1 Goals topenlarge
The main goals for open treatment of these fractures are:
- Anatomical reduction
- Uncomplicated healing
- No secondary displacement
- Avoiding joint incongruity
2 Preparation topenlarge
Instruments and implants
It is recommended to use 1.2 or 1.6 mm K-wires.
The following equipment is needed:
- K-wires of appropriate sizes
- Drill, preferably oscillating to avoid thermal injury, or a T-handle for manual insertion
- Wire cutting instruments
- Image intensifier
- Contrast medium for arthrography
Anesthesia and positioning
General anesthesia is recommended for this operation and it is helpful to use a tourniquet.
The patient is placed supine with the arm draped up to the shoulder.
4 Reduction topenlarge
There are three options to manipulate and reduce the fragments.
Option 1: Direct digital manipulation.
Option 2: Manipulation using a temporary K-wire in the fragment as a joystick.
Option 3: Holding and manipulating the fragment with a small towel clamp or pointed reduction forceps.
A blunt Hohmann lever retractor is inserted gently into the anterior joint, and around the medial articular border.
The fragment is reduced by one of the three options listed above, so that both cartilage fracture lines (on the fragment and the trochlea) are perfectly aligned.
5 K-wire fixation topenlarge
Fix the fragment with two divergent 1.2 or 1.6 mm K-wires.
The first oblique K-wire is used as a joystick to achieve reduction and then advanced into the metaphysis. The oblique K-wire is used first as, once advanced, its position in the metaphysis is less critical, whereas the track of the transverse K-wire must be parallel to the medial physis and totally within the epiphysis.
The fragment is additionally fixed with a second K-wire inserted parallel to the ulnar physis and totally within the epiphysis.
The wires are either buried deep to the skin or cut outside the skin and bent over. The first option requires a second operation for removal, but the second option risks pin-track infection.
Note: In the older child with a visible ossific center in the trochlea, consideration can be given to an intraepiphyseal screw instead of the horizontal K-wire.