closed manual reduction of supracondylar fracture

The pronation helps to tilt the distal fragment out of any varus position and also assists in stabilizing the fracture. The elbow is maintained in full flexion and the reduction is verified on AP and lateral image intensifier views. The reduction maneuver will need to be repeated if the distal fragment remains posterior. It is common to make small refinements to the reduction until a satisfactory position is obtained. Anatomical closed reduction is commonly obtained even in badly displaced fractures. Varus should not be accepted. Correction of rotational deformity On the lateral image intensifier view, mismatch between the apparent widths of the proximal and distal fragments indicates that rotational malalignment is still present. This malalignment is visible in the lateral view as a so-called rotational nose. Rotational malalignment may well require adjustment, as it markedly narrows the corridor for intraosseous pinning. The most displaced column is generally the medial side. Dynamic visualization under image intensification might be helpful to recognize if the incongruence is medial or lateral. Note: Rotational failure together with insufficient stabilization is the main reason for cubitus varus. Restoration of the hourglass appearance of the olecranon fossa in the lateral view is a good indication that there is correct rotational alignment. How the periosteum can aid reduction The majority of all extension type supracondylar fractures show a rupture of the anterior (cubital) and medial periosteum (as shown in these x-rays). The integrity of the posterior periosteum should be preserved, because it helps to reduce and stabilize the fracture as a tension band. These x-rays, taken after reduction, demonstrate this effect. 3. Closed reduction of flexion type supracondylar fractures Closed reduction of flexion type supracondylar fractures Flexion type supracondylar fractures account for less than 5% of all supracondylar fractures.

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This technique is not suitable for rarer ( An alternative technique for reduction of flexion type fractures will be presented below. 2. Closed reduction of extension type supracondylar fractures (types III and IV) It is important that the patient be well fixed and prepared, and that the image intensifier and equipment are ready prior to attempting reduction. With an assistant supporting the proximal humerus, progressive traction is applied at the wrist. Longitudinal traction on the forearm and wrist should be maintained for at least 5-10 minutes. The goal of this maneuver is to align the fragments by disengaging the humeral shaft from the anterior muscles and skin. If reduction cannot be achieved and there is no clear bone contact, the pierced brachialis muscle might be entrapped. A milking maneuver over the muscles (biceps and brachialis muscle), starting in the middle of the humerus and continuing distally, can be done in an attempt to release the muscle. This maneuver must be done repeatedly in order to reduce the soft tissue around the shaft. Once the fracture is aligned, and all soft tissue entrapment is released, the first C-arm check is performed with the arm extended. The fracture must be out to length and rotationally aligned as indicated by the visible olecranon fossa and the aligned lateral and medial columns. Angulation and translation are corrected by direct manipulation, using a thumb and index finger on the epicondyles. The correction is verified using an image intensifier. Correction of any internal or external malrotation noted on a true lateral x-ray should also be performed at this point. For this maneuver, the thumb is placed on the olecranon and pushes it anteriorly while the rest of the hand fixes the humerus. If a complete reduction cannot be assured, the maneuver has to be repeated. Note: During the flexion maneuver, the forearm should be rotated so that it is fully pronated when the arm reaches full flexion.

If alignment is not achieved, the maneuver should be repeated. Should a second maneuver fail, select lateral external fixation. The alignment must be checked under image intensification in a lateral view. If lateral and rotational alignments are perfect, internal fixation by K-wires is recommended. Note: K-wire fixation in this type of fracture can be difficult as these fractures are often oblique. Pearl: If the reduction maneuver described above fails, a joystick technique (using a K-wire) from posterior can be used to help to reduce the distal fragment. If the fracture still cannot be reduced, reduction and fixation can be attempted using a lateral external fixator, prior to proceeding to an open reduction technique. Even if a good reduction is achieved, a nonoperative treatment requires immobilizing the fracture in a fully extended long arm cast that includes the wrist and thumb. This fixation is nowadays not acceptable for a child and should be avoided. 4. Radiological signs of a good reduction AP view after initial traction The olecranon fossa should be elliptical. The medial and lateral columns must be perfectly aligned. There should be no mismatch between the proximal and distal fragment lines. Lateral view after initial traction In a true lateral view, the cortex of the olecranon fossa, together with the depression on the anterior part of the distal humerus, gives a virtual hourglass form. If the shape is perfectly aligned, this is a safe sign for a perfect rotational and angular reduction. The line along the anterior cortex of the humeral shaft (Roger's line) should intersect the capitellum. In younger children, the true size of the capitellum on a lateral view is estimated by placing a circle, equal in diameter to that of the humeral shaft, concentrically over the visible ossific center. In a true lateral view, the proximal and distal fracture lines have to be congruent and of the same length.

In this type of fracture, the traditional closed reduction maneuver, as described for extension type supracondylar fractures, cannot be used as the traditional hyperflexion of the elbow and dorsal pressure of the distal fragment displaces the fracture farther. Be aware that, in the case of flexion type supracondylar fractures, the posterior periosteum is ruptured whereas the anterior periosteum is mostly intact. In principle, the maneuver of reduction must be one of hyperextension. Once a good reduction has been obtained, it is best to stabilize the fracture with two K-wires. This allows the elbow to be brought back into a flexed position for cast immobilization. If the fracture is not fixed with K-wires, the elbow would have to be immobilized in uncomfortable hyperextension. No single closed reduction technique is going to be universally successful. However, the modifications described below to the standard closed reduction technique will help in certain settings. Note: An alternative method for reduction and fixation is the use of a lateral external fixation technique. Reduction maneuver Applying a variety of gentle techniques which are appropriate for the unique fracture pattern is recommended before proceeding to an open reduction. Strong traction and forceful maneuvers are not recommended as they may cause additional soft tissue damage. Gentle longitudinal traction is applied for 4-5 minutes. A good reduction should be attempted through direct manual manipulation of the distal fragment, which is anteriorly displaced. This detailed view shows direct manipulation of the distal fragment with the thumb pressing down. The length and alignment are verified using image intensification. Pearl: AP view is easy to obtain since the arm is extended. However, a lateral view in extension is very difficult. It is, therefore, recommended to rotate the C-arm around the arm to prevent a redisplacement of the fragment.

To improve the success rate and efficiency of closed reduction and to compare with the conventional manual reduction, the author uses a 1.6-mm K-wire inserting from the upper part of the proximal end of the fracture into the posterior cortical bone of the humerus for temporary fixation to make the rotational displacement better reduced and finally evaluate the complications and efficacy of both reduction methods. Open in a separate window Figure 1 Preoperative anteroposterior (left) and lateral (right) radiographs of an extension-type Gartland III supracondylar humerus fracture. 2.?Patients and methods 2.1. Patients A total of 68 cases of children with Gartland type III supracondylar humerus fractures were admitted in department of orthopedics, Shanghai Children's Hospital, China, from August 2014 to August 2016 to receive surgical treatment. They were randomly divided into two groups according to the order of admission. Auxiliary K-wire technique in which the patients with even inpatient numbers were assigned in Group A, whereas the odd inpatient number patients were allocated in Group B, which were treated with manual reduction alone. The inclusion criteria for this study were fresh closed fractures, significantly displaced Gartland III fracture, surgery by the same group of doctors. Patients with open, comminuted, old, and pathological fractures, combined with neurovascular injury, ipsilateral elbow congenital malformations, were excluded from the study. All patients were surgical treated within 24 hours of injury. The age, sex, side, interval from injury to operation, and other factors of the 2 groups were tested. Table 1 The comparison of general states between the 2 groups. Open in a separate window 2.2. Operative technique All patients were kept in a supine position under general anesthesia with the injured limb extended and off the bed under C-arm for closed reduction.

If the proximal and distal fracture lines are not congruent, there is: Remaining transverse displacement Rotational malalignment AO Davos Courses 2020 Join from wherever you are in the world. The use of a joystick technique facilitates closed reduction and percutaneous fixation of multidirectionally unstable supracondylar humeral fractures in children. Mid-America Orthopaedic Association Physician in Training Award: Surgical Technique: Pediatric Supracondylar Humerus Fractures: A Technique to Aid Closed Reduction Original Text by Clifford R. Wheeless, III, MD. Last updated by Data Trace Staff on Friday, August 19, 2016 10:47 am He founded Orthopaedic Specialists of North Carolina in 2001 and practices at Franklin Regional Medical Center and Duke Raleigh Hospital. Received 2019 Feb 13; Revised 2019 Jul 16; Accepted 2019 Jul 24. Published by Wolters Kluwer Health, Inc. This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. Abstract This study aimed to investigate the effect of auxiliary Kirschner wire (K-wire) technique in the closed reduction of children with Gartland type III supracondylar humerus fractures by comparing with manual reduction alone. Retrospective analysis was performed on the clinical data of 68 cases of supracondylar humerus fractures. Thirty-six patients received closed reduction and percutaneous fixation with auxiliary K-wire technique (group A). Thirty-two patients received conventional manual reduction and percutaneous pin fixation (Group B). And meanwhile, there is no significant effect on the imaging and functional outcomes of affected extremities, which is worthy of respect.

During the repositioning process, the elbow half extension position is first maintained, that is, the flexion is 30 degree, so that the tension of the flexion and extension muscles is reduced, and then the traction along the longitudinal axis of the upper limb is performed to achieve the “locking” state of the fractured end. In clinical work, we found that correcting the lateral displacement first, and then correcting the front and rear displacement usually can obtain a satisfactory reduction effect. Usually, when the closed reduction is performed, the distal end of the fracture is generally applied to the proximal end of the fracture. The traditional method of traction is relatively easy to repair the anterior and posterior angulation and lateral displacement. However, it is difficult to effectively restore the rotational displacement. Rotational displacement of the end is often the main reason for the failure of closure and restoration of supracondylar fractures of the humerus. In addition, the force of the reduction technique of conventional traction cannot effectively control the strength of the reduction process. It may be that the strength is not enough or excessive so that the reduction is unsatisfactory. Moreover, the fracture end movement occurs easily during the process of pinning and a change in body position when taking radiograph, which results in failure of reduction. The auxiliary K-wire technique is resetting the proximal end of the fracture to the distal end. The lever principle can be used to control the rotation of the proximal end of the humerus. It can effectively correct the rotational deformity of the fracture. The radiography confirms that the reduction effect is good, and the assistant is allowed maintaining the position of the K-wire and forearm simultaneously. It is then performed by the surgeon to perform percutaneous K-wire fixation.

This avoids the loss of the position of the fracture end during pin insertion and can effectively control the force of reduction, thus significantly improving success rate of closed reduction. The author tried both methods, and realized that the methods of Novais et al and Grenn et al must be guided by the C-arm machine to advance the pin inserting, and it is difficult to ensure a successful needle insertion. Besides, it is not easy to quickly grasp the operating skills, so the doctor's learning curve is extended. And these 2 methods have the risk of epiphysis injury, so we improved the methods of the above. Owing to the small number of cases, this group was not included in this study. The Gartland type III fractures in Group A were significantly reduced in operative time and intraoperative radiographic frequencies by the aid of the auxiliary K-wire technique. This technique can rapidly obtain a fracture reduction and does not affect the rate of fracture healing and complications. Whether auxiliary K-wire technique is with closed reduction or manual traction and closed reduction, it does not destroy the blood flow at the fracture end, which has little interference with the internal environment of the bone, minimizing the damage to the bone and the surrounding soft tissue, and provides beneficial callus growth environment, so there was no significant difference in mean fracture healing time between the 2 groups in this study. Therefore, it is proved that this technique is of great importance. With the aid of the K-wire technique, although an additional pin wound existed, it was a minimally invasive procedure that did not cause more trauma to the child and no postoperative wound infection occurred. The stability was satisfactory. There was no case lost after follow-up. No cases of radial nerve injury occurred after surgery. Two cases of median nerve injury occurred after surgery in both groups and they were self-recovered within 1 month after surgery.

Longitudinal traction was applied with the elbow in half-extension and the forearm in supination. Although the traction was maintained, the surgeon applied a valgus or varus force at the fracture site. The posterior displacement of the distal fragment was then corrected by applying a force to the posterior aspect while the elbow was gently hyperflexed and the reduction was confirmed by the C-arm. After confirming that the reduction was successful, 3 K-wires were percutaneously inserted from the lateral aspect of elbow across the lateral cortex to engage the medial cortex. After the C-arm machine was again in perspective, there was no loss of reduction, and the pins were bent and cut. The temporary K-wire was removed at last. After the elbow was bent 90 degrees, the forearm pronation was plastered. The x-ray examination was performed at 3 or 4 weeks after surgery to observe the growth of the callus. Once the callus grows satisfactorily, the K-wire and plaster were removed and the elbow flexion and extension exercises were started. Open in a separate window Figure 3 The assistant holds the forearm with one hand, whereas the other hand corrected the rotation of proximal humerus by swinging the pin. Open in a separate window Figure 4 Anteroposterior radiographic images of fracture reduction and fixation with 3 K-wires inserted percutaneously from the lateral sides. Open in a separate window Figure 5 Lateral intraoperative radiograph showed the anterior humeral line extended across the central one-third of the capitellum. Comparisons included operative time (starting closed reduction until the end of the cast immobilization), radiography frequency (the frequency of C-arm machine used during the operation), and fracture healing time (x-rays showed the time of bone union).Intraoperative and postoperative complications were recorded, with or without neurovascular injury, compartment syndrome, nail tract infection, delayed union, and nonunion.

The Fisher exact test and paired t test were applied to assess the outcome variables between the 2 groups. The P value 3.?Results All patients were followed up. There was a statistically significant difference in the average frequency of radiography. The difference in healing time was not statistically significant. Cubitus varus deformity was not seen in both two groups. Complications: In group A, there were two cases of nail tract infection, one case of median nerve injury. One case of nail tract infection and one case of median nerve injury occurred in group B. There were no complications such as vascular injury, delayed union, nonunion, compartment syndrome, etc. The difference in the total incidence of complications between the 2 groups was also not statistically significant. A group of Flynn elbow function scores: excellent in 26 cases, good in 10 cases, fair in 0 cases, poor in 0 cases, excellent rate was 72.2%. The Flynn elbow function score in group B was excellent in 24 cases, good in 8 cases, fair in 0 cases, poor in 0 cases, and excellent in 75%. There was no significant difference between the 2 groups. At present, it has become the preferred surgical method for the treatment of children with Gartland III supracondylar fracture of the humerus. Owing to the limited remodeling ability of the elbow joint, the fracture reduction must reach or approach the anatomical reduction to obtain its normal function, prevent the long-term complications caused by poor restoration, and the joint mechanics anomaly. Because the periosteum around humerus supracondyle completely ruptures, the role of soft tissue hinge no longer exists, so Gartland III fracture is extremely unstable. Closed reduction is to reset the fracture end under “non-straight vision.” The technical requirements for the surgeon are high. To reset the fracture end, the “locked” state of the fracture should firstly be released.

What is gratifying is that through practicing this technology, we have shortened the learning curve of young doctors. On average, senior resident doctors can perform this surgery after training for 3 times. This study has some limitations. The sample size is relatively small, the follow-up time is not long enough, and the dosage of x-ray is not described. We will strictly design and standardize the study and strive to conduct prospective studies in the future to further verify this method. In summary, compared with manual traction reduction, auxiliary K-wire technology can significantly improve the success rate of closed reduction of children with Gartland III humeral supracondylar fractures, which can significantly shorten the operation time and the frequency of intraoperative radiographs, and does not increase intraoperative and postoperative complications, which does not affect the healing of fractures, or reduce the final imaging and extremity function results in children. Therefore, for some patients with apparent rotation displacement of the Gartland type III supracondylar humerus fracture, it is recommended that the surgeon attempts a closed reduction with the aid of the auxiliary K-wire technique. Author contributions Conceptualization: Liangchao Dong, Yang Shen. Formal analysis: Yichen Wang, Muyu Qi. Methodology: Liangchao Dong, Sun Wang, Hao Ying, Yang Shen. Footnotes This study was funded by Scientific Research Project of Shanghai Municipal Health and Family Planning Commission (No. 201740087). The authors report no conflicts of interest.Surg Gynecol Obstet Curr Opin Pediatr Sixteen years’ experience with long-term follow-up. J Bone Joint Surg Am J Bone Joint Surg Am Med J Malaysia Arch Orthop Trauma Surg J Orthop Trauma J Pediatr Orthop J Pediatr Orthop J Clin Diagn Res Pak J Med Sci Indian J Orthop J Pediatr Orthop. The skin is intact and no evidence of puckering is seen. The patient is neurovascularly intact.

Representative radiographs of the injury are shown in Figures A and B. What is the optimal initial treatment for this injury based on the AAOS guidelines?A child complains of decreased sensation over the small finger acutely after an elbow injury. Which of the following radiographs is consistent with his injury?Which treatment will minimize complications?Radiographs of the elbow show a displaced supracondylar fracture. Radiographs of the wrist show an extra-articular distal radius fracture with 25 degrees of dorsal angulation. This injury is most appropriately treated with which of the following?Her past medical history is significant for a supracondylar fracture treated in a cast when as a younger child. She has no pain with motion and has 0 to 120 degrees range of motion. She does not have functional limitations but her parents would like to improve the appearance of her elbow. Which of the following procedures will correct the cubitus varus but may result in a lateral prominence?Orthobullets was not involved in the editorial process and does not have the ability to alter the question. If you prefer to hide SAE questions, simply turn them off in your Learning Goals.Examination in the emergency department reveals that he is unable to flex the interphalangeal joint of his thumb and the distal interphalangeal joint of his index finger. The radial pulse is palpable at the wrist, and sensation is normal throughout the hand. Radiographs are shown in Figures 6a and 6b. In addition to reduction and pinning of the fracture, initial treatment should includeOrthobullets was not involved in the editorial process and does not have the ability to alter the question. If you prefer to hide SAE questions, simply turn them off in your Learning Goals.His hand is pulseless and cold. What is the next step in management?Healing results in a mild gunstock deformity. Surgical treatment of this will most likely result in:What is the most common cause of this deformity?

Update your browser for more security, speed and the best experience on this site. The backslab and sling should be worn under clothing (e.g. loose fitting shirt) and not through the sleeve The backslab should extend as high above the elbow as possible (i.e. close to the axilla) and down to the metacarpophalangeal joints (MCP) joints. Undisplaced fractures can be followed up with the GP in 3 weeks. Repeat x-ray is not required. These must always be managed by orthopaedics The peak age is from 5-8 years. The usual mechanism is a fall onto the outstretched hand with hyperextension at the elbow. A displaced fracture in extension typically has an S-shaped deformity. Swelling can be very rapid. Younger children can present with the appearance of a dislocated elbow. A thorough neurological examination including screening of the median, radial and ulnar nerves should be undertaken and documented. The radial pulse should be felt and documented. The skin should be assessed for swelling and bruising. This is important for pain management. If there is any clinical suspicion of injury in the forearm or wrist then separate films of these areas should be ordered. To assess this accurately, the view must be a true lateral view of the elbow. In Gartland type I fractures, the anterior humeral line (yellow line) passes through the middle of the capitellum. These fractures may be difficult to see on plain x-ray.On lateral view the anterior humeral line is anterior to the middle of capitellum. On the AP view, fracture lines can be seen through the metaphyseal bone of the distal humerus on either side of the olecranon fossa. There may be medial or lateral translation or tilt of the distal fragment. Gartland type II supracondylar fractures can sometimes have a significant displacement in the AP x-ray with either tilt or translation, which would indicate treatment according to the treatment protocol for type III injuries.

The supracondylar injury in these patients appears to be a dislocation of the elbow but is usually a physeal separation (Salter-Harris type I). True elbow dislocation in this age group is very rare. Gartland type II fractures can be gently reduced by pushing anteriorly on the distal fragment as the elbow is flexed to 90 degrees. Gartland type III, and flexion supracondylar fractures are treated with reduction and percutaneous K-wire fixation. For open fractures, tetanus immunisation status should be assessed. No degree of tilt can be accepted on the post-reduction films. Such displacement would imply a more unstable fracture requiring surgical reduction. The backslab should extend as high above the elbow as possible (i.e. close to the axilla) and down to the MCP joints. These must always be managed by orthopaedics That is, immobilisation in greater than 90 degrees of flexion can result in significant swelling and potentially vascular compromise. This can have a much more profound effect on final functional outcome than a minor displacement of the fracture Repeat x-ray is not required. Emphasis should be placed on elevation of the limb (elbow above the heart) for the first 48 hours. The backslab and sling should be worn under clothing (e.g. loose fitting shirt) and not through the sleeve. In the majority of cases, full (or near) ROM returns with time and physiotherapy is not required. However, with appropriate management, Volkmann's ischaemia can be avoided and permanent nerve injury is very rare. The normal carrying angle of the arm is reversed and the forearm deviates to the midline when the elbow is extended. The great majority of the neurological injuries resolve with time. Guideline on the Treatment of Pediatric Supracondylar Humerus Fractures 2011.Management of supracondylar humerus fractures in children: Current concepts. J Am Acad Ortho Surg 2012; 20(2): 69-77. In Tachdjian's Pediatric Orthopedics, 4 th Ed. Saunders, Philadelphia 2008. p.2451-536.

Supracondylar fractures of the distal humerus. In Rockwood and Wilkins' Fractures in Children, 7 th Ed. Beaty JH, Kasser JR (Eds). They were divided into group A (emergency operation group) and group B (selective operation group) according to different operation timing. Perioperative situation, blood biochemical parameters, swelling degree and elbow joint function of affected limb were compared between two groups. Previous article in issue Next article in issue Keywords Emergency treatment Selective closed reduction Supracondylar fracture Percutaneous fixation Recommended articles Citing articles (0) The study protocol was performed according to the Helsinki declaration and approved by the ethic committee of Affiliated Hospital of Weifang Medical University. Informed written consent was obtained from Affiliated Hospital of Weifang Medical University. Peer review under responsibility of Hainan Medical College. The journal implements double-blind peer review practiced by specially invited international editorial board members. Production and hosting by Elsevier B.V. Recommended articles No articles found. Citing articles Article Metrics View article metrics About ScienceDirect Remote access Shopping cart Advertise Contact and support Terms and conditions Privacy policy We use cookies to help provide and enhance our service and tailor content and ads. By continuing you agree to the use of cookies. This technical note describes a simple method of CRPP using a radiolucent arm board and simpler handling of the C-arm. This technique is a simple method and easy to reproduce, can be adapted to any standard operating table, and gives predictable results. Keywords: Arm board technique, closed reduction percutaneous pinning, pediatric supracondylar humeral fractures. The board is adjusted to support the arm proximal to the fracture site. The elbow and the distal part of the limb are completely free to ease fracture reduction and pinning.