Aetiopathology and Management of Humeral Supracondylar fractures in Children

Dr. Situ Oladele, Orthopedic unit, NHA

Outline• Introduction and definition• Epidemiology• Relevant anatomy (including radiographic anatomy and elbow rules)• Aetiopathology

– Pathological anatomy– Mechanism of injury– Classification

• Management (History, Exam, investigation, treatment)• Complications• Follow-up• Conclusion and references

Introduction and Definition

• Malgaigne’s fracture• Children are prone to falls, often use upper

extremity to break falls (65-75% of all fractures in children are in the upper limb)

• Is a fracture through the thin distal humerus, just proximal to the capitulum usually involving the olecranon fossa or apex of coronoid fossa or metaphysis

Epidemiology

• commonest injury around the elbow (65.4% of elbow injuries)

• Age: < 10years (5-8yr)• Sex: commoner in boys (63.6%)• Usually fall from height (70%)• Commoner on the left humerus (58.6%)• Associated frequent nerve injury (7%)• Open fracture (2.3%)• Frequently a displaced fracture (90%)

Incidence of elbow injuries and Distal humeral fractures

Elbow injuries• Supracondylar

fracture 65.4%• Condylar fracture 25.3%• Fracture neck of

radius 4.70%• Monteggia fracture 2.2%• Olecranon fractures 1.6%• T-condylar fracture 0.8%

Distal humeral fractures• Supracondylar

fracture 69%• Lateral condyle 16.8%• Medial condyle 14.1%• T-condylar 1%

Relevant anatomy

• Carrying angle in children is ≈ 5-25 degree

• Range of motion at full flexion ≈ 150o

• Tips of medial, lateral condyles with olecranon

• Secondary Ossification centres (CRITOE)

Radiographic anatomy

Normal X-Ray: Elbow rules

Aetiopathology

Pathological anatomy

• Supracondylar region is vulnerable to fracture because:– Bone remodelling– Cortex is thin– Laxity of ligaments permits hyper extension of the

elbow against a taut anterior capsule– Anterior cortex has a defect in the area of the

coranoid fossa– Less cylindrical

Mechanism of injury

• Fall on an outstretched hand • Fall on the point of a flexed elbow• Spiked end of displaced proximal end may – penetrate brachialis muscle to damage it– lacerate brachial artery and/or median nerve

• Neurovascular deficit occurring with injury, manipulation, pinning, or compartment syndrome

Classification• EXTENSION TYPE (95-98%)

Gartland’s classification in children:– Type 1: undisplaced– Type 2: mild displacement with intact posterior

cortext• 2A: merely angulated distal fragment• 2B: fragment is both angulated and malrotated

– Type 3: complete displacement without intact posterior cortex

• FLEXION TYPE (2-5%)

• Displacements – Posteromedial (75%)– Posterolateral (25%)

• Open or Closed• Other structural changes– Medial rotation of distal segment– Sideways tilts (angulations)

Disrupted metaphyseal-diaphyseal angle

Management

Clinical presentation

• Acute• Late presentation• Isolated humeral fracture• Complicated by neurovascular compromise

History and Physical Examination

• History: – fall, pain, swelling, inability to use elbow.– Symptoms of neurovascular injury

• Examination: – “S”-shaped deformity of the arm– Local swelling ± bruising– Shortened arm (humerus)– Tender elbow

Physical Exam cont’d

• Dimple sign• Bony crepitus should not be elicited• ↓active and passive range of motion• examination of vascular compromise (elbow

collaterals my keep hand perfused)• Examination of nerve deficit (children may not

co-operate)• Rule out compartment syndrome

Diagnosis

• Essentially Clinical• Supportive investigations– X-ray elbow joint (AP/lateral views):– Posterior displacement of distal fragment • Fat pad sign (sail sign)• Displaced anterior humeral line• Displaced coronoid line• Loss of teardrop sign

DISPLACED TEAR DROP, FAT PAD,CORANOID LINE & CRESCENT SIGNS

–Coronal tilt of distal segment (varus deformity)• Increased Baumann’s angle• Disrupted Metaphyseal-diaphyseal angle• Disrupted humero-ulnar angle• Crescent sign

–Horizontal rotation of distal fragment• Fish-tail sign

FISH TAIL SIGN

BAUMANN’S ANGLE range = 64-81 O

DISPLACED ANTERIOR HUMERAL &CORONOID LINES

Treatment

• Resuscitation using the ATLS protocol in acute setting

• Adequate analgesia; General anaesthesia• Neurovascular compromise is an emergency• Treatment options depends on:– Nature of fracture (Gartland’s class)– General condition of the patient– Presence of neurovascular complication or not

Treatment

• Undisplaced Supracondylar fracture (Gartland type 1):– POP back slab with elbow in flexion for 3 weeks

• Angulated, malrotated or Displaced supracondylar fracture:– Closed reduction – Open reduction– Continuous traction

Treatment: principles of closed reduction

• Done under general anaesthesia• Gentle constant longitudinal traction: elbow at

10o flexion• Correct sideways tilt next• Correct rotational deformity next• Correct antero-posterior tilt/displacement next• Stabilize and immobilize fracture: hyperflex.

Collar and Cuffs, skeletal stabilization• Check X-rays

Treatment

• Gartland type 2A– Closed reduction ± percutaneous pinning with

crossed K- wire • Gartland type 2B and 3– Closed reduction + percutaneous pinning with

crossed K- wire

NB: rotational twist or tilt must be corrected, collar and cuff worn for 3 weeks

Open reduction

• Indications: – Failure of closed reduction– Open supracondylar fracture– Associated neurovascular compromise– Comminuted fracture

• Timing : within 5 days of injury • Complication: ulnar injury

Continuous traction

• Indications:– Failure of manipulation to achieve reduction– Failure to achieve >100O elbow flexion without

vascular compromise– Absence of image intensifier to permit

percutaneous pinning– Severe open injuries, comminuted fractures– Multiple ipsilateral limb injuries

• Skin(Dunlop) or skeletal (Smith’s) traction

Rx of Anteriorly displaced distal segment

• Closed reduction + POP back slab ± pinning with K wires

• Sultanpur (two stage casting) technique

Complications

• Immediaate:– Vascular injury (1%– Nerve injury (7%)

• Early:– Compartment syndrome

• Late:– Volkmann’s ischemic contracture– Joint stiffness– Malunion: Cubital varus or valgus deformity– Myositis ossificans– Non-union

Follow up Care

• Check X-ray in 5-7 days• K-wires are pulled out after 2 weeks• Finger exercises only for first 3 weeks • Supervised forearm and arm exercises for the

second 3 weeks• Osteotomies for correction of gunstock

deformity

Conclusion

• Supracondylar fractures in children is only second to distal forearm fractures in frequency

• Characteristic pathological anatomy and potential for serious functional and esthetic complications

• Early identification and restoration of clinicoradiological abnormalities is vital.

Thank you

References

• Apley’s systems in Orthopedics and fractures by Louis Solomon, David Warwick, Selvadurai Nayagam; Hodder Arnold Publications9th edition

• Textbook of orthopedics by John Ebenezar, Jaypee Brothers, 3rd edition

• Principles and practice of Surgery (Including Surgery in the Tropics) by Badoe, Achampong,

Acknowledgement

• Supracondylar fractures of humerus by Dr. Hardik Pawar, care hospital (slide share)