Cutting edge Orthopedics

16 • CUTTING EDGE - ORTHOPEDICS stabilized, while longitudinal traction and elbow flexion are performed (Video 2) [8, 9, 19]. For severely displaced fractures, traction with the elbow flexed approximately 20° can be held for approximately 1 min to gain compliance of the local soft tissue [9, 19]. Keeping the elbow slightly flexed helps avoid stretching the brachial artery and median nerve across the proximal fracture fragment [19]. The reduction maneuver can also be assisted by placing one’s thumb on the olecra- non and pushing anteriorly [8, 19]. Pronation or supination of the forearm may also be beneficial [9, 34]. Pronation may help with reduction of fractures that have posteromedial displacement [19, 34], whereas supination may help with reduction of fractures that have posterolateral dis- placement [34]. Once correction in the sagittal plane is achieved, the coronal alignment should be addressed. The proximal segment is stabilized, and the distal fragment is grasped between the thumb and index fingers to allow manipulation in the coronal plane [9, 19]. After the reduction maneuvers have been performed, the elbow should be held in hyperflexion to maintain alignment and assess the reduction. Clinically, an adequate reduction can be gauged by checking to see if the fingers touch the shoulder [8, 19]. Additionally, restoration of an isosceles triangle between the olecranon process of the ulna and the medial and lateral epicondyles of the humerus indicates an adequate reduc- tion (Fig. 13) [34]. Radiographic confirmation of anatomic reduction is also essential. A “shoot- through” AP, or Jones view, of the distal humerus is taken with the elbow in hyperflexion to evaluate Baumann’s angle and coronal plane alignment. Baumann’s angle should be 10° or greater [5, 8, 19]. If residual varus or valgus angulation is present, the reduction maneuver should be attempted again. Minimal translation without rotation may be accepted. Once an adequate reduction is obtained, the elbow should be stabilized and maintained in the hyperflexed positon, while the upper arm is externally rotated at the glenohumeral joint (Video 2). This facilitates performance of a lateral radiograph without displacing the fracture. If the fracture appears to be especially unstable, one should consider rotating the C-arm rather than the patient’s arm. A lateral view of Fig. 12: The image intensifier may be used as a hand table. Additionally, positioning the fluoroscopy monitor on the opposite side of the operating room table facilitates review of the intraoperative images while performing the procedure. The upper arm is stabilized at the axilla, while longitudinal traction and slow elbow flexion are performed (Courtesy of Shriners Hospital for Children, Philadelphia, PA). a “milking m neuver” along the in a proximal to distal direction is first (Video 4.2). The purpose of uver is to disengage the brachialis brachii muscle fibers from the dis- f the proximal fragment [ 8 , 9 , 19 ]. mal upper arm is then stabilized, itudinal traction and elbow flexion rmed (Video 4.2) [ 8 , 9 , 19 ]. For isplaced fractures, traction with the ed approximately 20° can be held imately 1 min to gain compliance of oft tissue [ 9 , 19 ]. Keeping the elbow exed helps avoid stretching the bra- y and median nerve across the prox- ture fragment [ 19 ]. The reduction can also be assisted by placing one’s the olecranon and pushing anteriorly onation or supination of the forearm be beneficial [ 9 , 34 ]. Pronation may reduction of fractures that have pos- l displacement [ 19 , 34 ], whereas may help wit reduction of frac- have posterolateral displacement e correction in the sagittal plane is achieved, the coro al alignment should be addr ssed. The proximal segment is stabilized, and the distal fragment is grasped between the thumb and index fingers to allow manipulation in the coronal plane [ 9 , 19 ]. After the reduc- tion maneuv rs have been p rformed, the elbow should be held in hyperflexion to main- tain alignment and assess the reduction. Clinically, an adequate reduction can be gauged by checking to see if the f ngers touch the shoulder [ 8 , 19 ]. Additionally, restoration of an isosceles triangle between the olecranon process of the ulna and the medial and lateral picondyles of the h merus indicates an ade- quate reduction (Fig. 4.13 ) [ 34 ]. Radiographic confirmation of anatomic reduction is also essential. A “shoot-through” AP, or Jones view, of the distal humerus is taken with the elbow in hyperf exion evaluate B umann’s angle d coronal plane alignment. Baumann’s angle should be 10° or greater [ 5 , 8 , 19 ]. If residual varus or valgus angulation is present, the reduction maneuver sho ld be attempted again. Minimal translation without rotation may be accepted. Once an adequate reduction he image ay be used le. , positioning py monitor ite side of room table view of the e images ming the he upper ized at the longitudinal slow elbow erformed Shriners Children, , PA) S.A. Russo and J.M. Abzug