Supracondylar Fracture Humerus & Circulation

The neurovascular status must be examined in patients with supracondylar fractures. Avoid treating the patient with a cast that may cause hyperflexion of the elbow. Bending the elbow too much may affect the brachial artery. It may not be acceptable to reduce the fracture at 90° of elbow flexion. In these cases, choose a different alternative to casting, such as pinning (closed or open technique).

It is important to remember that Volkmann’s ischemic contracture may occur due to injury to the brachial artery. You have to make sure that you restore the circulation.

A few scenarios to go over

1.       The Patient has good circulation with no radial pulse (hand perfused)

a.    In this case, you would do a closed reduction and pinning as well as in-patient monitoring for 24-48 hours in order to assess the circulation of the extremity

2.       Cold Cyanotic Hand (no perfusion or you may have underperfusion)

a.       This may occur before or after attempting reduction

b.      The patient must immediately go to the operating room for closed or open reduction and pinning (No matter if the hand is underperfused or perfused at all)

c.       Monitor the circulation for anticipation of improvement

d.      If there is no immediate improvement, explore the antecubital fossa in order to explore the brachial artery

e.      Have the help of a vascular surgeon

f.        Assess the circulation

You want to think of this scenario like a knee dislocation. If you have pulses or no pulses with a knee dislocation, then you reduce the knee dislocation. It is the same with supracondylar fractures: pulses or no pulses, pink or not pink hand, cold cyanotic hand—do closed reduction and pinning. It is a more urgent condition if there are perfusion problems.

3.       Perfusion Disappears During Reduction or Monitoring

a.       If the perfusion gets worse after reduction of the fracture, then you need to find out what has happened.

b.      You will need to perform an open exploration and without an arteriogram

4.       Circulation Disappears After Closed Reduction and Pinning

a.       Reduction caused harm to the patient

b.      The pins need to be removed, the fracture needs to be unreduced and check the circulation.

c.       Check to make sure that the neurovascular bundle does not become trapped in the fracture gap after closed reduction and pinning. 

Gout, Arthritis and Joint Pain

The most common joint affected by gout is the 1^st metatarsophalangeal joint. The most common joint affected by pesudogout is the knee joint (Figure 1). Gout and pseudogout are similar problems with different causes.

Gout is caused by the buildup of uric acid and the deposit of uric acid crystals inside a joint. The best test to diagnose gout is with a joint fluid analysis. Elevated uric acid is not a good criteria. 90% of patients suffering from gout are men between the ages of 40-60 years. Gout crystals are needle shaped and negatively birefringent. When placed under polarized light they will be yellow (Figure 2).

Uric acid builds up the body by two main mechanisms. These two mechanisms are excessive urate production and diminished urate clearance. Uric acid is produced from the breakdown of proteins inside the body and from the proteins of food that is eaten.

Precipitating Factors:

The sudden attack of gout can be brought on by anything that increases the level of uric acid in the blood such as dehydration, increased consumption of alcohol, eating large amount of meat or seafood, and trauma/surgery.

Diagnostic Testing:

Aspiration and analysis of the joint fluid is the best method for diagnosis (Figure 3). There are blood tests such as white blood cell count, C-reactive protein, erythrocyte sedimentation rate, and uric acid level that are helpful in supporting the diagnosis if elevated, but if normal, it cannot definitively rule out gout or pseudogout.

Pesudogout or chondrocalcinosis is the deposition of calcium pyrophosphate dehydrate crystals in the hyaline cartilage or fibrocartilage (CPPD). Pseudogout is a metabolic disease where calcium pyrophosphate dehydrate crystals (CPPD) are formed within the joint space. It most often affects the knee and occurs more in older patients. It is a calcification of fibrocartilage (chondrocalcinosis). Pseudogout crystals are rhomboid shaped and positively birefringent. Crystals will be blue when placed under polarized light (Figure 4). Associated conditions are hyperparathyroidism, rheumatoid arthritis and gout.

Gout and pseudogout both show a sudden onset of pain, redness and swelling typically affecting a single joint in 80% of the cases. Gout symptoms include joint pain, swelling and arthritis. Patients with gout have periarticular erosions along with the formation of uric acid soft tissue masses in and around the joint which can be seen on x-ray. Soft tissue tophus deposition with periarticular erosions called “punch-out” lesions (Figure 5).

X-rays in pseudogout will show this calcification in the articular cartilage or menisci, with involvement of the patellofemoral joint (Figure 6). Calcifications of the synovium, tendon, and ligaments can also be seen.

Treatment of Gout and Pseudogout:

Acute gout can be treated with indocine and colchicine (be aware of peptic ulcer). In cases of chronic gout the patient will be treated with allopurinol (xanthine oxidase inhibitor) and colchicine. Uricosuric drugs such as Probenecid may increase uric acid excretion by the kidneys may be helpful. Pseudogout is treated with NSAIDs and intra-articular injections.

Precious Blood Supply of Bones

There are five major bones with previous blood supply. Fractures in these bones can interrupt this peculiar blood supply, causing a threat of death of the bone and nonunion of the fracture. Fractures in these areas usually occur as a result of trauma or stress related injuries.

These areas are the proximal humerus, scaphoid, proximal femur, talus, and fifth metatarsal. Interruption of the blood supply causes death of the bone and nonunion.

 

There are three types of fractures at the fifth metatarsal; avulsion fracture, Jones fracture, and mid-shaft fractures. The avulsion and mid-shaft fractures have good healing due to a sufficient blood supply. The Jones fracture compromises the blood supply which leads to nonunion of the fracture. Treatment can be achieved by non-weight bearing immobilization or may require intramedullary screw fixation in athletes and active individuals.