AAOS Clinical Practice Guidelines: The treatment of pediatric supracondylar humerus fractures. Which of the following is important intra-operatively to ensure that the intercondylar screws are contained within the bone and are of appropriate length? Tested Concept, Osteoporotic periprosthetic distal femur fracture, Spiral humeral diaphyseal-metaphyseal fracture, Distal Femur Fracture ORIF with Single Lateral Plate, Femoral Shaft Fracture Retrograde Intramedullary Nailing, Type in at least one full word to see suggestions list, Trauma Implants & Instruments - Oldest Manufacturer in India - SIORA. The aim of this study is to discover this association and evaluate it in a level one trauma center. In the elderly, when the distal femur breaks, it can be a more serious fracture. Which of the following procedures will correct the cubitus varus but may result in a lateral prominence? J Bone Joint Surg Am. Tested Concept, Retrograde femoral nailing with adjunct BMP-4, Hybrid external fixation with adjunct BMP-4, Usage of a percutaneous locking plate with adjunct BMP-3, Open reduction and plating with autograft, Open reduction and plating with adjunct calcium phosphate, (OBQ06.70) supracondylar fractures are one of the most common traumatic fractures see in children and most commonly occur in children 5-7 years of age from a fall on an outstretched hand. A 5-year-old boy sustained an elbow injury. A supracondylar humerus fracture is a fracture of the distal humerus just above the elbow joint. Supracondylar fractures are the most common upper extremity fracture in the pediatric population therfore every emergency medicine provider should be deeply familiar with the known complications of such pathology. 8. Tested Concept, (OBQ12.112) His hand is pulseless and cold. If no deformity exists, the Supracondylar humerus fractures are common elbow injuries in children that occur in a vulnerable anatomical location with risk for sequelae ranging from neurovascular compromise to residual deformity. Displaced supracondylar fractures of the elbow in children. Background: Supracondylar fracture (humerus) is type of extra-articular fracture occurring in the distal metaphyseal site of humerus. They result from force applied across the elbow, usually following a fall. Supracondylar fractures of the distal humerus are the most common fractures about the elbow seen in children. Implant B is better able to control fractures with a small distal segment than Implants A and C. Implant C is better able to control coronal plane fractures than Implants A and B. What is a supracondylar humerus fracture? 1 The mechanism of injury typically involves a fall onto the outstretched upper extremity, with the vast majority of fractures resulting from a fall with the arm held in an extended or hyperextended position. Which treatment will minimize complications? This is the most common type of elbow fracture, and one of the more serious because it can result in nerve injury and impaired circulation. Supracondylar fractures are the … The annual incidence of supracondylar fractures has been estimated at 177.3 per 100,000. Representative radiographs of the injury are shown in Figures A and B. treatment is usually closed reduction and percutanous pinning (CRPP), with the urgency depending on whether the hand remains perfused or not. Tested Concept, (OBQ05.90) immediate electromyography and nerve conduction velocity studies. A pediatric SCH fracture is the most common elbow injury in children. Distal humerus fractures in adults are relatively uncommon injuries, representing only about 3% of all fractures in adults. Gartland originally described a classification for extension-type supracondylar humerus fractures, dividing them into three types: type I is non-displaced, type II is displaced with an intact posterior cortex, and type III is displaced without cortical contact [2, 5]. Join for free. Her past medical history is significant for a supracondylar fracture treated in a cast when as a younger child. What is the optimal initial treatment for this injury based on the AAOS guidelines? This post will introduce the types of supracondylar fractures and known complications. Pediatric Pelvis Trauma Radiographic Evaluation, Pediatric Hip Trauma Radiographic Evaluation, Pediatric Knee Trauma Radiographic Evaluation, Pediatric Ankle Trauma Radiographic Evaluation, Distal Humerus Physeal Separation - Pediatric, Proximal Tibia Metaphyseal FX - Pediatric, Chronic Recurrent Multifocal Osteomyelitis (CRMO), Obstetric Brachial Plexopathy (Erb's, Klumpke's Palsy), Anterolateral Bowing & Congenital Pseudoarthrosis of Tibia, Clubfoot (congenital talipes equinovarus), Flexible Pes Planovalgus (Flexible Flatfoot), Congenital Hallux Varus (Atavistic Great Toe), Cerebral Palsy - Upper Extremity Disorders, Myelodysplasia (myelomeningocele, spinal bifida), Dysplasia Epiphysealis Hemimelica (Trevor's Disease), e.g., internal (medial epicondyle) apophysis, ossifies/appears at age 6 years (table below), fuses at age ~ 17 years (is the last to fuse), AP and lateral x-ray of the elbow (really of the distal humerus), lucency on a lateral view along the posterior distal humerus and olecranon fossa is highly suggestive of occult fracture around the elbow, displacement of the anterior humeral line, anterior humeral line should intersect the middle third of the capitellum in children, capitellum moves posteriorly to this reference line in extension type fractures and anteriorly in flexion type fractures, Baumann's angle is created by drawing a line parallel to the longitudinal axis of the humeral shaft and a line along the lateral condylar physis as viewed on the AP image, normal is 70-75°, but best judge is a comparison of the contralateral side, deviation of >5-10° indicates coronal plane deformity and should not be accepted, time to CRPP dictated by neurovascular status, some argue can treat an isolated AIN injury in non-urgent fashion, splint in 30-40° elbow flexion, admit overnight for observation and elevation for elective surgery, ecchymosis, dimpling/puckering antecubital fossa, palpable subcutaneous bone fragment, indicates proximal fragment buttonholed through brachialis, implies more serious injury, higher likelihood of arterial injury, significant swelling, more difficult closed reduction, ipsilateral supracondylar humerus and forearm/wrist fractures warrant timely pinning of both fractures to decrease the risk of, if evidence of good distal perfusion admit for 48 hours of observation, if not well perfused perform vascular exploration, if well perfused admit and observe for 48 hours, open exploration and reduction if vascular status does not improve, more frequently required with flexion type fractures (compared to extension type), pulseless white OR pink hand that is unable to be reduced or there remains a gap, gap might represent entrapped vascular structure, posteromedial displacement: forearm pronated with hyperflexion, posterolateral displacement: forearm supinated with hyperflexion, if pronation or supination does not work, try the opposite, maximize separation of pins at fracture site, engage both medial & lateral columns proximal to fracture, engage sufficient bone in proximal & distal segments, biomechanically stronger in bending and torsion than 2-pin constructs, biomechanically strongest to torsional stress, anterior approach if pulseless or median nerve injury, a lateral or medial approach where periosteum is torn, never posterior as posterior dissection can --> AVN, identify median nerve and brachial artery, 2 or 3 K-wires depending on the degree of stability, mechanism = tenting of nerve on fracture, or entrapment in the fracture site, decision to explore is based on quality of extremity, arteriography is NOT indicated in isolated injuries, role of doppler is unclear and does not change treatment, may result from elbow hyperflexion casting. Orthobullets Techniques are largerly incomplete at this time, and will see rapid improvement as they are updated by experts in the field over the coming months. Supracondylar humerus fractures are among the most common orthopaedic injuries of childhood, comprising roughly two-thirds of all fractures involving the elbow. ... Is medial pin use safe for treating pediatric supracondylar humerus fractures? They are distinctly different from adult SCHFs and … Flexion-type (rare) - distal fragment is displaced anteriorly 2. vascular evaluation . Lateral-entry pin fixation in the management of supracondylar fractures in children. Which of the following radiographs is consistent with his injury? Usually, supracondylar femoral fractures are due to blunt force from an auto or motorcycle accident, being hit by a car, or a big fall. Radiographs of the elbow show a displaced supracondylar fracture. Most supracondylar humerus fractures occur in children aged 3 to 6 years, with an average age of 5.5 years for closed injuries. neurolysis of the anterior interosseous nerve. A 6-year-old presents with an elbow deformity after falling from the monkey bars. They result from force applied across the elbow, usually following a fall. INTRODUCTION. Although these injuries are relatively rare, most orthopedic surgeons are called upon to evaluate and treat patients with these injuries and, therefore, must be equipped to achieve optimal outc… A 7-year-old boy falls off the playground and sustains the injury shown in figure A. The fracture is usually transverse or oblique and above the medial and lateral condyles and epicondyles. In this type of fracture, the traditional closed reduction maneuver, as described for extension type supracondylar fractures, cannot be used as the traditional hyperflexion of the elbow and dorsal pressure of the distal fragment displaces the fracture farther. It constitutes about 65.4% of all the fractures about the elbow in children. Fracture pattern, soft-tissue interposition, patient characteristics, and surgeon experience may contribute individually or in combination. Nonoperative management of supracondylar humerus fractures (SCHFs) is indicated for nondisplaced fractures (Gartland type 1) or mildly displaced fractures without rotational deformity (Gartland type 2A). In a study of 4536 consecutive fractures in adults seen in the Massachusetts General Hospital emergency department, only 0.31% were supracondylar (bicolumn) fractures of the distal humerus. Above the elbow (supracondylar). traumatic injuries involving the region extending from the distal metaphyseal-diaphyseal junction to the articular surface of the femoral condyles, surgical treatment options include ORIF, IM nail, and distal femur replacement, high energy with significant displacement, low energy, often fall from standing, in osteoporotic bone, usually with lesser degree of displacement, medial condyle extends more distal than lateral, posterior halves of both condyles are posterior to the posterior cortex of femoral shaft, direction of deformity is dependent on the location of comminution and the relation of fracture lines to the adductor tubercle, extension at the fracture site (apex posterior), rotation of condyles when an intercondylar split is present, portion of the articular surface remains in continuity with shaft, 33B3 is in the coronal plane (Hoffa fragment), articular fragment separated from the shaft, pain of distal femur that is made worse with knee movement, knee effusion may be present with intraarticular involvement, evaluate for wounds concerning for an open fracture, <0.9 = 97% specific and 95% sensitive for major arterial injury, AP, lateral, and oblique traction views can help characterize injury but are painful for the patient, obtain imaging of entire femur to rule out associated injuries, consider views of the contralateral femur for pre-operative planning and templating, condyles are malrotated in sagittal plane with respects to each other, after external fixation to assess pattern, comminution, and intraarticular extension, separate osteochondral fragments in the area of the intercondylar notch, identifies vascular segments with diminished flow, displaced distal femur fractures may result in injury to the, patient with significant comorbidities presenting an unacceptably high degree of surgical/anesthetic risk, variable and dependent on multiple factors including patient characteristics and fracture pattern, temporizing measure to restore length, alignment, and stability, soft tissues not amenable to surgical incisions and internal fixation, or until the patient is stable, contamination requiring multiple debridements, variable and dependent on multiple factors including patient characteristics, fracture pattern, and degree of soft tissue injury, 92-100% union rates reported at an average of 4-6 months when used as definitive treatment, traditional 95 degree devices contraindicated in Hoffa fractures, periprosthetic fracture with osteoporotic bone, fixed-angle plates required for metaphyseal comminution, non-fixed angle plates are prone to varus collapse, periprosthetic fractures with implants with an, distal femoral replacements do not allow retrograde nail fixation, independent screw stabilization of intraarticular components placed around nail, high union rates reported, more symmetric callus formation compared to plates, reduced rates of malunion and higher patient satisfaction compared to ORIF has been reported, preexisting osteoarthritis with amenable fracture pattern, fracture around prior total knee arthroplasty with loose component, restricted weight-bearing until evidence of fracture union, serial radiographs to assess for displacement, avoid pin placement in the area of planned plate placement, if possible, arthrotomy for direct reduction of articular components, best when used for extraarticular fractures, distal incision large enough to insert plate sub-muscularly, screws placed through smaller proximal incisions, midline anterior incision that angles slightly lateral, facilitates articular and lateral distal femur exposure, fractures with complex articular extension, extend incision into quadriceps tendon to evert patella, used for complex medial femoral condyle fractures, most often used for type B2 and B3 patterns, can be used to augment fixation with medial plate in type C3 patterns, used for very posterior Hoffa fragment fixation, midline incision over the popliteal fossa, develop a plane between medial and lateral gastrocnemius, restore articular surface before fixation of extraarticular component, stable fixation of articular component to diaphysis for early ROM, direct visualization of the joint allows perfect reduction of intraarticular fractures with lag screw fixation before attaching the articular block to the proximal fragment, allows better control of coronal plate compared to 95º angled blate plate and dynamic condylar screw, multi-plane screw trajectory allows fixation of, lag screws with locked screws (hybrid construct), intercondylar fractures (usually in conjunction with locked plate), locking screw constructs don't rely on bone-plate contact for stability, helpful when pre-contoured plates do not precisely match patient anatomy, potential to create too stiff of construct leading to nonunion or plate failure, NOT an appropriate construct for isolated medial femoral condyle fractures, requires precise initial implantation of the blade into the distal fragment, may provide poor fixation osteoporotic bone, precise sagittal plane alignment is not necessary as plate rotates around the barrel, mid substance longitudinal patellar tendon split, 2.5 cm incision parallel to medial aspect of patellar tendon, no attempt to visualize articular surface, incise extensor mechanism 10 mm medial to the patella, eversion of patella not typically necessary, need to stabilize articular segments before nail placement, articular reduction and fixation before nail placement, lag screws placed out of the intended IMN path, starting point at the superior margin of Blumensaat line (lateral) and center of intercondylar notch (AP), blocking screws facilitate reduction and strengthen the construct, implant should reach lesser trochanter to reduce risk of vascular injury, IMN for periprosthetic fractures may result in, resect fracture to allow full weight-bearing, endoprosthetic metal or polyethylene component fracture, excessively long screws can irritate medial soft tissues, determine appropriate intercondylar screw length by obtaining an AP radiograph of the knee with the leg internally rotated 30 degrees, percutaneous submuscular fixation with pre-contoured locking plate, revision internal fixation with osteotomy, functional results satisfactory if malalignment is within 5 degrees in any plane, up to 19%, most commonly in metaphyseal area with articular portion healed (comminution, bone loss and open fractures more likely in metaphysis), consider changing fixation technique to improve biomechanics, hardware removal if fracture stability permits, stainless steel implants may be inferior to titanium, Adult Knee Trauma Radiographic Evaluation, Proximal Humerus Fracture Malunion and Nonunion, Distal Radial Ulnar Joint (DRUJ) Injuries, can be difficult to visualize intraarticular extension, sagittal intra-articular splut is most common, i.e., hard and soft signs (pulselessness, rapidly expanding hematoma, massive bleeding, etc. Breaks, it is important intra-operatively to ensure that the intercondylar screws are contained within the bone and are treated! 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