supracondylar fractures in children
TRANSCRIPT
Aetiopathology and Management of Humeral Supracondylar fractures in Children
Dr. Situ Oladele, Orthopedic unit, NHA
Outline• Introduction and definition• Epidemiology• Relevant anatomy (including radiographic anatomy and elbow rules)• Aetiopathology
– Pathological anatomy– Mechanism of injury– Classification
• Management (History, Exam, investigation, treatment)• Complications• Follow-up• Conclusion and references
Introduction and Definition
• Malgaigne’s fracture• Children are prone to falls, often use upper
extremity to break falls (65-75% of all fractures in children are in the upper limb)
• Is a fracture through the thin distal humerus, just proximal to the capitulum usually involving the olecranon fossa or apex of coronoid fossa or metaphysis
Epidemiology
• commonest injury around the elbow (65.4% of elbow injuries)
• Age: < 10years (5-8yr)• Sex: commoner in boys (63.6%)• Usually fall from height (70%)• Commoner on the left humerus (58.6%)• Associated frequent nerve injury (7%)• Open fracture (2.3%)• Frequently a displaced fracture (90%)
Incidence of elbow injuries and Distal humeral fractures
Elbow injuries• Supracondylar
fracture 65.4%• Condylar fracture 25.3%• Fracture neck of
radius 4.70%• Monteggia fracture 2.2%• Olecranon fractures 1.6%• T-condylar fracture 0.8%
Distal humeral fractures• Supracondylar
fracture 69%• Lateral condyle 16.8%• Medial condyle 14.1%• T-condylar 1%
Relevant anatomy
• Carrying angle in children is ≈ 5-25 degree
• Range of motion at full flexion ≈ 150o
• Tips of medial, lateral condyles with olecranon
• Secondary Ossification centres (CRITOE)
Radiographic anatomy
Normal X-Ray: Elbow rules
Aetiopathology
Pathological anatomy
• Supracondylar region is vulnerable to fracture because:– Bone remodelling– Cortex is thin– Laxity of ligaments permits hyper extension of the
elbow against a taut anterior capsule– Anterior cortex has a defect in the area of the
coranoid fossa– Less cylindrical
Mechanism of injury
• Fall on an outstretched hand • Fall on the point of a flexed elbow• Spiked end of displaced proximal end may – penetrate brachialis muscle to damage it– lacerate brachial artery and/or median nerve
• Neurovascular deficit occurring with injury, manipulation, pinning, or compartment syndrome
Classification• EXTENSION TYPE (95-98%)
Gartland’s classification in children:– Type 1: undisplaced– Type 2: mild displacement with intact posterior
cortext• 2A: merely angulated distal fragment• 2B: fragment is both angulated and malrotated
– Type 3: complete displacement without intact posterior cortex
• FLEXION TYPE (2-5%)
• Displacements – Posteromedial (75%)– Posterolateral (25%)
• Open or Closed• Other structural changes– Medial rotation of distal segment– Sideways tilts (angulations)
Disrupted metaphyseal-diaphyseal angle
Management
Clinical presentation
• Acute• Late presentation• Isolated humeral fracture• Complicated by neurovascular compromise
History and Physical Examination
• History: – fall, pain, swelling, inability to use elbow.– Symptoms of neurovascular injury
• Examination: – “S”-shaped deformity of the arm– Local swelling ± bruising– Shortened arm (humerus)– Tender elbow
Physical Exam cont’d
• Dimple sign• Bony crepitus should not be elicited• ↓active and passive range of motion• examination of vascular compromise (elbow
collaterals my keep hand perfused)• Examination of nerve deficit (children may not
co-operate)• Rule out compartment syndrome
Diagnosis
• Essentially Clinical• Supportive investigations– X-ray elbow joint (AP/lateral views):– Posterior displacement of distal fragment • Fat pad sign (sail sign)• Displaced anterior humeral line• Displaced coronoid line• Loss of teardrop sign
DISPLACED TEAR DROP, FAT PAD,CORANOID LINE & CRESCENT SIGNS
–Coronal tilt of distal segment (varus deformity)• Increased Baumann’s angle• Disrupted Metaphyseal-diaphyseal angle• Disrupted humero-ulnar angle• Crescent sign
–Horizontal rotation of distal fragment• Fish-tail sign
FISH TAIL SIGN
BAUMANN’S ANGLE range = 64-81 O
DISPLACED ANTERIOR HUMERAL &CORONOID LINES
Treatment
• Resuscitation using the ATLS protocol in acute setting
• Adequate analgesia; General anaesthesia• Neurovascular compromise is an emergency• Treatment options depends on:– Nature of fracture (Gartland’s class)– General condition of the patient– Presence of neurovascular complication or not
Treatment
• Undisplaced Supracondylar fracture (Gartland type 1):– POP back slab with elbow in flexion for 3 weeks
• Angulated, malrotated or Displaced supracondylar fracture:– Closed reduction – Open reduction– Continuous traction
Treatment: principles of closed reduction
• Done under general anaesthesia• Gentle constant longitudinal traction: elbow at
10o flexion• Correct sideways tilt next• Correct rotational deformity next• Correct antero-posterior tilt/displacement next• Stabilize and immobilize fracture: hyperflex.
Collar and Cuffs, skeletal stabilization• Check X-rays
Treatment
• Gartland type 2A– Closed reduction ± percutaneous pinning with
crossed K- wire • Gartland type 2B and 3– Closed reduction + percutaneous pinning with
crossed K- wire
NB: rotational twist or tilt must be corrected, collar and cuff worn for 3 weeks
Open reduction
• Indications: – Failure of closed reduction– Open supracondylar fracture– Associated neurovascular compromise– Comminuted fracture
• Timing : within 5 days of injury • Complication: ulnar injury
Continuous traction
• Indications:– Failure of manipulation to achieve reduction– Failure to achieve >100O elbow flexion without
vascular compromise– Absence of image intensifier to permit
percutaneous pinning– Severe open injuries, comminuted fractures– Multiple ipsilateral limb injuries
• Skin(Dunlop) or skeletal (Smith’s) traction
Rx of Anteriorly displaced distal segment
• Closed reduction + POP back slab ± pinning with K wires
• Sultanpur (two stage casting) technique
Complications
• Immediaate:– Vascular injury (1%– Nerve injury (7%)
• Early:– Compartment syndrome
• Late:– Volkmann’s ischemic contracture– Joint stiffness– Malunion: Cubital varus or valgus deformity– Myositis ossificans– Non-union
Follow up Care
• Check X-ray in 5-7 days• K-wires are pulled out after 2 weeks• Finger exercises only for first 3 weeks • Supervised forearm and arm exercises for the
second 3 weeks• Osteotomies for correction of gunstock
deformity
Conclusion
• Supracondylar fractures in children is only second to distal forearm fractures in frequency
• Characteristic pathological anatomy and potential for serious functional and esthetic complications
• Early identification and restoration of clinicoradiological abnormalities is vital.
Thank you
References
• Apley’s systems in Orthopedics and fractures by Louis Solomon, David Warwick, Selvadurai Nayagam; Hodder Arnold Publications9th edition
• Textbook of orthopedics by John Ebenezar, Jaypee Brothers, 3rd edition
• Principles and practice of Surgery (Including Surgery in the Tropics) by Badoe, Achampong,
Acknowledgement
• Supracondylar fractures of humerus by Dr. Hardik Pawar, care hospital (slide share)