Cutting edge Orthopedics

Supracondylar Humerus Fractures • 19  Postoperative Care Following CRPP, the patient is observed overnight with neurovascular checks every 4–6 h, and the arm is elevated [8, 9, 19]. Non-sedating analgesics are preferred with nonnarcotic medica- tions, such as acetaminophen or ibuprofen, which are usually sufficient after CRPP. Evolving com- partment syndrome is typically marked by excessive swelling, change in the neurovascular exam, Fig. 16: Clinical photograph depicting the use of “pin caps” to aid in preventing pin migration (Courtesy of Shriners Hospital for Children, Philadelphia, PA). 51 P stoperative Care Following CRPP, the patient is obs rved over- night with neurovascular checks every 4–6 h, and the arm is elevated [ 8 , 9 , 19 ]. Non-sedating anal- gesics are preferred with nonnarcotic medica- tions, such as acetaminophen or ibuprofen, which are usually sufficient after CRPP. Evolving com- partment syndrome is typically marked by exces- has been maintained; however, according to a study performed by Tuomilehto and colleagues (2016), postoperative radiographs did not affect management or outcome [ 78 ]. The original splint or cast may be left in place, or a long-arm cast may be applied. Three weeks following the procedure, the splint or cast is removed for radio- graphs. If abundant callous formation is demon- strated, the pins may be removed [ 8 , 9 , 19 ]. In the absence of sufficient callous formation, a new cast is applied, and the pins are left in place for another week. After 4 weeks, if abundant callous forma- tion is still not present, the pins are removed and a cast is reapplied. Inadequate healing in a child for more than 6 weeks raises concern for infection [ 9 ]. After the pins are removed, a sling may be used for comfort, but active elbow motion is initi- ated. Children may be seen in the office 2–3 weeks later for a range of motion check [ 8 , 9 , 19 ]. Normal activities are generally sufficient for return of range of motion within approximately 4–9 weeks [ 51 , 52 ]. Comparable range of motion outcomes are expected at 1 year with or without physical therapy [ 53 ], and formal therapy is rarely required [ 8 , 9 , 52 , 53 ]. Alternative Pin Constructs The optimal pin configuration for fix tion of supr condylar humerus fractures remains ontro- versial. Both lateral-entry pins alone and cross pin constructs are utilized [ 79 ]. In the 2011 Clinical Practice Guideline of the American Academy of Orthopaedic Surgeons, a weak rec- ommendation stated that “the practitioner might use two or three laterally introduced pins to stabi- Fig. 4.16 Clinical photograph depicting the use of “pin caps” to aid in preventing pin migration (Courtesy of Shriners Hospital for Children, Philadelphia, PA) 4 Supracondylar Humerus Fractures intraoperatively with varus, valgus, flexion, extension, and rotary forces (Video 4.3) [ 9 ]. If any instability or excessive motion at the fracture site is noted, an additional lateral pin may be added. If there is not enough space for another lateral pin or medial column comminution is present, a medial pin may be placed. If a medial pin is needed, a small incision should be made over the medial epicondyle. Blunt dissection down to the bone is performed. With the elbow extended, the pin is placed into the cortex of the medial epicondyle under direct visualization. The pin is directed laterally across the fracture site in a slight posterior to anterior direction. The pin entry point is visualized during flexion and extension of the elbow to ensure that there is no tethering of the ulnar nerve. Once the fracture is stable to stress testing under fluoroscopy (Video 4.3) and pulses are verified to be intact, the pins are bent and cut outside the skin [ 8 , 9 ]. The pins may be wrapped in Xeroform, an antimicrobial gauze, or fitted with pin caps (Fig. 4.16 ) which have been sug- gested to help prevent pin migration [ 8 ]. The limb is then splinted or casted in approximately 45°–80° of elbow flexion [ 8 , 9 , 19 ]. Fig. 4.15 Proper pin placement for two and three lateral- entry pin constructs (Courtesy of Dan A. Zlotolow, MD) Fig. 15: Proper pin placement for two and three lateral-entry pin constructs (Courtesy of Dan A. Zlotol w, MD).