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Supra condylar humerus fracture in children

This document provides information on supracondylar fractures of the humerus in children. It discusses the anatomy and mechanisms of injury, classification, clinical presentation, management including closed and open reduction techniques, complications, and outcomes. Key points include: - Supracondylar fractures most commonly result from a fall onto an outstretched hand with the elbow hyperextended. - Gartland classification divides fractures into non-displaced (type I), displaced with intact posterior cortex (type II), displaced with rotational deformity (type III), and unstable fractures (type IV). - Closed reduction under fluoroscopy and percutaneous pinning is the standard treatment, with crossed pins providing more stability

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PRESENTED BY: DR. SURENDRA KUMAR GUPTA FIRST YEAR RESIDENT DEPARTMENT OF ORTHOPAEDICS
 Also called Malgaigne’s fracture  Fracture line passes just proximal to the bone masses of trochlea capitulum and often runs through the apices of coronoid and olecranon fossae  The fracture line is generally transverse
X-ray positioning. The correct method of taking a lateral view is with the upper extremity directed anteriorly rather than externally rotated.
 Bony architecture at the supracondylar region is weak and vulnerable because:  Bone is remodelling  It is less cylindrical  Metaphysis is just distal to 2 fossae, coronoid and radial fossa  Here the cortex is thin  Anterior cortex has a defect in the area of coronoid fossa  Laxity of ligaments permits hyperextension at the elbow
 The peak age is between 5 and 8 years.  The rate of occurence increases steadily in the first 5 yrs of life, and traditionally boys have higher incidence of this fracture than girls.  The average age at fracture is 6.7 years.  Left of nondominant side predominates.  2/3rd of children hospitalized with elbow injuries have supracondylar fractures.
 97.7% have extension type and 2.3% have flexion type  Nerve injury occurs in atleast 7% and significant vascular injury in 1 %  Radial nerve is most frequently involved (45%), median (32%) and ulnar (23%) is also involved.  0.5% develop volkman’s ischaemic contracuture  Almost all supracondylar fractures are caused by accidental trauma rather than abuse  70% s/c fractures are due to fall from height.
MACHANISM OF INJURY  Fall on outstretched hand with elbow in extension.  When it is extended beyond neutral position, flexor muscles are at poor mechanical advantage and there is little resistance to injury
 Hyper extension converts linear force into bending force.  When the elbow hyperextention, the olecranon forcefully pushes into the olecranon fossa and act as fulcrum while the anterior capsule simaltaneously provides a tensile force on the distal humerus at its insertion. TENSILE
 The elbow becomes tightly interlocked concentrating bending forces to the distal humerus.  As bending forces continue the distal humerus fails anteriorly in the supracondylar area, resulting in s/c fracture.
 When the fracuture is complete the distal fragment becomes displaced posteriorly and the strong action of triceps causes distal fragment to migrate proximally.
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 when on a lateral view the capitellum is anterior to the AHL with elbow flexion, and posterior to the AHL with elbow flexion
 Biceps tendon insertion and axis of muscle pull lies medial to the shaft of the humerus  During fall onto an outstretched supinated arm, the forces applied tend to disrupt the posteromedial periosteum first and displace the fragment posterolaterally.   Conversely, if a patient falls with the arm pronated, the distal fragment tends to become displaced posteromedially
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
 Swelling of elbow joint  Pain and inability to use limb.  Arm is short, forearm is normal in length  Crepitus is present  Symptoms related to vascular and nerve injury may be seen.
Distal humeral tenderness, elbow bruising, limited range of motion.
There may sometimes be puckering of the skin when the proximal Fragment has penetrated the brachialis and anterior fascia of the elbow DIMPAL SIGN
AP VIEW x- ray • Baumann’s angle • Metaphyseal-Diaphyseal angle • Humero-Ulnar angle
 It is the most frequently cited method for assessing the fracture reduction and can be co-realted will with the final carrying angle. .  A change in 5 degrees of Bauman’s angle results in change in 2 degrees of clinical carrying angle.
Tear drop sign
MANAGEMENT OF S/C #
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
Technique of close reduction:  Longitudinal traction and counter traction is applied
 After the length of limb is maintained lateral and medial tilt is corrected by manipulation  Rotational deformity is then corrected
 Posterior tilt is then corrected by flexion reduction maneuver which is then performed with pressure of the thumb over the olecranon and to a variable degree, over the distal condyles of the humerus
 Generally, the fracture reduction can be felt, and the elbow is then held in hyperflexion and pronation to achieve a stable reduction
 Distal vascular status should be assessed after reduction.  If radial pulse is not palpable, elbow should be extended till the appearance of radial pulse and splintage should be done 10 degrees beyond this.
 Before the development of the fluoroscopic unit, blind pinning was performed  Modern imaging techniques and improved power equipment have made percutaneous pinning the standard treatment.
Crossed pins is more stable than 2 lateral pins Crossed pinning Lateral pinning
 After close reduction, reduction is maintained, and is confirmed with image intensifier before pinning.  The lateral pin is always inserted first.  Position for inserting the pin is documented on AP and lateral views  A small incision is made in the skin, and pin is placed using power drill.  Pin will traverse the lateral portion of the ossified capitellum, cross the physis, proceed up the lateral column, and always engage the opposite medial cortex proximally.
 2nd pin is placed medially  Care shoule be taken not to injure ulnar nerve  Incision is made over the skin over medial epicondyle, blunt dissection is made, ulnar nerve is identified and protected and pin is inserted
 No risk of ulnar nerve injury  Less stable than crossed pin  Two pins are placed which are divergent both in AP and lat views  Sometimes a third pin may be inserted on lateral side or medial side if the fracture is found to be unstable
 First pin ia generally placed through the center of the ossified capitulum, cross the olecranon fossa, giving it greater stability, and then further penetrate the medial cortex.  A second pin is placed through the distal humeral epiphysis lateral to the capitulum but clearly within the epiphysis. The pin proceeds up the lateral column and engages the opposite cortex.  After stabilization of fracture limb should be kept in posterior slab with forearm in neutral postion and elbow flexed to 60-90 degrees.
 Maximal pin separation increases the stability with this technique.  After stabilization of fracture limb should be kept in posterior slab with forearm in neutral postion and elbow flexed to 60-90 degrees.
 Vascular injuries  Compartment syndrome  Neurological deficit  Pin tract infection  Pin migration  Myositis ossificans  Non union  Avascular necrosis  Loss of reduction  Cubitus varus
 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
 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 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
 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.  In A Flexion Type Of Supracondylar Fracture, Which Is Rare, The Ulnar Nerve Is The Most Likely Nerve To Be Injured.   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
 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.Pure horizontal without angulation 3. Pure posterior translocation without rotation or angulation of the distal fragment 4.Horizontal rotation with coronal tilting,producing a cubitus varus deformity
 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
 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
 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
 The distal humeral metaphysis is a well-vascularized area with markedly rapid healing, and nonunion of a supracondylar fracture is very rare
 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
For treatment of any posttraumatic malalignments, options include 1. Observation with expected remodeling 2. Hemi epiphysiodesis 3. Corrective osteotomy
 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
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
Machanism of injury  Due to fall directly on elbow rather than fall on outstretched hand.
 Distal fragment is displaced anteriorly and may migrate proximally in totally displaced fracture.  Ulnar nerve is vulnerable to injury in this pattern of injury, and may be entrapped in fracture of healing callus
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