Executive Editor: Fergal Monsell General Editor: Chris Colton

Authors: Andrew Howard, Theddy Slongo

Pediatric distal humerus 13-E/4.2

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Glossary

1 Goals top

The main goals of treatment of these fractures are:

  • Anatomical reduction and restoration of the joint surface
  • Uncomplicated healing Avoidance of malunion or nonunion

2 Preoperative planning top

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Instruments and implants

  • Standard orthopedic instrument set
  • Lag screws (if possible cannulated)
  • K-wires (preferably threaded at the tip)

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Anesthesia and positioning

General anesthesia is recommended and a sterile tourniquet should be available.

The patient should be placed lateral with the injured arm placed over a padded arm roll or a gutter support.

3 Approach top

A posterior approach can be used. The triceps may be split or reflected laterally and medially. Olecranon osteotomy is rarely necessary.

Note: Some surgeons prefer a lateral approach as it allows sufficient visualization of the intraarticular component, although access is more limited.


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Cleaning of the fracture site

The fracture is cleaned by removing blood clots, loose pieces of bone, and any interposed tissue.

4 Reconstruction of the articular surface top

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Condylar reassembly

The articular fragments are reduced using pointed reduction forceps, a towel clamp, or with the help of two K-wires.

An anatomical reconstruction of the joint surface (and alignment of the physis) is mandatory.


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Definitive interfragmentary fixation

A lag screw is used to obtain interfragmentary compression of the articular fracture plane. A partially or fully threaded screw can be used. If a fully threaded screw is used, it is necessary to overdrill the near fragment.


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Note: To achieve an optimal mechanical outcome, the physis can be ignored in children approaching skeletal maturity.


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If cannulated lag screws are available, the two reduced fragments are temporarily fixed with a K-wire.


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The guide wire for the cannulated screw is inserted through the center of the capitellum, parallel to the joint surface.


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An appropriate screw, depending on the fragment size (3.0, 3.5, or 4.0 mm), is inserted and both wires are removed, unless the first K-wire is required for additional stability.


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In contrast to adult patients with more unstable lesions, one lag screw, with or without an additional K-wire, is normally sufficient to reassemble the condylar mass in children.


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Note: Once the condylar mass has been reconstructed, the injury has been converted to a simple supracondylar fracture type.

Depending on the age of the child, different techniques for the reattachment of the condylar mass can be considered:

  • Divergent lateral 2.0 mm K-wire fixation
  • Medial and lateral crossed 1.6 or 2.0 mm K-wire fixation

Note: If additional stability for metaphyseal fracture is thought necessary, the alternatives to K-wire fixation are:

  • A small lateral external fixator
  • Biplanar plating in older children

5 Condylar reattachment with K-wires top

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Prerequisite:

  • Younger children
  • Small bone

The condylar block is reduced anatomically to the metaphysis.


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The first K-wire is inserted into the lateral aspect of the condylar mass passing up the lateral supracondylar column.

Depending on the technique (divergent monolateral or cross-wiring), a second K-wire is inserted from the lateral or medial side.


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Sometimes, with divergent lateral wires, if the open procedure destroys the posterior periosteal tension band, an additional medial K-wire may be necessary.

Note: Identify and protect the ulnar nerve throughout the medial wiring procedure.

6 Wound closure top

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The triceps dissection or split is closed by continuous resorbable 2/0 suture.

v1.0 2016-12-01