Cutting edge Orthopedics

24 • CUTTING EDGE - ORTHOPEDICS Technique The anterior approach to the antecubital fossa is best suited for open reduction of supracondylar humerus fractures [8, 9, 19]. A 4–5 cm transverse incision is made across the antecubital fossa [8, 9, 19, 25]. Alternatively, a “lazy S” incision can be made obliquely across the antecubital fossa with proximal and distal longitudinal extensions [9]. Following the skin incision, dissection through the dermis and bicipital aponeurosis is carefully performed to avoid injury to the neurovascu- lar structures that may be stretched over the distal spike of the proximal fracture fragment. The median nerve and brachial artery should be identified and sufficiently dissected to determine if they are entrapped at the fracture site in any way. The neurovascular structures are retracted, and any soft tissue within the fracture site, which may include brachialis muscle or fascial tissue of the biceps, must be removed. This facilitates anatomic reduction of the fracture fragments. The fracture is held reduced, bone forceps may be used to assist, while the pins are placed to maintain the reduction. The same pinning technique described in the "Closed Reduction and Percutaneous Pinning" section is utilized. Following pin placement, any neurovascular injuries are assessed. If the limb was dysvascular preoperatively and remains dysvascular, the brachial artery should be explored. Direct repair or venous bypass grafting may be required. Given the small caliber of the vessels in this patient population, a surgeon trained in microsurgery or pediatric vascular surgery is ideal for the vascular reconstruction. In cases with documented ischemia time greater than 6–8 h, prophylactic forearm fasciotomies should be performed along with revascularization [9]. Postoperative care is performed as described in the "Closed Reduction and Percutaneous Pinning" section except 24 h of postoperative antibiotics should be given. Complications Vascular Injury Loss of pulses or perfusion following CRPP suggests entrapment of the brachial artery in the frac- ture site. The pins should be removed, and the brachial artery should be explored as discussed in the "Open Reduction and Pinning" section. Compartment Syndrome Compartment syndrome occurs in approximately 0.1–0.5% of isolated supracondylar humerus fractures [38, 39]. With an associated, ipsilateral forearm injury, the risk increases to 7% [24]. Risk of developing compartment syndrome also increases in patients who require vascular repair for a dysvascular limb [40]. The typical signs of compartment syndrome (pain, pallor, pulseless, paresthesia, paralysis) are not reliable in children [41]. An increasing analgesic requirement is the most sensitive indicator of compartment syndrome in pediatric patients [41]. When an evolving compartment syndrome is suspected, initial management includes removing the splint and reducing the amount of flexion of the elbow [8]. If any concern remains,