Supracondylar humerus fractures are the most common elbow fractures in children, typically occurring between ages 5-6. They are usually caused by a fall onto an outstretched hand with the elbow extended. Displaced fractures are typically treated with closed reduction and percutaneous pinning, while nondisplaced or minimally displaced fractures can be treated with casting. Complications can include neurovascular injuries, compartment syndrome, loss of reduction, and malunion. Careful examination and management is required to prevent complications.

1. SUPRACONDYLAR HUMERUS
FRACTURES IN CHILDREN
By - Dr Harsh Kotadia
Resident - Orthopaedics
Bharati Vidyapeeth , pune

2. INTRODUCTION
 Supracondylar humerus fracture are the most common elbow fractures
seen in the children and the most common fracture requiring surgery
 The peak age range at which supracondylar humerus fractures occur is
5-6 years

3. MECHANISM OF INJURY
 Supracondylar humerus fractures can be divided grossly
into 2 types: flexion and extension
 Extension type of fractures accounts for 97 – 99 % of total
SCH fracture , usually caused by a fall onto a out stretched
hand with the elbow in full extension
 Flexion type of fractures occurs due to fall directly onto the
elbow ,accounts for about 2 % of SCH fractures
 SCH fractures most frequently results from falling ,
commonly off playground equipment .
 It has been postulated that ligamentous laxity with
resulting elbow hyperextension may present to SCH
fracture

4.  The proximal metaphyseal spike penetrates laterally with
Posteromedially displaced fractures places the radial
nerve at risk
 Posterolaterally displaced fractures , the spike
penetrates medially and places median nerve and
brachial artery at risk

5. ASSESEMENT
 A elbow or forearm fractures should be
suspected in a child with elbow pain or
failure to use the upper extremity after a fall, injury
 The S – shaped configuration is created
by the anterior prominence of the proximal fragment’s spike and extension of the distal
fragment.
 Recent studies shows that increasing anxiety and need for pain medication may be the
earliest warnings of compartment syndrome.
 Paediatric patients with compartment syndroms often presents with the three A’s – anxiety,
agitation, and increasing analgesic requirement

6.  An anterior pucker sign may be present if the
proximal fragment has penetrated brachialis and the
anterior fascia of the elbow
 This is a sign of considerable tissue loss,if any
bleeding from a puncture wound is present ,this
should be treated as open fracture

7.  Careful motor , sensory and vascular examination should be performed in
all the patients , 10-15 % of patients have a nerve injury ,
 with the anterior interosseous nerve being the most frequently injured in
the extension type ,
 the ulnar nerve is most frequently injured in flexion type fractures
Sensory examinations
 Radial nerve – dorsal web space
 Median nerve – palmar index finger tip
 Ulnar nerve – ulnar side of little finger tip
Motor examination
 Radial nerve – finger, wrist , and thumb extension
 AIN – anterior interosseous nerve – index finger DIP flexion , and thumb IP
flexion
 Median nerve – finger flexion strength
 Ulnar nerve - interossei

8.  Vascular examination should include determining the presence of pulse ,
as well as warmth , capillary refill , and color of the hand
 The vascular status may be classified into 3 categories :
 Hand well perfused, radial pulse present
 Hand well perfused, radial pulse absent
 Hand poorly perfused , radial pulse absent
 A vascular injury typically brachial artery , can occur in upto 10-20% of
patient with type 3 fractures

9. Imaging
 If physical examination does not localize the
trauma to the elbow alone this may include
obtaining Anteroposterior and lateral views of
entire upper extremity
 Two main parameters used to evaluate the
presence of supracondylar humerus fracture:
 1. Anterior Humeral Line (AHL)
The AHL should cross the capitellum on a true
lateral of the elbow
(previously it was stated that in a normal elbow ,
the AHL should pass through the middle third of
the capitellum ,

10. however , it has been demonstrated by Herman that
in a normal elbow , the AHL passes through the
middle third of the capitellum only 52 % of the time
in children under 10 years of age , and in children
younger than 4 years of age, the AHL is equally
likely to pass through the anterior third of the
capitellum as the middle third . )
So , it was found that the AHL should pass through
the center of the capitellum in all children 5 years
and older , and if dosen’t ,pathology should be
suspected.
 In an extension type supracondylar fracture , the
capitellum is posterior to this line

11.  2. Baumann’s angle(humero capitellar angle)
 It is the angle between line perpendicular to the long
axis of the humeral shaft and physeal line of lateral
condyle
Normal range – 9-26 degree
 A Baumann’s angle of at least 10 degree is acceptable
 Decrease in baumann’s angle compared to the other
side is a sign that fracture is in varus angulation
(medial comminution)

12. CLASSIFICATION
 MODIFFIED GARTLAND CLASSIFICATION

13.  Type 1 fracture
 It is a non displaced or minimally displaced fracture(less
than 2 mm) , the posterior fat pad sign may be only
evidence of the fracture ,these fractures are stable type
 Type 2 fracture
 It is displaced more than 2 mm with presumably intact ,
hinged posterior cortex
 The AHL line is usually anterior to the capitellum on a
true lateral of elbow ,though in mildly displaced fracture
it may touch the capitellum

14.  Type 3 fracture
 It is a displaced supracondylar fracture with a range of
cortical contact
 There is usually extension in the sagittal plane and
rotation in the frontal and /or transverse plane
 The periosteum is severly torn and the soft tissue and
neurovascular injuries aften accompany this fracture
 Type 4 fracture
 These fracture are characterized by incompetent
periosteal hinge circumferncially and defined by being
unstable in both flexion and extension
 The multidirectional instability is usually determined
under anaesthesia at a time of operation wjen on a
lateral view the capitellum is anterior to the AHL with
elbow flexion , and posterior to the AHL with elbow
flexion

15.  Medial comminution In supracondylar humerus fracture
 Medial collapse signifies malrotation in the frontal plane and is associated with loss of
baumann’s angle and varus malalingnment.
 The lateral view show reasonable alignment
 Which requires reduction and usually pin fixation to prevent late malunion.

16. TREATMENT OPTIONS FOR SUPRACONDYLAR
FRACTURE OF DISTAL HUMERUS
Treatment Type 1 Type 2 Type 3 type 4
Casting without
reduction
Almost always
Closed reduction
and casting
Rarely indicated ,
do not flex elbow >
90 degree
Closed reduction
and pinning
Great majority of
the cases
Great majority of
cases
Most cases
Open reduction and
fixation
Uncommonly
necessary
If closed reduction
inadequate
If closed reduction
inadequate

17. NON OPERATIVE MANAGEMNT
 CLOSED REDUCTION AND CASTING
 Type 1 fracture (undisplaced ) are treated with immobilization and casting
 Simple immobilization at 60 – 90 degree of elbow flexion , with the
forearm in neutral position .
 Mildly displaced fracture can be reduced closed , using the intact posterior
periosteum as a stabilizing force and then holding reduction by flexing the
elbow greater than 120 degree.
 Less flexion increases the risk of loss of reduction.
 Xrays are obtained at 3-7 days after fracture to document lack of
displacement
 The duration of immobilization is about 3 weeks

18. CLOSED REDUCTION AND PINNING
 Treatment of type 2 injuries is somewhat controversial , wilkins subdivided
into 2 parts into A and B
 Type 2A being stable and type 2B fractures having some degree of
rotation or translation making them unstable
 Closed reduction and casting can be used in type 2A inuries
 Closed reduction and percutaneous pinning typically with 2 or 3 lateral
pins has become the main form of treatment for type 2B

19. Closed reduction and pinning
 Three pinning techniques are described :
 Crossed : one medial and one lateral
 Divergent : two divergent lateral pins
 Parallel : two parallel lateral pins
 Two main issues with crossed pin versus lateral entry pinning are risk of
ulnar nerve injury and loss of reduction more in medial pinning

20.  The ideal pin configuration remains controversial ; although crossed
medial and lateral pins are more stable than 2 lateral pins in vitro, use of 2
or three lateral pins appears to be equal to crossed pins in vivo
 main issues with crossed pin versus lateral entry pinning is risk of ulnar
nerve injury more in medial pinning
 Studied reported that 2 or 3 lateral entry pins had comparable construct
stiffness to each other , and both were greater then crossed pins in all
types of stress, except in valgus , in which cross- pins had greater stiffness
 Recent papers suggest that lateral entry pins are being used more
commonly than cross – pins for most supracondylar fractures

21.  The important technical points for fixation with lateral entry pins are as follows :
 Maximum separation of the pins at the fracture site
 Engage the medial and lateral columns proximal to the fracture
 Maintain at least 2 mm separation of pins at fracture sites
 Engage sufficient bone in both the proximal and distal fragment
 Maintain a low threshold for use of a third lateral entry pin if there is a concern about
fracture instability or the location of the first two pins
 Use three pins for type 3 fractures

22. Technique for closed reduction and
pinning in supracondylar humerus
 Position the patient supine and position the elbow on an inverted image
intensifier
 For the most common extension type fracture , with countertraction on the
humerus , apply traction at the forearm and examine the fracture with c-
ARM
 With elbow in extension , correct rotation malalignment and medial and
lateral translation once this is corrected , maintain traction on the elbow
and gently flex the elbow to 120 degree
 Use pressure on the oleceranon as the elbow is flexed to correct extension
of the distal fragment .maximally flex the elbow and pronate the forearm
to lock posterior and medial soft tissue hinges

23.  For the rare flexion type injury , flexing the elbow will
further displace the fragment because of the
disruption of the posterior periosteal hinges .In this
case the elbow need to be pinned in extension this
can be difficult , and posterior open reduction is
needed oftenly .
 If a medial pin is used , make a 1 cm incision over the
medial epicondyle ,spread the soft tissue over the
medial epicondyle so that epicondyle can be seen and
ulnar nerve can be protected
 If the fingers cannot touch the shoulder , flexion
deformity may not be corrected

24. There are three types of pin fixation commonly found
errors :
 1. failure to engage Both fragments with two or
more pins
 2. failure to achieve bicortical fixation with two or
more pins
 3. failure to achieve adequate pin separation (2mm)
at fracture sites

25. COMPLICATION
 Vascular injuries
 Compartment syndrome
 Neurological deficit
 Pin tract infection
 Pin migration
 Myositis ossificans
 Non union
 Avascular necrosis
 Loss of reduction
 Cubitus varus

26. VASCULAR INJURIES
 Preoperative Evaluation And Care:approximately 1% To 15% Of
Patients With Supracondylar Fractures Present With An Absent Pulse But
Only A Minority Of These Patients Will Require Vascular Repair.
 At The Initial Evaluation The Presence Or Absence Of A Pulse And
Perfusion Of The Hand Should Be Determined.
 If There Is Not A Palpable Pulse ,A Doppler May Be Used To Assess. A
Pulse That Can Be Detected On Doppler May Be An Objective Sign Of
Good Perfusion.

27.  Fracture Reduction Should Not Be Delayed By Any Waiting
Time For An Angiographic Study, As Reduction Of The
Fracture Usually Restores The Pulse.
 An Absent Radial Pulse Is Not In Itself An Emergency. In The
Case Of A Pulseless, Perfused Hand, Urgent, But
Nonemergent, Reduction With Pinning In The Operating
Room Is Indicated.

28.  However, in the presence of an associated nerve injury,
there is higher risk of a compartment syndrome and more
close observation until surgery is indicated. If the arm is
pulseless and also has signs of poor perfusion this is an
emergency. When a patient with a severely displaced
supracondylar fracture presents to the emergency room
and has compromised vascularity to the limb, the arm
should be splinted with the elbow in approximately 20 to
40 degrees of flexion to protect further injury as the patient
progresses directly to surgery.

29. Management of patient with vascular
injury

30. Potential pitfalls and preventions
 Nerve /vascular entrapment
 If there is a gap in the fracture site or the
fracture is irreducible with a rubbery feeling
on attempting reduction , the median nerve
and /or brachial artery may be trapped in
the fracture site
 Proximal fragment has pierced the
bracialis
 “Milking maneuver”. The biceps are forcibly
‘milked’ in a proximal to distal direction
past the proximal fragment , often
culminating in a palpable release of the
humerus posteriorly through the brachialis

31. COMPARTMENT SYNDROME
 The prevalence of compartmemt syndrome is about 0.5 – 0.8%
 Classical 5 p’s for the diagnosis of compartment syndrome – pain , pallor,
pulselessness, paraesthesia, and paralysis are poor indicator in children
 Pediatric patients often presents with the three A’s – anxiety, agitation, and
increasing analgesic requirement

32. AVASCULAR NECROSIS
 Avascular necrosis of trochlea have been reported after supracondylar
humerus fracture
 The blood supply of the trochlea’s ossification center is fragile
 Symptoms of avascular necrosis of the trochlea do not occur for months or
years
 Healing is normal, but mild pain and occasional locking develop with
characteristic radiological changes and range of motion may be affected
depending upon the extent
 An important risk factor for AVN is following an open reduction of
fracture through posterior approach

33. Fishtail deformity
presenting at an average
4.7 years after fracture
80% of which had
mechanical symptoms of
locking ,catching and
painful limited range of
motion

34. NEUROLOGIC DEFICIT
 A Meta-analysis Of 3,457 Extension-type SCH Fractures
Found An Overall Neuropraxia Rate Of 13%, With The
Median Nerve (5%) Being The Most Common, Followed By
The Radial Nerve 4%. AIN Palsy Presents As Paralysis Of The
Long Flexors Of The Thumb And Index Finger Without
Sensory Changes.
 Complete Median Nerve Injury Has Also Been Described
With These Fractures Because Of Contusion Or Transection
Of The Nerve At The Level Of The Fracture And Presents
With Sensory Loss In The Median Nerve Distribution As
Well As Motor Loss Of All Muscles Innervated By The
Median Nerve.

35.  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. Conversely, 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.

36.  An Irreducible Fracture With Nerve Deficit Is An Indication
For Open Reduction Of The Fracture To Ensure That There
Is No Nerve Entrapment.
 Chronic Nerve Entrapment In Healed Callus Can Give The
Appearance Of A Hole In The Bone, Metev’s Sign.
 Iatrogenic Injury To The Ulnar Nerve Has Been Reported To
Occur In 1% To 15% Of Patients With Supracondylar
Fractures.
 The Course Of The Ulnar Nerve Through The Cubital
Tunnel, Between The Medial Epicondyle And The
Olecranon, Makes It Vulnerable When A Medial Pin Is
Placed.

37. ELBOW STIFFNESS
 Clinically loss of reduction after extension type supracondylar humerus
fracture is rare in children
 Although most children do not require formal physical therapy ,
 In most patients , treated with closed reduction with pinning elbow ROM
return to 72 % of contralateral elbow by 6 weeks,86 % by 12 weeks, 98 %
by 52 weeks

38.  Significant loss of flexion can be
caused by lack of anatomical fracture
reduction
 1.posterior distal fragment angulation
 2.posterior translation of the distal
fragment with anterior impingement
 3.medial rotation of the distal fragment
with a protruding medial metaphyseal
spike proximally

39. PIN TRACT INFECTIONS
 The reported prevalence is less than 1-2.5%
 Pin tract infection generally resolves with pin removal and antibiotics
 However , an untreated patient can result in septic joint and osteomyelitis ,
and thus be treated as soon as diagnosed or suspected

40. PIN MIGRATION
 It is most common complication in SCH fractures
 This complication can be minimized by both bending at least 1 cm of the
pin at a 90 degree angle , at least 1 cm from the skin , and protecting the
skin with thick felt over the pin ort using pin covers

41. MYOSISTIS OSSIFICANS
 It is remarkably rare complication , but it can
occur
 This complication have been described after
closed and open reductions due to disruption
of the brachialis with injury , but vigorous post-
operative manipulation or physical therapy

42. NON UNION
 The distal humeral metaphysis is a well – vascularized area with markedly
rapid healing , and nonunion of a supracondylar fracture is very rare

43. CUBITUS VARUS
 Cubitus varus also known as ‘Gunstock Deformity’
 The malunion also includes hyperextension which
leads to increased elbow extension and decreased
elbow flexion
 On AP view , the angle of the physis of the lateral
condyle (baumann’s angle ) is more horizontal than is
normal
 On Lateral view , hyperextension of the distal
fragment posterior to the AHL goes along with the
clinical findings of increased extension and decreased
flexion of the elbow

44.  The most common reason for cubitus varus in patient with supracondylar
fractures is likely malunion rather than growth arrest
 Cubitus varus can be prevented by making certain Baumann’s angle is
intact at the time of reduction and remains so during healing by achieving
stable reduction and remains so during healing by achieving stable fixation
 Avascular necrosis of the trochlea or medial portion of the distal humeral
fragment can result in progressive varus deformity

46. TREATMENT
 For treatment of any posttraumatic malalignments , options include
1. Observation with expected remodeling
2. Hemi epiphysiodesis
3. Corrective osteotomy

47. 1. Observation with expected remodeling
 Observation is generally not successful in achieving
anatomical alignment as hyperextension may
remodel to some degree in a young child , but in
older children , insufficient remodeling occurs even in
joint’s plane of motion

48. 2. Osteotomy
 Osteotomy is the only way to correct a cubitus
varus deformity with high probablity of success
.
 It was found that when lateral entry pins were
used to fix the osteotomy , there were
significantly less complications
1. Medial open wedge osteotomy
2. Lateral closing wedge osteotomy
3. Dome osteotomy
4. Arch osteotomy

49. THANK YOU