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Introduction
  • Epidemiology
    • incidence
      • extension type most common (95-98%)
      • flexion type less common (<5%)
    • demographics
      • occur most commonly in children aged 5-7years
      • M = F
  • Pathophysiology
    • mechanism of injury
      • fall on outstretched hand
  • Associated injuries
    • 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
        • further diagnostic studies are not indicated in the acute setting
    • vascular compromise (5-17%)
      • rich collateral circulation can maintain circulation despite vascular injury
    • ipsilateral distal radius fractures
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 ~ 17 years (is the last to fuse) 
Ossification center
Years at ossification (appear on xray) (1)
Years at fusion (appear on xray) (1)
Capitellum
1
12
Radial Head
4
15
Medial epicondyle
6
17
Trochlea
8
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, which technically means it is not a Type 1 Fracture, and it requires reduction and pinning.
  • Treated with cast immobilization x 3-4wks, with radiographs at 1 wk
 
Type II
  • Displaced 
    • posterior cortex and posterior periosteal hinge intact 
  • Deformity is in the sagittal plane only
  • Typically treated with CRPP
 
Type III
  • Displaced, often in 2 or 3 planes
  • Treated most commonly with CRPP or open reduction if needed
Type IV**
  • Complete periosteal disruption with instability in flexion and extension
  • Diagnosed with examination under anesthesia during surgery
  • Treated most commonly with CRPP or open reduction if needed

  SCH flexed

Medial comminution* 
  • Collapse of medial column, loss of Baumann angle 
    • Leads to varus malunion/classic gunstock deformity
    • may or may not be sagittal plane deformity
  • Treated with CRPP, often requires significant valgus force to reduce
 
Flexion type
  • Mechanism of injury is usually a fall on the olecranon.
  • Treated with CRPP
 
*not a part of original Gartland classification   
**diagnosed intraoperatively when capitellum is anterior to AHL with elbow flexion and posterior with extension on lateral XR  
 
Presentation
  • Symptoms
    • pain
    • refusal to move the elbow
  • Physical exam
    • inspection
      • gross deformity
      • swelling
      • ecchymosis in ante-cubittal fossa
    • motion
      • limited active elbow motion
    • neurovascular
      • neurovascular exam must be done before any reduction maneuver to be certain nerve or vascular injury is not iatrogenic (stuck in fracture site). Evaluate for
        • AIN neurapraxia post
          • unable to flex the interphalangeal joint of his thumb and the distal interphalangeal joint of his index finger (can't make A-OK sign)
        • median nerve injury
          • loss of sensation over volar index finger
        • radial nerve neurapraxia
          • inability to extend wrist or MCP joints 
            • PIP and DIP can still be extended via intrinsic function (ulnar n.)
    • vascular exam
      • assess pulse
        • present or absent by palpation or doppler
      • assess vascular perfusion
        • well perfused
          • warm
          • pink
        • poorly perfused
          • cold
          • pale
          • arterial capillary refill > 2 seconds
        • poorly perfused hand initially treated with gentle traction and elbow flexion to 20-40 degrees immediately, this often restores perfussion and pulse.
        • poorly perfused hand after gentle traction and flexion is a surgical emergency - treat with emergent reduction and pinning in OR (see treatment below)  
        • pulseless but well-perfused hand requires timely treatment
Imaging
  • Radiographs
    • recommended views
      • AP and lateral x-ray of the elbow (really of the distal humerus)
    • findings
      • posterior fat pad sign
        • lucency on a lateral view along the posterior distal humerus and olecranon fossa is highly suggestive of occult fracture around the elbow
    • measurement
      • displacement of the anterior humeral line
        • anterior humeral line should intersect the middle third of the capitellum in children > 5 years old, and touches the capitellum in children in children <5.  
        • capitellum moves posteriorly to this reference line in extension type fractures, and anteriorly in flexion type fractures 
      • 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°, but best judge is a comparison of the contralateral side
        • deviation of >5-10° indicates coronal plane deformity and should not be accepted
Treatment 
  • Nonoperative
    • 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 capitellum
          • minimal swelling present
          • no medial comminution
      • technique
        • typically used for 3 weeks 
        • repeat radiographs at 1 week to assess for interval displacement
  • Operative  
    • closed reduction and percutanous pinning (CRPP)   
      • indications 
        • type II and III supracondylar fractures
        • flexion type
        • medial column collapse
      • timing 
        • emergency -- pulseless, poorly perfused hand   
        • urgent --  do not wait 8-10 hours overnight -- pulseless but well perfused, antecubittal fossa echymosis, sensory nerve injury, excessive swelling
        • "brachialis sign" 
          • ecchymosis, dimpling/puckering antecubittal fossa, palpable subcutaneous bone fragment
          • indicates proximal fragment buttonholed through brachialis 
          • implies more serious injury, higher likelihood of arterial injury, significant swelling, more difficult closed redution
        • "floating elbow"
          • ipsilateral supracondylar humerus and forearm /wrist fractures warrants timely pinning of both fractures to decrease risk of compartment syndrome 
        •  not urgent -- none of above,  isolated AIN injury 
          • splint in 30-40° elbow flexion, admit overnight for observation, elevation and elective surgery
    • open reduction with percutaneous pinning
      • indications
        • unacceptable closed reduction 
        • more frequently required with flexion type fractures (than extension type)
        • when vascular exploration needed
        • open fracture
      • technique
        • anterior apprach if pulseless or median nerve injury.  lateral or medial approach where periosteum is torn.  never posterior as posterior disecction can --> AVN 
Treatment of Pulseless Hand
  • Operative
    • emergent CRPP followed by serial vascular exams
      • indications
        • pulseless poorly perfused hand 
      • technique
        • check vascular status after reduction 
        • if evidence of good distal perfusion (warm, pink hand with good capillary refill, biphasic doppler pulses) admit for 48 hours of observation 
        • arteriography is typically not indicated
    • emergent CRPP followed immediately by vascular exploration
      • indications
        • pulseless white hand (pale, cool, no doppler) following fracture reduction
        • pulsatile and perfused hand that loses pulses following CRPP
          • Remove K-wires and reassess vascular status
            • open exploration and reduction if vascular status does not improve
    • open reduction and vascular exploration
      • indications
        • pulseless white OR pink hand that is unable to be reduced or their remains a gap
          • gap might represent entrapped vascular structure
    • urgent but not emergent treatment
      • Indications - pulseless, well perufsed hand (warm and pink)
      •  
        • check vascular status after reduction 
        • if evidence of good distal perfusion (warm, pink hand with good capillary refill, biphasic doppler pulses) admit for 48 hours of observation 
        • arteriography is typically not indicated
        • i need to review below algorithm
 

 
Techniques
  • Closed reduction and percutanous pinning (CRPP) post
    • fixation
      • closed reduction (extension-type)
        • posteromedial displacement: forearm pronated with hyperflexion
        • posterolateral displacement: forearm supinated with hyperflexion 
        • at times if pronation or suppination does not work, try the opposite
      • 2 lateral pins  
        • usually sufficient in type II fractures
        • test stability under fluoroscopy
        • technical pearls
          • maximize separation of pins at fracture site  
          • engage both medial & lateral columns proximal to fracture
          • engage sufficient bone in proximal & distal segments
          • low threshold for 3rd lateral pin if concern about stability with 1st 2 pins
      • 3 lateral pins  
        • biomechanically stronger in bending and torsion than 2-pin constructs
        • indications (where 2 lateral pins are insufficient)
          • comminution
          • type III and type IV (free floating distal fragment)
        • 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
      • Type IV fractures and Flexion type fractures
        • place 1-2  lateral pins initially in distal fragment only
        • reduce fracture in AP plane with AP imaging
      •  
        • rotate fluoro (not the patients arm) to obtain lateral image
        • flex or extend elbow as needed to reduce fracture in sagittal plane
        •  advance distal pins into proximal fragment
        • add a 2 or 3rd pin
      • crossed pins
        • biomechanically strongest to torsional stress 
        • higher risk of ulnar nerve injury (3-8%)  
          • highest risk if placed with elbow in hyperflexion as ulnar nerve subluxates anteriorly over medial epicondyle in some children
        • reduce risk of ulnar nerve injury by
          • placing medial pin with elbow in extension
          • use small medial incision (rather than percutaneous pinning)
          • remove pins postop at 3 weeks 
Complications
  • Pin migration
    • most common complication (~2%)
  • Infection
    • occurs in 1-2.4%
    • typically superficial and treated with oral antibiotics
  • Cubitus valgus
    • caused by fracture malunion
    • can lead to tardy ulnar nerve palsy
  • Cubitus varus (gunstock deformity) 
    • caused by fracture varus malunion, especially in  medial comminution pattern 
    • it is NOT caused by growth disturbance
    • usually a cosmetic issue with little functional limitations  , but pain may be present
  • Recurvatum
    • common with non-operative treatment of Type II and Type III fractures
  • Nerve palsy from injury 
    • usually resolve, nerves rarely torn
    • extension type fractures 
      • neuropraxia in 11%
      • most commonly AIN 
      • mechanism = tenting of nerve on fracture, or entrapment in fracture site
    • flexion type fractures 
      • neuropraxia in 17%
      • most commonly cause ulnar neuropraxia 
  • Vascular Injury
    • radial pulse absent on initial presentation in 7-12%
    • pulseless hand after closed reduction and pinning (3-4%)    
    • decision to explore is based on quality of extremity perfusion, rather than absence of pulse
    • arteriography is NOT indicated in isolated injuries
    • role of doppler unclear, does not change treatment
  • Volkmann ischemic contracture
    • rare, but dreaded complication
    • may result from elbow hyperflexion casting
      • increase in deep volar forearm compartment pressures and loss of radial pulse with elbow flexed >90°
    • rarely seen with CRPP and postoperative immobilization in less than 90°
  • Postoperative stiffness
    • rare after casting or after pinning procedures
      • remove pins and allow gentle ROM at 3 weeks postop 
    • resolves by 6 months 
    • literature does not support the use of physical therapy 
 

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Technique Guides (2)
Questions (39)
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(OBQ13.239) Figures A through E are injury radiographs of elbow injuries in children. A child complains of decreased sensation over the small finger acutely after an elbow injury. Which of the following radiographs is consistent with his injury? Review Topic

QID: 4874
FIGURES:
1

Figure A

84%

(2486/2975)

2

Figure B

4%

(109/2975)

3

Figure C

5%

(141/2975)

4

Figure D

4%

(121/2975)

5

Figure E

3%

(98/2975)

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(OBQ06.227) What is the etiology of cubitus varus following a supracondylar humerus fracture in a child? Review Topic

QID: 238
1

Overgrowth of the lateral physis

12%

(197/1613)

2

Malreduction of the fracture

69%

(1118/1613)

3

Growth arrest of medial physis

18%

(288/1613)

4

Injury to the ulnar nerve

0%

(3/1613)

5

Radial head dislocation

0%

(2/1613)

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PREFERRED RESPONSE 2
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(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 nerve most commonly injured in this fracture pattern? Review Topic

QID: 840
FIGURES:
1

Weakness of the flexor digitorum profundus to the index finger

15%

(252/1655)

2

Weakness of the extensor pollicis longus

6%

(103/1655)

3

Wrist drop

6%

(99/1655)

4

Weakness of the flexor pollicis longus

13%

(214/1655)

5

Hand intrinsic weakness

59%

(977/1655)

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

QID: 1245
FIGURES:
1

flexor digitorum profundus index finger

1%

(10/982)

2

flexor digitorum profundus middle finger

2%

(15/982)

3

flexor pollicis longus

2%

(23/982)

4

extensor pollicis longus

93%

(912/982)

5

pronator quadratus

2%

(20/982)

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

QID: 3490
1

Capitellum

3%

(94/3325)

2

External (lateral) epicondyle

46%

(1514/3325)

3

Radial head

2%

(56/3325)

4

Internal (medial) epicondyle

48%

(1589/3325)

5

Trochlea

2%

(68/3325)

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(OBQ08.248) A child falls off of the monkey bars at school and sustains the left elbow injury shown in Figure A. What is a disadvantage of the fixation construct shown in Figure B compared to Figure C for this injury pattern? Review Topic

QID: 634
FIGURES:
1

Less biomechanical stability

4%

(29/726)

2

Higher incidence of compartment syndrome

0%

(3/726)

3

Higher chance of osteomyelitis

1%

(4/726)

4

Higher risk of iatrogenic injury to the ulnar nerve

93%

(674/726)

5

Higher risk of iatrogenic injury to the anterior interosseous nerve

2%

(15/726)

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(OBQ12.54) Following successful operative treatment, routine removal of hardware is recommended at 3-4 weeks for which of the following procedures? Review Topic

QID: 4414
FIGURES:
1

Figure A

0%

(17/3791)

2

Figure B

2%

(80/3791)

3

Figure C

3%

(101/3791)

4

Figure D

94%

(3564/3791)

5

Figure E

0%

(12/3791)

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(OBQ05.90) A 10-year-old boy sustained the injury shown in figure A while jumping off a trampoline. His hand is pulseless and cold. What is the next step in management? Review Topic

QID: 976
FIGURES:
1

Loose-fitting splint application and reassess in 1 hour

1%

(4/606)

2

Emergent closed reduction and pin fixation

88%

(534/606)

3

Angiogram

1%

(8/606)

4

Open vascular exploration

9%

(57/606)

5

Forearm skeletal traction pin

0%

(0/606)

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(OBQ12.112) A 7-year-old patient presents with a fracture of her left supracondylar humerus and distal radius as evidenced in Figure A. She is neurovascularly intact and the skin shows no evidence of open wounds. Radiographs of the elbow show a displaced supracondylar fracture. Radiographs of the wrist show an extra-articular distal radius fracture with 25 degrees of dorsal angulation. This injury is most appropriately treated with which of the following? Review Topic

QID: 4472
FIGURES:
1

Closed reduction and casting of the supracondylar humerus fracture and distal radius fracture

1%

(39/3783)

2

Closed reduction and pinning of both the supracondylar humerus fracture and distal radius fracture

51%

(1920/3783)

3

Closed reduction and casting of the supracondylar humerus fracture and pinning of distal radius fracture

1%

(44/3783)

4

Open reduction and pinning of both the supracondylar humerus and the distal radius fracture

6%

(235/3783)

5

Closed reduction and pinning of the supracondylar humerus fracture and closed reduction and casting of distal radius fracture

40%

(1524/3783)

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(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: Review Topic

QID: 123
1

improved functional outcome

7%

(40/565)

2

improved cosmesis

81%

(458/565)

3

improved pain relief

1%

(3/565)

4

improved range of motion

9%

(52/565)

5

reduce non-union rates

1%

(8/565)

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

QID: 793
1

Greater ultimate clinical arc of elbow motion

0%

(3/1033)

2

Lower revision rate

1%

(11/1033)

3

Lower incidence of ulnar nerve injury

1%

(13/1033)

4

Greater experimental biomechanical stability

95%

(978/1033)

5

More anatomic fracture reduction

2%

(24/1033)

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(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? Review Topic

QID: 1330
1

Malreduction causing malunion

72%

(409/568)

2

Medial epicondyle growth arrest

17%

(95/568)

3

Lateral condyle overgrowth

9%

(53/568)

4

Medial epicondyle avascular necrosis

1%

(5/568)

5

Unrecognized compartment syndrome

0%

(1/568)

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