Supracondylar fractures humerus

Dr.Roshan Zameer1st year pg

Orthopaedics

• Most common elbow fractures seen in children

• 5 to 6yrs• Boys vs gals- 3:2• Left or non dominant side more common

Mechanism

• Depending on direction of displacement of distal fragment

• Extension & flexion types• Outstretched hand with elbow full extension

• Between the olecranon fossa posteriorly and the coronoid fossa anteriorly, the medial and lateral columns of the distal humerus are connected by a thin segment of bone

• elbow is hyperextended, the olecranon engages the olecranon fossa and acts as a fulcrum through which the extension force can propogate a fracture

Displacements posteromedial vs posterolateral

Classification

• Modified gartland

Signs & symptoms

• History- pulling or fall• Pain,swelling• Tenderness-both condyles• Decreased ROM• Limited extension• Gross deformity• Anterior pucker sign

S-configuration

Associated injuries

Motor & sensory examination

• Sensory-• Radial nerve- dorsal 1st web space• Median nerve – palmar index finger• Ulnar nerve – palmar little finger

• Motor• Finger, wrist, thumb extension -Radial nerve• Distal IP flexion & thumb IP flexion -Anterior

interosseous nerve• Thenar strength -Median nerve• Interossei -Ulnar nerve

Vascular examination

• Presence of pulse, warmth, capillary refill, and colour of the hand.

• Vascular status three categories• Hand well-perfused (warm and red), radial

pulse present• Hand well-perfused, radial pulse absent• Hand poorly perfused (cool and blue or

blanched), radial pulse absent

Forearm compartment syndrome

• High suspicion-look for• Swelling or Ecchymosis• Anterior skin puckering• Absent pulse• Tenseness of the volar compartment• Passive finger extension & flexion tested

Radiographic evaluation

• True Ap ,Lat,Oblique views• Initial xray may be negative except for a posterior

fat pad sign• Anterior humeral line • Baumann angle or Humeral capitellar angle -Normal range 9 to 26 deg, - 10 degrees is acceptable -A decrease in the Baumann angle is a sign that

a fracture is in varus angulation

• Young child, epiphyseal separation mimic an elbow dislocation.

• In an epiphyseal separation, the fracture propagates through the physis without a large metaphyseal fragment

• Differentiating this injury from an elbow dislocation is the alignment of the capitellum with the radial head

Management

Initial Management

• Initial splinting - elbow in 20 to 40 degrees of flexion

• Avoid Tight bandaging,excess flexion,extension

-vascular injury• Limb elevated• Neurologic & vascular status• Look for compartment syndrome

Closed Reduction and Pinning

• initially attempted - including type III fractures• first reduced in the frontal plane • elbow is then flexed while the olecranon is

pushed anteriorly to correct the sagittal deformity

Indications of a successful reduction

• Restoration of the Baumann angle –Apview > 10 deg

• Intact medial and lateral columns on oblique views

• Anterior humeral line passing through the middle third of the capitellum on the lateral view

• immobilized in 50 to 60 degrees of flexion

• Ulnar nerve injury ?• Migration of nerve? Medial / anterior• Small incision over medial epicondyle.

• Medial pin inserted in extension with out flexing

• Construct stability- 2 divergent lateral pins > crossed pins > 2 parallel pins

• 2 lateral pins,unstable- 3rd lateral pin,still unstable than put a medial pin.

Indications for open reduction

• Gap in the fracture site • An irreducible fracture with a rubbery feeling

on attempted reduction may be signs that the median nerve and/or brachial artery is trapped in the fracture site,

Open Reduction

• Closed reduction fails • Fractures associated with a dysvascular limb• Approches-medial• lateral• posterior• Transverse.

Treatment with Traction(conservative)

• Severe comminution• Lack of anesthesia• Medical conditions prohibiting

• Malunion is common

Type I Fracture (Nondisplaced)

• Periosteum is intact • Xray limited to a posterior fat pad sign• Posterior splint applied at 60 to 90 degrees of

elbow flexion @ 3 wks• Any signs of compartment syndrome

• Type II Fracture (Hinged Posteriorly, with Posterior Cortex in Continuity)

–closed reduction & pinning -immobilization in 90 deg flexion & supination

Type III Fractures-

• Elbow in either extreme flexion or extension avoided

• 30 deg flexion -prevent vascular insult,compartment

• Periosteum is torn, there is no cortical contact between the fragments

• Open or closed reduction with pinning• After reduction if casting-elbow in 120 deg

flexion,to prevent rotation @ 3-4 wks.

Type IV Fractures

• Extremely unstable fracture• Reduction in both planes• Open reduction and pinning

• Medial Column Comminution• Open or closed reduction with pinning• Or leads to varus deformity

Procedure

• Pt supine with # arm over arm board• Traction with the elbow flexed 20 deg to

avoid tethering the neurovascular structures • Held for 60 seconds to allow soft tissue

realignment

• If it the proximal fragment appears to have pierced the brachialis muscle, the “milking maneuver”

• milked” in a proximal to distal direction

• Next, varus and valgus angular alignment is corrected

• By direct movement of the distal fragment by the surgeon's thumb

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

• After 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

• “rubbery” feeling- median nerve or brachial artery entrapment- open reduction

• “bone on bone” feeling• elbow is taped in the reduced position of

elbow hyperflexion

• Acceptable• some translation of the distal fragment (up to

25%) • moderate rotational malalignment

• As a rule, 2 pins for type II fractures and 3 pins for type III fractures

• Stress applied in varus and valgus under fluoroscopy to ensure fracture stability

• lateral views should be obtained with the elbow flexed and extended to assess movement of the capitellum relative to the anterior humeral line

• Posterior slab or casting with less than 70 deg flexion @ 3 wks

• > 90 deg-risk of compartment syndrome

Complications

• Vascular injury• Compartment syndrome• Neurologic defect• Elbow Stiffness• Pin Track Infections• Myositis Ossificans• Cubitus varus“gunstock deformity”

Reference

• Campbell• Gray’s anatomy

Thanku