Upper Extremity Injuries

Reduction of Anterior Displacement

Anesthesia is achieved with conscious sedation techniques or hematoma block. The patient is placed supine, with a bolster between the scapulae. An assistant applies longitudinal traction to both upper extremities, and gentle posterior pressure is applied to the displaced medial metaphyseal fragment to obtain reduction. The displaced medial fragment may be grasped with a towel clip to help facilitate reduction. As noted, if reduction cannot be achieved or the reduction is unstable, we generally accept the deformity, with the knowledge that significant remodeling almost always occurs. ^{, ,}

Reduction of Posterior Displacement

If the metaphyseal fragment is displaced posteriorly with evidence of compression of the mediastinal structures, we first attempt closed reduction under general anesthesia. The patient is placed supine with a bolster between the shoulder blades. Longitudinal traction is applied to the arm, with the shoulder adducted. A posteriorly directed force is applied to the shoulder while the medial end of the clavicle is grasped with a towel clip in an effort to bring the metaphyseal fragment anteriorly. If closed reduction fails, we proceed to open reduction with repair of the sternoclavicular and costoclavicular ligaments. Patients with minimal posterior displacement can be managed symptomatically with a sling or harness. Closed reduction is contraindicated in late presenting posteriorly displaced fractures, as the fracture may be adherent to underlying vascular structures in the mediastinum.

Emergency Treatment

It is important that the child and limb receive proper care while awaiting definitive treatment. Unless the patient has an ischemic hand or tented skin, the limb should be immobilized as it lies with a simple splint. If possible, radiographs should be obtained before splinting, or radiolucent splint material should be used. If the distal extremity is initially ischemic, an attempt to align the fracture fragments better should be made immediately in the emergency department. This can be accomplished by extending the elbow, correcting any coronal plane deformity, and reducing the fracture by bringing the proximal fragment posteriorly and the distal fragment anteriorly ( Fig. 29.41 ). Often, this simple maneuver immediately restores circulation to the hand. In extension-type fractures, hyperflexion of the elbow should be avoided because it may cause further damage to the neurovascular structures. The distal circulation should always be checked before and after the splint is applied. Sensation, motor function, and skin integrity should also be carefully checked and recorded. Patients with open fractures should receive intravenous antibiotics and appropriate tetanus prophylaxis (see discussion of open fractures in Chapter 26 ). All patients should be kept from having any food or drink by mouth (NPO) until a definitive treatment plan has been outlined.

Treatment of Nondisplaced Fractures

Treatment of nondisplaced fractures is straightforward and noncontroversial. It consists of long-arm cast immobilization for 3 weeks. We often initially treat the patient in the emergency department with a posterior splint. For truly nondisplaced fractures there is no theoretic advantage to pronation or supination of the forearm. We generally immobilize nondisplaced fractures with the forearm in neutral position. The patient returns 5 to 10 days after injury for removal of the splint. Radiographs are repeated to ensure that no displacement has occurred, and the patient is placed in a long-arm cast for an additional 2 to 3 weeks, at which time immobilization is discontinued, but the patient is still restricted from sports and physical education class for another 4 weeks. After cast removal, the parents are forewarned that normal use of the arm may not resume for 1 to 2 weeks, and that some pain and stiffness should be expected for the first 2 months. Parents should be reassured that mild loss of motion for the first 2 months out of the cast is normal and will resolve on its own.

There are a few potential pitfalls in the management of nondisplaced supracondylar humeral fractures that merit further discussion. An occult infection or nursemaid’s elbow may be misdiagnosed as a nondisplaced supracondylar humeral fracture. A thorough history will suggest the correct diagnosis. At times, undisplaced fractures cause soft tissue swelling acutely and may even result in compartment syndrome, especially when the injured arm stays in a dependent position. We are careful to not immobilize the arm in more than 90 degrees of flexion and often use a posterior splint rather than a cast. If a cast is applied, it is generously split. The parents must be educated on the importance of edema control and watching for signs of increased swelling and pressure. Too often patients are discharged from the emergency department with instructions to elevate the arm and use a sling. Unfortunately, the sling keeps the extremity in a dependent position and promotes swelling. Time should be taken in the emergency department to explain to the parents (and the nurses giving discharge instructions) that the extremity should be elevated with the fingers above the elbow and the elbow above the heart for the first 48 hours after the injury. The sling is for comfort after the swelling has subsided. Parents should be instructed to return immediately to the emergency department if it appears that the splint or cast is becoming too tight or the pain seems to be increasing inappropriately.

Treatment of Displaced Fractures

Several treatment options are available for the management of displaced fractures (types II and III). By definition, all these fractures require reduction. Usually, even for severe type III injuries, reduction can be accomplished in a closed fashion. Options exist in regard to the method of maintaining the reduction until the fracture has healed, including cast immobilization, traction, and percutaneous pin fixation. If adequate closed reduction cannot be achieved, open reduction should be performed; this is almost universally followed by pin fixation.

Reduction of Extension-Type Fracture

Under general anesthesia, the child is positioned at the edge of the operating table, with the arm over a radiolucent table to allow assessment of the reduction with an image intensifier ( Fig. 29.42 ). Some surgeons elect to use the image intensifier itself as the table. An assistant grasps the proximal humerus firmly to allow traction to be placed on the distal fragment. If there is puckering of the anterior soft tissues over the proximal metaphyseal fragment, known as the “brachialis sign,” the entrapped muscle and soft tissue most be extricated with the “milking maneuver” where the biceps and brachialis muscle bellies are milked in a distal direction to release the muscles from the metaphyseal fragment. Once the soft tissues are extricated, longitudinal traction should be applied with a steady continuous force, with the elbow in full extension. Once adequate traction has been applied, the coronal plane deformity (translation and varus-valgus) is corrected while traction is maintained (see Fig. 29.42 B). Continuing to maintain traction with the dominant hand, the surgeon uses the fingers of the nondominant hand to apply a posteriorly directed force to the proximal fragment. The thumb of that hand is then placed on the olecranon to apply an anterior force to the distal fragment while the fingers continue to pull the proximal fragment posteriorly (see Fig. 29.42C ). Concurrently, the dominant hand flexes the elbow and pronates the forearm for posterior medially displaced fractures and supinates the forearm for posterior lateral fractures. While the elbow is being flexed, the surgeon’s dominant hand can continue to exert a distracting force on the distal fragment. The patient’s hand should be touching the shoulder. With the elbow hyperflexed, the reduction is then assessed on AP and lateral views. The lateral is obtained by externally rotating the shoulder while keeping the elbow hyperflexed. If hyperflexion causes malreduction in the coronal plane, pressure from the nondominant fingers and thumb on both the distal fragment and opposing metaphyseal spike may be needed to maintain coronal alignment during the flexion maneuver. With very unstable fractures the surgeon may need to rotate the image intensifier to avoid displacing the fracture.

In general, Gartland type IIa fractures without coronal malalignment can be treated with either cast immobilization or pin fixation after reduction, depending on surgeon preference. Reduction and immediate casting may be performed in the emergency department with fluoroscopy and sedation if needed. Parikh and colleagues reported a success rate of 72% in maintaining alignment in emergency department closed reduction and casting. However, varus or valgus malalignment cannot be controlled in a cast and mandates pin fixation after reduction to maintain alignment.

Gartland type III fractures are almost always stabilized with percutaneous pin fixation after reduction.

There are several caveats to achieving successful closed reduction that need mention. The first is that every effort should be made to avoid vigorous manipulations and remanipulations because they only damage soft tissue and elicit more swelling. The second is the management of extremely unstable fractures, which are often posterolaterally displaced. Maintenance of reduction is difficult because supination is not as effective at tightening the intact lateral soft tissue hinge as pronation is at stabilizing posteromedially displaced fractures (see Fig. 29.31 ). During reduction, as the elbow is placed into hyperflexion, these fractures occasionally displace into valgus. When this occurs, a varus force must be applied with the nondominant hand as the elbow is flexed, and flexion is stopped at 90 degrees. The reduction is confirmed (the image intensifier generally needs to be rotated for a lateral view) and stabilized with percutaneous pinning (see Fig. 29.42D and E).

Closed Reduction of Flexion-Type Fractures

Closed reduction is obtained with longitudinal traction and the elbow in extension; the distal fragment is reduced with a posteriorly directed force ( Fig. 29.43 ). Any coronal plane deformity is then corrected. Once adequate reduction has been confirmed, it is maintained with percutaneous pinning. Severely displaced flexion-type injuries and those with ulnar nerve injuries are more likely to require open reduction than the more common extension-type fractures.

Open Reduction of Supracondylar Humerus Fractures

Open reduction of supracondylar humerus fractures is needed when closed reduction fails to adequately reduce the fracture. Other indications for open reduction include operative debridement in open fractures, compartment syndrome, and neurovascular injuries that require open exploration and potential repair of injured structures. The decision that a closed reduction is unacceptable and an open reduction is indicated must be made on an individual basis. We accept mild angulation in the sagittal plane as long as the anterior humeral line intersects the capitellum. Mild amounts of translation in the coronal plane and sagittal plane are also acceptable, as is a minimal amount of valgus angulation in the coronal plane. However, varus angulation in the coronal plane, particularly if associated with a small amount of hyperextension in the sagittal plane or a contralateral carrying angle that is neutral or varus, is likely to yield a cosmetically poor result that will not remodel ( Fig. 29.44 ) and predisposes to development of posterolateral rotatory instability and ulnar nerve symptoms as an adult. ^{, ,} If significant varus deformity exists after the best attempt at closed reduction, we proceed to open reduction.

The surgical approach can be anterior, medial, or lateral, and is based on the location of the metaphyseal spike. The posterior approach has increased risk of postoperative stiffness, the potential for disruption of the blood supply, and is rarely, if ever, used at our institution. Approaching the fracture from the metaphyseal spike allows direct visualization of the structures impeding reduction. Skin incisions should be planned to avoid compromised skin that may cause necrosis or problems with wound healing. The anterior approach has the most utility as it allows for exploration of the neurovascular bundle in extension-type fractures. A “lazy S” incision in the flexion crease of the antecubital fossa is made, with the proximal limb extending medially and the distal limb extending laterally to allow for increased exposure if needed.( Fig. 29.45 ) Blunt dissection is used to complete the deep exposure and identify the proximal metaphyseal fragment. Many times, the metaphyseal spike has performed the dissection already. If the approach is used to extract interposed structures from the fracture site, the dissection should be lateral to the biceps tendon to avoid iatrogenic injury to the neurovascular bundle. However, the neurovascular bundle can be displaced in a nonanatomic position in severely displaced supracondylar humerus fractures, so care during dissection is of paramount importance. Once the metaphysis is exposed, the interposed structures can be extricated and the fracture reduced under direct visualization. This maneuver is similar to the maneuver for a closed reduction of an extension supracondylar. If difficulty is encountered with obtained length, a small Hohmann retractor or Freer elevator can be used as a lever on the distal fragment while balancing the instrument shaft on the proximal metaphysis fulcrum. The reduction and maintenance of reduction are often difficult once the fracture has been opened due to the complete lack of stability from the periosteal stripping. Many times, the reduction is only stable at 90 degrees of flexion with the surgeon’s fingers manually holding the reduction while an assistant percutaneously drives the K-wire pins across the fracture site.

The medial approach is used for posterolaterally displaced fractures as well as flexion type fractures that cannot be reduced due to entrapment of the ulnar nerve or other soft tissue. Once the skin incision is made, blunt dissection is used to identify the ulnar nerve, which is mobilized and protected. The brachialis muscle is then reflected anteriorly to expose the proximal metaphyseal fragment.

Percutaneous Pinning

Percutaneous pin fixation yields the most predictable results with the fewest complications and is the preferred technique for immobilization of displaced supracondylar humeral fractures. ^hh

References , , , , , , , , , , , , , , , , , , , .

The technique for percutaneous pinning involves the placement of two or three 0.62-inch smooth K-wires (smaller K-wires may be used in patients younger than 2 years) distally to proximally in a crossed or parallel fashion. While the use of a crossed pin or parallel pin technique has been the subject of considerable debate, it is now accepted that lateral-entry parallel pins are the safest and most appropriate stabilization of supracondylar humerus fractures although a medial-entry pin is acceptable when needed to obtain sufficient stability of the fracture ( http://www.orthoguidelines.org/go/auc/auc.cfm?auc_id=224922 ). Once closed reduction has been achieved, the extremity is held in the reduced position by the surgeon’s nondominant hand or by an assistant. For successful all-lateral pin construct several objectives must be achieved: (1) Two or more pins must engage both fracture fragments; (2) all pins must achieve bicortical fixation; (3) pins must have maximal pin separation at the fracture site, ideally with one in the medial column and one in the lateral column ( Fig. 29.46 ); and (4) use of a third lateral-entry pin if more stability is required.

If a medial pin is used, care must be taken to ensure that the ulnar nerve is not injured. As 28% of children have subluxating ulnar nerves, and 10% have dislocating nerves, the elbow should be held at less than 80 degrees of flexion when placing a medial pin, and after pinning, the elbow should not be flexed past 90 degrees to avoid tethering of the ulnar nerve ( Fig. 29.47 ). The starting position for a medial pin is the inferiormost aspect of the medial epicondyle ( Fig. 29.48 ). The pin should be started as far anteriorly as possible. The surgeon can often palpate the ulnar nerve subcutaneously, just proximal to the medial epicondyle. He or she should milk the soft tissue posteriorly, with the thumb placed immediately posterior to the medial epicondyle to protect the ulnar nerve with the elbow held in gentle extension ( Fig. 29.49 ). If the elbow is extremely swollen, a small incision can be made and blunt dissection can ensure that there are no interposing structures between the pin and medial epicondyle.

Placement of K-wires percutaneously through the narrow distal humerus requires some finesse. As in all percutaneous procedures in orthopaedics, it is facilitated by knowing the anatomy and by reducing the task into two separate, two-dimensional problems. Appropriate pin placement is made easier by first lining up the pin driver in the AP plane, locking this angle in, and then lining up the pin driver in the lateral plane without changing the angle in the AP plane. Positioning the pin driver and subsequently the pin sequentially in only these two orthogonal planes simplifies a conceptually difficult task.

Once the fracture has been stabilized with at least two pins, the elbow is extended, and the reduction and pin placement are confirmed on orthogonal radiographic views. If the reduction and pin placement are acceptable, the pins are bent, cut (it is best to leave a few centimeters of pin out of the skin to facilitate removal), and covered with sterile felt to decrease skin motion around the pin. The arm is immobilized in 60 to 85 degrees of flexion in a posterior splint or widely split or bivalved cast. If a medial pin is used, care should be taken to ensure that the elbow is not flexed past 80 degrees to avoid tethering of the ulnar nerve over the medial pin. While the majority of type II supracondylar humerus fractures can be safely treated as outpatient surgery, most type III fractures should be observed in the hospital for swelling and pain control after surgery. The family should be educated on cast care and elevation. The child usually returns in 7 to 10 days for examination, and in-plaster radiographs are generally taken to check for maintenance of reduction. At 3 weeks the radiographs are repeated, the pins are removed, and the immobilization is discontinued. Although several recent studies have called into question the utility of postoperative radiographics, it is still our practice to obtain radiographs at 1 week and 3 weeks. The parents are instructed to expect gradual ROM and to avoid forced manipulation. Final follow-up is at 7 to 10 weeks post-operatively to evaluate alignment and ROM and to allow return to activities.

As with all treatment methods, there are potential complications with percutaneous pinning, including pin tract inflammation or infection, iatrogenic ulnar nerve injury, and loss of reduction. Pin tract inflammation or infection occurs in 2% to 3% of patients in most large series of supracondylar humeral fractures treated by pin fixation. Fortunately these infections usually respond to removal of the pin and a short course of oral antibiotics, although osteomyelitis can develop. Ulnar nerve injury from a medially placed percutaneous pin is another potential complication, although several randomized prospective series have not demonstrated a statistically significant difference in complication rates between lateral entry compared to medial and lateral entry pin fixation. ^{, ,} If an ulnar nerve deficit is noted postoperatively and a medial pin is present, we recommend removal of the medial pin and observation. Fortunately, in most cases, the ulnar nerve makes a complete recovery. ⁱⁱ

References , , , , , , , .

Loss of reduction can occur after closed reduction and percutaneous pinning of supracondylar humeral fractures ( Fig. 29.50 ). This complication is generally the result of inadequate surgical technique and can be minimized by close attention to detail to ensure that the pins are maximally separated at the fracture and have adequate purchase in the proximal fragment.

Cast Immobilization

The advantages of cast immobilization are that a cast is easy to apply, readily available, and familiar to most orthopaedists. Casting does not require sophisticated equipment, there is little chance of iatrogenic infection or growth arrest, and it can yield good results. However, most displaced supracondylar fractures are stable only if immobilized in more than 90 degrees of flexion. Casting an injured elbow in hyperflexion may lead to further swelling, increased compartment pressure, and possibly the development of Volkmann’s ischemic contracture (compartment syndrome) in the setting of a rigid circumferential dressing.

In our institution, cast immobilization as the only form of treatment is utilized in type Ia fractures and some select type IIa fractures without coronal malalignment. Attention to detail is needed when casting type IIa fractures after a closed reduction is performed. First, the cast should be carefully applied to avoid compression in the antecubital fossa. Second, the parents must understand the importance and technique of edema control. Finally, repeat radiographs are obtained with the arm in the cast in 7 to 10 days to ensure that alignment is maintained. If significant swelling has resolved and the cast is loose, the cast may need to be reapplied to maintain reduction. Again, the cast is maintained for 3 to 4 weeks after the reduction, and the parents are warned to expect a period of pain and stiffness after cast removal.

Traction

While numerous traction techniques have been historically described, including overhead or lateral traction with skin or skeletal traction applied with an olecranon pin or screw, we do not use traction in the management of supracondylar humeral fractures. It is mentioned here only for historical completeness. It may have a role in the rare fracture that cannot be managed routinely because of extenuating circumstances.

Management of Minimally Displaced Fractures

There is debate regarding the necessity of closed reduction and pinning for all displaced supracondylar fractures, particularly minimally displaced type IB or II fractures. A number of studies have reported good results with closed reduction and casting of extension supracondylar fractures. ^{, ,}

Although we recognize that some minimally displaced fractures may be managed successfully without pin fixation, there are several potential hazards with cast management of minimally displaced supracondylar fractures. Type IB or IIB fractures with medial column collapse or comminution may be more unstable than appreciated on initial radiographs ( Fig. 29.51 ). If treated by simple immobilization, these occultly unstable fractures are likely to displace into varus and hyperextension, leading to malunion and a cosmetically unacceptable result. Second, even if the fracture is stable, collapse of the medial column may produce enough varus and hyperextension to produce a poor result if the fracture is not reduced.

There are also two potential problems with closed reduction and cast management of type II fractures. The first is loss of reduction, and the second is increased swelling and the potential development of compartment syndrome secondary to immobilization with the elbow in flexion. The difficulty with cast management of minimally displaced fractures was demonstrated in the studies of Parikh and colleagues and Hadlow and colleagues. Both series reported successful treatment with closed reduction and casting in 72% to 77% of patients with type II extension-type. However, 23% of Hadlow’s cohort required a second procedure, due to unacceptable alignment, and 20% of Parikh’s group required secondary reduction and pinning, with an additional two patients having a poor result after losing reduction but failing to have any intervention. Obviously, the problem is correctly identifying which fractures are at risk for malunion. To our knowledge, no reliable predictors of malunion exist, and many studies have reported superior results with percutaneous pinning of displaced supracondylar fractures. ^{, ,} Therefore we prefer closed reduction and pinning for all types IB and IIB supracondylar humeral fractures and will occasionally attempt closed reduction and cast treatment for very minimally extended IIA fractures. Although this aggressive management may lead to a few unnecessary pinnings, we believe that it also results in the fewest complications.

Timing of Reduction for Type III Fractures

Although it is agreed that pin fixation yields the best results for type III fractures, there is some controversy regarding the timing of treatment. Historically, type III fractures were regarded as an orthopaedic emergency that had to be treated immediately. However, good results have been reported when type III fractures were treated on an urgent rather than emergency basis. Those who advocate delayed treatment cite the advantages of an adequate NPO status and more efficient operative setting.

Provided that the skin is intact and not tented, the swelling is minimal, and the neurovascular examination is normal, we will allow an 8- to 10-hour delay to avoid operating on these fractures in the middle of the night. Type III injuries that are treated in delayed fashion are splinted in minimal flexion, with care taken to ensure that the proximal fragment is not displacing the skin, and patients are admitted for elevation and observation until definitive treatment. Patients in whom the skin is compromised, the swelling is severe, or the neurovascular examination is abnormal are treated by closed reduction and pinning on an emergency basis. A multicenter review found 11 patients who developed compartment syndromes of the forearm. Severe swelling on presentation was present in all, all had palpable pulses, and delay of treatment averaged 22 hours. When severe soft tissue injury is noted, urgent treatment seems indicated, especially since soft tissue injury is associated with neurovascular compromise as well as a decline in a previously normal neurologic or vascular exam.

Pinning Technique and Iatrogenic Ulnar Nerve Injury

Pin placement configuration unfortunately still continues to be debated. Although several biomechanical studies have shown that crossed pins are the most stable configuration, a number of reports have shown good clinical results with parallel lateral pin fixation. ^jj

References , , , , , , , , , , , , , , , , , , , , .

In a randomized trial, Kocher and co-workers found no difference in outcome comparing crossed pins with lateral pins, with no ulnar nerve injuries in either group. In follow-up, five of eight surgeons at the originating institution had changed from crossed to lateral pin fixation. Although more stable, the crossed pin technique requires the placement of a medial pin, which may injure the ulnar nerve. ^kk

References , , , , , , , , , , .

A meta-analysis showed a 4.3-fold increased incidence of ulnar nerve injury with cross pinning. Slobogean and co-workers calculated a number needed to harm relative to ulnar nerve injury and proposed an iatrogenic ulnar nerve injury for every 28 patients treated with cross pinning. Skaggs and colleagues, in a review of 369 supracondylar fractures, reported that the incidence of ulnar nerve injury could be decreased from 15% to 2% by placing two lateral pins, followed by the selective use of medial pins only for fractures that remain unstable after placement of the lateral pins.

In our institution, we use two lateral-entry pins in type II fractures and three lateral-entry pins in type III fractures. However, we do not hesitate to place a medial pin using the careful technique described earlier if the fracture demonstrates continued instability after three lateral-entry pins or if the fracture is a very proximal fracture or obliquely oriented pattern that precludes two divergent lateral-entry pins.

Although iatrogenic ulnar nerve injury almost always recovers, there are case reports of permanent injury. Thus we believe that an ulnar nerve palsy associated with a medial pin requires immediate treatment. Initially we ensure that the elbow is immobilized in a semi-extended position. Often the ulnar nerve is not directly injured by the K-wire but is stretched around the medial pin when the elbow is in a flexed position (see Fig. 29.47 ). If the elbow is adequately extended or if extension does not alleviate the ulnar nerve symptoms, we remove the medial pin immediately.

Management of a Viable, Pulseless Hand

Controversy exists regarding the best management of a pulseless pink hand. The elbow’s abundant collateral circulation allows the distal extremity to remain viable, despite complete disruption of the brachial artery ( Fig. 29.52 ). Past recommendations for management of a viable but pulseless hand range from observation to arteriography to immediate surgical exploration. ^ll

References , , , , , , , , , , , , , , , , , , , , .

Several groups have shown that the hand can remain viable and a radial pulse can even return after ligation of the brachial artery. ^{, ,} Scannell and colleagues reported 20 patients with pink pulseless hand after a supracondylar fracture; at follow-up, 5 patients had occluded brachial arteries and 1 patient had a stenotic brachial artery; despite this, patients had a palpable radial pulse, normal growth of the arm, and good/excellent outcomes although one occluded patient had cold intolerance. Nevertheless, some recommend aggressive surgical attempts to restore a normal pulse because of concern that conservative management of a pulseless viable extremity could lead to progressive ischemia as a result of thrombus formation or future problems with cold intolerance, exercise claudication, or growth discrepancy. ^mm

References , , , , , , , .

Our approach to a viable hand with abnormal pulses is close observation postoperatively using the Doppler ultrasound to evaluate distal radial pulses. Our institution reported on 54 pink pulseless hands after supracondylar fracture; 26 patients had restoration of palpable radial pulses after closed reduction and pin fixation, and 20 patients had restoration of a dopplerable but nonpalpable radial pulse. Four patients underwent an immediate vascular procedure due to lack of dopplerable pulses after pinning. However, one patient who had restoration of dopplerable pulses after reduction and pinning was observed to have a cool, pale hand at 9 hours post-operatively and was emergently brought to surgery for a saphenous vein graft due to a thrombosed brachial artery. This highlights the necessity of close hospital observation and serial examinations for 24 to 48 hours following closed reduction and pinning of these fractures.

Management of Late-Presenting or Malreduced Fractures

Appropriate management of a patient who is initially evaluated 1 to 2 weeks after injury and found to have a nonreduced or unacceptably reduced fracture is often difficult to determine. Some surgeons advocate watchful waiting because attempts at manipulation once early callus begins to form may not improve the reduction and could risk increasing stiffness. This argument is strengthened by the knowledge that functional limitations are rare after malunion. Others favor a more aggressive approach and attempt closed or open reduction of these fractures. Unfortunately, there is little in the literature to guide the decision-making process. Alburger and colleagues have shown that a 3- to 5-day delay before closed reduction and pinning is not deleterious. Lal and Bhan reported good results in 20 children treated by open reduction 11 to 17 days after injury. Vahvaven and Aalto performed routine remanipulation at 2 weeks for all redisplaced fractures, without adverse sequelae.

We have had success with remanipulation of supracondylar fractures after delays of 2 to 3 weeks ( Fig. 29.53 ). Management of these injuries must be determined on an individual basis and must take into account factors such as the patient’s age, condition of the soft tissue, amount of residual deformity, and degree of radiographic healing. It is important that treatment decisions regarding these malreductions be made based on good information. Unfortunately, obtaining an adequate examination and radiographs in a young patient a few weeks after a displaced supracondylar fracture can be extremely difficult and may require examination under anesthesia. Although functional limitations are uncommon in the pediatric population with malunion of supracondylar humeral fractures, these injuries have little potential to remodel. Even a small improvement in alignment may represent the difference between a cosmetically acceptable result and one that is unacceptable. In addition, malunited supracondylar humerus fractures may lead to elbow instability as an adult. If an attempt is made to improve the alignment of a supracondylar fracture in delayed fashion, a perfect anatomic reduction may not be an achievable goal. In such cases, we usually accept an adequate nonanatomic reduction rather than proceed to open reduction.

Vascular Injury

Management of the pink, pulseless hand with a supracondylar humerus fracture was discussed earlier. The incidence of vascular compromise in type III extension supracondylar fractures has been reported to be between 2% and 38%. ⁿⁿ

References , , , , , , , , , , .

However, the reported incidence varies with the definition of vascular compromise inasmuch as this term has been used to describe a wide variety of patients, including those with a diminished pulse, those without a pulse, and those with an ischemic limb. Vascular injury may be induced directly or indirectly. Direct injury by the fracture may result in complete transection of the brachial artery, an intimal tear, or compression between the fracture fragments or over the anteriorly displaced fragment. Indirect injury is usually the result of compression. Compression can produce temporary ischemia that is reversible with reduction, reversible spasm, or permanent sequelae, such as intimal tears, aneurysms, or thrombosis. If the level of vascular injury, whether produced directly or indirectly, is distal to the inferior ulnar collateral artery, the rich collateral circulation about the elbow will generally provide adequate blood supply to the forearm and hand (see Fig. 29.52 ).

Management of acute vascular injury associated with supracondylar fractures of the humerus is controversial and must be individualized. The initial treatment consists of a thorough assessment of the skin and neurologic status, as well as evaluation for other injuries. If the hand is obviously ischemic, the arm should be immediately manipulated into a semi-extended position. Often this instantly restores circulation to the hand (see Fig. 29.41 ). If improving the alignment fails to provide distal circulation, the child should be immediately taken to the operating room for closed reduction and pinning.

We do not believe that arteriography or other studies are warranted before an operative attempt at closed reduction for two reasons. First, reduction of the fracture frequently restores the circulation. Second, even if the limb remains ischemic after reduction, the location of the arterial pathology is known. Thus an arteriogram provides little information that will alter the clinical management but can significantly prolong the ischemic time. Similarly, we do not generally obtain preoperative vascular or microsurgical consultation because the ischemia frequently resolves with reduction. If the limb remains ischemic, exposure of the brachial vessels can be performed while awaiting the arrival of a vascular surgeon or microsurgeon. If on exploration the artery is found to be trapped within the fracture fragments, the pins can be removed, the artery liberated, the fracture repinned, and circulation of the limb reassessed. Spasm and intimal lesions of the brachial artery may require arteriography for complete assessment, which can usually be performed intraoperatively with little difficulty using standard fluoroscopy. Spasm may be relieved with a stellate ganglion block or local application of papaverine, or resection and reverse interpositional vein grafting may be required. These decisions are generally made in conjunction with a vascular surgeon or microsurgeon. It is important to remember to perform a fasciotomy if there has been significant ischemic time or there is any concern about elevated compartment pressure.

Peripheral Nerve Injury

Peripheral nerve injury occurs in approximately 10% to 15% of supracondylar humeral fractures. ^oo

References , , , , , , , , , , , , , .

There has been a growing consensus that the anterior interosseous nerve is the nerve that is usually injured with extension-type supracondylar fractures, although the median, radial, and ulnar nerves all may be damaged. ^pp

References , , , , , .

Anterior interosseous nerve palsy is probably underreported because it is not associated with sensory loss. Median nerve injury has been reported more commonly with posterolaterally displaced fractures and radial nerve injury with posteromedial displacement. Although ulnar nerve injury may occur as a consequence of the fracture, the ulnar nerve is more frequently injured iatrogenically from a medial pin. ^qq

References , , , , , , , , .

Perhaps the single most important and often the most difficult aspect of managing peripheral nerve injuries associated with supracondylar humeral fractures is the challenge of reaching an accurate and timely diagnosis. Unfortunately, it is often impossible to perform an adequate neurologic examination in a young child with a supracondylar humeral fracture in the emergency department. Thus it is imperative to counsel the parents that as time progresses, there is a chance that a nerve injury will be discovered. Fortunately, the parents can be reassured that almost all such injuries will spontaneously improve. Because the majority of motor nerve palsies can be expected to recover spontaneously within 6 months, little treatment is required other than close monitoring for recovery and perhaps splinting or ROM exercises, or both, to ensure that a fixed contracture does not develop. Although most peripheral nerve injuries recover fully, there have been numerous reports of those that do not. ^rr

References , , , , , , , , , , , , , .

Thus, if within 6 months there is no advancing Tinel’s sign or demonstrable return of motor function, consideration should be given to electrodiagnostic testing and exploration. If a peripheral nerve is found to be transected, appropriate reanastomosis with grafting or tendon transfers should be undertaken.

Volkmann’s Ischemic Contracture (Compartment Syndrome)

In 1881, Richard von Volkmann described ischemic paralysis and contracture of the muscles of the forearm and hand and, less frequently, the leg after the application of taut bandages in the treatment of injuries occurring in the region of the elbow and knee. He suggested that the pathologic changes primarily resulted from obstruction of arterial blood flow, which if unrelieved would result in death of the muscles. Fortunately, with improved management of elbow fractures in children, the incidence of Volkmann’s ischemic contracture after supracondylar humeral fractures has decreased. Patients with floating elbows may be at increased risk for compartment syndrome and should be monitored appropriately. This potentially devastating complication may be better described as a consequence of a high-energy injury and may develop despite appropriate care.

The pathophysiology, diagnosis, and management of compartment syndrome are discussed in Chapter 26 . A supracondylar fracture associated with a compartment syndrome is generally best managed by emergency closed reduction and pinning followed by fasciotomies. After decompression of a compartment syndrome, proper splinting and active and passive ROM exercises for the extremity are essential to maintain joint mobility until function returns.

Management of an established Volkmann’s contracture consists of two stages. In the first stage, all necrotic and fibrosed muscle is debrided via an extensile approach from the elbow to wrist; utmost care is taken to identify and protect the median and ulnar nerves as well as the radial and ulnar arteries. The tendon ends are likewise carefully preserved. Range of motion of the fingers and wrist is started once the wounds are healed at 2 to 3 weeks. Once full passive range of motion is established and maintained, the 2nd stage consists of harvesting a free gracilis muscle transfer with an accompanying proximal skin paddle. The proximal gracilis is sutured to the medial epicondyle, and artery, vein, and nerve anastomoses are performed using the anterior interosseous nerve and a branch of the brachial artery as a donor. The flexor digitorum profundii and flexor pollicis longus tendon ends are sutured to the gracilis muscle at its resting tension.

Malunion: Cubitus Varus and Cubitus Valgus

Cubitus varus and cubitus valgus are the most common complications of supracondylar humeral fractures. The reported incidence ranges from 0% to 50%. ^ss

References , , , , , , , , , , , , , , , , , , , , , , .

In general, posteromedially displaced fractures tend to develop varus angulation, and posterolaterally displaced fractures tend to develop valgus deviation. Cubitus varus deformity is more commonly noted to be a problem than cubitus valgus, probably because posteromedial fractures are more common. However, varus deformity may be more frequently reported simply because it is more cosmetically noticeable. Although some have suggested that angular deformity is a result of growth imbalance, the consensus opinion is that cubitus varus and valgus are the result of malunion ( Fig. 29.54 ). ^tt

References , , , , , , , , , , .

Cubitus varus or valgus is assessed by measuring the carrying angle of the arm. This is the angle created by the medial border of the fully supinated forearm and medial border of the humerus, with the elbow extended ( Fig. 29.55 ). The carrying angle exhibits considerable individual variation. Thus, comparison should be made with the contralateral side rather than with any normal standard. As the elbow extends, the carrying angle decreases (more varus); thus hyperextension tends to accentuate a cubitus varus deformity, whereas a flexion contracture can create the appearance of cubitus valgus. Smith has demonstrated that changes in the carrying angle are a result of angular displacement or tilting of the distal fragment, not translation or rotation. However, rotation of the distal fragment can contribute to the cosmetic deformity of a malunion. A residual rotational deformity is almost always present after a corrective osteotomy for cubitus varus ( Fig. 29.56 ).

Problems arising from cubitus varus or valgus include functional limitation, recurrent elbow fracture, and cosmetic deformity. In cubitus valgus, functional problems may be related to a coexisting flexion contracture or, in extreme cases, to tardy ulnar nerve symptoms. With cubitus varus, functional problems are almost always related to limitation of flexion, although tardy ulnar nerve palsy and elbow instability have also been reported as functional complications of varus deformity. ^{, ,} The limitation in flexion is a result of the hyperextension associated with varus malunion. Usually the arc of elbow motion remains constant. Thus, varus-hyperextension malunion creates a flexion deficit. If significant, this flexion deficit can interfere with activities of daily living. Lateral condyle fractures, distal humeral epiphyseal separation, and shoulder instability have also been described as potential complications of varus malunion. ^{, ,} However, cosmetic deformity is the most common problem associated with malunion of supracondylar fractures.

Unfortunately, because of the limited growth and the fact that deformity is usually perpendicular to the plane of motion, little potential exists for angular malunion of the distal humerus to remodel, so the best treatment of malunion of a supracondylar humeral fracture is avoidance. Mild degrees of malunion can be treated by simple reassurance. However, if the deformity is severe, cosmetic concerns and the risk of future functional limitations and elbow instability may warrant surgical reconstruction.

The resultant cubitus varus deformity is a combined deformity of varus, extension, and internal rotation to various degrees. Most corrective osteotomies have focused on the correction of varus and extension deformity. The rotational deformity is well tolerated due to the universal motion at the shoulder and is best left untreated because rotation of the distal fragment makes the osteotomy unstable and there is little to no bony contact between the fragments. Complications from distal humeral osteotomies have been well described and include iatrogenic nerve injury, residual deformity, infection, unsightly scarring, and loss of fixation; a recent meta-analysis reporting a 14.5% complication rate should alert the surgeon and parents to the technical demands of this corrective surgery.

In an effort to limit these complications, a wide variety of osteotomy and fixation techniques have been described. Osteotomy techniques include lateral closing wedge osteotomy, step-cut osteotomy, dome osteotomy, external fixation with distraction osteogenesis, and computer-aided multiplanar osteotomy.

The author’s preferred technique is to perform two oblique lateral closing wedge osteotomies to minimize the lateral prominence that occurs with the traditional lateral closing wedge osteotomy ( Fig. 29.57 ). The radiographs of the contralateral uninjured elbow are used as a template to determine the degree of planned osteotomy and the size of the closing wedge. The apex of the osteotomy is planned to be just proximal to the medial epicondyle. Technical peals include placing lateral-entry wires up to the level of the planned distal osteotomy prior to performing the osteotomy, and leaving the medial cortex intact so as to not destabilize the osteotomy. Correction of hyperextension can also be incorporated into one of the osteotomy cuts.

Elbow Stiffness and Myositis Ossificans

These complications of supracondylar humeral fractures occur rarely. ^uu

References , , , , , , .

We usually assess elbow ROM 4 to 6 weeks after the cast has been removed. Mean relative arc of motion was 90% of normal by week 9 after injury in a cohort of 373 supracondylar fractures. If significant stiffness is present, we begin a supervised home program of gentle ROM exercises and continue to monitor the patient’s progress on a monthly basis. Mild stiffness generally resolves with a few months of gentle therapy, although some patients need more intensive therapy, including a splinting program. Persistent stiffness requiring surgical release is extremely uncommon. Mih and associates reported an average 53-degree increase in ROM in nine pediatric patients who underwent capsular release through a lateral and, if necessary, medial approach.

Myositis ossificans is an extremely unusual complication. This has been found to resolve spontaneously over a period of 1 to 2 years ( Fig. 29.58 ).