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Self-Assessment Questions

Orthopaedic Surgery

Answer 4
  1. Closed reduction and lateral pinning of the distal humerus. This patient has a type III (completely displaced) fracture of the supracondylar humerus. Supracondylar humerus fractures represent 50% to 70% of elbow fractures in children, commonly occurring between age 3 and 10 years.4 The mechanism of injury is a fall onto an outstretched hand, often during sporting activities and falls from playground equipment, resulting in an extensio-type injury (95%).4 Because the olecranon is not fractured in this case, closed reduction and lateral percutaneous pinning of the olecranon is not appropriate. Open reduction and plating of the distal humerus is incorrect because plating is more extensive than what is necessary to stabilize the fracture. Violation of multiple growth plates around the distal humerus and early physeal closure will likely occur with plate and screw fixation of a pediatric elbow fracture. Closed reduction and casting is not sufficient for treating this unstable fracture pattern. Without secure fixation, type III supracondylar humerus fractures will displace, as anatomic alignment is difficult to achieve and maintain in a cast. Closed reduction with percutaneous fixation using smooth pins, not screws, is the most appropriate treatment to decrease the risk of premature physeal closure and growth disturbance.4 Two lateral pins placed divergently have been shown to provide adequate fracture stability for healing with relatively minimal neurovascular risk.4

     Shrader MW. Pediatric supracondylar fractures and pediatric physeal elbow fractures. Orthop Clin North Am 2008;39:163–71, v.

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