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Supracondylar Fracture
From WikiSM
Contents
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
- Ulnar Nerve Injury
- Radial Nerve Injury
- Anterior Interosseous Nerve (AIN) injury
- Vascular injury
- Up to 20% of fractures[4]
- Distal Radius Fractures
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
- Fractures
- Adult
- Pediatric
- Dislocations & Instability
- Tendinopathies
- Bursopathies
- Ligament Injuries
- Neuropathies
- Arthropathies
- Other
- Pediatric Considerations
- Little League Elbow
- Panners Disease (Avascular Necrosis of the Capitellum)
- Nursemaids Elbow (Radial Head Subluxation)
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
- Infection
- Volkmann Ischemic Contracture
- Nerve Injury
- Postoperative stiffness/ loss of range of motion
- Varus/Valgus angulation
- Pin Migration
- Acute Compartment Syndrome
See Also
- Internal
- External
- Sports Med Review Elbow Pain: https://www.sportsmedreview.com/by-joint/elbow/
References
- ↑ Benson M, Fixsen J, MacNicol M. Children's Orthopaedics and Fractures. Springer Verlag. (2010) ISBN:1848826109
- ↑ 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
- ↑ Mahan ST, May CD, Kocher MS. Operative management of displaced flexion supracondylar humerus fractures in children. J Pediatr Orthop. 2007;27:551-6
- ↑ 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
- ↑ Fajiah P. Surgical Radiology: Clinical Cases. PasTest Ltd. (2007) ISBN:1905635214
- ↑ https://www.orthobullets.com/pediatrics/4007/supracondylar-fracture--pediatric