Cutting edge Orthopedics

30 • CUTTING EDGE - ORTHOPEDICS Avascular Necrosis Avascular necrosis (AVN) of the distal humerus is an uncommon complication of supracondy- lar humerus fractures (Fig. 24) [111]. The exact incidence is unknown [111]. Disruption of the blood supply to the trochlea is thought to be the cause of the AVN of the distal humerus [111]. Open reduction of a supracondylar humerus fracture via a posterior approach can be a primary cause of AVN of the trochlea, as it directly disrupts the blood flow [19]. Two types of AVN have been described: (A) AVN of the lateral ossification center and (B) AVN of the medial crista and metaphyseal portion [111]. Type A is associated with early osteoarthritis and decreased range of motion at the elbow, while type B leads to progressive varus deformity of the trochlea. Avascular necrosis of the trochlea is associated with late ulnar neuropathy. Treatment options include observation, strengthening, supracondylar osteotomy, and ulnar nerve transposition [111]. Future Directions Despite the relatively high incidence of pediatric supracondylar humerus fractures, there are many aspects of management that remain unclear. A major area for future research is determin- ing a treatment algorithm for the pink, pulseless limb. For example, little is known regarding the long-term outcomes of relying on collateral circulation versus a reconstructed brachial artery. Additionally, there is continued debate regarding the best pin construct. There is a lack of sound the The the otomy site corrects the coronal and sagittal plane deformi- ties (Courtesy of Shriners Hospital for Children, Philadelphia, PA) om full ion hia, Fig. 4.23 Multi-planar deformities can be corrected by a dome osteotomy. This type of osteotomy is more techni- cally challenging than a traditional closing wedge osteot- omy (Courtesy of Shriners Hospital for Children, Philadelphia, PA) Fig. 23: Multi-planar deformities can be corrected by a dome osteotomy. This type of osteotomy is more technically challenging than a traditional closing wedge osteotomy (Courtesy of Shriners Hospital for Children, Philadelphia, PA).