supracondylar fracture - ed central

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SUPRACONDYLAR FRACTURE “Children’s Games”, oil on canvas, 1560, Peter Breugel, the Elder, Kunsthistorisches Museum, Vienna, Austria. The following are entries taken from The Calendar of Coroner’s Rolls, for the city of London, in the early to mid Fourteenth century. A Game On The Way To School, AD 1301: On Tuesday (19 July), Richard, the son of John le Mazon, who was eight years old, was walking immediately after dinner across London Bridge to school. For fun, he tried to hang by his hands from a beam on the side of the bridge, but his hands giving way, he fell into the water and drowned. Being asked who were present, the jurors say a great

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Page 1: Supracondylar Fracture - ED Central

SUPRACONDYLAR FRACTURE

“Children’s Games”, oil on canvas, 1560, Peter Breugel, the Elder, Kunsthistorisches

Museum, Vienna, Austria.

The following are entries taken from The Calendar of Coroner’s Rolls, for the city of

London, in the early to mid Fourteenth century.

A Game On The Way To School, AD 1301:

On Tuesday (19 July), Richard, the son of John le Mazon, who was eight years old, was

walking immediately after dinner across London Bridge to school. For fun, he tried to

hang by his hands from a beam on the side of the bridge, but his hands giving way, he fell

into the water and drowned. Being asked who were present, the jurors say a great

Page 2: Supracondylar Fracture - ED Central

multitude of passers-by whose names they know not, but they suspect no one of the death

except mischance.

Playing On The Timber Pile, AD 1322:

On the Sunday before the Feast of St. Dunstan, Robert, son of John de St Botulph, a boy

seven years old, Richard, son of John de Chesthunt, and two other boys whose names are

unknown were playing on certain pieces of timber in the lane called “Kyroune Lane” in

the ward of Vintry, and one piece fell on Robert and broke his right leg. In the course of

time Johanna his mother arrived and rolled the timber off him and carried him to the

shop, were he lingered until the Friday before the feast of St Margaret, when he died at

the hour of prime, of the broken leg and of no other felony; nor do the jurors suspect

anyone of the death, but only the accident and the fracture.

A Boy Thief, AD 1324:

On Monday (in April, 1324) at the hour of Vespers John, son of William de Burgh, a boy

five years old, was in the house of Richard le Latthere and had taken a parcel of wool

and placed it in his cap. Emma, the wife of Richard, chastising him, struck him with her

right hand under his left ear so that he cried. On hearing this, Isabella, his mother raised

the hue and carried him thence. He lingered until the hour of curfew of the same day,

when he died of the blow and not of any other felony. Emma forthwith fled, but where she

went or who received her, the jurors knew not. Afterwards she surrendered herself to the

prison at Newgate.

A Lost Ball, AD 1337:

On Tuesday in Pentecost Week John, son of William atte Noke, chandler, got out of a

window in the rent of John de Wynton, plumber, to recover a ball lost in a gutter at play.

He slipped and fell, and so injured himself that he died on the Saturday following of the

fall.

Children throughout the ages do not change in at least one respect. As depicted in Peter

Breugel the Elder’s painting of the mid Sixteenth century they will always play games

and because of their youthful inexperience will forever be prone to injury from these. In

bygone centuries injuries that today seem relatively innocuous would often prove fatal, as

can be seen from the heart wrenching Coroner’s rolls of Fourteenth century London.

Death from infection and lack of medical knowledge and skills in general were

commonplace. In an age when very few could swim even a simple fall into a river could

prove lethal despite the presence of “a great multitude of passers-by”. In the 21st century

great progress has been made, yet children still play games and are prone to injury. One

of the commonest is the supracondylar fracture following a fall from the monkey bar,

slide or trampoline. Fortunately in the 21st century death would not be expected from an

injury such as this, however significant disability is still possible without appropriate

treatment.

Page 3: Supracondylar Fracture - ED Central

SUPRACONDYLAR FRACTURE

Introduction

This is a fracture that occurs in the distal third of the humerus, but proximal to the bone

masses of the trochlea and capitulum.

It is a common fracture of childhood.

The most immediate serious complication is that of vascular compromise. Severe injuries

have high potential for this.

Epidemiology

Supracondylar fractures are predominantly childhood fractures of the first decade of life.

They are the most common elbow fracture in children.

Peak incidence occurs at about 5 - 8 years of age and becomes much less common after

about 15 years of age.

Mechanism

These injuries will generally be due to a fall on the outstretched hand with:

● Elbow bent, resulting in a posteriorly displaced fracture.

● With the elbow straight, resulting in an anteriorly displaced fracture.

Classification

Supracondylar fractures are classified as:

● Flexion-type, (these are rare, 2 %)

♥ Here the distal fragment is displaced anteriorly.

● Extension-type (the usual form, 98%)

♥ Here the distal fragment is displaced posteriorly.

Extension type fractures are further classified according to the Gartland classification.

Page 4: Supracondylar Fracture - ED Central

Gartland Type I Gartland Type II Gartland Type III

Gartland Type I:

● These are undisplaced fractures

Gartland Type II:

● These are angulated fractures with retain an intact posterior cortex

Gartland Type III:

● These are fractures with posteriorly displaced distal fragments with no cortical

contact.

Complications

1. Vascular injury:

● The most serious complication is vascular compromise of the brachial

artery.

● If not relieved there is a risk of ischaemia of the anterior compartment of

the forearm with consequent Volkmann’s ischaemic contracture.

● The risk of vascular injury increases with the grade of Gartland’s type,

(Gartland I < Gartland II < Gartland III).

2. Nerve injury:

● This is not as common as vascular injury.

Page 5: Supracondylar Fracture - ED Central

● In order of frequency:

♥ Anterior interosseus nerve palsy > median nerve palsy > ulnar

nerve palsy > radial nerve palsy.

3. Compartment syndrome.

Late complications may include:

4. Elbow stiffness.

● A lack of full elbow extension through sagittal malalignment is common.

● It is not generally improved with physiotherapy, but some remodelling can

occur over years.

5. Myositis ossificans.

6. Malunion:

● This can result in cubitus varus (or gunstock) deformity.

Cubitus varus deformity results in the normal carrying angle of the arm

being reversed causing the forearm to deviate abnormally to the midline

when the elbow is extended.

Functional deficit is minimal but there can be significant cosmetic effect.

7. Malalignment:

● Malalignment in the sagittal plane (i.e. flexion or extension).

● Fortunately however this is usually not a cosmetic or functional problem

because of the large range of movement in the elbow joint and because of

compensation through shoulder movements.

Clinical Assessment

1. Pain and variable swelling / bruising.

● Extensive anterior bruising indicates a more severe injury.

2. Neurovascular status:

● The most immediate priority will be the assessment of the distal

neurovascular status of the injured limb (pulse, peripheral perfusion).

♥ Significant compromise will mandate more urgent intervention.

Page 6: Supracondylar Fracture - ED Central

3. Variable deformity, this can range from none to severe:

Clinically a dislocated elbow may be confused with a displaced supracondylar

fracture. The 2 conditions may be distinguished clinically, however by examining

the relationship of the olecranon to the epicondyles. 1

● Normally the olecranon and

epicondyles form a straight line

in the fully extended elbow,

whilst in the fully flexed elbow

the olecranon forms an

equilateral triangle with the

epicondyles.

● In supracondylar fractures the

equilateral triangle relationship is

preserved, whilst in a dislocation

it will be distorted.

1. Normal relationship in

flexed elbow

2. Normal relationship in

supracondylar fracture.

3. Disturbed relationship in

elbow dislocation.

4. Skin tethering:

● Assess for any significant skin tethering, which may indicate potential for

ischaemic skin loss.

Investigations

Plain radiography:

Displaced fractures will be readily seen on plain A-P and lateral radiographs.

Fractures may be difficult to detect in cases of:

● The very young, due to the large numbers of ossification centres around the

elbow (see appendix 1 below).

● Non displaced fractures, where radiological signs can be quite subtle.

Page 7: Supracondylar Fracture - ED Central

When fracture is not obvious on plain radiography, but clinical suspicion is high,

the more subtle features of bony injury need to be carefully searched for:

Signs that raise suspicion for injury when fracture is not readily apparent include

the following 4 signs:

Fat pad signs:

Anterior and Posterior “Fat pads”

If a fracture line cannot be definitely determined, yet clinical suspicion remains, evidence

of soft tissue effusion should be looked for as an indication of possible underlying occult

intra-capsular fracture.

Effusion is suggested by the “fat pad” signs, (see above).

● The anterior fat pad may normally be seen as a lucent line adjacent to the bone.

It is abnormal if it is elevated away from the bone.

● The posterior fat pad is not normally seen. If it is present in any degree an

effusion is present.

Cortical Buckling:

● A most subtle sign can be slight cortical buckling on each supracondylar ridge

seen on the A-P (see 1 below).

● With more significant injury, a “hairline” fracture will become visible on the AP

view and with greater injury again the fracture line will become detectable on the

lateral view (see 2&3 below).

Page 8: Supracondylar Fracture - ED Central

Cortical buckling suggesting fracture.

Anterior humeral line malaligment:

It should first be established that the lateral radiograph is in fact a true lateral. This can be

determined by the “hourglass” or “figure of 8” sign.

On a true lateral (left) there is a symmetric figure of eight/hourglass sign at the

distal humerus. On an imperfect lateral radiograph (right) this is asymmetric.

Next the alignment of the anterior humeral line should be examined.

Page 9: Supracondylar Fracture - ED Central

The Anterior Humeral Line

The anterior humeral line is obtained by extending a line along the anterior humeral

cortex on a true lateral radiograph with the elbow flexed to 90 degrees. Normally, this

line will pass through the middle one third of the capitellum, as seen with the yellow

line above (middle image). The red line shows the normal radiocapitellar line.

The anterior humeral line of a toddler or child must intersect the middle third of an

ossified capitellum. On the right above this lines passes in front of it, indicating that a

fracture (Gartland I) is present. Backward tilt of the distal fragment is also seen. Note that

in the normal elbow the articular surface of the distal humerus lies at 45 degrees

(anteriorly) to the long axis of the shaft of the humerus

Baumann’s angle:

Another diagnostic aid in evaluating radiographs of suspected

supracondylar fractures in children is the determination of

Baumann’s angle on the AP film.

This is the humeral capitellar angle or the angle measured

between the long axis of humeral shaft and the growth plate of

lateral condyle, (see left).

This is normally 75 degrees.

Therefore an increase in Baumann’s angle indicates medial

tilting of the distal fragment.

Page 10: Supracondylar Fracture - ED Central

Management

Initial management:

1. The first priority in management will be to check the circulation:

● If there is vascular compromise the elbow should be extended until the

circulation is restored. 1

● If this manoeuvre does not restore the circulation, then urgent reduction

will be necessary.

2. Analgesia as clinically indicated.

● Intranasal fentanyl is a good option for children.

3. Sling immobilization:

● If the circulation is not compromised, then

immobilization in a sling with the elbow

flexed to 90 degrees will help stabilize and

splint posteriorly displaced fractures, (the

flexion counteracting the backwards pull

of the triceps muscle).

● Note, that excessive flexion (> 90 degrees) may compromise the

circulation, especially where there is significant swelling.

The position of the elbow after supracondylar fracture can actually be

more important than the position of the fracture itself. That is,

immobilization in greater than 90 degrees of flexion can result in

significant swelling and potentially vascular compromise. This can have a

much more damaging effect on final functional outcome than a minor

displacement of the fracture. 2

Subsequent management

Subsequent management will then depend on a range of factors, including:

More urgent management will be required for cases of:

● High grade Gartland injury (III)

Page 11: Supracondylar Fracture - ED Central

● Secondary complications

● Neurovascular compromise

● Significant skin tethering

● Compound injuries

● Compartment syndrome.

Gartland I:

● If no other complications, these do not need urgent Orthopaedic referral.

● No reduction is required.

● Immobilization is then in an above - elbow backslab with 90 degrees elbow

flexion with sling for a period of 3 weeks.

♥ Note that the backslab should extend as high above the elbow as possible

(i.e. close to the axilla) and down to the MCP joints.

● Gartland type I fractures can be followed up by a GP in three weeks. Repeat x-ray

is not routinely necessary.

Gartland II:

● Depending on expertise available, most will need Orthopaedic referral.

● Reduction is achieved by an anterior push on the distal fragment as the elbows is

flexed to 90 degrees.

● If there is also coronal deformity i.e. lateral (valgus) or medial (varus)

displacement on A-P views, these do not remodel well and so will require

reduction.

Note that the normal “carrying angle” is about 10 degrees valgus.

● Immobilization is then in an above-elbow backslab with 90 degrees elbow

flexion with sling for a period of 3 weeks.

● At 3 weeks post-injury the backslab can be removed and a check x-ray out of

backslab is taken Check for adequate callus. Allow gentle ROM.

A check x-ray at 6 weeks post-injury should also be taken.

Page 12: Supracondylar Fracture - ED Central

Gartland III:

● These all require urgent Orthopaedic referral.

● They require reduction and percutaneous pin fixation.

● A post operative check x-ray is taken at 6 weeks.

Neurological injury:

The great majority of neurological injuries are neuropraxias and will resolve with time.

Persistent neurological injury should be investigated with nerve conduction studies if still

unchanged three months after injury.

Disposition:

Indications for timely/urgent Orthopaedic referral include:

● Associated absence of pulse or ischaemia

● Open or impending open fracture (extensive anterior bruising)

● Associated nerve injuries

● Gartland type II & III fractures

● Associated same arm forearm or wrist injury

● Flexion supracondylar fractures

● Failure to maintain a reduction.

Page 13: Supracondylar Fracture - ED Central

Appendix 1

Epiphyseal lines at the elbow 1

Typical appearances at ages 2, 4, 6 and 9

years are shown above.

Average times for appearance of ossification

centers:

Capitulum 1 year of age.

Radial Head 3 years

Medial Epicondyle 5 years

Trochlea 7 years

Olecranon 9 years

Lateral Epicondyle 11 years

Fusion of the various epiphyseal lines occurs

by 15-20 years.

Patients less than 3 years of age do not yet have full ossification of the capitellum. The

supracondylar injury in these patients may appear to be a dislocation of the elbow but is

usually a physeal separation (Salter-Harris type I). True elbow dislocation in this age

group is very rare.

Page 14: Supracondylar Fracture - ED Central

Appendix 2

Above: Supracondylar fracture (Gartland I) in a 7 year old boy. There is mild dorsal

displacement and a prominent posterior fat pad.

Left: Very severely displaced Gartland III

supracondylar fracture in a 12 year girl. The

brachial artery is at extreme risk with such an

injury.

Page 15: Supracondylar Fracture - ED Central

The modern face of supracondylar fracture! Every modern child is aware of superman’s

vulnerability to “kryptonite”, but unfortunately not their own to gravity! (Photograph

and radiograph courtesy Dr H. Stergiou)

References

1. McRae R, Practical Fracture Treatment, 3rd

ed 1994, p.131-137.

2. RCH Fracture Guidelines.

Dr. J. Hayes

Dr. P. Papadopoulos

Reviewed November 2012