Closed reduction and percutaneous pinning of supracondylar humerus fracture

Patient and case

1. Name / Age / Sex
2. UHID / IP no. / Ward-Bed
3. Date of surgery / OT no.
4. CaseElectiveEmergency (non-elective)if emergency, state urgency and reason
5. Timesin OT ___ anaesthesia start ___ incision ___ closure ___ out of OT ___

Team

1. Operating surgeonname, designation
2. Assistant(s)
3. Supervising consultantpresent in OT / available / not applicable
4. Steps done by the residentwhole procedure / named steps, under whose supervision
5. Anaesthetist
6. Scrub nurse / circulating nurse

Diagnosis and procedure

1. Pre-operative diagnosis
2. Post-operative diagnosis
3. Procedure planned
4. Procedure performedif different from plan, state why
5. Extra procedure done and reason'none' if none. Only to save life or health if not consented

Consent and safety checks

1. Informed consentGeneralProcedure-specificHigh-riskAnaesthesiain a language the patient understands: language ___ witness ___
2. Site / side markedYesNot applicable
3. WHO Surgical Safety ChecklistSign inTime outSign out
4. Antibiotic prophylaxisdrug, dose, route, time given before incision
5. VTE prophylaxisMechanicalPharmacologicalNot indicated

Risks to explain in the consent for this operation

• failure of closed reduction and need for open reduction
• nerve injury: ulnar nerve with a medial pin, AIN, median or radial nerve
• vascular problem and need for brachial artery exploration
• compartment syndrome and Volkmann ischaemic contracture
• pin-site infection, pin migration
• loss of reduction
• cubitus varus (gunstock) deformity
• elbow stiffness

Pre-operative details for this operation

1. Side, age, weightweight for drug dosing
2. Fracture typeExtension, Gartland IIExtension, Gartland IIIExtension, Gartland IVFlexion typeopen or closed; ipsilateral forearm / wrist fracture
3. Radial pulse and hand perfusion before surgeryRadial pulse present, hand pinkPulseless, pink warm handPulseless, pale cold hand (emergency)capillary refill in seconds, temperature, colour
4. Nerve status before surgeryAIN (thumb IP and index DIP flexion, 'OK' sign), median sensation, radial (wrist, thumb and finger extension, first web space), ulnar (finger abduction, little finger sensation); write 'not assessable' if child will not cooperate
5. Compartmentsforearm soft / tense; pain on passive finger stretch; agitation, anxiety, rising analgesic need
6. Time of injury and time of surgeryif delayed, reason and neurovascular checks done while waiting
7. Consent from parent / guardianname and relation; consent includes open reduction if needed

Anaesthesia and position

1. AnaesthesiaGeneral
2. PositionSupine, elbow on inverted image intensifierSupine with hand table (if open reduction likely)
3. TourniquetNot usedSterile tourniquet available for open reductionif used: pressure and time
4. C-armoperator; AP and lateral taken by rotating the shoulder, or C-arm rotated for unstable type IV

Operative findings

1. Reduction obtainedanterior humeral line through capitellum, medial and lateral columns intact on oblique views
2. Stability after pinningstressed and rotated under C-arm: stable / needed third pin
3. Carrying angle compared with the other side
4. Radial pulse and hand perfusion after reductionpulse present / absent, capillary refill, colour

Procedure (steps)

1. Parts painted and draped
2. Traction and correction in extensioncountertraction on arm; translation and varus / valgus corrected; rotation corrected by pronation or supination
3. Flexion manoeuvreElbow flexed to about 120 degrees with anterior push on olecranon, forearm pronatedFlexion type: pinned in extension / push-pull
4. C-arm check of reductionAP through forearm, oblique views of both columns, lateral by external rotation of shoulder; number of attempts
5. Pin configurationTwo lateral divergent pinsThree lateral pinsCrossed: lateral + medialTransolecranon provisional pinpins divergent, bicortical, both columns engaged, at least 2 mm apart at fracture line
6. K-wire size and numberdiameter, number, entry point
7. Medial pin (if used)1 cm incision over medial epicondyle, soft tissue spread, ulnar nerve protected with retractor or drill sleeve; elbow not in maximal flexion
8. Stability testelbow extended as far as possible, stressed and rotated under C-arm
9. Pins cut and bent outside skinfinal C-arm images after bending; number saved
10. Open reduction (if closed failed)Not neededAnterior approachOther approach (reason)number of closed attempts before opening

Closure, drains and dressing

1. Pin sitesdressing; medial incision closed with absorbable suture
2. ImmobilisationWell-padded posterior splintBivalved long arm castelbow angle (about 60 to 75 degrees, not hyperflexed)
3. Radial pulse, hand perfusion and nerve status at endpulse, capillary refill, colour; AIN / radial / ulnar when child wakes

Specimens and implants

1. K-wiresnumber, diameter, configuration, left outside skin; make, lot/batch, sticker
2. C-arm images savednumber, final AP and lateral

End of procedure

1. Estimated blood lossml
2. IV fluids and blood / products givenfluids (ml); blood: type, units, bag nos.
3. Swab, needle and instrument countCorrectIncorrect: action taken
4. Intra-operative complications / difficultieswhat happened and what was done; 'none' if none
5. Implant stickersNo implantAffixed in case sheet, OT register and for discharge summary
6. Condition at end of surgery / shifted toPACUWardICU/HDU

Post-operative orders

1. Limb elevationon pillow; elbow not hyperflexed
2. Neurovascular watchradial pulse, capillary refill, colour, finger movement: frequency written
3. Compartment syndrome watchagitation, anxiety, rising analgesic need, pain on passive finger stretch: inform surgeon at once
4. Nerve examination when awakeAIN, median, radial, ulnar: record and compare with pre-op
5. Analgesiaweight-based drug and dose
6. Check X-rayAP and lateral elbow
7. Pin-site carekeep dry; watch for discharge
8. Follow-upX-ray at 1 week, change to long arm cast at 90 degrees; pins out at 3 to 4 weeks, then gentle movement

Signature

1. Name and designation of person writing note
2. Medical Council registration no.
3. Signature / date / time of writingwrite before the patient leaves recovery