SUPRACONDYLAR FRACTURE

Most common fracture around the elbow in children (60 percent of elbow fractures)

Peak age between 5 and 7 years- boys had a higher incidence

At the peak age for supracondylar fractures, there is a naturally occurring hyperextension of the elbow, which predisposes the distal humerus to this type of fracture

MECHANISM OF INJURY Almost all supracondylar fractures are

caused by accidental trauma rather than abuse

Fall on an outstreched hand with hyperextension at the elbow with abduction or adduction,with hand dorsiflexed.

The most commonly associated fractures are distal radial fractures, but fractures of the scaphoid and proximal humerus do occur. Monteggia fractures have also been reported

Asso injury- radial n, meadian n, ulnar n, brachial artery.

EXTENSION-TYPE SUPRACONDYLAR FRACTURES 95 percent are extension type injuries,

which produces posterior displacement of the distal fragment

Fall onto the outstretched hand with the elbow in full extension

Ligamentous laxity and hyperextension of the elbow are important mechanical factors

Medial displacement of the distal fragment is more common than lateral displacement

CLASSIFICATION Gartland (1959) Type 1 non-displaced

Type 2 Angulated/displaced fracture with intact posterior cortex

Type 3 Complete displacement, with no contact between fragments

Type 1: Non-displaced

• Note the non- displaced fracture (Red Arrow)

• Note the posterior fat pad (Yellow Arrows)

Type 2: Angulated/displaced fracture with intact posterior

cortex

Type 2: Angulated/displaced fracture with intact posterior

cortex• In many cases, the

type 2 fractures will be impacted medially, leading to varus angulation.

• The varus malposition must be considered when reducing these fractures, applying a valgus force for realignment.

Type 3: Complete displacement, with no contact between

fragments

SIGNS AND SYMPTOMS Suspected in a child with elbow pain or

failure to use the upper extremity after a fall

Type I supracondylar fracture, there may be distal humeral tenderness, distension or swelling in the anconeus soft spot (elbow effusion), restriction of motion, and evidence of bruising

X-rays may be negative except for a posterior fat pad sign

In type III fractures, gross displacement of the elbow is evident.

An anterior pucker sign may be present if the proximal fragment has penetrated the brachialis and the anterior fascia of the elbow

Careful motor, sensory, and vascular examinations should be performed in all patients

SUPRACONDYLAR HUMERUS FRACTURES: ASSOCIATED INJURIES

• Nerve injury incidence is high, between 7 and 16 % (radial, median, and ulnar nerve)

• Anterior interosseous nerve injury is most commonly injured nerve

• In many cases, assessment of nerve integrity is limited , because children can not always cooperate with the exam

Supracondylar Humerus Fractures: Associated Injuries

• 5% have associated distal radius fracture

• Physical exam of distal forearm

• Radiographs if needed

• If displaced pin radius also

Supracondylar Humerus Fractures: Associated Injuries• Vascular injuries are rare, but pulses

should always be assessed before and after reduction

• In the absence of a radial and/or ulnar pulse, the fingers may still be well-perfused, because of the excellent collateral circulation about the elbow

• Doppler device can be used for assessment

TREATMENT

TREATMENT Initial management of all patients

suspected of having an elbow injury is splinting in a comfortable position, generally 20 to 30 degrees of elbow flexion, pending careful physical examination and x-ray evaluation.

The initial responder should assess the neurovascular status and other injuries

Tight bandaging or splinting, excessive flexion or forced extension should be avoided, as they may compromise vascularity

TYPE I (NONDISPLACED) Simple immobilization with a posterior

splint applied at 60 to 90 degrees of elbow flexion with side supports or a simple collar and cuff

This arrangement allows swelling to occur and does not put the brachial artery at risk of compression

Before the splint is applied, it should be confirmed that the pulse is intact and that there is good capillary refill

If there is any evidence of distal fragment extension, as judged by lack of intersection of the anterior humeral line with the capitullum, the fracture should be reduced and placed in a cast or treated with percutaneous pinning to secure the reduction.

The most common cause of cubitus varus deformity is inadequate treatment of types I and II fractures.

TYPE II FRACTURE (DISPLACED WITH AN INTACT CORTICAL CONTACT)

Good stability should be obtained with closed reduction.

Significant swelling, obliteration of pulse

with flexion, neurovascular injuries, excessive angulation, and other injuries in the same extremity are indications for pin stabilization of most type II fractures

Medial Impaction Fracture

Cubitus varus 2 years later

If pinning is chosen, two lateral pins through the distal humeral fragment, engaging the opposite cortex of the proximal fragment, are generally sufficient to maintain fracture alignment

Pins are left protruding through the skin and are removed at 3 to 4 weeks after fixation, generally without the need for sedation or anesthesia.

Lateral Pin Placement

• AP and Lateral views with 2 pins

TYPE 3 FRACTURES These fractures have a high risk of

neurologic and/or vascular compromise, and can be associated with a significant amount of swelling.

Current treatment protocols use percutaneous pin fixation in almost all cases.

In rare cases, open reduction may be necessary, especially in cases of vascular disruption

TECHNIQUE OF REDUCTION For closed reduction, traction is applied

first, followed by correction of rotational deformity.

The extension deformity is corrected with pressure by the surgeon's thumb over the olecranon and posterior humeral condyles.

Traction is applied with the elbow in extension and the forearm in supination.

The assistant stabilizes the proximal fragment. After traction has been applied and the length regained, the fracture is hyperextended to obtain apposition of the fragments.

While traction is maintained, the varus or valgus angulation along with the rotation of the distal fragment is corrected.

Once the length and alignment have been corrected, the elbow is flexed. Pressure is applied over the posterior aspect of the olecranon to facilitate reduction of the distal fragment.

The distal fragment is finally secured to the proximal fragment by pronating the forearm

Brachialis Sign- Proximal Fragment Buttonholed through

Brachialis

Milking Maneuver- Milk Soft Tissues over Proximal Spike

Adequate Reduction?

• No varus/valgus• anterior hum line• minimal rotation

C-arm Views

• Oblique views with the C-arm can be useful to help verify the reduction

Supracondylar Humerus Fractures

• If pin fixation is used, the pins are usually bent and cut outside the skin.

• The skin is protected from the pins by placing felt pad around the pins.

• The arm is immobilized.• The pins are removed in the clinic

3 weeks later, after radiographs show periosteal healing.

• In most cases, full recovery of motion can be expected.

Pitfalls of Pin Placement

• Pins Too Close together

• Instability• Fracture

displacement• Get one pin in

lateral and one in medial column

Supracondylar Humerus Fractures: Indications for

Open Reduction• Inadequate reduction with closed methods

• Vascular injury• Open fractures

TRACTION MANAGEMENT OF TYPE III By allowing swelling to decrease and facilitating

closed reduction In this technique, patients are placed in sidearm or

overhead skin traction for 3 to 5 days until elbow hyperflexion can be tolerated for closed reduction.

Definitive treatment of the fracture with 14 days of traction or until healing has occurred historically has led to a very low incidence of cubitus varus deformity

Dunlop's traction Skeletal traction overhead with use of an

olecranon wing nut

VASCULAR INJURY Type III supracondylar fractures have

significant incidences of brachial artery injury, vascular insufficiency, and compartment syndrome

BRACHIAL ARTERY INJURIES AND VASCULAR INSUFFICIENCY About 10% to 20% of patients with type

III present with an absent pulse emergency management of a patient

with a type III , the arm should be splinted with the elbow in about 30 degrees of flexion

Perfusion is estimated by color, warmth, and capillary refill

The initial approach to managing a patient with vascular compromise should be immediate closed reduction and stabilization with K-wires.

If an anatomic reduction cannot be obtained closed, open reduction through an anterior approach with medial extension allows evaluation of the brachial artery and removal of the neurovascular bundle entrapped within the fracture site or repair of the brachial artery.

COMPARTMENT SYNDROME increased pressure in a closed fascial

space causes muscle ischemia. With untreated ischemia, muscle edema

increases, further increasing pressure, decreasing flow, and leading to muscle necrosis, fibrosis, and death of involved muscles.

The diagnosis of a compartment syndrome is based on resistance to passive finger movement and dramatically increasing pain after fracture.

The classic five “P” s for the diagnosis of compartment syndrome

Pain pallor pulselessness paresthesias, and paralysis

fasciotomy if clinical signs of compartment syndrome are present or if intracompartmental pressure is greater than 30 mm Hg

contribute to the development of compartment syndrome are direct muscle trauma at the time of injury, swelling with intracompartmental fractures (associated forearm fracture), decreased arterial inflow, restricted venous outflow, and elbow position.

NEUROLOGIC DEFICIT AIN appears to be the most commonly

injured , with loss of motor power to the flexor pollicis longus and the deep flexor to the index finger

The direction of the fracture's displacement determines the nerve most likely to be injured

If the distal fragment is displaced posteromedially, the radial nerve is more likely to be injured.

if the displacement of the distal fragment is posterolateral, the neurovascular bundle is stretched over the proximal fragment, injuring the median nerve or AIN or both.

In a flexion type of supracondylar fracture, which is rare, the ulnar nerve is the most likely nerve to be injured.

if the nerve deficit is present and the fracture is reducible, open reduction of the fracture and exploration of the injured nerve are not indicated.

In most cases, nerve recovery, whether radial, median, or ulnar, generally occurs at an average of 2 to 2½ months.

COMPLICATIONS Elbow Stiffness Myositis Ossificans Nonunion -distal humeral metaphysis is

a well-vascularized area with remarkably rapid healing, and nonunion is rare

Avascular Necrosis- trochlea after supracondylar fracture has been reported

ANGULAR DEFORMITY A decrease in frequency of cubitus varus

deformity after the use of percutaneous pin fixation

The usual etiology of cubitus varus deformity is malunion of the distal humeral fragment rather than growth disturbance

CUBITUS VARUS

TREATMENT OF CUBITUS VARUS DEFORMITY As for the treatment of any

posttraumatic malalignment, options include

(a) observation with expected remodeling,

(b) hemiepiphysiodesis and growth alteration

(c) corrective osteotomy- is the only way to correct a cubitus varus deformity with a high probability of success

FLEXION-TYPE SUPRACONDYLAR FRACTURE 2% of humeral fractures May not be recognized until reduction is

attempted Unstable in flexion, whereas extension-

type fractures generally are stable in hyperflexion

A laterally displaced supracondylar fracture may actually be a flexion-type injury.

The mechanism of injury is generally believed to be a fall directly onto the elbow

The distal fragment is displaced anteriorly and may migrate proximally in a totally displaced fracture.

The ulnar nerve is vulnerable in this fracture pattern

Flexion Type

X-RAY FINDINGS Mild angular deformity to complete

anterior displacement Anterior displacement is often

accompanied by medial or lateral translation

Fracture classification is the same as for extension-type supracondylar fractures :

type I, nondisplaced fracture type II, minimally angulated with cortical

contact type III, totally unstable displaced distal

fracture fragment

TREATMENT Type I flexion-type supracondylar

fractures are stable nondisplaced fractures that can simply be protected in a long-arm cast

If mild angulation, as in a type II fracture, requires some reduction in extension, the arm can be immobilized with the elbow fully extended

A problem with type III flexion supracondylar fractures is that reduction is not easy to achieve and when achieved, the elbow is usually in extension, making it quite difficult to stabilize the distal fragment using pins.

Pinning is generally required for unstable type II and III flexion supracondylar fractures

Pinning should be performed after closed reduction with the elbow in mild flexion or full extension.

Flexion Type - Pinning

Open reduction may be required for flexion type supracondylar fractures.

Open reduction is best performed through an anteromedial or posterior approach, rather than an anterior approach, as is used for extension-type supracondylar fractures

Traction is used very rarely for this type of fracture

The elbow is generally unstable in increased flexion, which is a comfortable position for the patient in traction

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