3:45-3:55 “When and How to Open Supracondylar Humerus Fractures?” Introduction

“When and How to Open Supracondylar Humerus Fractures?”
Donald S. Bae, MD, Children’s Hospital Boston, Boston, Massachussetts
-­‐ 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
-­‐ Open fractures
-­‐ Fractures with vascular insufficiency after attempted closed reduction
-­‐ Inadequate alignment after attempted closed reduction
-­‐ 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
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