Supracondylar fracture of the humerus

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Published on March 21, 2014

Author: johnebnezar

Source: authorstream.com

Supracondylar fracture of the humerus: Supracondylar fracture of the humerus By Dr John Ebnezar Vice President Indian Orthopedic Association Welcome to the world of Supracondylar fractures: Welcome to the world of Supracondylar fractures Fracture of children Not scary but spectacular It is a great teacher – teaches you the values of basics in orthopedics It is kind and forgiving – if you make a mistake ( Cubitus varus ), it forgives you (No functional impairment ) but will not allow you to forget ( Cosmetic disability) In its own humble way it teaches you the values of life! What happens when you fall- Can be adventurous but not when you break your bone From Text Book Of Orthopedics, by Dr. John Ebnezar, ,IV Edition, Jaypee Brothers: What happens when you fall- Can be adventurous but not when you break your bone From Text Book Of Orthopedics, by Dr. John Ebnezar , ,IV Edition, Jaypee Brothers When children fall – they break the elbow more often When elders fall - they break the wrist more often When adults fall – they break other bones more Supracondylar fracture – Leader among the injuries around elbow : Supracondylar fracture – Leader among the injuries around elbow In children, incidences of fractures around the elbow region Injuries Percentage • Supracondylar fractures 65.4 • Condylar fractures 25.3 • Fracture neck radius 4.7 • Monteggia’s fractures 2.2 • Olecranon fractures 1.6 • T- condylar fractures 0.8 The incidence of distal humeral fractures is as follows: • Supracondylar 69     • Lateral condyle 16.8 • Medial condyle 14.1 • T- condylar 1    In Children, Supracondylar fractures account for 65.4% of the injuries around the elbow and 69% of distal humerus fractures Quick review of statistics, there is a pattern try to unravel it : Quick review of statistics, there is a pattern try to unravel it • Age — first decade, 5–8 years , 84% cases < 10 years • Sex — boys 63.6 % (More prone to fall) • Sides (L)—58.6 % (Non dominant -Weak) (R)—42.4% • Open fracture—2.3% Nerve injury —7% Radial nerve—45% Median nerve—32% Ulnar nerve—23 % VIC —0.5% • Fracture of ipsilateral Extremity— 1.2 % • Flexion type —2.3% • Extension type —97.7% Why children < 10 years are sitting ducks? From Text Book Of Orthopedics, by Dr. John Ebnezar, ,!V Edition, Jaypee Brothers :  Why children < 10 years are sitting ducks? From Text Book Of Orthopedics, by Dr. John Ebnezar , ,!V Edition, Jaypee Brothers Culprit: Bony architecture Bone is thin Bone is remodeling Defect in the anterior cortex • Laxity of ligaments permits hyperextension at the elbow. Mechanism of Injury From Text Book Of Orthopedics, by Dr. John Ebnezar, ,!V Edition, Jaypee Brothers : Mechanism of Injury From Text Book Of Orthopedics, by Dr. John Ebnezar , ,!V Edition, Jaypee Brothers Fall on an outstretched hands with hyperextension converts linear force into bending force Olecranon concentrates this force to the weak supracondylar area Children <=3 years fall at home Children >= 3 years fall from tree, play grounds etc Classification – Time honoured : Classification – Time honoured Supracondylar fracture is broadly classified into extension type and flexion type . In extension type, the fracture line runs upwards and backwards and in flexion type, it runs downwards and forwards Extension type of supracondylar fracture is further classified into the following subtypes Gartland’s Classification – In Children: Gartland’s Classification – In Children • Type I: Undisplaced • Type II: Displaced, but posterior cortex is intact. • Type III: Displaced, but no intact posterior cortex and the distal fragment could be either displaced: a. Posteromedial or b. Posterolateral . Adults - AO-ASIF classification: Adults - AO-ASIF classification Rare Only 3% Type A - Extraarticular fractures A1 - Epicondylar avulsions A2 - Supracondylar fractures A3 - Supracondylar fractures with comminution Type B - Unicondylar fractures B1 - Fracture of the lateral condyle B2 - Fracture of the medial condyle B3 - Tangental fracture of the condyle Type C - Bicondylar fractures C1 - T-shaped or Y-shaped fracture C2 - T-shaped or Y-shaped fractures with comminution of 1 or 2 pillars C3 - Extensive comminution of the condyles and pillars Modified Gartland’s Classification : Modified Gartland’s Classification Type I Type-II Non or   m in imally displaced (<2 mm) Anterior  humeral  l in e intact There may or may not be evidence   of osseous  in jury Posterior fat-pad sign may be the only   evidence of fracture Stable as periosteum is  in tact circumferentially Displaced (by >2   mm) Posterior cortex is in tact, but h in ged The anterior  humeral   l in e does not go through the middle third of the capitellum No rotational deformity Modified Gartland’s Classification : Modified Gartland’s Classification Type-III Type IV Displaced  No mean in gful cortical contact. Extension   in the sagittal plane Rotation  in  the frontal and/or transverse   planes. Periosteum is extensively torn Soft-tissue   and neurovascular  in juries seen Comminution /collapse   of medial column In competent periosteal h in ge circumferentially In stability  in  both flexion and extension.   Is usually determ in ed under anesthesia May be due to the  in itial  in jury or iatrogenic Multidirectional   in stability has treatment implications Clinical Features From Step by Step Fracture treatment, by Dr. John Ebnezar, Jaypee : Clinical Features From Step by Step Fracture treatment, by Dr. John Ebnezar , Jaypee Pain and swelling which is gross, S-shaped deformity of the upper arm Loss of both active and passive movements of the elbow. Symptoms relating to vascular and nerve injury may be seen. The patient may also complain of pseudo-paralysis . Radial nerve, the median and ulnar nerves may be injured Clinical signs • Arm is short, forearm is normal in length. • Gross swelling, and tenderness. • Crepitus is present but should not be elicited • Dimple sign due to one of the spikes of proximal fragment penetrating the muscle and tethering the skin. • Relationship between three bony points is maintained. • “Soft spots” is an effusion beneath anconeus muscle . Radiographs – There are plenty of signs but each sign tells one tale : Radiographs – There are plenty of signs but each sign tells one tale AP view • Baumann’s angle • Angle between the long axis of humerus and the transverse axis of the elbow - Normally 90°. — Less than 90° suggests cubitus valgus — Greater than 90° suggests cubitus varus . Lateral view • Tear drop sign Anterior humeral line • The coronoid line • Fat pad sign Fish-tail sign Crescent sign Get familiar with Radiological signs From Forthcoming Orthopedics Radiology made easy, by Dr. John Ebnezar, Jaypee Brothers : Get familiar with Radiological signs From Forthcoming Orthopedics Radiology made easy, by Dr. John Ebnezar , Jaypee Brothers Posterior displacement: Loss of tear drop sign Anterior humeral line Coronoid line Fat pad sign Coronal tilt: • Crescent sign. • Baumann’s angle. Horizontal rotation Fish-tail sign Treatment methods – Plenty of choices but do we know the right choice?: Treatment methods – Plenty of choices but do we know the right choice? Immobilization with a slab or cuff collar Closed reduction and Plaster cast Closed reduction and Percutaneous fixation with K-wires Traction – Skin or Skeletal Open Reduction and Internal fixation Your eyes will see what your minds know: Your eyes will see what your minds know Do you know the correct technique of closed reduction Do you know the value of the radiological signs Do you know how to interpret these radiological signs We all assume we know But how many actually know Overlook these basics and the elbow will stare at you with an ugly Cubitus varus deformity ATRP – Always Try Reducing Perfectly From Text Book Of Orthopedics, by Dr. John Ebnezar, ,!V Edition, Jaypee Brothers: ATRP – Always Try Reducing Perfectly From Text Book Of Orthopedics, by Dr. John Ebnezar , ,!V Edition, Jaypee Brothers My professor told me that there is method for everything and there is a method to kick even a dog, kick it wrong and it will bite you. So is with the reduction of SC Fracture. Get it right: A – Axial traction and counter traction T – Translation to be corrected first R – Rotation to be corrected next by Supinopronation movements P – Posterior displacement corrected last ATRP – Always Take Radiological Pictures: ATRP – Always Take Radiological Pictures Is your job over with what you think is a perfect reduction? No, now put to use your knowledge of radiological signs: True AP view of the distal humerus and not elbow True lateral view of the elbow Interpret Baumann’s angle properly Check for restoration of the radiological signs If not 2-3 attempts of reduction and restoration may be tried in the same anesthesia Baumann’s Angle – Post-reduction assessment From Text Book Of Orthopedics, by Dr. John Ebnezar, ,!V Edition, Jaypee Brothers: Baumann’s Angle – Post-reduction assessment From Text Book Of Orthopedics, by Dr. John Ebnezar , ,!V Edition, Jaypee Brothers Frequently used to assess post fracture reduction Normal value is < 5 degrees or an average of 72 degrees (range being 64-81 deg) Change of 5 deg of BA = 2 deg change in Carrying angle Compare with the opposite side ATRP - Always Try to Retain in Pronation (With few exceptions): ATRP - Always Try to Retain in Pronation (With few exceptions) Is your job over with reduction and interpreting radiological signs? No Not Yet! Put the limb in proper position which is pronation . Why? It tightens the medial periosteal hinge Closes the lateral wedge Useful in all types of SC fractures except in Posterolateral displacement The Mnemonic ATRP says it all: The Mnemonic ATRP says it all ATRP – Always Try Reducing Perfectly ATRP – Always Take Radiological Pictures ATRP - Always Try to Retain in Pronation , with few exceptions Remember these 4 R’s: Each step is important Reduction Restore Radiology Retention Learn the values of basics in life and orthopedics. It pays you handsomely Retention – Fight between 2 P’s : Retention – Fight between 2 P’s How are you going to do it till nature takes over? P laster cast in elbow hyper-flexion after Closed reduction P ercutaneous Pinning with K-wires after closed reduction Full Elbow flexion is a boon or a curse? From Text Book Of Orthopedics, by Dr. John Ebnezar, ,!V Edition, Jaypee Brothers: Full Elbow flexion is a boon or a curse? From Text Book Of Orthopedics, by Dr. John Ebnezar , ,!V Edition, Jaypee Brothers We were taught that most stable position is full elbow flexion (triceps acts as an internal splint) with a 90 forearm pronation Sounds good but with gross swelling of the elbow it brings in the dangerous vascular problems Is everything alright with Hyperflexion? Think again: Is everything alright with Hyperflexion ? Think again Hyperflexion -  in creases compartment pressures Doppler shows decrease flow   in the brachial artery( Mapes and Hennrikus ) Hence position   of flexion and sup in ation for "vascular safety" but stability is compromised Pin  fixation    obviates need for considerable elbow flexion The basic concept is that, in any   case requiring elbow flexion of >90° ,use pins and keep elbow in less flexion (usually about   45° to 70°) Is this is the only reason? There is still more to it!: Is this is the only reason? There is still more to it! Distal humerus – only 20%   growth and little remodel in g   Toddlers (< 3yrs) have some remodel in g potential so non-operative   treatment of a type-II fracture accepted  Child of 8 to 10 years has only 10% of growth, so an adequate reduction   is essential to prevent malunion . Is it little wonder then that the current trend is operative in tervention? Closed reduction and PCF, The Current Craze – Where does it score? Is PCF with K wire a boon in fixing SC Fractures?: Closed reduction and PCF, The Current Craze – Where does it score? Is PCF with K wire a boon in fixing SC Fractures? Reduction and retention is difficult due to the thin bone in the SC area Acute flexion in swollen elbow poses the threat of vascular problems Hence PCF is the treatment of choice Need for immediate emergency fixation reduced Emergency treatment (<8 hours) and Emergent treatment (>8 but <24 hours) – No difference Ideally definitive treatment within 24 hours It offers excellent stability in any position of the elbow Closed Reduction and Percutaneous K-wire fixation From Step by Step fracture treatment , by Dr. John Ebnezar, Jaypee Brothers: Closed Reduction and Percutaneous K-wire fixation From Step by Step fracture treatment , by Dr. John Ebnezar , Jaypee Brothers How many pins and where? From Step by Step fracture treatment , by Dr. John Ebnezar, Jaypee Brothers: How many pins and where? From Step by Step fracture treatment , by Dr. John Ebnezar , Jaypee Brothers 2 crossed Medial and lateral pins (Swenson et al): Preferred in communited or unstable fractures 2 Lateral pins ( Arino et al): Preferred if the fracture is stable after reduction as it prevents damage to ulnar nerve 2 Lateral divergent pins (Foster and Paterson) 3 Lateral pins (Skaggs et al) 2 lateral pins and 1 medial (Haddad et al) Controversies – Crossed Pins Vs Lateral Entry Pins: Controversies – Crossed Pins Vs Lateral Entry Pins Iatrogenic ulnar nerve  in jury Medial   and lateral p in fixation (3.4%)   with lateral entry p in  fixation (0.7%) When the medial   p in is placed without elbow hyperflexion – 4% with the elbow   in hyperflexion – 15% Of course, the simplest way   to avoid iatrogenic nerve injuries is to not place a medial   pin. It does not take a genius to say this! But what about fracture stability, fortunately it does not really matter: But what about fracture stability, fortunately it does not really matter   crossed p in s were found to be stronger than two lateral p in s.   two divergent lateral p in s separated at the fracture site were   superior to crossed p in s (Lee et al) Know the Pin Basics: Do’s and Dont’s to get the best out of K-wire: Know the Pin Basics: Do’s and Dont’s to get the best out of K-wire To prevent ulnar nerve injury in medial pinning Insert k wire after making a small incision over the medial epicondyle and drilling the medial cortex (Royce et al) The lateral p in (s) should be placed first, the elbow   should then be extended, and the medial p in  should be placed   without hyperflexion of the elbow. Angulate pins 40 deg superior and 10 deg posterior Pins should pierce opposite cortex Smooth pins are preferred Supine position better than prone With Pining ruling the roost, is the time tested plaster cast relegated to the dust bin?: With Pining ruling the roost, is the time tested plaster cast relegated to the dust bin? Is it necessary to CR+PCF for all displaced fractures? Or there is a place for the plaster cast? According to a study approximately 60% of the cases can be treated by inelastic strapping and collar, cuff immobilization ( Williamson et al) The only study reported comparing this with pinning, does not show any advantage with the latter All is not well with pinning, it has it’s limitation too : All is not well with pinning, it has it’s limitation too Injury to ulnar nerve Pin tract infection Breakage Migration C – arm required Needs another procedure to remove Thus there is a pressing need for an effective alternative! Alternative to Pinning - Blount’s technique: Alternative to Pinning - Blount’s technique About 1/3 can be treated with this technique Indicated for a reducible fracture that is stable under GA Closed reduction done by ATRP technique Cast around the wrist with forearm in pronation and elbow in full flexion and a collar and cuff sling Monitor the patient for 24 hours Useful for type II and a few Type III fractures Where Blount’s Fail and Pinning Succeeds - Limitations of Blount’s technique: Where Blount’s Fail and Pinning Succeeds - Limitations of B lount’s technique Major elbow swelling that prevents full flexion Vascular injury Irreducible fractures or unstable fractures after closed reduction Cast Vs Pins: What does EBM say?: Cast Vs Pins: What does EBM say? 2 Studies of CR and Cast ( Hadlow et al and Parikh et al) In contrast, in a study closed reduction and pin   fixation The results of two studies support the  in itial treatment of   type II  fractures  with closed reduction and a cast. 23% lost reduction.  20% had delayed   surgery 8% had an unsatisfactory outcome accord in g   to the criteria of Flynn et al There was no radiographic or cl in ical loss of reduction   No cubitus varus No hyperextension No loss of motion No iatrogenic   nerve palsies No need for additional surgery No vascular  in juries   No delayed orMal -union Type-I Fractures - Recap: Type-I Fractures - Recap Long arm cast Elbow  - 60° to   90° of flexion Approximately 3 weeks Follow-up radiographs - 1 and 2 weeks to identify   any fracture displacement Type-II Fractures - Recap: Type-II Fractures - Recap If fracture is stable after reduction and no gross swelling – Blount’s technique If otherwise – Pinning Blount’s hold an edge in this variety Type-III Fractures - Recap: Type-III Fractures - Recap First, the arm is placed  in  30° of flexion to m in imize vascular   in sult and compartment pressure. If fracture is stable after reduction and no gross swelling – Blount’s technique If otherwise - Pinning However, Current trend is operative intervention Type-IV Fractures - Recap: Type-IV Fractures - Recap Preferred Method Leitch et al’s Closed reduction and K-Wire technique   open reduction and internal fixation with K-wires or plate and screws is the preferred method First place 2 K-wires  in to the distal   fragment. Next, fracture reduced  in  the AP and then sagittal plane K - wires are driven   across the fracture site All   fracture united No cubitus varus , mal-union,   or loss of motion No additional operative treatment was   required. Is there a place for other Methods?: Is there a place for other Methods? Traction methods – Is it a history? Open reduction – What is its role? Do not hasten to push Traction to the oblivion for it still has a role: Do not hasten to push Traction to the oblivion for it still has a role Limited role Gross swelling – to tide over If patient presents late For initial maintenance before fixation either open or closed Open reduction and internal fixation – Not a taboo in SC fractures: Open reduction and internal fixation – Not a taboo in SC fractures Indications Failed closed reduction Puckered skin Open fractures Vascular injury Complications Infection Vascular injury Myossitis ossificans Excessive callus Loss of motion When to do? Emergently or Urgently but not later than 5 days. If there is vasular injury, fasciotomy is done at the same time Plethora of choices – What is the moral?: Plethora of choices – What is the moral? Plaster Pinning Traction Operation There is nothing wrong with any of the above methods, what is wrong is the choice we make. Ultimate result not on placement of the cast or pin but quality of reduction (Follow ATRP) Make the right choice and allow the nature to do its best If not you bring in the complications Residual cubit varus is seen in 21% and is due to poor position after reduction Cubitus varus (Gunstock elbow) From Practical Orthopedics , by Dr. John Ebnezar, IK Publishers : Cubitus varus (Gunstock elbow) From Practical Orthopedics , by Dr. John Ebnezar , IK Publishers Most common complication Incidence - 9 to 58 percent Causes of cubitus varus: 4 ‘I’s (It is more due to human error than nature’s error) : Causes of cubitus varus : 4 ‘I’s (It is more due to human error than nature’s error) I mproper persons treating • I mproper reduction(Hence Follow ATRP) • I mproper interpretation of radiographs (Learn all the radiological signs) • I mproper follow-up Cubits Varus- Some Myths: Cubits Varus - Some Myths 1. Myth: Due to Unequal growth  in  the distal   part of the humerus Reality: unlikely as there is not enough residual growth left   in  this area to cause cubitus varus with in  the time  in  which   it is recognized 2. Myth: The most common reason for cubitus varus  is mal-union   rather than growth arrest Reality: Yes 3. Myth: Cubitus varus cannot be   prevented Reality: Can be prevented by mak in g certa in  that the Baumann angle is  in tact   at the time of reduction and rema in s so dur in g heal in g. Who told you that the problems of Cubitus Varus only Cosmetic – Think again: Who told you that the problems of Cubitus Varus only Cosmetic – Think again Myth 4: In  the past treatment for cosmetic reasons only Reality: Several other consequences   of cubitus varus   In creased risk of lateral condyle   fractures Pa in Tardy postero -lateral rotatory   in stability Path mechanics : Path mechanics Posterior displacement Horizontal rotation Coronal tilt. All these three components causes cubitus varus deformity Treatment : Treatment Corrective osteotomy after Skeletal maturity Lateral closed-wedge osteotomy (French ) From Text Book Of Orthopedics, by Dr. John Ebnezar, ,!V Edition, Jaypee Brothers: Lateral closed-wedge osteotomy (French ) From Text Book Of Orthopedics, by Dr. John Ebnezar , ,!V Edition, Jaypee Brothers Simple and easy Posterior triceps splitting approach First screw - anteriorly in the distal fragment Second screw - posterior in the proximal fragment Osteotomy is done between two screws Distal fragment is rotated Both screws become parallel and correction of rotational deformity A wedge of bone is removed from the lateral cortex a figure of ‘8’ stainless steel wire is applied Modified French ( Bellemore ) - LWO is just short of the medial cortex. Results are superior. Other Osteotomies – they also have a role in specific instances:  Other Osteotomies – they also have a role in specific instances Uniplanar Supracondylar close wedge osteotomy (Voss et al) Simple Good correction Minimal complication Medial open-wedge osteotomy (King’s osteotomy ) This is the opposite of lateral closed-wedge osteotomy . Gains length and inherently unstable Oblique De-rotation Osteotomy Not as popular as the lateral closed and medial open-wedge osteotomies . Beneficial but de-rotation is not necessary Step cut Osteotomy Step cut Translation Osteotomy with a Y - shaped humeral plate When more extensive osteotomies needed in older children and Young adults The Golden adage, Prevention is better than cure holds good for Cubitus Varus?: The Golden adage, Prevention is better than cure holds good for Cubitus Varus ? Clinical Tests : Long axes of the forearm and humerus should be parallel when elbow is flexed after reduction. Radiographs AP view: Baumann’s angle should restored Lateral view : All the radiological signs should be restored. Ignoring these criteria after closed reduction results in future cubitus varus deformity. Cubitus valgus: Cubitus valgus R are S een in postero -lateral displacement in the extension type. C osmetically acceptable T reatment is by medial closed-wedge osteotomy . Tardy ulnar nerve palsy is a distinct possibility Complications Causing Functional Impairment - :  Complications Causing Functional Impairment - Neurological Complications : incidence is 7 % Vascular injury:  The incidence is 0.5 and 1  %. Loss of mobility:   Average loss of flexion is 4 ° Myositis ossificans :  R are and is seen in manipulative closed reduction and open reduction. Complications – Nerve injury Mercifully do not require active interventions : Complications – Nerve injury Mercifully do not require active interventions Seen in 3-22% Usually a neuropraxia Any of the peripheral nerves may be involved Mixed nerve lesions also seen Continued nerve palsy indicates entrapment in fracture callus Observe: Usually recovers within 2-4 months Operate: If not explore and do neurolysis ( usually after 5 months) Culp et al. Vascular injury – Rare but is a Scare : Vascular injury – Rare but is a Scare Seen in 10-20% of the cases Usually corrected once reduction is done If circulation does not return within 5 minutes, consult a vascular surgeon Doppler and pulse oxymeter needs to be used Arteriogram if entrapment or if vessel is severed Closed reduction, K wire fixation and immobilization in less than 90 deg If the radial pulse remains to be absent but the hand is well perfused , observation Radial pulse may appear as late as 1-2 weeks Compartment syndrome Stages of Volkman’s ischemia – Impending, Establishing, Established From Text Book Of Orthopedics, by Dr. John Ebnezar, ,!V Edition, Jaypee Brothers: Compartment syndrome Stages of Volkman’s ischemia – Impending, Establishing, Established From Text Book Of Orthopedics, by Dr. John Ebnezar , ,!V Edition, Jaypee Brothers Rare but serious The rate 0.1% to 0.3% Impending Ischemia 24-48 hours. 5 P’s/Stretch pain. Split, reduce and open. No circulation: Inject (1% lignocaine )/Repair/ Anastomose / Resect Establishing ischemia 48 hours to 3 weeks. Fasciotomy Established VIC After 3 weeks. Reconstructive surgeries Fasciotomy – When, Where and how? From Text Book Of Orthopedics, by Dr. John Ebnezar, ,!V Edition, Jaypee Brothers: Fasciotomy – When, Where and how? From Text Book Of Orthopedics, by Dr. John Ebnezar , ,!V Edition, Jaypee Brothers Indications: Motor or sensory loss If CP > than 35-40 mm hg Interrupted circulation more than 4 hours Standard anterior Henry approach most preferred method (Eaton and Green et al) Pin Track Infections: Pin Track Infections For K-wire fixation of a fracture - <1%   to 21%. For  supracondylar fractures  - <1% to 6.6% Resolves with adm in istration of oral   antibiotics and p in  removal What do to if the patient presents late?: What do to if the patient presents late? Initial traction Closed reduction and plaster Closed reduction and PCIF Open reduction and internal fixation To continue with traction Flexion type of Supracondylar fracture and Sultanpur technique From Text Book Of Orthopedics, by Dr. John Ebnezar, ,!V Edition, Jaypee Brothers: Flexion type of Supracondylar fracture and Sultanpur technique From Text Book Of Orthopedics, by Dr. John Ebnezar , ,!V Edition, Jaypee Brothers This is extremely rare and has an incidence of only 2.5 percent. Mechanism of Injury C ommon method of injury is direct blow to the posterior aspect of the arm. Angulations are reverse of extension type. High incidence of ulnar nerve injury . Treatment Closed reduction and above elbow cast in extension To overcome this, Sultanpur technique is used . If reduction can be achieved by closed methods, the fracture can be stabilized in flexion with percutaneous pins. If reduction cannot be achieved then open reduction and internal fixation is contemplated Take home message – What is that Supracondylar fracture teaches us?: Take home message – What is that Supracondylar fracture teaches us? A senior friend told me that SC fracture humerus is an UG topic and not a PG topic PG’s know everything about SC fracture and there is nothing to learn for them This set me thinking I got the answer when my friend Dr Anand posted an interesting case on the BOS Website Let me share that with you A case of Supracondylar fracture in a 10 year old boy: A case of Supracondylar fracture in a 10 year old boy Type IIIA Likely Options: Closed reduction or casting (Blount’s) Closed reduction or PC pinning Or even traction and later fixation could be tried Of all the better options, Fracture was opened and fixed: Of all the better options, Fracture was opened and fixed 4 years later, an ugly CV deformity despite opening and fixing the fracture under direct vision: 4 years later, an ugly CV deformity despite opening and fixing the fracture under direct vision We need to wake up: We need to wake up A gross cubitus deformity despite opening the fracture site Extremely rare (very few references in the literature) Why did this happen? Improper reduction? Improper evaluation? Improper fixation? Or utter disregard to the basics? Or a combination of all Who is to be blamed? The teacher who did not teach or the student who did not learn We Can do arthroplasty and arthroscopy but not correctly reduce and fix a simple SC fracture We need to introspect I am happy I have chosen this Undergraduate topic for PG students For let us have good UG knowledge first, then let us have a better PG knowledge and finally let us become a good orthopedic surgeon who will not take false pride in doing big things but take pride in doing simple things correctly!! Let us try to leave our footprints in the sands of time -The path we choose: Let us try to leave our footprints in the sands of time -The path we choose We disregard basics We are keen to do surgeries, nothing wrong but We do not know, learn, respect or are interested in basics Hence we sink into oblivion with all the choices while our forefathers soared into the zenith with hardly any choices! So what we want to be, again the choice is with us Hope you have learnt this from the story of the supracondylar fracture of the humerus Practical orthopedics by Dr John Ebnezar: Practical orthopedics by Dr John Ebnezar Only book in the World that deals with all about practical examination in orthopedics Published by IK International publishers, Now in the Medical Book Stores Get your copy now Thank you for your kind attention

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