Primary Surgery Vol.2 – Trauma: SUPRACONDYLAR FRACTURES OF THE HUMERUS IN ADULTS

SUPRACONDYLAR FRACTURES OF THE HUMERUS IN ADULTS

INDICATIONS FOR REFERRAL (1) If the lower end of the patient’s humerus is in one or two fragments only, and you can refer him to a superb technician, he may benefit from internal fixation, especially if he is young. (2) Injuries to his median or ulnar nerves.

TRANSVERSE SUPRACONDYLAR FRACTURES

If the lower fragment is in one piece, treat it as for a child’s supracondylar fracture (72.6).

T–SHAPED, Y–SHAPED, OR COMMINUTED SUPRACONDYLAR FRACTURES

EARLY ACTIVE MOVEMENTS if necessary, anaesthetize the patient and try to get the fragments into a better position. Try to start active movements as soon as possible. If his arm is very swollen keep it raised for a few days. Put his arm in a collar and cuff for not more than a week. During this time take it out several times a day and encourage him to move it.

CAUTION! (1) FlexIon and extension are subsequently likely to be limited, so make sure they are in the most useful range, as in Fig. 72-13. (2) For the same reason his forearm should be in mid–pronation.

Start pendulum exercises for his shoulder (Fig 71-7), and exercises for his wrist and fingers immediately after the injury.

After a week, provided he continues to be able to put his hand to his mouth, put his arm in a sling. Keep him in the sling for 5 weeks. Encourage him to use his hand and move his elbow as much as he can. Tell him that he will not regain any movement in his elbow unless he tries very hard to use it.

OLECRANON TRACTION If the patient’s olecranon is intact, pass a Kirschner wire through it (70.10), and tension the wire with a Gissane stirrup (1), or, less satisfactorily, use a thin (less than 4 mm) Steinmann pin. The danger with a pin is that it is more likely to get in the way of his ulnar nerve. If the fragments are displaced, ask an assistant to exert traction on the stirrup while you press the fragments back into place (2).

Apply enough traction to keep his upper arm under tension (3) but not enough to lift his shoulder off the mattress. You may need to apply 2 to 5 kg.

Apply a sling (4) to keep his elbow at 90 $\ensuremath{^ \circ }$ and his wrist half–way between pronation and supinaton, with his hand over his opposite shoulder.

Apply 0.5 to 1 kg of backward traction on his upper arm (5). This is not essential.

Feel the bony prominences on the back of his elbow (6) and adjust the direction of traction so that the position of the prominences matches that on the normal side, and corrects any sideways shift. You may have to tie the traction cord to one of the outer holes in the stirrup (7).

CAUTION! Check his radial pulse often. Don’t apply too much traction, or you may obstruct the circulation to his arm, injure his nerves, or distract the fragments and so prevent union.

X–ray him. Slight backward displacement is acceptable, but there should be no angulation or lateral displacement.

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Figure 72.15: INJURIES OF THE DISTAL HUMERAL EPIPHYSES. The medial epicondyle and lateral condyle differ considerably. A, The lateral condyle is a pressure epiphysis to which the common extensor origin is attached. It is fractured in young children. The fracture line enters the joint displacing the centre for the capitulum and sometimes part of the shaft. The displaced fragment must be accurately replaced. B, the medial epicondyle is a traction epiphysis outside the elbow joint to which the common flexor origin is attached. It is displaced in teenagers, and unless it happens to go inside the elbow joint it need not be removed or reattached.

While he is in traction, encourage him to move his elbow as much as he can. Let him take hold of the traction cord and assist his elbow movements himself.

Remove the traction at 2 to 3 weeks, put his arm in a sling with his elbow at 90 $\ensuremath{^\circ }$ and his forearm in 45 $\ensuremath{^\circ }$ of pronation. Start carefully graded active movements without using force. Recovery will take several months.

DIFFICULTIES WITH SUPRACONDYLAR FRACTURES IN ADULTS

If a patient’s HUMERUS IS BADLY COMMINUTED AND OPEN, AND HIS RADIUS AND ULNA ARE INJURED TOO, this is likely to be the result of a car accident in which he had his elbow over the edge of the window. Toilet his wound. If his elbow is dislocated, reduce it. Suspend his arm in the position of function, and get it moving. Dress it, but do not close it by primary suture. Look at it in 4 or 5 days, and either close it or graft it. (1) Hang it up with metacarpal Kirschner wire (70.12), or (2) use skin traction on his fingers while watching their circulation carefully. Hang his hand up in the same position as for forearm traction.