Supracondylar Humerus Fracture in Pediatric Age Group.

Supracondylar Humerus Fracture in Pediatric Age Group.

DR.SUBODH PATHAK

As the fact Remains.Upper-extremity fractures account for 65% to 75% of all fractures in children

7% to 9% of upper-extremity fractures involve the elbow.

The distal humerus accounts for approximately 86% of fractures about the elbow region

Supracondylar fractures are the most frequent elbow injuries in children, reported to occur in 55% to 75%

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Elbow injuries are much more common in children and adolescents than in adults . The peak age for fractures of the distal humerus is between 5 and 10 years old. Houshian et al 1 reported that the average age of 355 children with elbow fractures was 7.9 years (7.2 years in boys, 8.5 years in girls). Cheng et al2 found a median age of 6 years (6.6 years in boys and 5 years in girls) and a predominance of injuries (63%) in boys

ANATOMY

Blood SupplyExtraosseousrich arterial network around the elbow brachial artery

Blood SupplyThe major arterial trunk, the brachial artery, lies anteriorly in the antecubital fossa. Most of the intraosseous blood supply of the distal humerus comes from the anastomotic vessels that course posteriorly.

OSSIFICATION CENTERS

CRITOE

Intra-Articular Structures

The articular surface lies within the confines of the capsule, but nonarticulating areas involving the coronoid and radial fossae anteriorly and the olecranon fossa posteriorly are also within the confines of the articular cavity.The capsule attaches just distal to the coronoid and olecranon processes. Thus, these processes are intra-articular The entire radial head is intra-articular, with a recess or diverticulum of the elbow's articular cavity extending distally under the margin of the orbicular ligament. The medial and lateral epicondyles are extra-articular.

TYPESFLEXION TYPEEXTENSION TYPE

EXTENSION TYPE: MechanismFall onto the outstretched hand with the elbow in full extension.

The olecranon in its fossa in the distal humerus acts as a fulcrum, whereas the capsule transmits an extension force to the distal humerus just proximal to the physis as the elbow hyperextends.

Posteromedial versus Posterolateral Displacement Medial displcement is more common- 75%

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 at risk

The position of the hand and forearm at the time of injury plays a role in the direction of the distal humeral fragment's displacement.

In a patient who falls onto an outstretched supinated arm, the forces applied tend to disrupt the posteromedial periosteum first and displace the fragment posterolaterally.

If a patient falls with the arm pronated, the distal fragment tends to become displaced posteromedially.

Role of the Periosteum

Supracondylar fracture displaces posteriorly, the anterior periosteum fails and tears away from the displaced distal fragment.

The anterior loss of periosteal integrity leads to frequent failure of anterior callus formation in early fracture healing

Intact medial or lateral periosteum, the periosteal hinge, has been said to provide stability after fracture reduction .

Forearm pronation after reduction of a posteromedially displaced supracondylar fracture is said to stabilize reduction by closing the fracture gap laterally, tensioning the medial periosteal hinge, and tightening the lateral ligaments of the elbow.

Forearm pronation after reduction of a posteromedially displaced supracondylar fracture is said to stabilize reduction by closing the fracture gap laterally, tensioning the medial periosteal hinge, and tightening the lateral ligaments of the elbow.

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 , which in turn, generates clockwise forces about the medial side of the fracture.

Why is it Important to know the Direction of Displacement????

Because it determines which soft tissue structures are at risk from the penetrating injury of the proximal metaphyseal fragment.

RADIOLOGYStandard ViewsAnteroposterior (AP) view with the elbow extended. A lateral view with the elbow flexed to 90 degrees and the forearm neutral

Jones View

Darracq et al.15 found that limitation of active range of motion was 100% sensitive for fracture or effusion, while preservation of active range of motion was 97% specific for the absence of fracture. Other studies16,24,32 have confirmed a high sensitivity (91% to 97%) of an inability to extend the elbow as a predictor of elbow fracture in both children and adults.

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JONES VIEW

Anteroposterior LandmarksBaumann Angleshaft-physeal angle physeal line and the long axis of the humerus Baumann angle is a good measurement of any deviation of the angulation of the distal humerusNormal :72 degrees (range 64 to 81 degrees)

rotation of the distal fragment or the entire reduced humerus can also alter the projection of the Baumann angle. They found that to be accurate, the humerus must be parallel to the x-ray plate, with the beam directed perpendicular to the film as well. Thus, in the routine AP radiographs of the distal humerus, including the Jones view, the Baumann angle is a good measurement of any deviation of the angulation of the distal humerus26

Humeral-ulnar angle humeral-ulnar angle is the most accurate in determining the true carrying angle of the elbow

Metaphyseal-Diaphyseal angle

The Baumann angle also has a good correlation with the clinical carrying angle, but it may be difficult to measure in adolescents in whom the ossification center of the lateral condyle is beginning to fuse with other centers. The metaphyseal-diaphyseal angle is the least accurate of the three28

Lateral LandmarksTeardropPosterior margin of the coronoid fossaanterior margin of the olecranon fossaSuperior border of ossification center of the capitellum

Shaft-Condylar Angleangulation of 40 degrees between the long axis of the humerus and the long axis of the lateral condyle

On the lateral radiograph, there is an angulation of 40 degrees between the long axis of the humerus and the long axis of the lateral condyle 29

Anterior Humeral Lineanterior border of the distal humeral shaft, it should pass through the middle third of the ossification center of the capitellum

Coronoid Lineanterior border of the coronoid process should barely touch the Anterior portion of the lateral condyle

Passage of the anterior humeral line through the anterior portion of the lateral condylar ossification center or anterior to it indicates the presence of posterior angulation of the distal humerus. In a large study of minimally displaced supracondylar fractures, Rogers et al.41 found that this anterior humeral line was the most reliable factor in detecting the presence or absence of occult fractures

Posterior displacement of the lateral condyle projects the ossification center posterior to this coronoid line30

What are we Looking For???

Figure of 8 sign

Anterior Humeral Line

Fat Pad SignsAnterior fat pad: coronoidTriangular lucencyThe anterior fat pad extends anteriorly out of the margins of the coronoid fossaCoronoid fossa is shallow- sensitive, but not specific

Posterior fat pad : olecranon DeepModerate to large effusions needed to displace itHigh specificity for intra articular disorder( # present in 70%)

Results support the practice of managing children who have a history of trauma to the elbow, an elevated posterior fat pad, and no other radiographic evidence of fracture as if they have a nondisplaced fracture of the elbow.

Radio-Capitellar line

The brachial artery is placed further at risk by the ulnar-sided tether of the supratrochlear artery

The supratrochlear branch that arises from the anterior ulnar recurrent artery may bind the main trunk of the brachial artery against the sharp end of the proximal fragment46

Gartland (1959)Type 1non-displaced

Type 2Angulated/displaced fracture with intact posterior cortex

Type 3Complete displacement, with no contact between fragments

Type 1

Type 2

Type 2

Type 2: Angulated/displaced fracture with intact posterior cortex

In many cases, the type 2 fractures will be impacted medially, leading to varus angulation.

The varus malposition must be considered when reducing these fractures, applying a valgus force for realignment.

Type 3

Type 4Described by Leitch et al.Type IV fractures are unstable in both flexion and extension because of complete loss of a periosteal hinge. These fractures occur either as result of trauma or by excessive flexion force applied during the closed reduction maneuver.

Signs and Symptoms.Elbow pain or a child who fails to use the upper extremity after a fall.Point tenderness over the medial and lateral columns

Type I supracondylar fracture, there is distal humeral tenderness and restriction of motion, particularly lack of full extension

In type III fractures, gross displacement(deformity) of the elbow is evident

initial radiographs should include the entire extremity because multiple fractures may be present . the differential diagnosis should include occult fracture, nursemaid's elbow, and infection. With a clear history of a pulling type of injury, manipulation for a nursemaid's elbow can be done before a radiograph is obtained55

Signs and Symptoms.An anterior pucker sign may be present if the proximal fragment has penetrated the brachialis and the anterior fascia of the elbow

Brachialis SignProximal Fragment Buttonholed through Brachialis

A high index of suspicion is needed to recognize signs of a developing forearm compartment syndrome, such as considerable swelling or ecchymosis, anterior skin puckering, and an absent pulse

Ref: Rockwood and Wilkins' Fractures in Children, 7th ed

Initial ManagementFor fractures with displacement that require reduction, initial splinting with the elbow in approximately 20 to 40 degrees of flexion provides comfort and allows further evaluation.

Avoid Tight bandaging or splinting ,excessive flexion or extension, which may compromise the vascularity of the limb and increase compartment pressure. The arm should then be gently elevated

Closed Reduction and Pin Fixationmost common operative treatment

patient under general anesthesia, the fracture is first reduced in the frontal plane with fluoroscopic verification.

The elbow is then flexed while the olecranon is pushed anteriorly to correct the sagittal deformity and reduce the fracture

An initial attempt at closed reduction is indicated for almost all displaced supracondylar fractures that are not open. Gupta et al., Mehlman et al., and Leet et al. all reported no difference in emergency treatment (8 hours but 10) on the anteroposterior radiograph (with in 4 degrees of normal side) ,

intact medial and lateral columns as seen on the oblique radiographs, and

the anterior humeral line passing through the middle third of the capitellum on the lateral radiograph.

As there is considerable rotationat the shoulder, a certain amount of rotational malalignment inthe axial plane can be tolerated at the fracture site. Any rotational malalignment is detrimental to fracture stability, so, if it is present, one must be especially careful in assessing the stability of the reduction and probably use a third fixation pin64

Milking maneuverThis maneuver is carried out by manipulating the soft tissue over the fracture to pull the soft tissue away from the proximal fragment rather than simply applying traction on the bones, which may not allow reduction of a buttonholed proximal fragment.Described by Archibeck and Peters

If it the proximal fragment appears to have pierced the brachialis muscle, the milking maneuver is used

Milking ManeuverMilk Soft Tissues over Proximal Spike

Archibeck. Brachialis muscle entrapment in displaced supracondylar humerus fractures: a technique of closed reduction and report of initial results. J Pediatr Orthop. 1997;17:298.

Next, varus and valgus angular alignment is corrected by movement of the forearm.

Medial and lateral fracture translation is corrected with direct movement of the distal fragment by the surgeon's thumb(s) with image confirmation.

The elbow is then slowly flexed while anterior pressure is applied to the olecranon with the surgeon's thumb

Reduction maneuver

After successful reduction, the child's elbow should sufficiently flex so that the fingers touch the shoulder. If not, the fracture likely is still not reduced and is in extension

Check for intact medial and lateral column under c-arm (oblique views)

Technique of Reduction

If there is a considerable gap in the fracture site or the fracture is irreducible with a so-called rubbery feeling on attempted reduction, the median nerve and/or brachial artery may be trapped

proceed to an open reduction

Once reduction is satisfactory, the elbow is taped in the reduced position of elbow hyperflexion

Type 1 Fractures

Treated with immobilization for approximately 3 weeks, at 60- 90 degrees of flexion.

If there is significant swelling, do not flex to 90 degrees until the swelling subsides.

follow-up radiographs be made at one and two weeks to identify any fracture displacement

Type 2 Fractures

Reduction of these fractures is usually not difficultMaintaining reduction usually requires flexion beyond 90Excessive flexion may not be tolerated because of swellingMay require percutaneous pinning to maintain reduction Percutaneous pinning is the safest form of treatment for many of these fracturesPins maintain the reduction and allow the elbow to be immobilized in a more extended positionFitzgibbons. Predictors of failure of nonoperative treatment for type-2 supracondylar humerus fractures. J Pediatr Orthop. 2011;31:372.

Type 3 FracturesThese fractures have a high risk of neurologic and/or vascular compromiseCan be associated with a significant amount of swellingCurrent treatment protocols use percutaneous pin fixation in almost all casesIn rare cases, open reduction may be necessaryEspecially in cases of vascular disruption

Indications for Open ReductionInadequate reduction with closed methodsVascular injuryOpen fractures

Closed Reduction Percutaneous PinningTreatment of choice for most supracondylar fractures.

Open Reduction Usually not Necessary

Done under strict C Arm Control

Various configuartions

Biomechanically Stable

Pinning

Maximal pin separation at the fracture site.

The pins should engage both medial and lateral columns just proximal to the fracture site.

They should engage an adequate amount of bone proximal and distal to the fragments.

On the lateral view, pins should incline slightly in the anterior to posterior direction in accordance with normal anatomy.

If placing a medial pin, extend the elbow when placing the pin to keep the ulnar nerve posterior and out of harm's way.

Royce et al. and Gordon et al. recommended using a small incision over the medial epicondyle and placing a drill guide on the bone, through which the wire is inserted. The pins should be angulated superiorly approximately 40 degrees and posteriorly 10 degrees. The pins must continue into the opposite cortex to provide solid fixation. Smooth pins are preferred. Some authors have advised placing the patient prone with the elbow flexed rather than supine. We routinely use the supine position; however, we have tried the prone position, and it does provide easier accessibility for pin placement, but orientation of the fragments with the patient prone is difficult even when the image intensifier is being used. We use two lateral pins and use a medial pin only if the fracture seems to be unstable intraoperatively

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If any rotational malalignment present careful in assessmeny of the stability of the reduction and probably use a third fixation pin

The fracture reduction is held with two or three Kirschner wires

Elbow is immobilized in 40 to 60 of flexion, depending on the amount of swelling and the vascular status.

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Loss of Fixation..In a study of eight supracondylar humeral fractures thatlost reduction, Sankar et al. reported that the loss of fixation in all cases was due to technical errors that were identifiable on the intraoperative fluoroscopic images and could have been prevented with proper technique. They identified three types of pin-fixation errors: Failure to engage both fragments with two pins or more Failure to achieve bicortical fixation with two pins or more, and Failure to achieve adequate pin separation (>2 mm) at the fracture site.

Conclusions:We found no statistical difference in the radiographic outcomes between lateral-entry and medial and lateral-pin techniques for the management of Type 3 supracondylar fractures in children when evaluated in this prospective and surgeon-randomized trial, but 2 cases of iatrogenic injury to the ulnar nerve occurred with medially placed pins.

For operative fixation with medial/lateral entry pins, the probability of ulnar nerve injury is 5.04 times higher than with lateral entry pins. When all documented operative nerve injuries are included, the probability of iatrogenic nerve injury is 1.84 times higher with medial/lateral entry pins than with isolated lateral pins. Medial/lateral pin entry provides a more stable configuration, and the probability of deformity or loss of reduction is 0.58 times lower than with isolated lateral pin entry. When the prospective studies alone were analyzed, there were no significant difference in the probability of iatrogenic nerve injury or deformity and displacement, although the confidence intervals were wide. This systematic review indicates that medial/lateral entry pinning, of pediatric supracondylar fractures, remains the most stable configuration and that care needs to be taken regardless of technique to avoid iatrogenic nerve injury and loss of reduction.

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When to Operate??

Earlier Closed reduction and pinning of type IIIsupracondylar fractures was performed as an emergent procedure.

BUT.

Is it beneficial??

The puzzle of pulse and perfusion

Pink Pulseless HandInjury to the brachial artery can have potentially serious consequences, such as Volkmann ischemia, loss of limb, and retarded development of the limb.

The common practice of watchful waiting for pulseless and perfused supracondylar fractures may be open to question in favor of a more aggressive approach.

Doppler ultrasound may be useful in differentiating patients at risk and can be part of an effective vascular evaluation.

Prospective studies are needed to provide more definitive information on management of supracondylar humerus fractures.

Absent pulse on ArrivalClosed reduction and Lateral pinningPalpable PulsePink Pulseless HandReturn of Pulse in 48 HoursPink hand with Absent Radial PulsePeriodic Weekly review for 6 weeks

Obliteration of the intact preoperative radial pulse after closed reduction and pinning is a strong indication for brachial artery exploration only when accompanied by evidence of impaired circulation to the hand. After 10 to 15 minutes is allowed for resolution of arterial spasm as a cause for loss of pulse, the brachial artery should be explored if the hand is not warm and pink.Either direct arterial entrapment at the fracture or arterial compression by a fascial band pulling across the artery may cause loss of pulse after fracture reduction.Other indication for brachial artery exploration is persistent vascular insufficiency after reduction and pinning

The management of a persistent pink pulseless hand after a satisfactory closed reduction in a pediatric supracondylar fracture of the humerus is controversial. Several recent publications have recommended vascular exploration in contrast to a more conservative approach accepted traditionally. We report the results of seven patients with a mean follow-up of 36.6 months with a persistent pulseless, but well-perfused hand postreduction. All patients were managed conservatively without vascular exploration. A palpable return of the radial pulse was seen in six patients at 3 weeks and at 6 weeks follow-up in the other patient with no long-term dysfunction. We believe that the management of a persistent pink pulseless hand remains a 'watchful expectancy'. Surgical exploration should be recommended only if there is either severe pain in the forearm persisting for more than 12 h after the injury or if there are signs of a deteriorating neurological function.

The pink pulseless hand: a review of the literature regarding management of vascular complications of supracondylar humeral fractures in children.Griffin KJ, Walsh SR, Markar S, Tang TY, Boyle JR, Hayes PD.AbstractSupracondylar fractures of the humerus are the commonest upper limb fractures in children, accounting for up to 70% of all paediatric elbow fractures.] and are often complicated by neurovascular injury. Much confusion surrounds the management of the child with a "pink pulseless hand" post-fracture reduction and several treatment options have been proposed including observation, immediate exploration and angiography. The literature contains a number of case series with variable follow-up. A child with a pink pulseless hand post-fracture reduction can be managed expectantly unless additional signs of vascular compromise develop, in which case exploration should be undertaken.PMID:18851922,2009[PubMed - indexed for MEDLINE]

CONCLUSION: The presence of a waveform on a pulse oximeter is a sensitive and easily available modality in determining vascular perfusion as compared to other more complex investigations. The high sensitivity of this test will allow surgeons to objectively determine the requirement for surgical exploration of the brachial artery.RESULTS:In this series of pulseless perfused hands following operative fixation of supracondylar fracture, a total of 26 patients were reviewed. All were Gartland grade III extension type fractures. Postoperative pulse oximeter waveforms were present in all but 4 patients. These patients subsequently had exploration of the brachial artery with significant findings. In the remaining 22 patients, waveforms were present and the child had return of the radial pulse soon after operative fixation without any further need for surgical exploration. At 24 months follow-up, all children were well with no neurovascular compromise

Pale Hand ,Absent Pulse

NO CONTROVERSY

Pale Hand ,Absent Pulse

IMMEDIATE EXPLORATION

Vascular involvement (10-15% with type III Present with absent pulse)

Open reduction through an anterior approach with medial extension allows evaluation of the brachial artery and removal of the neurovascular bundle entrapped within the fracture site or repair of the brachial artery.

Brachial Artery ExplorationOrthopaedic surgeon + Vascular surgeon Release of a fascial band or an adventitial tether resolves the problem of obstructed flow.The brachial artery should be approached through a transverse incision across the antecubital fossa, with a medial extension turning proximally at about the level of the medial epicondyle .

If Arterial Spasm is the cause ----Release the spasmVascular Graft might be Required.

Arterial reconstruction using the basilic vein from the zone of injury in pediatric supracondylar humeral fractures: a clinical and radiological series.Lewis HG, Morrison CM, Kennedy PT, Herbert KJ

The authors describe the advantages of using the basilic vein as an arterial conduit in the management of children with supracondylar humeral fractures requiring vascular repair. This series confirms the safety of using a donor vein from within the zone of injury for arterial reconstruction, after a supracondylar humeral fracture. Benefits include a single surgical wound on the less conspicuous medial side of the arm, reduced operating time, and preservation of donor veins that may be subsequently required for the management of atherosclerotic disease.

Supracondylar Humerus Fractures:ComplicationsVascular injury / compromiseCompartment syndromeNeurologic deficitElbow StiffnessPin Track InfectionsMyositis Ossificans- rareNonunion- very very rareOsteonecrosis

Neurologic Injury10% and 20%the anterior interosseous nerve actually appears to be the most commonly injuredparalysis of the long flexors of the thumb and index finger without sensory changesNerve transections are rare and almost exclusively involve the radial nerveClosed #- observationNeural recovery, regardless of which nerve is injured, generally occurs after two to 2.5 months of observation, but it may take up to six monthsOpen #- exploration

Compartment Syndrome0.1% to 0.3%

Skaggs et al. showed that ecchymosis and severe swelling even in the presence of an intact radial pulse with good capillary refill should alert the treating physician to the possibility of a compartment syndrome

Cubitus VarusSome authors have proposed that unequal growth in the distal part of the humerus as the cause.This is unlikely as there is not enough residual growth left in this area

The most common reason for cubitus varus in patients with a supracondylar fracture is therefore malunion rather than growth arrest

Treatment for cubitus varus has in the past been considered for cosmetic reasons only. Consequences of cubitus varus Increased risk of lateral condyle fracturesPainTardy posterolateral rotatory instability

which may be indications for an operative reconstruction with a supracondylar humeral osteotomy

POST RECOVERY

FLEXTION TYPERare, only 2%Distal fracture fragment anterior and flexedUlnar nerve injury more commonReduce with extensionOften requires 2 sets of hands in OFHold elbow at 90 degrees after reduction to facilitate pinning

Mahan. Operative management of displaced flexion supracondylar humerus fractures in children. J Pediatr Orthop. 2007;27:551.

Radiographic findingsAnterior displacement ,medial or lateral translation Associated fractures proximal humerus and radius. Fracture classification Type I, nondisplaced fracture; type II, minimally angulated with cortical contact; and type III, totally unstable displaced distal fracture fragment

Flexion Type

Flexion TypePinning

Treatment Reduce with extensionhold elbow at 90 degrees after reduction to facilitate pinningImmobilization for type 1CR+extension cast closed reduction and percutaneous pinning Open reduction -anteromedial or posterior approach

1Chen RS, Liu CB, Lin XS et al. Supracondylar Extension Fracture of the Humerus in Children. J Bone Joint Surg Am. 2001Rockwood and Wilkins' Fractures in Children, 7th edCampbell operative orthopaedics 11 edCurrent Concepts Review Supracondylar Humeral Fractures in Children, JBJS may 2008.Archibeck MJ, Scott SM, Peters CL. Brachialis muscle entrapment in displaced supracondylar humerus fractures: a technique of closed reduction and report of initial results. J Pediatr Orthop. 1997 Apr.;17(3):298302.

References

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