Supracondylar Humerus Fractures Treatment & Management
- Author: Mark A Noffsinger, MD; Chief Editor: Jason H Calhoun, MD, FACS more...
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.
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.
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.
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.
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).
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.
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.
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.
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.)
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.
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. 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.
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.
Farley et al studied outcomes in 444 children with supracondylar humerus fractures according to the type of treating orthopedic surgeon (pediatric or nonpediatric). Outcome factors included the following:
Open reduction rate
Postoperative nerve injury
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.
A comparative study of techniques for treating supracondylar humerus fractures in children was carried out by Pescatori et al.
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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