6. Alternative: Inside–out technique for indirect reduction and fixation
As the fragment is covered by the muscle/ligament attachment, after digital reduction it may be difficult to localize the center and the deepest part of the fragment. Therefore there is a risk of inadequate fixation or even splitting of the fragment.
A safe and straight forward inside-out technique is useful, guaranteeing that the fragment is always fixed via its strongest part.
The reduction is then performed indirectly and fixed with a lag screw (preferable cannulated).
Note: Even though the reduction may not be anatomical, with a small step in the fracture surface, the main goal of stable and safe fixation has been achieved. This allows early functional postoperative management.
Both the fracture surfaces are debrided and the fracture hematoma is washed out.
It is not absolutely necessary to expose the ulnar nerve unless it is trapped within the fracture.
A hole is made in the center of the metaphyseal surface using a 1.6 or 2.0 mm K-wire (or a 2.0 or 2.5 mm drill) within the ulnar column, as illustrated.
The epicondylar fragment is held digitally and a hole is similarly created through the center of the fracture surface from inside out, as illustrated.
As the bone of this fragment can be hard and sometimes also very small, it is safer to make the hole a little larger, using a 2.5 mm drill. This prevents splitting of the fragment when the lag screw is inserted.
A guide wire for a cannulated lag screw is then inserted by hand from inside-out leading with the pointed tip.
The blunt end of the K-wire is then introduced into the metaphyseal hole and the fragment is pushed along the guidewire into a reduced position.
An appropriate screw, depending on the fragment size, is then passed over the guide wire and driven home.
As the screw is finally tightened, the fragment is held to prevent its rotating.
7. Immobilization and implant removal
If the child remains for some hours/days in bed, the elbow should be elevated on pillows to reduce swelling and pain.
Early motion is preferred. After elbow dislocation, a removable posterior splint is worn. The parents/carers can then take this off from time to time for gentle active elbow motion, once the child is comfortable.
If intraoperative radiographic documentation of the fixation is not possible, an x-ray is taken before the child is discharged
Discharge from hospital according to local protocol
Healing control by x-ray undertaken 4–5 weeks postoperative
Implants are removed, if desired, according to local practice.
8. 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.
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.
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
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.
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.
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.