Executive Editor: Fergal Monsell General Editor: Chris Colton

Authors: Andrew Howard, Theddy Slongo

Pediatric distal humerus 13-M/3.1 III and IV

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Glossary

General considerations

This is a common fracture pattern. Complete fractures are usually displaced and are unstable following reduction because of the anatomy of the distal humerus.

Accurate, closed reduction stabilized with K-wires is the mainstay of treatment for these fracture patterns.

Olecranon screw traction can be useful in emerging healthcare settings if an image intensifier is not available.

Straight arm skin traction is also widely used in such settings. It requires no anesthesia, but the elbow is dependent, pain relief is less immediate, and the forearm is supinated rather than pronated. This will not be addressed in detail here.

These techniques are also applicable in sophisticated health care systems, as an alternative to an open approach.

External fixation is an alternative technique, which may be useful for fractures that are difficult to reduce, or patterns that are difficult to stabilize with K-wires.

ESIN is an alternative technique for fractures that can be reduced anatomically and where earlier motion is preferred.

Note: It is rare for a complete fracture to be stable enough to be treated with simple immobilization.

Timing of treatment

There is evidence that in nonurgent cases a delay in treatment of up to 2-3 days has no negative effect on healing or outcome.

Urgent cases include open supracondylar fractures, fractures with a pulseless perfused and/or white hand, dense neurological deficit with a severely displaced fracture.

The following points influence the timing of the treatment:

  • Availability of surgical resources, including an experienced surgeon
  • The patient should be treated on a routine operating list, preferably the day after injury. In the meantime, plaster splint immobilization of the elbow joint is recommended for pain management
Splint immobilization
Main indication Skill Equipment
Temporary immobilization whilst awaiting definitive treatment Basic surgical experience, no specialized skills Basic equipment only

Indications

  • Child unfit for general anesthesia
  • Temporary immobilization whilst awaiting definitive treatment

Contraindications

  • Most complete fractures are too unstable to reliably achieve a satisfactory position at healing with any closed treatment method

Advantages

  • Initial comfort is improved
  • May be performed without general anesthetic

Disadvantages

  • High likelihood of displacement and malunion
  • Splint may cause compartment syndrome in the presence of swelling
  • Poor control over the position of the distal fragment as swelling resolves or if cast needs to be removed
Closed reduction; K-wire fixation
Main indication Skill Equipment
Any 13-M/3.1 III & IV fracture that can be reduced anatomically Some specialized surgical experience Full specialized surgical and imaging resources

Indications

  • Any 13-M/3.1 III & IV fracture that can be reduced anatomically, or so nearly anatomically as to permit intraosseous K-wires

Advantages

  • Better control of distal fragment
  • Reduced incidence of malunion

Disadvantages

  • Requires general anesthesia
  • Requires implant removal
  • Risk of pin-track infection
Open reduction; K-wire fixation
Main indication Skill Equipment
Any 13-M/3.1 III and IV fracture that cannot be reduced anatomically Some specialized surgical experience Simple surgical and imaging resources

Indications

  • Inability to obtain anatomical closed reduction due to interposed soft tissue
  • Open fractures
  • Vascular injury requiring brachial artery exploration

Advantages

  • Direct access to blocks to reduction (eg, interposed muscle, or periosteum)
  • Direct visualization of neurovascular structures possible
  • Ability to provisionally stabilize fracture

Disadvantages

  • Inability to view entire fracture from any single approach
  • Image intensifier still required for insertion of K-wires
  • Requires implant removal
  • Risk of infection
  • Joint stiffness
External fixator
Main indication Skill Equipment
Difficulty in obtaining closed anatomical reduction Some specialized surgical experience Simple surgical and imaging resources

Indications

  • Difficulty in obtaining closed anatomical reduction (eg, long oblique fractures)
  • Difficulty in obtaining stable pin configuration
  • Primary, or secondary, vascular problems (may require open exploration)
  • Revision of secondarily displaced, or imperfectly reduced, fractures, until 14 days post-injury
  • Fracture patterns with absent posterior periosteal stability

Contraindications

  • If K-wires can maintain position, then anatomical closed reduction and pinning is preferred

Advantages

  • No need for cast, or splint
  • No need for open reduction
  • Early functional rehabilitation
  • Easier monitoring for compartment syndrome

Disadvantages

  • Technically demanding
  • Risk of radial nerve damage
  • Risk of pin-track infection
  • Requires implant removal
ESIN
Main indication Skill Equipment
Anatomical closed reduction achievable and requirement for early motion Highly experienced and skilled surgeon Full specialized surgical and imaging resources

Indications

  • Anatomical closed reduction achievable
  • Requirement for early motion without external support
  • Fractures that are reduced, but because of the fracture morphology (long oblique fracture plane), cannot be stabilized with K-wires
  • Revision of secondarily displaced, or imperfectly reduced, fractures, up to 7 days of injury

Contraindications

  • Inability to achieve anatomical reduction
  • Lack of extensive ESIN experience

Advantages

  • No need for cast, or splint
  • Avoids radial and ulnar nerve irritation/damage
  • Early functional rehabilitation
  • Rotationally stable

Disadvantages

  • Technically demanding
  • Long learning curve for surgeons
  • Time-consuming
  • Considerable radiation exposure
  • Risk of nail tip perforation into the joint
  • Second procedure required for nail removal
  • Normally requires two image intensifiers
Olecranon screw traction
Main indication Skill Equipment
Any 13-M/3.1 III & IV fracture that cannot be reduced anatomically Basic surgical experience, no specialized skills Basic equipment only

Indications

  • Inability to obtain satisfactory closed reduction
  • Inability to obtain stable pin configuration
  • Image intensification not available

Contraindications

  • If anatomical closed reduction and K-wire fixation is achievable

Advantages

  • Good functional results reported
  • Can be performed without image intensification

Disadvantages

  • Requires general anesthesia
  • Requires longer hospital stay
  • Requires screw removal
*Skill
Basic surgical experience, no specialized skills Basic surgical experience, no specialized skills
Some specialized surgical experience Some specialized surgical experience
Highly experienced and skilled surgeon Highly experienced and skilled surgeon
*Equipment
Basic equipment only Basic equipment only
Simple surgical and imaging resources Simple surgical and imaging resources
Full specialized surgical and imaging resources Full specialized surgical and imaging resources

v1.0 2016-12-01