Cutting edge Orthopedics

Supracondylar Humerus Fractures • 25  emergent fasciotomies should be performed. A volar incision is made from the wrist to the elbow, which allows for release of the superficial and deep flexors of the volar compartment, as well as the carpal tunnel. Direct visualization is important to ensure that no neurovascular struc- tures are inadvertently injured during the fascial release. The lacertus fibrosus should be released; however, care should be taken not to damage the biceps tendon. The flexor pollicis longus and pronator quadratus may have separate fascial compartments and thus need to be individually released [9]. Attention is then turned to the dorsal aspect of the forearm. Compartment pres- sures of the dorsal compartment and mobile wad are measured. In some cases, the dorsal and mobile wad compartments may not be involved, or the intracompartmental pressures may be sufficiently relieved by release of the volar compartment. Excellent outcomes have been reported in 90% of patients with compartment syndrome who undergo fasciotomy within an average of 30.5 h from diagnosis [41]. Neurologic Injury Iatrogenic ulnar nerve injuries may occur during medial pinning. If this occurs, pin removal has been suggested to improve recovery time [8]. Most injuries are neuropraxias and spontaneously resolve in 6–8 weeks [9]. If there are no signs of recovery at 3 months, an electromyogram (EMG) and nerve conduction study can be performed. Lack of recovery combined with electrodiagnostic testing consistent with denervation warrants exploration. Pin Site Infection Pin site infections occur at a rate of approximately 1–2.5% in patients with supracondylar humerus fractures [39, 61, 105]. Pin removal and oral antibiotics are the typical first line of treatment. If the pin(s) are removed prior to sufficient callous formation, the arm should be placed in a long arm cast. Pin Migration The rate of pin migration is estimated to be approximately 1.8% [39]. Leaving at least 1 cm of wire out of the skin and bending the wire 90° are recommended [8]. Additionally, covering the end of the wire with felt, sponge, or other cap has been suggested to help prevent pin migration [8] (Fig. 16). Loss of Reduction Bashyal and colleagues (2009) reported loss of reduction in 0.8% of Types II and III supracondylar humerus fractures treated with CRPP [39], while Sankar and colleagues (2007) found a 2.9% rate of loss of fixation among Types II and III fractures treated with CRPP [106]. Technical factors have been identified as the primary reason for loss of reduction. Sankar and colleagues (2007)