supracondylar fractures in_children
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SUPRACONDYLAR SUPRACONDYLAR FRACTURES IN FRACTURES IN
CHILDRENCHILDREN
DEPT. OF ORTHOPEDICSDEPT. OF ORTHOPEDICS
MMMCMMMC
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RADIOLOGYRADIOLOGY
2 VIEWS – AP & LATERAL2 VIEWS – AP & LATERAL
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JONE’S VIEW- IN INJURED ELBOW , POST REDN. [ With elbow in full flexion ]
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ANTERIOR POST. VIEWANTERIOR POST. VIEW
BAUMANN’S ANGLEBAUMANN’S ANGLE
ANGLE FORMED BY THE LATERAL EPI ANGLE FORMED BY THE LATERAL EPI PHYSEAL LINE AND THE LONG AXIS PHYSEAL LINE AND THE LONG AXIS OF THE HUMERUS : 80 degreeOF THE HUMERUS : 80 degree
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HUMERO ULNAR ANGLEHUMERO ULNAR ANGLEMETAPHYSEAL DIAPHYSEAL ANGLEMETAPHYSEAL DIAPHYSEAL ANGLE
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Lateral viewLateral viewTear drop sign
Ant. dense line – represents the post margin of the coronoid fossa
Post. dense line- represents the ant margin of olecranon fossa
Inf margin is capitellum
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Elbow Fractures in Children:Elbow Fractures in Children:Radiograph Radiograph
Anatomy/LandmarksAnatomy/Landmarks
Anterior humeral Anterior humeral line: line:
• It is drawn along It is drawn along the anterior the anterior humeral cortex. humeral cortex.
• It passes through It passes through the middle of the the middle of the capitellum. capitellum.
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Elbow fractures in children:Elbow fractures in children:radiographic anatomy/landmarksradiographic anatomy/landmarks
The capitellum The capitellum is angulated is angulated anteriorly about anteriorly about 30 degrees.30 degrees.The appearance The appearance of the distal of the distal humerus is humerus is similar to a similar to a hockey stick.hockey stick.
30
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SHAFT CONDYLAR ANGLE- SHAFT CONDYLAR ANGLE- 30 DEG30 DEG
ANT HUMERAL LINE
PASS THR. MIDDLE THIRD OF OSSIFICATION CENTER OF CAPITELLUM
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Elbow Fractures in Children:Elbow Fractures in Children:Radiograph Radiograph
Anatomy/LandmarksAnatomy/LandmarksThe physis of The physis of the capitellum is the capitellum is usually wider usually wider posteriorly, posteriorly, compared to the compared to the anterior portion anterior portion of the physisof the physis
Wider
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Elbow Fractures in Children:Elbow Fractures in Children:Radiographic Anatomy/LandmarksRadiographic Anatomy/Landmarks
Radiocapitellar Radiocapitellar line – should line – should intersect the intersect the capitellumcapitellumMake it a habit Make it a habit to evaluate this to evaluate this line on every line on every pediatric elbow pediatric elbow filmfilm
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What are the problems you see here?
Test your Ortho. Sense.
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Supracondylar Humerus FracturesSupracondylar Humerus Fractures
Most common fracture around the elbow in Most common fracture around the elbow in children (60 percent of elbow fractures)children (60 percent of elbow fractures)95 percent are extension type injuries, which 95 percent are extension type injuries, which produces posterior displacement of the distal produces posterior displacement of the distal fragmentfragmentMay be associated with a distal radius or May be associated with a distal radius or forearm fractureforearm fracture
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CLASSIFICATIONCLASSIFICATION
EXTENSION TYPE- EXTENSION TYPE- 95%95%
FLEXION TYPE- FLEXION TYPE- 5%5%
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SUPRACONDYLAR #SUPRACONDYLAR #
Very commmon in children less than 10 Very commmon in children less than 10 yrsyrs
Bec. the bony architecture at the sc Bec. the bony architecture at the sc region is weak region is weak
More common in children with hyper More common in children with hyper flexibilityflexibility
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Mechanism of injuryMechanism of injury
Fall on out stretched Fall on out stretched hand [FOOH]hand [FOOH]
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QUICK REVIEW OF FACTSQUICK REVIEW OF FACTS
AGE – 84% < 10 YRSAGE – 84% < 10 YRS
SEX – BOYS 63.6%SEX – BOYS 63.6%
SIDE – LEFT- 58.6% , RT—42.4%SIDE – LEFT- 58.6% , RT—42.4%
NERVE INJURY- 7%NERVE INJURY- 7%
MEDIANMEDIAN
RADIALRADIAL
ULNARULNAR
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CLINICAL FEATURESCLINICAL FEATURES
H/O FALL ON OUTSTRETCHED HANDH/O FALL ON OUTSTRETCHED HAND
Failure to use upper extremityFailure to use upper extremity
GROSS SWELLING & TENDERNESSGROSS SWELLING & TENDERNESS
S SHAPED DEFORMITYS SHAPED DEFORMITY
ANT. PUCKER SIGNANT. PUCKER SIGN
CREPITUSCREPITUS
3 PT RELATIONSHIP MAINTAINED3 PT RELATIONSHIP MAINTAINED
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Examine in Elbow injuryExamine in Elbow injury
VASCULAR STATUS –Radial artery VASCULAR STATUS –Radial artery Pulsation [most important ] & Cap.refillPulsation [most important ] & Cap.refill
NEUROLOGICAL STATUS-NEUROLOGICAL STATUS-
M , R ,UM , R ,U
Check Finger movement Check Finger movement
Check for ‘Stretch sign’ : compartment Check for ‘Stretch sign’ : compartment syndromesyndrome
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Pucker sign/ Brachialis sign
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Brachialis Sign- Proximal Fragment Brachialis Sign- Proximal Fragment Buttonholed through BrachialisButtonholed through Brachialis
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Milking Maneuver- Milk Soft Milking Maneuver- Milk Soft Tissues over Proximal SpikeTissues over Proximal Spike
From Archibeck et al. JPO 1997
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POST MEDIAL POST LATERAL
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Supracondylar Humerus Fractures:Supracondylar Humerus Fractures:ClassificationClassification
Gartland (1959)Gartland (1959)
Type 1Type 1 non-displacednon-displaced
Type 2Type 2 Angulated/displaced fracture Angulated/displaced fracture with posterior cortex in contactwith posterior cortex in contact
Type 3Type 3 Complete displacement, with no Complete displacement, with no contact between fragmentscontact between fragments
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GARTLAND CLASSFN FOR GARTLAND CLASSFN FOR EXTN TYPEEXTN TYPE
TYPE 1 –UNDISPLACEDTYPE 1 –UNDISPLACED
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Type 1: Non-displacedType 1: Non-displaced
Note the non- Note the non- displaced fracture displaced fracture (Red Arrow)(Red Arrow)
Note the posterior Note the posterior fat pad (Yellow fat pad (Yellow Arrows)Arrows)
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FAT PAD SIGNSFAT PAD SIGNS
Olecronon post fat pad signOlecronon post fat pad signCoronoid ant fat pad signCoronoid ant fat pad signHelpful in occult # with effusionHelpful in occult # with effusion
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Type 2: Angulated/displaced Type 2: Angulated/displaced fracture with posterior cortex in fracture with posterior cortex in
contactcontact
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TYPE 2TYPE 2
DISPLACED BUT POST CORTEX IS DISPLACED BUT POST CORTEX IS INTACTINTACT
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Type 2: Angulated/displaced Type 2: Angulated/displaced fracture with intact posterior cortexfracture with intact posterior cortexIn many cases, the type 2 In many cases, the type 2 fractures will be impacted fractures will be impacted medially, leading to varus medially, leading to varus angulation. angulation.
The varus malposition The varus malposition must be considered when must be considered when reducing these fractures, reducing these fractures, applying a valgus force applying a valgus force for realignment.for realignment.
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TYPE 3TYPE 3
Totally displaced typeTotally displaced type
3 a –post medial3 a –post medial
3 b –post lateral3 b –post lateral
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ManagementManagementAll suspected cases should be splinted in All suspected cases should be splinted in around 20-30 deg at elbow before sending around 20-30 deg at elbow before sending for xrayfor xrayNeurologic evaluationNeurologic evaluationVascular assessmentVascular assessment
Peripheral pulse- radial arteryPeripheral pulse- radial artery Capillary fillingCapillary filling Doppler testDoppler testEvaluate for ipsilat injuries- anywhere from Evaluate for ipsilat injuries- anywhere from
wrist to sternoclavicular jt.wrist to sternoclavicular jt.
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TYPE 1 # UNDISPLACEDTYPE 1 # UNDISPLACED
SIMPLE IMMOBILIZATION WITH A SIMPLE IMMOBILIZATION WITH A POST SLAB IN 90DEG. WITH A CUFF POST SLAB IN 90DEG. WITH A CUFF AND COLLAR AND COLLAR
XRAY TO BE RPTED AT 5-7 DAYS TO XRAY TO BE RPTED AT 5-7 DAYS TO DOCUMENT FOR ANY DISPLACEMENTDOCUMENT FOR ANY DISPLACEMENT
SLAB KEPT FOR 3 WEEKSSLAB KEPT FOR 3 WEEKS
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Type ii (displaced with post Type ii (displaced with post cortex in contact)cortex in contact)
Treatment – closed reduction under anaes
Traction is applied followed by correction of rotational deformity
Extension deformity is corrected with pressure by thumb over the olecranon
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Necessity for hyperflexionNecessity for hyperflexion
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TYPE III # TREATMENT TYPE III # TREATMENT METHODSMETHODS
Closed reduction & percut.K wire Closed reduction & percut.K wire fixationfixation
Open redn. & K wire fixationOpen redn. & K wire fixation
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METHOD OF CLOSED REDN. METHOD OF CLOSED REDN. UNDER GEN. ANAESUNDER GEN. ANAES
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Percutaneous K wire fixationPercutaneous K wire fixation
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CLOSED REDN WITH K WIRE CLOSED REDN WITH K WIRE FIXATIONFIXATION
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Lateral Pin PlacementLateral Pin Placement
AP and Lateral views with 2 pins AP and Lateral views with 2 pins
[ fluoroscopic view ][ fluoroscopic view ]
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C-arm / Fluoroscopic ViewsC-arm / Fluoroscopic Views
Jones views with the C-arm can Jones views with the C-arm can be useful to help verify the be useful to help verify the reductionreduction
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Indications for SurgeryIndications for Surgery
Volkmann’s IschemiaVolkmann’s Ischemia
Irreducible fractureIrreducible fracture
Vascular injuryVascular injury
Open fracturesOpen fractures
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Medial coloumn collapseMedial coloumn collapse
Can lead to varus deformity from simple closed redn. If no stabilization is done
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Medial Impaction FractureMedial Impaction Fracture
Type II fracture with medial impaction – not recognized and varus / extension not reduced
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Medial Impaction FractureMedial Impaction Fracture
Cubitus varus 2 years later
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Supracondylar Humerus Fractures: Supracondylar Humerus Fractures: Associated InjuriesAssociated Injuries
Nerve injury incidence is high, between 7 and 16 % Nerve injury incidence is high, between 7 and 16 % (radial, median, and ulnar nerve)(radial, median, and ulnar nerve)
Anterior interosseous nerve injury is most commonly Anterior interosseous nerve injury is most commonly injured nerveinjured nerve
In many cases, assessment of nerve integrity is limited , In many cases, assessment of nerve integrity is limited , because children can not always cooperate with the because children can not always cooperate with the examexamCarefully document pre-manipulation exam, as post-Carefully document pre-manipulation exam, as post-manipulation neurologic deficits can alter decision manipulation neurologic deficits can alter decision makingmaking
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Supracondylar Humerus Fractures: Supracondylar Humerus Fractures: Associated InjuriesAssociated Injuries
5% have associated 5% have associated distal radius fracturedistal radius fracture
Physical exam of Physical exam of distal forearmdistal forearm
Radiographs if Radiographs if neededneeded
If displaced pin radius If displaced pin radius alsoalso
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Supracondylar Humerus Fractures: Supracondylar Humerus Fractures: Associated InjuriesAssociated Injuries
Vascular injuries are rare, but pulses should Vascular injuries are rare, but pulses should always be assessed before and after reductionalways be assessed before and after reduction
In the absence of a radial and/or ulnar pulse, In the absence of a radial and/or ulnar pulse, the fingers may still be well-perfused, because the fingers may still be well-perfused, because of the excellent collateral circulation about the of the excellent collateral circulation about the elbowelbow
Doppler device can be used for assessmentDoppler device can be used for assessment
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Supracondylar Humerus Fractures: Supracondylar Humerus Fractures: Associated InjuriesAssociated Injuries
Type 3 Type 3 supracondylar supracondylar fracture, with absent fracture, with absent ulnar and radial ulnar and radial pulses, but fingers pulses, but fingers had capillary refill had capillary refill less than 2 seconds. less than 2 seconds.
The pink, pulseless The pink, pulseless extremityextremity
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Supracondylar Humerus Fractures:Supracondylar Humerus Fractures:ComplicationsComplications
Malunion –cubitus Malunion –cubitus varus varus
Volkmann’s ischemiaVolkmann’s ischemia
Vascular injury Vascular injury
Loss of reduction Loss of reduction
Loss of elbow motionLoss of elbow motion
Pin track infectionPin track infection
Neurovascular injury Neurovascular injury with pin placementwith pin placement
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Volkmann’s ischemiaVolkmann’s ischemia
Diagnose / suspect byDiagnose / suspect by
Severe pain/symptomSevere pain/symptom
Stretch Pain /signStretch Pain /sign
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Myositis Ossificans
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WHY TO PREFER K WIRE IN WHY TO PREFER K WIRE IN TYPE3#TYPE3#
Type 3 # are intrinsically Type 3 # are intrinsically unstable unstable
1.1. No periosteal hingeNo periosteal hinge
2.2. Rotation of the distal fragment Rotation of the distal fragment cant be controlled until elbow is cant be controlled until elbow is hypreflexedhypreflexed
3.3. # Tends to rotate in less flexion# Tends to rotate in less flexion
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4. In fresh cases with swollen elbow 4. In fresh cases with swollen elbow not possible to get hyper flexion i.e. not possible to get hyper flexion i.e. More than 90 degMore than 90 deg
5. If app cast after 2-3 days swelling 5. If app cast after 2-3 days swelling decreases cast becomes loose again decreases cast becomes loose again rotation is lostrotation is lost
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Supracondylar Humerus Fractures- Supracondylar Humerus Fractures- Flexion typeFlexion type
Rare, only 2%Rare, only 2%
Distal fracture fragment Distal fracture fragment anterior,flexedanterior,flexed
Ulnar nerve injury -higher Ulnar nerve injury -higher incidenceincidence
Reduce with extensionReduce with extension
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Flexion TypeFlexion Type
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Flexion Type - PinningFlexion Type - Pinning
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????????????
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THANK YOUTHANK YOU