An Introduction, Biomechanics, Radiological Diagnosis, Management of Suracondylar Fractures of Children.

1. Supracondylar Fractures
Presented by Dr. W. G. P. Kanchana
Registrar in Surgery
Teaching Hospital Peradeniya

2. Introduction
• Fracture of distal humerus which is
proximal to bone masses of the
trochlear and capitulum.
• Often runs through the apices of
coronoid and olecranon fossae, just
above the fossae or through the
metaphysis of humerus.
• # goes through the thinnest portion of
the bone

3. Epidemiology
• Most common elbow injury in Children (around 60%)
• Becomes less common with increasing age
• Peak age : 5 – 7 yrs
• Boys > Girls
• Non Dominant Limb > Dominant Limb
• Nerve injuries – 7% (Radial > Median > Ulnar)
• Vascular Injuries – 1%
• Open # - < 1%

4. Mechanism of Injury
• Extension Type
• Commonest Type (95% - 97%)

5. Mechanism of Injury

6. Mechanism of Injury
• Flexion Type

7. Gartland Classification
• During the 1950s, these injuries were called the ‘‘misunderstood fracture,’’
as such injuries often resulted in bony deformity and Volkmann’s
contracture.
• In 1959, Gartland described a simple classification scheme to reemphasize
principles underlying treatment of patients with a supracondylar humerus
fracture.
• Reliability evaluated by multiple studies. (Barton et al. & De Gheldere et al.
– inter-observer reliability 0.74)

8. Gartland Classification

9. Modified Gartland Classification

10. AO Muller Classification of Distal humeral #

11. Radiographic Diagnosis
• Ossification Centers around the elbow

12. Radiographic Diagnosis
• X-Ray Views
• True AP
• Lateral
• Oblique
• Axial (jones view)
AP of an elbow in 90 degrees of
flexion will give a roughly 45-
degree angulated view of the
distal humerus and proximal
radius and ulna

13. Radiographic Diagnosis

14. Radiographic Diagnosis
• A rule of thumb is that a Baumann’s angle ≥10 degrees is OK.
• A decrease in Baumann’s angle compared to the other side is a sign
that a fracture is in varus angulation.
• Further Evaluation May be need,
• (a) impaction of the medial column
• (b) supracondylar comminution
• (c) vertical split of the epiphyseal fragment (T-condylar fractures)

15. Radiographic Diagnosis
Gartland type I
fracture. Non displaced
/ Minimally displaced
(<2mm)
AHL goes across the
capitulum.
Only sign +ve for a # is
the Posterior Fat Pad
sign (sail sign)

16. Radiographic Diagnosis
Gartland type II
fracture. Displaced >
2mm
AHL goes anterior to
the capitulum.
Posterior Cortical
Contact is present.

17. Radiographic Diagnosis
Gartland type III
fracture.
No meaningful cortical
contact between two
fragments.

18. Radiographic Diagnosis
Gartland type IV fracture.
Has Multidirectional
instability.
Diagnosed Intraoperatively
when in extension capitulum
lies posterior to AHL and in
flexion capitulum lies anterior
to AHL (as in figure)

19. Radiographic Diagnosis
Medial collapse signifies
malrotation in the frontal plane.
(which defines the injury
as at least a type II fracture).
There is a loss of Baumann’s angle
and varus malalignment.
The lateral view show reasonable
alignment.
requires reduction and usually pin
fixation to prevent late malunion.

20. Patient Evaluation
• Approach according to ATLS guidelines.
• With History of fall - # is high in DDs.
• Other DDs.
• Nurse maid elbow - Radial head subluxation
• Inflammatory arthritis
• Infection
• Time and mechanism of injury.

21. Examination
• Vascular Examination
• Warm / Cold periphery
• Red / Blue periphery
• CRFT
• Radial pulse present / absent
• Signs of developing compartment syndrome.
• Maintain high index of suspicion
• Pain on passive flexion and extension of fingers
• Swelling, ecchymosis and anterior skin puckering
• Tenseness of the volar compartment
• Anxiety, Agitation and Increased analgesic requirement (3As)

22. Examination
• Neurological deficits
• Radial Nerve – Sensation over the dorsal 1st web space, Wrist and finger
extension
• AIN – OK sign
• Median Nerve – Sensation over the index finger, Flexion of Fingers
• Ulnar Nerve – Sensation over the little finger, Interrosei function.
• Median nerve injury / AIN may mask the pain of compartment
syndrome, Thus close monitoring needed.
• All Documented and informed to relatives / parents

23. Initial Management
• Initially kept splinted with elbow in a comfortable position. (20 – 40
degree of flexion).
• Extreme flexion of extension may increase compartment pressure.
• Avoid tight bandage and splinting.
• Elbow and hand elevated above heart.

24. Urgency of treatment
• puckeringtreatment should be urgent In the presence of,
• poor distal perfusion
• firm compartments
• associated forearm #
• considerable swelling
• antecubital ecchymosis and skin
• Several studies have shown that delay of around 8 – 20 hours does
not produce significant deleterious effects.

25. Methods of treatment
• Cast only
• Closed Reduction and Cast
• Closed Reduction and Percutaneous Pinning
• Open Reduction

26. Closed Reduction and Cast
• Stable, non-displaced #s. (type I)
• Mildly displaced # (type II) can be reduced closed, using the posterior
periosteum as the stabilizing force and maintaining reduction by
flexing the elbow >120 degrees.
• Flexion >120 degrees is the risk of vascular compromise
and/or compartment syndrome. Close monitoring needed.
• Close radiographic follow-up is necessary in the first 3 weeks. (May
need to convert to pinning when can not maintain reduction)

27. Closed Reduction and Percutaneous Pinning
(CRPP)
• Most common operative treatment.
• Initial attempt at closed reduction is indicated in almost all displaced
supracondylar fractures that are not open fractures.
• Technique:
• Placement of patient and C-arm and the screen is important.
• Fracture is first reduced in the frontal plane with fluoroscopic verification.
• The elbow is then flexed while pushing the olecranon anteriorly to correct the
sagittal deformity and reduce the fracture.

28. Technique
Release of fragment impacted on brachialis
muscle
Flexing the elbow while pushing olecranon
forward to reduce the #

29. Acceptable Reduction
• Restoration of Baumann’s angle (generally >10 degrees) on the AP
view
• intact medial and lateral columns on oblique views.
• AHL passing through the middle third of the capitulum on the lateral
view.
• Translation of less than 5mm may be accepted.
• If # Gap present and Rubbery feeling in reduction, Brachial artery or
median nerve may entrapped, thus require open reduction

30. CRPP – Pin configuration

31. Open Reduction
• Indicated in cases of failed closed reduction, a loss of pulse or poorly
perfused hand following reduction, and open fractures.
• Open reductions led to concerns of elbow stiffness, myositis
ossificans, ugly scarring, and iatrogenic neurovascular injury.
• In setting of severe soft tissue injury and bone injury, better results
seen with open reduction.

32. Vascular Injury
• Radial pulse is absent on initial
presentation in 7% to 12% of
patients with supracondylar
fractures.
• But an occluded or tethered artery
may recover with adequate fracture
reduction.
• Incidence of impaired circulation
after an adequate fracture reduction
is less than 0.8%.

33. Vascular Injury
• Pulse may not return immediately after reduction due to arterial
spasm.
• Wait at least 15mins before deciding on brachial artery exploration.
• Absent radial pulse is not an indication for exploration if good
perfusion is maintained.
• If pulse does not return and hand is poorly perfused, then need
brachial artery exploration.
• If poor perfusion for 6 hours or more, prophylactic forearm
compartment release is needed.

34. Vascular Injury
• Pulseless + median nerve / AIN injury -> Warrants very low threshold
for brachial artery exploration and compartment release as,
• Severe injury is suspected
• Masking of compartment syndrome

35. Post-op Management
• Elbow kept at 40 – 70 degrees of flexion.
• Flexion of 70 degrees or more will increase
the risk of vascular compromise and
compartment syndrome.
• Cast is applied with adequate padding.
• Limb is elevated above the level of the
heart atleast 48 hours.

36. Post-op Management
• Analgesics.
• Monitor for distal perfusion and compartment syndrome.
• AP and Lateral Xrays taken at one week. (May need re-reduction if
loss of reduction)
• Cast is removed at 3 weeks. Then Xrays taken out of the cast and pins
removed.
• Gentle ROM exercises are taught. (gentle flexion and extension)
• R/V at 6 weeks for ROM Check.

37. Complications
• Pin tract infections
• 1% to 2.5%. Resolve with removal of pins and antibiotic therapy. One study
showed incidence of 0.2% for osteomyelitis.
• Elbow stiffness
• Rare. Few studies have shown near normal ROM after 1 year from injury
without any formal physiotherapy.
• Myositis Ossificans (Heterotrophic ossification of muscle)
• Rare. Can be managed conservatively.

38. Complications
• Non-union – rare
• Avascular Necrosis
• Of trochlear
• Fragile blood supply to ossification center (more distal # this supply is at risk)
• Posterior approach to open reduction has increased risk

39. Complications
• Cubitus Varus
• malunion rather than growth arrest
• prevented by making certain Baumann’s angle is intact at the time of
reduction and remains so during healing.

40. Thank You