SC Fracture

7/24/2019 SC Fracture

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SC fracture

Much attention has been directed to the problem of malreduction of supracondylar fractures of

the humerus in children. In the past, cubitus varus or valgus frequently was thought to occur

because of growth arrest of the distal humeral physis, rather than because of malreduction of thefracture. Wilkins, reviewing !"# fractures in $% ma&or series, made several pertinent

observations' (%) *+.+ of the fractures were of the e-tension type, and only "." were of the

fle-ion type (") most occurred in boys, especially between ages ! and / years and ($) a0olkmann ischemic contracture occurred in #.! of the fractures the radial, median, and ulnar

nerves were involved in that order of frequency.

1revention of cubitus varus or valgus by obtaining as anatomical a reduction as possible is

necessary. It is no longer acceptable to hear 2not bad for a supracondylar fracture.3 4ameronlisted, depending on the type of fracture, four basic types of treatment' (%) side5arm skin traction,

(") overhead skeletal traction, ($) closed reduction and casting with or without percutaneous

pinning, and () open reduction and internal fi-ation. 6artland proposed a useful classificationfor supracondylar fractures' type I, undisplaced type II, displaced with intact posterior corte-

and type III, displaced with no cortical contact. 7is classification also noted whether the fracture

is displaced posteromedially or posterolaterally. 8ype I nondisplaced fractures can be

satisfactorily treated closed with e-ternal fi-ation, such as a plaster cast. 8ype II fractures aredisplaced and are difficult to reduce and to hold reduced by e-ternal methods. 8ype III fractures

are displaced posteromedially or posterolaterally with no cortical contact, and the periosteum

may be stripped reduction is difficult, and maintaining reduction is almost impossible withoutsome form of internal fi-ation (9ig. $$5+#).

Fig. 33-70 Internal fi-ation of supracondylar fracture. Aand B,Severely displaced type III supracondylar fracture. Cand D,:fterclosed reduction and percutaneous pinning. Eand F,6ood result soon after removal of pins.

:n occasional author has mentioned holding the reduction by e-tension of the elbow to get good

radiographs and to avoid any cubitus varus or valgus. ;btaining satisfactory radiographs to

determine whether any cubitus varus or valgus is present seems to be the biggest problem in thetreatment of these fractures. 0arious methods of overhead traction and side5arm traction have

been recommended.


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radiograph seems to be no problem. 8he >ones view in the anteroposterior plane should be taken

properly with the elbow fle-ed ma-imally, the cassette underneath the elbow, and the tube at a

*#5degree angle to the cassette. 8he


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Fig. 33-73 Measurement of


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Fig. 33-75 Mechanism of coronal tilting. A,Impaction of fracture medially. B,8ilting of fragment medially. C,7ori=ontal rotation.

(Redrawn from Marion J, LaGrange J, Faysse R, et al: Les fractures d l'extremite inferieure de l'humerus chez l'enfant, Re !hir"rtho# $%:&&, )*+-

Fig. 33-76 8hree static components that combine to produce cubitus varus. A,7ori=ontal rotation. B,Coronal tilting. C,:nteriorangulation.

(Redrawn from .il5ins 04: Fractures and dislocations of the el6ow region 7n Roc5wood !8 Jr, .il5ins 04, 0ing R4, eds:Fractures in children, 3hiladel#hia, )%$, Li##incott-

Fig. 33-77 Deduction of lateral tilt by pronation of forearm. A,Supination opening fracture laterally. B,1ronation closing fracturelaterally.(Redrawn from 86raham 4, 3owers 9, .itt 3, et al: 4x#erimental hy#erextension su#racondylar fractures in mon5eys, !lin "rtho#

Relat Res :&), )%+-

Closed reduction with splint or cast immobili=ation traditionally has been recommended fordisplaced supracondylar fractures, but loss of reduction and the necessity of repeated

manipulations have been reported frequently to cause elbow stiffness and physeal damage.

1irone et al. reported that closed reduction and casting of displaced fractures resulted in a lowerpercentage of good results and higher percentages of early and late complications compared withskeletal traction, percutaneous pinning, and open reduction they recommended cast treatment

only for undisplaced fractures. Criteria for closed reduction are easy reduction, stable fracture,

minimal swelling, and no vascular compromise. Several authors have described reduction of thefracture in e-tension and maintenance of the reduction through the use of the triceps bridge by

holding the elbow in fle-ion if the pulse and vasculature tolerate this. Mapes and 7ennrikus,

using 4oppler ultrasonography, concluded that in displaced e-tension supracondylar fractures,


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e-tending the elbow and supinating the forearm enhance vascular safety. Chen et al. reported

good results using manipulation, reduction, and immobili=ation with the elbow in full e-tension

in a plaster slab.


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Fig. 33-78 1inning of supracondylar fracture. A,8wo lateral pins are inserted parallel, crossing fracture site and opposite medialcorte-. B,4ivergent pins crossing same structures.(Redrawn from 8rino ;L, Lluch 44, Ramirez 8M, et al: 3ercutaneous fixation of su#racondylar fractures of the humerus inchildren, J 2one Joint


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of the fragments with the patient prone is difficult even when the image intensifier is being used.

We use two lateral pins and use a medial pin only if the fracture seems to be unstable

intraoperatively.

1ercutaneous fi-ation after closed reduction has the advantage of providing e-cellent stability of

the supracondylar fracture in any position of the elbow (9ig. $$5+*). 8he ultimate result is onlyas good as the initial reduction, however, and does not depend on the placement of the pins. If

the fracture is not satisfactorily reduced and is held in an unsatisfactory position with pins, theoutcome is unsatisfactory, &ust as if no pin fi-ation were used. :ronson and 1rager evaluated the

quality of reduction by measuring the


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: long arm posterior plaster splint is worn for $ weeks. Alnar, radial, and median nerve function

should be checked after anesthesia. 8he pins are removed at $ weeks, and another posterior splint

is applied. :t weeks, the splint is removed, intermittent active range5of5motion e-ercises arestarted at home they should be taught by the physical therapist to the child and the parent,

e-plaining that the child is to carry out his or her own active range5of5motion program. 1assive

motion and forceful manipulative motion must be avoided in a child because they decrease therange of motion and frighten the child.

AFTERTREATMENT

:ftertreatment is the same as for fi-ation with crossed pins (see 8echnique $$5%).

;pen Deduction and Internal 9i-ation

;pen reduction and internal fi-ation of supracondylar fractures are indicated when closed

reduction is unsatisfactory. In a type III displaced fracture with no cortical contact and

completely detached periosteum, or with the fracture fragment 2puckering3 or even penetratingthe skin (open fracture), a satisfactory closed reduction may be impossible. If after one or two

attempts at closed reduction with the child under general anesthesia the fragments cannot be

reduced and held by percutaneous pinning, open reduction and internal fi-ation are indicated.

:ccording to Dasool and ?aidoo, manipulation should be avoided in displaced type IIIposterolateral supracondylar fractures with neurovascular deficit if clinical evidence indicates

that the fracture fragment has buttonholed through the brachialis muscle because the

neurovascular bundle may be trapped in the fracture site. If the elbow is so severely swollen thata closed reduction cannot be maintained, olecranon traction can be used for several days,

followed by closed or, if necessary, open reduction. ;ther indications for open reduction include

open fractures that require irrigation and dbridement and fractures complicated by vascular

in&ury. 1ossible complications of open reduction include infection, vascular in&ury, myositisossificans, e-cessive callus formation with residual stiffness, and decreased range of motion.

6ruber and 7udson treated $% difficult fractures with open reduction and internal fi-ation and

obtained satisfactory results even in the most severe fractures.

If open reduction and internal fi-ation are to be done, they should be performed emergently (G/hours) or urgently (J" hours) or after the swelling has decreased, but not later than ! days after

in&ury because the possibility of myositis ossificans apparently increases after that time. We

prefer an anterior or lateral approach. EekomKki et al. used an antecubital approach. 4anielssonand 1ettersson used a medial approach. Eumar et al. used a medial approach in uncomplicated

cases. In patients with brachial artery compromise, an anteromedial approach was used, and in

patients with radial nerve palsy, lateral and medial approaches are recommended. Deitman et al.recommended a medial approach for posterolaterally displaced fractures, a lateral approach for

posteromedially displaced or fle-ion5type fractures, and an anterior approach for posteriorly

displaced fractures. L-posure was through the disrupted periosteum so that the fractures were notdevasculari=ed further or destabili=ed. When vascular compromise was present, the e-posure was

anterior. In their report of @! fractures, @ fractures were irreducible, %@ had associated vascular

compromise, eight were open, and one had postreduction nerve palsy and nonanatomical

reduction. 8wenty patients had brachialis entrapment usually associated with a transverse


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fracture pattern with bayonet apposition, and nine patients had fle-or5pronator origin entrapment

usually associated with an oblique fracture pattern e-tending from pro-imal5lateral to distal5

medial with posterolateral displacement.

:ll studies reported good results using open reduction and internal fi-ation of severely displaced

fractures that could not be reduced or had significant vascular embarrassment. 8hey alsorecommended fasciotomy at the same time. :lthough rare, deep infections, nerve in&uries,

myositis ossificans, cubitus varus, and limited elbow motion can occur.

AFTERTREATMENT

: posterior plaster splint is applied, and the radial pulse and neurological function are checked

after anesthesia. 8he pins are removed at $ to weeks, and an active, not passive, range5of5

motion program is started.

Larly Complications

?eurological compromiseusually a neurapra-iais reported to occur in $ to "" of patients

with supracondylar fractures. :ny of the peripheral nervesmedian, anterior interosseous,radial, or ulnarmay be damaged, and mi-ed nerve lesions have been reported.

In a young child, it often is difficult to determine the neurological status of the upper e-tremity

postoperatively. We described a 2passive assist3 sign in which the child assists in carrying out

passive motor function of the involved hand using the contralateral hand. 8his test is usefulbecause it shows that the child understands the command (request), and that movement of the

part is not painful (without a compartment syndrome), but that the child cannot perform active

e-tension or fle-ion of the hand. When this sign is observed, it should be a warning that a nervedeficit may be present.

Complete return of nerve function is usual, although this may require several months. Some

authors recommend surgical e-ploration if nerve function has not returned within @ to / weeks of

reduction, whereas others recommend allowing a minimum of " to months for resolution.Continued nerve palsies after fracture may indicate nerve entrapment in the fracture callus. Culp

et al. reported %/ neural in&uries in children with supracondylar humeral fractures, nine of which

resolved spontaneously an average of ".! months after in&ury. 8he remaining nine lesions weree-plored at an average of +.! months after in&ury. ?eurolysis was performed on eight, and one

completely lacerated nerve required grafting. 8hese authors concluded that observation should be

the initial approach, but if clinical or electromyographic evidence of neural function is notpresent at ! months after in&ury, e-ploration and neurolysis are indicated. If the nerve is in

continuity, the prognosis after neurolysis is e-cellent. :millo and Mora reported "! neuralin&uries at the elbow &oint in children. 9indings at surgery revealed discontinuity of the affected

nerve trunk in eight patients %+ had a constrictive lesion with the nerve trunk in continuity. 8hesurgical technique in eight involved repair by interfascicular grafting and epineural suture, and in

%+ repair was by neurolysis. L-cellent results were found in nearly /# of the continuous lesions

treated by neurolysis. In discontinuous lesions, @@ had e-cellent results with grafting.


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than $! mm 7g (slit or wick catheter technique) or greater than # mm 7g (needle technique),

and ($) interrupted arterial circulation to the e-tremity for more than hours. ?umerous

techniques have been advocated for fasciotomy of the forearm, but the standard 7enry approach(9ig. $$5/%), as recommended by Laton and 6reen and 6elberman et al., is used most often.

Fig. 33-81 A,7enry approach to volar aspect of forearm. B,7enry approach to superficial and deep compartments of forearm.(Redrawn from Rora6ec5 !?: 8 #ractical a##roach to com#artmental syndromes: 777 Management, 7nstr !ourse Lect &&:+,)%&-

Bate Complications

Cubitus varus is the most common angular deformity that results from supracondylar fractures in

children. Cubitus valgus, although mentioned in the literature as causing tardy ulnar nerve palsy,rarely occurs and is more often caused by nonunion of lateral condylar fractures.


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correction of the cubitus varus deformity is a lateral closing wedge osteotomy. ;ccasionally, a

hypere-tension deformity requires the addition of a fle-ion component.

8hree basic types of osteotomies have been described' a medial opening wedge osteotomy with abone graft, an oblique osteotomy with derotation, and a lateral closing wedge osteotomy. Eing

and Secor described the medial opening wedge osteotomy. 8he disadvantages of this osteotomyare that it gains length, which is not a problem in the upper e-tremity, and it creates a certain

amount of inherent instability. Bengthening the medial aspect of the humerus also can stretch anddamage the ulnar nerve, unless it is transposed anteriorly. :n oblique osteotomy can be

beneficial, but the derotation described is probably unnecessary for the reasons given earlier.

:mspacher and Messenbaugh reported good results with an oblique osteotomy fi-ed withcortical screws, but this procedure attempts to correct a two5plane deformity with one osteotomy

and requires rotation to correct the varus deformity. Achida et al. described a three5dimensional

osteotomy for correction of cubitus varus deformity, in which medial and posterior tilt androtation of the distal fragment can be corrected if necessary (9ig. $$5/").

Fig. 33-82 8hree5dimensional osteotomy for correction of cubitus varus deformity. Medial and posterior tilt is corrected. :fter

osteotomy, distal fragment is compacted with pro-imal fragment by adding e-ternal rotation using wedge of humeral corte-.


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8hey used image intensification and ulnar nerve isolation to prevent nerve complications in %%

children with cubitus varus (9ig. $$5/). ?one had a prominent lateral condyle, and the operative

scars were well concealed along the medial aspect of the elbow. ;ne patient had transient ulnarnerve paresis with residual varus.

Fig. 33-83 A,Wedge to be removed from affected arm is determined on preoperative radiograph. B,1reset Eirschner wires andincomplete osteotomy.(Redrawn from ;oss FR, 0asser JR, 9re#man 4, et al: @ni#lanar su#racondylar humeral osteotomy with #reset 0irschner wires for

#ostBtraumatic cu6itus arus, J 3ediatr "rtho# $:$, ))$-

Fig. 33-84 Eirschner wires delineate wedge to be made.

9rench used two parallel screws that are attached by a single figure5of5eight wire that is

tightened for fi-ation.


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4eDosa and 6ra=iano reported good and e-cellent results in %# of %% patients with a step5cut

osteotomy technique fi-ed with a single cortical screw (see 9ig. $$5/+). 8he one patient with a

poor result had persistent varus caused by unrecogni=ed fracture of the cortical spike, whichcaused loss of fi-ation. 8hey reported no ulnar or radial nerve in&uries, infections, nonunions, or

hypertrophic scars, and all patients retained preoperative ranges of motion. 8hey concluded that

this osteotomy with single5screw fi-ation is a safe procedure that can correct multiple planes of

deformity, but they emphasi=ed the importance of careful preoperative planning and specialattention to surgical detail.

Fig. 33-87 A,;steotomy designed to correct cubitus varus deformity of %$ degrees. 4istal fragment can be rotated to correctadditional deformity. B,:fter wedge removal and closure, screw is used for fi-ation.(Redrawn from /eRosa G3, Graziano G3: 8 new osteotomy for cu6itus arus, !lin "rtho# Relat Res +&*:*, )%%-

If a more e-tensive osteotomy is needed, Eim et al. recommended the use of a simple step5cuttranslation osteotomy and fi-ation with a N5shaped humeral plate for firm fi-ation that allows

early movement of the &oint. 8hey treated cubitus varus or valgus secondary to supracondylar or

lateral condylar fractures in older children and young adults with this method and obtained good

clinical results (see 9ig. $$5//).

Fig. 33-88 Step5cut translation osteotomy. A,:fter humerus5elbow5wrist angle is determined on anteroposterior radiograph, initial

transverse osteotomy line is made about #.! to % cm superior to olecranon fossa and perpendicular to a-is of humerus. 8riangulararea indicates area to be resected. Band C,Cubitus varus is corrected by rotating distal fragment and translating it medially aftercompleting initial transverse osteotomy. 8riangular overlapping of pro-imal and distal humeral portions means that resection isindicated. 9or cubitus varus, degree of correction increases as location of ape- moves medially. Dand E,Cubitus valgus is

corrected by rotating distal part of humerus medially and translating it laterally according to anatomical shape of normal elbow. F,9i-ation of osteotomy site.(From 0im ?9, Lee J


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%&& "! $. &"" Fig. 33-83/

:fter standard preparation and draping and inflation of the tourniquet, approach the

elbow through a lateral incision.

With fluoroscopic guidance, insert two Eirschner wires into the lateral condyle before

osteotomy, and advance them &ust distal to the planned distal cut (see 9ig. $$5/$:).


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TECHNIQUE 33-19

F#"'

L-pose the distal humerus through a posterior longitudinal incision.

Split the triceps muscle and aponeurosis, detach the lateral half of the triceps from its

insertion, and reflect it pro-imally the posterior surface and lateral border of thehumerus are now visible, and the ulnar nerve can be e-posed.

Insert two drill points to act as guides in making the osteotomy, and check theirposition by radiographs.


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at the medial corte-.

L-tend the elbow, and close the wedge by fracturing the medial corte-, carefully

retaining a periosteal hinge.

1lace the forearm in supination, and evaluate the carrying angle. If it is satisfactory,

tighten a wire loop around the heads of the screws to appose the cut surfaces firmly. Ifnecessary, correct any rotational deformity at this time by offsetting the distal screw.4erotate the distal fragment, correct for rotational deformity, and align it with the

superior screw. 8ighten the wires around the screw heads.

AFTERTREATMENT

8he elbow is fle-ed *# degrees with the forearm in neutral rotation in a posterior plastic splint

for $ weeks. :n active mobili=ation program is started at that time.

TECHNIQUE 33-21

*$i" *&!"%!%+ i! D"#%!!i%'

A+&"# ') M"&&"'g

With the patient prone and a pneumatic tourniquet in place, e-pose the elbowposteriorly through a longitudinal incision that fashions a tongue of triceps fascia and

divides the triceps muscle in line with its fibers (see 8echnique %5/!). L-pose

subperiosteally the supracondylar part of the humerus, protecting the radial and ulnarnerves in the periphery of the wound.

Ase an oscillating saw to make an oblique osteotomy about $./ cm pro-imal to the

distal end of the humerus, directing it from posteriorly above to anteriorly below

complete it anteriorly with an osteotome. 8ilt and rotate the distal fragment until the

internal rotation and cubitus varus have been corrected.

With the fragments in proper position, fi- them with a screw inserted across the

middle of the osteotomy.

AFTERTREATMENT

8he arm is immobili=ed in a long5arm splint or cast until union is solid at to @ weeks.

TECHNIQUE 33-22

!"-C! *&!"%!%+

D"R%& ') :#;i'%

With the patient prone and a tourniquet inflated, make a posterior approach to the

distal humerus (see 8echnique %5/!), and reflect the triceps tendon, protecting theulnar and radial nerves.

Asing a template constructed preoperatively, make a lateral closing wedge osteotomy

in the metaphyseal region superior to the olecranon fossa. 1lace the ape- of the

template (angle to be corrected) medially with the superior margin perpendicular to

the humeral shaft. >oin the inferior margin to the superior margin to outline the


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osteotomy (9ig. $$5/+:). Demove the osteotomy wedge, leaving a lateral spike ofbone on the distal fragment. Some trimming of the lateral part of the pro-imal

fragment may be necessary for close appro-imation of the osteotomy.

8emporarily fi- the osteotomy with crossed Eirschner wires, and e-amine the arm for

any remaining deformity. If necessary, correct rotational malalignment andhypere-tension deformity. Insert a cortical screw as a lag screw through the lateral

spike into the pro-imal fragment, and remove the Eirschner wires (9ig. $$5/+


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Joint


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capitellum is not present. With arthrography, using single or double contrast, these authors were

able to confirm a diagnosis and alter treatment in numerous children. Some children thought to

have condylar fractures actually had transverse epiphyseal fracture5separations (Salter57arristype II fractures), and several thought to have intraarticular fractures had supracondylar fractures.

Some children originally considered for surgery were treated nonoperatively after an accurate

arthrographic diagnosis.


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a supracondylar fracture.

Irrigate the wound copiously. :pply a posterior splint with the elbow at *# degrees of

fle-ion. Check the radial pulse.

AFTERTREATMENT

:ftertreatment is the same as for open reduction of supracondylar fractures (see 8echnique $$5

%@).

TECHNIQUE 33-16

A'!"#i%# A#%

1repare and drape the arm in the usual fashion with the patient supine.

Make a curved incision over the lateral humeral condyle, beginning about " cm distal

to the olecranon and carrying it pro-imally for about @ cm above the condyle. 4issectthe soft tissue, including the anconeus and common e-tensor origins, and retract these

anteriorly and posteriorly. Lnsure the radial nerve is retracted posteriorly. : largehematoma may require evacuation before the fracture can be seen.

If an anterior approach is to be used, develop a plane between the biceps andbrachialis tendons. Delease the biceps aponeurosis, while protecting the brachial

artery. Detract the biceps and brachialis muscle medially and the brachioradialis

laterally. 1rotect the radial nerve and posterior interosseous artery.

;bserve the supracondylar fragment, and note its alignment with the pro-imal

fragment. Ase a small curet to remove any hematoma at the fracture site. ?ote anyinterdigitations on the ends of the bone, and by matching them, reduce the fracture.

Ase two crossed Steinmann pins in a manner similar to that described for

percutaneous pinning. Image intensification simplifies pin placement, as does a powerdrill. Cut the pins off outside the skin for easy removal later.

Close the incision in layers.

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SC Fracture

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