|
https://upload.orthobullets.com/topic/4007/images/supracondylar-courtesy wheeless_moved.jpg
https://upload.orthobullets.com/topic/4007/images/ossifcation of the elbow_moved.jpg
https://upload.orthobullets.com/topic/4007/images/elbow ossification and fusion_moved.jpg
https://upload.orthobullets.com/topic/4007/images/gartland.jpg
https://upload.orthobullets.com/topic/4007/images/supracondylar type i ap.jpg
https://upload.orthobullets.com/topic/4007/images/lateral supracondylar type i.jpg
Introduction
  • Epidemiology
    • incidence
      • extension type most common (95-98%)
      • flexion type less common (<5%)
    • demographics
      • occur most commonly in children aged 5 to 7
      • 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, and therefore, further diagnostic studies are not indicated in the acute setting
    • vascular injury (1%)
      • 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
  • Anterior periosteum detached from anterior humerus by up to 3cm (but not torn)
  • Treated with cast immobilization x 3-4wks, with radiographs at 1 wk, pull pins at 3 wks
 
Type II
  • Displaced, posterior cortex and posterior periosteal hinge intact 
  • Pure sagittal plane deformity
  • Usually treated with CRPP
 
Type III
  • Displaced, often in two planes.  May have some intact cortex
  • Treated most commonly with CRPP or open reduction if needed
Type IV*
  • Complete periosteal disruption with instability in flexion and extension
  • Treated most commonly with CRPP or open reduction if needed

  SCH flexed

Medial comminution* in Type II
  • Collapse of medial column, loss of Baumann angle (leads to varus malunion/classic gunstock deformity)
  • Treated with CRPP, often requires significant valgus force to reduce
 
Flexion type
  • Shear mechanism, oblique orientation, inherently unstable
  • 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
      • bruising
    • motion
      • limited active elbow motion
    • neurovascular
      • nerve exam
        • 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)
        • 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
    • recommended views
      • AP and lateral x-ray of the elbow
    • findings
      • posterior fat pad sign
        • lucency 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 
        • 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°, but best judge is a comparison of the contralateral side
        • deviation of >5° indicates coronal plane deformity and should not be accepted
Treatment of Perfused Hand
  • Nonoperative
    • 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  
    • emergent closed reduction and percutanous pinning (CRPP)
      • timing
        • surgical emergency, take patient from ER directly to OR
      • indications ("red flag" warning signs)
        • dysvascular hand
          • see treatment of pulseless hand below
        • neurological defect
        • severe elbow swelling 
        • "brachialis sign"
          • ecchymosis, dimpling/puckering, 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 
    • urgent closed reduction and percutanous pinning (CRPP)   
      • indications
        • type II and III supracondylar fractures
        • flexion type
        • type II with De Boeck pattern (medial column collapse)
      • timing
        • if no concern for vascular injury operate when surgical team available (surgical "urgency" rather than "emergency")
          • splint in 30-40° elbow flexion, admit overnight for observation
    • 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
        • a variety of approaches include anterior, medial or lateral
Treatment of Pulseless Hand
  • Operative
    • emergent CRPP followed by serial vascular exams
      • indications
        • pulseless BUT perfused pink hand on presentation that is successfully reduced without a gap
      • 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) that is successfully reduced without a gap
        • pulsatile and perfused hand that looses pulses following CRPP
    • emergent 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

Techniques
  • Closed reduction and percutanous pinning (CRPP) post
    • fixation
      • closed reduction (extension-type)
        • posteromedial fragments: forearm pronated with hyperflexion
        • posterolateral fragments: forearm supinated with hyperflexion 
      • 2 lateral pins  
        • usually sufficient in most cases
        • 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
        • for difficult cases (type IV free floating segment)
          • place 2 parallel lateral pins initially in distal fragment as joysticks
          • rotate fluoro (not the patients arm) to obtain lateral image
          • after adequate reduction, advance distal pins into proximal fragment
          • add a 3rd pin
      • 3 lateral pins  
        • biomechanically stronger in bending and torsion than 2-pin constructs
        • indications (where 2 lateral pins are insufficient)
          • comminution
          • 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 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 
          • these techniques reduce complication risk to equal to lateral-only pins
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 De Boeck medial comminution pattern 
    • usually a cosmetic issue with little functional limitations 
  • Recurvatum
    • common with non-operative treatment of Type II and Type III fractures
  • Nerve palsy from injury 
    • usually resolve
    • extension type fractures 
      • neuropraxia in 11%
      • most commonly AIN (34% of extension-type fracture nerve injuries)
      • mechanism = tenting of nerve on fracture, or entrapment in fracture site
    • flexion type fractures 
      • neuropraxia in 17%
      • most commonly cause ulnar neuropraxia (91% of flexion-type fracture nerve injuries)
  • 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
  • Volkmann ischemic contracture
    • rare, but dreaded complication
    • result of brachial artery compression with treatment utilizing elbow hyperflexion casting than true arterial injury
      • 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 
 

Please rate topic.

Average 4.1 of 109 Ratings

Technique Guides (2)
Questions (39)
EVIDENCE & REFERENCES (95)
POSTS (1)
VIDEOS (3)
CASES (10)
GROUPS (1)
Topic COMMENTS (107)
Private Note