Peggers’ Super Summary of Supracondylar Fractures

Indications:

  • Closed reduction / percutaneous fixation is required for all displaced fractures i.e. type IIB and III
  • Or n/v compromise
  • Compartment syndrome

Anatomy:

VASCULAR STRUCTRES

  • Brachial artery (TAN)

NERVES

  • Radial nerve and PIN (Motor)
  • Median nerve and AIN (Motor)
  • Ulnar nerve

Associated injuries

  • Wrist

Preoperative Planning:

  • Posterior fat pad is always abnormal
  • Rotation is unacceptable

Equipment

  • Smooth wires
  • Power drill
  • Wire cutters
  • Pliers
  • II
  • Soft tissue instruments; blade & retractors for open reduction
  • Cast trolley

Operative Room Planning

INTRODUCTION

  • Confirm Consent / Mark / WHO form / Abx at induction

POSITION

  • Supine
  • Arm over the side of the operating table

DRAPING

  • Antiseptic solution from hand to upper arm
  • Perforated drape
  • Drape from upper arm leaving all of lower arm and hand free.

Fracture reduction:

  • Manual longitudinal traction is placed on the forearm and counter traction on the upper arm
  • Medial or lateral displacement is then corrected with manual pressure and rotation corrected using rotation.
  • Hyperflex the elbow AND pronate forearm whilst placing pressure on the olecranon

Failure of reduction:

  • Torn posterior periosteum
  • Proximal bone spike has pieced the brachialis
  • Attempts to dislodge the button holing through the muscle can be carried out by milking the muscle from proximal to distal, whilst applying pressure on the lateral side (so avoiding n/v damage medially)
  • If this fails open reduction should be considered

Percutaneous fixation:

  • AP II view is almost impossible thus use a transcondylar view i.e. through the elbow
  • If this view is still difficult but the lateral view is satisfactory then wires can be passed and AP image taken to confirm positioning
  • Insert a lateral pin through the lateral epicondyle directed medially at an angle of 35-450 on AP and in line with the humerus on LAT
  • Engage the medial cortex to maintain stability and reduction
  • A second lateral pin is inserted in parallel or crucifix
  • If a medial pin is used it must be placed in the anterior portion of the medial epicondyle under direct approach to avoid the medial nerve
  • Keep the elbow flexed at 900 whilst inserting the medial smooth wire with the forearm externally rotated / supinated
  • Take standard AP, transcondylar, medial and lateral oblique’s and Lateral II images

Closure

  • Check distal radial pulse with the elbow at 900
  • Irrigation
  • Haemostasis of any incision
  • Bend the wires outside the skin and place end caps
  • Splint the elbow at 900
  • Keep in for n/v obs overnight
  • X ray in 1 week to check for displacement
  • Remove k wires 3-4 weeks
  • Cast for a further 2 weeks

Complications:

Early

  • Damage to n/v structures
  • Compartment syndrome

Late

  • Failure
  • Stiffness
  • Carrying angle alteration
  • Volkmann's Contracture