18-01-2023 18:13 Supracondylar Humeral Fracture - Physiopedia

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Contents
1 Clinically Relevant Anatomy
2 Epidemiology
3 Mechanism of Injury / Etiology
4 Clinical Presentation
5 Diagnostic Procedures
6 Classification of Supracondylar fracture
7 Complications of supracondylar fracture[2]
8 Management / Interventions
8.1 Medical
8.2 Physiotherapy Management
9 Evidence
9.1 Advice and Exercises During the Immobilization Period
9.2 1-2 Weeks After Removal of Cast
9.3 Advice and Exercise After 2 Weeks of Cast Removal
10 Conclusion
11 References
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Clinically Relevant Anatomy

The Supracondylar fracture of the humerus is a fracture of the distal end of the humerus just above the elbow joint. The transverse
section of the shaft of the humerus is somewhat circular in shape which gets more flattered as it descends down to meet the distal end
of the humerus.[1]

The distal end of humerus comprises of both articular and non-articular structures. Non- articular structure comprises of the medial
epicondyle, lateral epicondyle, anterior coronoid and radial fossa and posterior olecranon fossa.Whereas articular structure includes the
lateral capitulum articulating with radial head and the medial trochlea articulates with the ulna.

The medial epicondyle is the site for the common origin of flexor musculature of the forearm and the ulnar nerve runs in a groove on
the back of this epicondyle. The lateral epicondyle is the site for the common origin of extensor musculature of the forearm. These
muscles attachment are responsible for the displacement and rotation of the distal fragment.[2] In the anterior aspect of distal humerus
allow the passage of the brachial artery (https://www.ncbi.nlm.nih.gov/books/NBK537145/) and median nerve.[1] The brachial artery

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which commonly gets involved in supracondylar fracture of humerus lies

along the anteromedial aspect of the distal humerus just superficial to the
brachialis muscle.[2] The radial nerve runs between the brachialis and
brachioradialis muscles before crossing the elbow and penetrating the
supinator muscle.[2]

Epidemiology
Supracondylar fractures of the humerus are the most frequent
fractures of the pediatric humerus, with the median age being 6 years
and a peak incidence at the ages of five to eight years.
It is the second most common bony injury in the pediatric
population.[3]
It accounts for 55% to 80% of total elbow fractures in children and up
to two-thirds of pediatric elbow injuries requiring hospitalization.
Their incidence has been estimated at 177.3 per 100 000.
Higher incidence of supracondylar fractures is in boys, affecting the
non-dominant arm 1.5 times more frequently.
About 10% to 20% of displaced supracondylar fractures present with
alterations in vascular status. In most cases, fracture reduction restores
perfusion.
Neural injuries occur in 6.5% to 19% of cases involving displaced Relation of distal end of arm with brachial artery and median nerve.
fractures. Most of them are neurapraxias. [4]

Mechanism of Injury / Etiology

Pediatric population predisposed, especially during ages when the
supracondylar bone is undergoing skeletal maturation and has a thin and weak
cortex. The ossification process of distal humerus occurs at different ages. The
supracondylar area undergoes remodelling between 6 to 7 years of age and is
typically thinner with a more slender cortex, predisposing this area to
fracture.[5][2]
Extension type of Supracondylar fracture of humerus
The distal humerus anatomy is especially predisposed to injury because its
configuration in two columns connected by thin bone represents a zone of
weakness.[4]

Supracondylar fractures usually occur as a result of a fall from height or from sports or leisure or fall on outstretched hand( FOOSH).

Extension type injury (97% to 99%) is more common than flexion type(1-3%). [4]

When a fall on the outstretched hand occurs, the olecranon engages on the olecranon fossa
and if elbow extension progresses, the olecranon finally acts as a fulcrum on the fossa. While
the anterior elbow joint capsule produces an anterior tensile load, resulting in fracture and
disruption of anterior periosteum. Therefore, the bone begins to break at first anteriorly and
the fracture progresses posteriorly. If the energy is high, the posterior cortex disrupts, and
finally complete posterior displacement of the distal fragment occurs with the posterior
periosteum acting as a hinge. This is the mechanism of extension-type fractures.[4]

Flexion-type fractures are usually caused by direct trauma to the flexed elbow. In these cases,
the anterior periosteum acts as a hinge, and the progression of the injury goes from the
posterior to the anterior part of the distal humerus. The distal fragment also tends to be
translated in the coronal plane.[4][2]
Fall on outstretched hand ( FOOSH)
Clinical Presentation
Supracondylar fracture often present with associated forearm fractures, soft tissue damage, neurologic injury, and significant risk for
developing compartment syndrome, thus an examination of the entire upper extremity should be performing thoroughly. It
includes:[2][4]

History

Classical history of fall on an outstretched hand followed by pain and swelling over the elbow with loss of function of the upper
limb, the onset of pain holds special consideration.
It is very important to know whether the pain is due to fracture or because of muscle ischemia which has a late-onset (hours after
the injury).[2]

Observation

Painful swollen elbow and forearm with hesitant to move.[2]

Ecchymosis, skin puckering (this sign appears when the proximal fragment transects the brachialis muscle, ‘puckering’ the deep
dermis), bruises[4]
Bleeding puncture wound (indicates open fracture)
In displaced extension-type fractures, the so-called ‘S-deformity’ is usually present.[4]

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Vascular status evaluation:

Vascular compromise exists in up to 10% to 20% of displaced fractures. Both radial and ulnar pulses must be palpated at the wrist of the
injured extremity. In case of pulselessness ( Pulseless hand), other signs of perfusion must be checked viz., color (the hand should be
pink), temperature, capillary refill ( less than 2 seconds), and oxygen saturation on the pulse oximeter. [2]

Classification:

Class I - well perfused (warm and red) with radial pulse

Class II – well perfused but radial pulse absent
Class III – poorly perfused (cool and blue or blanched) and radial pulse absent

Neurologic status:

The degree of involvement and possible progression/ regression of symptoms of the nerve is a must before and after treatment.
Neuropraxias is common and generally resolve with the restoration of normal alignment and lengths.[2]Neuropraxias that usually resolve
within two to three months.

Anterior Interosseous Nerve Branch (AIN) of the median nerve is most prone to get involved in postero-lateral displacement of the
distal fracture fragment. A child may present with no sensory loss in hand but a weak" OK sign" (e.g., more of a pincer grasp than an
OK sign) on physical examination.
Radial nerve impingement most commonly occurs when the distal fracture fragment is displaced posteromedially. It can be
examined with decreased sensation in dorsal aspect of the hand and weak wrist extensors.
Ulnar nerve is prone to injury following flexion type of supracondylar fractures and loss of sensation in its distribution can be
examined following weakness of intrinsic muscles of the hand.[2][4]

Compartment syndrome: Severe swelling and/or ecchymosis, anterior skin puckering, and vascular compromise with severe pain.

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Supracondylar Fractures Of The Humerus In Children

[6]

Diagnostic Procedures
Radiographs should include true AP of distal humerus (not elbow) and true lateral elbow views.If
there is only minimal or no displacement these fractures can be occult on radiographs. The only
sign will be a positive fat pad sign.[2]

On lateral view

The lateral view also allows assessing the degree of displacement and the integrity of the
posterior cortex.
Displaced Supracondylar fracture in X-ray
On the lateral view, the following radiological parameters are looked for: (a) Anterior humeral
line; (b) Coronoid line; (c) Fish tail sign; (d) Fat pad sign; (Anterior and Posterior).

Anterior humeral line (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6335593/#!po=14.1026) to capitulum orientation on a lateral view

Normal elbow - line continues the anterior cortical of the humerus and should traverse the capitulum in its middle third line.
Extension type injury: capitulum posterior to line
Flexion type injury: capitulum anterior to the line[3]

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On AP view

It helps to evaluate the direction of displacement, the presence of varus or valgus

alignment, and the extent of the fracture comminution.

The Baumann angle (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6335593/#!po=16.666

7) (Humeral capitular angle) on AP view

Angle between linea perpendicular to longthe axis of humeral shaft and the physeal line
of the capitulum, isused to assess varus or valgus alignment of the distal humerus.
Normal range – 64º to 82º degrees
Decrease in angle – varus angulated fracture with possible medial column comminution

The Ulnohumeral angle or radiological carrying angle on AP view

The angle formed by the diaphyseal axis of the humerus and the axis of the proximal
third of the ulna.
Anterior Humeral Line Abnormal
It is also used to assess varus or valgus deformity and it is more accurate and useful
than Baumann’s angle [4]

Classification of Supracondylar fracture

Modified Gartland classification( 2006)of supracondylar fractures (based on lateral radiograph):[5][4][7]

Type I

Nondisplaced or minimally displaced (<2mm) with intact anterior humeral line

No disruption of periosteum – stable fracture
Fat pad signs may be only found

Type II

Displaced (>2mm) with hinged intact posterior cortex

Anterior humeral line does not pass through the middle third of capitulum on lateral radiographs
No rotational deformity on AP radiograph

Type III

Displaced with no meaningful cortical contact, usually sagittal plane extension and frontal/horizontal plane rotation
Significant periosteum disrupture, soft tissue and neurovascular injuries common
Medial column comminution and collapse with malrotation in the frontal plane

Type IV

Multidirectional instability
Incompetent periosteal hinge circumferentially, with instability in flexion and extension

Complications of supracondylar fracture[2]

Immediate complications are associated with neurovascular involvement including

1. Vascular insufficiency / pink pulseless hand- involvement of the brachial artery is most commonly associated with Type II and III
supracondylar fractures, frequently encountered in posterolaterally displaced fracture.
2. Compartment syndrome: It can occur in 0.1% to 0.3% of cases.Associated forearm fractures and elbow flexion > 90° increase
compartment pressures. To minimize the risk of compartment syndrome, the elbow should be immobilized in about 30° of flexion in
the emergency room and 60° to 70° of after surgery.[2]
3. Neurologic deficit-10 to 20 percent of supracondylar fracture and mainly associated with Type III supracondylar fractures.[4]
4. Open or associated forearm fractures

Long term complications in Pediptric population is due to the fact that bones in this age group have an enormous growth as well as
remodelling ability. So that long term functional outcome and radiological appearance of a fracture may be quiet different than that of
immediate post-management status.

1. Cubitus varus deformity: (https://www.slideshare.net/ramachandrareddy5/cubitus-varus-deformity) It occurs due to the malunion

and also known as "gunstock” deformity. Posttraumatic cubitus varus deformity has important problems, which are associated with
tardy ulnar nerve palsy, tardy Postero-Lateral Rotatory Instability (PLRI), shift of the medial head of the triceps and secondary distal
humeral fractures. Modern surgical techniques (e.g., closed reduction with percutaneous pinning) have reduced its frequency from
58 percent to approximately 3 percent in children treated for supracondylar fractures. Humeral osteotomy is used to correct this
deformity and to avoid such later complications.[4]

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2. Volkmann’s ischemic contracture: If compartment syndrome is not treated timely, the associated ischemia may progress to infarction
and subsequent development of Volkmann's ischemic contracture: fixed flexion of the elbow, pronation of the forearm, flexion at the
wrist, and joint extension of the metacarpal-phalangeal joint.[2]

Management / Interventions
Medical
Management of supracondylar fracture is determined based on the type of fracture based on Modified Gartland Classification.

Type I ( Non-displaced fracture)

Immobilization with a long-arm cast or splint.

With elbow flexion up to 80° to 90° and mid pronation-supination are well toleratable for ~3weeks.
Flexion of the elbow within the cast should not pass 90° because it can increase forearm pressures and impede distal vascular flow.
Radiographic check at 1 and 2 weeks

Types II

A closed reduction(CR) and percutaneous pinning fixation is recommended than CR and immobilization as the risk of complication
are low. Pins are removed in the hospital approximately three weeks after surgery.[8]

Type III and Type IV

Closed reduction and percutaneous pinning is the gold standard for all displaced fractures and is widely used in Type III and IV
fractures.
Open reduction is indicated:

1. When the surgeon is not able to reduce the fracture by closed means
2. When there is soft-tissue entrapment (i.e. muscle, median nerve, brachial artery) or
3. When a cold hand remains without perfusion after an attempt at closed reduction has been performed.

There is an increased incidence of infection, stiffness, and myositis ossificans in open reduction. The anterior approach is the most widely
used approach for open reduction mainly when vascular repair is necessary. The lateral approach is standard for elbow surgery but in
supracondylar fracture increases the risk of radial nerve injury and stiffness. The bilaterotricipital posterior approach (Alonso-Llames
approach) is not recommended as it has a high rate of complications described, such as stiffness, unsightly scarring and risk of trochlea
osteonecrosis.

Physiotherapy Management
Physiotherapy treatment is vital in all patients with a supracondylar fracture to hasten healing and ensure an optimal outcome. The goal
of physiotherapy treatment is:

To achieve painless and full mobility of the elbow joint.

To enhance healing process.
To strength the affected musculature.
To improve overall functional abilities of children.

Outcome measures that can be used to compare and evaluate the outcome of treatment are :

Numerical pain rating scale (NPRS)/ Faces Pain Scale (https://www.iasp-pain.org/Education/Content.aspx?ItemNumber=1519#:~:text

=The%20Faces%20Pain%20Scale%20%E2%80%93%20Revised,pain%20intensity%20developed%20for%20children.&text=Numerica
l%20self%2Drating%20scales%20(0,to%20provide%20a%20self%2Dreport.)
Range of motion- Goniometry
Manual muscle testing ( MMT)
ASK-p (Activities Scale for Kids-performance version) (http://www.activitiesscaleforkids.com/)[8]
Flynn's criteria include two factors 'cosmetic factor' (loss of carrying angle) and 'Functional factor' (motion loss in degrees).[9]
Neuro-vascular assessment is must post-operatively and during rehabilitation.

Evidence
The physical therapy management in the pediatric population is very controversial, in both its effect and its necessity. A randomized
controlled trial was done by Schmale et al. in 2014, had shown that children with supracondylar fracture treated with either casting or CR
with percutaneous pining followed by casting were not benefited by a short course of physical therapy (six sessions of physical therapy
performed over a five-week period beginning the week after cast removal) in terms of either return of function or motion.[8]Supporting
the above study, another study was done in 2018, also shows that children managed with CR for uncomplicated supracondylar fracture
with immobilization for three weeks regain their functional ROM within 12 weeks of mobilization by themselves, with no added benefit
from physiotherapy.[9]

Physiotherapy treatment has not shown significant difference, it may be due to the involvement of children of a ( 5- 10 years) in more
involved in daily household activities from an early period and urge for a motion for playing.[9] It would be either affected as the
therapist may have been unduly aggressive or unduly conservative while providing treatment.[9][8]

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On the contrary, in a more severe type of injury with neurovascular involvement and in an adult patient, physiotherapy treatment has a
significant role.[8] And in the pediatric population, evidence has been lacking to address the strength of upper extremity as an outcome
after physiotherapy treatment.

Therefore,

Optimal loading(pain-free activities based on a child) is very necessary for the pediatric population with supracondylar fracture as
pain aggravating activities may delay the healing process and cause further damage as they are in the growing phase.[8]
Thus, active exercise and active involvement in sports and ADLs are recommended rather than passive joint mobilization and
stretching exercises.[9]
Those activities such as lifting, weight-bearing, or pushing activities that pose large amounts of stress through the humerus should
also be avoided in the initial week after immobilization removable.[9]
Progressive strengthening exercises can be addressed.

Advice and Exercises During the Immobilization Period

Normally elbow is immobilized for 3 weeks so, during that period, adjacent joints ( Shoulder joint and wrist joint and hand) should
be kept moving active or active-assisted exercises frequently in a day.
Elbow shouldn't be moved and used of arm sling should be proper.
Postural training( sitting upright with relaxed shoulder and retraction of the scapula) should be taught.

1-2 Weeks After Removal of Cast

Hot fermentation can be used to ease joint stiffness.
Gentle soft tissue release can be done in arm and forearm musculature.
Gentle active and active-assisted exercises using a wand and be taught in pain- free limit- frequently in a day.
Isometric exercises for arm and forearm musculature can be addressed.
Educate parents and child to use the affected hand to use in daily activities like brushing, writing, eating, dressing, etc.
Avoid weight lifting and pushing activities.

Advice and Exercise After 2 Weeks of Cast Removal

Progressive and interactive range of motion exercise and strengthening exercise should be addressed eg: passing a ball, dressing
and undressing clothes.

Conclusion
Supracondylar fractures of the humerus are the most frequent fractures in children with a peak incidence at the ages of five to eight
years.
FOOSH is the most mechanism of injury of Supracondylar fracture of the humerus.
The Neurovascular assessment is must pre and post-operatively.
Closed reduction with percutaneous pinning is the recommended medical management for displaced fracture without neurovascular
involvement.
Active exercise is recommended in pediatric elbow fracture rather than passive treatment.

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