SUPRACONDYLAR

FRACTURES OF
HUMERUS
DR.P.N.PRASAD
 Distal Humerus Anatomy
 Medial epicondyle
proximal to trochlea –

 Lateral epicondyle
proximal to capitellum
–

 Radial fossa –
accommodates margin of
radial head during flexion

 Coronoid fossa –
accepts coronoid process of
ulna during flexion
 Supracondylar Fractures of Humerus
 It is # which involves the lower end of the humerus usually
involving the thin portion of the humerus through
Olecranon fossa or
Just above the fossa or
Metaphysis
 Most common elbow injuries in children.

 Makes up approximately 60% of elbow injuries.

 Becomes uncommon as the age increases.

 General considerations
 Incidence of supracondylar #:
a) Age : peak age : 5-7 yrs
Average age : 6.7 yrs
b) Sex : Boys > Girls (Earlier)
Boys = Girls (Latest Trends)
c) Side : Left > Right
( Non dominant > dominant )
d) Nerve injuries : 7% - Median> Radial > Ulnar
e) Vascular injuries : 1%
f) Open injuries : < 1%
g) Cause of #
Fall from height 70% ----- children > 3 yrs
Fall from bed children < 3 yrs
Non accidental injury ( Child abuse) children < 15 months

h) Associated #s
Distal radius > Scaphoid > Proximal humerus >
Monteggia
i) Clinical types
Extension type: 98%
Flexion type : 2%
 Mechanism of injury
 For Extension type of
SC # humerus

Fall on outstretched hand

Elbow hyper extended

Fore arm – pronated or

supinated
 Mechanism of injury

 For Flexion type

of SC # humerus

Fall directly on the

elbow rather than
out stretched hand
 Radiographic anatomy of distal
Humerus

 What are the radiographic views:

Antero posterior
Lateral
Oblique
Axial ( jones view )
 What to look for in

AP View----- Baumann`s angle

Humero ulnar angle
Metaphysio diaphyseal angle
Radiographic Anatomy

 Baumann’s angle is formed by a line

perpendicular to the axis of the humerus, and a
line that goes through the superior part of
physis of the capitellum.

 There is a wide range of normal for this value,

and it can vary with rotation of the radiograph.

 The Baumann angle is good measurement of

any deviation of distal humerus`s angulation

 In this case, the medial impaction and varus

position alters the Bauman’s angle.
Radiograph Anatomy/Landmarks
 Anterior Humeral
Line:
This is drawn along
the anterior humeral
cortex.
It should pass
through the junction
of anterior &
middle 3rd of the
capitellum.
Radiograph Anatomy/Landmarks
 The capitellum is
angulated anteriorly
about 30 degrees.

 The appearance of the

distal humerus is similar
to a hockey stick.

30
 Radiograph Anatomy/Landmarks

 The physis of the

capitellum is usually
wider posteriorly,
compared to the
anterior portion of
the physis

Wider
Anatomical classification of SC #
 Radiographic Classification of SC #s
 Based on X- Ray appreance # displacement Gartland
described 3 types:

 Type – I : Undisplaced

 Type – II : Displaced (posterior cortex intact)

 Type –III : Displaced ( no cortical contact)

Posteromedial
Posterolateral
 Type 1: Non-displaced

 Note the non-

displaced fracture
(Red Arrow)

 Note the posterior fat

pad (Yellow Arrows)
Type 2: Angulated/Displaced Fracture
with Intact Posterior Cortex
Type 3: Complete Displacement, with
No Contact between Fragments
 Clinical signs & Symptoms
 In most cases, children will not move the elbow if a fracture is present,
although this may not be the case for non-displaced fractures.

 Swelling about elbow is a constant feature, develop within first few hrs.

 S shaped deformity

 Distal humeral tenderness

 Anterior plucker sign +ve

S-shaped configuration of UL
 Physical Examination
 Neurologic exam is essential, as nerve injuries are common. In most
cases, full recovery can be expected

 Neuro-motor exam may be limited by the childs ability to

cooperate because of age, pain, or fear.

 Thumb extension– EPL (radial – PIN branch)

 Thumb flexion – FPL (median – AIN branch)

 Cross fingers - Adductors (ulnar)

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

 Anterior interosseous nerve is most commonly injured nerve

 In many cases, assessment of nerve integrity is limited , because children

can not always cooperate with the exam

 Carefully document pre manipulation exam, as post manipulation

neurologic deficits can alter decision making
 Physical Examination
 Vascular 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 about the elbow

 Doppler device can be used for assessment

 Physical Examination

 Thorough documentation of all findings is important. A

simple record of “neurovascular status is intact” is
unacceptable.

 Individual assessment and recording of motor, sensory, and

vascular function is essential

 Always palpate the arm and forearm for signs of compartment

syndrome.
 Treatment
 General principles:
Splinting elbow in comfortable position
20-30degrees of flexion of elbow, pending
Careful physical examination & X-ray evaluation.
Tight bandaging/ excessive flexion or excessive
extension should be avoided
Associated life threatening complications ( if any)
to be attended first.
 Treatment of type – I #
 Simple posterior long arm splint for 3-7days.

 Elbow 60-90o flexion & Forearm neutral position.

 Check X-ray after 3-7 days to document any displacement

or lack of it.

 Splint converted to long arm cast if no displacement.

 If displacement noticed # reduction done & cast applied or

pinning done.
 Duration of immobilisation 3-4wks.

 No need for any physiotheraphy ( Generally )

 Outcome: Predictablly excellent if alignment is

maintained during early healing.

Hence type – I #s requires careful

treatment &
follow up.
 Treatment of type – II #
 Good stability obtained after closed reduction.

 Once satisfactory reduction achieved further management is

same as type – I.

 If medial column collapse present then skeletal stabilisation

with 2 lateral pins is advocated.

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

 SELECTIVE PINNING
Closed reduction is done
Splinting in flexion
Non movable cuff & collar sling
Early careful X-ray follow up
If # displacement /angulation noticed
pin stabilisation is done .
 Treatment of type – III #
 Treatment involves management of skeletal
injuries & associated soft tissue injuries (if any).

 Treatment of skeletal injury:

Reduction either closed or open
Stabilisation either with pins or cast
 Technique of reduction (closed)
 Traction – to restore length & alignment.
 Milking maneuver -- if length & alignment
not restored by traction
 Correction of medial/ lateral displacements.
 Correction of rotational deformities.
 Correction of posterior displacement by --
flexion reduction maneuver
 Elbow held in hyper flexion.
 Fore arm held in pronation – if distal fragment is
postero medially displaced,
 Fore arm held in supination -- if distal fragment is
postero laterally displaced.
 Indications for open reduction
 Open reduction is indicated to obtain alignment if
closed reduction is unsuccessful as with the following,
 Button holing of the proximal fragment through
the anterior soft tissues ,

 Interposition of the biceps ,

 Interposition of the neurovascular structures .

An open reduction is also indicated if there is an open

fracture ,that requires irrigation and debridement .
 ANATOMIC OR NEAR ANATOMIC
REDUCTION IS A PREREQUISITE FOR
SKELETAL STABILISATION
 Skeletal stabilization after reduction
 Skeletal stabilization after reduction is done either
with pins or cast

 Now a days skeletal stabilization by casing is not done

as reduction maintenance is not achieved .

 Generally skeletal stabilization is achieved by means of

passing pins across the fracture site .
 Pin Fixation
 Many children have anterior subluxation of the ulnar nerve
with hyperflexion of the elbow .

 The medial pin can injury the ulnar nerve.

 Some advocate 2 lateral pins to avoid injuring the median

nerve.

 Some advocate usage of a small incission of size 1.5 cm

over the medial epicondyle and dissection is performed up
to the level of the medial epicondyle and the ulnar nerve
identified and protected and the medial pin applied
 Medial pin placement :
this pin is placed directly through
the medial epicondyle , using the
opposite thumb to pull the soft
tissues posteriorly, thus
protecting the ULNAR
NERVE .

 The pin is directed from

posteromedial to anterolateral
(10o posterior & 40o with shaft)
under c arm imaging with the
upper extremity fully
EXTERNALLLY ROTATED
 If 2 lateral pins are used, they should be widely spaced at the
fracture site.

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

 BIOMECHANICAL STUDIES HAVE PROVED :

DIVERGENT PIN CONFIGURATION IS FAR
SUPERIOR CONSTRUCT WHEN COMPARED TO
THE PARALLEL PIN CONFIGURATION.
 If pin fixation is used, the pins are
usually bent and cut outside the skin.

 The skin is protected from the pins

by placing felt pad around the pins.

 The arm is immobilized.

 Pins can easily be removed

3 - 4 weeks later.

 If adequate callus formation is

present, gentle range of motion
exercises are initiated.

 In most cases, full recovery of

motion can be expected.
 Lateral Pin Placement
 AP and Lateral views with 2 pins
 OR Setup
 The monitor
should be
positioned across
from the OR table,

to allow easy
visualization of the
monitor during the
reduction and
pinning
 The C-Arm
fluoroscopy unit can be
inverted, using the base
as a table for the elbow
joint.

 The child should be

positioned close to the
edge of the table, to
allow the elbow to be
visualized by the c-arm.
 Mobilize the image
intensifier but not
elbow
 Complications
 Immediate :
a) neurological
b) vascular
 Early :
a) compartment syndrome
b) volkmann`s ischemia
 Late :
a) mal union : cubitus varus / cubitus valgus
b) volkmann`s ischemic contracture
c) myositis ossificans
d) elbow stiffness