Supracondylar fracture in children

Supracondylar fracturein children5 min talkExt

Supracondylar fracture

Most common in children 5-8 year the bony architecture at the supracondylar region is weak Most common fracture around the elbow in children (60 percent of elbow fractures)May be associated with a distal radius or forearm fracture

Supracondylar fracture

Male: Female 2:195 percent are extension type injuries, which produces posterior displacement of the distal fragmentMore common in children with hyper flexibility

4Classification2 typesExtension typeFlexion typeExtension typeDistal fragment is posteriorly displaced95% of cases

Mechanism of injuryCaused by a fall on outstretched hand with hyperextension of the elbow

7Extension typeGreen stick fracture may occurredAnterior periosteum is tornThere may be a significant amount of local bleeding and swellingNerves & blood vessels are contused, compressed, or lacerated by bone fragments & blood that infiltrates the antecubital fossa;

Extension type - ClassificationGartland Classification:

- Type I: undisplaced -Type II:displaced with intact posterior cortex -Type III:displaced with no cortical contact

Gartland Classification

Clinical featuresHx - FALL ON OUTSTRETCHED HANDFailure to use upper extremityGross swelling & TendernessS-shaped deformityAnterior Pucker sign CrepitusMaintained three-point relationship11Examine in Elbow injuryVASCULAR STATUS Radial artery Pulsation [most important ] & Cap. refillNEUROLOGICAL STATUS- Median, Radial, Ulnar nerveCheck finger movement Check for compartment syndrome

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Pucker sign/ Brachialis sign15Brachialis Sign- Proximal Fragment Buttonholed through Brachialis

16Milking Maneuver- Milk Soft Tissues over Proximal Spike

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POST MEDIAL POST LATERAL18Type 1: Non-displacedNote the non- displaced fracture (Red Arrow)

Note the posterior fat pad (Yellow Arrows)

19Fat Pad SignHelpful in occult fracture with effusion

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23Type 2: Angulated/displaced fracture with intact posterior cortex

24Type 2: Angulated/displaced fracture with intact posterior cortexIn many cases, the type 2 fractures will be impacted medially, leading to varus angulation.

The varus malposition must be considered when reducing these fractures, applying a valgus force for realignment.

25Type 3Totally displaced type 3 a post medial 3 b post lateral26

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29ManagementAll suspected cases should be splinted in around 20-30 deg at elbow before sending for X-rayNeurologic evaluationVascular assessment Peripheral pulse- radial artery Capillary filling Doppler testEvaluate for ipsilateral injuries- anywhere from wrist to sternoclavicular jt.

30Type 1 - UndisplacedSimple immobilization with a long arm posterior slab in 90 degree with cuff and collar for 3 weeksX-ray repeated at 5-7 days 31

Type 2 - displaced with intact posterior cortex

Treatment closed reduction under GA Traction is applied followed by correction of rotational deformity Extension deformity is corrected with pressure by thumb over the olecranon May use hyperflexion33Type 3 - Totally displacedClosed reduction & percutaneous K. wire fixationOpen reduction & K. wire fixation (if the patient has indication for Sx)34

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37Percutaneous K. wire fixation

38Peter to comment

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41Indications for SurgeryVolkmanns IschemiaIrreducible fractureVascular injuryOpen fractures

42Supracondylar Fractures: Associated Injuries - NerveNerve injury incidence is high, between 7 and 16 % (radial, median, and ulnar nerve)

Anterior interosseous nerve injury is most commonly injured nerve

43Supracondylar Fractures: Associated Injuries - Bone5% have associated distal radius fracturePhysical exam of distal forearmRadiographs if neededIf displaced pin radius also

44Supracondylar Fractures: Associated Injuries - VascularVascular injuries are 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 around the elbow

Doppler device can be used for assessment

Beware of Compartment Syndrome45Supracondylar Fractures:ComplicationsMalunion cubitus varus Volkmanns ischemia ContractureMyositis OssificansVascular injury Loss of reduction Loss of elbow motionPin track infectionNeurovascular injury with pin placement

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Myositis OssificansFlexion type5-10% of all supracondylar fractureposterior cortex fails firstresulting fracture has anterior displacement of the distal fragment

Mechanism of injuryoccurs from fall with elbow flexed as it hits the ground

Flexion type

52Flexion typeSoft tissue swelling and damage are usually much less than in the extension type and neurovascular complications are rareUlnar nerve palsy occurs in some cases; injured by the sharp spike ofproximal fragment Flexion type - ClassificationCan use a similar classification scheme as extension type injury: types I, II, III Type I: undisplaced or minimally displacedType II: integrity of anterior cortex remains, but with anterior displacement of distal fragmentType III: complete displacementFlexion type - ManagementType I: cast/splintType II: reduce and cast in extension, may need pinningType III: usually requires open reduction and percutaneouspinsFlexion type - Pinning

56Referrencehttp://www.wheelessonline.comhttp://www.slideshare.net/Naufal_Alwi/supracondylar-fractures-inchildren fracture and dislocation of the upper extremities in children .

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