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Supracondylar Fracture

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Other Names

  • Supracondylar Humeral Fracture

Background

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

Epidemiology

  • One of the most common pediatric fractures
  • Most commonly occur in children age 5-7[1]
  • Left or non-dominant arm most commonly injured[2]

Pathophysiology

  • Extension-type (>95%), Flexion-type (<5%)[3]
  • Fall on outstretched hand/ extremity
  • Fall from moderate height such as bunk bed, monkey bars
  • Elbow is hyper-extended

Associated Injuries

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

Differential Diagnosis


Clinical Features

  • General: Physical Exam Elbow
  • History
    • Pain, swelling, refuse to range or move elbow
  • Physical Exam
    • 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

  • Radiographs
    • 3 view radiographs
    • 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: Should intersect middle third of Capitellum in most children 5 or older, in children under 5 it may pass through anterior third

Classification

Gartland Classification

  • Type I: Non-displaced[5]
  • 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

Acute

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

Nonoperative

  • Indications[6]
    • 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)
  • Technqiues
    • Closed reduction, percutaneous pinning (CRPP)
    • Open reduction, percutaneous pinning

Return to Play

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

Complications


See Also


References


  1. Benson M, Fixsen J, MacNicol M. Children's Orthopaedics and Fractures. Springer Verlag. (2010) ISBN:1848826109
  2. 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
  3. Mahan ST, May CD, Kocher MS. Operative management of displaced flexion supracondylar humerus fractures in children. J Pediatr Orthop. 2007;27:551-6
  4. 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
  5. Fajiah P. Surgical Radiology: Clinical Cases. PasTest Ltd. (2007) ISBN:1905635214
  6. https://www.orthobullets.com/pediatrics/4007/supracondylar-fracture--pediatric
Created by:
John Kiel on 18 June 2019 01:16:36
Authors:
Last edited:
11 November 2020 14:34:19
Categories:
Trauma | Pediatrics | Elbow | Arm | Fractures | Acute