Cutting edge Orthopedics

Supracondylar Humerus Fractures • 15  tissue damage should be treated more urgently [9, 14, 68–70, 72, 74]. Additionally, children who are unable to provide a reliable physical exam, i.e., very young age, cognitive disability, complete median nerve palsy, etc., should be treated emergently as the ability to detect developing com- partment syndrome is compromised [14]. Supracondylar humerus fractures with the following characteristics should be considered for emergent management: open fracture, dysvascular limb, skin puckering, floating elbow, median nerve palsy, evolving compartment syndrome, young age, and cognitive disability [14] (Table 2). Technique Closed reduction and percutaneous pinning are performed under general anesthesia in the oper- ating room. Preoperative antibiotics are administered, and the patient is positioned supine on the operating room table at the edge of the table on the injured side. The fluoroscopy unit is inverted to allow the image intensifier to serve as a hand table, and the monitor is positioned on the oppo- site side of the operating room table to facilitate ease of viewing intraoperative images (Fig. 12) [9, 34]. A traditional hand table setup allows for rotation of the C-arm rather than the patient’s limb, which may be useful for avoiding loss of reduction with rotation, particularly for unstable fractures [8, 19]. The upper arms of children under age 3 may be too short to permit the elbow to be centered over the image intensifier. In this case, a hand table is recommended so that the patient’s head may be positioned over the indentation between the hand table and the operating room table to facilitate imaging of the elbow without inadvertently pulling the child’s head off the table [8, 19]. The patient’s extremity is then sterilely prepared and draped from hand to axilla utilizing a fully sterile or semi-sterile setup according to surgeon preference [9]. The semi-sterile tech- nique saves time, hospital expenses, and medical waste (Video 1). For extension-type fractures, a “milking maneuver” along the upper arm in a proximal to distal direction is performed first (Video 2). The purpose of this maneuver is to disengage the brachialis and biceps brachii muscle fibers from the distal spike of the proximal fragment [8, 9, 19]. The proximal upper arm is then Table 2: Exam findings that indicate consideration of emergent management for supracondylar humerus fractures. Exam findings Open fracture Dysvascular limb (white, absolute; pink pulseless, relative) Floating elbow Skin puckering Evolving compartment syndrome Median/AIN nerve palsy Unreliable exam (young age, cognitive disability, etc.)