Chapter 90. Common Fracture Reduction

Extremity fractures are a common reason for Emergency Department (ED) visits. If there is no neurologic or vascular compromise, most closed fractures can be managed conservatively in the ED with splinting and Orthopedic Surgeon follow-up. This chapter addresses four common fractures of the upper extremity that may require reduction by the Emergency Physician (EP). These include clavicular fractures, Colles fractures, displaced surgical neck fractures of the humerus, and supracondylar fractures of the humerus. The reduction of fractures in the ED should involve consultation with an Orthopedic Surgeon prior to performing the procedure. The only exception to this is if neurologic or vascular compromise exists in the extremity.

Introduction

Clavicular fractures are common and represent approximately 5% of all fractures.1–3 Most of these occur at the junction of the middle and distal third of the clavicle, just medial to the coracoclavicular ligament. The clavicular fracture is the most common fracture encountered in childhood and occurs most often as a result of a fall. These fractures are usually detectable clinically, with plain radiographs helping to confirm the diagnosis. Although these fractures are relatively common, there is a small but definite risk of associated complications.

Anatomy and Pathophysiology

The clavicle is the only bony attachment of the upper extremity to the axial skeleton. It serves as a strut to support the shoulder girdle. It provides support and stabilization of the upper limb while allowing a broad range of movements. The clavicle is securely attached at both the acromioclavicular and sternoclavicular joints by ligaments (Figure 90-1). The great vessels of the upper extremity and nerves of the brachial plexus pass posteriorly to the clavicle at its midportion where it overlies the first rib. The proximity of these neurovascular structures, as well as the underlying lung, accounts for most of the potential complications of clavicular fractures.

The most commonly used classification for clavicular fractures was proposed by Allman.4 This simple classification is useful clinically and mechanistically to the EP. Group I fractures are midclavicular and account for approximately 80% of clavicular fractures. These most often result from a shearing force applied to the lateral aspect of the shoulder. Group II fractures involve the distal third of the clavicle and account for approximately 15% of all clavicular fractures. These most often result from a direct blow to the top of the shoulder. Several additional subclassifications have been proposed for these fractures based on the location of the fracture and associated ligamentous injury. Operative repair is suggested for some of these subtypes. All distal clavicular fractures should therefore be referred for follow-up within 24 hours to an Orthopedic Surgeon.1,2 Group III fractures represent about 5% of clavicular fractures and involve the proximal third of the clavicle. They often result from a direct blow to the chest.

Patients with clavicular fractures are easily identified clinically. The clavicle is almost entirely subcutaneous, allowing most fractures to be palpated. Presenting signs and symptoms include localized pain, ecchymoses, and edema. Physical examination findings include superior and posterior displacement of the proximal portion of the clavicle due to traction from the sternocleidomastoid muscle (Figure 90-2). The shoulder is often displaced inferiorly by the weight of the upper extremity and the force of gravity. Medial displacement of the shoulder may be seen due to traction from the pectoral and the latissimus dorsi muscles.

Most fractures are readily identifiable on standard anteroposterior radiographs. Some group II and III fractures may not be readily identifiable.1 Additional views at a 45° angle cephalad (apical lordotic view) or 15° posteroanterior radiograph may be useful to assess displacement.1,3,11 Evaluation of fracture union with spiral computed tomography may allow the best assessment of displacement. Computed tomography is usually required for adequate visualization of medial-end fractures, particularly those extending into the sternoclavicular joint.12 Special views (e.g., cone views, tomograms, and upper rib films) may be required and are best determined in consultation with an Orthopedic Surgeon.

Clavicular injury and pain in children present two concerns. First, nondisplaced greenstick fractures to the clavicle may not be radiographically visible for 7 to 10 days.2,3 Clinical suspicion of a clavicular fracture with a negative radiograph should prompt conservative management. Follow-up should be arranged for 7 to 10 days after the injury to obtain repeat radiographs. Second, it may be unclear if the epiphyses are involved in some group II and III fractures.2,3 Any fracture through the epiphysis, or possibly through the epiphyses, requires an urgent referral to an Orthopedic Surgeon.

Indications

Reduction of clavicular fractures is necessary in a few circumstances. It is required if neurologic and/or vascular compromise is present in the affected extremity. This includes medial fracture displacement producing superior mediastinal compromise. In these circumstances, an emergent attempt at closed reduction should be made.11,13 Consider patients who are actively involved in athletics or have jobs that require overhead use of their arms (e.g., painters) for operative reduction by an Orthopedic Surgeon. Distal clavicular fractures that are displaced should be reduced. Otherwise, reduction is optional and at the discretion of the treating physician.

Contraindications

Reduction of most clavicular fractures is not usually necessary in either the pediatric or adult patient.1,2 A sling for simple arm support provides results comparable to the figure-of-eight reduction without the risk of brachial plexus injury or patient discomfort.1–3 The sling may be additionally supported by a swath (Figure 90-3A) or a Velpeau wrap (Figure 90-3B). However, many physicians still prefer the use of a figure-of-eight strap (Figures 90-3C & D). The figure-of-eight splint still represents the treatment of choice in patients over the age of 10 years in the presence of greatly displaced fragments.2,3 Despite this, there is no evidence that the figure-of-eight splint offers any advantage over a simple sling for midclavicular fractures. It is of note that the rates of compression of the neurovascular bundle, axillary pressure sores, and nonunion are higher in patients treated with the figure-of-eight splint.11,12

Contraindications to the reduction of a clavicular fracture include other injuries that represent a threat to life or limb. The patient's airway, breathing, and circulation must first be addressed and stabilized. Patients with open clavicular fractures require emergent consultation with an Orthopedic Surgeon, intravenous antibiotics, and hospital admission for possible open reduction and internal fixation. Reduction is also contraindicated if an expanding hematoma, indicative of a vascular injury, is observed. Finally, unfamiliarity with technique is a relative contraindication.

Equipment

• Figure-of-eight splint strap (commercially available)
• Sling
• Swath
• Kerlix rolls
• Elastic bandage

Patient Preparation

Explain the risks, and benefits of the reduction technique and aftercare to the patient and/or their representative. As with any procedure, informed consent should be obtained. Consider the administration of oral, intramuscular, or intravenous analgesics for patient comfort during the procedure. Procedural sedation is not needed or required for this fracture reduction.

Technique

Sit the patient upright on the side of the stretcher with their feet on the floor. Alternatively, the patient may be standing upright. Stand behind the patient. Grasp and pull both of the patient's shoulders backward as if the patient were standing at attention. Instruct an assistant to apply the figure-of-eight splint while the patient is in this position. Apply the splint like a backpack and tighten the straps (Figures 90-3C & D). Reassess the neurologic and vascular integrity of the affected extremity after applying the splint.

Assessment

The neurologic and vascular integrity of the upper extremity should be assessed for all patients both initially, following any reduction attempts, and after the application of a figure-of-eight splint. Any neurologic and/or vascular compromise requires an emergent consultation with an Orthopedic Surgeon.

Aftercare

Patients with uncomplicated fractures should be referred to an Orthopedic Surgeon in 7 to 10 days. Patients with group II distal fractures and any fracture in a child potentially involving the epiphysis should have an urgent consultation with an Orthopedic Surgeon within 24 to 48 hours. Any patient with neurologic or vascular compromise, a pneumothorax, or signs of vascular injury should be admitted to the hospital after an emergent consultation with an Orthopedic Surgeon.

Once the acute pain has subsided, the use of the sling can normally be discontinued and patients are encouraged to participate normal activities as pain allows. Most patients respond well to self-administered range-of-motion exercises. Recovery of the range of motion of the shoulder is usually swift, and supervised physiotherapy is very rarely required.13

General principles of orthopedic care are recommended. These include the application of ice, rest, nonsteroidal anti-inflammatory drugs, and narcotic analgesics as needed. Most patients find the figure-of-eight splint difficult to apply, extremely uncomfortable, and remove it shortly after its application. If the patient tolerates the splint, it should be tightened daily. The figure-of-eight splint should be worn until there is evidence of clinical union and the arm can be abducted without pain. This generally requires 3 to 5 weeks in children and 6 or more weeks in adults.1,2 It may be more advantageous to apply a sling and swath or a sling and Velpeau wrap for patient comfort and compliance (Figures 90-3A & B). The outcomes of applying a figure-of-eight splint versus a sling are equivalent.18,19 Alternatively, apply a shoulder immobilizer.

The sling is used to immobilize and elevate the elbow, forearm, and hand. It is also used to support the upper extremity. Slings are often used to support casts or splints of the upper extremity. These devices are simple, inexpensive, and effective. It is imperative that the sling not be too short to allow the wrist and hand to hang over the sling. This can result in an ulnar nerve neuropraxia.

The addition of a swath to a sling is used to immobilize dislocated shoulders that have been reduced and proximal humeral fractures (Figure 90-3A). The swath immobilizes the humerus against the torso to limit motion at the shoulder. A shoulder immobilizer may be substituted for a sling and swath.

The Velpeau wrap is a sling-and-swath technique that positions the forearm diagonally rather than horizontally (Figure 90-3B). The Velpeau wrap has no practical advantages over a sling and swath.

Complications

Complications of the reduction procedure include injuries to the brachial plexus, subclavian artery, and/or vein.1,2 Commonly, these are the result of the initial injury and not the reduction procedure. It is imperative to perform a neurologic and vascular examination prior to and after any attempt at reducing a clavicular fracture. Any neurologic or vascular deficit requires an immediate consultation with an Orthopedic Surgeon.

Summary

Clavicular fractures are common, easily diagnosed, and often treated in the ED. Fractures of the distal or medial third may be more challenging. Although the incidence of complications is low, a thorough search for resultant or concomitant injury is required. Any evidence of neurologic or vascular compromise requires an emergent consultation with an Orthopedic Surgeon.

Introduction

A Colles fracture is a transverse fracture of the distal radial metaphysis with dorsal displacement and angulation of the distal fragment. The fracture usually occurs 2 cm from the distal end of the radius (Figure 90-4). The most common mechanism producing a Colles fracture is a fall on an outstretched hand.5,6 The majority of fractures occur in patients 50 years of age and older.5,6 This fracture is more commonly seen in women than in men.

The Colles fracture is the most common fracture of the wrist.5,6 Familiarity with its presentation, indications for reduction, and method of reduction are essential for the EP. Consult an Orthopedic Surgeon for the reduction of most fractures, due to the high incidence of long-term complications that may result, even when these fractures are appropriately managed and reduced.5,6

Anatomy and Pathophysiology

The distal radius is involved in two important articulations. First is the distal radioulnar joint, which is responsible for pronation and supination of the forearm. The second is the wrist articulation. The distal radius normally displays approximately 15° to 30° of angulation relative to the ulna. It also has a volar tilt of up to 23°. It is important to maintain this anatomic position of the distal radius with the reduction of a Colles fracture so that the patient retains good function of the wrist and distal radioulnar joints.6

The Colles fracture can be associated with several other significant injuries. Up to 60% of patients have a fracture of the ulnar styloid process.5,6 Other injuries include carpal fractures, distal radioulnar joint subluxations, flexor tendon injuries, median nerve injuries, ulnar neck fractures, and ulnar nerve injuries. A thorough physical examination and evaluation of the radiographs will uncover these injuries.

Standard radiographs include the anteroposterior and lateral views of the wrist. The Colles fracture is classically described as a “dinner fork” deformity when seen on lateral view (Figure 90-4A). Intraarticular involvement with the fracture is rare and should prompt an emergent consultation with an Orthopedic or Hand Surgeon in the ED for reduction.6

A variation of the Colles fracture is the Smith fracture (reversed Colles). The Smith fracture is similar to the Colles fracture except that the distal fracture fragment is displaced in a volar direction. This fracture most often results from a direct blow to the wrist while the hand is flexed. It is more commonly seen in young males. The management of these fractures is similar to that of the Colles fracture.

Indications

Nondisplaced Colles fractures can be placed in a splint or cast and the patient follow-up with an Orthopedic or Hand Surgeon on an outpatient basis. Displaced fractures should be reduced in the ED.5,6 Simple Colles fractures may be reduced after consultation with an Orthopedic or Hand Surgeon. Many Orthopedic and Hand Surgeons prefer to reduce these fractures themselves, often prior to open reduction and internal fixation. The fracture must be emergently reduced if the patient has any neurologic and/or vascular compromise. The EP should reduce the fracture if the Orthopedic or Hand Surgeon is not immediately available. The goal is to relieve the neurologic and/or vascular compromise. Ideal positioning is not required as the Surgeon can later reduce the bony defect.

Contraindications

Contraindications to the reduction of a Colles fracture include other injuries that represent a threat to life or limb. Airway, breathing, and circulation must first be addressed and stabilized. An Orthopedic or Hand Surgeon should reduce any fractures that involve the radioulnar or wrist joint. Complex, comminuted, or open fractures also require reduction by an Orthopedic or Hand Surgeon. Unfamiliarity with the reduction technique is a relative contraindication.

Any patient presenting with a Colles fracture should be evaluated for the presence of a compartment syndrome. Any suspicion of a compartment syndrome necessitates having intracompartmental pressures measured. Elevated compartmental pressures require an emergent consultation with an Orthopedic, Hand, or General Surgeon. Reduction and fasciotomies should be performed in the Operating Room. Refer to Chapters 74 and 75 for the details regarding a compartment syndrome and a fasciotomy, respectively.

Equipment

• Povidone iodine or chlorhexidine solution
• Local anesthetic solution, 1% to 2% lidocaine
• 10 mL syringe
• 18 gauge needle
• Finger trap
• Compressive cotton bandage (Webril)
• Elastic wrap
• 8 to 10 pounds of weights
• Casting material (plaster, fiberglass, and prepackaged splints)
• Anesthesia and analgesia supplies

Patient Preparation

Obtain an informed consent for reduction of the fracture after explaining to the patient and/or their representative the indications, anticipated outcome, risks, benefits, and potential complications.

The patient should be given adequate anesthesia for the procedure. This can often be accomplished with a hematoma block. The procedure is briefly described here. Refer to Chapter 125 for a more complete discussion of this procedure. Clean the skin overlying the fracture of any dirt and debris. Apply povidone iodine or chlorhexidine solution to the skin and allow it to dry. Place a subcutaneous wheal of local anesthetic solution over the area of the hematoma. Insert an 18 gauge needle through the anesthetized skin and into the hematoma. Aspirate blood from the hematoma site to confirm proper needle placement. Inject 5 to 10 mL of the local anesthetic solution into the hematoma surrounding the fracture. Although a hematoma block will provide adequate anesthesia in most patients, it may be incomplete. Adjunctive or alternative anesthesia includes intramuscular analgesics, intravenous analgesics, regional nerve blocks (Chapter 126), intravenous regional anesthesia (Chapter 127), and procedural sedation (Chapter 129).

Technique

Place the patient supine on a stretcher. Perform a hematoma block as described above. Provide supplemental analgesia to the patient if required. Position the patient as in Figure 90-5A. Abduct the arm 90° and allow it to hang over the edge of the bed. Flex the elbow 90° with the hand pointing upright. Insert the thumb, index finger, and long finger into the finger trap (Figure 90-5B). Suspend 8 to 10 pounds of weights from the distal humerus (Figure 90-5C). Allow the patient to remain in this position for 5 to 10 minutes to distract and disimpact the fracture fragments.

The fracture reduction involves traction followed by manipulation of the distal radial fragment to reverse the action that resulted in the fracture (Figure 90-6). Place both hands around the patient's wrist with the thumbs at the base of the fracture site (Figure 90-6A). Displace the fracture fragment distally with your thumbs while maintaining traction with the finger trap and the weights (Figure 90-6A). This maneuver allows the distal fragment to become free from any contacts with the proximal radius, which may prevent its movement. Continue to manipulate the fragment distally while simultaneously manipulating it in a volar direction until the fragment assumes the proper anatomic position. In the case of a volar angulation or Smith fracture, these manipulations would simply be reversed to reduce the displacement. Slight ulnar deviation of the fragment is often necessary (Figure 90-6B). Remove the weights. Palpation of a smooth surface at the radial and dorsal aspects of the radius indicates an appropriate reduction. Remove the finger trap and apply a splint.

Immobilize the forearm with a sugar tong splint. Place the forearm in a neutral position, halfway between pronation and supination. Place the wrist in 15° to 20° of flexion and 20° of ulnar deviation. Unstable fractures are best splinted immediately after the reduction while the hand is still maintained in the finger trap for traction (Figure 90-6C). If a long arm cast is applied, be sure to bivalve it to prevent complications. A short arm splint or cast may be used if the fracture is stable and impacted or is stable in an elderly person who needs to maintain mobility of the elbow.

Assessment

All patients should be assessed both initially and following any reduction attempts for neurologic and vascular integrity of the extremity. Postreduction radiographs should be obtained to confirm proper bony positioning. The procedure may be repeated if the radiographs show an incomplete reduction. Bedside ultrasound is a reliable and convenient method of assessing the reduction.20 It is noninvasive, does not use ionizing radiation, involves minimal contact, and does not require the patient to remain motionless.14

The goal is the restoration of the normal relationships and angles of the radius with congruity of the radiocarpal and radioulnar joints. The lateral radiograph should reveal a 23° angle of the radiocarpal joint in a palmar direction with no dorsal angulation. The anteroposterior radiograph should reveal a radioulnar joint angle of 15° to 30° with the ulna in relation to the radiocarpal joint.

Positioning is not critical if the reduction was performed for neurologic and/or vascular compromise. The primary consideration is the relief of the compromised nerve and/or artery. The Orthopedic or Hand Surgeon can later reduce the bony defect that remains.

Aftercare

Patients with uncomplicated or nondisplaced fractures should be referred to an Orthopedic or Hand Surgeon in 24 to 48 hours. Patients with unstable fractures should be evaluated within 24 hours. All patients should be given written instructions regarding the signs and symptoms of the splint or cast being too tight or a potential compartment syndrome. Any patient with an open fracture, evidence of neurologic and/or vascular compromise, or suspicion of a compartment syndrome should be admitted to the hospital after an emergent consultation with an Orthopedic or Hand Surgeon.

General principles of orthopedic care are recommended. These include rest, elevation of the arm, nonsteroidal anti-inflammatory drugs, and narcotic analgesics as needed. The patient should be instructed to exercise the fingers and shoulder to prevent weakness, muscular atrophy, and the ligaments surrounding these joints from becoming taut.

Complications

Complications of the reduction procedure include postreduction edema and bleeding into the forearm. These may contribute to the development of a compartment syndrome. Although infrequent, a neuropraxia of the median nerve is possible. Most complications result from the injury that produced the fracture and underlie the need for a good neurologic and vascular examination prior to any attempts at reduction. Any diminished or absent neurologic or vascular function requires an emergent consultation with an Orthopedic or Hand Surgeon. Incomplete reduction can result in future morbidity (i.e., pain, decreased range of motion, and deformity).

Summary

The Colles fracture is the most common fracture of the wrist. Familiarity with its presentation and method of reduction are essential for the EP. Many Orthopedic and Hand Surgeons prefer to reduce these fractures. Consultation is advised prior to reduction unless the extremity has evidence of neurologic or vascular compromise. These fractures have a high incidence of long-term complications, even when appropriately managed and reduced.5,6

Introduction

Proximal humeral fractures are relatively common. Most patients presenting to the ED with a proximal humeral fracture are elderly and usually have osteoporosis. The most common mechanism of injury involves a fall on an outstretched hand with the elbow extended.3,7 The EP can manage most of these fractures conservatively. However, the EP must have a basic knowledge of the types of proximal humeral fractures, those that should be managed by the Orthopedic Surgeon, and the indications for emergent reduction.

Anatomy and Pathophysiology

The proximal humerus is composed of the articular segment, the greater and lesser tuberosities, and the proximal humeral shaft. This anatomic division is based on the epiphyseal lines and the development of the humerus.2,3,7 The commonly used Neer classification utilizes the observation that proximal humeral fractures separate primarily along these epiphyseal lines.2,3,7 Using this classification, it is the displacement of fragments, not the total number of fracture lines, that is important. Significant displacement is considered to be a separation of greater than 1 cm, angulation of more than 45°, or displacement of the greater tuberosity greater than 0.5 cm.3,7 The classification separates fractures into one- to four-part fractures. The vast majority, approximately 80%, of proximal humeral fractures are one-part or minimally displaced fractures.3,7 These fractures can be managed conservatively. Multiple-part fractures often require surgical intervention by an Orthopedic Surgeon. A surgical neck fracture of the humerus is the only proximal humeral fracture that should be reduced by the EP.

Indications

Surgical neck fractures of the humerus may be reduced in the ED after consultation with an Orthopedic Surgeon. If the patient has neurologic and/or vascular compromise, the reduction should be undertaken emergently after consultation with the Orthopedic Surgeon.

Contraindications

Contraindications to the reduction of humeral fractures include other injuries that represent a threat to life or limb. Airway, breathing, and circulation must first be addressed and stabilized. An Orthopedic Surgeon should manage any open fracture, complex comminuted fracture, or multiple-part fracture as the patient often requires operative repair and reduction.2,3,7 Unfamiliarity with the reduction technique is a relative contraindication. Children presenting with separation of the proximal humeral epiphyses require meticulous realignment. These fractures should be reduced by an Orthopedic Surgeon.2

Equipment

• Supplies and equipment for procedural sedation (Chapter 129)
• Compressive cotton bandage (Webril)
• Casting material (plaster, fiberglass, and prepackaged splints)
• Sling
• Elastic wrap

Patient Preparation

Obtain an informed consent for reduction of the fracture after explaining to the patient and/or their representative the indications, anticipated outcome, risks, benefits, and potential complications of the procedure. Adequate anesthesia for this procedure is best accomplished with procedural sedation. Obtain an informed consent for the procedural sedation procedure. Refer to Chapter 129 for complete details regarding procedural sedation.

Technique

Place the patient supine. Apply procedural sedation. Completely flex the patient's elbow. Apply a distractive force along the long axis of the humerus by applying traction on the patient's elbow (Figure 90-7A). Simultaneously slightly adduct the arm across the chest (to allow relaxation of the pectoralis muscle), slightly flex the arm, and apply lateral pressure to the fracture site while distracting the humerus (Figure 90-7B). Slowly release the traction on the elbow as the fragments come into good reduction.

Apply a sugar tong splint from over the deltoid muscle, under the elbow, and up into the axilla (Figure 90-8A). Secure the splint in the usual manner with an elastic wrap. Apply a sling (Figure 90-8B). Place the arm slightly across the chest and apply a sling and swath in the event of an unstable proximal humeral fracture (Figure 90-3A). This can help to limit the pull of the pectoralis muscle on the fracture site.

Assessment

All patients should be assessed both initially and following any reduction attempts for neurologic and vascular integrity of the extremity. Postreduction radiographs should be obtained to confirm proper bony positioning. The procedure may be repeated if the radiographs show incomplete reduction.

Positioning is not critical if the reduction was performed for neurologic or vascular compromise. The primary consideration is the relief of the compromised nerve and/or artery. The Orthopedic Surgeon can later reduce the bony defect that remains.

Aftercare

Patients with uncomplicated or nondisplaced fractures should be referred to an Orthopedic Surgeon in 24 to 48 hours. All patients should receive written instructions on the signs and symptoms of the splint being too tight or a potential compartment syndrome. Patients with unstable fractures should be evaluated within 24 hours. Any patient with an open fracture, evidence of neurologic and/or vascular compromise, or suspicion of a compartment syndrome should be admitted to the hospital after an emergent consultation with an Orthopedic Surgeon.

Complications

Complications of the reduction procedure include primarily neurologic and/or vascular compromise. However, most complications result from the injury that produced the fracture. This underlies the need for a good neurovascular examination prior to any reduction attempt.

Summary

Proximal humeral fractures are common. While the EP can manage most of these conservatively, a displaced surgical neck fracture is the only proximal humeral fracture that should be reduced in the ED. Reduction is often reserved for patients who have evidence of neurologic and/or vascular compromise. Most of these injuries require open reduction and internal fixation in the Operating Room by an Orthopedic Surgeon. Close follow-up should be arranged for any patient discharged from the ED.

Introduction

Distal fractures of the humerus located within 2 cm or just proximal to the epicondyles are known as supracondylar fractures (Figure 90-9). Supracondylar fractures are classified as extension and flexion fractures.8–10 These fractures are common in children under the age of 15 and are rare in people over the age of 20.8–10 Supracondylar fractures are the most common elbow fractures seen in children.15 The most common mechanism of injury involves a fall onto an outstretched hand with the elbow locked in extension.8–10 The same mechanism of injury in an adult often results in a posterior elbow dislocation. The bones of an adult are much stronger than those of a child, so that the ligaments rupture rather than the bone fracturing.8,9 These injuries have a significant incidence of associated neurologic and/or vascular injury. There is a significant incidence of a subsequent compartment syndrome. All supracondylar fractures should be referred to an Orthopedic Surgeon for follow-up care.

Anatomy and Pathophysiology

On presentation, the child will be holding the affected extremity with the elbow flexed 90° and the arm adducted.8,10 Localized tenderness and swelling will be found upon examination. Extension fractures have posterior displacement of the distal fragment of the humerus that is aggravated by the pull of the triceps muscle.8,10 The olecranon will be displaced posteriorly due to traction from the triceps muscle. The posterior displacement of the olecranon may mimic a posterior elbow dislocation. Anterior angulation of the sharp proximal fragment (Figure 90-9B) may injure the brachial artery or median nerve (Figure 90-10). A thorough neurovascular examination is essential. There will be loss of the normal olecranon prominence with flexion injuries. These fractures are frequently open and vascular injury is less frequent.8,10

The modified Gartland classification of supracondylar humeral fractures is the most commonly accepted and used system.17 A Gartland type-I supracondylar fracture is nondisplaced or minimally displaced by <2 mm and is associated with an intact anterior humeral line. A type-II supracondylar fracture is displaced by >2 mm, and the posterior cortex is intact, but may be hinged. On a true lateral radiograph of the elbow, the anterior humeral line does not go through the middle third of the capitellum. Type-III fractures are displaced with no meaningful cortical contact. Gartland type-IV fractures are characterized by an incompetent periosteal hinge circumferentially and are defined by instability in both flexion and extension.17 The EP's primary role in a supracondylar humeral fracture is to ascertain if there is any neurological and/or vascular compromise of the extremity distal to the fracture.

Radiological evaluation of supracondylar fractures is best appreciated on the lateral view. One-quarter of these fractures in children are of the greenstick variety.8,10 The posterior fat pad sign and anterior humeral line should be closely examined. Initial radiographs may show no evidence of a fracture except for a posterior fat-pad sign.15 Even without any radiologic signs, a child with localized tenderness in the supracondylar area should be treated conservatively with splinting and referral to an Orthopedic Surgeon.8,10 The anteroposterior view allows an assessment of any displacement. Displaced fractures should be emergently referred to and reduced by an Orthopedic Surgeon.

Indications

The only indication for reducing a supracondylar fracture of the humerus emergently is neurologic and/or vascular compromise of the extremity distal to the fracture and an Orthopedic Surgeon is not immediately available.

Contraindications

Contraindications to the reduction of a supracondylar fracture include other injuries that represent a threat to life or limb. The patient's airway, breathing, and circulation must first be addressed and stabilized. An Orthopedic Surgeon should manage any open or displaced fractures. Unfamiliarity with the reduction technique is a relative contraindication. If the EP is uncomfortable with the reduction procedure, simple traction on the extended elbow may be sufficient to restore neurologic and/or vascular integrity.

Equipment

• Supplies and equipment for procedural sedation (Chapter 129)
• Compressive cotton bandage (Webril)
• Elastic wraps
• Casting material (plaster, fiberglass, and prepackaged splints)
• Prepackaged splinting sheets
• Sling

Patient Preparation

Obtain an informed consent for the reduction of the fracture after explaining to the patient and/or their representative the indications, anticipated outcome, risks, benefits, and potential complications. Adequate anesthesia for this procedure is best accomplished with procedural sedation. Obtain an informed consent for this procedure in addition to the reduction procedure. Refer to Chapter 129 for the complete details regarding procedural sedation.

Technique

Place the patient supine. Apply procedural sedation. Slightly abduct the affected extremity. Place the patient's hand in the midposition between pronation and supination with the thumb pointing upward (Figure 90-11A). Grasp the patient's elbow region with the dominant hand and grasp the wrist with the nondominant hand (Figure 90-11A). Instruct an assistant to stabilize the distal humerus (Figure 90-11A). Apply distal traction in line with the long axis of the arm by pulling on the wrist while simultaneously correcting any medial or lateral displacement at the elbow (Figure 90-11A). Supinate the patient's arm and correct any remaining medial or lateral displacement at the elbow while simultaneously distracting the wrist (Figure 90-11B). Place the thumb of the dominant hand across the joint line of the elbow with the fingers behind the olecranon process and slowly flex the elbow to just beyond 90° while distracting the elbow (Figure 90-11C). Splint the arm in this position. Avoid tight bandaging or splinting as significant swelling may occur up to 24 hours after the reduction. Excessive flexion or extension may compromise the limb's vascularity and increase compartment pressures.16

Assessment

All patients should be assessed both initially and following any reduction attempts for neurologic and vascular integrity of the extremity. Postprocedural swelling is common. Postreduction radiographs should be obtained to confirm proper bony positioning. The procedure may be repeated if the radiographs show incomplete reduction.

Positioning is not critical if the reduction was performed for neurologic or vascular compromise. The primary consideration is the relief of the compromised nerve and/or artery. The Orthopedic Surgeon can later reduce the bony defect that remains.

Aftercare

Patients with supracondylar fractures should be admitted to the hospital to be monitored for a delayed compartment syndrome, neurologic compromise, or vascular compromise. Any patient with an open fracture, evidence of neurologic or vascular compromise, or suspicion of a compartment syndrome should be admitted to the hospital after an emergent consultation with an Orthopedic Surgeon.

Complications

Most complications result from the injury that produced the fracture and not the reduction. Complications of the reduction procedure include primarily neurologic and vascular compromise. This is most often a neuropraxia and may involve any of the three nerves crossing the fracture. The neurovascular structures crossing the fracture may become lacerated or entrapped during the reduction. The necessity of an accurate and complete neurovascular examination prior to and after reduction cannot be overemphasized.

Summary

Supracondylar fractures of the humerus are common in children under the age of 15 and rare over the age of 20. The most common mechanism of injury involves a fall onto an outstretched hand with the elbow locked in extension. These injuries have a significant incidence of associated neurologic injury, vascular injury, and the subsequent development of a compartment syndrome. The only indication for the reduction of a supracondylar fracture of the humerus by the EP is neurologic and/or vascular compromise distal to the fracture.