SUPRACONDYLAR HUMERUS

FRACTURE IN CHILDRERN
EPIDEMIOLOGY

 peak age between 5 and 6 years

 boys have a higher incidence of this fracture than girls.
 left or nondominant side predominates
 A fall from a height accounts for 70% of all fractures
 Nerve injury occurs in at least 7% and significant vascular injury in 1%.
 CAUSES

 Remodeling of bone causes decreased AP diameter

 Ligamentous laxity permits hyperextension injury
 Anterior capsule is thicker and stronger than the posterior capsule
 The periosteal hinge remains intact on the side of the displacement
MECHANISM OF INJURY

 Divided into extension and flexion

types(direction of displacement of distal
fragments)
 Extension type 97 to 99% of SCH
fractures
 Caused by fall onto outstretched hand
with elbow in full extension
 Medial and lateral columns
 Connected by thin segment of bone
 Olecranon fossa posteriorly and coronoid
fossa anteriorly
 Results in high risk of fracture
 Normal anatomic variant
 Olecranon fossa may be absent
 Normal anatomic variant
 Supracondylar process
 1.5 % of adult cadavers
 Mistaken for fracture pathology
 Site of Median nerve compression
POSTEROMEDIAL
 Medial periosteum is usually intact
 Elbow flexion and forearm pronation
 Medial and posterior periosteum on
tension
 Corrects varus and extension
malalignment
 Stability to fracture reduction
 More common
 Soft tissue injury depends on displacement of
distal fragment
 Penetrating injury of the proximal metaphyseal
fragment
 Medial displacement of distal fragment risk
Radial nerve
 Lateral displacement places Median nerve and
brachial artery at risk
RADIOGRAPHIC DIAGNOSIS

 AP and lateral view of the entire upper extremity

 Occasionally comparision view may be needed to evaluate an ossifying epiphysis
 ER physician’s interpretation have an overall accuracy of only 53%
 True AP of distal humerus more accurate evaluation and decrease error in
determining Baumann’s angle
 Oblique views when SC fracture is suspected but not seen on AP and Lateral
views
 BAUMANN’S ANGLE

 Referred as humeral capitellar angle

 Angle between long axis of humeral shaft
and the physeal line of the lateral condyle
 Normal range: 9 to 26 degree
 A rule of thumb is that a baumann’s
angle of atleast 10 degree is acceptable
 A decrease in Baumann’s angle ia sign
that a fracture is in varus angulation
 METAPHYSEAL-DIAPHYSEAL ANGLE

•On anteroposterior radiograph, transverse line is drawn through

metaphysis at its widest point, and longitudinal line is drawn
through axis of diaphysis;
•angle is measured between lateral portion of metaphyseal line and
proximal portion of diaphyseal line.
•Normal angle is 90 degrees.
• Angle greater than 90 degrees indicates varus angulation.
•Angle less than 90 degrees indicates valgus angulation
HUMERAL-ULNAR ANGLE

 This angle is subtended by the

intersection of the diaphyseal bisectors of
the humerus and ulna
 Reflects the true carrying angle
 Normal value:5 to 15 degree
 FAT PAD SIGN
•The anterior fat pad is a triangular
radiolucency anterior to the distal humeral
diaphysis.
•It is seen clearly, and in the presence of
elbow effusion, it is displaced anteriorly.
•The posterior fat pad is not normally visible
when the elbow is flexed at right angles.
•If an effusion is present, it will also be visible
posteriorly .
 Initial radiographs may be negative
except for posterior fat pad sign
 SCH fracture 53%
 Proximal ulna 26%
 Lateral condyle 12%
 Radial neck 9%
ANTERIOR HUMERAL
LINE
 AHL cross middle third of capitellum on
true lateral view
CORONOID LINE

•linedirected proximally
along the anterior border of
the coronoid process should
barely touch the anterior
portion of the lateral condyle
•Posterior displacement of the
lateral condyle projects the
ossification center posterior
to this coronoid line
 RADIOCAPITELLAR LINE

 Radiocapitellar line – should intersect the

capitellum
 this line should be evaluated on every
pediatric elbow film
DIAPHYSEAL-CONDYLAR ANGLE

 This projects 30 to 45 degree anteriorly

 The posterior capitellar physis is wider
than the anterior physis
 TEAR DROP

 Formed by posterior margin of coronoid

fossa anteriorly
 Anterior margin of olecranon fossa
posteriorly
 Superior margin of capitellar ossification
center inferiorly
OSSIFICATION CENTER

 With the exception of

capitellum,ossification centers appear
approximately 2 years earlier in girls
compared with boys(CRMTOL)
 Capitellum-6 months to 2 years
 Radial head -4 years
 Medial epicondyle-6 to 7 years
 Trochlea-8 years
 Olecranon-8 to 10 years
 Lateral epicondyle-12 years
GARTLAND’S CLASSIFICATION

 Type I-undisplaced
 Type II-displaced but posterior cortex is intact
 Type III-displaced with breakage of posterior cortex and the distal fragment may
displaced
 IIIA-posteromedial
 IIIB-posterolateral
WILKIN’S CLASSIFICATION

 Type I-undisplaced fractures

 Type II-displaced fracture with the posterior cortex still in continuity
 IIA-less severe and merely angulated
 IIB-angulated severely and malrotated

 Type III –completely displaced fractures

 TYPE I SCF
 Non-displaced or minimally displaced(<2 mm)
 Intact AHL
 Osseous injury may or may not
 Posterior fat pad sign may be only evidence of fracture
 Intact olecranon fossa
 No medial or lateral displacement
 No medial column collapse
 Normal Baumann’s angle
 Stable fracture
 TYPE II SCF

 Displaced >2mm
 Intact posterior cortex
 AHL anterior to capitellum on true lateral view
 rotational deformity on AP
 Loss of Baumann’s angle
 TYPE III SCF

 Displaced
 No cortical contact
 Extension in the sagittal plane and rotation in the
frontal and transverse planes
 Periosteum is turn
 Soft tissue and neurovascular injuries
 TYPE IV SCF

 Extension type SCF with multidirectional instability

 Incompetent periosteal hinge circumferentially
 Unstable in both flexion and extension
 Capitellum is anterior to AHL with elbow flexion
 MEDIAL
COMMINUTION

 Loss of normal alignment and collapse of medial

column
 Malrotation in frontal plane
 Loss of Baumann’s angle
 Varus malalignment
 Greater than 10 degree of obliquity in coronal
plane or 20 degree in sagittal plane more likely to
result in malunion
SIGNS AND SYMPTOMS

 Elbow pain
 Failure to use upper extremity after fall
 tenderness
 Swelling
 Lack of full elbow extension
 An anterior pucker sign may be present if
proximal fragment has penetrated the
brachialis and anterior fascia of elbow
 Sign of soft tissue damage
 S-shaped configuration
 Bleeding from punctate wound consider
as open fracture
 Careful motor,sensory and vascular
examination
RED FLAGS FOR POSSIBLE
COMPARTMENT SYNDROME
 Fracture with considerable swelling
 Ecchymosis
 Anterior skin puckering
 Absent pulse
 Pain with passive finger extension and flexion
 Increasing anxiety and need for pain medicine may be earliest warning
 3A’s:Anxiety,agitation and increasing analgesic requirement
MANAGEMENT

 Closed reduction
 Traction method
 Surgery
 crpp(closed reduction and percutaneous pinning)
 open reduction and internal fixation.
TRACTION
 side arm skin traction (Dunlop traction)
 overhead Skeletal traction
  indications of traction
 An unstable comminuted fracture
 Supracondylar comminution or medial column comminution that
is not suitable for pinning
 Fracture that would certainly collapse with simple casting after
reduction.
 TREATMENT

 Displaced fractures initially splinted with elbow in 20 to 40 degree of flexion

 Avoid excessive flexion and extension
 Careful examination of the neurovascular status
 Assesment of potential for compartment syndrome
 Delay of 8 to 21 hours did not have any deleterious effects on outcome
 However poor perfusion,associated forearm fracture,firm compartment,skin
puckering,antecubital ecchymosis,very considerable swelling, operative
shouldnot be dalayed
CRITERIA FOR CLOSED REDUCTION

 Easy reduction
 Stable fracture
 Minimal swelling
 No vascular compromise
CLOSED REDUCTION AND CASTING

 Cast immobilation for stable,nondisplaced fractures(type I)

 Closed reduction with percutaneous pinning for all unstable displaced
fractures(type II and III)
 Mildly displaced fractures cab be reduced closed
 Posterior periosteum as a stabilizing force
 Holding reduction by flexing the elbow gtreater than 120 degree
 Monitered closely for neurovascular compromise and loss of reduction
 Closed radiographic follow up for 3 weeks if necessary rereduction or conversion
to pinning needs to occur before full healing occurs
 REDUCTION MANEUVER

•Tractionis applied with the elbow in extension (10

degree short of full extension) and the forearm in
supination for 5 minutes
•The assistant stabilizes the proximal fragment.

fracture is hyperextended to obtain apposition of the

fragments.
• While traction is maintained, the varus or valgus
angulation along with the rotation of the distal
fragment is corrected with thumb and index finger in
epicondyles.
•Once the length and alignment have been corrected, the elbow is flexed.
• Pressure is applied over the posterior aspect of the olecranon to facilitate reduction of the distal
fragment.
•The distal fragment is finally secured to the proximal fragment by pronating or supinating
forearm to tighten th posterior perisoteum.
•PM : posterior medial pronation
•PL : posterior lateral supination

•Flexio up to 120 degree and take jhones views.

•No vasrus ia acceptable.

•Iftraction does not restore length and alignment, a milking
manoeuvre has been described to disengage the proximal
fragment from the soft tissue.
•It is done by manipulating the soft tissue over the fracture to
pull the soft tissue away from the proximal fragment, which
may not allow reduction of a buttonholed proximal fragment
•sling holds the
hand and elbow in
a dependent
position, thereby
creating edema and
pain.
•true elevation of
the extremity, with
the fingers above
the elbow and the
elbow above the
heart. .
The long arm cast
should be supported
with ring in distal part
of the cast and sling
around the neck to
support the weight of
the cast.
With out this an
extension torque
occurs at distal
humerus and can
displace the fracture.
CLOSED REDUCTION AND PINNING

 Most common operative treatment

 Initial attempt indicated in almost all displaced SCF that are not open
 Under GA the fracture is first reduced in the frontal plane with fluoroscopic
verification
 The elbow is then flexed while pushing the olecranon anteriorly to correct the
sagittal deformity and reduce the fracture
 Minor rotational malalignment in the axial plane is tolerated
 The fracture reduction is held with two to three Kirschner wires
 The elbow is immobilized in 75 degree of flexion
 If there is considerable gap in the fracture site or the fracture is irreducible with
rubbery feeling on attempted reduction,
 The Median nerve or brachial artery may be trapped in the fracture site
 Open reduction should be performed
 No diference in emergency treatment(<8 hrs) and urgent treatment(>8 hrs but <24
hrs)
 Gross malalignment needs to be temporarily reduced as an emergency, with
definative treatment being done in < 24 hrs
CRPP(CROSSED MEDIAL AND
LATERAL PINS)
 Supine or prone
 Longitudinal traction
 Manipulate with thumbs to correct lateral
tilt,medial impaction and posterior
displacement
 Lateral pin across the fracture site and
engage medial cortex
 Second or third lateral pin if additional
stability is required
 Medial pin cab be inserted for extreme  Post-op care
stability  A long-arm posterior plaster splint or
 Extend elbow to 45 degree of flexion bivalved cast for 3 weeks

 Make a medial incision to identify the

 Median,ulnar,radial nerve function and
vascular status checked
medial epicondyle and ulnar nerve
 The pins are removed at 3 to 4 weeks
CRPP(TWO LATERAL PINS)

 Supine
 Traction and countertarction
 Pronate or supinate the forearm to rotate
the distal fragment
 While maintaining traction gently flex the
elbow
 Pressure on olecranon on flexed elbow to
correct posterior displacement of distal
fragment
ACCEPTABLE REDUCTION CRITERIA

 Restoration of Baumann’s angle(generally >10 degree) on AP view

 Intact medial and lateral columns on oblique view
 The AHL passing through the middle third of the capitellum on the lateral view
INDICATIONS OF ORIF

 Open fractures
 Irreducible fractures
 Vascular injuries
 Nerve or vessel entrapment
 Unacceptable closed reduction
 Type III displaced fracture
 puckering of fracture fragment
 Fracture fragment buttonholed through brachialis
ANTERIOR APPROACH

 Transverse incision
 Plane between biceps and brachialis
 Protect radial nerve and posterior
interosseous artery
 Note its alignment with proximal
fragment
 Remove heamatoma
 Reduce fracture
 Use two or three pins
 Confirm
COMPLICATIONS OF ORIF

 Infection
 Vascular injury
 Myositis ossificans
 Excessive callus formation with residual stiffness
 Decreased range of motion
COMPLICATIONS OF SCF

 EARLY:Early vascular injury

 peripheral nerve palsies
 compartment syndrome.
 LATE:. malunion
 stiffness
 myositis ossificans
BRACHIAL ARTERY INJURY

 10 % of patients with SCF

 A pulseless,cool,pale hand ia an indication for exploration
 If circulation doesnot return to normal (elbow flexed <45 degree) within about 5
min
 Conssultation with vascular surgeon and surgical exploration
 Capillary refill ,pulse,doppler
 Disappearance of radial pulse with reduction implies interposition of artery in
fracture site and requires surgical exploration
NERVE INJURY

 Peripheral nerve injury occurs in approximately 10% to 15% of supracondylar

humeral fractures.
 anterior interosseous nerve is the most commonly injured nerve with extension-
type supracondylar fractures.
 nearly all such injuries will spontaneously improve.
 within 8 to 12 weeks function is not returning, consideration should be given to
performing nerve conduction and electromyographic studies
COMPARTMENT SYNDROME

 Uncommon but serious complication

 Occurs as the result of hypoxic damage caused by interruption of circulation to
the muscles
 Pressure in deep volar compartment have been significantly increases
 Flexion beyond 90 degree produces significant pressure elevation and should be
avoided
INDICATIONS OF FASCIOTOMY

 Pain with passive motion

 Pain out of proportion to the injury
 Clinical signs such as demonstrable motor or sensory loss
 Compartment pressure >35mm Hg
 Interrupted arterial circulation to the extremity for more than 4 hours
LATE COMPLICATIONS

 Cubitus varus most common

 Cubitus valgus is not cosmetically noticeable because carrying angle increases
from childhood to adulthood
 Rotational malalignment is compensated by shoulder joint
 CAUSES OF VARUS DEFORMITY
 Medial displacement and rotation of distal fragment
 Varus tilting of distal fragment
 Growth disturbances in the distal humerus
 Osteonecrosis and delayed growth of trochlea
 CUBITUS VARUS

 Three components that produce cubitus

varus
 Horizontal rotation
 Coronal tilting
 Anterior angulation
 OSTEOTOMIES
 Three basic types of osteotomies
 Medial opening wedge osteotomy with a bone graft
 Oblique osteotomy with derotation
 Lateral closing wedge osteotomy

The primary difference in types of lateral closing wedge osteotomy are methods of
fixation
Combination of screw and Kirschner wires may be needed for younger patients
Plates and screw fixation for adolescents
LATERAL CLOSING WEDGE
OSTEOTOMY
 Lateral incision
 Under fluoroscopic insert two K wire into
lateral condyle
 Make closing wedge osteotomy laterally
leaving medial cortex intact
 Complete osteotomy by drilling medial
cortex
 Advance k wire proximally
 Splint arm in 90 degree of flexion and
full supination
FLEXION TYPE

• it
results from a blow to the
posterior aspect of the elbow
 FLEXION TYPE
•Distalfragmet is
displaced anteriorly and may
migrate proximally in a totally
displaced fracture
•Accounts for 2 to 3 % of all SCF
•Ulner nerve lession is common in
displaced fractures
TREATMENT

•type I flexion supracondylar fractures

are treated with a splint or cast with
the elbow flexed
•Minimally displaced type II fractures
that reduce in extension are treated in
an extension cast
•Unstable types II and III fractures are
pinned.
REFERENCES

 Cambell’s operative orthopedic

 Rockwood and Green’s fractures in children
 Frank H.netter
 Apley’s system of orthopaedics and fractures
THANK YOU