Supracondylar fractures humerus

1. Supracondylar fractures humerus
Dr.Roshan Zameer
1st year pg
Orthopaedics

2. • Most common elbow fractures seen in
children
• 5 to 6yrs
• Boys vs gals- 3:2
• Left or non dominant side more common

3. Mechanism
• Depending on direction of displacement of
distal fragment
• Extension & flexion types
• Outstretched hand with elbow full extension

5. • Between the olecranon fossa posteriorly and
the coronoid fossa anteriorly, the medial and
lateral columns of the distal humerus are
connected by a thin segment of bone
• elbow is hyperextended, the olecranon
engages the olecranon fossa and acts as a
fulcrum through which the extension force
can propogate a fracture

7. Displacements
posteromedial vs posterolateral

8. Classification
• Modified gartland

10. Signs & symptoms
• History- pulling or fall
• Pain,swelling
• Tenderness-both condyles
• Decreased ROM
• Limited extension
• Gross deformity
• Anterior pucker sign

11. S-configuration

12. Associated injuries

13. Motor & sensory examination
• Sensory-
• Radial nerve- dorsal 1st web space
• Median nerve – palmar index finger
• Ulnar nerve – palmar little finger

14. • Motor
• Finger, wrist, thumb extension -Radial nerve
• Distal IP flexion & thumb IP flexion -Anterior
interosseous nerve
• Thenar strength -Median nerve
• Interossei -Ulnar nerve

15. Vascular examination
• Presence of pulse, warmth, capillary refill,
and colour of the hand.
• Vascular status three categories
• Hand well-perfused (warm and red), radial
pulse present
• Hand well-perfused, radial pulse absent
• Hand poorly perfused (cool and blue or
blanched), radial pulse absent

16. Forearm compartment syndrome
• High suspicion-look for
• Swelling or Ecchymosis
• Anterior skin puckering
• Absent pulse
• Tenseness of the volar compartment
• Passive finger extension & flexion tested

17. Radiographic evaluation
• True Ap ,Lat,Oblique views
• Initial xray may be negative except for a posterior
fat pad sign
• Anterior humeral line
• Baumann angle or Humeral capitellar angle
-Normal range 9 to 26 deg,
- 10 degrees is acceptable
-A decrease in the Baumann angle is a sign
that a fracture is in varus angulation

20. • Young child, epiphyseal separation mimic an
elbow dislocation.
• In an epiphyseal separation, the fracture
propagates through the physis without a large
metaphyseal fragment
• Differentiating this injury from an elbow
dislocation is the alignment of the capitellum
with the radial head

22. Management

23. Initial Management
• Initial splinting - elbow in 20 to 40 degrees of
flexion
• Avoid
Tight bandaging,excess flexion,extension
-vascular injury
• Limb elevated
• Neurologic & vascular status
• Look for compartment syndrome

24. Closed Reduction and Pinning
• initially attempted - including type III fractures
• first reduced in the frontal plane
• elbow is then flexed while the olecranon is
pushed anteriorly to correct the sagittal
deformity

25. Indications of a successful reduction
• Restoration of the Baumann angle –Apview >
10 deg
• Intact medial and lateral columns on oblique
views
• Anterior humeral line passing through the
middle third of the capitellum on the lateral
view
• immobilized in 50 to 60 degrees of flexion

26. • Ulnar nerve injury ?
• Migration of nerve? Medial / anterior
• Small incision over medial epicondyle.

27. • Medial pin inserted in extension with out
flexing
• Construct stability- 2 divergent lateral pins >
crossed pins > 2 parallel pins
• 2 lateral pins,unstable- 3rd lateral pin,still
unstable than put a medial pin.

28. Indications for open reduction
• Gap in the fracture site
• An irreducible fracture with a rubbery feeling
on attempted reduction may be signs that the
median nerve and/or brachial artery is
trapped in the fracture site,

29. Open Reduction
• Closed reduction fails
• Fractures associated with a dysvascular limb
• Approches-medial
• lateral
• posterior
• Transverse.

30. Treatment with Traction(conservative)
• Severe comminution
• Lack of anesthesia
• Medical conditions prohibiting
• Malunion is common

31. Type I Fracture (Nondisplaced)
• Periosteum is intact
• Xray limited to a posterior fat pad sign
• Posterior splint applied at 60 to 90 degrees of
elbow flexion @ 3 wks
• Any signs of compartment syndrome

32. • Type II Fracture (Hinged Posteriorly, with
Posterior Cortex in Continuity)
–closed reduction & pinning
-immobilization in 90 deg flexion & supination

33. Type III Fractures-
• Elbow in either extreme flexion or extension
avoided
• 30 deg flexion -prevent vascular
insult,compartment
• Periosteum is torn, there is no cortical contact
between the fragments
• Open or closed reduction with pinning
• After reduction if casting-elbow in 120 deg
flexion,to prevent rotation @ 3-4 wks.

35. Type IV Fractures
• Extremely unstable fracture
• Reduction in both planes
• Open reduction and pinning
• Medial Column Comminution
• Open or closed reduction with pinning
• Or leads to varus deformity

37. Procedure
• Pt supine with # arm over arm board
• Traction with the elbow flexed 20 deg to
avoid tethering the neurovascular structures
• Held for 60 seconds to allow soft tissue
realignment

38. • If it the proximal fragment appears to have
pierced the brachialis muscle, the “milking
maneuver”
• milked” in a proximal to distal direction

39. • Next, varus and valgus angular alignment is
corrected
• By direct movement of the distal fragment by
the surgeon's thumb
• Elbow is then slowly flexed while anterior
pressure is applied to the olecranon with the
surgeon's thumb

40. • After reduction, the child's elbow should
sufficiently flex so that the fingers touch the
shoulder.
• If not, the fracture likely is still not reduced
and is in extension

41. • “rubbery” feeling- median nerve or brachial
artery entrapment- open reduction
• “bone on bone” feeling
• elbow is taped in the reduced position of
elbow hyperflexion

42. • Acceptable
• some translation of the distal fragment (up to
25%)
• moderate rotational malalignment
• As a rule, 2 pins for type II fractures and 3
pins for type III fractures

43. • Stress applied in varus and valgus under
fluoroscopy to ensure fracture stability
• lateral views should be obtained with the
elbow flexed and extended to assess
movement of the capitellum relative to the
anterior humeral line

45. • Posterior slab or casting with less than 70 deg
flexion @ 3 wks
• > 90 deg-risk of compartment syndrome

46. Complications
• Vascular injury
• Compartment syndrome
• Neurologic defect
• Elbow Stiffness
• Pin Track Infections
• Myositis Ossificans
• Cubitus varus“gunstock deformity”

47. Reference
• Campbell
• Gray’s anatomy

48. Thanku