Skip to main content
UploadLanguage (EN)Support
BusinessMobileSocial MediaMarketingTechnologyArt & PhotosCareerDesignEducationPresentations & Public SpeakingGovernment & NonprofitHealthcareInternetLawLeadership & ManagementAutomotiveEngineeringSoftwareRecruiting & HRRetailSalesServicesScienceSmall Business & EntrepreneurshipFoodEnvironmentEconomy & FinanceData & AnalyticsInvestor RelationsSportsSpiritualNews & PoliticsTravelSelf ImprovementReal EstateEntertainment & HumorHealth & MedicineDevices & HardwareLifestyle
Uploaded byharshkotadia
PPTX, PDF702 views

SCH- supracondylar humerus fracture in childrens

Supracondylar humerus fractures are the most common elbow fractures in children, typically occurring between ages 5-6. They are usually caused by a fall onto an outstretched hand with the elbow extended. Displaced fractures are typically treated with closed reduction and percutaneous pinning, while nondisplaced or minimally displaced fractures can be treated with casting. Complications can include neurovascular injuries, compartment syndrome, loss of reduction, and malunion. Careful examination and management is required to prevent complications.

Education◦
Downloaded 36 times
SUPRACONDYLAR HUMERUS FRACTURES IN CHILDREN By - Dr Harsh Kotadia Resident - Orthopaedics Bharati Vidyapeeth , pune
INTRODUCTION  Supracondylar humerus fracture are the most common elbow fractures seen in the children and the most common fracture requiring surgery  The peak age range at which supracondylar humerus fractures occur is 5-6 years
MECHANISM OF INJURY  Supracondylar humerus fractures can be divided grossly into 2 types: flexion and extension  Extension type of fractures accounts for 97 – 99 % of total SCH fracture , usually caused by a fall onto a out stretched hand with the elbow in full extension  Flexion type of fractures occurs due to fall directly onto the elbow ,accounts for about 2 % of SCH fractures  SCH fractures most frequently results from falling , commonly off playground equipment .  It has been postulated that ligamentous laxity with resulting elbow hyperextension may present to SCH fracture
 The proximal metaphyseal spike penetrates laterally with Posteromedially displaced fractures places the radial nerve at risk  Posterolaterally displaced fractures , the spike penetrates medially and places median nerve and brachial artery at risk
ASSESEMENT  A elbow or forearm fractures should be suspected in a child with elbow pain or failure to use the upper extremity after a fall, injury  The S – shaped configuration is created by the anterior prominence of the proximal fragment’s spike and extension of the distal fragment.  Recent studies shows that increasing anxiety and need for pain medication may be the earliest warnings of compartment syndrome.  Paediatric patients with compartment syndroms often presents with the three A’s – anxiety, agitation, and increasing analgesic requirement
 An anterior pucker sign may be present if the proximal fragment has penetrated brachialis and the anterior fascia of the elbow  This is a sign of considerable tissue loss,if any bleeding from a puncture wound is present ,this should be treated as open fracture
 Careful motor , sensory and vascular examination should be performed in all the patients , 10-15 % of patients have a nerve injury ,  with the anterior interosseous nerve being the most frequently injured in the extension type ,  the ulnar nerve is most frequently injured in flexion type fractures Sensory examinations  Radial nerve – dorsal web space  Median nerve – palmar index finger tip  Ulnar nerve – ulnar side of little finger tip Motor examination  Radial nerve – finger, wrist , and thumb extension  AIN – anterior interosseous nerve – index finger DIP flexion , and thumb IP flexion  Median nerve – finger flexion strength  Ulnar nerve - interossei
 Vascular examination should include determining the presence of pulse , as well as warmth , capillary refill , and color of the hand  The vascular status may be classified into 3 categories :  Hand well perfused, radial pulse present  Hand well perfused, radial pulse absent  Hand poorly perfused , radial pulse absent  A vascular injury typically brachial artery , can occur in upto 10-20% of patient with type 3 fractures
Imaging  If physical examination does not localize the trauma to the elbow alone this may include obtaining Anteroposterior and lateral views of entire upper extremity  Two main parameters used to evaluate the presence of supracondylar humerus fracture:  1. Anterior Humeral Line (AHL) The AHL should cross the capitellum on a true lateral of the elbow (previously it was stated that in a normal elbow , the AHL should pass through the middle third of the capitellum ,
however , it has been demonstrated by Herman that in a normal elbow , the AHL passes through the middle third of the capitellum only 52 % of the time in children under 10 years of age , and in children younger than 4 years of age, the AHL is equally likely to pass through the anterior third of the capitellum as the middle third . ) So , it was found that the AHL should pass through the center of the capitellum in all children 5 years and older , and if dosen’t ,pathology should be suspected.  In an extension type supracondylar fracture , the capitellum is posterior to this line
 2. Baumann’s angle(humero capitellar angle)  It is the angle between line perpendicular to the long axis of the humeral shaft and physeal line of lateral condyle Normal range – 9-26 degree  A Baumann’s angle of at least 10 degree is acceptable  Decrease in baumann’s angle compared to the other side is a sign that fracture is in varus angulation (medial comminution)
CLASSIFICATION  MODIFFIED GARTLAND CLASSIFICATION
 Type 1 fracture  It is a non displaced or minimally displaced fracture(less than 2 mm) , the posterior fat pad sign may be only evidence of the fracture ,these fractures are stable type  Type 2 fracture  It is displaced more than 2 mm with presumably intact , hinged posterior cortex  The AHL line is usually anterior to the capitellum on a true lateral of elbow ,though in mildly displaced fracture it may touch the capitellum
 Type 3 fracture  It is a displaced supracondylar fracture with a range of cortical contact  There is usually extension in the sagittal plane and rotation in the frontal and /or transverse plane  The periosteum is severly torn and the soft tissue and neurovascular injuries aften accompany this fracture  Type 4 fracture  These fracture are characterized by incompetent periosteal hinge circumferncially and defined by being unstable in both flexion and extension  The multidirectional instability is usually determined under anaesthesia at a time of operation wjen on a lateral view the capitellum is anterior to the AHL with elbow flexion , and posterior to the AHL with elbow flexion
 Medial comminution In supracondylar humerus fracture  Medial collapse signifies malrotation in the frontal plane and is associated with loss of baumann’s angle and varus malalingnment.  The lateral view show reasonable alignment  Which requires reduction and usually pin fixation to prevent late malunion.
TREATMENT OPTIONS FOR SUPRACONDYLAR FRACTURE OF DISTAL HUMERUS Treatment Type 1 Type 2 Type 3 type 4 Casting without reduction Almost always Closed reduction and casting Rarely indicated , do not flex elbow > 90 degree Closed reduction and pinning Great majority of the cases Great majority of cases Most cases Open reduction and fixation Uncommonly necessary If closed reduction inadequate If closed reduction inadequate
NON OPERATIVE MANAGEMNT  CLOSED REDUCTION AND CASTING  Type 1 fracture (undisplaced ) are treated with immobilization and casting  Simple immobilization at 60 – 90 degree of elbow flexion , with the forearm in neutral position .  Mildly displaced fracture can be reduced closed , using the intact posterior periosteum as a stabilizing force and then holding reduction by flexing the elbow greater than 120 degree.  Less flexion increases the risk of loss of reduction.  Xrays are obtained at 3-7 days after fracture to document lack of displacement  The duration of immobilization is about 3 weeks
CLOSED REDUCTION AND PINNING  Treatment of type 2 injuries is somewhat controversial , wilkins subdivided into 2 parts into A and B  Type 2A being stable and type 2B fractures having some degree of rotation or translation making them unstable  Closed reduction and casting can be used in type 2A inuries  Closed reduction and percutaneous pinning typically with 2 or 3 lateral pins has become the main form of treatment for type 2B
Closed reduction and pinning  Three pinning techniques are described :  Crossed : one medial and one lateral  Divergent : two divergent lateral pins  Parallel : two parallel lateral pins  Two main issues with crossed pin versus lateral entry pinning are risk of ulnar nerve injury and loss of reduction more in medial pinning
 The ideal pin configuration remains controversial ; although crossed medial and lateral pins are more stable than 2 lateral pins in vitro, use of 2 or three lateral pins appears to be equal to crossed pins in vivo  main issues with crossed pin versus lateral entry pinning is risk of ulnar nerve injury more in medial pinning  Studied reported that 2 or 3 lateral entry pins had comparable construct stiffness to each other , and both were greater then crossed pins in all types of stress, except in valgus , in which cross- pins had greater stiffness  Recent papers suggest that lateral entry pins are being used more commonly than cross – pins for most supracondylar fractures
 The important technical points for fixation with lateral entry pins are as follows :  Maximum separation of the pins at the fracture site  Engage the medial and lateral columns proximal to the fracture  Maintain at least 2 mm separation of pins at fracture sites  Engage sufficient bone in both the proximal and distal fragment  Maintain a low threshold for use of a third lateral entry pin if there is a concern about fracture instability or the location of the first two pins  Use three pins for type 3 fractures
Technique for closed reduction and pinning in supracondylar humerus  Position the patient supine and position the elbow on an inverted image intensifier  For the most common extension type fracture , with countertraction on the humerus , apply traction at the forearm and examine the fracture with c- ARM  With elbow in extension , correct rotation malalignment and medial and lateral translation once this is corrected , maintain traction on the elbow and gently flex the elbow to 120 degree  Use pressure on the oleceranon as the elbow is flexed to correct extension of the distal fragment .maximally flex the elbow and pronate the forearm to lock posterior and medial soft tissue hinges
 For the rare flexion type injury , flexing the elbow will further displace the fragment because of the disruption of the posterior periosteal hinges .In this case the elbow need to be pinned in extension this can be difficult , and posterior open reduction is needed oftenly .  If a medial pin is used , make a 1 cm incision over the medial epicondyle ,spread the soft tissue over the medial epicondyle so that epicondyle can be seen and ulnar nerve can be protected  If the fingers cannot touch the shoulder , flexion deformity may not be corrected
There are three types of pin fixation commonly found errors :  1. failure to engage Both fragments with two or more pins  2. failure to achieve bicortical fixation with two or more pins  3. failure to achieve adequate pin separation (2mm) at fracture sites
COMPLICATION  Vascular injuries  Compartment syndrome  Neurological deficit  Pin tract infection  Pin migration  Myositis ossificans  Non union  Avascular necrosis  Loss of reduction  Cubitus varus
VASCULAR INJURIES  Preoperative Evaluation And Care:approximately 1% To 15% Of Patients With Supracondylar Fractures Present With An Absent Pulse But Only A Minority Of These Patients Will Require Vascular Repair.  At The Initial Evaluation The Presence Or Absence Of A Pulse And Perfusion Of The Hand Should Be Determined.  If There Is Not A Palpable Pulse ,A Doppler May Be Used To Assess. A Pulse That Can Be Detected On Doppler May Be An Objective Sign Of Good Perfusion.
 Fracture Reduction Should Not Be Delayed By Any Waiting Time For An Angiographic Study, As Reduction Of The Fracture Usually Restores The Pulse.  An Absent Radial Pulse Is Not In Itself An Emergency. In The Case Of A Pulseless, Perfused Hand, Urgent, But Nonemergent, Reduction With Pinning In The Operating Room Is Indicated.
 However, in the presence of an associated nerve injury, there is higher risk of a compartment syndrome and more close observation until surgery is indicated. If the arm is pulseless and also has signs of poor perfusion this is an emergency. When a patient with a severely displaced supracondylar fracture presents to the emergency room and has compromised vascularity to the limb, the arm should be splinted with the elbow in approximately 20 to 40 degrees of flexion to protect further injury as the patient progresses directly to surgery.
Management of patient with vascular injury
Potential pitfalls and preventions  Nerve /vascular entrapment  If there is a gap in the fracture site or the fracture is irreducible with a rubbery feeling on attempting reduction , the median nerve and /or brachial artery may be trapped in the fracture site  Proximal fragment has pierced the bracialis  “Milking maneuver”. The biceps are forcibly ‘milked’ in a proximal to distal direction past the proximal fragment , often culminating in a palpable release of the humerus posteriorly through the brachialis
COMPARTMENT SYNDROME  The prevalence of compartmemt syndrome is about 0.5 – 0.8%  Classical 5 p’s for the diagnosis of compartment syndrome – pain , pallor, pulselessness, paraesthesia, and paralysis are poor indicator in children  Pediatric patients often presents with the three A’s – anxiety, agitation, and increasing analgesic requirement
AVASCULAR NECROSIS  Avascular necrosis of trochlea have been reported after supracondylar humerus fracture  The blood supply of the trochlea’s ossification center is fragile  Symptoms of avascular necrosis of the trochlea do not occur for months or years  Healing is normal, but mild pain and occasional locking develop with characteristic radiological changes and range of motion may be affected depending upon the extent  An important risk factor for AVN is following an open reduction of fracture through posterior approach
Fishtail deformity presenting at an average 4.7 years after fracture 80% of which had mechanical symptoms of locking ,catching and painful limited range of motion
NEUROLOGIC DEFICIT  A Meta-analysis Of 3,457 Extension-type SCH Fractures Found An Overall Neuropraxia Rate Of 13%, With The Median Nerve (5%) Being The Most Common, Followed By The Radial Nerve 4%. AIN Palsy Presents As Paralysis Of The Long Flexors Of The Thumb And Index Finger Without Sensory Changes.  Complete Median Nerve Injury Has Also Been Described With These Fractures Because Of Contusion Or Transection Of The Nerve At The Level Of The Fracture And Presents With Sensory Loss In The Median Nerve Distribution As Well As Motor Loss Of All Muscles Innervated By The Median Nerve.
 The Direction Of The Fracture’s Displacement Determines The Nerve Most Likely To Be Injured. If The Distal Fragment Is Displaced Posteromedially, The Radial Nerve Is More Likely To Be Injured. Conversely, If The Displacement Of The Distal Fragment Is Posterolateral, The Neurovascular Bundle Is Stretched Over The Proximal Fragment, Injuring The Median Nerve Or AIN Or Both.  In A Flexion Type Of Supracondylar Fracture, Which Is Rare, The Ulnar Nerve Is The Most Likely Nerve To Be Injured.
 An Irreducible Fracture With Nerve Deficit Is An Indication For Open Reduction Of The Fracture To Ensure That There Is No Nerve Entrapment.  Chronic Nerve Entrapment In Healed Callus Can Give The Appearance Of A Hole In The Bone, Metev’s Sign.  Iatrogenic Injury To The Ulnar Nerve Has Been Reported To Occur In 1% To 15% Of Patients With Supracondylar Fractures.  The Course Of The Ulnar Nerve Through The Cubital Tunnel, Between The Medial Epicondyle And The Olecranon, Makes It Vulnerable When A Medial Pin Is Placed.
ELBOW STIFFNESS  Clinically loss of reduction after extension type supracondylar humerus fracture is rare in children  Although most children do not require formal physical therapy ,  In most patients , treated with closed reduction with pinning elbow ROM return to 72 % of contralateral elbow by 6 weeks,86 % by 12 weeks, 98 % by 52 weeks
 Significant loss of flexion can be caused by lack of anatomical fracture reduction  1.posterior distal fragment angulation  2.posterior translation of the distal fragment with anterior impingement  3.medial rotation of the distal fragment with a protruding medial metaphyseal spike proximally
PIN TRACT INFECTIONS  The reported prevalence is less than 1-2.5%  Pin tract infection generally resolves with pin removal and antibiotics  However , an untreated patient can result in septic joint and osteomyelitis , and thus be treated as soon as diagnosed or suspected
PIN MIGRATION  It is most common complication in SCH fractures  This complication can be minimized by both bending at least 1 cm of the pin at a 90 degree angle , at least 1 cm from the skin , and protecting the skin with thick felt over the pin ort using pin covers
MYOSISTIS OSSIFICANS  It is remarkably rare complication , but it can occur  This complication have been described after closed and open reductions due to disruption of the brachialis with injury , but vigorous post- operative manipulation or physical therapy
NON UNION  The distal humeral metaphysis is a well – vascularized area with markedly rapid healing , and nonunion of a supracondylar fracture is very rare
CUBITUS VARUS  Cubitus varus also known as ‘Gunstock Deformity’  The malunion also includes hyperextension which leads to increased elbow extension and decreased elbow flexion  On AP view , the angle of the physis of the lateral condyle (baumann’s angle ) is more horizontal than is normal  On Lateral view , hyperextension of the distal fragment posterior to the AHL goes along with the clinical findings of increased extension and decreased flexion of the elbow
 The most common reason for cubitus varus in patient with supracondylar fractures is likely malunion rather than growth arrest  Cubitus varus can be prevented by making certain Baumann’s angle is intact at the time of reduction and remains so during healing by achieving stable reduction and remains so during healing by achieving stable fixation  Avascular necrosis of the trochlea or medial portion of the distal humeral fragment can result in progressive varus deformity
TREATMENT  For treatment of any posttraumatic malalignments , options include 1. Observation with expected remodeling 2. Hemi epiphysiodesis 3. Corrective osteotomy
1. Observation with expected remodeling  Observation is generally not successful in achieving anatomical alignment as hyperextension may remodel to some degree in a young child , but in older children , insufficient remodeling occurs even in joint’s plane of motion
2. Osteotomy  Osteotomy is the only way to correct a cubitus varus deformity with high probablity of success .  It was found that when lateral entry pins were used to fix the osteotomy , there were significantly less complications 1. Medial open wedge osteotomy 2. Lateral closing wedge osteotomy 3. Dome osteotomy 4. Arch osteotomy
THANK YOU