1) What is a supracondylar fracture of the humerus?
Supracondylar fracture of the humerus is the most common elbow fracture in children, accounting for approximately 50% to 70% of all elbow injuries and commonly occurring in children between the ages of 3 and 10. It is a serious type of injury to the elbow in children and can have a high rate of complications if not treated properly.
2) Is it possible for our child not to have surgery?
The need for surgery for supracondylar humerus fractures in children depends mainly on the severity of the fracture. The greater the fracture displacement, the more severe it is, the more difficult it is to reposition and the less stable it is to maintain after repositioning. Our orthopaedic surgeons generally use the Gartland staging based on the degree of fracture displacement. In general, type 1 and some type 2 fractures can be treated conservatively, while type 3 fractures should be treated surgically. type 2 fractures with ulnar compression, which are called “ulnar collapse”, also require surgery.
For type 3 supracondylar humerus fractures, before the advent of the “closed reduction percutaneous pin fixation” technique, most of the fractures were treated conservatively with plaster brace fixation, but there was a high probability of complications, such as ischemic muscle contracture of the forearm and inversion of the elbow joint, all of which were related to fracture instability. Clinically pinned fixation can greatly increase the stability of the fracture end, thus reducing the associated complications.
3) Does the surgery require an incision?
For type 3 supracondylar humerus fractures, our surgical method is “closed reduction percutaneous pin fixation”, which is an advanced minimally invasive surgical method that does not require an incision in most cases. Only in very rare cases, such as open fractures or irreducible fractures, an incision may be required.
4) Will there be any sequelae?
Supracondylar fractures of the humerus in children are severe types of injuries that are prone to malunion of the fracture, most commonly inversion of the elbow. The normal elbow joint has an outward angle, which is called the “carrying angle”, or “elbow turning outward” as they say. If the elbow is turned inward, the appearance becomes “elbow turned inward”, which will affect the appearance. In addition, elbow inversion increases the risk of secondary elbow fractures and sometimes affects the flexion and extension of the elbow joint. In addition, the nerves and blood vessels surrounding the elbow joint are easily damaged in conjunction with the fracture. However, even in the case of a severely displaced type 3 supracondylar fracture, most of these “sequelae” will not remain as long as the fracture is properly treated and the functional exercises are well coordinated after surgery.
5) Does my child need emergency surgery?
For supracondylar humerus fractures, if the fracture is open, displaced and affects the blood supply to the limb, the child should be operated as soon as possible after the preoperative examination and the anesthesia and water fasting requirements are met. Most fractures can be operated within 5 days after the injury, and we have had children referred from overseas who were operated 10 days after the injury, with a satisfactory outcome. If emergency surgery is not available, doctors usually do a simple repositioning of the fracture followed by temporary fixation with a plaster rest.
6) What are the complications associated with the surgery? Can anesthesia leave sequelae for the child?
In addition to the possible complications associated with the fracture, there are certain risks associated with the surgery itself, such as the risk of anesthesia, infection at the eye of the needle, and damage to the nerves and blood vessels during needle penetration. In particular, since the child’s elbow joint is obviously swollen after the fracture and the nerve position may have changed after the fracture is dislocated, the minimally invasive procedure of “percutaneous needle penetration” is not under direct vision and it is inevitable that the ulnar nerve will be damaged during the needle penetration. However, in fact, our department performs nearly 200 such surgeries a year, and there are less than 5 cases of ulnar nerve injury caused by needle penetration.
With the development of medicine, anesthesia technology and drugs are now very safe, and there is no scientific basis for the claim that “anesthesia will make children stupid”.
7) Can you tell me about how the surgery was done?
Once the child is in the operating room, the anesthesiologist and nurse will give the child fluids and anesthesia, and the surgeon will prepare the child for surgery. When the anesthesia is sufficient and the child’s arm is pain-free, the surgeon will begin to perform the manipulation under the fluoroscopic x-ray machine and continue to insert the needle under the fluoroscopic x-ray machine after the fracture is repositioned. The needle is then bent and cut short and wrapped with a dressing and secured with a plaster cast. It usually takes about 2 hours.
8) What do I need to pay attention to after the surgery? Are there any dietary contraindications?
After the surgery, the nurse will elevate the injured upper limb with a pillow, usually with the “hand over the elbow and the elbow over the heart”, so that the swelling of the injured arm can be reduced. At the same time, after the child’s anesthesia subsides and the hand is able to move, the doctor will instruct the child to do the fist-clenching and releasing action, which is also aimed at promoting the reduction of swelling. The fist clenching activity can be done 4 times a day for 10 minutes each time. It is good to eat a light diet, as children heal quickly and generally do not need to take foods or medications that “accelerate fracture healing”.
(9) Our child has trouble moving his fingers and the doctor said there is nerve damage.
The soft tissues around the elbow joint, such as the nerves and blood vessels, are prone to damage due to significant fracture displacement, and the doctor will determine whether and what nerve damage has occurred based on the movement of the finger. However, one advantage of children’s bones is that the periosteum is thick, and most nerve injuries associated with fractures are due to mechanical pulling, and it is less likely that the fracture end will actually be stabbed. If nerve injury does occur, most do not require deliberate surgical incision and exploration and can be given neurotrophic medications to promote recovery. It can be observed for 3 to 4 months that the nerve injury still has not recovered, and a review of the EMG confirms that surgical exploration may be needed to release the nerve.
10) When will we come back for a review? What else do we need to pay attention to after discharge from the hospital? When can we remove the cast and remove the stitches?
After discharge from the hospital, if the child is generally okay, he/she can go back to school. You need to take care of the injured arm to avoid falling again. You will also need to put a triangular bandage on the outside of the cast to prevent the injured arm from dropping for a long time. From the date of surgery, the cast can be removed at 3 weeks after surgery and the pins can be removed at 4 weeks after surgery. Steel needles can be removed in the outpatient clinic and no anesthesia is needed. In addition, because children are in a growth phase, we recommend that the child’s elbow function and appearance be reviewed again at 3 months, 6 months and 1 year after surgery.
11) What should I be aware of in terms of rehabilitation?
About 3 weeks after the surgery, the cast brace can be removed if the radiographs show satisfactory healing of the fracture. The child can be allowed to do simple elbow flexion and extension with the pin. After the pins are removed 4 weeks after surgery, your child can begin active elbow exercises under the guidance of an outpatient rehabilitator. It is a good idea to have the child use a dumbbell of appropriate weight for the activity. Generally, for younger children, active exercises like this are fine. However, for older children it may be necessary to recover with exercises under the professional guidance of a rehabilitator. It is important to note that rough passive exercises should be avoided as they may lead to complications such as “ossifying myositis”.
12) What should I do if my child has an inversion of the elbow?
The chance of elbow inversion after closed reduction and pinning of a supracondylar humerus fracture in children is about 3%. If the angle of asymmetry is more than 15° on both sides compared to the healthy side, surgical correction may be required. Orthopedic correction can be considered after the fracture has completely healed and elbow exercises have been completed, usually about six months after the injury.
Typical case.
A 5-year-old boy who fell and injured his right supracondylar humerus fracture was referred to our hospital and underwent “fracture closed reduction with percutaneous needle fixation”.