Supracondylar fracture of the humerus

Akana mohan phaneendraFinal M.B.B.S part-2

8th semester12th august 2016

Distal humerus anatomy• Medial epicondyle: Proximal to trochlea• Lateral epicondyle : Proximal to capitulum• Radial fossa: Accomodates margin of radial head during flexion• Coronoid fossa: Accepts coronoid process of ulna during flexion

Quick review of statistics• Age : 1st decade , 5-8 years , 84% cases <10 years• Sex : boys 63.6%• Sides : (L)-58.6% , (R)-42.4%• Open fracture : 2.3%• Extension type : 97.7%• Flexion type : 2.3%• Nerve injury : 7%– Radial nerve - 45%– Median nerve - 32%– Ulnar nerve - 23%

Vital facts of pathological anatomy

Why common in children <10 years of age???Bony architecture at the supracondylar region is weak &

vulnerable because in this region• Bone is remodelling• It is less cylindrical• Metaphysis is just distal to 2 fossae , coronoid & radial• Here the cortex is thin• Anterior cortex has a defect in the area of coroniod fossa• Laxity of ligaments permits hyperextension at the elbow

Predisposing factors for juvenile Supracondylar fracture are• Ligamentous laxity at the elbow leads to hyperextension• Hyperextension converts linear force into bending force• Olecranon concentrates this force to the weak condylar

area• Anterior capsule is taut• Bony architecture of supracondyalr area

GARTLAND’S CLASSIFICATION (CHILDREN):• TYPE I : Undisplaced

• TYPE II : Displaced,but posterior cortex is intact

• TYPE III : Displaced, but no intact posterior cortex & the distal fragment could be either displaced; A)posteromedial or B) posterolateral.

MECHANISM OF INJURY• Extension type : Fall on outstretched hand Elbow hyperextended Forearm pronated or supinated

MECHANISM OF INJURY• Flexion type: Fall directly on the elbow rather than out stretched hand

CHARECTERISTIC CLINICAL SIGNS IN SC #

• Arm is short , forearm is normal in length

• Gross swelling , and tenderness

• Crepitus is present but should not be elicited for fear of increasing the pain and damaging the neighbouring neurovascular structures

• Relationship between three bony points is maintained

• S-shaped deformity

• Dimple sign due to one of the spikes of proximal fragment penetrating the muscle and tethering the skin

• “soft spots” is an effusion beneath anconeus muscle• Movements of elbow both active & passive -- decreased

X-RAY OF ELBOW

Antero-posterior view:• BAUMANN’S ANGLE: Angle b/n horizontal line of elbow and line drawn through lateral epiphysis & long axis of the arm• Angle b/n long axis of humerus & transverse axis of

elbow is normally 90 degrees <90 degrees cubitus varus > 90 degrees cubitus valgus

LATERAL VIEW:• TEAR DROP SIGN : Disturbed in Supracondylar fracture

• Normally , there is an angulation of 40 degrees b/n long axis of humerus & long axis of lat. Epicondyle

• ANTERIOR HUMERAL LINE: A line drawn along ant. border or distal humeral shaft passes through the middle 1/3rd

of capitulum. If it passes through ant. 1/3rd ,it indicates posteriordisplacement of fragment

• FAT PAD SIGN: The olecranon process is deep & thus the fat pad here lies totally contained within the fossa Not seen on the lateral radiograph of the elbow at 90 degrees Distension of the capsule with an effusion due to trauma or infection

causes the olecranon pad to be visualized as a radiolucent gap

• CRESCENT SIGN: Here the normal radiolucent gap of the elbow joint is

missing & a crescent –shaped shadow due to the overlap of the capitulum’s over the olecranon is evident & indicates either varus or valgus tilt of the distal fragement

• THE CORONOID LINE : A line directed proximally along the anterior border

of the coronoid process of the ulna should barely touch the anterior portion of the lateral condyle.posterior displacement of the lateral condyle will project the ossification center posterior to this line

• FISH-TAIL SIGN: Due to rotation of the distal fragment,the anterior

border of the proximal fragment look like sharp spike

RADIOLOGICAL POINTS• Coronal tilt of the distal fragment : usally varus tilt

rarely valgus indicated on radiography by:– Crescent sign– Baumann’s triangle

• Horizontal rotation of the distal fragment:indicated by fish tail sign

• Posterior displacement of the distal fragment:– Loss of tear drop sign– Coronoid line– Fat pad sign– Anterior humeral line

MANAGEMENT• CONSERVATIVE MANAGEMENT• TRACTION METHODS• SURGERY : PCIF & OPEN REDUCTION• CLOSED REDUCTION & PERCUTANEOUS INTERNAL

FIXATION• OPEN REDUCTION

COMPLICATIONS• CAUSING FUNCTIONAL IMPAIRMENT• ONLY COSMETIC SEQUELAE• FUNCTIONAL IMPAIRMENT:– NEUROLOGICAL INVOLVEMENT – 7%– RADIAL NERVE – postero-medial displacement– MEDIAN NERVE – posterior displacement– ANTERIOR INTEROSSEUS NERVE – posterolateral

displacement of distal fragment– ULNAR NERVE – overhead skeletal traction & in flexion

type of SC #

– VASCULAR INJURY• 0.5 to 1 %• Common with extension type• Direct injury to brachial artery

– LOSS OF MOBILITY:• Avg. loss of flexion is 4 degrees due to posterior

displacement,which unites in that position causing mechanical block of flexion

– MYOSITIS OSSIFICANS• Seen in manipulative closed reduction & open reduction

REFERENCES:• ESSENTIAL ORTHOPAEDICS(5th edition)—

maheswari & mhaskar• TEXT BOOK OF ORTHOPAEDICS(4th edition) – john ebnezar

THANK ‘Q’ EVERY ‘1’

THE IS TIME FACT ONLY DECIDES THAT EVERYTHING -anonymous