3. As the fact Remains….
Upper-extremity fracturesaccount for 65% to 75% of
all fractures inchildren
7% to 9% of upper-extremity fractures involvethe
elbow.
Thedistal humerusaccounts forapproximately 86% of
fractures above the elbowregion
Supracondylarfractures are the most frequentelbow
injuries in children, reported tooccur in 55% to 75%
4. Elbow injuriesare much morecommon in children and
adolescents than in adults.
The peak age for fracturesof thedistal humerus is
between 5 and 10 yearsold.
7. Blood Supply
The major arterial trunk, the brachial artery, lies
anteriorly in the antecubital fossa. Most of the
intraosseous blood supplyof thedistal humeruscomes
from the anastomoticvessels thatcourse posteriorly.
11. Intra-Articular Structures
The articular surface lies within the confines of the capsule,
but non articulating areas involving the coronoid and radial
fossae anteriorly and the olecranon fossa posteriorly are also
within theconfinesof thearticularcavity.
The capsule attaches just distal to the coronoid and
olecranon processes. Thus, these processes are intra-
articular.Theentire radial head is intra-articular, with a
recess or diverticulum of the elbow's articular cavity
extending distally under the margin of the orbicular
ligament. The medial and lateral epicondyles areextra-
articular.
13. EXTENSION TYPE: Mechanism
Fall onto theoutstretched hand with theelbow in full
extension.
The olecranon in its fossa in thedistal humerusacts as a
fulcrum, whereas the capsule transmits an extension
force to thedistal humerus justproximal to the physisas
the elbowhyperextends.
14.
15. Posteromedial versus Posterolateral
Displacement
Medial displcement is more common-75%
Medial displacement of the
distal fragment places the
radial nerve atrisk,
lateral displacementof thedistal fragment places the
median nerve and brachial artery atrisk
16. The position of the hand and forearm at the time of
injury playsa role in thedirectionof thedistal humeral
fragment'sdisplacement.
In a patientwho fallsontoan outstretched supinated
arm, the forces applied tend to disrupt the
posteromedial periosteum first and displace the
fragmentposterolaterally.
If a patient falls with the arm pronated, the distal
fragment tends to become displacedposteromedially.
17. Role of the Periosteum
Supracondylar fracture displaces posteriorly, the
anterior periosteum failsand tears away from the
displaced distal fragment.
The anterior lossof periosteal integrity leads to frequent
failure of anterior callus formation in early fracture
healing
18. Intact medial or lateral periosteum, the periosteal
hinge, has been said toprovidestabilityafter fracture
reduction .
Forearm pronation after reduction of a
posteromedially displaced supracondylar fracture is
said tostabilize reduction byclosing the fracturegap
laterally, tensioning the medial periosteal hinge, and
tightening the lateral ligaments of theelbow.
19. Forearm pronation
after reduction of a
posteromedially
displaced supracondylar
fracture is said to
stabilize reduction by
closing the fracture gap
laterally, tensioning the
medial periosteal hinge,
and tightening the
lateral ligaments of the
elbow.
20. Supination of the forearm
creates a downward lateral
tilt of the distal fragment.
This producescompressive
forces between the
articulating surface of the
ulna and the trochlea's
medial border , which in
turn, generates clockwise
forces about the medial
side of thefracture.
21. Why is it Important to know the
Direction of Displacement????
22. Because it determines which soft tissue
structures are at risk from the penetrating
injury of the proximal metaphyseal fragment.
26. Anteroposterior Landmarks
Baumann Angle
“shaft-physeal” angle
physeal line and the
long axis of thehumerus
Baumann angle is agood
measurementof anydeviation
of theangulation of the
distal humerus
Normal :72 degrees
(range 64 to 81degrees)
29. Lateral Landmarks
he
Teardrop
Posterior margin of the
coronoid fossa
anterior margin of the
olecranon fossa
Superiorborderof ossification centerof t
capitellum
Shaft-CondylarAngle
angulation of 40 degreesbetween
the long axis of the humerus and
the long axis of the lateralcondyle
30. Anterior Humeral Line
anterior border of the distal
humeral shaft, it should pass
through the middle third of the
ossification center of thecapitellum
Coronoid Line
anterior border of the coronoid
process should barely touch the
Anterior portion of the lateralcondyle
34. Fat Pad Signs
Anterior fat pad:coronoid
Triangular lucency
Theanteriorfat pad extendsanteriorlyoutof the margins of the
coronoid fossa
Coronoid fossa is shallow- sensitive, but notspecific
35.
36. Posterior fat pad :olecranon
Deep
Moderate to large effusionsneeded
to displace it
High specificity for intra
articular disorder( # present in
70%)
44. The brachial artery is
placed further at risk
by the ulnar-sided
tether of the
supratrochlear artery
45. Gartland (1959)
Type 1 non-displaced
Type 2 Angulated/displaced fracture withintact
posteriorcortex
Type 3 Complete displacement, with nocontact
between fragments
50. Type 2: Angulated/displaced
fracture with intact posterior
cortex
In many cases, the type2
fractures will beimpacted
medially, leading tovarus
angulation.
The varus malposition
must be considered when
reducing these fractures,
applying a valgus force for
realignment.
52. Type 4
Described by Leitch etal.
Type IV fractures are unstable in both flexion and
extension because of complete loss of a periosteal
hinge.
These fracturesoccureitheras resultof traumaor by
excessive flexion force applied during the closed
reduction maneuver.
53. Signs and Symptoms.
Elbow pain ora child who fails to use the upper
extremity after afall.
Point tenderness over the medial and lateralcolumns
Type I supracondylar fracture, there is distal humeral
tenderness and restriction of motion, particularly lack
of full extension
In type III fractures, gross displacement(deformity) of
the elbow isevident
54. Signs and Symptoms.
An anteriorpuckersign may be present if the
proximal fragment has penetrated the brachialisand
the anterior fascia of theelbow
57. A high index of suspicion is needed torecognize
signs of a developing forearm compartment
syndrome, such as considerable swelling or
ecchymosis, anterior skin puckering, and an
absent pulse
59. Initial Management
For fractures with displacement that require
reduction, initial splinting with the elbow in
approximately 20 to 40 degrees of flexionprovides
comfort and allows furtherevaluation.
Avoid Tight bandaging orsplinting ,excessiveflexion
or extension, which may compromise the vascularity
of the limb and increase compartmentpressure.
The arm should then be gentlyelevated
60. Closed Reduction and Pin Fixation
most common operativetreatment
patient under general anesthesia, the fracture isfirst
reduced in the frontal plane with fluoroscopic
verification.
The elbow is then flexed whilethe
olecranon is pushedanteriorly
to correct the sagittal deformity and
reduce the fracture
61. Criteria for closed reductionare
easyreduction,
stable fracture,
minimal swelling
no vascularcompromise
62. Criteria for an acceptable reduction
1. Restoration of the Baumann angle (which isgenerally
>10) on the anteroposterior radiograph (with in4
degrees of normal side) ,
2. intact medial and lateral columns as seen on the
oblique radiographs, and
3. the anterior humeral line passing through themiddle
third of the capitellum on the lateralradiograph.
63.
64. Milking maneuver
This maneuver is carried out by manipulating the soft
tissueoverthe fracture topull the soft tissueaway from
the proximal fragment rather than simply applying
traction on the bones, which may not allow reduction
of a buttonholed proximal fragment.
Described by Archibeck andPeters
65. If it the proximal fragment appears to have piercedthe
brachialis muscle, the “milking maneuver” isused
66. Milking Maneuver
Milk Soft Tissues over Proximal Spike
Archibeck. Brachialis muscle entrapment in displaced supracondylar humerus fractures: a technique of closed reduction
and report of initial results. J Pediatr Orthop.1997;17:298.
67. Next, varus and valgus angularalignment is
corrected by movement of theforearm.
Medial and lateral fracture translation is
corrected with direct movement of the distal
fragment by the surgeon's thumb(s) withimage
confirmation.
Theelbow is then slowly flexed while anterior
pressure is applied to the olecranon with the
surgeon's thumb
69. After successful 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
70. Check for intact medial and lateral column underc-arm
(obliqueviews)
72. If there is a considerablegap in the fracture siteor the
fracture is irreducible with a so-called rubberyfeeling
on attempted reduction, the median nerve and/or
brachial artery may betrapped
proceed to an openreduction
Once reduction is satisfactory,
the elbow is taped in thereduced
position of elbowhyperflexion
73. Type 1 Fractures
Treated with immobilization for approximately 3weeks,
at 60- 90 degrees of flexion.
If there is significant swelling, do not flex to 90 degrees
until the swellingsubsides.
follow-up radiographs be made at oneand twoweeks to
identify any fracturedisplacement
74.
75. Type 2 Fractures
Reduction of these fractures is usually notdifficult
Maintaining reduction usually requires flexionbeyond
90°
Excessive flexion may not be tolerated becauseof
swelling
May require percutaneous pinning to maintainreduction
Percutaneous pinning is the safest formof
treatment for many of thesefractures
Pins maintain the reduction and allow theelbow to be
immobilized in a more extendedposition
Fitzgibbons. Predictors of failure of nonoperative treatment for type-2 supracondylar humerus fractures. J Pediatr
Orthop. 2011;31:372.
76. Type 3 Fractures
These fractures have a high risk of neurologic
and/or vascularcompromise
Can beassociated with a significant amountof
swelling
Current treatment protocols use percutaneous
pin fixation in almost allcases
In rare cases, open reduction may benecessary
Especially in cases of vascular disruption
77. Indications for Open Reduction
Inadequate reduction
with closed methods
Vascular injury
Open fractures
78. Closed Reduction Percutaneous Pinning
Treatment of choice for mostsupracondylar
fractures.
Open Reduction Usually notNecessary
Done understrict C Arm Control
Variousconfiguartions
Biomechanically Stable
80. 1. Maximal pin separation at the fracturesite.
2. The pins shouldengage both medial and lateral columns
just proximal to the fracturesite.
3. They should engagean adequateamountof bone proximal
and distal to thefragments.
4. On the lateral view, pins should incline slightly in the
anterior to posteriordirection in accordancewith normal
anatomy.
81. If placing a medial pin, extend theelbowwhen placing
the pin to keep the ulnar nerve posterior and out of
harm's way.
82.
83. If any rotational malalignment present carefulin
assessmeny of the stability of the reduction and
probably use a third fixationpin
The fracture reduction is held with twoor three
Kirschnerwires
Elbow is immobilized in 40 to 60 of flexion,
depending on the amount of swelling andthe
vascularstatus.
84.
85. Loss of Fixation…..
. three types of pin-fixationerrors:
(1) Failure toengage both fragmentswith twopins or more
(2) Failure toachieve bicortical fixation with twopins or
more, and
(3) Failure toachieveadequatepin separation (>2 mm) at
the fracturesite.
86.
87. Earlier Closed reduction and pinning oftype
III supracondylarfractureswas performed as an
emergent procedure.
BUT……………….
Is it beneficial??
92. Pink Pulseless Hand
• Injury to the brachial artery can have potentially serious consequences,
such as Volkmann ischemia, loss of limb, and retarded developmentof the
limb.
• Thecommon practice of watchful waiting forpulselessand perfused
supracondylar fractures may be open to question in favor of a more
aggressiveapproach.
• Dopplerultrasound may be useful in differentiating patientsat risk and
can be partof an effectivevascularevaluation.
• Prospectivestudiesare needed toprovide moredefinitive informationon
management of supracondylar humerusfractures.
93. Absent pulseon
Arrival
Closed reduction and Lateralpinning
Palpable Pulse
Pink Pulseless Hand
Return of Pulse
in 48 Hours
Pink hand with
Absent Radial Pulse
Periodic Weekly review for6
weeks
95. 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 orrepair
of the brachial artery.
96. Brachial Artery Exploration
Orthopaedic surgeon + Vascularsurgeon
Releaseof a fascial band oran adventitial tether
resolves the problem of obstructedflow.
The brachial artery should be approached through a
transverse incision across theantecubital fossa, with a
medial extension turning proximallyatabout the level
of the medial epicondyle.
97. If Arterial Spasm is thecause ----Release the spasm
Vascular Graft might beRequired.
99. Neurologic Injury
10% and 20%
theanterior interosseous nerveactuallyappears to be the
most commonlyinjured
paralysisof the long flexors of the thumband index finger
without sensorychanges
Nerve transections are rareand almost exclusively
involve the radial nerve
Closed #- observation
Neural recovery, regardless of which nerve is injured,generally
occurs after two to 2.5 months of observation, but it may take
up to sixmonths
Open #- exploration
100. Compartment Syndrome
0.1% to 0.3%
Skaggs et al. showed that ecchymosis and severe
swelling even in the presence of an intactradial pulse
with good capillary refill should alert the treating
physician to the possibility of a compartment
syndrome
101. Cubitus Varus
Some authors have
proposed that unequal
growth in the distal partof
the humerus as thecause.
This is unlikely as there is
not enough residualgrowth
left in thisarea
The most common reason
for cubitusvarus in patients
with a supracondylar
fracture is therefore
malunion rather than
growtharrest
102. Treatment forcubitus varus has in the past been
considered for cosmetic reasonsonly.
Consequences of cubitusvarus
Increased risk of lateral condyle fractures
Pain
Tardy posterolateral rotatoryinstability
which may be indications for an operative
reconstruction with a supracondylarhumeral
osteotomy
103. FLEXTION TYPE
Rare, only 2%
Distal fracturefragment
anterior and flexed
Ulnar nerve injurymore
common
Reduce withextension
Often requires 2 sets ofhands
in OF
Hold elbowat 90 degreesafter
reduction to facilitatepinning
Mahan. Operative management of displaced flexion supracondylar humerus fractures in children. J Pediatr Orthop.
2007;27:551.
104.
105. Treatment
Reduce withextension
hold elbowat 90 degrees afterreduction to facilitate
pinning
Immobilization for type1
CR+extensioncast
closed reduction and percutaneouspinning
Open reduction -anteromedial orposteriorapproach
