Gãy xương cánh tay pot

In my experience with displaced fractures, when anatomic reduction has not been obtained, the most common position is lateral displacement.. Some surgeons advocate placing all fixation p

Fractures of the Lateral Condyle of the Humerus

Milch described two types of lat-eral condyle fractures (Figure 1) In Milch type I, the fracture ex-tends through the ossification center

of the capitellum and enters the joint lateral to the trochlear groove In Milch type II, the fracture extends medially into the trochlear groove

The most widely used system (not identified by name) identifies three fracture patterns (Figure 2) In a type

I fracture, the articular surface is in-tact and the fracture is nondisplaced and stable In types II and III, the frac-ture enters the joint Type II fracfrac-tures are minimally displaced (2 to 3 mm);

type III fractures are displaced >4 mm and may be rotated (For additional discussion of these systems, see Milch,1Jakob et al,2Ogden,3Herring,4 Wilkins et al,5and McIntyre.6)

Indications

Type I fractures and type II fractures displaced <2 mm may be treated by closed means.7Closed reduction and percutaneous pinning should be at-tempted in type II fractures displaced

2 to 3 mm;8however, if anatomic re-duction is not obtained, open reduc-tion and internal fixareduc-tion is required

Type II fractures displaced >2 to 3 mm and all type III fractures are unstable

Displaced fractures have an increased propensity to nonunion

Properly managed fractures

treat-ed by clostreat-ed manipulation and per-cutaneous pinning or by open reduc-tion and internal fixareduc-tion have a 95% union rate, making these the preferred methods of treatment

Contraindications

There are very few contraindications

to performing percutaneous or open

reduction and internal fixation in the properly selected patient The nondisplaced, stable fracture does not require surgical treatment; cast immobilization is sufficient When

an underlying medical condition prevents surgery or an anesthetic risk, then either nonsurgical treat-ment is required or the medical con-dition must be managed before un-dertaking a surgical procedure

Surgical Technique

The patient is positioned supine on the operating table and a general an-esthetic is induced A small child should be positioned with the arm and forearm lying on the operating table but close enough to the edge that the operative limb can be brought over the edge of the table for use with either standard fluoroscopy

or the mini C-arm fluoroscopy unit Some surgeons use the receiving unit of the fluoroscopy unit as an op-erating surface

The arm is prepared and draped in

a sterile manner, then is exsan-guinated and the tourniquet inflated When closed reduction and percuta-neous pinning is considered, we per-form this technique with fluoro-scopic imaging ( video) If this

fails or if open treatment is the method of choice, a curvilinear

later-al incision is made centered over the lateral condyle Minimal dissection

is preferred to avoid periosteal strip-ping of the blood supply The surgi-cal approach involves directly enter-ing the fracture hematoma and visualizing the fragment I recom-mend the surgical interval between the brachioradialis and the triceps Once the fragment is identified, the fracture site is irrigated thoroughly

J Andy Sullivan, MD

The video that

accom-panies this article is

″Supracondylar Fractures

of the Humerus in Children, ″ available

on the Orthopaedic Knowledge

On-line Website, at http://www5.aaos.org/

oko/jaaos/surgical.cfm

Dr Sullivan is Don H O’Donoghue

Professor and Chief Medical Officer,

Department of Orthopedic Surgery &

Rehabilitation, University of Oklahoma

Health Sciences Center, Children’s

Hospital, Oklahoma City, OK.

Neither Dr Sullivan nor the department

with which he is affiliated has received

anything of value from or owns stock in a

commercial company or institution

related directly or indirectly to the

subject of this article.

Reprint requests: Dr Sullivan, Children’s

Hospital, Room 2MR2000, 940 NE

13th Street, Oklahoma City, OK 73104.

J Am Acad Orthop Surg 2006;14:

58-62

Copyright 2006 by the American

Academy of Orthopaedic Surgeons.

to remove all hematoma and to

im-prove visualization

Dissection is kept to a minimum

Usually no dissection is necessary on

the distal fragment Distal and

poste-rior dissection should be avoided in

order to avert damage to the

circula-tion of the fragment, which can cause

osteonecrosis The periosteum of the

proximal fragment, which overhangs

the fracture site, may have to be

stripped back slightly to remove it

from the fracture site

It is important to adequately

visu-alize the joint articular surface In

some cases, the fragment is rotated

180°; in these situations, I have found

it easier to visualize the fragment by

applying a varus movement to the

el-bow, which reproduces the

mecha-nism of injury and opens the fracture

site so that it may be easily seen

Once the hematoma has been

evac-uated, the distal fragment is

manip-ulated into position onto the end of

the proximal fragment (distal

hu-merus) To accomplish this reduction,

the distal fragment is grasped with a

bone-holding forceps or a towel clip

and rotated back into proper

align-ment This maneuver is facilitated by

flexing the elbow in order to take

ten-sion off the distal fragment

My preferred technique is to place

a large towel clip or a small-bone

point-to-point forceps with one tong

in the lateral condyle, then hook the

other tong into the periosteum of the

proximal fragment (Figure 3) The

el-bow is flexed and the clamp gently

closed It is important at this point

to place retraction in the wound to

directly visualize the joint articular

surface The key component of this

procedure is to ensure anatomic

re-duction of the joint articular surface

At times, the joint surface cannot be

entirely visualized By palpation

an-teriorly and posan-teriorly, one is

usual-ly able to get a good idea of the

suit-ability of the reduction

After anatomic reduction is

achieved, the arm is brought out

over the fluoroscopy machine, and

anteroposterior and lateral

radio-graphic views are obtained In my experience with displaced fractures, when anatomic reduction has not been obtained, the most common position is lateral displacement

Usually reduction can be improved

by loosening the clamp, placing pres-sure on the fragment to push it more medially, then closing the clamp

Once the anatomic reduction is obtained, internal fixation should be secured with Kirschner wires (K-wires) (Figure 4) Other fixation tech-niques include compression screws and absorbable pins I have found that K-wires are simple, efficient, in-expensive, and effective In most of these patients, a 0.62-in K-wire is

sufficient In a very small child, I recommend 0.45-in K-wires Some surgeons advocate placing all fixation pins or screws in the metaphyseal fragment, thus avoiding the ossific nucleus and physis of the lateral condyle With a very large fragment, this is usually possible However, in many of these condylar fractures, the reduction and articular surface are difficult to visualize A sufficiently large fragment is needed

to confirm that the pin has adequate purchase However, when the frac-ture fragment is small, I do not hes-itate to place the pins through the condyle and across the physis into the medial aspect of the distal

hu-Figure 1

A,Milch type I fracture The fracture line is through the ossific nucleus of the

capitellum B, Milch type II fracture The fracture line is lateral to the ossific nucleus.

Figure 2

Fracture types I through III A, In a type I fracture, the fracture line does not violate the articular surface and therefore is stable B, A type II fracture is through the articular surface but minimally displaced C, A type III fracture is displaced and often

rotated

merus The anatomy of the distal

hu-merus is such that most of the

growth occurs in the lateral condyle

and the trochlea Occasionally,

pa-tients end up with a fishtail

appear-ance to the distal humerus, which

does not interfere with function In

my experience, I have never seen a

true arrest of the entire lateral

condyle

A variety of pin configurations

may be used Some advocate parallel

pins, as in the video ( video);

how-ever, I prefer convergent pins placed through the lateral condyle and up into the shaft of the humerus A sec-ond pin is placed transversely across the fracture line through the meta-physeal fragment This provides good stability and divergence of the pins

Parallel pins or diverging pins are more stable than converging pins

What is to be avoided is having the pins converge at the fracture site

be-cause this is a less stable construct

An important intraoperative tech-nique is to pick up the skin of the pos-terior aspect of the incision gently with forceps and start the K-wires away from the incision in order to avoid having the pins come out through the incision In most in-stances, the pins can be cut subcuta-neously to bring them retrograde through the skin (by pressing the skin over them)

Pin placement and adequacy of re-duction should be confirmed and doc-umented radiographically This pro-vides a baseline for postoperative care The fracture site should be inspected visually and by palpation to ensure continuity of the joint articular sur-face The wound is irrigated, and layer closure is accomplished with absorb-able sutures, including an absorbabsorb-able subcuticular suture When the frac-ture treatment has been delayed and there is excessive swelling or concern about skin tension, then mattress or tension-releasing sutures should be used in the skin Either absorbable or nonabsorbable may be used, depend-ing on surgeon preference

The K-wires previously inserted are cut off outside the skin and bent over ( video) Nonadherent gauze

is placed around the pins, and a felt pad is cut and placed over the pin The arm is wrapped with cotton cast padding, and a posterior splint is ap-plied For elevation to prevent depen-dent edema, the arm is placed in a sling after the procedure

Follow-up Care

The patient is seen at 1 week after pri-mary treatment; the cast is removed, the pin sites are examined, and radio-graphs are obtained If the pins are in satisfactory position and the reduc-tion maintained, a fiberglass long arm cast is applied In children younger than age 6 or 7 years, an additional 2 weeks of immobilization is recom-mended, although 3 weeks or more of immobilization is preferred after a cast application, giving a total of 4

Figure 3

A, A type III fracture with displacement and rotation B, The fracture has been

reduced and is being held with a clamp

Figure 4

Anteroposterior (A) and lateral (B) views of fixation secured with K-wires.

weeks of immobilization (I have not

had any problems with the children

regaining elbow motion after lateral

condylar fractures and find that I sleep

a little easier with the extra week of

immobilization.)

At 4 weeks, anteroposterior and

lateral radiographs are obtained If

there is new bone formation

indicat-ing the early stage of healindicat-ing, the

K-wires are removed If there is no

ev-idence of bone formation (which is

extremely uncommon, in my

experi-ence), pins still can be removed and

additional cast immobilization

per-formed Reexamination at 6 weeks is

necessary Failure to demonstrate

union of the fracture at that point

would require an additional 6 weeks

of cast or splint immobilization

Be-yond 12 weeks, I would consider the fracture to be nonunited and would proceed with bone grafting

Although I have not done a formal review, I do not recall having had a nonunion in a lateral condylar frac-ture that was treated acutely, nor do

I recall one that was not sufficiently united at 4 weeks in which I could not remove the pins and begin mobi-lization

Delayed Presentation or Nonunion

Nonunion of the lateral condyle can result in cubitus valgus deformity and

in a tardy ulnar nerve palsy.9If the fracture is not united in a patient who presents between 6 and 12 weeks, the

standard surgical approach described

is recommended With nonunion, the surgical procedure is more difficult

In the established nonunion, the frac-ture site is separated from the prox-imal fragment with sharp dissection with a scalpel or a small osteotome Once the two fragments are sepa-rated, curets are used to remove the reactive fibrous tissue, taking care to dissect the distal fragment as mini-mally as possible The surfaces of the proximal and distal fragments must

be cleaned of this fibrous tissue Once this is achieved, I try to obtain as near

an anatomic reduction as possible There are no good anatomic land-marks at this point, and achieving an-atomic reduction is more difficult than in an acute case

Once the anatomic position is de-termined, the fracture fragments are reduced with a towel clip and pins are inserted I still prefer iliac crest bone as the bone donor site There are bone graft substitutes available that may be equally effective With an established nonunion, I prefer internal fixation and bone graft, followed by 6 weeks of cast im-mobilization Most fractures in my experience have united with this treatment at 6 to 12 weeks Patients may present with established non-unions that are in an older age group Roye et al10have demonstrated that, even in adolescents, treatment can

be successful by means of open re-duction, cleaning the bony surfaces, inserting a cancellous screw, and making use of bone grafting With surgical intervention, the stability of the elbow is improved, and the risk

of cubitus valgus is reduced.11

References

1 Milch H: Fractures and fracture dislo-cations of the humeral condyles.

J Trauma1964;15:592-607.

2 Jakob R, Fowles JV, Rang M, Kassab MT: Observations concerning frac-tures of the lateral humeral condyle in

children J Bone Joint Surg Br 1975;

57:430-436.

3 Ogden JA: Skeletal Injury in the

Child, ed 2 Philadelphia, PA: WB

Pearls

• Position the patient close enough to the edge of the operating table

that the arm can be visualized by fluoroscopy, but with sufficient

room that the arm is completely supported during the surgical

pro-cedure

• In a larger child, I recommend use of a hand table During surgery,

extend the elbow and apply varus movement to visualize the

frac-ture Flex the arm at the moment of reduction to relax the distal

frag-ment

• Warn the family preoperatively of potential complications,

includ-ing nonunion, cubitus varus, osteonecrosis, and protuberance of the

lateral condyle Protuberance of the lateral condyle is the most

com-mon The other complications are extremely rare but are serious

Clinical series report that up to half of cases of lateral condyle

frac-ture have a lateral protuberance Although there is no functional

dis-ability from the protuberance and no surgical treatment is required,

it is disconcerting to parents to see the deformity, so it is best to have

warned them preoperatively Although the exact cause is not

known, it is thought that dissection of the periosteum may increase

the likelihood of this result For this reason, dissection should be

limited to that necessary to expose the fracture site

Pitfalls

• Failure to visualize the intra-articular component of the fracture and

obtain anatomic reduction

• Inadequate internal fixation or fracture reduction with rotational

displacement

• Failure to recognize displacement or rotation in fractures treated

closed or with percutaneous pinning

• Aggressive early return to sports It is best to keep patients out of

sports for 2 months following fracture treatment

Saunders, 1990.

4 Herring JA: Tachdjian’s Pediatric

Or-thopedics, ed 3 Philadelphia, PA: WB

Saunders, 2002.

5 Wilkens KE, Beaty JH, Chambers

HG,Toniolo RM: Fractures and

dislo-cations of the elbow region, in

Rock-wood CA Jr, Wilkens KE, Beaty JH

(eds): Fractures in Children

Philadel-phia, PA: Lippincott-Raven, 1996, vol

3, pp 653-904.

6 McIntyre W: Lateral condylar

frac-tures of the humerus, in Letts RM (ed):

Management of Pediatric Fractures.

New York, NY: Churchill Living-stone, 1994, pp 241-258.

7 Foster DE, Sullivan JA, Gross RH: Lat-eral humLat-eral condylar fractures in

children J Pediatr Orthop

1985;5:16-22.

8 Mintzer CM, Waters PM, Brown DJ, Kasser JR: Percutaneous pinning in the treatment of displaced lateral

condyle fractures J Pediatr Orthop

1994;14:462-465.

9 Masada K, Kawai H, Kawabata H,

Masatomi T, Tsuyuguchi

Y,Yamamo-to K: Osteosynthesis for old, estab-lished non-union of the lateral

condyle of the humerus J Bone Joint

Surg Am1990;72:32-40.

10 Roye DP, Bini SA, Infosino A: Late surgical treatment of lateral condylar fractures in children. J Pediatr Orthop1991;11:195-199.

11 Morrissy RT, Wilkins KE: Deformity following distal humeral fracture in

childhood J Bone Joint Surg Am 1984;

66:557-562.