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Fracture Supracondylar Humerus
Some important Facts!
Major fracture in children.
80% of elbow injury
3% of paediatric #
Side- R:L = 42:58.
SEX- Male: female = 2:1
AGE: Occurs mostly between 5-8 years
Definition: An injury around the elbow where fracture line runs just above the
coronoid and radial fossa transversely sparing the epicondyles.
Classification: Two major classifications
A) According to the direction of fracture line
1. Extension type: 98%
2. Flexion type: 2%
Extension type: # line above to below from posterior anterior
Flexion type: # line below to above from anteriorposterior.
B) According to the Displacement of fracture: Gartland’s classification
1. Undisplaced fracture: Type I
2. Partially displaced # with posterior hinge intact: Type II
3. Completely displaced fracture: Type III
Mechanism of Injury:
Fall on outstretched hand
Investigations:
1. Plain xray of elbow: AP, Lateral view
Displacement of the fracture
1) Posterior shift
2) Posterior tilt
3) Medial shift
4) Medial tilt
5) Internal rotation
Treatment:
Reduce it as early as possible. Edema well not subside unless # being reduced.
Treatment depends upon TWO major factors:
1. Displacement according to GARTLAND type
2. Injury to brachial artery/vascular deficit
So, in a normal vascular limb-- factor to decide treatment is: “Displacement”
1. Gartland Type 1: Undisplaced #
Above elbow slab application for three weeks
2. Gartland type 2: Partially displaced #
Above elbow slab application for three weeks with elbow in 100-1100
flexion. (Increased flexion closes the anterior opening of fracture)
3. Gartland type 3: Completely displaced #
Closed reduction under GA and above elbow cast application
Or
Closed reduction under GA with K wire fixation & further cast application
In case of Supracondylar # associated with injury to brachial artery
1. Immediate exploration of brachial artery and repair of vessels
2. Fixation of fracture with K wires
Rehabilitation: After cast removal (at 3 weeks), gentle active elbow
mobilisation is started. Massage or forcible passive mobilisation should be
avoided to prevent Myositis ossificans.
Complication: ACUTE complications
1. Nerve injury:
In extension type of fracture: Radial > Median > Ulnar
In flexion type: Ulnar nerve injury is more common
Most are neuropraxia or axonotmesis, and mostly recover
Often can be IATROGENIC while cross K wire fixation especially from
ulnar side (See above figure of K wire fixation)
2. Vascular injury: Injury to brachial artery is not infrequent due to
displaced fracture. (see figure below)
3. Compartment syndrome: Volkmann Ischaemia (read complications of
fracture chapter)
CHRONIC complications
1. Volkmann’s Ischemic contracture: it is a sequel of Volkmann’s ischemia.
Due to ischaemia of muscles and nerves during compartment
syndrome.
Mostly Involves superficial and deep volar compartment of
forearm affecting flexor group of muscles. Occasionally, extensor
aspect is also involved.
Marked atrophy of forearm
Forearm skin: dry, scaly
Atrophic nails
Possible scars around elbow and forearm indication past surgery
(repair of vessel/fasciotomy)
Flexion deformity of wrist and fingers
Hypoaethsia or anaesthesia over wrist and hand due to ischemic
injury to three nerves
Volkmann’s sign: Fingers can be extended only if wrist is kept in
flexion (constant length phenomena)
Treatment:
Mild deformity: Passive stretching of contracted muscles. Splintage in
functional position
Moderate deformity: Maxpage operation: soft tissue sliding surgery. Muscles
are released from medial epicondyle and moved distally.
Severe deformity: shortening of forearm bones, carpal bone excision, tendon
transfers
(Read Manipal viva book for further reading of VIC: pg 67-70)
2. Malunion: Most often leads to Cubitus varus/Gunstock deformity
Three bony points relation normal
Full range of motion (ROM)
Slight hyperextension as compared to normal elbow
Functionally asymptomatic
Cosmetically remains unwanted!!
May require closed wedge osteotomy (Modified French
osteotomy) to correct varus deformity
(read viva book: pg 1-9)
3. Rarely malunion causes Cubitus Valgus deformity
Can produce tardy Ulnar nerve palsy
Deformity may not require correction but TUN palsy may require
Anterior Ulnar nerve transposition
4. Myositis ossification: (read chapter on complications of fractures and
viva book pg 16-23)
5. Stiffness of elbow
Recommended