Supracondylar Fracture - Pediatric

Author: Chris Souder

Topic updated on 04/26/13 7:18pm

Introduction

Mechanism
- fall on outstretched hand
Epidemiology
- consists of more than half of all pediatric elbow fractures
- extension type most common (95-98%)
Associated injuries
- neuropraxia
  - anterior interosseous nerve (branch of median n.) neuropraxia
    - the most common nerve palsy seen with supracondylar humerus fractures
  - radial nerve palsy
    - second most common neuropraxia (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
- vascular injury (1%)
  - rich collateral circulation can maintain circulation despite vascular injury

Anatomy

Ossification centers of elbow
- 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 ~ 14 years (is the last to fuse)

Ossification center	Years at ossification (appear on xray) (1)	Years at fusion (appear on xray) (1)
Capitellum	1
Radius	4
Medial epicondyle	6
Trochlea	8
Olecranon	10
Lateral epicondyle	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

Physical exam
- nerve exam
  - AIN neuropraxia
    - 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 neuropraxia
    - inability to extend wrist or digits may be present due to radial nerve injury neuropraxia
- vascular status
  - 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
- 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
  - created by a line perpendicular to the humeral shaft and a line along the lateral condylar physis as viewed on the AP image
  - indicates coronal plane deformity

Treatment

Nonoperative
- posterior molded splint then long arm casting at ~90°
  - indications
    - Type I (non-displaced) fractures which are very rare
    - Type II fractures that meet the following criteria
      - anterior humeral line intersects capitellum
      - minimal swelling present
      - no medial comminution
  - technique
    - typically used for 3 weeks
Operative
- closed reduction and percutanous pinning
  - indications
    - in most supracondylar fractures
  - technique
    - two lateral pins
      - usually sufficient
      - perform and confirm stability
      - pin separation should be enough to allow pins to engage both medial and lateral columns
    - 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
- open reduction with percutaneous pinning
  - indications
    - reduction cannot be obtained closed
    - more frequently required with flexion type fractures
  - technique
    - anterior approach typically utilized
- immediate closed reduction and percutanous pinning
  - indications
    - vascular compromise is present (e.g, pale, cool hand)
  - 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

Complications

Pin migration
- most common complication (~2%)
Infection
- occurs in 1-2.4%
- typically superficial and treated with oral antibiotics
Cubitus varus (gunstock deformity)
- caused by fracture malunion
- can lead to tarda ulnar nerve palsy
- usually a cosmetic issue with little functional limitations
Recurvatum
- common with non-operative treatement of Type II and Type III fractures
Nerve palsy
- usually resolve
Vascular Injury
Volkmann ischemic contracture
- rare, but dreaded complication associated with supracondylar humerus fractures
- 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°
- rarely seen with CRPP and postoperative immobilization in less than 90°

Please Rate Educational Value!

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Qbank (11 Questions)

TAG

(OBQ11.67) Which of the following elbow apophyses is the last to fuse during growth? Topic

Review Topic

1. Capitellum
2. External (lateral) epicondyle
3. Radial head
4. Internal (medial) epicondyle
5. Trochlea

PREFERRED RESPONSE ▶

DISCUSSION: While the external (lateral) epicondyle is the last apophyses to APPEAR on radiographs, this question is asking for which of the apopphyses is the last to FUSE. Therefore, the correct answer is the internal (medial) epicondyle, which is the last to FUSE at around 16 to 19 years. While the order of appearance is discussed more often, it is helpful to know the typical order and age of apophyseal closure when evaluating teenagers (often throwers) with atraumatic elbow pain.

An accepted mnemonic of the order of APPEARANCE of the individual ossification centers of the elbow is C-R-I-T-O-E: Capitellum, Radial head, Internal (medial) epicondyle, Trochlea, Olecranon, External (lateral) epicondyle.

Cheng et al performed a series to re-examine the sequence and pattern of elbow ossification based on a cross-sectional study of 3,154 elbow radiographs in children ranging in age from newborn to 17 years. The sequence of ossification in both boys and girls was found to be the same. The ages at which 50% of the girls were found to have positive radiologic ossification for each of these centers were ages 1, 5, 5, 9, 9, and 10 years, respectively. In boys, with the exception of the capitelum, an average delay of 2 years was found in each of the ossification centers, although the sequence remained similar.

Illustration A shows the different ossification centers. Illustration B shows the age of APPEARANCE and age of FUSION of the different ossification centers. It should be noted that appearance and fusion of the ossification centers do not correlate.

Illustrations: A

REFERENCES:

1. Beaty JH, Kasser JR. The elbow region: general concepts in the pediatric patient. In: Beaty JH, Kasser JR, eds. Rockwood and Wilkins' Fractures in Children. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:530-534.

2. Cheng JC, Wing-Man K, Shen WY, Yurianto H, Xia G, Lau JT, Cheung AY. A new look at the sequential development of elbow-ossification centers in children. J Pediatr Orthop. 1998 Mar-Apr;18(2):161-7. PMID:9531396 (Link to Abstract)

Question Authors:

Joshua Blomberg MD, Ben Taylor MD, John Badylak MD,

Please Rate Educational Value!

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TAG

(OBQ07.132) What is the advantage of medial and lateral crossed pins compared to two lateral pins in the treatment of supracondylar humerus fractures? Topic

Review Topic

1. Greater ultimate clinical arc of elbow motion
2. Lower revision rate
3. Lower incidence of ulnar nerve injury
4. Greater experimental biomechanical stability
5. More anatomic fracture reduction

PREFERRED RESPONSE ▶

DISCUSSION: Supracondylar fractures of the humerus in children are commonly treated with closed reduction and percutaneous pin fixation. Zionts et al found maximum stability for supracondylar humerus fractures was provided by two crossed pins placed from the medial and lateral condyles in a cadaveric laboratory study. Lee et al also found crossed pins were more stable. No clinical difference has ever been shown between the various pin configurations.

REFERENCES:

1. Zionts LE, et al: Torsional strength of pin configurations used to fix supracondylar fractures of the humerus in children. J Bone Jt Surg Am 1994; 76: 253-256 PMID:8113261 (Link to Abstract)

2. Lee SS, Mahar AT, et al., Displaced pediatric supracondylar humerus fractures: Biomechanical analysis of percutaneous pinning techniques. J Pediatric Orthop 2002; 22: 440-443 PMID:12131437 (Link to Abstract)

Question Authors:

Greg Galano MD, Derek Moore, Eric Shirley MD,

Please Rate Educational Value!

3.0

Average 3.0 of 9 Ratings

TAG

(OBQ07.179) A 7-year-old boy falls off the playground and sustains the injury shown in figure A. What motor deficit is associated with the neurologic injury most common to this fracture pattern? Topic

Review Topic

FIGURES: A

1. Weakness of the flexor digitorum profundis to the index finger
2. Weakness of the extensor pollicis longus
3. Wrist drop
4. Weakness of the flexor pollicis longus
5. Hand intrinsic weakness

PREFERRED RESPONSE ▶

DISCUSSION: The radiograph demonstrates a flexion type supracondylar humerus (SCH) fracture, in which the distal fragment is displaced anteriorly. In these fracture patterns, the ulnar nerve is the most likely to be injured, specifically by the sharp spike of the proximal fragment. Extension type SCH fractures are more common than flexion type and are commonly associated with injury to the anterior interosseous nerve (AIN). Weakness of the flexor digitorum profundis to the index finger and flexor pollicis longus would be associated with AIN palsy. Wrist drop would be associated with radial nerve palsy. Weakness of extensor pollicis longus correlates with posterior interosseous nerve palsy. Ulnar nerve palsy would cause hand intrinsic weakness and clawing.

REFERENCES:

1. Green, NE, Swiontkowski, MF (ed). Skeletal Trauma in Children. 4th ed, Philadelphia, PA, Saunders/Elsevier, 2009

Question Authors:

Greg Galano MD, Guillem Lomas MD, Eric Shirley MD,

Please Rate Educational Value!

4.0

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TAG

(OBQ06.227) What is the cause of cubitus varus after a supracondylar humerus fracture in a child? Topic

Review Topic

1. Overgrowth of the lateral physis
2. Malunion of the fracture
3. Growth arrest of medial physis
4. Injury to the ulnar nerve
5. Radial head dislocation

PREFERRED RESPONSE ▶

DISCUSSION: Cubitus varus is typically caused by malreduction of the fracture at the time of fixation resulting in malunion; not usually by growth arrest. The study referenced is a retrospective review of 84 patients with supracondylar fractures of the humerus treated by closed reduction and splinting, traction, and closed reduction and percutaneous pinning (CRPP) to determine the adequacy of the initial reduction and the maintenance of the reduction. Initially, Baumann's angle was adequate and similar in all patients, but the humerocapitellar angle was better with CRPP. Maintenance of reduction in both planes was superior with CRPP, and significantly better clinical results were achieved by CRPP. Nevertheless, there was no functional loss in any patient, and no parent wanted correction of deformity.

REFERENCES:

1. France J, Strong M. Deformity and function in supracondylar fractures of the humerus in children variously treated by closed reduction and splinting,traction, and percutaneous pinning. J Pediatr Orthop. 1992 Jul-Aug;12(4):494-8. PMID:1613094 (Link to Abstract)

Question Authors:

Dan Prince MD, Derek Moore,

Please Rate Educational Value!

4.0

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TAG

(OBQ05.90) A 10-year-old boy jumped from the playground and sustained the injury shown in figure A. His hand is pulseless and cold. What is the next step in management? Topic

Review Topic

FIGURES: A

1. Loose-fitting splint application and reassess in 1 hour
2. Closed reduction
3. Angiogram
4. Open vascular exploration
5. Forearm skeletal traction pin

PREFERRED RESPONSE ▶

DISCUSSION: Otsuka and Kasser stated: "Vascular insufficiency at presentation (prevalence, 5%-17%) should be managed initially by rapid reduction and pinning without arteriography." Copley et al looked at 128 consecutive children with grade III supracondylar humeral fractures. 17 had absent or diminished radial pulses on initial examination. 14 of these 17 children recovered pulse (palpable) after reduction and stabilization of their fractures. The remaining three had persistent absence of radial pulse. Each of these three children were explored immediately and found to have a significant vascular injury requiring repair.

REFERENCES:

1. Otsuka NY, Kasser JR: Supracondylar fractures of the humerus in children. J Am Acad Orthop Surg 1997;5:19-26. PMID:10797204 (Link to Abstract)

2. Copley LA, Dormans JP, Davidson RS: Vascular injuries and their sequelae in pediatric supracondylar humeral fractures: Toward a goal of prevention. J Pediatr Orthop 1996;16:99-103. PMID:8747364 (Link to Abstract)

3. Sponseller PD (ed): Orthopaedic Knowledge Update: Pediatrics 2. Rosemount, IL, American Academy of Orthopaedic Surgeons, 2002, pp 93-107.

Question Authors:

Greg Galano MD, Patrick McCulloch MD, Eric Shirley MD,

Please Rate Educational Value!

3.0

Average 3.0 of 15 Ratings

TAG

(OBQ04.12) A 5-year-old boy sustains a type II (Gartland classification) supracondylar fracture which is treated with cast immobilization. Healing results in a mild gunstock deformity. Surgical treatment of this will most likely result in: Topic

Review Topic

1. improved functional outcome
2. improved cosmesis
3. improved pain relief
4. improved range of motion
5. reduce non-union rates

PREFERRED RESPONSE ▶

DISCUSSION: A gunstock deformity, also known as cubitus varus, is the most common complication following a pediatric supracondylar humerus fracture. Cubitus varus typically does not affect range of motion, pain, function or growth. However, cosmetic concerns or recurrent elbow fractures may result. Tardy ulnar nerve palsy may also result, but is not common.

The primary indication for surgical correction of cubitus varus is cosmesis. Surgical treatment may result in neurovascular complications, lateral bone prominence, or failure to maintain correction. In a study by Ippolito et al reviewing the long-term outcome of the treatment of cubitus varus with a supracondylar valgus osteotomy, it was discovered that all but 3 of the 24 patients were satisfied with their clinical and functional outcomes in spite of partial recurrence in almost all patients.

REFERENCES:

1. Ippolito E, Moneta MR, D'Arrigo C. Post-traumatic cubitus varus. Long-term follow-up of corrective supracondylar humeral osteotomy in children. J Bone Joint Surg Am. 1990 Jun;72(5):757-65 PMID:2355039 (Link to Abstract)

Question Authors:

Paul D. Kim MD, Derek Moore, Patrick McCulloch MD,

Please Rate Educational Value!

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TAG

(OBQ04.140) The most common nerve injured in the fracture shown in Figure A innervates all of the following muscles EXCEPT? Topic

Review Topic

FIGURES: A

1. flexor digitorum profundus index finger
2. flexor digitorum profundus middle finger
3. flexor pollicis longus
4. extensor pollicis longus
5. pronator quadratus

PREFERRED RESPONSE ▶

DISCUSSION: The anterior interosseus nerve (AIN) is the most common nerve injured with extension type pediatric supracondylar fractures as shown in Figure A. The AIN, a branch of the median nerve, is principally a motor nerve and innervates the Flexor Digitorum Profundus Index, Flexor Digitorum Profundus Middle, Flexor Pollicis Longus and Pronator Quadratus. It DOES NOT innervate the Extensor Pollicis Longus, which is innervated by the posterior interosseous nerve, a continuation of the deep branch of the radial nerve. The illustration below shows motor and sensory innervation in the upper extremities.

Illustrations: A

REFERENCES:

1. Dormans JP, Squillante R, Sharf H. Acute neurovascular complications with supracondylar humerus fractures in children. J Hand Surg Am. 1995 Jan;20(1):1-4. PMID:7722246 (Link to Abstract)

2. Cramer KE, Green NE, Devito DP. Incidence of anterior interosseous nerve palsy in supracondylar humerus fractures in children. J Pediatr Orthop. 1993 Jul-Aug;13(4):502-5. PMID:8370784 (Link to Abstract)

Question Authors:

Paul D. Kim MD, Patrick McCulloch MD,

Please Rate Educational Value!

3.0

Average 3.0 of 15 Ratings

TAG

(OBQ04.225) A 8-year-old boy has a cubitus varus deformity of his left elbow after a supracondylar humerus fracture was treated in a splint. What is the most common cause of this deformity? Topic

Review Topic

1. Malreduction causing malunion
2. Medial epicondyle growth arrest
3. Lateral condyle overgrowth
4. Medial epicondyle avascular necrosis
5. Unrecognized compartment syndrome

PREFERRED RESPONSE ▶

DISCUSSION: Supracondylar humerus fractures are the most common elbow fractures in children, accounting for 60-80% of pediatric elbow fractures. While growth disturbance, vascular injury, compartment syndrome and infection are recognized complications of supracondylar fractures and their treatment, none have been associated with the development of cubitus varus (gunstock) deformity. This usually is the result of malunion caused by failure to reduce a collapsed medial column or failure to correct rotation at the fracture site. Current standard treatment for displaced supracondylar humerus fractures is reduction and pinning (closed or open). Cheng et al found an increase in CRPP of supracondylar fractures from 4 to 40% over a 10 year period.

Illustrations: A

REFERENCES:

1. Cheng JC, Ng BK, Ying SY, Lam PK: A 10 year study of the changes in the pattern and treatment of 6493 fractures. J Pediatric Orthopaedics, 1999;19:344-350 PMID:10344317 (Link to Abstract)

2. Koval KJ (ed): Orthopaedic Knowledge Update 7. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 299-306

Question Authors:

Greg Galano MD, Patrick McCulloch MD, Eric Shirley MD,

Please Rate Educational Value!

4.0

Average 4.0 of 8 Ratings

Cases

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Videos

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Groups

ABOS II: Supracondylar Fracture - Pediatric

General - Oral Boards Review

7/29/2011

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Evidence & References Show References

Level of Evidence 3 (Retrospective Cohort Study or Case-Control Study)

Green DW, Widmann RF, Frank JS, Gardner MJ. Low incidence of ulnar nerve injury with crossed pin placement for pediatric supracondylar humerus fractures using a mini-open technique. J Orthop Trauma. 2005 Mar;19(3):158-63. PMID:15758668 (Link to Abstract)

Textbooks

Review of Orthopaedics, 6th Edition, Mark D. Miller MD, Stephen R. Thompson MBBS MEd FRCSC, Jennifer Hart MPAS PA-C ATC, an imprint of Elsevier, Philadelphia, Copyright 2012
AAOS Comprehensive Orthopaedic Review, Jay R. Leiberman. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2009
Orthopaedic Knowledge Update 10, John M Flyn. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2011
Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009
Orthopaedic In-training Examination (OITE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Self-Assessment Examination (SAE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Wattenbarger JM, Frick SL. Shoulder, upper arm, & elbow trauma: pediatrics. In: Flynn J, ed. Orthopaedic Knowledge Update 10. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2011:675-686.

Undefined

Beaty JH, Kasser JR. The elbow region: general concepts in the pediatric patient. In: Beaty JH, Kasser JR, eds. Rockwood and Wilkins' Fractures in Children. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:530-534.
Cheng JC, Wing-Man K, Shen WY, Yurianto H, Xia G, Lau JT, Cheung AY. A new look at the sequential development of elbow-ossification centers in children. J Pediatr Orthop. 1998 Mar-Apr;18(2):161-7. PMID:9531396 (Link to Abstract)
Beaty JH, Kasser JR, eds. Rockwood & Wilkins Fractures in Children. 7th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2010:521-522.
Pankaj A, Dua A, Malhotra R, Bhan S. Dome osteotomy for posttraumatic cubitus varus: a surgical technique to avoid lateral condylar prominence. J Pediatr Orthop. 2006 Jan-Feb;26(1):61-6 PMID:16439904 (Link to Abstract)
Yun YH, Shin SJ, Moon JG. Reverse V osteotomy of the distal humerus for the correction of cubitus varus. J Bone Joint Surg Br. 2007 Apr;89(4):527-31. PMID:17463124 (Link to Abstract)
Brauer CA, Lee BM, Bae DS, et al: A systematic review of medial and lateral entry pinning versus lateral entry pinning for supracondylar fractures of the humerus. Pediatr Orthop 2007;27:181-186 PMID:17314643 (Link to Abstract)
Lyons JP, Ashley E, Hoffer MM: Ulnar nerve palsies after percutaneous cross-pinning of supracondylar fractures in children’s elbows. J Pediatr Orthop 1998;18:43-45 PMID:9449100 (Link to Abstract)
Zionts LE, et al: Torsional strength of pin configurations used to fix supracondylar fractures of the humerus in children. J Bone Jt Surg Am 1994; 76: 253-256 PMID:8113261 (Link to Abstract)
Lee SS, Mahar AT, et al., Displaced pediatric supracondylar humerus fractures: Biomechanical analysis of percutaneous pinning techniques. J Pediatric Orthop 2002; 22: 440-443 PMID:12131437 (Link to Abstract)
Green, NE, Swiontkowski, MF (ed). Skeletal Trauma in Children. 4th ed, Philadelphia, PA, Saunders/Elsevier, 2009
France J, Strong M. Deformity and function in supracondylar fractures of the humerus in children variously treated by closed reduction and splinting,traction, and percutaneous pinning. J Pediatr Orthop. 1992 Jul-Aug;12(4):494-8. PMID:1613094 (Link to Abstract)
Review of Orthopaedics, 5th Edition, Mark D. Miller (editor), Saunders, an imprint of Elsevier, Philadelphia, Copyright 2008
Otsuka NY, Kasser JR: Supracondylar fractures of the humerus in children. J Am Acad Orthop Surg 1997;5:19-26. PMID:10797204 (Link to Abstract)
Copley LA, Dormans JP, Davidson RS: Vascular injuries and their sequelae in pediatric supracondylar humeral fractures: Toward a goal of prevention. J Pediatr Orthop 1996;16:99-103. PMID:8747364 (Link to Abstract)
Sponseller PD (ed): Orthopaedic Knowledge Update: Pediatrics 2. Rosemount, IL, American Academy of Orthopaedic Surgeons, 2002, pp 93-107.
Ippolito E, Moneta MR, D'Arrigo C. Post-traumatic cubitus varus. Long-term follow-up of corrective supracondylar humeral osteotomy in children. J Bone Joint Surg Am. 1990 Jun;72(5):757-65 PMID:2355039 (Link to Abstract)
Dormans JP, Squillante R, Sharf H. Acute neurovascular complications with supracondylar humerus fractures in children. J Hand Surg Am. 1995 Jan;20(1):1-4. PMID:7722246 (Link to Abstract)
Cramer KE, Green NE, Devito DP. Incidence of anterior interosseous nerve palsy in supracondylar humerus fractures in children. J Pediatr Orthop. 1993 Jul-Aug;13(4):502-5. PMID:8370784 (Link to Abstract)
Cheng JC, Ng BK, Ying SY, Lam PK: A 10 year study of the changes in the pattern and treatment of 6493 fractures. J Pediatric Orthopaedics, 1999;19:344-350 PMID:10344317 (Link to Abstract)
Koval KJ (ed): Orthopaedic Knowledge Update 7. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 299-306

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Supracondylar Fracture - Pediatric

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