Primary Surgery Vol.2 – Trauma: A CHILD’S SUPRACONDYLAR FRACTURE POSTERIORLY DISPLACED

A CHILD’S SUPRACONDYLAR FRACTURE POSTERIORLY DISPLACED

The following description assumes that the child’s fracture is on the right side, and follows Fig. 72-9.

If possible, reduce the fracture immediately. If there am signs of ischaemia this is urgent.

If immediate reduction is impossible because his arm is swollen like a balloon, apply forearm traction as in Fig. 72-11, and reduce the fracture as soon as the swelling has subsided sufficiently for you to feel the fragments. If the skin of his forearm is blistered, so that you cannot apply traction to it, elevate it in a stockinette sleeve or towel pinned together and suspended from a drip stand, as in Fig. 75-1. Reduction is possible up to a week later, but not more.

If the fracture is more than a week old, it will be difficult to manipulate, so leave it. Six months later, if there is a severe deformity, refer him for a corrective osteotomy.

Check his median, ulna, and radial nerves (Fig. 75-3).

ANAESTHETIC (1) intravenous ketamine (A 8.3).(2) General anaesthesia.

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Figure 72.9: REDUCING A SUPRACONDYLAR FRACTURE. The principles of reduction are to exert traction on a child’s elbow and while doing so to correct the sideways displacement of the diatal fragment. Then, flex his arm while still exerting traction, so as to use his biceps tendon to bold the lower fragment in place. Kindly contributed by Peter Bewes.

REDUCTION OF A SUPRACONDYLAR FRACTURE

Flex the child’s normal elbow, feel its bony anatomy carefully, and compare it with his injured elbow. Feeling the bony parts of the injured elbow may be impossible if it is very swollen. Note especially the position of his olecranon in relation to the axis of his humerus. This is a useful guide to satisfactory reduction.

Feel how much external rotation of his flexed elbow is possible on the normal side. Later, when you come to reduce a medially displaced fragment, you will need to rotate his injured forearm externally to the limit of what is possible on the normal side, and a bit more. This external rotation may be critical. Sideways displacement either corrects itself, or is easily corrected.

What happens to his pulse if you flex and exert gentle traction on his arm? If his pulse disappears when you do this and only reappears when his arm is nearly straight, it may merely be due to the swelling round his elbow, or he may have a brachial artery lesion.

DIAGRAM A, REDUCING A SUPRACONDYLAR FRACTURE

Steady the child’s shoulder. Ask your assistant to hold it by passing a towel round it (1). Pull to disimpact the fracture and correct angulation Extend the child’s elbow gently. Grip his wrist and distal forearm. Pull hard in a longitudinal direction for at least 1 minute by the clock (2). You will feel the fragments disimpact and release the soft tissues trapped between them. Check that you have disimpacted them by feeling that the lower fragment is free.

DIAGRAM B, REDUCING A SUPRACONDYLAR FRACTURE

Correcting medial and lateral displacement. The distal fragment is usually displaced medially. Traction usually corrects this. If it does not, now is the time to try to correct it. Feel the distal fragment, although the child’s elbow may be so swollen that this is impossible. If necessary, move the distal fragment towards the midline of his arm (2a).

DIAGRAM C, REDUCING A SUPRACONDYLAR FRACTURE

Correct the posterior displacement. While still exerting longitudinal traction with your right hand (3), press the olecranon with your thumb (4).

Begin flexing (5) with your thumb pressing on his olecranon. Do this while your assistant maintains traction in the child’s axilla. Keep pressing his olecranon with your left thumb as you do so. Externally rotate his forearm a little more than was possible on the normal side. This will help to restore the normal carrying angle.

Continue flexing. As the child’s arm reaches 90 $\ensuremath{^\circ }$ , pull posteriorly on his humerus, and anteriorly on his forearm.

CAUTION! Use only moderate tension as his arm reaches 90 $\ensuremath{^\circ }$ . If you pull too hard at this stage, it is possible to pull the distal fragment in front of the end of the humerus. Fortunately this is rare.

DIAGRAM D, REDUCING A SUPRACONDYLAR FRACTURE

Complete flexing. Beyond 90 $\ensuremath{^\circ }$ further flexion does not improve reduction, but it does stabilize reduction by wrapping the child’s triceps tendon round the distal fragment and fixing it. This also impacts the fragments. Lateral displacement of the distal fragment cannot now be corrected.

The position of the point of the olecranon is the best guide to satisfactory reduction. It should be in line with the axis of the humerus or perhaps little anterior to it (8). You should also be able to feel both epicondyles forming, with the tip of the olecranon, the 3 bony points of the elbow in A, Fig. 72-2.

DIAGRAMS E, F and G, REDUCING A SUPRACONDYLAR FRACTURE

Check the child’s pulse (7). This may be difficult because of oedema. If his pulse disappears when you flex his arm, extend it until his pulse reappears.

If he has a good radial pulse, put his arm in a collar and cuff in as much flexion as his pulse will allow. His hand should be able to reach his mouth. If you cannot feel his pulse, extend his elbow until you can free it. Make a cuff out of two lengths of stockinette filled with cotton wool (8).

If you cannot get his arm beyond 70 $\ensuremath{^\circ }$ without his pulse disappearing put him in forearm traction (Fig. 72-11), as described below.

If you are not sure if you can feel his pulse or not, don’t worry for the moment. But immediately he wakes from the anaesthetic, ask him if he can flex his fingers. If he cannot do this, proceed as in Section 72.8.

CAUTION! (1) Make the knot of the collar and cuff so secure that neither the child, nor his parents, nor his grandparents can remove it. A good way to secure it is to cover it with plaster. Provided there are no complications, it will need to stay on for 3 weeks. In whatever way the child twists and turns, he must not be able to extend his elbow more than 90 $\ensuremath{^\circ }$ or reduction will be lost. (2) Don’t fit a plaster backslab, it is unnecessary and make it difficult to flex his elbow sufficiently.

As soon as he awakes, make sure he can flex and extend his fingers. Check the function of his median and ulnar nerves. They may be injured, but they usually recover eventually.

CHECK REDUCTION The post reduction X–rays are of less help than they might be in seeing if angulation has been successfully reduced or not, because: (1) the child’s arm must be kept flexed after reduction, and (2) the centres of ossification in the lower fragment may still be small. However, do your best by the the X–ray criteria in Fig. 72-10. If they are not met, have one further attempt at reduction, not more, or you will damage the child’s elbow, and increase the chances of post–traumatic ossification.

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Figure 72.10: CHECKING THE REDUCTION OF A SUPRACONDYLAR FRACTURE. A, the post reduction X–ray; This is schematic only and is from an older patient. B, positioning the arm and the film to take the X–ray. Don’t let the X–ray assistant remove the child’s collar and cuff to X–ray his arm. Take a lateral X-ray, and an AP view through the point of his elbow as shown: (1) There should be no angulation of the lower fragment in the AP view, (2) There should be no significant forward bowing in the lateral view. (3) The fragments must be in contact. If these criteria are met, reduction is satisfactory. Sideways and posterior displacement are not important.

PREVENT ISCHAEMIC PARALYSIS Don’t send the child home because he may return with an irreversible Volkmann’s contracture! Admit him to the ward and monitor the circulation in his hand carefully for 36 hours. Watch him for early signs of ischaemia. Check his pulse, and then press on his nail beds and see how quickly his capillaries refill. The first signs of ischaemic paralysis are: (1) pain on passive extension of his fingers, (2) paraesthesiae (3) pallor, and (4) paralysis as shown by the inability to use his fingers.

Make sure the ward staff know why they are monitoring the child’s circulation and what signs they should watch for. If they don’t know this, they may be quite content to feel the pulse in his normal arm!

CAUTION! Don’t give him morphine or any analgesic until you are sure that ischaemia is no longer a danger.

POSTOPERATIVE CARE AFTER REDUCING A SUPRACONDYLAR FRACTURE

If you have to reduce the flexion of a child’s elbow, because of his impaired circulation, flex it again as his swollen elbow recovers. Then, X–ray him again.

Keep his collar and cuff on for 3 weeks. Don’t let him take it off during this period. Make sure his parents understand this.

At 3 weeks his fracture will have united, so remove his collar and cuff, and replace it by a sling for 3 more weeks.

If, when you remove his collar and cuff, he ceases to be able to touch his mouth, replace it, and gradually tighten it until he can.

His elbow will be stiff for a long time. Encourage him to use it, but let movement return on its own, using its own active movements. Even when movement is slow to return, you can assure his mother that it will be better at the end of a year.

CAUTION! (1) Forceful passive movements will make the stiffness worse. (2) Don’t try to straighten his elbow by making him carry weights.

DON’T SEND HIM HOME FOR 36 HOURS AFTER REDUCTION