Authors of section

Authors

Andrew Howard, Theddy Slongo

Executive Editor

Fergal Monsell

General Editor

Chris Colton

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Open reduction; internal fixation

1. Principles

Introduction

Minor comminution is common. Significant comminution is rare, particularly in younger children.

Closed reduction and percutaneous K-wiring therefore, usually result in accurate reduction and stability. The technique described for single fractures (13-M/3.1 III and 13-M/3.1 IV) is used.

open reduction internal fixation

If there is medial impaction, particular attention should be paid to restoring Baumann's angle and thereby avoiding varus malposition.

open reduction internal fixation

Younger children

In unusual fractures that are axially unstable, alternative techniques, such as external fixation or overhead olecranon traction, can be applied.

olecranon screw traction

Skeletally immature adolescents

Younger adolescents, with multifragmentary fractures can be managed using approaches described for adults, ie, prone, or lateral, positioning with two column exposure and fixation.

After provisional fixation of both columns with K-wires, the relative stability of the construct can be assessed and decisions about definitive fixation made.

Plate fixation is usually appropriate for the more comminuted column but it is not always necessary to plate both columns.

The noncomminuted column may be treated with K-wires or cannulated screws. This limits dissection and reduces the bulk of implants.

A plate may be used on the noncomminuted column if additional stability is necessary.

13 m 32 iii and iv

Skeletally mature adolescents

High-energy, multifragmentary fractures may occur in skeletally mature adolescents.

These fractures cannot be adequately stabilized with K-wires alone.

The recommended treatment for a completely unstable, adult pattern fracture, involves two plates at right angles, to provide anatomical reduction and allow early motion.

This treatment is appropriate for the older adolescent and the more unstable comminuted fracture pattern.

Please refer to 13-A3.2 fractures in adult AO Surgery Reference.

open reduction internal fixation

2. Postoperative care

Supracondylar humeral fractures heal rapidly and often within 3-5 weeks.

Immobilization with the elbow in 90° flexion is recommended for fractures treated without pinning.

Immobilization with the elbow in 45°-90° flexion is recommended for fractures treated with intraosseous K-wires.

Analgesia, including ibuprofen and paracetamol, should be administered regularly, with additional oral narcotic medication for breakthrough pain.

splint immobilization

Compartment syndrome

Compartment syndrome is a possible early postoperative complication that may be difficult to diagnose in younger children.

The child should be examined regularly, to ensure finger range of motion is comfortable and adequate.

Neurological and vascular examination should also be performed.

Increasing pain, decreasing range of finger motion, or deteriorating neurovascular signs should prompt consideration of compartment syndrome.

See also the additional material on postoperative infections.

splint immobilization

Discharge care

When the child is discharged from the hospital, the parent/caregiver should be taught how to assess the limb.

They should also be advised to return if there is increased pain or decreased range of finger motion.

It is important to provide parents with the following additional information:

  • The warning signs of compartment syndrome, circulatory problems and neurological deterioration
  • Hospital telephone number
  • Information brochure

For the first few days, the elbow and forearm can be elevated on a pillow, until swelling decreases and comfort returns.

When the limb is comfortable, the child may optionally use a sling to support any splint if desired. Many children are more comfortable without a sling.

splint immobilization

Follow-up x-rays

Control x-rays may be taken at one week following injury to assess fracture position and then at three weeks, out of any splintage, to assess fracture healing.

Removal of cast or splint

Fractures treated by closed reduction with splints, or casts, and fractures treated with closed reduction and percutaneous pinning should have the splintage removed 3 weeks after the injury date.

K-wire removal

Protruding K-wires can be removed in the clinic, without anesthesia.

A simple sling can be provided for comfort.

Recovery of motion

As symptoms recover, the child should be encouraged to remove the sling and begin active movements of the elbow.

The majority of elbow motion is recovered rapidly within the two months after the splint is removed. The older child may take a little longer.

Once the child is comfortable, with a nearly complete range of motion, he/she may resume noncontact sports incrementally. Resumption of unrestricted physical activity is a matter for judgment by the treating surgeon.