import { OnePagerSummary, ExamWarning, InfoCardGrid, InfoCard, MnemonicCard, EvidenceCard, VivaScenarioSection, VivaScenario, ExamCheatSheet, ContentSection, ExamPearl, SafetyAlert, NumberHighlightRow, NumberHighlight, Tabs, Tab, ComparisonTable } from '@/components/mdx' **Brachial artery**. Location: Anterior to distal humerus, medial to median nerve. Protection: Assess pulse pre/post reduction, reduce flexion if pulse lost, have vascular on standby. **Median nerve**. Location: Anterior, medial to brachial artery at antecubital fossa. Protection: Avoid excessive anterior dissection, gentle reduction technique. **Radial nerve**. Location: Lateral distal humerus, 7-10cm proximal to lateral epicondyle. Protection: Limit proximal/lateral dissection, identify if extending approach. **Ulnar nerve**. Location: Cubital tunnel, 10-20mm medial to olecranon tip. Protection: Identify before medial pin, flex elbow maximally, palpate during insertion. **Anterior Interosseous Nerve (AIN)**. Location: Branch of median nerve, proximal forearm. Protection: Document OK sign pre-op, most palsies from injury not surgery. **Patient Position**: Supine with arm across chest or lateral decubitus with affected arm over bolster - allows posterior approach access **Surgical Approach**: Posterior triceps-splitting or triceps-reflecting approach to distal humerus **Incision**: 8-10cm midline posterior over distal humerus ### Gartland Classification and Management Algorithm | Grade | Description | Posterior Cortex | Management | |-------|-------------|------------------|------------| | **I** | Undisplaced or minimally displaced | Intact | Above-elbow cast, 3 weeks | | **IIA** | Displaced, angulated | Intact, acts as hinge | Closed reduction + percutaneous pinning | | **IIB** | Displaced, rotated | Intact | Closed reduction + pinning (may need open) | | **III** | Completely displaced | Disrupted | Closed reduction + pinning (open if irreducible) | **Key Points:** - Anterior humeral line should pass through middle third of capitellum (lateral view) - Baumann angle 65-75° on AP (compare to contralateral) - Rotational malreduction = most common cause of cubitus varus ### Pin Configuration Options | Configuration | Stability | Ulnar Nerve Risk | Best For | |--------------|-----------|------------------|----------| | **Crossed Pins** (Medial + Lateral) | Highest | 10-20% if not careful | Unstable fractures, larger children | | **2 Lateral Divergent** | Good | Negligible | Most cases, safer option | | **3 Lateral** | High | Negligible | Highly comminuted patterns | **Lateral Pin Technique:** - Enter lateral epicondyle, aim proximally-medially - Diverge pins to engage both columns - Engage opposite cortex for maximum purchase **Medial Pin Technique (if needed):** - Flex elbow to 130° to displace ulnar nerve posteriorly - Palpate nerve continuously during insertion - Small incision to visualize nerve if uncertain ### Pulseless Hand Algorithm **Step 1: Reduce fracture and flex to 60-70°** - Excessive flexion kinks brachial artery - Remove constricting dressings **Step 2: Reassess perfusion** - Check radial pulse, capillary refill, digital color **Step 3: Decision Making** | Hand Status | Pulse | Action | |-------------|-------|--------| | **Pink, warm** | Present | Standard care | | **Pink, warm** | Absent | "Pulseless pink hand" - close observation, consider explore | | **White, cold** | Absent | URGENT brachial artery exploration | **Controversy: Pulseless Pink Hand** - Traditional: Observe if perfusion adequate (collaterals sufficient) - Emerging evidence: Consider exploration to prevent late complications ### Compartment Syndrome Prevention and Recognition **Risk Factors:** - Gartland III fractures - Prolonged time to reduction - Tight splint/cast - Elbow flexion greater than 90° - Associated forearm fracture (floating elbow) **Early Signs (The 5 P's are LATE):** - Pain out of proportion to injury - Pain with passive finger extension (earliest sign) - Increasing analgesia requirements - Tense forearm compartments **Management:** - Clinical diagnosis - do NOT wait for pressures - Remove all dressings immediately - If no improvement: Emergent forearm fasciotomy - Both volar (Henry) and dorsal compartments **Volkmann's Contracture:** Claw hand deformity from missed compartment syndrome - devastating, permanent ### Key Radiographic Parameters **Lateral View:** - **Anterior humeral line**: Should pass through middle third of capitellum - If anterior to capitellum = extension malreduction (posterior tilt) - If posterior = flexion malreduction (rare) **AP View:** - **Baumann angle**: Angle between humeral shaft and capitellar physis (65-75°) - Compare to contralateral - Difference greater than 5° = rotational malreduction - **Carrying angle**: Usually 5-15° valgus **Intraoperative Checks:** - All 4 views: AP, lateral, medial oblique, lateral oblique - Confirm pins engage both cortices - No intra-articular pin placement ### Step 1: Patient Positioning and Arm Preparation Patient Positioning and Arm Preparation: Position supine with affected arm across chest on radiolucent arm board, or lateral decubitus with arm over bolster. Apply tourniquet to upper arm (typically NOT inflated unless needed for hemostasis - avoid in vascular injury cases). Ensure C-arm access for AP, lateral, and oblique views. Prep entire upper limb from shoulder to fingertips including circumferential coverage. **Technical Tip**: EXAM KEY: AVOID TOURNIQUET in cases with suspected vascular injury. Lateral position provides excellent posterior exposure and prevents arm from falling off table. Ensure adequate padding at pressure points. Have vascular surgery on standby if pulse absent pre-operatively. - Positioning nerve injury (ulnar nerve at elbow, brachial plexus stretch) - Inadequate C-arm access limiting intraoperative imaging - Tourniquet time >45-60 minutes in children risks compartment syndrome ### Step 2: Posterior Triceps-Splitting Approach Posterior Triceps-Splitting Approach: Make midline posterior incision 8-10cm long centered over distal humerus, extending from 6cm proximal to olecranon tip to 2cm distal to tip. Identify and protect ulnar nerve in cubital tunnel - DO NOT routinely decompress unless nerve injury suspected. Split triceps in midline longitudinally (triceps-splitting technique) or reflect medially/laterally (triceps-reflecting). Expose posterior distal humerus and fracture site. **Technical Tip**: EXAM KEY: ULNAR NERVE is at highest risk - lies in cubital tunnel posteromedial, 1-2cm from incision midline. Palpate nerve, protect with vessel loop or Penrose drain. DO NOT routinely transpose unless nerve caught in fracture or pre-op ulnar neuropathy. Triceps split heals better than reflection in children and preserves extensor mechanism strength. - Ulnar nerve iatrogenic injury during dissection (15-20% risk if not identified) - Radial nerve injury if dissection extends too far laterally/proximally - Triceps denervation if branches from radial nerve injured ### Step 3: Fracture Site Exposure and Hematoma Evacuation Fracture Site Exposure and Hematoma Evacuation: Complete triceps split exposing fracture site. Evacuate hematoma with suction and irrigation. Identify proximal and distal fragments. Remove interposed soft tissues (brachialis muscle commonly trapped anteriorly, periosteum invaginated). Inspect anterior neurovascular structures if visible through fracture - avoid excessive anterior dissection to preserve blood supply to fragments. **Technical Tip**: EXAM KEY: INTERPOSED SOFT TISSUE is common reason for failed closed reduction - usually brachialis muscle anteriorly or periosteal flap. Gentle removal essential for reduction. Minimize anterior dissection to preserve vascular supply to distal fragment which enters from anterior supracondylar vessels. If vascular injury suspected (absent pulse), inspect brachial artery - kinked, contused, or lacerated. - Brachial artery injury during anterior inspection (use gentle technique) - Median nerve injury (lies anterior, adjacent to artery) - Devascularization of distal fragment from excessive stripping ### Step 4: Fracture Reduction - Distal Fragment First Fracture Reduction - Distal Fragment First: Key reduction sequence: First, correct ROTATION by aligning condyles with humeral shaft using direct visualization posteriorly - lateral condyle should be slightly more distal than medial (carrying angle 5-15 degrees). Second, correct ANGULATION by flexing elbow to 90-110 degrees which uses intact anterior periosteum as hinge (posterior tilt typical in extension injuries). Third, correct TRANSLATION by aligning fragments anatomically. **Technical Tip**: EXAM KEY: ROTATION is the hardest parameter to assess and most important to correct - malrotation causes cubitus varus/valgus. Check BAUMANN'S ANGLE on fluoroscopy (65-75 degrees), compare to contralateral. Ensure MEDIAL and LATERAL COLUMNS align - palpate directly. Anterior periosteal hinge helps maintain reduction if intact (preserve it). - Rotational malreduction causing cubitus varus (gunstock deformity) - Inadequate restoration of carrying angle - Loss of reduction during pinning if held poorly ### Step 5: Provisional Fixation with K-wires Provisional Fixation with K-wires: Once reduced, hold with bone clamps or assistant. Insert 2-3 smooth K-wires (1.6-2.0mm diameter based on size) for provisional fixation. Standard configuration: 2 crossed wires (medial and lateral) for maximum stability. Lateral wire first (safer, no nerve risk) from lateral epicondyle aimed proximally-medially. Medial wire second from medial epicondyle aimed proximally-laterally, AVOID ULNAR NERVE. **Technical Tip**: EXAM KEY: MEDIAL PIN placement requires meticulous technique - flex elbow maximally to displace ulnar nerve posteriorly away from pin trajectory. Palpate nerve, ensure no tension. Alternative: use 2 lateral divergent pins to avoid ulnar nerve entirely (slightly less stable biomechanically but safer). Ensure wires engage proximal cortex for stability - bicortical purchase required. - Iatrogenic ulnar nerve injury from medial pin (up to 15% if not careful) - Radial nerve injury from lateral pin if aimed too proximally/anteriorly - Inadequate pin purchase causing loss of reduction ### Step 6: Fluoroscopic Confirmation of Reduction and Fixation Fluoroscopic Confirmation of Reduction and Fixation: Obtain AP, lateral, and both oblique views with C-arm. Assess: 1) Baumann's angle 65-75° (AP view), 2) Anterior humeral line through middle third capitellum (lateral), 3) No coronal or sagittal plane angulation, 4) Medial/lateral columns aligned, 5) Pins engage both cortices proximally, 6) No intra-articular pin penetration. Compare to contralateral elbow if uncertain. **Technical Tip**: EXAM KEY: ANTERIOR HUMERAL LINE is critical on lateral view - should pass through MIDDLE THIRD of capitellum. If anterior, you have extension malreduction. BAUMANN'S ANGLE compared to contralateral limb best assesses rotation - difference >5 degrees indicates rotational malreduction. Ensure ZERO medial/lateral translation on AP view. - Accepting malreduction (most common cause of cubitus varus) - Missing intra-articular pin placement causing chondral injury - Inadequate fixation allowing secondary displacement ### Step 7: Pin Bend, Cut, and Secure Pin Bend, Cut, and Secure: Once position confirmed perfect, advance pins until just engaging far cortex (avoid prominent sharp tips). Bend pins 90 degrees at skin level to prevent migration. Cut pins leaving 1cm proud of skin for easy removal at 3-4 weeks in clinic. Some surgeons bury pins beneath skin if compliant family for removal under brief sedation later. **Technical Tip**: EXAM KEY: PIN MIGRATION is prevented by bending at skin. Buried pins reduce infection risk (debated) but require second anesthetic for removal - NOT necessary in most cases. Left-out pins removed easily in clinic at 3-4 weeks without sedation (quick pull). Dress pins with Betadine gauze and splint to prevent snagging. - Pin track infection (2-5% incidence) - Pin migration causing neurovascular injury - Lost pins if cut too short and fall into soft tissues ### Step 8: Assessment of Elbow Stability and Range of Motion Assessment of Elbow Stability and Range of Motion: Release tourniquet if used. Assess elbow stability through gentle flexion/extension range (avoid forced motion causing fracture displacement or compartment syndrome). Should be stable throughout arc. Check mediolateral stability - no opening. Palpate radial pulse - should be present and strong. Check capillary refill <2 seconds. Assess median, radial, ulnar nerve function if patient cooperative. **Technical Tip**: EXAM KEY: POST-REDUCTION VASCULAR ASSESSMENT is mandatory. Pink, pulsatile limb essential. If pulse absent: 1) Reduce elbow flexion angle (kinked artery), 2) Remove any constricting dressings, 3) Consider brachial artery exploration if no pulse after reduction. NERVE examination may be limited by cooperation but attempt anterior interosseous (median), PIN (radial), and ulnar motor/sensory. - Brachial artery kink from excessive elbow flexion post-reduction - Missed compartment syndrome (perform fasciotomy liberally if concern) - Missed nerve injury that was iatrogenic vs pre-existing ### Step 9: Triceps Repair Triceps Repair: Repair triceps split with interrupted absorbable sutures (2-0 or 3-0 Vicryl) in figure-of-8 or simple interrupted fashion. Ensure secure repair as extensor mechanism critical for function. If triceps was reflected, reattach to olecranon with suture anchors or transosseous sutures. Test repair integrity by gently extending elbow. **Technical Tip**: EXAM KEY: TRICEPS REPAIR must be secure to allow early mobilization post-operatively. Children heal quickly - split repairs universally successful. Avoid excessive tension which can cause dehiscence. Some surgeons leave split unrepaired in very young children (controversial) but standard practice is repair for optimal healing. - Triceps dehiscence causing extension lag - Inadequate repair leading to weakness - Suture knots causing skin irritation ### Step 10: Layered Closure and Splint Application Layered Closure and Splint Application: Close fascia over triceps with running or interrupted absorbable suture. Close subcutaneous layer with 3-0 or 4-0 absorbable suture. Close skin with running subcuticular 4-0 or 5-0 absorbable suture or interrupted nylon. Dress wound with Betadine gauze at pin sites. Apply well-padded above-elbow posterior splint with elbow at 60-90 degrees flexion (AVOID >90 degrees - vascular risk), forearm neutral rotation. **Technical Tip**: EXAM KEY: ELBOW FLEXION ANGLE in splint critical - traditional teaching was >90° flexion for stability but CONTRAINDICATED if vascular injury or swelling risk (causes artery kink/compartment syndrome). Safe position is 60-90 degrees. Monitor neurovascular status in recovery. Parents instructed on warning signs: pain, numbness, white fingers, inability to move fingers. - Compartment syndrome from tight splint or excessive flexion (most feared complication) - Volkmann's ischemic contracture from missed compartment syndrome - Pin site infection from inadequate dressing ### Step 11: Post-operative Neurovascular Monitoring Post-operative Neurovascular Monitoring: Admit overnight for neurovascular observation. Hourly checks: radial pulse, capillary refill, finger motion/sensation, pain assessment. If any concern for compartment syndrome (pain out of proportion, tense forearm, pain with passive finger extension, progressive neurological deficit), REMOVE SPLINT immediately and reassess. Low threshold for return to OR for fasciotomy. **Technical Tip**: EXAM KEY: COMPARTMENT SYNDROME is the most devastating complication of pediatric supracondylar fractures - leads to Volkmann's contracture (permanent disability). CLINICAL DIAGNOSIS - do not wait for compartment pressure measurement. Pain out of proportion to injury and pain with passive finger/thumb extension are earliest signs. Missed diagnosis = medicolegal catastrophe. Maintain HIGH index of suspicion. - Volkmann's ischemic contracture from missed compartment syndrome - Permanent nerve palsy (AIN most commonly affected) - Delayed diagnosis causing irreversible muscle necrosis ### Step 12: Post-operative Radiographs and Mobilization Plan Post-operative Radiographs and Mobilization Plan: Obtain AP and lateral elbow radiographs in recovery to document maintained reduction. Check weekly for first 2-3 weeks to ensure no loss of reduction. Pins removed at 3-4 weeks in clinic (fracture healed by this time in children). Gentle active ROM started after pin removal - children regain motion quickly. Expect full ROM by 6-8 weeks. No contact sports for 8-12 weeks. **Technical Tip**: EXAM KEY: PEDIATRIC BONE HEALS RAPIDLY - 3 weeks adequate for union in supracondylar fracture. REMODELING POTENTIAL excellent in children for residual angulation (NOT rotation - cannot remodel). Encourage early ROM after pin removal to prevent stiffness. Physical therapy rarely needed - children self-mobilize through play. Parents reassured full recovery expected in uncomplicated cases. - Loss of reduction in first 2 weeks (weekly X-rays detect) - Residual stiffness from prolonged immobilization (rare) - Cubitus varus from malreduction (cosmetic deformity, no functional impact typically) Above-elbow posterior splint 60-90° flexion. Overnight neurovascular monitoring (hourly checks). Weekly radiographs x 3 weeks to ensure maintained reduction. Pin removal 3-4 weeks in clinic. Active ROM started after pin removal. Expect full motion by 6-8 weeks. No contact sports x 8-12 weeks. ## References 1. Skaggs DL, Flynn JM. Supracondylar fractures of the distal humerus. In: Rockwood and Wilkins' Fractures in Children. 8th ed. 2015. 2. Leitch KK, Kay RM, Femino JD, et al. Treatment of multidirectionally unstable supracondylar humeral fractures in children: A modified Gartland type-IV fracture classification. J Bone Joint Surg Am. 2006;88(5):980-985. 3. Skaggs DL, Cluck MW, Mostofi A, et al. Lateral-entry pin fixation in the management of supracondylar fractures in children. J Bone Joint Surg Am. 2004;86(4):702-707. 4. Slobogean BL, Jackman H, Engel C, et al. Iatrogenic ulnar nerve injury after the surgical treatment of displaced supracondylar fractures of the humerus: Number needed to harm, a systematic review. J Pediatr Orthop. 2010;30(5):430-436. 5. Blakey CM, Biant LC, Birch R. Ischaemia and the pink, pulseless hand complicating supracondylar fractures of the humerus in childhood: long-term follow-up. J Bone Joint Surg Br. 2009;91(4):521-526. 6. Brauer CA, Lee BM, Bae DS, et al. A systematic review of medial and lateral entry pinning versus lateral entry pinning for supracondylar fractures of the humerus. J Pediatr Orthop. 2007;27(2):181-186. 7. Mazzini JP, Rodriguez-Martin J, Andres-Esteban EM. Surgical approaches for open reduction and pinning in severely displaced supracondylar humerus fractures in children: a systematic review. J Child Orthop. 2010;4(2):143-152. 8. Ramachandran M, Birch R, Eastwood DM. Clinical outcome of nerve injuries associated with supracondylar fractures of the humerus in children: the experience of a specialist referral centre. J Bone Joint Surg Br. 2006;88(1):90-94. 9. Mapes RC, Hennrikus WL. The effect of elbow position on the radial pulse measured by Doppler ultrasonography after surgical treatment of supracondylar elbow fractures in children. J Pediatr Orthop. 1998;18(4):441-444. 10. Omid R, Choi PD, Skaggs DL. Supracondylar humeral fractures in children. J Bone Joint Surg Am. 2008;90(5):1121-1132.

ORIF Supracondylar Fracture Humerus - Paediatric

ORIF Supracondylar Fracture Humerus - Paediatric