Successfully reported this slideshow.
P A R T N E R S O R T H O P A E D I C Trauma Rounds Case Reports from the Mass General Hospital and Brigham & Women’s Hospital A Quarterly Case Study Volume 3, Fall 2011 Pediatric Supracondylar Fractures Samantha A. Spencer, MD propriate setup with a hand table, sterile Pediatric supracondylar fractures are the most tourniquet, C-arm common elbow fractures in children. Approxi- and hand instru- mately 7-10% of supracondylar fractures and up ment set. A vascular to 50% of severely displaced Type III supracon- surgeon should be dylar fractures present with a neurologic injury: available if needed. radial nerve (41.2%); median nerve (36%); ulnarnerve (22.8%). Vascular injury is seen in 1% of displaced supra- When opening pe-condylar fractures. Nondisplaced fractures/minimally dis- diatric fractures, it isplaced Type II fractures can be safely managed with 3 weeks of best to always openimmobilization. The standard of care for displaced fractures is over the tear in thereduction/pin ﬁxation for 3-4 weeks, then early mobilization. periosteum. For supracondylar frac-Problematic Fractures: Tips for Identification tures, a 3-5 cm ante-The majority (90-95%) of displaced supracondylar fractures can rior incision in thebe managed with closed reduction and pinning with excellent elbow crease usu-outcomes. However, a subset of fractures need open reduction ally allows easy ex-and are at risk for neurovascular sequelae. A problematic frac- posure of the frac-ture should be suspected whenever there is less than a fully ture and the neuro-intact neurovascular exam or severe fracture displacement. vascular structures. These are oftenAn adequate neurovascular exam can be difﬁcult in a child but tented over theshould always be documented, or – should an adequate exam proximal fracturenot be possible - whatever can be obtained should be docu- fragment. Oncemented. Capillary reﬁll should be immediate; sluggish reﬁll any entrapped mus-should raise concern for vascular injury or entrapment. Simi- cle and/or nerves/larly, nerve deﬁcits or paresthesias signify nerve stretch or en- vessels are cleared,trapment. These fractures need urgent treatment. the fracture can beRadiographically, the direction of the proximal metaphyseal open reduced andspike predicts the likely neurovascular injury: anterior (direct Figure 1: Elbow x-ray demonstrating severely pinned in the usual displaced supracondylar fracture.posterior extension type)-median nerve/brachial artery, medial fashion. The nerves(posterolateral extension type or ﬂexion type)-ulnar nerve, lat- and vessels can then be assessed with the tourniquet down. Iteral (posteromedial extension type)-radial nerve. Figure 1 often takes warming and dripping vasodilative agents on theshows a severely displaced extension type which had en- brachial artery for 10-15 minutes to relieve vasospasm. If pulsa-trapped median nerve and brachial artery. tile ﬂow returns - which is common - standard closure and bi-How to Open Reduce & Fix Pediatric Supracondylar Fractures valved casting can proceed. If ﬂow does not return or an arte-Once a fracture has been identiﬁed as possibly problematic and rial injury is visible, a vascular surgery assessment for need ofhas unsatisfactory closed reduction, it is important to have ap- brachial artery repair must occur.Trauma Rounds, Volume 3, Fall 2011 1
P A R T N E R S O R T H O P A E D I C T R A U M A R O U N D S Figure 2: Postoperative AP and Lateral x-rays of pin conﬁgurations.After either closed or openreduction and pinning of asupracondylar fracture (Fig-ure 2), children should becomfortable with little nar-cotic requirement and nonegative change to their pre-operative neurologic exam.Significant pain and increas-ing pain medicine require-ments are the best indicatorsin children of evolving com-partment syndrome or missedarterial injury or entrappednerve. Entrapment shouldparticularly be suspected ifpain increases and nerve function is decreased after closed reduc- Bibliography 1. White L, Mehlman CT, Crawford AH. Perfused, pulseless, and puzzling: a sys-tion and pinning. These issues require emergent surgical explora- tematic review of vascular injuries in pediatric supracondylar humerus fracturestion. and results of a POSNA questionnaire: J Pediatr Orthop 2010; 30(4):328-35.Conclusions 2. Campbell CC, et al, Neurovascular injury and displacement in type III supracon- dylar humerus fractures: J Pediatr Orthop 1995; 15(1):47-52.The majority of displaced supracondylar fractures can be man- 3. Kasser JR and Beaty JH, Supracondylar Fractures of the Distal Humerus: Chapaged with closed reduction and pin ﬁxation in a regularly 14 In Rockwood and Wilkins, Fractures in Children, 6th ed. Lippincott Wil-scheduled OR time. However, displaced fractures with preop- liams & Wilkins; Philadelphia, PA. 2006: 543-589.erative neurovascular deﬁcits should raise concern for neuro-vascular entrapment and injury. Indications for open reduction New England Regional Fracture Summit, Stowe, VTof closed pediatric supracondylar fractures include inadequate The popular AO Fracture Summit will be held January 13 – 16, 2012 inhand perfusion after pinning, inability to obtain an adequate Stowe, VT. The course is chaired by Drs Mark Vrahas, Jesse Jupiter andreduction, and evidence of iatrogenic neurovascular injury Raymond White, and features several BWH and MGH Orthopaedicpostoperatively. When open reduction is performed, an ante- Faculty. This year’s special guest is Dr Joseph Schatzker.rior antecubital crease incision affords access to the torn perios- The course uses an informal, discussion-based, highly interactive format.teum as well as the neurovascular structures. The chief aim is to educate community orthopaedic surgeons who areDr. Samantha Spencer is a pediatric orthopaedist at Childrens Hospital, Boston actively involved in the treatment of patients with fractures. Partici-specializing in trauma, lower extremity, vascular anomalies, osteogenesis imper- pants are invited to bring their own cases for discussion.fecta and skeletal dysplasias. Samantha.Spencer@childrens.havard.edu Registration is still open! For more information: www.aona.org AchesAndJoints.org/Trauma Please share your comments online, or by email:Trauma Faculty Michael Weaver, MD — 617-525-8088 Mark Vrahas, MD / firstname.lastname@example.org BWH Orthopedic TraumaMark Vrahas, MD — 617-726-2943 Yawkey Center for Outpatient Care, Suite 3C email@example.comPartners Chief of Orthopaedic Trauma 55 Fruit Street, Boston, MA firstname.lastname@example.org Jesse Jupiter, MD — 617-726-5100 MGH Hand & Upper Extremity Service Editor in ChiefMitchel B Harris, MD — 617-732-5385 email@example.com Mark Vrahas, MDChief, BWH Orthopedic Traumambharris@partners.org David Ring, MD — 617-724-3953 MGH Hand & Upper Extremity Service Program DirectorR Malcolm Smith, MD, FRCS — 617-726-2794 firstname.lastname@example.org Suzanne Morrison, MPHChief, MGH Orthopaedic Trauma (617) 525-8876 Brandon E Earp, MD — 617-732-8064 email@example.com@partners.org BWH Hand & Upper Extremity ServiceDavid Lhowe, MD — 617-724-2800 firstname.lastname@example.org Editor, PublisherMGH Orthopaedic Trauma George Dyer, MD — 617-732-6607 Arun Shanbhag, PhD, MBAdlhowe@partners.org BWH Hand & Upper Extremity Service www.MassGeneral.org/ortho email@example.com www.BrighamAndWomens.org/orthopedics2 Trauma Rounds, Volume 3, Fall 2011