Supracondylar fracture of humerus in children

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A BRIEF REVIEW ON

SUPRACONDYLAR FRACTURE OF

HUMERUS IN CHILDREN

ALIREZA MIRZASADEGHI MD, MPH, MS (Ortho) 25.07.2012

GRAND WARD ROUND PRESENTATION© - 2 from23

GENERAL CONCEPTS

1) Lee E.H, et al, Supracondylar Fractures of the Humerus in Children, Singapore Med J 2000 Vol 41(9) : 4232) http://www.wheelessonline.com/ortho/pediatric_supracondylar_fractures_of_the_humerus, date of received 13-11-09

Unlike adults children usually sustain fractures in the upper limb.

Not only one of the most common injury but potentially can result in serious complications.

Most often around age 6-7 years

Extension type 95% and rest are flexion type


GENERAL CONCEPTS

1) Steenbrugge F et al, Guidelines and pitfalls in the management of supracondylar humerus fractures in children, Current Orthopaedics (2001) 15, 214-219

2) Kasser JR. Supracondylar Fractures of the Distal Humerus. In Rockwood C, Wilkins K, King R (eds). Fractures in Children, 6th ed. Philadelphia: JB Lipincott 2006; 544-586.

In children typically remains extra-articular & involves thin bone between coronoid fossa & olecranon fossa of distal humerus

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


CLASSIFICATION

Type I UndisplacedAnterior humeral line still passes through the ossification centre of the lateral condyle.

Type IIDisplaced (with intact posterior cortex

Obvious fracture line with displacement of the distal fragment, but there is still an intact cortical hinge posteriorly

Type III

Displaced (no cortical contact) Posteromedial Posterolateral

elbow is flexed to 120° and rotated, there is not enough intact cortex to provide intrinsic stability

1) Gartland J. Management of supracondylar fractures of the humerus in children. Surg Gynecol Obstet 1959; 109: 145-159 2) Steenbrugge F. et al, Guidelines and pitfalls in the management of supracondylar humerus fractures in children, Current Orthopaedics (2001) 15, 214-219

Type IVmultidirectional instability

functioning periosteal hinge

can displace into either flexion or extension

3) Leitch K et al, Treatment of Multidirectionally Unstable Supracondylar Humeral Fractures in Children. A Modified Gartland Type-IV Fracture, J Bone Joint Surg Am. 2006;88:980-985

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CLINICAL FEATURES

Pain –Tenderness

Swelling

Deformity (in type III)

Anterior pucker sign

Kasser JR. Supracondylar Fractures of the Distal Humerus. In Rockwood C, Wilkins K, King R (eds). Fractures in Children, 6th ed. Philadelphia: JB Lipincott 2006; 544-586.


CLINICAL FEATURES – Pucker sign

The pucker sign:

Penetration of the proximal fragment's spike into the subcutaneous tissue

Distal fragment has pulled the skin inward.



CLINICAL FEATURES

Look for neurologic Sign Wrist, and thumb extension (radial nerve) Index distal interphalangeal flexion and thumb interphalangeal flexion (AIN), Thenar strength (median) Interossei (ulnar nerve) muscle function. Sensory deficit

Look for Compartment syndrome sign and symptom

Look for vascular compromise sign and symptom



RADIOLOGIC FEATURESAnterior Humeral Line

http://www.radiologyassistant.nl/en/4214416a75d87, date-received: 15.11.09

Anterior humeral line

Noramal X Ray

Anterior humeral line

Supracondylar fracture


RADIOLOGIC FEATURESFat Pad Sign


Any elbow joint distention either hemorrhagic, inflammatory or traumatic gives rise to a positive fat pad sign


RADIOLOGIC FEATURESFat Pad Sign


If a positive fat pad sign is not present in a child, significant intra-articular injury is unlikely.

A visible fat pad sign without the demonstration of a fracture should be regarded as an occult fracture


MANAGEMENT

Emergency treatment has been recommended to avoid vascular compromise and compartment syndrome

•However, recent studies suggest that delay does not influence outcome

Mangwani J. et al, Supracondylar humeral fractures in children TEN YEARS’ EXPERIENCE IN A TEACHING HOSPITAL, J Bone Joint Surg [Br] 2006;88-B:362-5


MANAGEMENTType I

Nondisplaced or minimally displaced - above-elbow cast for 3 weeks.

Any medial impaction of the medial metaphysis may indicate a fracture that requires reduction.



MANAGEMENTType I

This fracture is a diagnostic trap - collapse of the medial column may be very subtle

The Baumann angle - more than 10º of varus impaction - closed reduction and percutaneous pinning


Difficult to maintain the reduction by POP alone, and residual deformity will not remodel


MANAGEMENTType II

Some of these are stable after closed reduction and casting in 90 to 100 degrees of flexion.

If >100º flexion is required, percutaneous pinning is recommended, with immobilization in less than 90º of flexion.


2) Mangwani J. et al, Supracondylar humeral fractures in children TEN YEARS’ EXPERIENCE IN A TEACHING HOSPITAL, J Bone Joint Surg [Br] 2006;88-B:362-5

Weekly follow-up for 2 weeks is recommended following closed management to diagnose and treat any loss of reduction.


MANAGEMENTType III

Treatment begins with a complete neurovascular assessment

Primary percutaneous pinning is the preferred treatment for type III injuries



In the absence of neurovascular compromise, displaced fractures can be splinted and managed safely in a delayed manner as long as the child is closely monitored


MANAGEMENTType III

Two lateral pins are chosen as the initial postreduction fixation method in nearly all cases.

The decision whether to place a third lateral pin or a medial pin if two lateral pins fail to provide acceptable fixation is not clearly data driven at this time.


If one chooses a medial pin, a small incision over the medial epicondyle to visualize and protect the ulnar nerve is mandatory.


MANAGEMENTMedical vs Lateral K-wires

Kim showed that most surgeons (93.4%) in the UK use medial and lateral pinning, known as crossed pinning

In US most surgeons find lateral pinning as a safer method comparing crossed pinning.

The primary risk with crossed pinning is injury to the ulnar nerve by a medial pin.

The frequency of ulnar nerve injury in reported series ranges from 0% to 15%

Newton et al found that divergence of two lateral pins was superior to parallel configuration


2) Kim WY, Chandru R, Bonshahi A, et al. Displaced supracondylar humeral fractures in children: results of a national survey of paediatric orthopaedic consultants. Injury 2003 34(4):274-277


OPEN REDUCTIONIndiction

When closed reduction is not possible Especially in postrolaterally displaced fracture Generally is due to the proximal fragment being buttonholed through soft tissue or interposition of the biceps or neurovascular structures

Vascular compromiseOpen reduction

1) Otsuka NY, Kasser JR. Supracondylar fractures of the humerus in children. J Am Acad Orthop Surg 1997;5:19-262) Kasser JR. Supracondylar Fractures of the Distal Humerus. In Rockwood C, Wilkins K, King R (eds). Fractures in

Children, 6th ed. Philadelphia: JB Lipincott 2006; 544-586.3) Kasser JR. Percutaneous pinning of supracondylar fractures of the humerus. InstrCourse Lect 1992;41:385-90.


OPEN REDUCTION

Becoming widely acceptedAnterior, medial, lateral, and

posterior approaches have all been recommended

Transverse anterior incision in the antecubital fossa, extending proximally, medially as needed is preferred method

Pin removal, generally 3 to 4 weeks after injury. prolonged pin fixation is not necessary

1) Otsuka NY, Kasser JR. Supracondylar fractures of the humerus in children. J Am Acad Orthop Surg 1997;5:19-262) Kasser JR. Supracondylar Fractures of the Distal Humerus. In Rockwood C, Wilkins K, King R (eds). Fractures in

Children, 6th ed. Philadelphia: JB Lipincott 2006; 544-586.3) Kasser JR. Percutaneous pinning of supracondylar fractures of the humerus. InstrCourse Lect 1992;41:385-90.


COMPLICATIONS

Neurovascular entrapment and vascular compromise

Compartment syndromeElbow stiffness (rare)Myositis OssificansNonunionAVNAngular Deformity (cubitus varus) Volkmann ischemic contracture,



COMPLICATIONSNeurovascular Injury


Neurovascular relations. If the distal spike penetrates the brachialis muscle laterally (posteromedial fractures), the radial nerve may be tethered (left). If the spike penetrates medially (posterolateral fractures), both the median nerve and brachial artery can be tethered (right).


COMPLICATIONSPink pulseless hand – a great field of controversy

Much confusion surrounds the management of a child with “pink pulseless hand

Compromise of the brachial artery has been reported in approximately 11% of cases of supracondylar fracture

In the event of a pulseless extremity, prompt reduction of the supracondylar fracture usually restores arterial flow

1) Griffin KJ, Walsh SR, Markar S, et al. The pink pulseless hand: a review of the literature regarding management of vascular complications of supracondylar humeral fractures in children. Eur J Vasc Endovasc Surg 2008;36:697-702.

2) Blakey, et al, Ischaemia and the pink, pulseless hand complicating supracondylar fractures of the humerus in childhood, J Bone Joint Surg [Br] 2009;91-B:1487-92



The pink pulseless limb is ischaemic. Persistent and increasing pain with a deepening nerve lesion indicate that there is critical ischaemia and Blakey et al recommend urgent exploration of the vessel and nerve in this situation

Mangwani et al, believe a pre-operative angiogram in such a limb-threatening situation may lead to unnecessary delay


2) Blakey, et al, Ischaemia and the pink, pulseless hand complicating supracondylar fractures of the humerus in childhood, J Bone Joint Surg [Br] 2009;91-B:1487-92



A child with a pink pulseless hand post-fracture reduction can be managed conservatively unless additional signs of vascular compromise develop, in which case exploration should be undertaken.

If the hand remains pulseless but well perfused after stabilization the preferred option would be to observe and rely on collateral circulation rather than treating it more aggressively.

1) Griffin KJ, Walsh SR, Markar S, et al. The pink pulseless hand: a review of the literature regarding management of vascular complications of supracondylar humeral fractures in children. Eur J Vasc Endovasc Surg 2008;36:697-702

2) Malviva A. et al, Pink pulseless hand following supra-condylar fractures: an audit of British practice. J Pediatr Orthop B. 2006 Jan;15(1):62-4


COMPLICATIONSPink pulseless hand – Maybe a Conclusion

Robb et al. with a reviewing and discussion on some articles from both opinion concluded: Until further information is available it would be reasonable to monitor 48 hours after satisfactory reduction and pinning of the fracture. If perfusion deteriorates and pain worsens and if there is any sign of neurological picture, exploration of the brachial artery and the affected nerve is indicated

1) Robb J E, The pink, pulseless hand after supracondylar fracture of the humerus in children, J Bone Joint Surg [Br] 2009;91-B:1410-12.



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Supracondylar fracture of humerus in children