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“When and How to Open Supracondylar Humerus Fractures?”
Donald S. Bae, MD, Children’s Hospital Boston, Boston, Massachussetts
Introduction
-‐ Displaced fractures
o Up to 49% associated neurological injury
o 3 – 19% associated vascular injury
o 1% open injuries
o Malunion results in loss of motion, aesthetic differences
-‐ Standard of care: timely closed reduction and percutaneous pinning
Indications
-‐ Open fractures
-‐ Fractures with vascular insufficiency after attempted closed reduction
-‐ Inadequate alignment after attempted closed reduction
Principles
-‐ Anterior approach for extension-type supracondylar fractures
-‐ Identification and protection of median and/or radial nerves, brachial artery
-‐ Removal of interposed soft tissue
-‐ Anatomic reduction
Surgical Technique
-‐ Supine, hand table, tourniquet rarely needed
-‐ Medially-based, transverse incision over antecubital flexion crease
o Incorporate traumatic wounds
o Avoids scar contracture
o May extend proximal-medially (and distal-laterally)
-‐ Subcutaneous dissection
o Basilic vein
o Release lacertus fibrosis
-‐ Identify and retract neurovascular structures
o Median nerve and brachial artery (nerve medial to artery)
o Radial nerve (brachialis-brachioradialis interval)
-‐ Identify and debride fracture
o Periosteum
o Brachialis
o Neurovascular structures!
-‐ Anatomic reduction
o Liberate and sweep soft-tissues off prominent (anteromedial) metaphyseal spike
o Tactile, visual, fluoroscopic confirmation
-‐ Standard pin fixation
-‐ Simple skin closure
-‐ Vascular insufficiency
o Extended proximal and distal incisions
o Identification of brachial artery beyond zone of injury
o Decompression vs. repair vs. vein grafting
o Fasciotomies as needed
Expected Outcomes
-‐ Adequate exposure and fracture reduction
-‐ Aesthetic scars
-‐ Restoration of function
-‐ Preserved vascularity with appropriate exploration and treatment
Selected References
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