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