Occult supracondylar fracture treatment11/28/2023 ![]() ![]() In the majority of cases the pulse will return within 24-hours of the injury. Most surgeons recommend urgent closed reduction and pinning followed by a period of close observation rather than openly exploring the injury. ![]() Ī “ pink, pulseless hand” on examination presents a further area of controversy as although the pulse is absent, clinically the hand appears warm and pink with a normal capillary refill time and hence is evidently well perfused. Therefore, it is recommended that surgery should be done on a scheduled trauma list in daylight hours as soon as is safe and practicable to proceed. This is still the case when neurovascular injury is suspected, or if the fracture is open, however in fractures without significant soft tissue injury or neurovascular compromise, recent evidence has demonstrated no significant difference in peri-operative complications or open reduction rates in children undergoing early versus late surgical treatment. Regarding timing of surgery, displaced supracondylar humeral fractures were traditionally considered an orthopaedic emergency requiring immediate operative intervention. Although biomechanically less stable, when performed correctly, the technique provides sufficient fixation stability with similar clinical results, without the risk of iatrogenic ulnar nerve injury. Thus, an alternative of two pins placed from a lateral position was advocated to avoid injuring the nerve. However, it carries the disadvantage of an increased risk of iatrogenic ulnar nerve injury, estimated to occur in 1 in 28 patients, due to the course of the nerve posterior to the medial epicondyle and the fact that the wire is usually placed with the elbow in deep flexion, when in some patients, the ulnar nerve subluxates anteriorly. Early descriptions of percutaneous pinning advocating a medial and lateral cross pin-configuration following closed reduction were described by Swenson and is proffered as being more biomechanically stable than two lateral pins. ![]() unable to reduce fracture closed, open injury, associated neurovascular injury).Ĭlosed reduction and percutaneous pinning can be achieved using different pin-configurations and is historically a controversial area. Therefore Grade 2b and 3 injuries are managed surgically with closed reduction and percutaneous pinning +/- open reduction when required ( e.g. Success with elevated straight arm traction has been shown in some specialist centres, but is not widely used and pragmatically speaking, surgical management to reduce and secure fractures anatomically has generally provided superior results compared with non-operative management with both open and closed methods advocated. Grade 2a fractures, with no evidence of rotation, and an anterior humeral line that still intersects any part of the capitellar ossification centre can be managed the same way.Ĭonservative management of significantly displaced or rotated fractures is usually not advised due to high complication rates. Grade 1 injuries with no or minimal displacement are managed non-operatively in a long arm cast in 90-100 degrees of flexion for 3-4 weeks. ![]()
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