SUPRACONDYLAR HUMERUS

FRACTURE IN PEDIATRICS

PREPARED BY: DR. LAWRENCE D. MEHDEH – MCS YEAR 1 COSECSA (PAEDIATRIC SURGERY)

SUPERVISED BY: DR. INGABIRE J.C. ALLEN. MD, MBBS, FCS (ORTHO)
OUTLINE

 Objectives
 Introduction
 Anatomy
 Etiology
 Classification
 Clinical Presentation
 Management modalities
 Complications
 Take home message
 References

Photo credit: Orthobullet.com

 OBJECTIVES

 By the end of the presentation, you should be able to:

- Define what supracondylar humerus fracture is

- Describe the mechanism of injury and identify both extension and flexion types.

- Summarize the clinical presentations

- Summarize the associated injuries of supracondylar humerus and their assessment

- Know the standard classifications of the extension and flexion types

- Summarize the management approach & List the complications of supracondylar humerus
 INTRODUCTION

 One of the most common traumatic fractures seen in children

 It occurs at age 5 – 7, & Boys are more commonly affected (3:2)

 85% of elbow fracture occurs at the distal humerus ( 55% - 75% are Supracondylar fracture)

 95 – 98% are Extension type while < 5% are Flexion type.

 In LMICs Supracondylar humerus fractures (SHFs) account for 13-17% of all paediatric fractures and 60-

80% of all elbow injuries.

 Associated with morbidity; includ-ing malunion, neurovascular complications, compartment syndrome, and
 ANATOMY
 Review of Elbow joint

- Hinged joint made up of three bones (Humerus, Ulna and

radius)

- 3 joints (Ulnohumeral joint, Radiocapitellar joint and

Proximal radioulnar joint

- 3 Ligaments (Medial collateral, lateral collateral and

annular ligaments)

- 2 tendons (Biceps and Triceps tendons)

- 3 nerves (Radial, Median and Ulnar nerves)

 ANATOMY
 Appearance and Fusion of Ossification
centers in distal humerus.
 Ossification centers appear during growth in a
predictable pattern
 The ossification centre for the capitellum
develops at one year.
 Followed by the radial head, media
epicondyle, trochlea, olecranon and lateral
epicondyle.
 6 Ossification centers around the elbow joint
 C.R.I.T.O.E
 1-4-6-8-10-12 years
 ETIOLOGY

 Mechanism of injury

- Fall on an outstretched hand with hyperextension of elbow.

- Forearm position decides the rotational deformity (Pronation >

Supination)

- This results in an extension type of injury.

- Direct trauma or fall on a flexed elbow

- This result in a Flexion type of injury.

Photo credit: Google
ETIOLOGY
 Injuries that accompany both types of fractures

1. Nerve

- Anterior interosseous nerve (AIN) neuropraxia (MC)

- Radial nerve palsy (2nd MC)

- Ulnar nerve palsy (seen with flexion type)

II. Vascular (brachial a.)

III. Other bone

 CLASSIFICATION

 Gartland Classification 1959

 It is based on the degree and direction of

displacement and of intact cortex.

 Eg: None, buckle or break (Cortical

reference)

 Four types
 CLASSIFICATION
 Type I – Nondisplaced
 Type II – Displaced in one plane /
Angulation with posterior cortex intact
 IIA – Angulation
 IIB – Angulation with rotation
 Type III – Displaced in 2 0r 3 planes
 IIIA – Medial periosteal hinge intact,
distal fragment goes posteriomedially.
 IIIB – Lateral periosteal hinge intact,
Distal fragment goes posterolaterally
 Type IV – Periosteal disruption with
instability in both flexion and extension.
CLASSIFICATION

 Lagrange and Rigault classification 1962

 Describe extension – type of supracondylar fractures of the humerus.

 It is based on the amount of displacement of the distal fragment

 Originally composed of five stages

 It helps in making decision on the type of treatment to apply per stage.

 The fifth stage is infrequently used because it is rare.

 LAGRANGE AND RIGAULT CLASSIFICATION

 Stage I – Undisplaced fractures, only

the anterior cortex is disrupted.
 Stage II - Fractures involving both
corticals, no or little displacement.
 Stage III – Fractures with substantial
displacement
 Stage IV – substantial displacement
fractures with no contact between bone
fragments
 Stage V – Metaphyseal-diaphyseal
fractures
CLINICAL PRESENTATIONS/ASSESSMENT

 Pain, inability or refusal to move the affected elbow

 PE follow a common pattern of LOOK – MOVE - FEEL

 LOOK  Swelling, ecchymosis in antecubital fossa & gross deformity

 MOVE  limited active elbow motion

 FEEL  Assess nerves (AIN, Median nerve and radial nerve injury)
 MANAGEMENT MODALITIES
 Imaging

- X-ray ( AP and Lateral view)

- Posterior fat pad sign - joint effusion raises the

anterior and posterior fat pads, indicating intra-

capsular injury

- Less than one third of the capitulum of the

humerus lies in front of the anterior humeral line.

- Normally, the anterior humeral line should

intersect the middle third of the capitellum in

children (>5 and touch in <5).
 MANAGEMENT MODALITIES

 Imaging

- X-ray ( AP and Lateral view)

- Baumann’s angle or humeral-capitellar angle

- Use to evaluate for displacement

- Formed by the humeral axis and a straight line

through the epiphyseal plate of the capitulum.

- Normal is 70-75 degree

- Deviation of >5 – 10 degree (Supports diagnosis)

MANAGEMENT MODALITIES

 Non-Operative
- Indications –

I. Warm perfused hand without neuro deficits

II. Type I

III. Type II ( Anterior humeral line intersects the capitellum, minimal swelling present, no medial
comminution
MANAGEMENT MODALITIES
 Non-Operative

- Type I

- Immobilize elbow with splint or cast for 3wks,

followed by physiotherapy

- Long arm elbow casting at 60 – 90 deg flexion for

extension type & full extension for flexion type.

- Control xray at 1week to assess for interval

displacement
MANAGEMENT MODALITIES

 Non-Operative

- Type II

- Closed reduction and splinting the elbow for 3

wks.

- May require pin fixation if unstable.

- Control xray at 1week

 CLOSED REDUCTION OF SUPRACONDYLAR HUMERUS
FRACTURE

Closed reduction of supracondylar humerus fracture. (a) Extending the elbow to

correct the displacement in the coronal plane, (b) Correction of sagittal plane
displacement with elbow flexion, (c) Stabilization of reduction with elbow flexion and
forearm pronation.
MANAGEMENT MODALITIES

 Operative

- Indications –

I. Type IIB, Type III and Type IV

II. Flexion type

III. Medial column collapse

IV. Pulseless, sensory nerve deficits , brachialis sign, floating elbow

 CLOSED REDUCTION AND PERCUTANEOUS PINNING (CRPP)

 Urgent
 Non-urgent
- Indications  Emergent
- Indications - Pulseless, well-perfused
- Indications
- Warm perfused hands hand
- Pulseless, poorly perfused
without neuro deficits - Sensory nerves deficits
hand
- 30 – 40 deg elbow flexion - Excessive swelling

over night. - Brachialis sign / Floating

elbow
 CRPP TECHNIQUE

 The Surgeon should start with Closed reduction under C-arm guidance

 2 lateral pins in case of type II fractures and test stability using the C-arm

 IF stability is questionable, a 3rd lateral pin can be placed.

 Pins should be inserted with flexed elbow for extension-type fracture

 Pins should be inserted in elbow extension for flexion-type fracture

 DON’T FORGET THE IMPORTANCE OF ASSESSING FOR STABILITY UNDER

C-ARM guidance
 CRPP TECHNIQUE

 3 lateral pins has proven to be biomechanically stronger than 2-pin constructs

 It should be used when there is questionable stability with the 2-pin constructs

 Also in comminution, type III and Type IV fractures.

 Crossed pins is superior to both 3 & 2 Lateral pins constructs but has higher risk of

ulnar nerve injury.

 To reduce the risk of ulnar nerve injury with crossed pins technique, elbow should be

in extension when placing medial pin.

COMPLICATIONS

 Early Complications

- Vascular injury – brachial a. causing peripheral ischemia leading to contractures

- Nerves injury – radial, median (AIN) and ulnar

- Compartment syndrome – excessive swelling due to hyperflexion of elbow to

maintain reduction.

- Infection
COMPLICATIONS

 Late Complications

 Pin migration

-Malunion (Cubitus valgus/Cubitus varus – gunstock deformity)

-Heterotopic ossification/ Myositis ossificans

-Elbow stiffness
TAKE HOME MESSAGE
 Supracondylar fracture is a fracture involving the lower part of the humerus close to the elbow joint.

 It is the most common fracture we will see in children

 It diagnosis is based on the history and physical assessment

 Attention should be pay to the identification nerves and vascular injury.

 Management is based on the type of fracture pattern (non-displaced, partially displaced and completely

displaced)

 Most common method of management is the CRPP

 complications should always be anticipated and found

 Delay in management has serious consequences

REFERENCES

 Apley & Solomon’s System of Orthopeadics and Trauma 10th edition

 Orthobullets.com

 Slideshare

 Google images
THANK
YOU