SUPRACONDYLAR SUPRACONDYLAR FRACTURES OF FRACTURES OF

HUMERUSHUMERUS

DR.P.N.PRASADDR.P.N.PRASAD

Distal Humerus Distal Humerus AnatomyAnatomy

Medial epicondyleMedial epicondyle proximal to proximal to trochleatrochlea – –

Lateral Lateral epicondyleepicondyle proximal to proximal to capitellumcapitellum – –

Radial fossaRadial fossa – – accommodates margin accommodates margin of radial head during of radial head during flexionflexion

Coronoid fossaCoronoid fossa – – accepts coronoid accepts coronoid process of ulna during process of ulna during flexionflexion

Supracondylar Fractures of Supracondylar Fractures of HumerusHumerus

It is # which It is # which involves the lower end of the involves the lower end of the humerushumerus usually usually involving the thin portion of involving the thin portion of the humerus throughthe humerus through

Olecranon fossa orOlecranon fossa or

Just above the fossa orJust above the fossa or

MetaphysisMetaphysis Most common elbow injuries in children.Most common elbow injuries in children.

Makes up approximately 60% of elbow injuries.Makes up approximately 60% of elbow injuries.

Becomes uncommon as the age increases.Becomes uncommon as the age increases.

General considerationsGeneral considerations Incidence of supracondylar #:Incidence of supracondylar #:

a) Agea) Age : peak age : 5-7 yrs : peak age : 5-7 yrs Average age : 6.7 yrsAverage age : 6.7 yrsb) Sexb) Sex : Boys > Girls (Earlier) : Boys > Girls (Earlier) Boys = Girls (Latest Trends)Boys = Girls (Latest Trends)c) Sidec) Side : Left > Right : Left > Right ( Non dominant > dominant )( Non dominant > dominant )d) Nerve injuriesd) Nerve injuries : 7% - Median> Radial > Ulnar : 7% - Median> Radial > Ulnare) Vascular injuriese) Vascular injuries : 1% : 1%f) Open injuriesf) Open injuries : < 1% : < 1%

g) Cause of #g) Cause of # Fall from height 70% ----- children > 3 yrsFall from height 70% ----- children > 3 yrs

Fall from bed children < 3 yrsFall from bed children < 3 yrs

Non accidental injury ( Child abuse) children < 15 Non accidental injury ( Child abuse) children < 15 monthsmonths

h) Associated #s h) Associated #s

Distal radius > Scaphoid > Proximal Distal radius > Scaphoid > Proximal humerus > humerus >

Monteggia Monteggia

i) Clinical typesi) Clinical types

Extension type: 98%Extension type: 98%

Flexion type : 2% Flexion type : 2%

Mechanism of injuryMechanism of injury

For For Extension typeExtension type of SC # humerusof SC # humerus

Fall on outstretched Fall on outstretched handhand

Elbow Elbow hyper extendedhyper extended

Fore arm – Fore arm – pronated pronated oror

supinatedsupinated

Mechanism of injuryMechanism of injury

For For Flexion Flexion typetype of SC # of SC # humerushumerus

Fall directly on Fall directly on the elbowthe elbow rather than rather than out stretched out stretched handhand

Radiographic anatomy of Radiographic anatomy of distal Humerusdistal Humerus

What are the radiographic views:What are the radiographic views:

Antero posteriorAntero posterior

LateralLateral

ObliqueOblique

Axial ( jones view )Axial ( jones view )

What to look for in What to look for in

AP View-AP View----- Baumann`s angle---- Baumann`s angle

Humero ulnar angleHumero ulnar angle

Metaphysio diaphyseal Metaphysio diaphyseal angleangle

Radiographic AnatomyRadiographic Anatomy

Baumann’s angleBaumann’s angle is formed by a line is formed by a line perpendicular to the axis of the perpendicular to the axis of the humerus, and a line that goes through humerus, and a line that goes through the superior part of physis of the the superior part of physis of the capitellum.capitellum.

There is a wide range of normal for There is a wide range of normal for this value, and it can vary with this value, and it can vary with rotation of the radiograph.rotation of the radiograph.

The Baumann angle The Baumann angle is good is good measurement of any deviation of distal measurement of any deviation of distal humerus`s angulationhumerus`s angulation

In this case, the medial impaction and In this case, the medial impaction and varus position alters the Bauman’s varus position alters the Bauman’s angle.angle.

Radiograph Radiograph Anatomy/LandmarksAnatomy/Landmarks

Anterior Anterior Humeral Line:Humeral Line:

This is drawn This is drawn along the along the anterior humeral anterior humeral cortex. cortex.

It should pass It should pass through the through the junction of junction of anterior & anterior & middle 3middle 3rdrd of the of the capitellum. capitellum.

Radiograph Radiograph Anatomy/LandmarksAnatomy/Landmarks

The capitellum is The capitellum is angulated angulated anteriorly about anteriorly about 30 degrees.30 degrees.

The appearance of The appearance of the distal humerus the distal humerus is similar to a is similar to a hockey stick.hockey stick.

30

Radiograph Radiograph Anatomy/LandmarksAnatomy/Landmarks

The physis of The physis of the capitellum the capitellum is usually wider is usually wider posteriorly,posteriorly,

compared to the compared to the anterior portion anterior portion of the physisof the physis

Wider

Anatomical classification of Anatomical classification of SC #SC #

Radiographic Classification Radiographic Classification of SC #sof SC #s

Based on X- Ray appreance # Based on X- Ray appreance # displacement displacement GartlandGartland described 3 types: described 3 types:

Type – IType – I : Undisplaced : Undisplaced

Type – IIType – II : Displaced (posterior cortex : Displaced (posterior cortex intact)intact)

Type –IIIType –III : Displaced ( no cortical : Displaced ( no cortical contact)contact)

PosteromedialPosteromedial PosterolateralPosterolateral

Type 1: Non-displacedType 1: Non-displaced

Note the non- Note the non- displaced fracture displaced fracture (Red Arrow)(Red Arrow)

Note the Note the posterior fat pad posterior fat pad (Yellow Arrows)(Yellow Arrows)

Type 2: Angulated/Displaced Type 2: Angulated/Displaced Fracture with Intact Posterior Fracture with Intact Posterior

CortexCortex

Type 3: Complete Type 3: Complete Displacement, with Displacement, with No Contact between No Contact between

FragmentsFragments

Clinical signs & Clinical signs & SymptomsSymptoms

In most cases, children will In most cases, children will not move the elbownot move the elbow if a if a fracture is present, although this may not be the case fracture is present, although this may not be the case for non-displaced fractures.for non-displaced fractures.

SwellingSwelling about elbow is a about elbow is a constantconstant feature, develop feature, develop within first few hrs.within first few hrs.

S shaped deformityS shaped deformity

Distal humeral tendernessDistal humeral tenderness

Anterior plucker sign +ve Anterior plucker sign +ve

S-shaped configuration S-shaped configuration of ULof UL

Physical ExaminationPhysical Examination Neurologic exam is essential,Neurologic exam is essential, as nerve injuries are as nerve injuries are

common. In most cases, full recovery can be expectedcommon. In most cases, full recovery can be expected

Neuro-motor exam may be limited by the childs Neuro-motor exam may be limited by the childs ability to cooperate because of age, pain, or ability to cooperate because of age, pain, or fear.fear.

Thumb extension– EPL (radial – PIN branch)Thumb extension– EPL (radial – PIN branch)

Thumb flexion – FPL (median – AIN branch)Thumb flexion – FPL (median – AIN branch)

Cross fingers - Adductors (ulnar)Cross fingers - Adductors (ulnar)

Nerve injury incidence is high, between 7 and 16 % Nerve injury incidence is high, between 7 and 16 % (median, radial and ulnar nerve)(median, radial and ulnar nerve)

Anterior interosseous nerve is most commonly injured Anterior interosseous nerve is most commonly injured nervenerve

In many cases, assessment of nerve integrity is In many cases, assessment of nerve integrity is limited , because children can not always cooperate limited , because children can not always cooperate with the examwith the exam

Carefully document pre manipulation exam, as post Carefully document pre manipulation exam, as post manipulation neurologic deficits can alter decision manipulation neurologic deficits can alter decision makingmaking

Physical ExaminationPhysical Examination

Vascular injuriesVascular injuries are rare, but pulses should are rare, but pulses should always be assessed before and after reductionalways be assessed before and after reduction

In the absence of a radial and/or ulnar pulse, In the absence of a radial and/or ulnar pulse, the fingers may still be well-perfused, the fingers may still be well-perfused,

because of the excellent collateral because of the excellent collateral circulation about the elbowcirculation about the elbow

Doppler device can be used for assessmentDoppler device can be used for assessment

Physical ExaminationPhysical Examination

Physical ExaminationPhysical Examination

Thorough documentation of all findings is Thorough documentation of all findings is important. A simple record of “neurovascular important. A simple record of “neurovascular status is intact” is unacceptable.status is intact” is unacceptable.

Individual assessment and recording of motor, Individual assessment and recording of motor, sensory, and vascular function is essentialsensory, and vascular function is essential

Always palpate the arm and forearm for Always palpate the arm and forearm for signs signs of compartment syndrome.of compartment syndrome.

TreatmentTreatment General principlesGeneral principles::

Splinting elbow in comfortable position Splinting elbow in comfortable position 20-30degrees of flexion of elbow, pending 20-30degrees of flexion of elbow, pending Careful physical examination & X-ray Careful physical examination & X-ray

evaluation.evaluation.Tight bandaging/ excessive flexion or Tight bandaging/ excessive flexion or

excessive excessive extension should extension should be avoidedbe avoided

Associated life threatening complications Associated life threatening complications ( if any) ( if any) to be attended to be attended first. first.

Simple posterior long arm splint for 3-7days.Simple posterior long arm splint for 3-7days.

Elbow 60-90Elbow 60-90oo flexion & Forearm neutral flexion & Forearm neutral position.position.

Check X-ray after 3-7 days to document any Check X-ray after 3-7 days to document any displacement or lack of it.displacement or lack of it.

Splint converted to long arm cast if no Splint converted to long arm cast if no displacement.displacement.

If displacement noticed # reduction done & If displacement noticed # reduction done & cast applied or pinning done.cast applied or pinning done.

Treatment of type – I #Treatment of type – I #

Duration of immobilisation 3-4wks.Duration of immobilisation 3-4wks.

No need for any physiotheraphy ( Generally )No need for any physiotheraphy ( Generally )

Outcome:Outcome: Predictablly excellent if alignment Predictablly excellent if alignment is maintained during early healing.is maintained during early healing.

Hence type – I #s requires careful Hence type – I #s requires careful treatment & follow up. treatment & follow up.

Treatment of type – II #Treatment of type – II # Good stability obtained after closed reduction.Good stability obtained after closed reduction.

Once satisfactory reduction achieved further Once satisfactory reduction achieved further management is same as type – I.management is same as type – I.

If medial column collapse present then skeletal If medial column collapse present then skeletal stabilisation with 2 lateral pins is advocated.stabilisation with 2 lateral pins is advocated.

Recent trends led to Recent trends led to SELECTIVE PINNINGSELECTIVE PINNING for for type – II #s type – II #s

SELECTIVE PINNINGSELECTIVE PINNING

Closed reduction is done Closed reduction is done

Splinting in flexionSplinting in flexion

Non movable cuff & collar slingNon movable cuff & collar sling

Early careful X-ray follow upEarly careful X-ray follow up

If # displacement /angulation noticed If # displacement /angulation noticed

pin stabilisation is pin stabilisation is done .done .

Treatment of type – III #Treatment of type – III #

Treatment involves management of Treatment involves management of skeletal injuries & associated soft skeletal injuries & associated soft tissue injuries (if any).tissue injuries (if any).

Treatment of skeletal injury:Treatment of skeletal injury:

ReductionReduction either closed or open either closed or open

Stabilisation Stabilisation either with pins or either with pins or castcast

Technique of reduction Technique of reduction (closed)(closed)

Traction – to restore length & alignment.Traction – to restore length & alignment. Milking maneuver -- if length & alignment Milking maneuver -- if length & alignment

not restored by not restored by tractiontraction

Correction of medial/ lateral displacements.Correction of medial/ lateral displacements. Correction of rotational deformities.Correction of rotational deformities. Correction of posterior displacement by -- Correction of posterior displacement by --

flexion reduction maneuver flexion reduction maneuver Elbow held in hyper flexion.Elbow held in hyper flexion. Fore arm held in pronation – if distal fragment is Fore arm held in pronation – if distal fragment is

postero medially postero medially displaced,displaced,

Fore arm held in supination -- if distal fragment is Fore arm held in supination -- if distal fragment is postero laterally postero laterally

displaced.displaced.

Indications for open Indications for open reductionreduction

Open reduction is indicated to obtain alignment Open reduction is indicated to obtain alignment if closed reduction is unsuccessful as with the if closed reduction is unsuccessful as with the following,following,

Button holingButton holing of the proximal fragment through of the proximal fragment through the anterior soft tissues , the anterior soft tissues ,

Interposition of the biceps ,Interposition of the biceps ,

Interposition of the neurovascular structures .Interposition of the neurovascular structures .

An open reduction is also indicated if there is An open reduction is also indicated if there is an an open fracture ,open fracture ,that requires irrigation and that requires irrigation and debridement .debridement .

ANATOMIC OR NEAR ANATOMICANATOMIC OR NEAR ANATOMIC

REDUCTION IS A PREREQUISITE REDUCTION IS A PREREQUISITE FOR FOR SKELETAL STABILISATION SKELETAL STABILISATION

Skeletal stabilization after Skeletal stabilization after reductionreduction

Skeletal stabilization after reduction is Skeletal stabilization after reduction is done either with done either with pins or castpins or cast

Now a days skeletal stabilization by casing Now a days skeletal stabilization by casing is not done as reduction maintenance is is not done as reduction maintenance is not achieved .not achieved .

Generally skeletal stabilization is achieved Generally skeletal stabilization is achieved by means of passing pins across the by means of passing pins across the fracture site .fracture site .

Pin FixationPin Fixation Many children have Many children have anterior subluxation of the anterior subluxation of the

ulnar nerveulnar nerve with hyperflexion of the elbow . with hyperflexion of the elbow .

The medial pin can injury the ulnar nerve. The medial pin can injury the ulnar nerve.

Some advocate Some advocate 2 lateral pins2 lateral pins to avoid injuring to avoid injuring the median nerve.the median nerve.

Some advocate usage of a Some advocate usage of a small incission of small incission of sizesize 1.5 cm over the medial epicondyle1.5 cm over the medial epicondyle and and dissection is performed up to the level of the dissection is performed up to the level of the medial epicondyle and the ulnar nerve identified medial epicondyle and the ulnar nerve identified and protected and the medial pin appliedand protected and the medial pin applied

Medial pin placement :Medial pin placement : this pin is placed directly this pin is placed directly

through the medial through the medial epicondyle , using the epicondyle , using the opposite thumb to pull the opposite thumb to pull the soft tissues posteriorly, thus soft tissues posteriorly, thus protecting the protecting the ULNAR ULNAR NERVE .NERVE .

The pin is directed from The pin is directed from posteromedial to posteromedial to anterolateral anterolateral

(10(10oo posterior & 40 posterior & 40oo with with shaft) under c arm imaging shaft) under c arm imaging with the upper extremity with the upper extremity fully fully EXTERNALLLY EXTERNALLLY ROTATED ROTATED

If 2 lateral pins are used, they should be If 2 lateral pins are used, they should be widely widely spaced at the fracture site.spaced at the fracture site.

If the lateral pins are If the lateral pins are placed close togetherplaced close together at the at the fracturefracture site, the pins site, the pins may not provide much may not provide much resistance to rotationresistance to rotation and further displacement. and further displacement.

BIOMECHANICAL STUDIESBIOMECHANICAL STUDIES HAVE PROVED : HAVE PROVED :

DIVERGENT PINDIVERGENT PIN CONFIGURATION IS FAR CONFIGURATION IS FAR

SUPERIOR CONSTRUCT WHEN SUPERIOR CONSTRUCT WHEN COMPARED TO COMPARED TO

THE THE PARALLEL PINPARALLEL PIN CONFIGURATION CONFIGURATION..

If pin fixation is used, the If pin fixation is used, the pins are usually bent and cut pins are usually bent and cut outside the skin.outside the skin.

The skin is protected from The skin is protected from the pins by placing felt pad the pins by placing felt pad around the pins.around the pins.

The arm is immobilized.The arm is immobilized.

Pins can easily be removed Pins can easily be removed 3 - 4 weeks later.3 - 4 weeks later.

If adequate callus formation If adequate callus formation is present, gentle range of is present, gentle range of motion exercises are motion exercises are initiated.initiated.

In most cases, full recovery In most cases, full recovery of motion can be expected.of motion can be expected.

Lateral Pin PlacementLateral Pin Placement

AP and Lateral views with 2 pinsAP and Lateral views with 2 pins

OR SetupOR Setup The monitor The monitor

should be should be positioned positioned across from the across from the OR table, OR table,

to allow easy to allow easy

visualization of visualization of the monitor the monitor during the during the reduction and reduction and pinningpinning

The C-Arm The C-Arm fluoroscopy unit can fluoroscopy unit can be inverted, using be inverted, using the base as a table the base as a table for the elbow joint.for the elbow joint.

The child should be The child should be positioned close to positioned close to the edge of the the edge of the table, to allow the table, to allow the elbow to be elbow to be visualized by the c-visualized by the c-arm.arm.

Mobilize the image Mobilize the image intensifier but not intensifier but not elbowelbow

ComplicationsComplications Immediate :Immediate :

a) neurological a) neurological

b) vascularb) vascular Early :Early :

a) compartment syndrome a) compartment syndrome

b) volkmann`s ischemia b) volkmann`s ischemia Late :Late :

a) mal union : cubitus varus / cubitus a) mal union : cubitus varus / cubitus valgus valgus

b) volkmann`s ischemic contractureb) volkmann`s ischemic contracture

c) myositis ossificans c) myositis ossificans

d) elbow stiffnessd) elbow stiffness