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Supracondylar Fracture of the Humerus in Children

 

The age is between 4-10 years. The injury is caused by a fall onto an outstretched hand. The majority of the fractures are extension type fractures. Type III is a displaced fracture, and it carries a high incidence of neurovascular deficit and compartment syndrome. Compartment syndrome may not develop right away; it may take hours to develop. The physician should not confuse compartment syndrome with the arterial injury. You can have arterial injury and compartment syndrome or compartment syndrome without arterial injury, and in this case, you will need fasciotomy to release the compartment syndrome. The anterior interosseous nerve is involved in the extension type injury. The patient cannot do the OK sign. If you have an extension type injury and you find that the patient has an ulnar nerve palsy after surgery, then it is probably not due to the extension type injury, but rather is due to the medial pin that may have affected the ulnar nerve. In the flexion type injury, the ulnar nerve injury is more common. Based on the Gartland Classification System, a Type I fracture is nondisplaced, a Type I fracture is angulated with an intact posterior cortex, and a Type III fracture is displaced. To treat a Type I fracture, immobilize the patients arm. To treat Type II and Type III fractures, do closed reduction and percutaneous pinning. If you cannot get the alignment correct, then do open reduction. You will place two or three lateral pins. If a medial pin is needed, be careful of the position of the ulnar nerve. Use open incision to introduce the medial pin. Have the elbow in extension, not in flexion, when you place the medial pin because this will relax the ulnar nerve. When you use the pins, do diversion pins.


The cross pins configuration, medial and lateral pins, gives the maximum rotatory stability. The crossing should be approximately 2 cm proximal to the fracture. Normally we use two diversion lateral pins and adding a third pin will increase the stiffness in case of medial comminution. Avoid malposition of the fragments because it can lead to malunion and cubitus varus. Very rarely you may have to do corrective osteotomy for the cubitus varus (it is only a cosmetic problem, not a functional problem. If you have a pulseless, pink hand or a pulseless, white hand, then there is decreased perfusion. You will need to do emergency closed reduction and pinning. If closed reduction cannot be done, then you will do open reduction and pinning. After this, if the hand is pink and warm, then you observe. Observe for capillary refill, for temperature, and for color with the elbow in some flexion, but not in hyperflexion. If after the closed reduction and pinning the hand continues to be white and cold, you will do exploration of the artery. A pulseless, white hand from the beginning and you reduced and pinned the fracture, but the hand continues to be white, then you need to explore and repair the artery. You will repair the artery through an anterior approach and you will do fasciotomy after that. Initially, if the circulation was good, but after reduction and fixation you have a pulseless, white hand, then you need to unreduced the fracture fixation. When you have a nerve injury, observe the patient, do not explore the nerve. The recovery will start in about 6-12 weeks and the majority are completed in 4-5 months. Do not explore the nerve in closed fractures. The anterior humeral line should intersect the middle third of the capitellum in children more than 5 years old, and it touches the capitellum in children less than 5 years old. You want to maintain this relationship between the anterior humeral line and the capitellum. You will remove the pin at 3 weeks, you will allow gentle range of motion, you do not need routine physical therapy and the stiffness usually resolves in about 6 months. Do reduction and fixation when the hand is well perfused (pink and warm), then you can wait overnight to do the reduction in the morning. The urgent cases where you cannot wait to do reduction and fixation are the open fractures, the ones with neurovascular deficit, floating elbow, or impending compartment syndrome.

Author
Nabil Ebraheim, MD

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