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Supracondylar Fracture - Pediatric

Authors: Ujash Sheth, Ben Taylor


Topic updated on 02/19/15 12:26pm

Introduction

Epidemiology
incidence

consists of more than


half of all pediatric
elbow fractures
extension type most
common (95-98%)
o demographics
occur most commonly in children aged 5 to 7
M=F
Pathophysiology
o mechanism of injury
fall on outstretched hand
Associated injuries
o neuropraxia
anterior interosseous nerve neurapraxia (branch of median
n.)
the most common nerve palsy seen with

supracondylar humerus fractures

radial nerve palsy


second most common neurapraxia (close second)
ulnar nerve palsy
seen with flexion-type injury patterns

nearly all cases of neurapraxia following supracondylar


humerus fractures resolve spontaneously, and therefore,
further diagnostic studies are not indicated in the acute
setting
o vascular injury (1%)
rich collateral circulation can maintain circulation despite
vascular injury
o ipsilateral distal radius fractures
Anatomy
Ossification centers of elbow
o age of ossification/appearance and age of fusion are two independent
events that must be differentiated
e.g., internal (medial epicondyle) apophysis
ossifies/appears at age 6 years (table below)
fuses at age ~ 17 years (is the last to fuse)
Ossification center

Years at ossification
(appear on xray) (1)

Years at fusion (appear on


xray) (1)

Capitellum

12

Radius

15

Medial epicondyle

17

Trochlea

12

Olecranon

10

15

Lateral epicondyle

12

12

(1) +/- one year, varies between boys and girl

Classification
Gartland Classificaiton
(may be extension or flexion type)
Type I

Nondisplaced, beware of subtle medial comminution leading


to cubitus varus

Type II

Displaced, posterior cortex intact

Type III

Completely displaced

Type IV*

Complete periosteal disruption with instability in flexion and


extension

*not apart of original Gartland classification

Presentation

Symptoms
o pain
o refusal to move the elbow
Physical exam
o inspection
gross deformity
swelling
bruising

o motion
limited active elbow motion
o neurovascular
nerve exam
AIN neurapraxia
unable to flex the interphalangeal joint of his thumb
and the distal interphalangeal joint of his index
finger (can't make A-OK sign)
radial nerve neurapraxia
inability to extend wrist or digits may be present due
to radial nerve injury neurapraxia
vascular exam
vascular insufficiency at presentation is present in 5 -17%
defined as cold, pale, and pulseless hand
a warm, pink, pulseless hand does not qualify
as vascular insufficiency
treat with immediate reduction and pinning in OR.
Attempted closed reduction in ER first (see treatment
below)

Imaging

Radiographs
o recommended views

AP and lateral x-ray of the elbow

o findings

posterior fat pad sign

lucency along the posterior distal humerus and olecranon fossa is


highly suggestive of occult fracture around the elbow

o measurement

displacement of the anterior humeral line

anterior humeral line should intersect the middle third of the


capitellum

capitellum moves posteriorly to this reference line in extension


type fracture

alteration of Baumann angle

Baumann's angle is created by drawing a line parallel to the


longitudinal axis of the humeral shaft and a line along the lateral
condylar physis as viewed on the AP image

normal is 70-75 degrees, but best judge is a comparison of the


contralateral side

deviation of more than 5 degrees indicates coronal plane deformity


and should not be accepted

Treatment
Nonoperative
o long arm posterior splint then long arm casting with less
than 90 of elbow flexion
indications

Type I (non-displaced) fractures

Type II fractures that meet the following criteria

anterior humeral line intersects the anterior half


of capitellum
minimal swelling present
no medial comminution
technique
typically used for 3-4 weeks and maybe followed for
additional time in removable long arm posterior splint
Operative
o closed reduction and percutanous pinning

indications

in type II and III supracondylar fractures

o open reduction with percutaneous pinning


indications
adequate reduction cannot be obtained closed
more frequently required with flexion type fractures
technique
a variety of approaches are acceptable, including the
anterior, medial or lateral
o immediate closed reduction and percutanous pinning
indications

vascular compromise is present (e.g, pale, cool hand)


"floating elbow"
ipsilateral supracondylar humerus and forearm
fractures necessitate immediate pinning of both
fractures to decrease risk of compartment
syndrome

technique
check vascular status after reduction
explore if pulse lost after reduction or if pulseless,
pale hand persists after reduction
arteriography is typically not indicated
Techniques

Closed reduction and percutanous pinning


o fixation

closed reduction (extension-type)


posteromedial fragments: forearm pronated with
hyperflexion
posterolateral fragments: forearm supinated with
hyperflexion
two lateral pins

usually sufficient

confirm stability under fluoroscopy


three lateral pins

biomechanically stronger in bending and torsion than 2-pin


contructs
when comminution is present, 2 lateral pins may be
insufficient, and a 3-pin construct such as this is needed
no significant difference in stability between three lateral
pins and crossed pins
risk of iatrogenic nerve injury from a medial pin
makes three lateral pins the construct of choice
crossed pins
biomechanically strongest to torsional stress

higher risk of ulnar nerve injury (3-8%)

highest risk if placed with elbow in hyperflexion


pins removed post-operatively around 3 weeks

Complications
Pin migration
o most common complication (~2%)
Infection

o occurs in 1-2.4%
o typically superficial and treated with oral antibiotics
Cubitus valgus
o caused by fracture malunion
o can lead to tardy ulnar nerve palsy
Cubitus varus (gunstock deformity)
o caused by fracture malunion
o usually a cosmetic issue with little functional limitations
Recurvatum
o common with non-operative treatement of Type II and Type III
fractures
Nerve palsy
o usually resolve
Vascular Injury
Volkmann ischemic contracture
o rare, but dreaded complication associated with supracondylar
humerus fractures
o more often as a result of brachial artery compression with
treatment utilizing elbow hyperflexion and casting than true
arterial injury
increase in forearm compartment pressures and loss of

radial pulse with elbow flexed greater than 90


o rarely seen with CRPP and postoperative immobilization in less
than 90
Postoperative Stiffness
o rare after casting or after pinning procedures
o resolves by 6 months

o literature does not support the use of physical therapy