Trauma 101: Orthopedics Study Tool

Indication

Gartland type I fractures with no or minimal displacement and a normal neurovascular examination.

Implant design notes

No implant. Above-elbow cast with the elbow at around ninety degrees of flexion, avoiding hyperflexion which compromises the circulation.

Approach

Non-operative with close early review.

Steps overview

1. Document radial, median including the anterior interosseous branch, and ulnar nerve function, and the radial pulse
2. Confirm the diagnosis on true anteroposterior and lateral views, checking the anterior humeral line and Baumann's angle
3. Apply an above-elbow cast with the elbow at about ninety degrees
4. Elevate, give analgesia, and give explicit written compartment syndrome warnings
5. Review with radiographs within a week to confirm position is maintained
6. Remove the cast at three weeks and allow spontaneous return of motion

Notes

The anterior humeral line should pass through the middle third of the capitellum; if it does not, the fracture is displaced and not a type I.

Indication

Displaced Gartland type II fractures that cannot be held in an acceptable position, and all type III and unstable patterns.

Implant design notes

Smooth Kirschner wires — smooth so they cross the physis without causing growth arrest, left outside the skin for easy removal. Two divergent lateral wires engaging both columns give adequate stability in most fractures; a medial wire adds rotational stability at the cost of ulnar nerve risk.

Approach

Closed, percutaneous, on an image intensifier used as the operating table.

Steps overview

1. Document the neurovascular examination again before anaesthesia and after reduction
2. Position supine with the arm over the image intensifier
3. Reduce by traction with the elbow extended, correct medial or lateral translation and rotation, then flex and pronate while pushing the olecranon forward
4. Confirm reduction on anteroposterior, lateral and oblique views, checking Baumann's angle and the anterior humeral line
5. Insert two divergent lateral wires engaging the far cortex and both columns
6. Add a medial wire only if needed, through a small incision with the elbow extended to displace the ulnar nerve posteriorly
7. Test stability under fluoroscopy, bend and cut the wires outside the skin, apply an above-elbow cast
8. Re-check the pulse and nerve function in recovery; remove wires at three to four weeks

Notes

A pale pulseless hand that stays poorly perfused after reduction is a surgical emergency needing exploration of the brachial artery. A pink pulseless hand after satisfactory reduction may be observed closely in a monitored setting.

Indication

Failed closed reduction, open fracture, vascular injury requiring exploration, or interposed soft tissue or nerve blocking reduction.

Implant design notes

Same smooth wires after direct reduction; the exposure adds the ability to release entrapped structures.

Approach

Anterior approach if vascular exploration is needed, giving access to the brachial artery and median nerve; lateral or medial approach for a simple reduction block.

Steps overview

1. Choose the approach based on the direction of displacement and the reason for opening
2. Expose the fracture, release interposed periosteum, brachialis or neurovascular structures
3. Reduce anatomically and confirm on both views
4. Stabilise with the same wire configuration
5. Explore and repair the artery with vascular assistance if indicated
6. Cast and monitor perfusion and compartments intensively

Notes

Do not repeat forceful closed attempts — each attempt adds swelling and raises the compartment syndrome risk.