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SUPRACONDYLAR
 FRACTURES OF
   HUMERUS
   DR.P.N.PRASAD
Distal Humerus Anatomy
   Medial epicondyle
    proximal to trochlea –

   Lateral epicondyle
    proximal to capitellum
    –

   Radial fossa –
    accommodates margin of
    radial head during flexion

   Coronoid fossa –
    accepts coronoid process of
    ulna during flexion
Supracondylar Fractures of Humerus
   It is # which involves the lower end of the humerus usually
    involving the thin portion of the humerus through
                      Olecranon fossa        or
                      Just above the fossa or
                      Metaphysis
   Most common elbow injuries in children.

   Makes up approximately 60% of elbow injuries.

   Becomes uncommon as the age increases.
General considerations
   Incidence of supracondylar #:
        a) Age               : peak age         : 5-7 yrs
                                 Average age : 6.7 yrs
        b) Sex               : Boys > Girls (Earlier)
                                 Boys = Girls (Latest Trends)
        c) Side              : Left > Right
                                 ( Non dominant > dominant )
        d) Nerve injuries : 7% - Median> Radial > Ulnar
        e) Vascular injuries : 1%
        f) Open injuries      : < 1%
g) Cause of #
       Fall from height 70% ----- children > 3 yrs
       Fall from bed              children < 3 yrs
       Non accidental injury ( Child abuse) children < 15 months


h) Associated #s
         Distal radius > Scaphoid > Proximal humerus >
                                                    Monteggia
i) Clinical types
         Extension type: 98%
         Flexion type : 2%
Mechanism of injury
   For Extension type of
    SC # humerus

Fall on outstretched hand

Elbow hyper extended

Fore arm – pronated or
               supinated
Mechanism of injury

   For Flexion type
    of SC # humerus

Fall directly on the
  elbow rather than
  out stretched hand
Radiographic anatomy of distal
                  Humerus

   What are the radiographic views:
      Antero posterior
      Lateral
      Oblique
      Axial ( jones view )
   What to look for in

       AP View----- Baumann`s angle
                   Humero ulnar angle
                   Metaphysio diaphyseal angle
Radiographic Anatomy

          Baumann’s angle is formed by a line
           perpendicular to the axis of the humerus, and a
           line that goes through the superior part of
           physis of the capitellum.

          There is a wide range of normal for this value,
           and it can vary with rotation of the radiograph.

          The Baumann angle is good measurement of
           any deviation of distal humerus`s angulation

          In this case, the medial impaction and varus
           position alters the Bauman’s angle.
Radiograph Anatomy/Landmarks
   Anterior Humeral
    Line:
     This is drawn along
    the anterior humeral
    cortex.
     It should pass
    through the junction
    of anterior &
    middle 3rd of the
    capitellum.
Radiograph Anatomy/Landmarks
   The capitellum is
    angulated anteriorly
    about 30 degrees.

   The appearance of the
    distal humerus is similar
    to a hockey stick.



                                30
Radiograph Anatomy/Landmarks

   The physis of the
    capitellum is usually
    wider posteriorly,
    compared to the
    anterior portion of
    the physis


                            Wider
Anatomical classification of SC #
Radiographic Classification of SC #s
   Based on X- Ray appreance # displacement Gartland
    described 3 types:

   Type – I       : Undisplaced

   Type – II      : Displaced (posterior cortex intact)

   Type –III      : Displaced ( no cortical contact)
                           Posteromedial
                           Posterolateral
Type 1: Non-displaced

   Note the non-
    displaced fracture
    (Red Arrow)

   Note the posterior fat
    pad (Yellow Arrows)
Type 2: Angulated/Displaced Fracture
     with Intact Posterior Cortex
Type 3: Complete Displacement, with
  No Contact between Fragments
Clinical signs & Symptoms
   In most cases, children will not move the elbow if a fracture is present,
    although this may not be the case for non-displaced fractures.

   Swelling about elbow is a constant feature, develop within first few hrs.

   S shaped deformity

   Distal humeral tenderness

   Anterior plucker sign +ve
S-shaped configuration of UL
Physical Examination
   Neurologic exam is essential, as nerve injuries are common. In most
    cases, full recovery can be expected

   Neuro-motor exam may be limited by the childs ability to
    cooperate because of age, pain, or fear.

   Thumb extension– EPL (radial – PIN branch)

   Thumb flexion – FPL (median – AIN branch)

   Cross fingers - Adductors (ulnar)
Physical Examination
   Nerve injury incidence is high, between 7 and 16 %
    (median, radial and ulnar nerve)

   Anterior interosseous nerve is most commonly injured nerve

   In many cases, assessment of nerve integrity is limited , because children
    can not always cooperate with the exam

   Carefully document pre manipulation exam, as post manipulation
    neurologic deficits can alter decision making
Physical Examination
   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
Physical Examination

   Thorough documentation of all findings is important. A
    simple record of “neurovascular status is intact” is
    unacceptable.

   Individual assessment and recording of motor, sensory, and
    vascular function is essential

   Always palpate the arm and forearm for signs of compartment
    syndrome.
Treatment
   General principles:
       Splinting elbow in comfortable position
      20-30degrees of flexion of elbow, pending
      Careful physical examination & X-ray evaluation.
      Tight bandaging/ excessive flexion or excessive
                            extension should be avoided
      Associated life threatening complications ( if any)
                                    to be attended first.
Treatment of type – I #
   Simple posterior long arm splint for 3-7days.

   Elbow 60-90o flexion & Forearm neutral position.

   Check X-ray after 3-7 days to document any displacement
    or lack of it.

   Splint converted to long arm cast if no displacement.

   If displacement noticed # reduction done & cast applied or
    pinning done.
D) supracondylar fracture
   Duration of immobilisation 3-4wks.

   No need for any physiotheraphy ( Generally )

   Outcome: Predictablly excellent if alignment is
    maintained during early healing.

    Hence type – I #s requires careful
                                   treatment &
    follow up.
Treatment of type – II #
   Good stability obtained after closed reduction.

   Once satisfactory reduction achieved further management is
    same as type – I.

   If medial column collapse present then skeletal stabilisation
    with 2 lateral pins is advocated.

   Recent trends led to SELECTIVE PINNING for type – II #s
SELECTIVE PINNING
     Closed reduction is done
     Splinting in flexion
     Non movable cuff & collar sling
     Early careful X-ray follow up
If # displacement /angulation noticed
                          pin stabilisation is done .
Treatment of type – III #
   Treatment involves management of skeletal
    injuries & associated soft tissue injuries (if any).

   Treatment of skeletal injury:
       Reduction either closed or open
       Stabilisation either with pins or cast
Technique of reduction (closed)
   Traction – to restore length & alignment.
   Milking maneuver -- if length & alignment
                                       not restored by traction
   Correction of medial/ lateral displacements.
   Correction of rotational deformities.
   Correction of posterior displacement by --
                                   flexion reduction maneuver
   Elbow held in hyper flexion.
   Fore arm held in pronation – if distal fragment is
                                      postero medially displaced,
   Fore arm held in supination -- if distal fragment is
                                        postero laterally displaced.
D) supracondylar fracture
Indications for open reduction
   Open reduction is indicated to obtain alignment if
    closed reduction is unsuccessful as with the following,
   Button holing of the proximal fragment through
                      the anterior soft tissues ,

   Interposition of the biceps ,

   Interposition of the neurovascular structures .

    An open reduction is also indicated if there is an open
    fracture ,that requires irrigation and debridement .
   ANATOMIC OR NEAR ANATOMIC
    REDUCTION IS A PREREQUISITE FOR
      SKELETAL STABILISATION
Skeletal stabilization after reduction
   Skeletal stabilization after reduction is done either
    with pins or cast

   Now a days skeletal stabilization by casing is not done
    as reduction maintenance is not achieved .

   Generally skeletal stabilization is achieved by means of
    passing pins across the fracture site .
Pin Fixation
   Many children have anterior subluxation of the ulnar nerve
    with hyperflexion of the elbow .

   The medial pin can injury the ulnar nerve.

   Some advocate 2 lateral pins to avoid injuring the median
    nerve.

   Some advocate usage of a small incission of size 1.5 cm
    over the medial epicondyle and dissection is performed up
    to the level of the medial epicondyle and the ulnar nerve
    identified and protected and the medial pin applied
    Medial pin placement :
    this pin is placed directly through
     the medial epicondyle , using the
     opposite thumb to pull the soft
     tissues posteriorly, thus
     protecting the ULNAR
     NERVE .

    The pin is directed from
     posteromedial to anterolateral
    (10o posterior & 40o with shaft)
     under c arm imaging with the
     upper extremity fully
     EXTERNALLLY ROTATED
   If 2 lateral pins are used, they should be widely spaced at the
    fracture site.

   If the lateral pins are placed close together at the fracture site,
    the pins may not provide much resistance to rotation and
    further displacement.

   BIOMECHANICAL STUDIES HAVE PROVED :
    DIVERGENT PIN CONFIGURATION IS FAR
    SUPERIOR CONSTRUCT WHEN COMPARED TO
    THE PARALLEL PIN CONFIGURATION.
   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.

   Pins can easily be removed
     3 - 4 weeks later.

   If adequate callus formation is
    present, gentle range of motion
    exercises are initiated.

   In most cases, full recovery of
    motion can be expected.
Lateral Pin Placement
   AP and Lateral views with 2 pins
OR Setup
   The monitor
    should be
    positioned across
    from the OR table,

to allow easy
  visualization of the
  monitor during the
  reduction and
  pinning
   The C-Arm
    fluoroscopy unit can be
    inverted, using the base
    as a table for the elbow
    joint.

   The child should be
    positioned close to the
    edge of the table, to
    allow the elbow to be
    visualized by the c-arm.
   Mobilize the image
    intensifier but not
    elbow
Complications
   Immediate :
              a) neurological
              b) vascular
   Early :
             a) compartment syndrome
             b) volkmann`s ischemia
   Late :
            a) mal union : cubitus varus / cubitus valgus
            b) volkmann`s ischemic contracture
            c) myositis ossificans
            d) elbow stiffness

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D) supracondylar fracture

  • 1. SUPRACONDYLAR FRACTURES OF HUMERUS DR.P.N.PRASAD
  • 2. Distal Humerus Anatomy  Medial epicondyle proximal to trochlea –  Lateral epicondyle proximal to capitellum –  Radial fossa – accommodates margin of radial head during flexion  Coronoid fossa – accepts coronoid process of ulna during flexion
  • 3. Supracondylar Fractures of Humerus  It is # which involves the lower end of the humerus usually involving the thin portion of the humerus through Olecranon fossa or Just above the fossa or Metaphysis  Most common elbow injuries in children.  Makes up approximately 60% of elbow injuries.  Becomes uncommon as the age increases.
  • 4. General considerations  Incidence of supracondylar #: a) Age : peak age : 5-7 yrs Average age : 6.7 yrs b) Sex : Boys > Girls (Earlier) Boys = Girls (Latest Trends) c) Side : Left > Right ( Non dominant > dominant ) d) Nerve injuries : 7% - Median> Radial > Ulnar e) Vascular injuries : 1% f) Open injuries : < 1%
  • 5. g) Cause of # Fall from height 70% ----- children > 3 yrs Fall from bed children < 3 yrs Non accidental injury ( Child abuse) children < 15 months h) Associated #s Distal radius > Scaphoid > Proximal humerus > Monteggia i) Clinical types Extension type: 98% Flexion type : 2%
  • 6. Mechanism of injury  For Extension type of SC # humerus Fall on outstretched hand Elbow hyper extended Fore arm – pronated or supinated
  • 7. Mechanism of injury  For Flexion type of SC # humerus Fall directly on the elbow rather than out stretched hand
  • 8. Radiographic anatomy of distal Humerus  What are the radiographic views: Antero posterior Lateral Oblique Axial ( jones view )
  • 9. What to look for in AP View----- Baumann`s angle Humero ulnar angle Metaphysio diaphyseal angle
  • 10. Radiographic Anatomy  Baumann’s angle is formed by a line perpendicular to the axis of the humerus, and a line that goes through the superior part of physis of the capitellum.  There is a wide range of normal for this value, and it can vary with rotation of the radiograph.  The Baumann angle is good measurement of any deviation of distal humerus`s angulation  In this case, the medial impaction and varus position alters the Bauman’s angle.
  • 11. Radiograph Anatomy/Landmarks  Anterior Humeral Line: This is drawn along the anterior humeral cortex. It should pass through the junction of anterior & middle 3rd of the capitellum.
  • 12. Radiograph Anatomy/Landmarks  The capitellum is angulated anteriorly about 30 degrees.  The appearance of the distal humerus is similar to a hockey stick. 30
  • 13. Radiograph Anatomy/Landmarks  The physis of the capitellum is usually wider posteriorly, compared to the anterior portion of the physis Wider
  • 15. Radiographic Classification of SC #s  Based on X- Ray appreance # displacement Gartland described 3 types:  Type – I : Undisplaced  Type – II : Displaced (posterior cortex intact)  Type –III : Displaced ( no cortical contact) Posteromedial Posterolateral
  • 16. Type 1: Non-displaced  Note the non- displaced fracture (Red Arrow)  Note the posterior fat pad (Yellow Arrows)
  • 17. Type 2: Angulated/Displaced Fracture with Intact Posterior Cortex
  • 18. Type 3: Complete Displacement, with No Contact between Fragments
  • 19. Clinical signs & Symptoms  In most cases, children will not move the elbow if a fracture is present, although this may not be the case for non-displaced fractures.  Swelling about elbow is a constant feature, develop within first few hrs.  S shaped deformity  Distal humeral tenderness  Anterior plucker sign +ve
  • 21. Physical Examination  Neurologic exam is essential, as nerve injuries are common. In most cases, full recovery can be expected  Neuro-motor exam may be limited by the childs ability to cooperate because of age, pain, or fear.  Thumb extension– EPL (radial – PIN branch)  Thumb flexion – FPL (median – AIN branch)  Cross fingers - Adductors (ulnar)
  • 22. Physical Examination  Nerve injury incidence is high, between 7 and 16 % (median, radial and ulnar nerve)  Anterior interosseous nerve is most commonly injured nerve  In many cases, assessment of nerve integrity is limited , because children can not always cooperate with the exam  Carefully document pre manipulation exam, as post manipulation neurologic deficits can alter decision making
  • 23. Physical Examination  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
  • 24. Physical Examination  Thorough documentation of all findings is important. A simple record of “neurovascular status is intact” is unacceptable.  Individual assessment and recording of motor, sensory, and vascular function is essential  Always palpate the arm and forearm for signs of compartment syndrome.
  • 25. Treatment  General principles: Splinting elbow in comfortable position 20-30degrees of flexion of elbow, pending Careful physical examination & X-ray evaluation. Tight bandaging/ excessive flexion or excessive extension should be avoided Associated life threatening complications ( if any) to be attended first.
  • 26. Treatment of type – I #  Simple posterior long arm splint for 3-7days.  Elbow 60-90o flexion & Forearm neutral position.  Check X-ray after 3-7 days to document any displacement or lack of it.  Splint converted to long arm cast if no displacement.  If displacement noticed # reduction done & cast applied or pinning done.
  • 28. Duration of immobilisation 3-4wks.  No need for any physiotheraphy ( Generally )  Outcome: Predictablly excellent if alignment is maintained during early healing. Hence type – I #s requires careful treatment & follow up.
  • 29. Treatment of type – II #  Good stability obtained after closed reduction.  Once satisfactory reduction achieved further management is same as type – I.  If medial column collapse present then skeletal stabilisation with 2 lateral pins is advocated.  Recent trends led to SELECTIVE PINNING for type – II #s
  • 30. SELECTIVE PINNING Closed reduction is done Splinting in flexion Non movable cuff & collar sling Early careful X-ray follow up If # displacement /angulation noticed pin stabilisation is done .
  • 31. Treatment of type – III #  Treatment involves management of skeletal injuries & associated soft tissue injuries (if any).  Treatment of skeletal injury: Reduction either closed or open Stabilisation either with pins or cast
  • 32. Technique of reduction (closed)  Traction – to restore length & alignment.  Milking maneuver -- if length & alignment not restored by traction  Correction of medial/ lateral displacements.  Correction of rotational deformities.  Correction of posterior displacement by -- flexion reduction maneuver  Elbow held in hyper flexion.  Fore arm held in pronation – if distal fragment is postero medially displaced,  Fore arm held in supination -- if distal fragment is postero laterally displaced.
  • 34. Indications for open reduction  Open reduction is indicated to obtain alignment if closed reduction is unsuccessful as with the following,  Button holing of the proximal fragment through the anterior soft tissues ,  Interposition of the biceps ,  Interposition of the neurovascular structures . An open reduction is also indicated if there is an open fracture ,that requires irrigation and debridement .
  • 35. ANATOMIC OR NEAR ANATOMIC REDUCTION IS A PREREQUISITE FOR SKELETAL STABILISATION
  • 36. Skeletal stabilization after reduction  Skeletal stabilization after reduction is done either with pins or cast  Now a days skeletal stabilization by casing is not done as reduction maintenance is not achieved .  Generally skeletal stabilization is achieved by means of passing pins across the fracture site .
  • 37. Pin Fixation  Many children have anterior subluxation of the ulnar nerve with hyperflexion of the elbow .  The medial pin can injury the ulnar nerve.  Some advocate 2 lateral pins to avoid injuring the median nerve.  Some advocate usage of a small incission of size 1.5 cm over the medial epicondyle and dissection is performed up to the level of the medial epicondyle and the ulnar nerve identified and protected and the medial pin applied
  • 38. Medial pin placement : this pin is placed directly through the medial epicondyle , using the opposite thumb to pull the soft tissues posteriorly, thus protecting the ULNAR NERVE .  The pin is directed from posteromedial to anterolateral (10o posterior & 40o with shaft) under c arm imaging with the upper extremity fully EXTERNALLLY ROTATED
  • 39. If 2 lateral pins are used, they should be widely spaced at the fracture site.  If the lateral pins are placed close together at the fracture site, the pins may not provide much resistance to rotation and further displacement.  BIOMECHANICAL STUDIES HAVE PROVED : DIVERGENT PIN CONFIGURATION IS FAR SUPERIOR CONSTRUCT WHEN COMPARED TO THE PARALLEL PIN CONFIGURATION.
  • 40. 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.  Pins can easily be removed 3 - 4 weeks later.  If adequate callus formation is present, gentle range of motion exercises are initiated.  In most cases, full recovery of motion can be expected.
  • 41. Lateral Pin Placement  AP and Lateral views with 2 pins
  • 42. OR Setup  The monitor should be positioned across from the OR table, to allow easy visualization of the monitor during the reduction and pinning
  • 43. The C-Arm fluoroscopy unit can be inverted, using the base as a table for the elbow joint.  The child should be positioned close to the edge of the table, to allow the elbow to be visualized by the c-arm.  Mobilize the image intensifier but not elbow
  • 44. Complications  Immediate : a) neurological b) vascular  Early : a) compartment syndrome b) volkmann`s ischemia  Late : a) mal union : cubitus varus / cubitus valgus b) volkmann`s ischemic contracture c) myositis ossificans d) elbow stiffness