Executive Editor: Fergal Monsell General Editor: Chris Colton

Authors: Andrew Howard, Theddy Slongo

Pediatric distal humerus 13-M/3.1 II

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Glossary

1 Introduction top

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Extension type supracondylar fractures that are minimally displaced may be treated with closed manipulation and splinting.

The stability of the distal fragment cannot be ensured in a splint and loss of reduction, or incomplete reduction, leading to malunion is possible.


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The best time to assess the carrying angle of the elbow is during examination and manipulation.

If the extended elbow is in an anatomical or slightly valgus position, compared with the uninjured elbow, closed reduction and splinting of minimally displaced (less than 15° of extension) 13-M/3.1 II fractures is an option.

Note: A control x-ray should be taken within 7 days to monitor for loss of reduction.

If the extended elbow appears to be in a varus position compared to the uninjured elbow, then reduction in the operating room and intraosseous pin fixation is required.

2 Closed reduction top

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Correction of extension type supracondylar fractures

Any incomplete fracture which is oblique in an AP view will have a small component of varus or valgus deformity.

This will correct itself at the same time as the extension angulation and with the following maneuver.

With the elbow extended, a thumb is positioned on the back of the olecranon and pushed distally and anteriorly whilst the elbow is smoothly flexed.

If the elbow will not flex fully it is likely that the reduction is incomplete. A complete reduction may be felt.


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The elbow is maintained in maximal possible flexion and the reduction is verified on an AP image. Baumann's angle should be correct (70-80°) at this stage.

Visually evident varus malposition should not be accepted. The carrying angle should be equal to the opposite arm.


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The reduction is also verified on a lateral view taken by externally rotating the entire arm as a unit held with the elbow maximally flexed.


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An alternative is not to rotate the arm, but to rotate the C-arm.

Note: Anatomical closed reduction is the objective of this procedure.

3 Splint application top


With the elbow positioned in 90° of flexion, a posterior plaster backslab is applied.

The addition of medial and lateral slabs stiffens the splint and prevents it from flexing and extending.


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Application of cast padding

Cast padding is wrapped around the upper arm, elbow, forearm and hand, as far as the transverse flexor crease of the palm (the MP joints are left free). According to surgeon's preference a tubular bandage may be applied to the arm beneath the padding.

The elbow is held in 90° flexion and the forearm in neutral rotation.

It is important to make sure that the epicondyles of the humerus and the antecubital area are padded well.


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Application of splint

A splint of fiberglass or plaster is applied on the posterior aspect of the arm and forearm. It should be wide enough to cover more than half the circumference of the arm and forearm.


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The splint is secured with a noncompressive bandage.

It is very important to ensure that this is not tight and can accommodate subsequent swelling.


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Sling

The injured arm is supported with a sling.


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Analgesia

Nonnarcotic analgesia may be required.

Caregivers should be taught to monitor for excessive pain or other signs of potentially dangerous swelling.

Pearl: The ability to passively or actively fully extend the fingers without discomfort indicates normal perfusion and absence of neurological compression.

v1.0 2016-12-01