This document discusses humeral supracondylar fractures in children. It begins with an introduction and definition. It then covers the epidemiology, relevant anatomy, aetiopathology including classification, management, complications and follow up. Supracondylar fractures are common in children aged 5-8 years from falls. They involve the thin distal humerus above the elbow. Displaced fractures are classified using Gartland's system and treated based on degree of displacement with closed or open reduction and percutaneous pinning. Complications can include neurovascular injury, compartment syndrome and malunion.

1. Aetiopathology and Management of
Humeral Supracondylar fractures in
Children
Dr. Situ Oladele, Orthopedic unit,
NHA

2. Outline
• Introduction and definition
• Epidemiology
• Relevant anatomy (including radiographic anatomy and
elbow rules)
• Aetiopathology
– Pathological anatomy
– Mechanism of injury
– Classification
• Management (History, Exam, investigation, treatment)
• Complications
• Follow-up
• Conclusion and references

3. Introduction and Definition
• Malgaigne’s fracture
• Children are prone to falls, often use upper
extremity to break falls (65-75% of all
fractures in children are in the upper limb)
• Is a fracture through the thin distal humerus,
just proximal to the capitulum usually
involving the olecranon fossa or apex of
coronoid fossa or metaphysis

4. Epidemiology
• commonest injury around the elbow (65.4% of
elbow injuries)
• Age: < 10years (5-8yr)
• Sex: commoner in boys (63.6%)
• Usually fall from height (70%)
• Commoner on the left humerus (58.6%)
• Associated frequent nerve injury (7%)
• Open fracture (2.3%)
• Frequently a displaced fracture (90%)

5. Incidence of elbow injuries and Distal
humeral fractures
Elbow injuries
• Supracondylar
fracture 65.4%
• Condylar fracture 25.3%
• Fracture neck of
radius 4.70%
• Monteggia fracture 2.2%
• Olecranon fractures 1.6%
• T-condylar fracture 0.8%
Distal humeral fractures
• Supracondylar
fracture 69%
• Lateral condyle 16.8%
• Medial condyle 14.1%
• T-condylar 1%

6. Relevant anatomy
• Carrying angle in
children is ≈ 5-25
degree
• Range of motion at full
flexion ≈ 150o
• Tips of medial, lateral
condyles with
olecranon
• Secondary Ossification
centres (CRITOE)

8. Radiographic anatomy

9. Normal X-Ray: Elbow rules

10. Aetiopathology

11. Pathological anatomy
• Supracondylar region is vulnerable to fracture
because:
– Bone remodelling
– Cortex is thin
– Laxity of ligaments permits hyper extension of the
elbow against a taut anterior capsule
– Anterior cortex has a defect in the area of the
coranoid fossa
– Less cylindrical

12. Mechanism of injury
• Fall on an outstretched hand
• Fall on the point of a flexed elbow
• Spiked end of displaced proximal end may
– penetrate brachialis muscle to damage it
– lacerate brachial artery and/or median nerve
• Neurovascular deficit occurring with injury,
manipulation, pinning, or compartment
syndrome

14. Classification
• EXTENSION TYPE (95-98%)
 Gartland’s classification in children:
– Type 1: undisplaced
– Type 2: mild displacement with intact posterior
cortext
• 2A: merely angulated distal fragment
• 2B: fragment is both angulated and malrotated
– Type 3: complete displacement without intact
posterior cortex
• FLEXION TYPE (2-5%)

16. • Displacements
– Posteromedial (75%)
– Posterolateral (25%)
• Open or Closed
• Other structural changes
– Medial rotation of distal segment
– Sideways tilts (angulations)
Disrupted metaphyseal-
diaphyseal angle

17. Management

18. Clinical presentation
• Acute
• Late presentation
• Isolated humeral fracture
• Complicated by neurovascular compromise

19. History and Physical Examination
• History:
– fall, pain, swelling, inability to use elbow.
– Symptoms of neurovascular injury
• Examination:
– “S”-shaped deformity of the arm
– Local swelling ± bruising
– Shortened arm (humerus)
– Tender elbow

20. Physical Exam cont’d
• Dimple sign
• Bony crepitus should not be elicited
• ↓active and passive range of motion
• examination of vascular compromise (elbow
collaterals my keep hand perfused)
• Examination of nerve deficit (children may not
co-operate)
• Rule out compartment syndrome

21. Diagnosis
• Essentially Clinical
• Supportive investigations
– X-ray elbow joint (AP/lateral views):
– Posterior displacement of distal fragment
• Fat pad sign (sail sign)
• Displaced anterior humeral line
• Displaced coronoid line
• Loss of teardrop sign

22. DISPLACED TEAR DROP, FAT PAD,
CORANOID LINE & CRESCENT SIGNS

24. –Coronal tilt of distal segment (varus
deformity)
• Increased Baumann’s angle
• Disrupted Metaphyseal-diaphyseal angle
• Disrupted humero-ulnar angle
• Crescent sign
–Horizontal rotation of distal fragment
• Fish-tail sign

25. FISH TAIL SIGN
BAUMANN’S ANGLE range = 64-81 O
DISPLACED ANTERIOR HUMERAL &
CORONOID LINES

26. Treatment
• Resuscitation using the ATLS protocol in acute
setting
• Adequate analgesia; General anaesthesia
• Neurovascular compromise is an emergency
• Treatment options depends on:
– Nature of fracture (Gartland’s class)
– General condition of the patient
– Presence of neurovascular complication or not

27. Treatment
• Undisplaced Supracondylar fracture
(Gartland type 1):
– POP back slab with elbow in flexion for 3 weeks
• Angulated, malrotated or Displaced
supracondylar fracture:
– Closed reduction
– Open reduction
– Continuous traction

28. Treatment: principles of closed
reduction
• Done under general anaesthesia
• Gentle constant longitudinal traction: elbow at
10o flexion
• Correct sideways tilt next
• Correct rotational deformity next
• Correct antero-posterior tilt/displacement next
• Stabilize and immobilize fracture: hyperflex.
Collar and Cuffs, skeletal stabilization
• Check X-rays

30. Treatment
• Gartland type 2A
– Closed reduction ± percutaneous pinning with
crossed K- wire
• Gartland type 2B and 3
– Closed reduction + percutaneous pinning with
crossed K- wire
NB: rotational twist or tilt must be corrected,
collar and cuff worn for 3 weeks

32. Open reduction
• Indications:
– Failure of closed reduction
– Open supracondylar fracture
– Associated neurovascular compromise
– Comminuted fracture
• Timing : within 5 days of injury
• Complication: ulnar injury

33. Continuous traction
• Indications:
– Failure of manipulation to achieve reduction
– Failure to achieve >100O elbow flexion without
vascular compromise
– Absence of image intensifier to permit
percutaneous pinning
– Severe open injuries, comminuted fractures
– Multiple ipsilateral limb injuries
• Skin(Dunlop) or skeletal (Smith’s) traction

36. Rx of Anteriorly displaced distal
segment
• Closed reduction + POP back slab ± pinning
with K wires
• Sultanpur (two stage casting) technique

37. Complications
• Immediaate:
– Vascular injury (1%
– Nerve injury (7%)
• Early:
– Compartment syndrome
• Late:
– Volkmann’s ischemic contracture
– Joint stiffness
– Malunion: Cubital varus or valgus deformity
– Myositis ossificans
– Non-union

39. Follow up Care
• Check X-ray in 5-7 days
• K-wires are pulled out after 2 weeks
• Finger exercises only for first 3 weeks
• Supervised forearm and arm exercises for the
second 3 weeks
• Osteotomies for correction of gunstock
deformity

40. Conclusion
• Supracondylar fractures in children is only
second to distal forearm fractures in
frequency
• Characteristic pathological anatomy and
potential for serious functional and esthetic
complications
• Early identification and restoration of
clinicoradiological abnormalities is vital.

41. Thank you

42. References
• Apley’s systems in Orthopedics and fractures
by Louis Solomon, David Warwick, Selvadurai
Nayagam; Hodder Arnold Publications9th
edition
• Textbook of orthopedics by John Ebenezar,
Jaypee Brothers, 3rd edition
• Principles and practice of Surgery (Including
Surgery in the Tropics) by Badoe, Achampong,

43. Acknowledgement
• Supracondylar fractures of humerus by Dr.
Hardik Pawar, care hospital (slide share)