Introduction Overview supracondylar fractures are one of the most common traumatic fractures see in children and most commonly occur in children 5-7 years of age from a fall on an outstretched hand treatment is usually closed reduction and percutanous pinning (CRPP), with the urgency depending on whether the hand remains perfused or not. 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 extremity Associated injuries neuropraxia anterior interosseous nerve (AIN) 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 I Fracture, and it requires reduction and pinning Treated with cast immobilization x 3-4wks, with radiographs at 1 week 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 Medial comminution* Collapse of medial column, loss of Baumann angle leads to varus malunion/classic gunstock deformity may or may not be associated with a 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 More likely to require open reduction *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 antecubital fossa motion limited active elbow motion neuro exam 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 unable to flex the interphalangeal joint of the thumb and the distal interphalangeal joint of the 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, MCP joints, thumb IP joint PIP and DIP can still be extended via intrinsic function (ulnar n.) vascular exam assess pulse present or absent by palpation present or absent by biphasic doppler pulse assess vascular perfusion well perfused warm pink poorly perfused cold pale arterial capillary refill > 2 seconds 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 Angiography is typically not indicated Treatment Nonoperative long arm casting with less than 90° of elbow flexion indications warm perfused hand without neuro deficits and 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 immediate bedside closed reduction indications poorly perfused hand technique gentle traction and elbow flexion to 20-40 degrees this often restores perfusion if perfusion not restored take to OR for CRPP in an urgent or emergent manner (see below) if perfusion is restored take to OR in an urgent manner Operative closed reduction and percutanous pinning (CRPP) indications fracture pattern type II and III supracondylar fractures flexion type medial column collapse time to CRPP dictated by neurovascular status non-urgent (can wait overnight) indications warm perfused hand without neuro deficits some argue can treat an isolated AIN injury in non-urgent fashion technique splint in 30-40° elbow flexion, admit overnight for observation and elevation for elective surgery urgent (same day - do not wait overnight) indications pulseless, well-perfused hand sensory nerve deficits excessive swelling "brachialis sign" ecchymosis, dimpling/puckering antecubital 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 reduction "floating elbow" ipsilateral supracondylar humerus and forearm/wrist fractures warrant timely pinning of both fractures to decrease the risk of compartment syndrome technique check vascular status after reduction if evidence of good distal perfusion admit for 48 hours of observation if not well perfused perform vascular exploration emergent (within hours) indications pulseless, poorly perfused hand technique check vascular status after reduction if well perfused admit and observe for 48 hours if not well perfused perform vascular exploration emergent vascular exploration and CRPP indications pulseless white hand (pale, cool, no doppler) following CRPP pulsatile and perfused hand that loses pulse following CRPP technique remove K-wires and reassess vascular status open exploration and reduction if vascular status does not improve open reduction, percutaneous pinning, +/- vascular exploration indications open fracture failed closed reduction more frequently required with flexion type fractures (compared to extension type) pulseless white OR pink hand that is unable to be reduced or there remains a gap gap might represent entrapped vascular structure Techniques Closed reduction and percutaneous pinning (CRPP) fixation closed reduction (extension-type) posteromedial displacement: forearm pronated with hyperflexion posterolateral displacement: forearm supinated with hyperflexion if pronation or supination 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 first 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 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 the 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 Open Reduction with Percutaneous Pinning approach anterior approach if pulseless or median nerve injury a lateral or medial approach where periosteum is torn never posterior as posterior dissection can --> AVN soft tissue identify median nerve and brachial artery bone work confirm reduction with C-arm instrumentation 2 or 3 K-wires depending on the degree of stability 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 is NOT caused by growth disturbance usually a cosmetic issue with little functional limitations, but 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 the 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 is unclear and 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 3-4 weeks postop resolves by 6 months literature does not support the use of physical therapy
Supracondylar Humerus Fx Closed Reduction and Percutanous Pinning (CRPP) Technique guide are not considered high yield topics for orthopaedic standardized exams including the ABOS, EBOT and RC. Authors: Lindsay Andras David Skaggs Supracondylar Humerus Fx Open Reduction and Internal Fixation Technique guide are not considered high yield topics for orthopaedic standardized exams including the ABOS, EBOT and RC. Authors: Nina Lightdale Lindsay Andras
QUESTIONS 1 of 45 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 Previous Next Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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: A B C D E 1 Figure A 84% (2623/3127) 2 Figure B 4% (111/3127) 3 Figure C 5% (145/3127) 4 Figure D 4% (127/3127) 5 Figure E 3% (99/3127) Select Answer to see Preferred Response PREFERRED RESPONSE 1 Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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% (202/1661) 2 Malreduction of the fracture 69% (1145/1661) 3 Growth arrest of medial physis 18% (304/1661) 4 Injury to the ulnar nerve 0% (3/1661) 5 Radial head dislocation 0% (2/1661) Select Answer to see Preferred Response PREFERRED RESPONSE 2 Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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: A 1 Weakness of the flexor digitorum profundus to the index finger 15% (268/1775) 2 Weakness of the extensor pollicis longus 6% (110/1775) 3 Wrist drop 6% (106/1775) 4 Weakness of the flexor pollicis longus 13% (226/1775) 5 Hand intrinsic weakness 59% (1053/1775) Select Answer to see Preferred Response PREFERRED RESPONSE 5 (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: A 1 flexor digitorum profundus index finger 1% (12/1015) 2 flexor digitorum profundus middle finger 1% (15/1015) 3 flexor pollicis longus 2% (23/1015) 4 extensor pollicis longus 93% (940/1015) 5 pronator quadratus 2% (21/1015) Select Answer to see Preferred Response PREFERRED RESPONSE 4 Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ11.67) Which of the following elbow apophyses is the last to fuse during growth? Review Topic QID: 3490 1 Capitellum 3% (96/3372) 2 External (lateral) epicondyle 46% (1535/3372) 3 Radial head 2% (56/3372) 4 Internal (medial) epicondyle 48% (1610/3372) 5 Trochlea 2% (68/3372) Select Answer to see Preferred Response PREFERRED RESPONSE 4 (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: A B C 1 Less biomechanical stability 4% (29/733) 2 Higher incidence of compartment syndrome 0% (3/733) 3 Higher chance of osteomyelitis 1% (4/733) 4 Higher risk of iatrogenic injury to the ulnar nerve 93% (681/733) 5 Higher risk of iatrogenic injury to the anterior interosseous nerve 2% (15/733) Select Answer to see Preferred Response PREFERRED RESPONSE 4 (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: A B C D E 1 Figure A 0% (18/3893) 2 Figure B 2% (86/3893) 3 Figure C 3% (105/3893) 4 Figure D 94% (3654/3893) 5 Figure E 0% (12/3893) Select Answer to see Preferred Response PREFERRED RESPONSE 4 Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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: A 1 Loose-fitting splint application and reassess in 1 hour 1% (4/645) 2 Emergent closed reduction and pin fixation 88% (569/645) 3 Angiogram 1% (9/645) 4 Open vascular exploration 9% (60/645) 5 Forearm skeletal traction pin 0% (0/645) Select Answer to see Preferred Response PREFERRED RESPONSE 2 (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: A 1 Closed reduction and casting of the supracondylar humerus fracture and distal radius fracture 1% (41/3904) 2 Closed reduction and pinning of both the supracondylar humerus fracture and distal radius fracture 51% (1984/3904) 3 Closed reduction and casting of the supracondylar humerus fracture and pinning of distal radius fracture 1% (46/3904) 4 Open reduction and pinning of both the supracondylar humerus and the distal radius fracture 6% (249/3904) 5 Closed reduction and pinning of the supracondylar humerus fracture and closed reduction and casting of distal radius fracture 40% (1562/3904) Select Answer to see Preferred Response PREFERRED RESPONSE 2 (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% (45/670) 2 improved cosmesis 81% (546/670) 3 improved pain relief 1% (4/670) 4 improved range of motion 9% (59/670) 5 reduce non-union rates 1% (10/670) Select Answer to see Preferred Response PREFERRED RESPONSE 2 (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% (5/1159) 2 Lower revision rate 1% (11/1159) 3 Lower incidence of ulnar nerve injury 1% (17/1159) 4 Greater experimental biomechanical stability 94% (1093/1159) 5 More anatomic fracture reduction 2% (28/1159) Select Answer to see Preferred Response PREFERRED RESPONSE 4 (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 73% (450/616) 2 Medial epicondyle growth arrest 17% (103/616) 3 Lateral condyle overgrowth 8% (52/616) 4 Medial epicondyle avascular necrosis 1% (5/616) 5 Unrecognized compartment syndrome 0% (1/616) Select Answer to see Preferred Response PREFERRED RESPONSE 1 Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK
pdf AAOS Clinical Practice Guidelines: The treatment of pediatric supracondylar humerus fractures. Pediatrics - Journal Club Howard A1, Mulpuri K, Abel MF, Braun S, Bueche M, Epps H, Hosalkar H, Mehlman CT, Scherl S, Goldberg M, Turkelson CM, Wies JL, Boyer K; American Academy of Orthopaedic Surgeons. J Am Acad Orthop Surg. 2012 Feb;20(2):69-77. PMID: 22553104 (Link to Abstract)
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