supracondylar fractures humerus
TRANSCRIPT
Supracondylar fractures humerus
Dr.Roshan Zameer1st year pg
Orthopaedics
• Most common elbow fractures seen in children
• 5 to 6yrs• Boys vs gals- 3:2• Left or non dominant side more common
Mechanism
• Depending on direction of displacement of distal fragment
• Extension & flexion types• Outstretched hand with elbow full extension
• Between the olecranon fossa posteriorly and the coronoid fossa anteriorly, the medial and lateral columns of the distal humerus are connected by a thin segment of bone
• elbow is hyperextended, the olecranon engages the olecranon fossa and acts as a fulcrum through which the extension force can propogate a fracture
Displacements posteromedial vs posterolateral
Classification
• Modified gartland
Signs & symptoms
• History- pulling or fall• Pain,swelling• Tenderness-both condyles• Decreased ROM• Limited extension• Gross deformity• Anterior pucker sign
S-configuration
Associated injuries
Motor & sensory examination
• Sensory-• Radial nerve- dorsal 1st web space• Median nerve – palmar index finger• Ulnar nerve – palmar little finger
• Motor• Finger, wrist, thumb extension -Radial nerve• Distal IP flexion & thumb IP flexion -Anterior
interosseous nerve• Thenar strength -Median nerve• Interossei -Ulnar nerve
Vascular examination
• Presence of pulse, warmth, capillary refill, and colour of the hand.
• Vascular status three categories• Hand well-perfused (warm and red), radial
pulse present• Hand well-perfused, radial pulse absent• Hand poorly perfused (cool and blue or
blanched), radial pulse absent
Forearm compartment syndrome
• High suspicion-look for• Swelling or Ecchymosis• Anterior skin puckering• Absent pulse• Tenseness of the volar compartment• Passive finger extension & flexion tested
Radiographic evaluation
• True Ap ,Lat,Oblique views• Initial xray may be negative except for a posterior
fat pad sign• Anterior humeral line • Baumann angle or Humeral capitellar angle -Normal range 9 to 26 deg, - 10 degrees is acceptable -A decrease in the Baumann angle is a sign that
a fracture is in varus angulation
• Young child, epiphyseal separation mimic an elbow dislocation.
• In an epiphyseal separation, the fracture propagates through the physis without a large metaphyseal fragment
• Differentiating this injury from an elbow dislocation is the alignment of the capitellum with the radial head
Management
Initial Management
• Initial splinting - elbow in 20 to 40 degrees of flexion
• Avoid Tight bandaging,excess flexion,extension
-vascular injury• Limb elevated• Neurologic & vascular status• Look for compartment syndrome
Closed Reduction and Pinning
• initially attempted - including type III fractures• first reduced in the frontal plane • elbow is then flexed while the olecranon is
pushed anteriorly to correct the sagittal deformity
Indications of a successful reduction
• Restoration of the Baumann angle –Apview > 10 deg
• Intact medial and lateral columns on oblique views
• Anterior humeral line passing through the middle third of the capitellum on the lateral view
• immobilized in 50 to 60 degrees of flexion
• Ulnar nerve injury ?• Migration of nerve? Medial / anterior• Small incision over medial epicondyle.
• Medial pin inserted in extension with out flexing
• Construct stability- 2 divergent lateral pins > crossed pins > 2 parallel pins
• 2 lateral pins,unstable- 3rd lateral pin,still unstable than put a medial pin.
Indications for open reduction
• Gap in the fracture site • An irreducible fracture with a rubbery feeling
on attempted reduction may be signs that the median nerve and/or brachial artery is trapped in the fracture site,
Open Reduction
• Closed reduction fails • Fractures associated with a dysvascular limb• Approches-medial• lateral• posterior• Transverse.
Treatment with Traction(conservative)
• Severe comminution• Lack of anesthesia• Medical conditions prohibiting
• Malunion is common
Type I Fracture (Nondisplaced)
• Periosteum is intact • Xray limited to a posterior fat pad sign• Posterior splint applied at 60 to 90 degrees of
elbow flexion @ 3 wks• Any signs of compartment syndrome
• Type II Fracture (Hinged Posteriorly, with Posterior Cortex in Continuity)
–closed reduction & pinning -immobilization in 90 deg flexion & supination
Type III Fractures-
• Elbow in either extreme flexion or extension avoided
• 30 deg flexion -prevent vascular insult,compartment
• Periosteum is torn, there is no cortical contact between the fragments
• Open or closed reduction with pinning• After reduction if casting-elbow in 120 deg
flexion,to prevent rotation @ 3-4 wks.
Type IV Fractures
• Extremely unstable fracture• Reduction in both planes• Open reduction and pinning
• Medial Column Comminution• Open or closed reduction with pinning• Or leads to varus deformity
Procedure
• Pt supine with # arm over arm board• Traction with the elbow flexed 20 deg to
avoid tethering the neurovascular structures • Held for 60 seconds to allow soft tissue
realignment
• If it the proximal fragment appears to have pierced the brachialis muscle, the “milking maneuver”
• milked” in a proximal to distal direction
• Next, varus and valgus angular alignment is corrected
• By direct movement of the distal fragment by the surgeon's thumb
• Elbow is then slowly flexed while anterior pressure is applied to the olecranon with the surgeon's thumb
• After reduction, the child's elbow should sufficiently flex so that the fingers touch the shoulder.
• If not, the fracture likely is still not reduced and is in extension
• “rubbery” feeling- median nerve or brachial artery entrapment- open reduction
• “bone on bone” feeling• elbow is taped in the reduced position of
elbow hyperflexion
• Acceptable• some translation of the distal fragment (up to
25%) • moderate rotational malalignment
• As a rule, 2 pins for type II fractures and 3 pins for type III fractures
• Stress applied in varus and valgus under fluoroscopy to ensure fracture stability
• lateral views should be obtained with the elbow flexed and extended to assess movement of the capitellum relative to the anterior humeral line
• Posterior slab or casting with less than 70 deg flexion @ 3 wks
• > 90 deg-risk of compartment syndrome
Complications
• Vascular injury• Compartment syndrome• Neurologic defect• Elbow Stiffness• Pin Track Infections• Myositis Ossificans• Cubitus varus“gunstock deformity”
Reference
• Campbell• Gray’s anatomy
Thanku