Post on 28-Apr-2022
SUPRACONDYLAR FRACTURE
“Children’s Games”, oil on canvas, 1560, Peter Breugel, the Elder, Kunsthistorisches
Museum, Vienna, Austria.
The following are entries taken from The Calendar of Coroner’s Rolls, for the city of
London, in the early to mid Fourteenth century.
A Game On The Way To School, AD 1301:
On Tuesday (19 July), Richard, the son of John le Mazon, who was eight years old, was
walking immediately after dinner across London Bridge to school. For fun, he tried to
hang by his hands from a beam on the side of the bridge, but his hands giving way, he fell
into the water and drowned. Being asked who were present, the jurors say a great
multitude of passers-by whose names they know not, but they suspect no one of the death
except mischance.
Playing On The Timber Pile, AD 1322:
On the Sunday before the Feast of St. Dunstan, Robert, son of John de St Botulph, a boy
seven years old, Richard, son of John de Chesthunt, and two other boys whose names are
unknown were playing on certain pieces of timber in the lane called “Kyroune Lane” in
the ward of Vintry, and one piece fell on Robert and broke his right leg. In the course of
time Johanna his mother arrived and rolled the timber off him and carried him to the
shop, were he lingered until the Friday before the feast of St Margaret, when he died at
the hour of prime, of the broken leg and of no other felony; nor do the jurors suspect
anyone of the death, but only the accident and the fracture.
A Boy Thief, AD 1324:
On Monday (in April, 1324) at the hour of Vespers John, son of William de Burgh, a boy
five years old, was in the house of Richard le Latthere and had taken a parcel of wool
and placed it in his cap. Emma, the wife of Richard, chastising him, struck him with her
right hand under his left ear so that he cried. On hearing this, Isabella, his mother raised
the hue and carried him thence. He lingered until the hour of curfew of the same day,
when he died of the blow and not of any other felony. Emma forthwith fled, but where she
went or who received her, the jurors knew not. Afterwards she surrendered herself to the
prison at Newgate.
A Lost Ball, AD 1337:
On Tuesday in Pentecost Week John, son of William atte Noke, chandler, got out of a
window in the rent of John de Wynton, plumber, to recover a ball lost in a gutter at play.
He slipped and fell, and so injured himself that he died on the Saturday following of the
fall.
Children throughout the ages do not change in at least one respect. As depicted in Peter
Breugel the Elder’s painting of the mid Sixteenth century they will always play games
and because of their youthful inexperience will forever be prone to injury from these. In
bygone centuries injuries that today seem relatively innocuous would often prove fatal, as
can be seen from the heart wrenching Coroner’s rolls of Fourteenth century London.
Death from infection and lack of medical knowledge and skills in general were
commonplace. In an age when very few could swim even a simple fall into a river could
prove lethal despite the presence of “a great multitude of passers-by”. In the 21st century
great progress has been made, yet children still play games and are prone to injury. One
of the commonest is the supracondylar fracture following a fall from the monkey bar,
slide or trampoline. Fortunately in the 21st century death would not be expected from an
injury such as this, however significant disability is still possible without appropriate
treatment.
SUPRACONDYLAR FRACTURE
Introduction
This is a fracture that occurs in the distal third of the humerus, but proximal to the bone
masses of the trochlea and capitulum.
It is a common fracture of childhood.
The most immediate serious complication is that of vascular compromise. Severe injuries
have high potential for this.
Epidemiology
Supracondylar fractures are predominantly childhood fractures of the first decade of life.
They are the most common elbow fracture in children.
Peak incidence occurs at about 5 - 8 years of age and becomes much less common after
about 15 years of age.
Mechanism
These injuries will generally be due to a fall on the outstretched hand with:
● Elbow bent, resulting in a posteriorly displaced fracture.
● With the elbow straight, resulting in an anteriorly displaced fracture.
Classification
Supracondylar fractures are classified as:
● Flexion-type, (these are rare, 2 %)
♥ Here the distal fragment is displaced anteriorly.
● Extension-type (the usual form, 98%)
♥ Here the distal fragment is displaced posteriorly.
Extension type fractures are further classified according to the Gartland classification.
Gartland Type I Gartland Type II Gartland Type III
Gartland Type I:
● These are undisplaced fractures
Gartland Type II:
● These are angulated fractures with retain an intact posterior cortex
Gartland Type III:
● These are fractures with posteriorly displaced distal fragments with no cortical
contact.
Complications
1. Vascular injury:
● The most serious complication is vascular compromise of the brachial
artery.
● If not relieved there is a risk of ischaemia of the anterior compartment of
the forearm with consequent Volkmann’s ischaemic contracture.
● The risk of vascular injury increases with the grade of Gartland’s type,
(Gartland I < Gartland II < Gartland III).
2. Nerve injury:
● This is not as common as vascular injury.
● In order of frequency:
♥ Anterior interosseus nerve palsy > median nerve palsy > ulnar
nerve palsy > radial nerve palsy.
3. Compartment syndrome.
Late complications may include:
4. Elbow stiffness.
● A lack of full elbow extension through sagittal malalignment is common.
● It is not generally improved with physiotherapy, but some remodelling can
occur over years.
5. Myositis ossificans.
6. Malunion:
● This can result in cubitus varus (or gunstock) deformity.
Cubitus varus deformity results in the normal carrying angle of the arm
being reversed causing the forearm to deviate abnormally to the midline
when the elbow is extended.
Functional deficit is minimal but there can be significant cosmetic effect.
7. Malalignment:
● Malalignment in the sagittal plane (i.e. flexion or extension).
● Fortunately however this is usually not a cosmetic or functional problem
because of the large range of movement in the elbow joint and because of
compensation through shoulder movements.
Clinical Assessment
1. Pain and variable swelling / bruising.
● Extensive anterior bruising indicates a more severe injury.
2. Neurovascular status:
● The most immediate priority will be the assessment of the distal
neurovascular status of the injured limb (pulse, peripheral perfusion).
♥ Significant compromise will mandate more urgent intervention.
3. Variable deformity, this can range from none to severe:
Clinically a dislocated elbow may be confused with a displaced supracondylar
fracture. The 2 conditions may be distinguished clinically, however by examining
the relationship of the olecranon to the epicondyles. 1
● Normally the olecranon and
epicondyles form a straight line
in the fully extended elbow,
whilst in the fully flexed elbow
the olecranon forms an
equilateral triangle with the
epicondyles.
● In supracondylar fractures the
equilateral triangle relationship is
preserved, whilst in a dislocation
it will be distorted.
1. Normal relationship in
flexed elbow
2. Normal relationship in
supracondylar fracture.
3. Disturbed relationship in
elbow dislocation.
4. Skin tethering:
● Assess for any significant skin tethering, which may indicate potential for
ischaemic skin loss.
Investigations
Plain radiography:
Displaced fractures will be readily seen on plain A-P and lateral radiographs.
Fractures may be difficult to detect in cases of:
● The very young, due to the large numbers of ossification centres around the
elbow (see appendix 1 below).
● Non displaced fractures, where radiological signs can be quite subtle.
When fracture is not obvious on plain radiography, but clinical suspicion is high,
the more subtle features of bony injury need to be carefully searched for:
Signs that raise suspicion for injury when fracture is not readily apparent include
the following 4 signs:
Fat pad signs:
Anterior and Posterior “Fat pads”
If a fracture line cannot be definitely determined, yet clinical suspicion remains, evidence
of soft tissue effusion should be looked for as an indication of possible underlying occult
intra-capsular fracture.
Effusion is suggested by the “fat pad” signs, (see above).
● The anterior fat pad may normally be seen as a lucent line adjacent to the bone.
It is abnormal if it is elevated away from the bone.
● The posterior fat pad is not normally seen. If it is present in any degree an
effusion is present.
Cortical Buckling:
● A most subtle sign can be slight cortical buckling on each supracondylar ridge
seen on the A-P (see 1 below).
● With more significant injury, a “hairline” fracture will become visible on the AP
view and with greater injury again the fracture line will become detectable on the
lateral view (see 2&3 below).
Cortical buckling suggesting fracture.
Anterior humeral line malaligment:
It should first be established that the lateral radiograph is in fact a true lateral. This can be
determined by the “hourglass” or “figure of 8” sign.
On a true lateral (left) there is a symmetric figure of eight/hourglass sign at the
distal humerus. On an imperfect lateral radiograph (right) this is asymmetric.
Next the alignment of the anterior humeral line should be examined.
The Anterior Humeral Line
The anterior humeral line is obtained by extending a line along the anterior humeral
cortex on a true lateral radiograph with the elbow flexed to 90 degrees. Normally, this
line will pass through the middle one third of the capitellum, as seen with the yellow
line above (middle image). The red line shows the normal radiocapitellar line.
The anterior humeral line of a toddler or child must intersect the middle third of an
ossified capitellum. On the right above this lines passes in front of it, indicating that a
fracture (Gartland I) is present. Backward tilt of the distal fragment is also seen. Note that
in the normal elbow the articular surface of the distal humerus lies at 45 degrees
(anteriorly) to the long axis of the shaft of the humerus
Baumann’s angle:
Another diagnostic aid in evaluating radiographs of suspected
supracondylar fractures in children is the determination of
Baumann’s angle on the AP film.
This is the humeral capitellar angle or the angle measured
between the long axis of humeral shaft and the growth plate of
lateral condyle, (see left).
This is normally 75 degrees.
Therefore an increase in Baumann’s angle indicates medial
tilting of the distal fragment.
Management
Initial management:
1. The first priority in management will be to check the circulation:
● If there is vascular compromise the elbow should be extended until the
circulation is restored. 1
● If this manoeuvre does not restore the circulation, then urgent reduction
will be necessary.
2. Analgesia as clinically indicated.
● Intranasal fentanyl is a good option for children.
3. Sling immobilization:
● If the circulation is not compromised, then
immobilization in a sling with the elbow
flexed to 90 degrees will help stabilize and
splint posteriorly displaced fractures, (the
flexion counteracting the backwards pull
of the triceps muscle).
● Note, that excessive flexion (> 90 degrees) may compromise the
circulation, especially where there is significant swelling.
The position of the elbow after supracondylar fracture can actually be
more important than the position of the fracture itself. That is,
immobilization in greater than 90 degrees of flexion can result in
significant swelling and potentially vascular compromise. This can have a
much more damaging effect on final functional outcome than a minor
displacement of the fracture. 2
Subsequent management
Subsequent management will then depend on a range of factors, including:
More urgent management will be required for cases of:
● High grade Gartland injury (III)
● Secondary complications
● Neurovascular compromise
● Significant skin tethering
● Compound injuries
● Compartment syndrome.
Gartland I:
● If no other complications, these do not need urgent Orthopaedic referral.
● No reduction is required.
● Immobilization is then in an above - elbow backslab with 90 degrees elbow
flexion with sling for a period of 3 weeks.
♥ Note that the backslab should extend as high above the elbow as possible
(i.e. close to the axilla) and down to the MCP joints.
● Gartland type I fractures can be followed up by a GP in three weeks. Repeat x-ray
is not routinely necessary.
Gartland II:
● Depending on expertise available, most will need Orthopaedic referral.
● Reduction is achieved by an anterior push on the distal fragment as the elbows is
flexed to 90 degrees.
● If there is also coronal deformity i.e. lateral (valgus) or medial (varus)
displacement on A-P views, these do not remodel well and so will require
reduction.
Note that the normal “carrying angle” is about 10 degrees valgus.
● Immobilization is then in an above-elbow backslab with 90 degrees elbow
flexion with sling for a period of 3 weeks.
● At 3 weeks post-injury the backslab can be removed and a check x-ray out of
backslab is taken Check for adequate callus. Allow gentle ROM.
A check x-ray at 6 weeks post-injury should also be taken.
Gartland III:
● These all require urgent Orthopaedic referral.
● They require reduction and percutaneous pin fixation.
● A post operative check x-ray is taken at 6 weeks.
Neurological injury:
The great majority of neurological injuries are neuropraxias and will resolve with time.
Persistent neurological injury should be investigated with nerve conduction studies if still
unchanged three months after injury.
Disposition:
Indications for timely/urgent Orthopaedic referral include:
● Associated absence of pulse or ischaemia
● Open or impending open fracture (extensive anterior bruising)
● Associated nerve injuries
● Gartland type II & III fractures
● Associated same arm forearm or wrist injury
● Flexion supracondylar fractures
● Failure to maintain a reduction.
Appendix 1
Epiphyseal lines at the elbow 1
Typical appearances at ages 2, 4, 6 and 9
years are shown above.
Average times for appearance of ossification
centers:
Capitulum 1 year of age.
Radial Head 3 years
Medial Epicondyle 5 years
Trochlea 7 years
Olecranon 9 years
Lateral Epicondyle 11 years
Fusion of the various epiphyseal lines occurs
by 15-20 years.
Patients less than 3 years of age do not yet have full ossification of the capitellum. The
supracondylar injury in these patients may appear to be a dislocation of the elbow but is
usually a physeal separation (Salter-Harris type I). True elbow dislocation in this age
group is very rare.
Appendix 2
Above: Supracondylar fracture (Gartland I) in a 7 year old boy. There is mild dorsal
displacement and a prominent posterior fat pad.
Left: Very severely displaced Gartland III
supracondylar fracture in a 12 year girl. The
brachial artery is at extreme risk with such an
injury.
The modern face of supracondylar fracture! Every modern child is aware of superman’s
vulnerability to “kryptonite”, but unfortunately not their own to gravity! (Photograph
and radiograph courtesy Dr H. Stergiou)
References
1. McRae R, Practical Fracture Treatment, 3rd
ed 1994, p.131-137.
2. RCH Fracture Guidelines.
Dr. J. Hayes
Dr. P. Papadopoulos
Reviewed November 2012