Supracondylar

Fractures in
Children
Dr DI U

Supracondylar Fractures
2/3 of all hospitalizations for elbow injuries in

children
Most common in children <10 years old, usually
between the ages of 5-8 years old.
Historically associated with significant morbidity
secondary to malunion, neurovascular
complications and compartment syndrome

Pertinent Anatomy
In children, the supracondylar region

encompasses an area of thin, weak bone

located in the distal humerus. This region is
bordered posteriorly by the olecranon fossa
and anteriorly by the coronoid fossa.
The medial and lateral aspects of the
supracondylar region extend distally to the
developing medial and lateral condyles and
epicondyles

Contd
. Vascular anatomyThe brachial artery is

superficial to the brachialis muscle along the

anteromedial aspect of the humerus.
As the brachial artery passes anterior to the
distal humerus, an extensive collateral
circulation develops. As the artery extends
into the forearm, it splits into the radial and
ulnar artery.

Contd
The median nerve crosses the elbow joint with the brachial artery.

Posterolateral distal fracture fragment displacement with medial

movement of the proximal fracture fragment puts the median nerve
and its anterior interosseous nerve branch at the greatest risk of
injury.
Median nerve injury results in weakness of the flexor muscles of the
hand and loss of two-point sensation on the palmar surface of the
thumb and the index and middle fingers. The anterior interosseous
nerve (AION) is the branch of the median nerve most commonly
injured. The AION lacks a superficial sensory component. Children and
adolescents with AION syndrome initially have proximal forearm pain
followed by weakness in the hand with no sensory deficits. On
physical examination they have a weak "OK sign" and/or a lack of
distal interphalangeal flexion when making an OK sign (eg, more of a
pincer grasp than an OK sign).

Contd
The radial nerve runs between the brachialis and brachioradialis

muscles before crossing the elbow and penetrating the supinator

muscle. Posteromedial distal fracture fragment displacement increases
the chance of radial nerve impingement because of lateral proximal
fracture fragment displacement. Injury to the radial nerve results in
weakness of wrist extension, hand supination, and thumb extension. In
addition, altered sensation is found in the dorsal web space between
the thumb and index finger.
The ulnar nerve crosses the elbow posterior to the medial epicondyle
and is typically not affected with extension type supracondylar
fractures. However, it is prone to injury following flexion type
supracondylar fractures. Ulnar nerve injury causes weakness of wrist
flexion and adduction, finger spread, and flexion of the distal phalanx
of the fifth digit (pinky or little finger). These motor findings are
accompanied by altered sensation of the ulnar side of the ring (fourth
digit) and little fingers.

Mechanism of injury
In general, fractures of the distal humerus are

most commonly due to a fall on an outstretched

hand (FOOSH) or direct trauma to the elbow.
Extension or flexion injuries
90-98% extension type
Extension injury is caused by fall on outstretched
hand with elbow hyperextended
Displacement of distal fragment in extension type
injuries has been reported to be posteromedial in
90% and posterolateral in 10%.

Clinical Findings
The child with a supracondylar fracture

typically has elbow pain, swelling, and very

limited to no range of motion at the elbow .
The clinician must rapidly assess the injury to
identify degree of fracture displacement,
neurovascular compromise, and evidence of
compartment syndrome

Contd
One approach is to initially inspect the

affected arm and perform a brief

neurovascular examination followed by a
more complete evaluation once pain is
controlled and radiographs have been
obtained. The clinician should not encourage
active or passive elbow movement in a
patient with a suspected supracondylar
fracture until a displaced fracture has been
excluded by radiography. Patients with an
obviously displaced supracondylar fracture
require initial immobilization before

Gartlands Classification
Type I nondisplaced
Type II displaced with variable angulation, but

posterior cortex of the humerous is intact

A. Posterior tilt
B. Posterior translation
Type III completely displaced with no cortical
contact

Contd

Physical examination
Rule out associated trauma evaluate for

midshaft humerus fractures(rare) and distal

forearm fractures(common)
Nerve injuries 11-49% associated with
supracondylar injuries
- posterolateral displacement associated with
median and
anterior interosseous nerve
dysfunction

Physical Examination
-posteromedial displacement associated with radial
nerve injury
- ulnar nerve injury more often associated with
flexion type
injuries
- anterior interosseous nerve most often injured
evaluate flexor pollicus longus and flexor
digitorum profundus of index finger.

Contd
Vascular injuries permanent vascular

compromise of extremity occurs in less that 1%

Brachial artery may become compromised by
anterior spike of proximal fragment
- Usually resolves with reduction of fracture
Entrapment of brachial artery in fracture site may
compromise circulation of extremity with
reduction
- constant vascular evaluation necessary

Contd
Following clinical assessment, immobilize injured

elbow with splint in a position of 20 to 30 degrees

of flexion
- will prevent further displacement of fracture and
additional neurovascular damage

Radiographic Evaluation
AP and lateral of elbow
fat pad sign may be helpful with minimally

displaced fractures
anterior humeral line should transect the
ossification center of the capitellum in the normal
elbow
- in Type II and Type III fractures will not transect
the capitellum

Contd
Baumanns angle intersection of a line drawn

perpendicular to the humeral axis and line drawn

along the growth plate of the lateral condyle of
the elbow
- contralateral elbow should be used for
comparison
- distal fracture fragment is often rotated medially
or internally and into varus deviation in
relation to the proximal humerus, which
produces an increased Baumanns angle
- also useful in evaluating postreduction .

Baumanns angle

Treatment
Type I splint or circular cast with the elbow

flexed to 90 degrees and the forearm in the

neutral position
- reray in one week to be sure displacement has
not occurred; usually appears as varus angulation
- 3 weeks of immobilization followed by protected
active range of motion exercises

Contd
Type II reduction achieved by flexion of the

elbow and pronation of the forearm with the

patient under anesthesia
- 120 degrees elbow flexion required to maintain
reduction
- hyperflexion in a circular cast carries a high risk
of compartment syndrome
- These fractures should be pinned
percutaneously if there is significant swelling,
there is inadequate circulation when the elbow is
flexed, or if the fracture might become unstable

Contd
Type III closed reduction with percutaneous

pinning
- to close reduce: 1) traction is applied to
disengage proximal fragment from brachialis
muscle, 2) translation of the distal fragment to
proper medial-lateral orientation, 3) internal
rotation deformity corrected, 4) distal fragment is
pushed forward with examiners thumb while
flexing the patients elbow to 120 degrees and
pronating the wrist to tighten the periosteal hinge

Contd
evaluate with AP and lateral radiograph
- deviation of >5 degrees relative to Baumanns
angle in non-injured elbow represents inadequate
reduction.

Contd
Percutaneous pinning use sterilely draped

screen of the fluoroscopy unit as the operating

surface
- with maximally flexed and pronated arm,
approach the lateral side first
- insert Kirchner wire thru lateral condyle,
crossing lateral to olecranon fossa and engaging
medial humeral cortex
- medial wire placed with arm in 80-90 degrees
flexion
- protect ulnar nerve and direct Kirchner wire
through medial condyle in more transverse
manner than lateral wire

Contd
Following pinning place elbow in splint at 60-90

degrees of flexion with the forearm in neutral

rotation
Remove wires in 3-4 weeks

Adequacy of reduction
Baumanns angle
Relationship of the capitellum to the anterior

humeral line
Restoration of the anatomy of the olecranon fossa

Traction
Lost popularity with acceptance of pinning
Primary indication for traction is supracondylar

comminution
Overhead traction with use of an olecranon screw
is the easiest to manage

Contd

Indication for open

reduction
Fracture irreducible by closed methods
Vascular compromise necessitating exploration

and repair of brachial artery

Open fracture requiring irrigation and
debridement

Flexion type Fractures

Only 2-10% supracondylar fractures
Classified like extension type injuries
Reduction maneuver is opposite to extension

injuries, with reduction done in extension

Pinning necessary for most flexion-type fractures
that require reduction

Complications
Most nerve deficits that occur at the time of injury

are neuropraxias(may take up to six months to

regain sensory)
Vascular insufficiency in 5-12%
- immediate closed reduction recommended
- Volkmanns contracture is complication of
vascular compromise fasciotomy may be
necessary

Complications
Angular deformities of distal humerus common

after supracondylar injuries

- cubitus varus deformity most common result of
malreduction

Conclusion
Expedient management with fracture reduction

and stabilization markedly decrease

neurovascular complications
Kirschner-wire fixation with attention to soft
tissues are key to management of this injury in
children