import { OnePagerSummary, ExamWarning, InfoCardGrid, InfoCard, MnemonicCard, EvidenceCard, VivaScenarioSection, VivaScenario, ExamCheatSheet, ContentSection, ExamPearl, SafetyAlert, NumberHighlightRow, NumberHighlight, Tabs, Tab, ComparisonTable } from '@/components/mdx' **Lies anterior to distal humerus, directly at fracture level.** Most commonly injured vessel in extension-type fractures. Can be kinked, tethered by fascial bands, or lacerated by sharp fracture spike. **PULSELESS PINK = collateral flow adequate, observe. PULSELESS WHITE = critical ischaemia, explore after reduction fails to restore perfusion.** **Pure motor branch of median nerve - most commonly injured nerve (10-15%).** Tests: FPL (thumb IP flexion) + FDP index finger flexion = 'OK sign'. No sensory component so easily missed. **Often neurapraxia - observe for recovery over 3-6 months before surgical exploration.** **Lies posterior to medial epicondyle in cubital tunnel.** At high risk (10-15% injury) with percutaneous medial pin placement. Subluxes anteriorly with elbow flexion in some children. **Protection: mini-open technique with direct visualisation if medial pin needed.** **Runs with brachial artery anterior to fracture.** Can be entrapped in fracture during reduction, especially if fracture spike buttonholes through brachialis. Tests: APB strength (thumb abduction), sensation thenar eminence and radial 3.5 digits. **Post-reduction motor loss = possible entrapment, may require open exploration.** ### Gartland Classification and Management **Type I - Non-displaced:** - Anterior humeral line through middle 1/3 of capitellum - Treatment: Long arm cast 3-4 weeks, 70-80° flexion - No surgery required **Type IIA - Displaced, Angulated Only:** - Posterior cortex intact, hinge present - Angulation but NO rotation - Treatment: Closed reduction and casting may suffice - Operate if reduction lost or unable to maintain **Type IIB - Displaced with Rotation:** - Rotational malalignment present - More unstable than IIA - Treatment: CRPP - closed reduction and pinning **Type III - Completely Displaced:** - No cortical contact, periosteal sleeve disrupted - Highest neurovascular risk (up to 20% nerve injury) - Treatment: Urgent CRPP **Type IV (Wilkins modification):** - Unstable in both flexion AND extension - Periosteal disruption circumferentially - Treatment: CRPP, may require open reduction ### Subtypes by Displacement Direction **Extension Type (95%):** - Falls on outstretched hand - Distal fragment displaced posteriorly - Apex anterior angulation **Flexion Type (5%):** - Falls on flexed elbow - Distal fragment displaced anteriorly - Higher risk of ulnar nerve injury - Reduction technique opposite (extend, push posteriorly) ### Mandatory Neurovascular Examination **Vascular Assessment:** - Radial pulse - present, diminished, or absent - Capillary refill - normal under 2 seconds - Hand colour - pink (perfused) versus white (ischaemic) - Temperature - compare to contralateral **Nerve Assessment (document each):** | Nerve | Motor Test | Sensory Test | |-------|-----------|--------------| | AIN | FPL + FDP index ('OK' sign) | None (pure motor) | | Median | APB (thumb abduction) | Thenar eminence, radial 3.5 digits | | Radial | Wrist/finger extension | First dorsal webspace | | Ulnar | FDI (finger abduction) | Little finger | ### Imaging Requirements **AP and Lateral Radiographs:** - Confirm fracture pattern and Gartland type - Assess displacement and rotation - Look for associated injuries (medial epicondyle) **Assessment Parameters:** - Anterior humeral line (lateral view): should pass through middle 1/3 capitellum - Baumann's angle (AP view): 70-80° - compare to contralateral - Rotation: medial/lateral column alignment ### Timing of Surgery **Immediate (within hours):** - Pulseless white hand (after initial reduction attempt in ED fails) - Open fracture - Impending compartment syndrome **Urgent (within 6-8 hours):** - Gartland Type III - Pulseless pink hand (operate but don't delay) - Neurological deficit **Semi-elective (within 24 hours):** - Gartland Type IIB - Type IIA with failed closed reduction ### Informed Consent Discussion **Parents must understand:** - Why surgery needed (unstable fracture requires stabilisation) - General anaesthesia risks in children - K-wires remain outside skin for 3-4 weeks - Wound care around pins, infection risk **Common Risks:** - Pin tract infection: 2-5% - Temporary nerve symptoms (often present pre-op): 10-15% - Need for pin removal at 3-4 weeks (office procedure) - Stiffness (usually resolves 6-12 months) **Rare but Serious Risks:** - Cubitus varus (cosmetic deformity if malreduction): 3-8% - Permanent nerve injury: less than 1% (usually neurapraxia) - Compartment syndrome: less than 1% - Volkmann's ischaemic contracture: rare but devastating - Need for open reduction if closed fails: 5-10% - Myositis ossificans: rare **Pre-existing Neurovascular Deficit:** - Explain that nerve/vessel may already be injured - Surgery aims to reduce fracture which often improves perfusion - May need additional surgery if deficit persists ### Equipment Checklist **Patient Positioning:** - Supine on radiolucent table - Arm on radiolucent arm board OR across chest (surgeon preference) - Image intensifier from opposite side, perpendicular to arm - Ensure true AP and lateral views achievable before draping **Instrumentation:** - K-wires: 1.6mm or 2.0mm (size appropriate for age/bone) - Power driver with chuck for K-wires - Wire cutters - Wire bender - Smooth trocar for pin introduction - Mini-open set if medial pin planned (small retractors, blade) **Sterile Preparation:** - Prep arm circumferentially from shoulder to fingertips - Drape free to allow manipulation - C-arm draped or positioned for sterile technique **Personnel:** - Anaesthetist for GA - Surgeon - Assistant essential for reduction manoeuvres (counter-traction) - Radiographer to operate C-arm ### C-arm Positioning Position C-arm perpendicular to arm. Test views BEFORE draping: - True AP: olecranon sits in trochlear notch, medial/lateral epicondyles symmetric - True lateral: capitellum and trochlea superimposed ### Step 1: Neurovascular Documentation and Induction Document pre-operative neurovascular status on anaesthetic chart. Induce general anaesthesia. Position supine with arm on radiolucent arm board. Prep and drape circumferentially. Confirm C-arm can obtain adequate AP and lateral views before starting. **Technical Tip**: Always document neurovascular status BEFORE induction. Any post-operative deficit needs comparison to baseline. If AIN or other nerve already injured pre-op, parents are reassured injury was from fracture not surgery. ### Step 2: Initial Traction - Disimpaction With elbow in EXTENSION, apply longitudinal traction for 2-3 minutes. Assistant provides counter-traction at upper arm. This allows muscle relaxation and disimpacts the fracture. Feel for 'give' as the fracture disengages. DO NOT flex initially as this locks the proximal spike into distal fragment. SEQUENCE: (1) Traction in extension to disimpact (2) Correct coronal translation (3) Correct rotation (4) Flex elbow with olecranon push. Flexing too early traps the fracture. Extension-type reduction fails if sequence wrong. ### Step 3: Correct Translation and Rotation While maintaining traction, correct coronal plane translation (usually posteromedial in extension-type). Push the distal fragment to align with proximal humeral shaft. Correct rotation by aligning medial and lateral columns - compare to forearm rotation and contralateral side. Rotation is the most commonly missed malreduction component. **Technical Tip**: Rotation malreduction causes functional deformity. Check rotation by comparing medial and lateral epicondyle orientation to the forearm. If unsure, obtain true lateral and look for 'teardrop' appearance of olecranon fossa. ### Step 4: Flexion with Anterior Olecranon Push This is the KEY reduction manoeuvre for extension-type fractures. While maintaining traction and column alignment, FLEX the elbow. Simultaneously push anteriorly on the olecranon (or posterior distal humerus) to push the distal fragment anterior. This corrects the apex anterior angulation. Flex to 100-120 degrees if vascular status allows. Pronate the forearm - this reduces the typical posterolateral rotation. If the hand was pulseless pre-operatively, do NOT hyperflex beyond 90 degrees until pulse checked. Hyperflexion can kink an already compromised brachial artery. Check pulse as you flex - if pulse diminishes, extend slightly. ### Step 5: Fluoroscopic Assessment of Reduction Obtain AP and lateral views with elbow flexed: **Lateral View:** - Anterior humeral line should pass through MIDDLE 1/3 of capitellum - Acceptable: anterior 1/3 (slight residual extension) - Unacceptable: anterior to capitellum (malreduction) **AP View:** - Baumann's angle: 70-80 degrees (compare to contralateral within 5 degrees) - Medial and lateral columns aligned - No coronal plane rotation **Technical Tip**: BAUMANN'S ANGLE is the gold standard. Take contralateral comparison X-ray pre-op if possible. Loss of Baumann's angle (more vertical) predicts cubitus varus deformity. Don't accept this - re-reduce. ### Step 6: First Lateral Pin Placement Entry point: LATERAL EPICONDYLE (palpable ossification centre). Under fluoroscopy, introduce 1.6-2.0mm K-wire through stab incision. Aim across the fracture into the MEDIAL COLUMN, engaging the far (medial) cortex. Trajectory should be slightly posterior to optimally cross the fracture. Start with wire parallel to C-arm beam to visualise entry, then advance under intermittent fluoroscopy. Confirm wire crosses fracture line and engages medial cortex but does NOT penetrate through. Pin too anterior misses the medial cortex and provides poor purchase. Pin that penetrates through medial cortex risks ulnar nerve or brachial artery injury. Engage but don't traverse the far cortex. ### Step 7: Second Lateral Pin - Divergence Critical Entry point: LATERAL COLUMN above the epicondyle (lateral supracondylar ridge). This pin must DIVERGE greater than 30 degrees from the first pin on AP view. This divergence is CRITICAL for rotational stability. Both pins should: - Cross the fracture line - Engage the medial cortex - Be divergent more than 30 degrees at the fracture **Technical Tip**: Biomechanical studies confirm 2 LATERAL DIVERGENT pins (greater than 30 degrees apart) provide equivalent rotational stability to crossed pins. This configuration AVOIDS ulnar nerve risk. Pins less than 30 degrees apart = poor rotational control. ### Step 8: Assess Stability and Decision on Third Pin Range the elbow through flexion-extension under fluoroscopy. The fracture should remain reduced. Assess stability: **Stable with 2 lateral pins:** - Fracture holds reduction through ROM - Proceed to completion **Unstable / Consider 3rd pin if:** - Fracture shifts with elbow motion - Medial column comminution - Type III with significant displacement **Third pin options:** - Third LATERAL pin (if bone stock allows) - MEDIAL pin (if lateral fixation inadequate) - use mini-open technique Percutaneous medial pinning has 10-15% ulnar nerve injury rate. If medial pin is required for stability, ALWAYS use mini-open technique with direct nerve visualisation. This reduces nerve injury to less than 1%. ### Step 9: Medial Pin Placement (If Required) - Mini-Open Technique Make 1-2cm incision over medial epicondyle. Blunt dissection through subcutaneous tissue. IDENTIFY the ulnar nerve - palpable cord posterior to medial epicondyle. Protect nerve with small retractor (nerve may sublux anteriorly with flexion in children). Under direct vision, place K-wire through medial epicondyle, crossing fracture into lateral cortex. Confirm position on fluoroscopy. The pin should cross the fracture and engage lateral cortex. **Technical Tip**: Mini-open technique for medial pin is the FRCS examiner-expected answer. Never describe percutaneous medial pinning without acknowledging ulnar nerve risk and the mini-open alternative. ### Step 10: Final Fluoroscopy and Pin Fixation Obtain final AP and lateral images confirming: - Adequate reduction (anterior humeral line, Baumann's angle) - Pins cross fracture appropriately - No joint penetration - Divergence maintained Bend pins 90 degrees at skin level to prevent migration. Cut pins leaving 1cm outside skin for later removal. Cover pin sites with sterile dressing. ### Step 11: Immobilisation and Vascular Check Apply long arm backslab or bivalved cast: - Elbow at 70-80 degrees flexion (NOT hyperflexed) - Forearm in pronation - Allow for swelling - not circumferential initially **Immediate post-procedure vascular check:** - Radial pulse - compare to pre-op - Capillary refill - Hand colour and perfusion DO NOT immobilise elbow above 90 degrees flexion. Hyperflexion can kink the brachial artery, especially in swollen or previously pulseless limbs. 70-80 degrees is optimal and safe. ### Step 12: Post-Procedure Documentation Document in operative note: - Pre-operative neurovascular status - Gartland type and reduction achieved - Pin configuration (2 lateral divergent, or crossed with mini-open) - Fluoroscopy findings - anterior humeral line position, Baumann's angle - Post-operative neurovascular status - Immobilisation method This is a common FRCS viva scenario. Your answer should be structured: **PULSELESS PINK Hand:** 1. Hand perfused despite absent pulse (collateral circulation adequate) 2. URGENT reduction in theatre (within hours) 3. Check pulse after reduction - often returns 4. If pulse returns: observe with neuro-obs q2h, admit 5. If remains pulseless but PINK: continue observation, vascular review 6. Serial checks - if deteriorates (becomes WHITE or painful), explore **PULSELESS WHITE Hand:** 1. Critical ischaemia - limb-threatening 2. EMERGENCY reduction in theatre immediately 3. Check pulse after reduction 4. If pulse returns and hand pinks up: observe closely 5. If remains pulseless WHITE: **immediate vascular exploration** 6. Brachial artery exploration - may need vessel repair or thrombectomy 7. Fasciotomy if prolonged ischaemia (greater than 6 hours) or compartment syndrome suspected **Intraoperative Vascular Concerns:** If reduction restores pulse: proceed with pinning, observe If pulse returns but weak/intermittent: may be vasospasm - warm limb, observe If remains pulseless after adequate reduction: - Extend skin incision anteriorly - Explore brachial artery at fracture level - May find: kinking, fascial band tethering, intimal injury, thrombosis - Vascular surgery input if repair needed ### Immediate Post-operative (Day 0) **Neurovascular Observations:** - Check pulse, cap refill, hand colour q2h for first 24 hours - Document motor function all nerves (AIN, median, radial, ulnar) - Pain assessment - severe pain may indicate compartment syndrome **Limb Elevation:** - Elevate arm on pillows - Ice to elbow (if accessible through cast) ### Ward Stay (Days 1-2) - Continue neuro-obs if vascular concerns - Check cast not too tight - bivalve if swelling - X-ray before discharge to confirm reduction maintained - Pain control with simple analgesia ### Discharge (Day 1-2) - Sling for comfort - Cast care instructions for parents - Pin site care - keep dry, watch for infection signs - Return immediately if: increasing pain, swelling, numbness, colour change ### Outpatient Follow-up **1 Week:** - Wound check - X-ray to confirm reduction maintained - Assess swelling - may convert to full cast if settling **3-4 Weeks:** - Pin removal (office procedure under Entonox or local) - Remove cast - Begin gentle ROM exercises - X-ray to confirm healing **6 Weeks:** - Check ROM - expect stiffness initially - X-ray to confirm consolidation - May need physiotherapy if stiff **3 Months:** - Final check - ROM should be returning - Compare to contralateral - Assess carrying angle (Baumann's angle equivalent clinically) ### Expected Recovery - Full ROM typically returns by 6-12 months - Paediatric bone remodels well in plane of joint motion - Rotational malreduction does NOT remodel - must get this right - Cubitus varus does NOT remodel - cosmetic issue, consider late osteotomy 1. Gartland JJ. Management of supracondylar fractures of the humerus in children. Surg Gynecol Obstet. 1959;109(2):145-154. 2. Skaggs DL, Flynn JM. Supracondylar fractures of the distal humerus. In: Rockwood and Wilkins' Fractures in Children. 8th ed. Wolters Kluwer; 2015:581-627. 3. Brauer CA, Lee BM, Bae DS, Waters PM, Kocher MS. 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. 4. Babal JC, Mehlman CT, Klein G. Nerve injuries associated with pediatric supracondylar humeral fractures: a meta-analysis. J Pediatr Orthop. 2010;30(3):253-263. 5. White L, Mehlman CT, Crawford AH. Perfused, pulseless, and puzzling: a systematic review of vascular injuries in pediatric supracondylar humerus fractures and results of a POSNA questionnaire. J Pediatr Orthop. 2010;30(4):328-335. 6. Zionts LE, McKellop HA, Hathaway R. Torsional strength of pin configurations used to fix supracondylar fractures of the humerus in children. J Bone Joint Surg Am. 1994;76(2):253-256. 7. Omid R, Choi PD, Skaggs DL. Supracondylar humeral fractures in children. J Bone Joint Surg Am. 2008;90(5):1121-1132. 8. Wilkins KE. The operative management of supracondylar fractures. Orthop Clin North Am. 1990;21(2):269-289. 9. Mooney JF, Hosseinzadeh P. Compartment syndrome of the upper extremity in children and adolescents. J Am Acad Orthop Surg. 2020;28(23):e1017-e1027. 10. Louahem D, Nebunescu A, Canavese F, Dimeglio A. Neurovascular complications and severe displacement in supracondylar humerus fractures in children: defensive or offensive strategy? J Pediatr Orthop B. 2006;15(1):51-57.

Paediatric Supracondylar Humerus Fracture - Closed Reduction and Percutaneous Pinning (CRPP)

Paediatric Supracondylar Humerus Fracture - Closed Reduction and Percutaneous Pinning (CRPP)