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Supracondylar Fracture

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Other Names

  • Supracondylar Humeral Fracture
  • Supracondylar Fracture
  • Epicondylar fracture

Background

  • Elbow fracture that occurs above the condyles of the distal Humerus seen in children

History

  • First discussed by Celsus (25 BC - AD 50)[1]

Epidemiology

  • One of the most common pediatric fractures
  • Most common pediatric elbow fracture in children under age 10[2]
  • Most commonly occur in children age 5-7[3]
  • Left or non-dominant arm most commonly injured[4]
  • Incidence ranges from 3.3% to 16.6%[5]
  • Accounts for 60% of all pedatric elbow fractures

Introduction

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Supracondylar Fracture in a 3 Year Old
Illustration of the supracondylar anatomy. The red dotted line demarcates where most fractures occur[6]
Illustration of supracondylar fractures[7]
Pre-reduction films show a type III supracondylar fracture. There is complete displacement of the distal humerus anteriorly. Specific findings for supracondylar fracture include: a posterior fat pad (red arrow) and a displaced anterior humeral line (yellow line).[8]

General

  • Common pediatric elbow fracture
  • Injury typically occurs from fall on outstretched hand with elbow hyperextended
  • Classified by Garland based on degree of displacement
  • Select non-displaced fractures can be managed nonoperatively, however the vast majority require surgical intervention
  • Immediate and long term neurovascular complications are a serious concern

Etiology

  • Extension-type (>95%), Flexion-type (<5%)[9]
  • Fall on outstretched hand/ extremity
  • Fall from moderate height such as bunk bed, monkey bars
  • Elbow is hyper-extended

Associated Injuries

Anatomy of the distal Humerus

Ossification Centers of the Elbow

Ossification center Age of Appearance on Xray Age of fusion
Capitellum 1 12
Radial Head 3 15
Medial Epicondyle 5 17
Trochlea 7 12
Olecranon 9 15
Lateral Epicondyle 11 12

Risk Factors

  • Male > Female
  • Risk is higher in younger children[11]
    • Decreases as children grow older, approach skeletal maturity

Differential Diagnosis

Differential Diagnosis Elbow Pain

Clinical Features

a) Skin puckering at the antecubital fossa should warn of a high energy fracture which transects the brachialis muscle and biceps. b) Very displaced type III fracture. When the fracture is very displaced, ‘S-deformity’ and skin puckering are usually present, and the possibility of neurovascular injury and compartment syndrome should be considered; c) The so-called ‘S-deformity’ is present in very displaced extension-type fractures.[12]

History

  • The parents/ patient can usually describe the injury
  • Most commonly, this involves fall on an outstretched hand
  • Pain, swelling, refuse to range or move elbow

Physical Exam: Physical Exam Elbow

  • Examination to some extent depends on degree of injury
  • The patient will have a painful, effused elbow that is difficult to examine
  • Gross deformity, swelling, bruising
  • Loss or limitation of range of motion
  • Document thorough neurovascular exam

Vascular Injury classification

  • Class I: Hand is well perfused (warm and red), radial pulse is present
  • Class II: Hand is well perfused, radial pulse is absent
  • Class III: Hand is poorly perfused (cool and blue or blanched), radial pulse is absent

Evaluation

Lateral radiograph showing both the anterior fat pad and posterior fat pad sign. Injury unknown.

Radiographs

  • Standard Radiographs Elbow
    • Obtain standard 3 view radiographs
    • Many fractures are obvious, some may be occult
  • Acute radiographic findings
    • Baumanns Angle: Measuring a angle formed by the humeral axis and the ephiphyseal plate of the capitulum
    • Posterior Fat Pad Sign: Radiolucent stripe posterior to distal humerus suggestive of joint effusion and occult fracture
    • Sail Sign: Anterior fat pad is elevated by a joint effusion appearing as a radiolucent triangle or 'sail'
    • Anterior Humeral Line: Line drawn down the anterior surface of the humerus should intersect the middle third of the capitellum
    • Coronoid Line: line drawn along superior ulna, through the coronoid and anterior aspect of distal humerus
    • Lateral Capitellohumeral Angle: angle between the long axis of the humeral shaft and a line drawn along the lateral edge of the capitellum
  • Late radiographic findings
    • Fish Tail Sign: abnormal contour of the lateral trochlear ossification center

Ultrasound

  • Role in pediatric elbow trauma remains undefined
  • Ashoobi et al looking at the sonographic posterior fat pad sign in general pediatric elbow fractures[13]
    • Sensitivity: 80%
    • Specificity: 97%

Classification

Gartland Classification

  • Type I: Non-displaced[14]
  • Type II: Angulated with intact posterior cortex
    • Type IIA: Angulation
    • Type IIB: Angulation with inversion
  • Type III: Complete displacement but have periosteal (medial/lateral) contact
    • Type IIIA: Medial periosteal hinge intact. Distal fragment goes posteromedially
    • Type IIIB: Lateral periosteal hinge intact. Distal fragment goes posterolaterally
  • Type IV: Periosteal disruption with instability in both flexion and extension
  • Medial Comminution: Collapse of medial column, loss of Baumann angle
  • Flexion Type: Mechanism of injury is usually a fall on the olecranon

Management

Demonstration of the long arm cast[15]

Acute

  • Emergent closed reduction if any neurovascular deficits
  • Immobilize: Posterior Long Arm Splint elbow approximately 20° to 40° of flexion

Nonoperative

  • Indications[16]
    • Must be warm, well perfused extremity with no neuro deficits
    • Type I
    • Type II with normal anterior humeral line on xray, minimal swelling, no medial comminution
  • Immobilization: Long Arm Cast with <90° elbow flexion

Operative

  • Indications
    • Type II, III
    • Flexion-type
    • Medial Comminution
  • Urgent (can wait)
    • No neurovascular deficits (Class I)
  • Urgent (can't wait)
    • Pulseless but well perfused (Class II)
    • Sensory nerve deficits, excessive sweating,
    • Brachialis sign: palpable bone fragment through brachialis muscle
    • Floating elbow: concomitant forearm fracture(s)
  • Emergent (within hours)
    • Pulseless and poorly perfused (Class III)
  • Techniques
    • Closed reduction, percutaneous pinning (CRPP)
    • Open reduction, percutaneous pinning
    • Open reduction, internal fixation (ORIF)

Rehab and Return to Play/Work

Rehabilitation

  • Needs to be updated

Return to Play/Work

  • Highly variable at the discretion of surgeon
  • Depends on quality of recovery

Prognosis and Complications

Prognosis

  • Needs to be updated

Complications

See Also

Internal

External

References

  1. ↑ Brorson, Stig. "Management of fractures of the humerus in Ancient Egypt, Greece, and Rome: an historical review." Clinical Orthopaedics and Related Research® 467 (2009): 1907-1914.
  2. ↑ Bell, Phillip, et al. "Adolescent distal humerus fractures: ORIF versus CRPP." Journal of Pediatric Orthopaedics 37.8 (2017): 511-520.
  3. ↑ Benson M, Fixsen J, MacNicol M. Children's Orthopaedics and Fractures. Springer Verlag. (2010) ISBN:1848826109
  4. ↑ Cheng JC, Lam TP, Maffulli N. Epidemiological features of supracondylar fractures of the humerus in Chinese children. J Pediatr Orthop B. 2001;10:63-7
  5. ↑ Shenoy, Pritom M., Amirul Islam, and Rahul Puri. "Current management of paediatric supracondylar fractures of the humerus." Cureus 12.5 (2020).
  6. ↑ Image courtesy of coreem.net
  7. ↑ Image courtesy of https://www.maimonidesem.org/
  8. ↑ Andrusaitis, Jessica, and Ben Feldman. "Supracondylar Fracture." Journal of Education and Teaching in Emergency Medicine 2.3 (2017).
  9. ↑ Mahan ST, May CD, Kocher MS. Operative management of displaced flexion supracondylar humerus fractures in children. J Pediatr Orthop. 2007;27:551-6
  10. ↑ Pirone AM, Graham HK, Krajbich JI. Management of displaced extension-type supracondylar fractures of the humerus in children. J Bone Joint Surg Am. 1988;70:641-50. Erratum in: J Bone Joint Surg Am. 1988;70:1114
  11. ↑ Yangs, C. P. "Fracture patterns and surgical outcomes of supracondylar humeral fractures in adolescents." Formosan Journal of Musculoskeletal Disorders 11 (2020): 102-8.
  12. ↑ Vaquero-Picado, Alfonso, Gaspar González-Morán, and Luis Moraleda. "Management of supracondylar fractures of the humerus in children." EFORT open reviews 3.10 (2018): 526-540.
  13. ↑ Ashoobi, Mohammad Amin, Enayatollah Homaie Rad, and Rayehe Rahimi. "The diagnostic value of sonographic findings in pediatric elbow fractures: A systematic review and meta-analysis." The American journal of emergency medicine 77 (2024): 121-131.
  14. ↑ Fajiah P. Surgical Radiology: Clinical Cases. PasTest Ltd. (2007) ISBN:1905635214
  15. ↑ Image courtesy of orthoinfo.aaos.org, "Care of Casts and Splints"
  16. ↑ https://www.orthobullets.com/pediatrics/4007/supracondylar-fracture--pediatric
Created by:
John Kiel on 18 June 2019 01:16:36
Authors:
Last edited:
18 February 2025 17:45:32
Categories:
Trauma | Pediatrics | Elbow | Arm | Fractures | Acute
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