Management of supracondylar fractures of the humerus in children

Abstract

Supracondylar fractures of the humerus are the most frequent fractures of the paediatric elbow, with a peak incidence at the ages of five to eight years.Extension-type fractures represent 97% to 99% of cases. Posteromedial displacement of the distal fragment is the most frequent; however, the radial and median nerves are equally affected. Flexion-type fractures are more commonly associated with ulnar nerve injuries.Concomitant upper-limb fractures should always be excluded. To manage the vascular status, distal pulse and hand perfusion should be monitored. Compartment syndrome should always be borne in mind, especially when skin puckering, severe ecchymosis/swelling, vascular alterations or concomitant forearm fractures are present.Gartland’s classification shows high intra- and inter-observer reliability. Type I is treated with casting. Surgical treatment is the standard for almost all displaced fractures. Type IV fractures can only be diagnosed intra-operatively.Closed reduction and percutaneous pinning is the gold standard surgical treatment. Open reduction via the anterior approach is indicated for open fractures, absence of the distal vascular flow for > 10 to 15 minutes after closed reduction, and failed closed reduction.Lateral entry pins provide stable fixation, avoiding the risk of iatrogenic ulnar nerve injury.About 10% to 20% of displaced supracondylar fractures present with alterations in vascular status. In most cases, fracture reduction restores perfusion.Neural injuries occur in 6.5% to 19% of cases involving displaced fractures. Most of them are neurapraxias and it is not routinely indicated to explore the nerve surgically.Cite this article: EFORT Open Rev 2018;3:526-540. DOI: 10.1302/2058-5241.3.170049

Vertical Continuous Meniscal Suture Technique

“…25 There are malleable needles with a lumen that allow the use of a single kit in >1 point; however, these cannulas are fragile and sometimes crush and obstruct their lumen during use, requiring often 2 devices to repair extensive injuries. 2,26 We herein describe the meniscal suture technique using the Meniscus 4-All device, which is resistant and allows countless stitches with a single device (Table 1). In addition, it allows the surgeon to use the suture of choice and availability, from specific threads like FiberWire to more common threads like Ethibond (Ethicon, Somerville, NJ).…”

“… 25 There are malleable needles with a lumen that allow the use of a single kit in >1 point; however, these cannulas are fragile and sometimes crush and obstruct their lumen during use, requiring often ≥2 devices to repair extensive injuries. 2 , 26 …”

“…The medial meniscus is C-shaped, and the lateral meniscus presents a similar format, but with closer roots and greater mobility. 1,2 Meniscal injuries are common in the population, representing the major cause of functional impairment in the knee. 3 Meniscal injuries can be degenerative or traumatic, with a bimodal profile.…”

Role of the Posterior Fat Pad Sign in Treating Displaced Extension Type Supracondylar Fractures of the Pediatric Elbow Using the Blount Method

“…The remaining fractures are classified as flexion type supracondylar fractures and are the result of a direct blow to the flexed elbow [2][3]. Extension type supracondylar fractures are further classified into three types, according to the Gartland classification [4]. Gartland I-type fractures are minimally displaced fractures while Gartland II-type fractures are complete fractures of the anterior cortex with a continuous posterior cortex.…”

“…Gartland III-type fractures are completely displaced fractures, without contact of both the anterior and posterior cortices of the distal humeral metaphysis. Provided that adequate reduction has been obtained, Gartland I and II-type fractures are usually stabilized by nonsurgical means while Gartland III fractures are almost routinely treated by closed reduction and percutaneous pinning (CRPP) [2][3][4]. In 20% of the cases, open reduction may be necessary to obtain an acceptable result [1].…”