Multifragmentary metaphyseal fractures of the distal humerus are uncommon in children. These fractures are unstable following reduction because of their multifragmentary nature.
Accurate closed reduction stabilized using K-wires is the mainstay of treatment for this fracture pattern.
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 fixator is a useful technique, because it takes advantage of indirect reduction and confers more stability than K-wires.
ESIN is an alternative, but highly demanding, technique for these fractures 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