent pins for CRPP.
Doppler and pulse oximetry may be useful
- make sure to check doppler and pulse oximetry before reduction.
Hand microvascular instruments and microscope on standby if pre-op avascular or dysvascular hand

Position

Position patient on the edge of the table with care taken to protect head and neck stability and safety of child staying on operative bed during reduction
- For small children, this is very important to assure adequate imaging
Place arm on image intensifier and check if appropriate images can be obtained before accepting final positioning (Figure 5-3)
Perform closed reduction and if acceptable, proceed with image intensifier as operative support for CRPP
- if not acceptable, or still avascular after reduction, position arm on the radiolucent table for ORIF and if needed vascular reconstruction
- consider prepping lower extremity, if there is a possibility for vein graft
Prep and drape while protecting limb for reduction and pinning (Figure 5-4)

Closed Reduction of Extension Type Supracondylar Fractures

Apply gentle longitudinal traction in 30° of flexion and obtain AP view (Figure 5-5)
Correct translation in coronal plane with medial or lateral translation depending on fracture and original displacement (Figure 5-6)

Figure 5-3 ▪ Fluoroscopy set-up for CRPP with image intensifier as a support table for arm.

Figure 5-4 ▪ Sterile set-up with arm resting on image intensifier.

Figure 5-5 ▪ View of distraction in ˜30° of flexion to disengage fracture fragments.

Figure 5-6 ▪ Distraction and angular correction before flexion maneuver.

Figure 5-7 ▪ Anterior ecchymosis and puckering of displaced extension supracondylar fracture.
If there is puckering of the skin anteriorly with ecchymosis (Figure 5-7), perform “milking” maneuver (Figure 5-8) to extract entrapped brachialis before reduction
Place thumb on olecranon distal to fracture and fingers of same hand on anterior distal humerus metaphysis proximal to fracture
Gently flex elbow to full flexion with olecranon pressure (Figure 5-9)
- a. Should easily reach 130° or greater without block
- b. If there is a block, then fracture is not reduced and so start over
Pronate forearm (most often with varus injuries, rarer to supinate for valgus injuries) during flexion for final reduction
Check fluoroscopic views of distal humerus with elbow flexed to assess anatomic reduction
- a. Straight AP and gentle maneuvering obliques for medial and lateral column views through shoulder not fracture site rotation (Figure 5-10)
Obtain lateral view of distal humerus by keeping fracture reduction stable and externally rotating upper arm. This is a key step, to obtain lateral view while maintaining fracture reduction: requires full flexion and stable hold of upper arm and forearm to move as a unit. Anatomic reduction of distal humerus is required (Figure 5-11)
- a. If not reduced, start over
- b. If not reducible, proceed to open reduction

Figure 5-8 ▪ Illustration of milking maneuver to disengage entrapped fracture from brachialis muscle. (Reprinted with permission from Beaty JH, Kasser JR. Rockwood and Green’s Fractures in Children. 7th ed. Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2010:505.)

Figure 5-9 ▪ A, Holding the metaphysis of humerus above the fracture with fingers and using thumb pressure on olecranon below the fracture to reduce extension deformity while safely flexing elbow. B, View of operative closed reduction with forearm pronated, elbow flexed fully.

Percutaneous Pin Fixation of Extension Type Fractures

With elbow in full flexion, forearm in pronation (at times supination if that results in anatomic reduction), upper arm resting on image intensifier, outline planned pin placement (Figure 5-12)

Penetrate the capitellar region skin free-hand with 0.625 C-wire and check fluoroscopy for alignment (Figure 5-13).

Figure 5-10 ▪ Check AP of distal humerus for completeness of reduction with fluoroscopy.

Figure 5-11 ▪ Check lateral of distal humerus for reduction. The fracture needs to be stabilized and all motion is through shoulder external rotation to prevent displacement.