Full Chapter Flashcards
What is a risk factor for the development of compartment syndrome after a supracondylar fracture?
Excessive swelling combined with delay in treatment.
What is one initial step in managing a suspected evolving compartment syndrome?
Removing all circumferential dressings.
According to Battaglia et al., what is the relationship between elbow flexion and volar compartment pressure?
Increasing elbow flexion above 90 degrees increases volar compartment pressure.
What is recommended for immediate stabilization in cases of suspected compartment syndrome after a fracture?
Stabilization with Kirschner wires to allow proper management of soft tissues.
How does warm ischemic time after injury contribute to the development of compartment syndrome?
Muscle ischemia is possible, depending on the time of oxygen deprivation.
When should prophylactic volar compartment fasciotomy be considered?
It can be considered at the time of arterial reconstruction.
What was found to be of some value even when the diagnosis of compartment syndrome is delayed or chronic?
Fasciotomy.
What suggests critical ischemia in a child with a ‘pink pulseless hand’ following fracture reduction?
Persistent and increasing pain.
What is the most common nerve injury in extension-type supracondylar fractures?
AIN (5%).
What nerve injuries were reported in the largest single-center study of type III supracondylar fractures?
12% nerve injuries at presentation, with a rate of 19% if associated forearm fracture required reduction.
What does a prospective study on nerve injuries in operatively treated supracondylar fractures suggest?
A trend between fracture severity and rate of preoperative nerve injury.
What was seen in the same study regarding the relationship between fracture severity and nerve injury rate?
Type II 7%, type III 19%, type IV 36%.
What potential nerve entrapment issue may occur during reduction of supracondylar fractures?
Median nerve and/or brachial artery may be trapped within the fracture site.
What technique is used to forcibly milk the biceps during the reduction of fractures?
“Milking maneuver” is used to force biceps past the proximal fragment.
How many pins are generally recommended for type II and type III fractures?
A minimum of two pins for type II fractures and three pins for type III fractures.
What is more critical in pin placement for fractures, pin separation, or pin orientation?
Pin separation is more important than whether the pins are divergent or parallel.
What should be ensured to correctly place a pin for fracture fixation?
Ensure the pin goes through the proximal cortex and engages the proximal fragment.
What should be done to verify the correct placement of K-wires before advancing with drilling?
Push K-wires into the cartilage in desired location and trajectory, verify with imaging.
What is the recommended elbow position during fixation to improve stabilization?
The elbow should be sufficiently flexed so that the fingers touch the shoulder.
What is the alternative approach if maintaining fracture reduction becomes difficult during imaging?
Move the C-arm instead of the patient’s arm during imaging.
In what instance would a medial pin be considered in fracture stabilization?
If three lateral pins do not stabilize the fracture, or there is an oblique fracture pattern.
What precaution should be taken when placing a medial pin to avoid nerve damage?
Extend the elbow when placing the pin to keep the ulnar nerve posteriorly out of harm’s way.
Why is it recommended to save images where reduction looks the worst postoperatively?
To compare during visits and determine if any movement or malreduction occurred.
What are the considerations for treating SCH fractures nonsurgically?
Likelihood of follow-up with an orthopedic surgeon for timely rereduction.
How does insurance status impact follow-up rates for SCH fractures?
Children with public or no insurance are almost three times less likely to follow up.
What are the results of closed reduction and percutaneous pinning for type II fractures?
No radiographic or clinical loss of reduction, cubitus varus, hyperextension, or loss of motion.
What are the reported complications of closed reduction and percutaneous pinning for type II fractures?
2% pin-tract infections, successfully treated with antibiotics and limited surgical interventions.
Why is operative treatment advocated for type II SCH fractures?
Hyperflexion needed for reduction in unpinned fractures raises compartment pressure risk.
What is the role of flexion in maintaining reduction for SCH fractures?
Elbow flexion >90 degrees increases neurovascular compromise risk; should be immobilized with pins.
Why is pinning recommended for type III SCH fractures?
Operative reduction and pinning produce better results compared to non-surgical methods.
What role does the periosteum play in extension-type SCH fractures?
The intact posterior periosteal hinge provides stability and facilitates fracture reduction.
Why should flexion of the elbow be limited for type III fractures?
Flexion up to 90 degrees increases risk of compartment syndrome, requires caution.
O que deve ser colocado primeiro antes de usar um pino medial?
Lateral pins
Por que razão o pino medial deve ser colocado sem hiperflexão do cotovelo?
To avoid hyperflexion of the elbow
De acordo com estudos biomecânicos, qual configuração de pino foi encontrada como mais forte do que dois pinos laterais?
Crossed pins
How should lateral pins be separated at the fracture site for optimal stability?
Clinically recommended to be separated at the fracture site
Nos estudos de Lee et al., qual técnica de fixação foi considerada superior em carga de extensão e varo?
Divergent: two divergent lateral pins
Bloom reportou que a força de três pinos divergentes de entrada lateral é superior à da travagem cruzada.
Three lateral entry divergent pins were equivalent and stronger
A maioria dos estudos biomecânicos contemporâneos apoia principalmente a configuração de pinos transversais para fixação de fraturas.
Lateral entry pins
Quais são os pontos técnicos importantes para a fixação com pinos de entrada lateral de acordo com uma série bem-sucedida de fraturas?
Maximize pin separation, engage medial and lateral columns, engage sufficient bone, consider a third pin for stability, use three pins for type III fractures
What were the identified pin-fixation errors by Sankar et al. that led to loss of fixation?
Failure to engage both fragments, failure to achieve bicortical fixation, failure to achieve adequate pin separation
Quais equipamentos são comumente usados na redução fechada e na fixação percutânea?
0.062-in smooth K-wires, sterile coban, sterile felt, sterile foam
Como deve o paciente ser posicionado para redução fechada e fixação percutânea?
Supine on the operating table with fractured elbow on a short radiolucent arm board
Quais são alguns passos cirúrgicos chave na redução fechada e fixação percutânea?
Prep and drape, traction, fracture reduction, check reduction, place K-wires, place pins, bend and cut wires
How should the elbow be positioned during traction to avoid tethering neurovascular structures?
Flexed at about 20 degrees
How long should significant traction be held for badly displaced fractures to allow soft tissue realignment?
60 seconds
How is varus and valgus angular alignment corrected in closed reduction and percutaneous pinning?
By movement of the forearm with the elbow almost straight
How is medial and lateral fracture translation realigned in closed reduction and percutaneous pinning?
With direct movement of the distal fragment by the surgeon with image confirmation
What should be allowed for recovery of perfusion in the operating room before deciding to explore the brachial artery?
Up to 10 to 15 minutes.
Why is the absence of a pulse alone not an indication for exploring a brachial artery?
Most patients without a palpable pulse regain and maintain adequate distal perfusion.
What is imperative for hand viability in cases of poorly perfused hands?
Exploration is imperative for all poorly perfused hands.
What is the risk associated with prolonged poor or absent pulse and poor perfusion during fracture reduction?
High risk of compartment syndrome.
What should be considered in cases of poor limb perfusion lasting over 6 hours?
Prophylactic forearm compartment release should be considered.
What should be done if a pulseless hand remains poorly perfused following reduction and pinning?
Arterial exploration should be performed emergently.
What measures may relieve associated arterial spasm following freeing the artery from the fracture?
Application of lidocaine, warming, and 10 to 15 minutes of observation.
What is indicated if the hand remains poorly perfused after anatomic fracture reduction and decompression of the NVB?
Vascular reconstruction by an appropriate specialist.
What is recommended if a pulse does not return but the hand is well perfused post-reduction?
Admitting the child to the hospital with observation for at least 48 hours.
What is considered as an objective sign of good perfusion in the context of a well-perfused yet pulseless hand?
Presence of a triphasic pulse detectable on Doppler.
Why is it recommended to take a true AP view of the distal humerus during radiographic examination of elbow fractures in children?
To allow a more accurate evaluation of the distal humerus and decrease errors in determining Baumann’s angle.
What percentage of accuracy has been reported for emergency room physicians’ interpretation of elbow fractures in children?
53%
What is the significance of the lateral film being taken as a true lateral during radiographic examination of elbow fractures?
It helps with accurate evaluation without external rotation, especially in determining Baumann’s angle.
When should oblique views of the distal humerus be taken during radiographic examination of elbow fractures in children?
Occasionally when supracondylar or occult condylar fractures are suspected but not seen on standard views.
What are the main radiographic parameters used to evaluate the presence of a supracondylar fracture?
The anterior humeral line (AHL) crossing the capitellum on a true lateral of the elbow.
What is the normal range for Baumann’s angle, also known as the humeral capitellar angle?
About 9 to 26 degrees.
How does the anterior humeral line (AHL) differ in children under 10 years of age compared to children 5 years and older?
In children under 10, AHL only passes through the capitellum’s middle third 52% of the time, while in children 5 and older, it should always pass through the center.
How should supracondylar fractures be initially splinted?
With the elbow in a comfortable position of 20 to 40 degrees flexion.
What action may restore a pulse if the arm is pulseless?
Gentle traction and elbow flexion alone may frequently restore a pulse.
What complications may arise from excessive flexion or extension of the elbow during splinting?
Compromise of the limb’s vascularity and increased compartment pressure.
What is the recommended position for the elbow and hand after initial splinting?
They should be gently elevated above the heart.
According to the course notes, what percentage of Pediatric Orthopaedic Society members would treat a type III supracondylar humerus fracture by splinting overnight if there were no emergent issues?
81% would treat by splinting overnight and fixing the following morning.
In the study by Larson et al., what percentage of type II supracondylar fractures had surgery more than 24 hours after injury?
52% had surgery more than 24 hours after injury.
When is operative treatment not unduly delayed for supracondylar fractures according to the notes?
It should not be unduly delayed if poor perfusion, pulselessness, firm compartments, etc., are present.
What timing for operative treatment of type II supracondylar fractures did Larson et al. find did not affect outcome?
Timing for operative treatment did not affect outcome.
What did Silva et al. find regarding closed reduction of type II supracondylar fractures treated 7 to 15 days after injury?
They found that closed anatomic reduction was achieved with equal outcomes to fractures treated within 7 days of injury.
Why is reliable fracture reduction after 2 weeks less likely in very young children?
Due to early callus formation making reduction less likely.
How is perfusion evaluated post-fracture reduction in the operating room?
Skin color is evaluated and a Doppler is used to assess for a triphasic pulse.
What symptoms indicate avascular necrosis of the trochlea?
Mild pain, occasional locking, radiologic findings, and limited motion.
What criteria indicate an acceptable reduction in supracondylar fractures?
Restoration of Baumann’s angle, intact medial and lateral columns, and appropriate alignment of the AHL.
What deformity is described as ‘gunstock deformity’?
Cubitus varus.
Describe the appearance of cubitus varus deformity on x-ray according to the notes.
Angle of the physis of the lateral condyle (Baumann’s angle) is more horizontal on the AP view.
What is Metev’s sign?
The appearance of a hole in the bone due to chronic nerve entrapment in healed callus.
