When will the pulse return in the supracondylar pink pulseless hand?
Range: As soon as cmr / pinning and stabilized fracture, to…. up to 1 Yr (monitor 48 hours post-op prior to discharge)
How can the brachial artery injured in a supracondylar humerus fracture?
Compression, thrombosis, spasm, transaction
So boleh discharge pink pulse less hand after cmr, pinning and 48 hrs observation
Which nerve is most commonly injured in the extension type?
- AIN = Direct contusion or stretch as it located at a less mobile region
- Zone 1 is the transition from the exit point to an entry point into the interosseous membrane (injured here usually)
- Zone 2 is interosseous portion (fixed)
- Radial then ulnar nerve
What are the structures that may be blocking the reduction of supracondylar humerus?
- Brachialis ms
- Brachial artery
- Median nerve
- Joint capsule
- Periosteum
Maneuver
- Milking maneuver of biceps when there is buckling in supracondylar fracture
Why pronate the forearm during reduction?
- Medial is pronate , lateral is supinate
Why traction is not encouraged anymore?
- Pin traction infection
- Prolonged hospitalization
- Discomfort
- Risk of ulnar nerve
- Compartment syndrome
- Potential loss of reduction
How to avoid ulnar nerve injury in medial pinning?
- Visualize the medial cortex of a bone (open)
- Do not hyperflex the elbow (Ulnar nerve sublux anteriorly in flexion)
- Pinning at the inferior anterior epicondyle
Pin size
- Less 6 years old =1.6mm
- More than 6 = 1.8-2.0mm
Why pinning is recommended by AAOS?
- Prevent the loss of reduction
- Increase stability
- CMR causes swelling and may cause loss of reduction after the swelling subsides.
- CMR and 90-degree cast may cause compartment syndrome
2a and 2b
2 a - extended, not rotated - cmr, cast
2b - extended, rotated, cmr pinning
What are the structures that a pin will pass through?
- Skin
- Subcutaneous tissue
- Epiphyseal cartilage
- Physis
- Metaphysics of distal fragment
- Metaphysics of proximal fragment
- The far cortex of the proximal fragment
Approach to pink pulseless hand
- Emergent CMR and pinning (can wait 1 day), observe perfusion for 48 hours
- If becomes pale pulseless = Exploration
- If ED pale pulseless, CMR and pinning within hours then reassesses
If pink, pulse, cmr, or next day op if needed
If pink, no pulse, cmr, still no pulse, urgent crpp (within the same day)
If pale pulse less, realignment of fracture /cmr, still pale and pulseless, emergency op within hours.
How to assess for vascular status?
- Color,
- Pulse,
- CRT,
- Doppler
Approach for exploration
Anterior, medial, and lateral
Never posterior (AVN of trochlear, affects blood supply)
Aim of reduction
- Baumen angle (Less than 5 degrees)
- Anterior humeral line (Middle third of capitulum)
- Rotation (No rotation) -?spike
Lateral condyle fracture
- 2nd common
- Avulsion of common extensor muscle or radial head impaction into the lateral condyle
Milch classification
Type 1 and 2
Type 1 = SH4
Type 2 = SH2
Indication for surgery (Weiss et al)
Displacement >2mm = Long arm cast
CRPP: Displacement 2-4mm = there is still articular hinge
Open reduction, pinning /screw: Displacement >4mm
Imaging in lateral condyle fracture?
- AP,
- Lateral,
- Internal oblique because the fracture is usually posterolateral
Complication of lateral condyle fracture?
- Non-union (Higher risk of nonunion because
- Delayed union
- Avn
- Joint stiffness
- Fishtail deformity
- ?Lateral prominence (Malunion)- Overgrowth of osteoblast = Leads to cubitus varus
Tardy ulnar nerve palsy
- Chronic condition where delayed onset ulnar neuropathy after an injury to the elbow
Causes :
- Cubitus valgus deformity
- Cubitus varus,
- Fractures of the medial condyle and of the olecranon,
- Radial head or Monteggia fractures/dislocation, with or without deformity
When do we need a medial pin?
- Medial comminution
- Configuration of fracture (Oblique to lateral pin)
- Unstable after lateral pinning
When to explore vascular injury?
After CMR and pinning
What’s the difference between Gartland 3 and 4?
3 is diagnosed with radiograph - No posterior hinge,
4 is complete periosteal disruption = only can assess intraoperative multidirectional instability)
