Supracondylar Fracture - Pediatric
Authors: Ujash Sheth, Ben Taylor
Topic updated on 02/19/15 12:26pm
Introduction
Epidemiology
incidence
consists of more than
half of all pediatric
elbow fractures
extension type most
common (95-98%)
o demographics
occur most commonly in children aged 5 to 7
M=F
Pathophysiology
o mechanism of injury
fall on outstretched hand
Associated injuries
o neuropraxia
anterior interosseous nerve neurapraxia (branch of median
n.)
the most common nerve palsy seen with
supracondylar humerus fractures
radial nerve palsy
second most common neurapraxia (close second)
ulnar nerve palsy
seen with flexion-type injury patterns
nearly all cases of neurapraxia following supracondylar
humerus fractures resolve spontaneously, and therefore,
further diagnostic studies are not indicated in the acute
setting
o vascular injury (1%)
rich collateral circulation can maintain circulation despite
vascular injury
o ipsilateral distal radius fractures
Anatomy
Ossification centers of elbow
o age of ossification/appearance and age of fusion are two independent
events that must be differentiated
e.g., internal (medial epicondyle) apophysis
ossifies/appears at age 6 years (table below)
fuses at age ~ 17 years (is the last to fuse)
Ossification center
Years at ossification
(appear on xray) (1)
Years at fusion (appear on
xray) (1)
Capitellum
12
Radius
15
Medial epicondyle
17
Trochlea
12
Olecranon
10
15
Lateral epicondyle
12
12
(1) +/- one year, varies between boys and girl
Classification
Gartland Classificaiton
(may be extension or flexion type)
Type I
Nondisplaced, beware of subtle medial comminution leading
to cubitus varus
Type II
Displaced, posterior cortex intact
Type III
Completely displaced
Type IV*
Complete periosteal disruption with instability in flexion and
extension
*not apart of original Gartland classification
Presentation
Symptoms
o pain
o refusal to move the elbow
Physical exam
o inspection
gross deformity
swelling
bruising
o motion
limited active elbow motion
o neurovascular
nerve exam
AIN neurapraxia
unable to flex the interphalangeal joint of his thumb
and the distal interphalangeal joint of his index
finger (can't make A-OK sign)
radial nerve neurapraxia
inability to extend wrist or digits may be present due
to radial nerve injury neurapraxia
vascular exam
vascular insufficiency at presentation is present in 5 -17%
defined as cold, pale, and pulseless hand
a warm, pink, pulseless hand does not qualify
as vascular insufficiency
treat with immediate reduction and pinning in OR.
Attempted closed reduction in ER first (see treatment
below)
Imaging
Radiographs
o recommended views
AP and lateral x-ray of the elbow
o findings
posterior fat pad sign
lucency along the posterior distal humerus and olecranon fossa is
highly suggestive of occult fracture around the elbow
o measurement
displacement of the anterior humeral line
anterior humeral line should intersect the middle third of the
capitellum
capitellum moves posteriorly to this reference line in extension
type fracture
alteration of Baumann angle
Baumann's angle is created by drawing a line parallel to the
longitudinal axis of the humeral shaft and a line along the lateral
condylar physis as viewed on the AP image
normal is 70-75 degrees, but best judge is a comparison of the
contralateral side
deviation of more than 5 degrees indicates coronal plane deformity
and should not be accepted
Treatment
Nonoperative
o long arm posterior splint then long arm casting with less
than 90 of elbow flexion
indications
Type I (non-displaced) fractures
Type II fractures that meet the following criteria
anterior humeral line intersects the anterior half
of capitellum
minimal swelling present
no medial comminution
technique
typically used for 3-4 weeks and maybe followed for
additional time in removable long arm posterior splint
Operative
o closed reduction and percutanous pinning
indications
in type II and III supracondylar fractures
o open reduction with percutaneous pinning
indications
adequate reduction cannot be obtained closed
more frequently required with flexion type fractures
technique
a variety of approaches are acceptable, including the
anterior, medial or lateral
o immediate closed reduction and percutanous pinning
indications
vascular compromise is present (e.g, pale, cool hand)
"floating elbow"
ipsilateral supracondylar humerus and forearm
fractures necessitate immediate pinning of both
fractures to decrease risk of compartment
syndrome
technique
check vascular status after reduction
explore if pulse lost after reduction or if pulseless,
pale hand persists after reduction
arteriography is typically not indicated
Techniques
Closed reduction and percutanous pinning
o fixation
closed reduction (extension-type)
posteromedial fragments: forearm pronated with
hyperflexion
posterolateral fragments: forearm supinated with
hyperflexion
two lateral pins
usually sufficient
confirm stability under fluoroscopy
three lateral pins
biomechanically stronger in bending and torsion than 2-pin
contructs
when comminution is present, 2 lateral pins may be
insufficient, and a 3-pin construct such as this is needed
no significant difference in stability between three lateral
pins and crossed pins
risk of iatrogenic nerve injury from a medial pin
makes three lateral pins the construct of choice
crossed pins
biomechanically strongest to torsional stress
higher risk of ulnar nerve injury (3-8%)
highest risk if placed with elbow in hyperflexion
pins removed post-operatively around 3 weeks
Complications
Pin migration
o most common complication (~2%)
Infection
o occurs in 1-2.4%
o typically superficial and treated with oral antibiotics
Cubitus valgus
o caused by fracture malunion
o can lead to tardy ulnar nerve palsy
Cubitus varus (gunstock deformity)
o caused by fracture malunion
o usually a cosmetic issue with little functional limitations
Recurvatum
o common with non-operative treatement of Type II and Type III
fractures
Nerve palsy
o usually resolve
Vascular Injury
Volkmann ischemic contracture
o rare, but dreaded complication associated with supracondylar
humerus fractures
o more often as a result of brachial artery compression with
treatment utilizing elbow hyperflexion and casting than true
arterial injury
increase in forearm compartment pressures and loss of
radial pulse with elbow flexed greater than 90
o rarely seen with CRPP and postoperative immobilization in less
than 90
Postoperative Stiffness
o rare after casting or after pinning procedures
o resolves by 6 months
o literature does not support the use of physical therapy
