2. Most common fracture around the
elbow in children (60 percent of
elbow fractures)
Peak age between 5 and 7 years- boys
had a higher incidence
At the peak age for supracondylar
fractures, there is a naturally
occurring hyperextension of the
elbow, which predisposes the distal
humerus to this type of fracture

3.  Almost all supracondylar fractures are caused
by accidental trauma rather than abuse
 Fall on an outstreched hand with
hyperextension at the elbow with abduction
or adduction,with hand dorsiflexed.
 The most commonly associated fractures are
distal radial fractures, but fractures of the
scaphoid and proximal humerus do occur.
Monteggia fractures have also been reported
 Asso injury- radial n, meadian n, ulnar n,
brachial artery.

4.  95 percent are extension type injuries, which
produces posterior displacement of the distal
fragment
 Fall onto the outstretched hand with the
elbow in full extension
 Ligamentous laxity and hyperextension of the
elbow are important mechanical factors
 Medial displacement of the distal fragment is
more common than lateral displacement

5.  Gartland (1959)
 Type 1 non-displaced
 Type 2 Angulated/displaced fracture with
intact posterior cortex
 Type 3 Complete displacement, with no
contact between fragments

6. Type 1: Non-displaced
• Note the non-
displaced fracture
(Red Arrow)
• Note the posterior
fat pad (Yellow
Arrows)

7. Type 2: Angulated/displaced
fracture with intact posterior
cortex

8. Type 2: Angulated/displaced
fracture with intact posterior
cortex
• In many cases, the type
2 fractures will be
impacted medially,
leading to varus
angulation.
• The varus malposition
must be considered
when reducing these
fractures, applying a
valgus force for
realignment.

9. Type 3: Complete displacement,
with no contact between fragments

10.  Suspected in a child with elbow pain or
failure to use the upper extremity after a fall
 Type I supracondylar fracture, there may be
distal humeral tenderness, distension or
swelling in the anconeus soft spot (elbow
effusion), restriction of motion, and
evidence of bruising
 X-rays may be negative except for a posterior
fat pad sign

11.  In type III fractures, gross displacement of the
elbow is evident.
An anterior pucker sign may be present if the
proximal fragment has penetrated the brachialis
and the anterior fascia of the elbow
 Careful motor, sensory, and vascular examinations
should be performed in all patients

12. • Nerve injury incidence is high, between 7 and 16 %
(radial, median, and ulnar nerve)
• Anterior interosseous nerve injury is most commonly
injured nerve
• In many cases, assessment of nerve integrity is
limited , because children can not always cooperate
with the exam

13. Supracondylar Humerus Fractures:
Associated Injuries
• 5% have associated
distal radius
fracture
• Physical exam of
distal forearm
• Radiographs if
needed
• If displaced pin
radius also

14. Supracondylar Humerus
Fractures: Associated Injuries
• Vascular injuries are rare, but pulses should
always be assessed before and after
reduction
• In the absence of a radial and/or ulnar
pulse, the fingers may still be well-
perfused, because of the excellent collateral
circulation about the elbow
• Doppler device can be used for assessment

16.  Initial management of all patients suspected
of having an elbow injury is splinting in a
comfortable position, generally 20 to 30
degrees of elbow flexion, pending careful
physical examination and x-ray evaluation.
 The initial responder should assess the
neurovascular status and other injuries
 Tight bandaging or splinting, excessive
flexion or forced extension should be
avoided, as they may compromise vascularity

17.  Simple immobilization with a posterior splint
applied at 60 to 90 degrees of elbow flexion
with side supports or a simple collar and cuff
 This arrangement allows swelling to occur
and does not put the brachial artery at risk
of compression
 Before the splint is applied, it should be
confirmed that the pulse is intact and that
there is good capillary refill

18.  If there is any evidence of distal fragment
extension, as judged by lack of intersection of the
anterior humeral line with the capitullum, the
fracture should be reduced and placed in a cast or
treated with percutaneous pinning to secure the
reduction.
 The most common cause of cubitus varus
deformity is inadequate treatment of types I and II
fractures.

19.  Good stability should be obtained with closed
reduction.
 Significant swelling, obliteration of pulse
with flexion, neurovascular injuries,
excessive angulation, and other injuries in
the same extremity are indications for pin
stabilization of most type II fractures

20. Medial Impaction Fracture
Cubitus varus 2 years later

21.  If pinning is chosen, two lateral pins through
the distal humeral fragment, engaging the
opposite cortex of the proximal fragment,
are generally sufficient to maintain fracture
alignment
 Pins are left protruding through the skin and
are removed at 3 to 4 weeks after fixation,
generally without the need for sedation or
anesthesia.

22. Lateral Pin Placement
• AP and Lateral views with 2 pins

23.  These fractures have a high risk of
neurologic and/or vascular compromise, and
can be associated with a significant amount
of swelling.
 Current treatment protocols use
percutaneous pin fixation in almost all cases.
 In rare cases, open reduction may be
necessary, especially in cases of vascular
disruption

24.  For closed reduction, traction is applied
first, followed by correction of rotational
deformity.
 The extension deformity is corrected with
pressure by the surgeon's thumb over the
olecranon and posterior humeral condyles.

25.  Traction is applied with the elbow in extension and
the forearm in supination.
 The assistant stabilizes the proximal fragment. After
traction has been applied and the length regained,
the fracture is hyperextended to obtain apposition of
the fragments.
 While traction is maintained, the varus or valgus
angulation along with the rotation of the distal
fragment is corrected.
 Once the length and alignment have been corrected,
the elbow is flexed. Pressure is applied over the
posterior aspect of the olecranon to facilitate
reduction of the distal fragment.
 The distal fragment is finally secured to the proximal
fragment by pronating the forearm

26. Brachialis Sign- Proximal Fragment
Buttonholed through Brachialis

27. Milking Maneuver- Milk Soft Tissues
over Proximal Spike

28. Adequate Reduction?
• No varus/valgus
• anterior hum line
• minimal rotation

29. C-arm Views
• Oblique views with
the C-arm can be
useful to help verify
the reduction

30. Supracondylar Humerus
Fractures
• If pin fixation is used, the pins are
usually bent and cut outside the skin.
• The skin is protected from the pins by
placing felt pad around the pins.
• The arm is immobilized.
• The pins are removed in the clinic 3
weeks later, after radiographs show
periosteal healing.
• In most cases, full recovery of motion
can be expected.

31. Pitfalls of Pin Placement
• Pins Too Close
together
• Instability
• Fracture
displacement
• Get one pin in
lateral and one in
medial column

32. Supracondylar Humerus
Fractures: Indications for Open
Reduction• Inadequate
reduction with
closed methods
• Vascular injury
• Open fractures

33.  By allowing swelling to decrease and facilitating
closed reduction
 In this technique, patients are placed in sidearm or
overhead skin traction for 3 to 5 days until elbow
hyperflexion can be tolerated for closed reduction.
 Definitive treatment of the fracture with 14 days of
traction or until healing has occurred historically
has led to a very low incidence of cubitus varus
deformity
 Dunlop's traction
 Skeletal traction overhead with use of an olecranon
wing nut

34.  Type III supracondylar fractures have
significant incidences of brachial artery
injury, vascular insufficiency, and
compartment syndrome

35.  About 10% to 20% of patients with type III
present with an absent pulse
 emergency management of a patient with a
type III , the arm should be splinted with the
elbow in about 30 degrees of flexion
 Perfusion is estimated by color, warmth, and
capillary refill

36.  The initial approach to managing a patient
with vascular compromise should be
immediate closed reduction and stabilization
with K-wires.
 If an anatomic reduction cannot be obtained
closed, open reduction through an anterior
approach with medial extension allows
evaluation of the brachial artery and removal
of the neurovascular bundle entrapped
within the fracture site or repair of the
brachial artery.

37.  increased pressure in a closed fascial space
causes muscle ischemia.
 With untreated ischemia, muscle edema
increases, further increasing pressure,
decreasing flow, and leading to muscle
necrosis, fibrosis, and death of involved
muscles.

38.  The diagnosis of a compartment syndrome is
based on resistance to passive finger
movement and dramatically increasing pain
after fracture.
 The classic five “P” s for the diagnosis of
compartment syndrome
 Pain
 pallor
 pulselessness
 paresthesias, and
 paralysis

39.  fasciotomy if clinical signs of compartment
syndrome are present or if
intracompartmental pressure is greater than
30 mm Hg
 contribute to the development of
compartment syndrome are direct muscle
trauma at the time of injury, swelling with
intracompartmental fractures (associated
forearm fracture), decreased arterial inflow,
restricted venous outflow, and elbow
position.

40.  AIN appears to be the most commonly
injured , with loss of motor power to the
flexor pollicis longus and the deep flexor to
the index finger
 The direction of the fracture's displacement
determines the nerve most likely to be
injured
 If the distal fragment is displaced
posteromedially, the radial nerve is more
likely to be injured.

41.  if the displacement of the distal fragment is
posterolateral, the neurovascular bundle is
stretched over the proximal fragment, injuring
the median nerve or AIN or both.
 In a flexion type of supracondylar fracture,
which is rare, the ulnar nerve is the most likely
nerve to be injured.
 if the nerve deficit is present and the fracture is
reducible, open reduction of the fracture and
exploration of the injured nerve are not
indicated.
 In most cases, nerve recovery, whether radial,
median, or ulnar, generally occurs at an average
of 2 to 2½ months.

42.  Elbow Stiffness
 Myositis Ossificans
 Nonunion -distal humeral metaphysis is a
well-vascularized area with remarkably rapid
healing, and nonunion is rare
 Avascular Necrosis- trochlea after
supracondylar fracture has been reported

43.  A decrease in frequency of cubitus varus
deformity after the use of percutaneous pin
fixation
 The usual etiology of cubitus varus deformity
is malunion of the distal humeral fragment
rather than growth disturbance

45.  As for the treatment of any posttraumatic
malalignment, options include
 (a) observation with expected remodeling,
 (b) hemiepiphysiodesis and growth alteration
 (c) corrective osteotomy- is the only way to
correct a cubitus varus deformity with a high
probability of success

46.  2% of humeral fractures
 May not be recognized until reduction is
attempted
 Unstable in flexion, whereas extension-type
fractures generally are stable in hyperflexion
 A laterally displaced supracondylar fracture
may actually be a flexion-type injury.

47.  The mechanism of injury is generally
believed to be a fall directly onto the elbow
 The distal fragment is displaced anteriorly
and may migrate proximally in a totally
displaced fracture.
 The ulnar nerve is vulnerable in this fracture
pattern

48. Flexion Type

49.  Mild angular deformity to complete anterior
displacement
 Anterior displacement is often accompanied
by medial or lateral translation
 Fracture classification is the same as for
extension-type supracondylar fractures :
 type I, nondisplaced fracture
 type II, minimally angulated with cortical
contact
 type III, totally unstable displaced distal
fracture fragment

50.  Type I flexion-type supracondylar fractures
are stable nondisplaced fractures that can
simply be protected in a long-arm cast
 If mild angulation, as in a type II fracture,
requires some reduction in extension, the
arm can be immobilized with the elbow fully
extended

51.  A problem with type III flexion supracondylar
fractures is that reduction is not easy to
achieve and when achieved, the elbow is
usually in extension, making it quite difficult
to stabilize the distal fragment using pins.
 Pinning is generally required for unstable
type II and III flexion supracondylar fractures
 Pinning should be performed after closed
reduction with the elbow in mild flexion or
full extension.

52. Flexion Type - Pinning

53.  Open reduction may be required for flexion
type supracondylar fractures.
 Open reduction is best performed through
an anteromedial or posterior approach,
rather than an anterior approach, as is used
for extension-type supracondylar fractures
 Traction is used very rarely for this type of
fracture
 The elbow is generally unstable in increased
flexion, which is a comfortable position for
the patient in traction

54. THANK YOU