1. Dr Amruth ram reddy Post graduate Department of orthopaedics Gandhi hospital

2. EPIDEMIOLOGY peak age between 5 and 7 years boys have a higher incidence of this fracture than girls. left or nondominant side predominates A fall from a height accounts for 70% of all fractures Nerve injury occurs in at least 7% and significant vascular injury in 1%. 3. CLINICAL ANATOMY IT IS ALSO CALLED AS MALGAIGNES FRACTURE FRACTURE LINE PASSES PROXIMAL TO THE BONE MASSES OF TROCHLEA AND CAPITELLUM. IT RUNS THROUGH THE APICES OF CORONOID AND OLECRENON FOSSAE. A THIN 1 MM WAFER OF BONE FLANKED BY LARGER MEDIAL AND LATERAL COLOUMNS FORMS THE DISTAL METAPHYSIS 4. Supracondylar area is weak and vulnerable because Bone is less cylindrical Metaphysis is distal to both coronoid and olecrenon fossae. Anterior cortex has defect in the area of coronoid fossa. Laxity of ligaments permits hyperextension at elbow 5. Most distal humeral supracondylar fractures are displaced in extension flexion-type injuries are seen infrequently. Mechanism of injury:children try to prevent their fall by falling on hand with elbow extended Because of the laxity of the ligaments, the elbow becomes locked into hyperextension olecranon in its fossa in the distal humerus acts as a fulcrum. capsule transmits an extension force to the distal humerus just proximal to the physis as the elbow hyperextends. 6. distal humerus fails anteriorly in the supracondylar area. the distal fragment becomes posteriorly displaced. strong action of the triceps produces proximal displacement of the distal fragment 7. Supination of the forearm creates a downward lateral tilt of the distal fragment This produces compressive forces between the articulating surface of the ulna and the trochlea's medial border. This generates clockwise forces about the medial side of the fracture. 8. Pronation of the forearm creates an upward tilt of the distal fragment due to the compressive forces between the articulating surface of the ulna and the lateral border of the trochlea. this generates counterclockwise forces about the medial side of the fracture. 9. if patient falls on a outstretched supinated arm, the posteromedial periosteum is disrupted first . Fragment is displaced posterolaterally if patient falls on pronated arm,the distal fragment is displaced posteromedially. Medial displacement of the distal fragment places the radial nerve at risk. lateral displacement of the distal fragment places the median nerve and brachial artery risk. 10. The brachial artery is placed at risk by the ulnar-sided tether of the supratrochlear artery 11. CLASSIFICATION MODIFIED GARTLAND Type 1:undisplaced Type2:hinged posteriorly with intact posterior cortex. Type3:displaced with no cortical contact. 3a:postero medial displacement. 3b:postero lateral displacement Type4:displaces in to flexion and flexion. Collapse of medial coloumn where there is loss of baumann angle. 12. CLINICAL FEATURES Pain and inability to use the upper extremity after the fall. Point tenderness over medial and lateral coloumns suggests this fracture where as tenderness on one side of elbow suggests other type of injury. Anterior pucker sign may be present. It occurs when brachialis has been penetrated by proximal fragment. This is a sign of considerable soft tissue damage 13. Motor, sensory, and vascular examinations should be performed in all patients. discrete sensory areas of the radial nerve (dorsal first web space) medial nerve (palmar index finger) ulnar nerve (palmar little finger). finger, wrist, and thumb extension (radial nerve), index ,distal interphalangeal flexion and thumb interphalangeal flexion (AIN), thenar strength (median), and interossei (ulnar nerve) muscle function. 14. vascular examination :presence of pulse, as well as warmth, capillary refill, and color of the hand. High index of suspicion to recognize signs of developing compartment syndrome. Passive finger extension and flexion should be tested and the findings should be accurately recorded. Entire limb should be evaluated for associated forearm fractures. If present there is increased risk of impending compartment syndrome. 15. RADIOLOGICAL EXAMINATION AP and lateral views of the entire upper extremity. AP x-ray should always be taken as an AP of the distal humerus rather than an AP of the elbow. lateral film should be taken as a true lateral with the humerus held in the anatomic position and not externally rotated 16. Baumans angle is formed by a line perpendicular to the axis of the humerus, and a line that goes through the physis of the capitellum. There is a wide range of normal for this value, and it can vary with rotation of the radiograph. In this case, the medial impaction and varus position reduces Baumans angle. Normal range:64 -81degrees 17. Decreased angle is a sign of varus angulation It is not obscured by elbow flexion or pronation. The Baumann angle is not equal to the carrying angle of the elbow . Change in 5 deg will result in 2 deg change of clinical carrying angle. 18. Metaphyseal-diaphyseal angle. On anteroposterior radiograph, transverse line is drawn through metaphysis at its widest point, and longitudinal line is drawn through axis of diaphysis; angle is measured between lateral portion of metaphyseal line and proximal portion of diaphyseal line. Normal angle is 90 degrees. Angle greater than 90 degrees indicates varus angulation. 19. ANTERIOR HUMERAL LINE Anterior Humeral Line: This is drawn along the anterior humeral cortex. It should pass through the middle of the capitellum. 20. Radiocapitellar line should intersect the capitellum this line should be evaluated on every pediatric elbow film 21. The capitellum is angulated anteriorly about 30 degrees. The appearance of the distal humerus is similar to a hockey stick. 30 22. FISH TAIL SIGN The sharp proximal fragment appears like a fish tail 23. CORONOID LINE line directed proximally along the anterior border of the coronoid process should barely touch the anterior portion of the lateral condyle Posterior displacement of the lateral condyle projects the ossification center posterior to this coronoid line 24. CRESCENT SIGN Normal rasdiolucent gap of elbow joint is missing. A crescent shaped shadow due to overlap of capitellum and olecrenon Indicates varus or valgus tilt of distal fragment. 25. FAT PAD SIGN The anterior fat pad is a triangular radiolucency anterior to the distal humeral diaphysis. it is seen clearly, and in the presence of elbow effusion, it is displaced anteriorly. The posterior fat pad is not normally visible when the elbow is flexed at right angles. if an effusion is present, it will also be visible posteriorly . 26. MANAGEMENT Closed reduction Traction method Surgery crpp(closed reduction and percutaneous pinning) open reduction and internal fixation. 27. TYPE 1 FRACTURES Anterior humeral line transects the capitellum. The periosteum is intact with inherent stability of fracture It may become apparent only after one to two weeks follow up after initial presentation. Simple immobilization with a posterior splint applied at 60 to 90 deg flexion. This angle will not put brachial artery at risk. 28. patient returns 5 to 10 days after injury for removal of the splint. Radiographs are repeated to ensure that no displacement has occurred. the patient is placed in a long-arm cast for an additional 2 to 3 weeks. The cast is then removed,mobilisation of elbow started. Final check up is done 6 to 8 weeks after cast removal to check range of movements. 29. sling holds the hand and elbow in a dependent position, thereby creating edema and pain. true elevation of the extremity, with the fingers above the elbow and the elbow above the heart. . 30. The long arm cast should be supported with ring in distal part of the cast and sling around the neck to support the weight of the cast. With out this an extension torque occurs at distal humerus and can displace the fracture. 31. TYPE 2 FRACTURES: Closed reduction and splinting in flexion. Stabilization with pins is required when there is excessive swelling. Neurovascular injuries Excessive angulation Other injuries in same extremity. 32. REDUCTION MANEUVER Traction is applied with the elbow in extension and the forearm in supination. The assistant stabilizes the proximal fragment. 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. 33. 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 34. If traction does not restore length and alignment, a milking maneuver has been described to disengage the proximal fragment from the soft tissue. It is done by manipulating the soft tissue over the fracture to pull the soft tissue away from the proximal fragment, which may not allow reduction of a buttonholed proximal fragment 35. PERCUTANEOUS PINNING It can be done by two lateral pins through the distal fragment. Engaging the opposite cortex of proximal fragment is sufficient to maintain the alignment. Crossed pinning can also be done but it is generally not required. The arm is immobilized in 30 to 60 degrees of flexion in either a posterior splint . The child is observed overnight and discharged with instructions on cast care and elevation Pins are removed 3 to 4 weeks after fixation. 36. TYPE 3 FRACTURES Neurovascular compramise should be asessed. Closed reduction can be attempted. In case of absent pulses,pale hand or compartment syndrome is suspeected immediate reduction and skeletal stabilization is mandatory. in Closed reduction and cast immobilization results are poor. Percutanious pinning or orif with pins is better option for type 3 fractures. 37. LATERAL PINNING First pin is passed through centre of ossified capitellum,further penetrating medial cortex. Second pin through distal humeral epiphysis,lateral to capitellum Pin proceeds up the lateral coloumn and engages the opposite cortex. Separate the pins as far as possible at the fracture site. Limb immobilised in neutral position in 60 to 90 degree flexion. 38. CROSSED PINNING Crossed pinning is more stable than two lateral pins. Lateral pin is always inserted first. unstable posterolaterally displaced fracture, the initial pin may have to be placed medially. Pin passes lateral to ossified capitellum,proceeds up the lateral coloumn It engages opposite medial cortex proximally. 2nd pin is placed medially starting position for a medial pin is the inferiormost aspect of the medial epicondyle care should be taken not to injure the ulnar nerve. 39. The assistant holding the reduction protects the ulnar nerve by sweeping the soft tissues posteriorly away from the medial epicondyle. 40. flexion of the elbow displaces the ulnar nerve anteriorly. Thus, it is safer to place a medial pin with the elbow in extension. Similarly, if the arm is immobilized in flexion, the nerve may be tented around the pin, leading to ulnar nerve symptoms without direct penetration of the nerve by the pin 41. INDICATIONS FOR ORIF ischemic, pale hand that does not revascularize with reduction of the fracture an open fracture, an irreducible fracture inability to obtain a satisfactory closed reduction. Anterior, medial, lateral, and posterior approaches have all been recommended. 42. operate through the side in which the periosteal hinge is torn. a lateral approach is used for posteromedial displacement a medial approach is used for posterolateral displacement. direct anterior approach through a transverse anterior incision in the antecubital fossa, extending proximally, medially as needed 43. If open reduction and internal fixation are to be done, they should be performed emergently (