Surgical Procedure for Supracondylar Humerus Fracture: Posterior Approach with Plating
Open reduction and internal fixation via posterior approach is the recommended treatment for adult supracondylar humerus fractures to achieve anatomical reduction with rigid fixation, allowing for immediate postoperative movement which provides the least morbidity and best results. 1, 2
Preoperative Considerations
- Obtain appropriate imaging including radiographs and CT scan to determine fracture pattern, displacement, and angulation
- Assess neurovascular status of the limb, particularly checking for ulnar nerve function
- Plan for appropriate plate selection based on fracture pattern
Surgical Procedure: Step-by-Step
1. Patient Positioning
- Position patient in lateral decubitus or prone position
- Support the affected arm on an arm board with elbow flexed at 90 degrees
- Prepare and drape the arm in standard sterile fashion
2. Incision and Exposure
- Make a straight posterior midline incision centered over the olecranon and extending proximally
- Deepen the incision through subcutaneous tissue to expose the triceps mechanism
- Choose one of the following approaches for triceps management:
- Triceps-splitting approach: Split the triceps muscle and tendon in the midline
- Triceps-reflecting approach: Elevate the triceps from lateral to medial
- TRAP (Triceps-reflecting anconeus pedicle) approach: Reflect triceps with anconeus as a continuous flap
3. Fracture Exposure and Nerve Protection
- Identify and protect the ulnar nerve by gentle retraction
- Expose the fracture site by retracting soft tissues
- Remove hematoma and debris from the fracture site
- Identify key anatomical landmarks including the olecranon fossa
4. Fracture Reduction
- Reduce the fracture anatomically using reduction clamps or temporary K-wires
- Confirm reduction with direct visualization and fluoroscopy
- Ensure restoration of the normal carrying angle and trochlear-capitellar alignment
5. Plate Application
- Select an appropriately contoured posterior plate
- Position the plate on the posterior surface of the distal humerus
- Ensure adequate proximal and distal fixation points
- Secure the plate with screws proximally and distally to the fracture
- Confirm plate position and screw length with fluoroscopy
6. Closure
- Repair the triceps mechanism meticulously
- Close the wound in layers
- Apply sterile dressing and posterior splint with elbow in 30-45 degrees of flexion
Postoperative Management
Begin early controlled mobilization as soon as pain allows (typically within 1-2 weeks)
Follow a three-phase rehabilitation protocol:
- Initial phase (0-2 weeks): Sling immobilization with pendulum exercises
- Early mobilization phase (2-6 weeks): Progressive active-assisted range of motion
- Strengthening phase (6-12 weeks): Progressive resistive exercises and scapular stabilization
Schedule regular follow-up with radiographic evaluation at 1,3, and 6 weeks
Potential Complications and Prevention
- Ulnar nerve injury: Careful identification and protection during surgery
- Triceps weakness: Adequate repair of the triceps mechanism
- Elbow stiffness: Early mobilization protocol
- Hardware prominence: Proper plate contouring and positioning
- Infection: Meticulous surgical technique and appropriate perioperative antibiotics
Important Considerations
- This approach is specifically for adult supracondylar fractures and differs from pediatric management
- Pediatric supracondylar fractures are typically managed with closed reduction and percutaneous pinning 3, 4, 5
- Anatomical reduction with rigid fixation is crucial for optimal functional outcomes 2
- The posterior approach provides excellent exposure of the fracture site but requires careful handling of the triceps mechanism