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Supracondylar Humerus Fractures Treatment & Management

  • Author: Mark A Noffsinger, MD; Chief Editor: Jason H Calhoun, MD, FACS  more...
 
Updated: Sep 16, 2014
 

Surgical Therapy

Optimally, surgery should be performed within the first 72 hours following the injury. Further delay may be necessary in patients with multiple traumatic injuries or in patients who are unable to undergo anesthesia for other medical reasons. In these cases, splint the limb in as near normal an anatomic position as possible and elevate it or keep it in sidearm olecranon traction.

Generally, unless an open injury, vascular compromise, or compartment syndrome is present, these fractures do not require emergency late-night surgery. Surgical treatment is best carried out by an experienced operating room (OR) staff at a time when all staff members are functioning optimally.[11]

Initial debridement of open wounds or compartment releases must be performed urgently, but even in these cases, the patient can be returned to the OR during more optimal hours for a second look and possible open reduction and internal fixation. In cases of vascular compromise, bony stability must be provided on an emergency basis to support and stabilize the vascular repair. In cases of severe polytrauma, temporary external fixation may be indicated for short-term stabilization.

The choice of operative exposure depends on the fracture pattern and the surgeon's preference. This article describes the chevron olecranon osteotomy, which is preferred by the author because it affords excellent exposure of the entire distal humerus and elbow joint. This procedure also allows stable fixation and early range of motion. The author believes that the bony fixation performed in an olecranon osteotomy permits safer early range of motion than a soft-tissue repair (eg, a triceps turndown exposure) would. Single-column fractures or fractures in which access to the articular surfaces is not necessary do not require such an extensive exposure.

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Preoperative Details

Preoperative planning must include careful review of adequate radiographs. This aids in planning the surgical approach and in selecting proper hardware. If fracture anatomy and fragments are difficult to ascertain, radiographs in longitudinal traction, computed tomography (CT), or both can be helpful.

General anesthesia most often is necessary to allow patient comfort and adequate time for the procedure. On occasion, axillary block can be used if the surgeon is confident that adequate time will be available to complete the procedure. A sterile arm tourniquet also should be available and can be used on the sterile field during the procedure if bleeding makes fragment identification and reduction difficult.

The author prefers supine positioning with the elbow flexed over a sterile towel roll on the patient's chest. This affords excellent posterior exposure, provides easy wound access for both the surgeon and a first assistant, and allows the use of a second assistant across the table to assist in retraction. The towel roll also can be used as a fulcrum to assist in obtaining length and in maintaining reduction during internal fixation.

The author also believes that the supine position yields better patient physiology and affords better anesthetic access. The author finds the supine position to be especially helpful in patients with multiple traumatic injuries. This position also allows easy access to the iliac crest if bone grafting is necessary.

The patient is given prophylactic antibiotics before induction of anesthesia. The arm is then prepared and draped in the usual sterile fashion; caution is employed to ensure exposure of the proximal third of the forearm distally and exposure to the axilla proximally.

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Intraoperative Details

The arm is elevated and exsanguinated with Esmarch, and the tourniquet is inflated to approximately 250 mm Hg. An incision is made along the proximal 5 cm of the medial ulnar border, curving to the medial side of the olecranon and returning to the midline posteriorly to approximately 15-20 cm above the elbow joint (see the image below). If abrasions or wounds are present, the skin incision can be altered.

Incision is made along proximal 5 cm of medial uln Incision is made along proximal 5 cm of medial ulnar border, curving to medial side of olecranon and returning to midline posteriorly to approximately 15-20 cm above elbow joint.

The first objective is exposure of the ulnar nerve, which often is not easily palpable because of swelling and displaced landmarks. The nerve usually can be located more easily as it emerges from the triceps fascia just medial to the inner muscular septum. It then is traced distally and released from the cubital tunnel and into the flexor muscle mass, with care taken to avoid the motor branch to the flexor carpi ulnaris. Articular branches must be sacrificed for later anterior transposition. The nerve then is carefully retracted and protected with a vascular tape (see the image below).

Nerve is traced distally and released from cubital Nerve is traced distally and released from cubital tunnel and into flexor muscle mass; care is taken to avoid motor branch to flexor carpi ulnaris. Articular branches need to be sacrificed for later anterior transposition. Nerve then is carefully retracted and protected with vascular tape.

The olecranon is isolated, and a small incision is made in the medial or lateral capsule for passage of a probe into the trochlea to palpate the level of the coronoid process. The apex of the chevron osteotomy then is planned 3-5 mm proximal to the coronoid, with the apex directed distally. (This also will correlate just proximal to the radioulnar articulation.) Because the author uses tension band wires for the fixation, no predrilling is done. If the surgeon prefers fixation with an intramedullary screw, predrilling will assist later anatomic reduction and screw placement.

The cut is made with an oscillating saw and completed with a sharp osteotome to prevent damage to the articular surfaces. A gauze sponge can be inserted into the joint before osteotomy completion to protect the articular cartilage further. The olecranon, with the intact triceps insertion, is reflected posteriorly and covered with moist sponge, allowing easy access to the entire supracondylar and to joint surfaces (see the image below). If the fracture extends far proximally, great care must be taken in locating the radial nerve as it exits the spiral groove at the junction of the distal two thirds of the humerus.

Cut is made with oscillating saw and completed wit Cut is made with oscillating saw and completed with sharp osteotome to prevent damage to articular surfaces. Gauze sponge can be inserted into joint prior to osteotomy completion to further protect articular cartilage. Olecranon, with intact triceps insertion, is reflected posteriorly and covered with moist sponge, allowing easy access to entire supracondylar and to joint surfaces.

The next goal is reconstruction of the joint surfaces. Fragments often must be rotated and intercalated into position in cases of comminution and displacement. Large retinacular reduction forceps are helpful in maintaining medial-to-lateral compression once the fragments of the trochlea are aligned. Carefully placed interfragmentary compression screws can provide excellent stability, provided that purchase can be obtained on both medial and lateral fragments.

The author prefers to use 4.0 cannulated cancellous screws for this fixation and finds that washers can be helpful if the bone is osteoporotic. He has also found it helpful to pass one screw from medial to lateral and one from lateral to medial when possible. When placing these screws, take care to avoid penetrating the trochlear sulcus or olecranon fossa. Also consider the possibility of later plate placement, and place screws so they will not interfere with plate positioning.

The next step is to attach the medial and lateral columns to the trochlea. This is accomplished with 3.5-mm reconstruction plates that are of sufficient strength yet can be contoured readily. If possible, the plates are placed directly medial and posterolateral. The bony anatomy lends itself well to this construct, and this construct is strongest biomechanically.

The lateral plate is placed in the most distal position possible, almost abutting the articular cartilage of the capitellum. In this way, the distal screw is directed proximally, avoiding the articular cartilage and providing an interlocking construct. If the thin wafer of bone in the olecranon fossa is comminuted, it need not be reconstructed, provided that both columns can be attached securely to the trochlea, thus restoring the distal humeral triangle.

Concern has been raised with regard to both plates terminating at the same level proximally, owing to the possibility of a significant stress riser being created. Although the author is unaware of related reported complications, staggering the proximal extent of the plate slightly to decrease this potential risk makes sense biomechanically.

The olecranon is then replaced in its position and held, and the joint is put through range of motion. Motion and stability are assessed. If the coronoid is fractured and posterior instability is present, it is reduced most easily and fixated before reduction of the olecranon osteotomy. The olecranon then is secured according to the surgeon's method of choice, with the goal of adequate stability for early range of motion in mind.

The triceps fascia is closed, and the ulnar nerve is transposed anteriorly, either submuscularly or subcutaneously, depending on the patient's size and the surgeon's preference. The tourniquet is released, hemostasis is obtained, and the wound is closed in standard fashion.

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Postoperative Details

A posterior long-arm splint is applied with the elbow at 60-90° of flexion, depending on the amount of swelling. The arm is elevated above the heart level, and finger and shoulder motion are encouraged. Intravenous antibiotics are continued for 24 hours postoperatively. If the patient is then comfortable on oral analgesics and is independent, discharge from the hospital is allowed.

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Follow-up

The author sees patients in the clinic 10-14 days postoperatively. At that visit, sutures are removed, and if the wound is stable, the patient is placed in a hinged elbow orthosis, and protected active range of motion is allowed. (See the image below.)

Between postoperative days 10 and 14, sutures are Between postoperative days 10 and 14, sutures are removed. If wound is stable, patient is placed in hinged elbow orthoses, and protected active range of motion is allowed. Passive assisted range of motion is allowed to point of discomfort, not pain. Importance of early range of motion to final outcome is well documented. Orthosis is worn until evidence (both clinical and radiographic) of fracture union is present, and then orthosis use is discontinued. This usually occurs 6-12 weeks postoperatively.

Passive assisted range of motion is allowed to the point of discomfort, not to the point of pain. The importance of early range of motion to final outcome has been well documented. The orthosis is worn until evidence (both clinical and radiographic) of fracture union is present, at which point orthosis use may be discontinued. This usually occurs 6-12 weeks postoperatively.

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Complications

Complications include infection, occurring at a rate of 0-6% in published cases, including open fractures. The rate of tardy ulnar nerve palsy has been reported to be as high as 15%, but the author believes that this percentage can be lowered by using routine anterior transposition of the ulnar nerve when hardware is placed medially.

Nonunion of the distal humerus is more common in cases of high-energy trauma or loss of fixation. Most of these patients require reoperation with enhanced fixation to alleviate symptoms.[12] Nonunion of the olecranon osteotomy also has been reported, but this author believes it is rare when the chevron osteotomy, which allows for greater bony surface and more stable fixation, is utilized.

Hardware irritation can occur secondary to plates and screws or fixation of the olecranon osteotomy, and it has been reported in up to 50% of cases in some series. If severe, this condition requires removal of the hardware after union. The most common cause appears to be the hardware used for fixation of the olecranon osteotomy, which causes tenderness when the elbow rests on a hard surface. In the author's series, 30% of the patients later required removal of their tension band wire fixation of the olecranon osteotomy.

Loss of fixation necessitates investigation into its cause. Osteoporosis, inadequate placement of hardware, patient noncompliance, and infection all are potential etiologies. Treatment depends on the cause. If loss of fixation is due to severe osteoporosis or patient noncompliance, further casting to gain union at the expense of motion may be the best alternative. If the patient presents with increased pain, decreased range of motion, and radiographic evidence of hardware breakage or loosening, nonunion can be expected if no intervention occurs. If loss of fixation occurs without infection, total elbow arthroplasty should be considered.

Iatrogenic nerve injuries after operative treatment of supracondylar fractures occur in as many as 3-4% of cases.[13]

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Outcome and Prognosis

Outcomes have improved dramatically over the past few decades as surgical technique and instrumentation have improved. Nevertheless, these patients must be informed early in their evaluation that the elbow will probably never be normal.

The goal is to provide a comfortable elbow that functions as near to normally as possible. Most activities of daily living require a flexion range of 30-130°, which allows eating and personal hygiene. Compensating for lack of extension will be easier than compensating for lack of flexion, and compensating for lack of pronation will be easier than compensating for lack of supination.

The final motion achieved appears to be related to the degree of initial trauma energy and to successful restoration of stability allowing early range of motion. High-energy trauma (eg, gunshot wounds, sideswipe injuries, or injuries from motor vehicle accidents) results in more soft-tissue damage and increased scarring, which is more likely to result in restricted range of motion.

Some reports indicate that capsular release performed at the time of initial fixation for these high-energy distal humerus fractures improves the long-term range of motion. Flexion usually returns first, within 2-4 months, and final extension may progress up to 12 months after the injury. Use of dynamic extension splints in gaining final extension has been shown to be of some benefit.

Numerous outcome evaluation schemes are available, but in low-energy trauma, a successful outcome is generally considered to be a 15-140° arc of motion with full supination and pronation and no pain or minimal pain. In high-energy trauma, these results are more difficult to obtain. Activity-related pain is present in approximately 25% of patients; however, it does not appear to be directly correlated with the amount of initial energy of trauma or with final range of motion.

Radiographs of type 3C distal humerus fracture 5 m Radiographs of type 3C distal humerus fracture 5 months after injury and fixation using olecranon osteotomy approach and medial and posterolateral plates. Range of motion, 10-140º without pain.

Farley et al studied outcomes in 444 children with supracondylar humerus fractures according to the type of treating orthopedic surgeon (pediatric or nonpediatric).[14] Outcome factors included the following:

  • Open reduction rate
  • Complications
  • Postoperative nerve injury
  • Repinning rate
  • Need for physical therapy
  • Residual nerve palsy at final follow-up

For severe fractures, significantly more fractures were treated with open reduction in the pediatric orthopedic surgeon group than in the nonpediatric group, but there were no other significant outcome differences between the two groups.[14]

A comparative study of techniques for treating supracondylar humerus fractures in children was carried out by Pescatori et al.[15]

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Future and Controversies

Treatment of these fractures is likely to continue to evolve. Primary total elbow arthroplasty is becoming increasingly accepted in elderly patients with severe osteopenia and limited functional demand. In limited series, good results have been reported. Fixation hardware, including lower-profile bioabsorbable plates and limited dissection application plates, will continue to stimulate interest. Methods of achieving better screw purchase in osteoporotic bone would also be a welcomed advancement.

Regardless of future technologic advancements, these fractures will continue to provide significant challenges to treating surgeons. If attention is paid to careful evaluation and preoperative planning, stable restoration of anatomy, and early motion, acceptable results can be achieved.

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Contributor Information and Disclosures
Author

Mark A Noffsinger, MD Clinical Instructor, Department of Orthopedic Surgery, Michigan State College of Human Medicine; Medical Director, Deptartment of Orthopedic Surgery, Bronson Methodist Hospital, Consulting Staff, Kalamazoo Orthopedic Clinic

Mark A Noffsinger, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association of Orthopaedic Medicine, American Association for Physician Leadership, American Fracture Association, American Medical Association, AMDA - The Society for Post-Acute and Long-Term Care Medicine, Christian Medical and Dental Associations, Indiana State Medical Association, International Society on Thrombosis and Haemostasis, Michigan State Medical Society, Mid-America Orthopaedic Association, Phi Beta Kappa

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Samuel Agnew, MD, FACS Associate Professor, Departments of Orthopedic Surgery and Surgery, Chief of Orthopedic Trauma, University of Florida at Jacksonville College of Medicine; Consulting Surgeon, Department of Orthopedic Surgery, McLeod Regional Medical Center

Samuel Agnew, MD, FACS is a member of the following medical societies: American Association for the Surgery of Trauma, American College of Surgeons, Orthopaedic Trauma Association, Southern Orthopaedic Association

Disclosure: Nothing to disclose.

Chief Editor

Jason H Calhoun, MD, FACS Department Chief, Musculoskeletal Sciences, Spectrum Health Medical Group

Jason H Calhoun, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, American Diabetes Association, American Medical Association, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, Michigan State Medical Society, Missouri State Medical Association, Southern Medical Association, Southern Orthopaedic Association, Texas Medical Association, Texas Orthopaedic Association, Musculoskeletal Infection Society

Disclosure: Nothing to disclose.

Additional Contributors

Jeffrey L Visotsky, MD Assistant Professor, Department of Clinical Orthopedic Surgery, Northwestern University, The Feinberg School of Medicine

Jeffrey L Visotsky, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association for Hand Surgery, American Association for Physician Leadership, American College of Surgeons, American Medical Association, American Society for Surgery of the Hand, Arthroscopy Association of North America, Chicago Medical Society, Illinois State Medical Society

Disclosure: Received consulting fee from Depuy for speaking and teaching; Received honoraria from Pegasus for board membership.

References
  1. Ilyas AM, Jupiter JB. Treatment of distal humerus fractures. Acta Chir Orthop Traumatol Cech. 2008 Feb. 75(1):6-15. [Medline].

  2. Pollock JW, Faber KJ, Athwal GS. Distal humerus fractures. Orthop Clin North Am. 2008 Apr. 39(2):187-200, vi. [Medline].

  3. Wong AS, Baratz ME. Elbow fractures: distal humerus. J Hand Surg [Am]. 2009 Jan. 34(1):176-90. [Medline].

  4. Reich RS. Treatment of intercondylar fractures of the elbow by means of traction. J Bone Joint Surg Am. 1936. 18:997-1004.

  5. Riseborough EJ, Radin EL. Intercondylar T fractures of the humerus in the adult. A comparison of operative and non-operative treatment in twenty-nine cases. J Bone Joint Surg Am. 1969 Jan. 51(1):130-41. [Medline].

  6. Mehne DK, Matta J. Bicolumn fractures of the adult humerus. Presented at: The 53rd Annual Meeting of the American Academy of Orthopaedic Surgeons. 1986. New Orleans, La.

  7. Milch H. Fractures and fracture-dislocation of the humeral condyles. J Trauma. 1964. 4:592-607.

  8. Athwal GS, Goetz TJ, Pollock JW, Faber KJ. Prosthetic replacement for distal humerus fractures. Orthop Clin North Am. 2008 Apr. 39(2):201-12, vi. [Medline].

  9. Silva M, Pandarinath R, Farng E, Park S, Caneda C, Fong YJ, et al. Inter- and intra-observer reliability of the Baumann angle of the humerus in children with supracondylar humeral fractures. Int Orthop. 2009 May 8. [Medline].

  10. Heal J, Bould M, Livingstone J, Blewitt N, Blom AW. Reproducibility of the Gartland classification for supracondylar humeral fractures in children. J Orthop Surg (Hong Kong). 2007 Apr. 15(1):12-4. [Medline].

  11. Reising K, Schmal H, Kohr M, Kuminack K, Südkamp NP, Strohm PC. Surgical Treatment of Supracondylar Humerus Fractures in Children. Acta Chir Orthop Traumatol Cech. 2011. 78(6):519-523. [Medline].

  12. Jupiter JB. The management of nonunion and malunion of the distal humerus--a 30-year experience. J Orthop Trauma. 2008 Nov-Dec. 22(10):742-50. [Medline].

  13. Joiner ER, Skaggs DL, Arkader A, Andras LM, Lightdale-Miric NR, Pace JL, et al. Iatrogenic nerve injuries in the treatment of supracondylar humerus fractures: are we really just missing nerve injuries on preoperative examination?. J Pediatr Orthop. 2014 Jun. 34(4):388-92. [Medline].

  14. Farley FA, Patel P, Craig CL, Blakemore LC, Hensinger RN, Zhang L, et al. Pediatric supracondylar humerus fractures: treatment by type of orthopedic surgeon. J Child Orthop. 2008 Mar. 2(2):91-5. [Medline]. [Full Text].

  15. Pescatori E, Memeo A, Brivio A, Trapletti A, Camurri S, Pedretti L, et al. Supracondylar humerus fractures in children: a comparison of experiences. J Pediatr Orthop B. 2011 Dec 26. [Medline].

  16. Ackerman G, Jupiter JB. Non-union of fractures of the distal end of the humerus. J Bone Joint Surg Am. 1988 Jan. 70(1):75-83. [Medline].

  17. Aitken GK, Rorabeck CH. Distal humeral fractures in the adult. Clin Orthop. 1986 Jun. (207):191-7. [Medline].

  18. Broudy AS, Jupiter J, May JW Jr. Management of supracondylar fracture with brachial artery thrombosis in a child: case report and literature review. J Trauma. 1979 Jul. 19(7):540-3. [Medline].

  19. Brown RF, Morgan RG. Intercondylar T-shaped fractures of the humerus. Results in ten cases treated by early mobilisation. J Bone Joint Surg Br. 1971 Aug. 53(3):425-8. [Medline].

  20. Bryan RS, Bickel WH. "T" condylar fractures of distal humerus. J Trauma. 1971 Oct. 11(10):830-5. [Medline].

  21. Bryan RS, Morrey BF. Fractures of the distal humerus. In: Morrey BF, ed. The Elbow and Its Disorders. Philadelphia:. WB Saunders Co. 1985:302-339.

  22. Buß FR, Schulz AP, Lill H, Voigt C. Supracondylar Osteotomies of Posttraumatic Distal Humeral Deformities in Young Adults - Technique and Results. Open Orthop J. 2011. 5:389-394. [Medline]. [Full Text].

  23. Cobb TK, Morrey BF. Total elbow arthroplasty as primary treatment for distal humeral fractures in elderly patients. J Bone Joint Surg Am. 1997 Jun. 79(6):826-32. [Medline].

  24. Evans EM. Supracondylar Y fractures of the humerus. J Bone Joint Surg Am. 1953. 35B:381-385.

  25. Gabel GT, Hanson G, Bennett JB, et al. Intraarticular fractures of the distal humerus in the adult. Clin Orthop. 1987 Mar. (216):99-108. [Medline].

  26. Helfet DL, Schmeling GJ. Bicondylar intraarticular fractures of the distal humerus in adults. Clin Orthop. 1993 Jul. (292):26-36. [Medline].

  27. Horne G. Supracondylar fractures of the humerus in adults. J Trauma. 1980 Jan. 20(1):71-4. [Medline].

  28. Jupiter JB, Neff U, Holzach P, Allgower M. Intercondylar fractures of the humerus. An operative approach. J Bone Joint Surg Am. 1985 Feb. 67(2):226-39. [Medline].

  29. Keon-Cohen BT. Fractures at the elbow. J Bone Joint Surg Am. 1966 Dec. 48(8):1623-39. [Medline].

  30. Knight RA. Fractures of the humeral condyle in adults. South Med J. 1955. 48:1165-1173.

  31. Kundel K, Braun W, Wieberneit J, Ruter A. Intraarticular distal humerus fractures. Factors affecting functional outcome. Clin Orthop. 1996 Nov. (332):200-8. [Medline].

  32. MacAustland WR, Wyman ET. Fractures of the adult elbow. AAOS Instr Course Lect. 1975. 24:165-181.

  33. Miller OL. Blind nailing of the T fracture of the lower end of the humerus which involves the joint. J Bone Joint Surg Am. 1939. 21:933-938.

  34. Miller WE. Comminuted factures of the distal end of the humerus. J Bone Joint Surg Am. 1964. 46A:644-656.

  35. Muller ME, Allgower M, Schneider R, Willengger H. In: Manual of Internal Fixation. 3rd ed. Berlin:. Springer-Verlag. 1992.

  36. Noffsinger MA. Treatment of Comminuted Distal Humerus Fractures in Adults. Presented at: American Fracture Association Annual Meeting. 1998. Tuczon, Ariz.

  37. Papaioannou N, Babis GC, Kalavritinos J, Pantazopoulos T. Operative treatment of type C intra-articular fractures of the distal humerus: the role of stability achieved at surgery on final outcome. Injury. 1995 Apr. 26(3):169-73. [Medline].

  38. Sanders RA, Raney EM, Pipkin S. Operative treatment of bicondylar intraarticular fractures of the distal humerus. Orthopedics. 1992 Feb. 15(2):159-63. [Medline].

  39. Speed JS. Surgical treatment of condylar fractures of the humerus. AAOS Instr Course Lect. 1950. 7:187-194.

  40. Suman RK, Miller JH. Intercondylar fractures of the distal humerus. J R Coll Surg Edinb. 1982 Sep. 27(5):276-81. [Medline].

  41. Van Gorder G. Surgical approach in supracondylar T fractures of the humerus requiring open reduction. J Bone Joint Surg Am. 1940. 22:278-292.

 
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Supracondylar humerus fractures: anatomy. Trochlea rests in 6-8º valgus in relation to humeral shaft.
Supracondylar humerus fractures: anatomy. When viewed on end, trochlea resembles spool.
Supracondylar humerus fractures: anatomy. Note medial and lateral columns, connected by trochlea, thus forming triangle of distal humerus. Also note location of sulcus for ulnar nerve in relation to placement of medial plate, as well as location of radial nerve sulcus in relation to proximal placement of plates.
Incision is made along proximal 5 cm of medial ulnar border, curving to medial side of olecranon and returning to midline posteriorly to approximately 15-20 cm above elbow joint.
Nerve is traced distally and released from cubital tunnel and into flexor muscle mass; care is taken to avoid motor branch to flexor carpi ulnaris. Articular branches need to be sacrificed for later anterior transposition. Nerve then is carefully retracted and protected with vascular tape.
Cut is made with oscillating saw and completed with sharp osteotome to prevent damage to articular surfaces. Gauze sponge can be inserted into joint prior to osteotomy completion to further protect articular cartilage. Olecranon, with intact triceps insertion, is reflected posteriorly and covered with moist sponge, allowing easy access to entire supracondylar and to joint surfaces.
Between postoperative days 10 and 14, sutures are removed. If wound is stable, patient is placed in hinged elbow orthoses, and protected active range of motion is allowed. Passive assisted range of motion is allowed to point of discomfort, not pain. Importance of early range of motion to final outcome is well documented. Orthosis is worn until evidence (both clinical and radiographic) of fracture union is present, and then orthosis use is discontinued. This usually occurs 6-12 weeks postoperatively.
Radiographs of type 3C distal humerus fracture 5 months after injury and fixation using olecranon osteotomy approach and medial and posterolateral plates. Range of motion, 10-140º without pain.
 
 
 
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