Pediatric Supracondylar Humerus Fracture CRPP 24538

Type III Suprracondylar Humerus Facture 

Type III Suprracondylar Humerus Facture crpp

Type III Suprracondylar Humerus Facture crpp
CPT Coding Technique: CRPP, ORIF
Indications Complications
Contraindications Follow-up Care
Alternatives Outomes
Pre-op Planning / Special Considerations Review References

synonyms: pediatric supracondylar humerus fracture CRPP, supracondylar humerus fracture percutaneous pinning, perc pinning

Pediatric Supracondylar Humerus Fracture CRPP CPT

Pediatric Supracondylar Humerus Fracture CRPP Indications

  • Type III supracondylar humerus fracture.
  • Unstable Type II supracondylar humerus fracture.
  • Open fracture
  • Ipsiliateral forearm fracture (Tabak AY, JBJS 2003;85Br:1169).
  • Open reduction indicated for: irreducible closed, vascular compromise necessitating exploration and repair, open fx

Pediatric Supracondylar Humerus Fracture CRPP Contraindications

  • Nerve deficit felt to be within the fracture site
  • Open Fracture
  • Vascular injury

Pediatric Supracondylar Humerus Fracture CRPP Alternatives

  • ORIF
  • Olecranon pin

Pediatric Supracondylar Humerus Fracture CRPP Pre-op Planning / Special Considerations

  • Milk brachialis, avoid medial pin especially if placed in flexion. OR try to preserve intact periosteum
  • Skaggs et all (JBJS 83A:736, 2001)after retrospective review of 345 cases does not recommend the routine use of crossed pins and found increased ulnar nerve injury with medial pins.
  • Zoints (JBJS 76A:253 1994)=crossed medial and lateral pins are strongest against rotational displacement; followed by 3 lateral pins>2 parallel lateral pins>>crossed lateral pins.  Avoid crossed lateral pins.
  • Can monitor pulseless well perfused arm
  • delayed CRPP is as effective as acute. (Mehlman, Cincinnati JBJS 83A;323,2001)
  • If the median nerve has been injured, the patient may not complain of the pain of an impending compartment syndrome.

Pediatric Supracondylar Humerus Fracture CRPP Technique

  • Pre-operative antibiotics, +/- regional block
  • General endotracheal anesthesia
  • Supine position. All bony prominences well padded.
  • Prep and drape in standard sterile fashion.
  • Reduction obtained with longitudinal traction in extension to regain length. Varus/valgus angulation and rotation correctd. Elbow flexed and pronated with thumb pressure over the olecranon securing the reduction.
  • Consider using coban around the forearm and arm to hold reduction while pins are placed.
  • 0.062-in pins
  • Evaluate and document the circulatory status of the arm after fixation.
  • Splint the arm in less than 90 degrees of flexion.

Pediatric Supracondylar Humerus Fracture ORIF Technique

  • Pre-operative antibiotics, +/- regional block
  • General endotracheal anesthesia
  • Supine position. All bony prominences well padded.
  • Prep and drape in standard sterile fashion.
  • 3cm longitudinal incision over medial condyle>SQ>fat>fracture hematoma/fracture. +/-lateral incision if needed. 
  • Consider anterior cubital approach (Ay S, JPO 2005;25:149).
  • Irrigate.
  • Close in layers.

Pediatric Supracondylar Humerus Fracture CRPP Complications

  • Cubitus varus: Most common complication, due to malreduction, not growth disturbance, sequela is cosmetic
  • Compartment syndrome
  • Neurologic Deficit: 5-19% nerve injury(JAAOS),  If no improvement either clinical or EMG at 5 months exploration recommended.(Culp,JBJS 72A:1211, 1990)
  • Vascular injury 5-12%
  • Volkmanns Ischemic contracture: <1%
  • Angular deformity: most commonly cubitus varus-primarily a cosmetic only deformity-remodeling potential is limited as distal humerus contributes only 20% of humeral growth.
  • Malunion: Completely displaced supracondylar fractures that become sufficiently rigid with new callous formation cannot be adequately manipulated approximately 7 days following the injury.  The treatment of choice at this time is to apply a new cast and let the fracture heal.  This should be followed by reassessment of the appearance and function of the fracture to determine if a corrective osteotomy is necessary.  Delayed open reduction carries a risk of producing myositis ossificans in 85% of patients with this injury.  (Atign'a JEO: Conservative management of supracondylar fractures of the humerus in Eastern Provincial General Hospital.  East Afr Med J 1984;61:557-560).   Malunion may lead to ulnar neuropathy, increased risk of late lateral condyle fractures, posterolateral rotatory instability and active extension loss.
  • Stiffness
  • Myositis Ossificans
  • Nonunion
  • Avascular Necrosis
  • Cubitus varus, Compartment syndrome, Neurologic Deficit, Vascular injury, Volkmanns Ischemic contracture, Angular deformity, Malunion, Stiffness, Myositis Ossificans, Nonunion, Avascular Necrosis

Pediatric Supracondylar Humerus Fracture CRPP Follow-up care

  • if CRPP  splint at 60-90 degrees, overwrap to LAC at f/u, remove K-wires in 3-4 wks
  • physical therapy is generally not needed.

Pediatric Supracondylar Humerus Fracture CRPP Outcomes

Pediatric Supracondylar Humerus Fracture CRPP Review References

  • Kasser JR, in Rockwood and Wilkins Fractures in Children, 6th Ed, 2006
  • Sullivan JA, AAOS-OKO
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