Supracondylar humeral fracture

Supracondylar humeral fracture

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  Supracondylar Humerus Fractures inChildren PG 2 Dr Min THU 5.10.2020
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  Anatomy • The elbowconsists of three joints: the ulnohumeral, radiocapitellar, and proximal radioulnar. • The vascularity to the elbow is a broad anastomotic network that forms the intraosseous and extraosseous blood supplies.
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  • The articulatingsurface of the capitellum and trochlea projects distally and anteriorly at an angle of approximately 30 to 45 degrees. • The center of rotation of the articular surface of each condyle lies on the same horizontal axis;
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  • thus, malalignmentof the relationships of the condyles to each other • changes their arcs of rotation, limiting flexion and extension.
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  • The carryingangle is influenced by the obliquity of the distal humeral physis; this averages 6 degrees in girls and 5 degrees in boys • is important in the assessment of angular growth disturbances
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  • In additionto anterior distal humeral angulation, there is horizontal rotation of the humeral condyles in relation to the diaphysis, • with the lateral condyle rotated 5 degrees medially. • This medial rotation is often significantly increased with displaced supracondylar fractures. • The elbow accounts for only 20% of the longitudinal growth of the upper extremity.
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  • Sequence ofossification are the same in boys and girls • Capitellum, radial head, medial epicondyle, trachea, olecranon, and lateral epicondyle • But ossification was delayed by about 2 years in boys in all ossification centers excep the capitellum • CRITOE
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  Epidemiology • Approximately 65%of pediatric trauma occur around elbow • Of all elbow fractures, 85% occur at the distal humerus, • 55% to 75% of these are supracondylar • most occur in 5 to 10 years of age, • Becomes less common with increasing age • more common in boys • the left, or nondominant side, is most frequently injured • Nerve injuries 7% • Vascular injuries 1% • Open fractures <1%
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  Mechanism of injury •Indirect - Common as a result of a fall onto an outstretched upper extremity (extension types 98 % ) • Direct - may occur from a fall onto a flexed elbow of from an object striking the elbow
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  • Remodeling ofbone in the 5- to 8-year-old causes a decreased AP diameter in the supracondylar region, making this area susceptible to injury. • Ligamentous laxity in this age range increases the likelihood of hyperextension injury. • The anterior capsule is thicker and stronger than the posterior capsule.
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  • In extension,the fibers of the anterior capsule are taut, serving as a fulcrum by which the olecranon becomes firmly engaged in the olecranon fossa. • With extreme force, hyperextension may cause the olecranon process to impinge on the superior olecranon fossa and supracondylar region. • The periosteal hinge remains intact on the side of the displacement.
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  Clinical Evaluation • Patientstypically present with a swollen, tender elbow with painful range of motion. • S-shaped angulation at the elbow • Pucker sign • Neurovascular examination
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  • Vascular examination 1.Hand well perfused (warm and red), radial pulse present 2. Hand well perfused (warm and red), radial pulse absent 3. Hand poorly perfused (cold and blue ), radial pulse absent
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  • Neurological examination 1.Anterior interosseous nerve 2. Median nerve 3. Ulnar nerve 4. Radial nerve
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  Radiographic Evaluation • APview • Lateral view
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  • Jones view •Internal and external rotation views (column view)
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  Baumann’s angle Incorrect
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  • Teardrop • Diaphyseal–condylarangle • Anterior humeral line • Coronoid line
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  Fat pad signs •Anterior (coronoid) fat pad • Posterior (olecranon) fat pad • Supinator fat pad
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  Elbow injuries inchildren
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  Flexion Type These constitute2% of supracondylar humerus fractures in children. • Type I : Nondisplaced • Type II : Displaced with intact anterior cortex • Type III : Complete displacement; usually anterolateral
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  Initial Management • Approachaccording to ATLS guidelines • With history of fall (other associated injuries) • Time and Mechanism of injury • Other DDx • Initially kept splinted with elbow in a comfortable position (20-40 degree of flexion) • Extreme flexion of extension may increase compartment pressure • Avoid tight bandage and splinting • Elbow and hand elevated above heart level
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  Type 1: Non-displaced •These fractures are managed in a long-arm cast • approximately 60 to 90 degrees of elbow flexion • approximately 3 weeks. • Follow-up X-rays at 1 week are recommended for assessment of fracture position.
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  • Mubarak andDavids subdivided type I fractures into IA and IB. • They expressed concern that if unreduced, these minimally displaced type IB fractures could lead to a cosmetically unacceptable result, • particularly in children with a neutral or varus preinjury carrying angle.
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  Type 2: Angulated/displaced fracturewith intact posterior cortex
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  • IIA: aless severe injury with the distal fragment merely angulated • IIB: a severe injury; the fragment is both angulated and malrotated
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  • Prefer closedreduction and pinning of most type II supracondylar fractures. • Two lateral pins are chosen • If two lateral pins fail to provide acceptable fixation we do not hesitate to place a third lateral pin. • It is safer to hold a type II fracture reduced with pins, rather than flexing the elbow greater than 90 degrees.
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  Type 3: Completedisplacement, with no contact between fragments
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  Reduction technique
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  • The reductionis then checked by fluoroscopic images in AP, lateral, and oblique planes. • Verify four points to check for a good reduction: (1) the AHL intersects the capitellum (2) Baumann’s angle is greater than 10 degrees (3) the medial and (4) lateral columns are intact on oblique views
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  Adequate Reduction • Novarus/valgus • AHL intersects the capitellum • Intact medial and lateral columns If above met • Can accept some translation (upto 5mm) • Can accept moderate amount of persistent rotational malalignment
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  Technique for percutaneous pinning •Two or three 0.62-inch smooth K-wires (1.5mm) • smaller K-wires for patients younger than 2 years • The use of a crossed pin or parallel pin technique (Controversies)
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  • Once closedreduction has been achieved, • the extremity is held in the reduced position by the surgeon’s nondominant hand or an assistant. • If two lateral pins are to be used, the first pin should be placed as close to the midline as possible (just lateral to the olecranon). • After the first pin is placed, the second pin is inserted laterally (in the center of the lateral column) Lateral pin placement
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  • The rotationalstability of the fixation is enhanced if the second pin crosses the fracture line at a significant distance from the first pin.
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  • For rotationalstability of the fixation • Careful attention must be given to ensure that the pins do not cross the fracture at the same point.
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  Medial pin placement •If only one lateral pin is to be placed, the starting point is the center of the lateral condyle. • The starting position for a medial pin is the inferiormost aspect of the medial epicondyle • The pin should be started as far anteriorly as possible.
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  • If theelbow is extremely swollen, a small incision can be made to identify and protect the ulnar nerve. • It is important to remember that flexion of the elbow displaces the ulnar nerve anteriorly. • Thus it is safer to place a medial pin with the elbow in extension
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  • Vascular statusis assessed. • The wires are bent and cut. • Take care to leave the wires at least 1 to 2 cm off the skin • The cast is then applied in 45 to 70 degrees of elbow flexion • Remember that the pins, not the cast, are holding the fracture reduction
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  Postoperative Care • acetaminophenis as effective as narcotic analgesics for providing pain control • perioperative ketorolac (a nonsteroidal anti-inflammatory) • Monitor compartment syndrome • recommend the elbow is elevated over the heart for at least 48 hours postoperatively.
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  • 5 to7 days postop take AP and lateral radiographs • If loss of reduction were to occur, this would be sufficient time for re-reduction. • The cast is generally removed 3 weeks postoperatively • At which time radiographs are obtained out of the cast. • The pins are removed in the OPD
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  • Range-of-motion exercisesare taught to the family, • targeting gentle flexion and extension, • to be started a few days after cast removal. • The child returns 6 weeks postoperatively for a range of motion check, with no radiographs at that time. • Clinically significant loss of motion after extension-type supracondylar fractures is rare in children.
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  • In areport of 63 patients with closed reduction percutaneous pinning of supracondylar fractures of the humerus stabilized with either two or three lateral entry pins, • elbow ROM returned to 72% of contralateral elbow motion by 6 weeks after pinning and • progressively increased to 86% by 12 weeks, • 94% by 26 weeks, and • 98% by 52 weeks. • Pins were removed by 3 to 4 weeks. No patient participated in formal physical therapy.
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  • A follow-upappointment to assess range of motion, if motion is not nearly normal at 4-8 week, • a physical therapy to improve elbow motion is begun. • Significant loss of flexion can be caused by a lack of anatomic fracture reduction:
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   Either posteriordistal fragment angulation,  posterior translation of the distal fragment with anterior impingement, or  medial rotation of the distal fragment with a protruding medial metaphyseal spike proximally
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  Supracondylar Humerus Fractures: AssociatedInjuries • Type 3 supracondylar fracture, with absent ulnar and radial pulses, but fingers had capillary refill less than 2 seconds. • The pink, pulseless extremity
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  • Vascular injuriesare rare, but pulses should always be assessed before and after reduction • In the absence of a radial and/or ulnar pulse, the fingers may still be well-perfused, because of the excellent collateral circulation about the elbow • Doppler device can be used for assessment
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  Pucker sign
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  Supracondylar Humerus Fractures: AssociatedInjuries • Nerve injury incidence is high, between 7 and 16 % (radial, median, and ulnar nerve) • Anterior interosseous nerve injury is most commonly injured nerve • In many cases, assessment of nerve integrity is limited , because children can not always cooperate with the exam • Carefully document pre-manipulation exam, as post- manipulation neurologic deficits can alter decision making
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  Supracondylar Humerus Fractures: Indicationsfor Open Reduction • Inadequate reduction with closed methods • Vascular injury • Open fractures Disadvantage of ORIF • Elbow stiffness • Myositis ossificans • Ugly scarring • Iatrogenic neurovascular injury
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  Other treatment options
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  Complications of supracondylar humeralfractures Early complications • Peripheral injury (7 to 10%) • Vascular injury (0.5%) • Volkmann’s ischemia (Compartment syndrome , <1%) Late complications • Malunion (Cubitus varus > Cubital valgus) • Elbow stiffness • Myositis ossificans • Avascular necrosis of the trochlea (fishtail deformity)
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  Management of Late-Presenting orMalreduced Fractures • Appropriate management of a patient who is initially evaluated 1 to 2 weeks after injury and found to have a nonreduced or unacceptably reduced fracture is often difficult to determine.  Some surgeons advocate a wait and see approach to these fractures because attempts at manipulation once early callus begins to form may not improve the reduction and could risk increasing stiffness.  Others favor a more aggressive approach and attempt closed or even open reduction of these fractures.  recommend gradual reduction with skin traction.
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  • have hadsuccess with remanipulation of supracondylar fractures after delays of 2 to 3 weeks. • Management of these injuries must be determined on an individual basis and must take into account factors such as  the patient’s age,  condition of the soft tissue,  amount of residual deformity, and  degree of radiographic healing. Percutaneous osteoclas
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  • Although functionallimitations are uncommon, these injuries have little potential to remodel. • Even a small improvement in alignment may represent a cosmetically acceptable result • an anatomic reduction may not be an achievable goal. • usually accept an adequate nonanatomic reduction rather than proceed to open reduction.
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  Malunion • Cubital varus (gunstockdeformity)
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  Positive crescent sign
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  • Some authorshave proposed that unequal growth in the distal humerus causes cubitus varus deformity, • The most common reason for cubitus varus 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.
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  • Treatment forcubitus varus has in the past been considered for cosmetic reasons only. • However, there are several consequences of cubitus varus such as  an increased risk of lateral condyle fractures,  pain,  tardy posterolateral rotatory instability,  Tardy ulnar nerve palsy
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  Treatment of CubitusVarus Deformity • The treatment of any posttraumatic malalignment options include:  Observation with expected remodeling,  Hemiepiphysiodesis and growth alteration, and  Corrective osteotomy
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  • The resultantcubitus varus deformity is a combined deformity of varus, extension, and internal rotation to various degrees. • Most corrective osteotomies have focused on the correction of varus and extension deformity. • The rotational deformity is well tolerated and best left untreated because rotation of the distal fragment makes the osteotomy unstable.
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  Wiltse type osteotomy
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  Reference • Tachdjian’s PediatricOrthopaedics, Fifth Edition • Rockwood and Wilkins’ Fractures in Children, Eight Edition
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  Thank you