summary Supracondylar Fractures are one of the most common traumatic fractures seen in children and most commonly occur in children 5-7 years of age from a fall on an outstretched hand. Diagnosis can be made with plain radiographs. Treatment is usually closed reduction and percutanous pinning (CRPP), with the urgency depending on presence or absence of hand perfusion. Epidemiology Incidence extension type most common (95-98%) flexion type less common (<5%) Demographics occur most commonly in children aged 5-7years M = F Etiology Pathophysiology mechanism of injury fall on outstretched extremity Associated injuries neuropraxia anterior interosseous nerve (AIN) neurapraxia (branch of median n.) login to view 1 more bullet radial nerve palsy login to view 1 more bullet ulnar nerve palsy login to view 1 more bullet nearly all cases of neurapraxia following supracondylar humerus fractures resolve spontaneously login to view 1 more bullet 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 login to view 2 more bullets +/- one year, varies between boys and girl Ossification Centers of the Elbow Ossification Center Years at ossification (appear on xray) Years at fusion (appear on xray) Capitellum 1 12-14 Radial Head 3 14-16 Medial epicondyle 5 16-18 Trochlea 7 12-14 Olecranon 9 15-17 Lateral epicondyle 11 12-14 Classification Gartland Classification (may be extension or flexion type) Characteristics Treatment Type I Nondisplaced Beware of subtle medial comminution leading to cubitus varus which technically means it is not a Type I Fracture Treated with cast immobilization x 3-4wks, with radiographs at 1 week Type II Displaced, in 1 plane Posterior cortex and posterior periosteal hinge intact Deformity is in the sagittal plane only Typically treated with CRPP Type III Displaced, 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 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 login to view 7 more bullets vascular exam assess pulse login to view 2 more bullets assess vascular perfusion login to view 7 more bullets Imaging Radiographs recommended views AP and lateral x-ray of the elbow (really of the distal humerus) findings posterior fat pad sign login to view 1 more bullet measurement displacement of the anterior humeral line login to view 2 more bullets alteration of Baumann angle login to view 3 more bullets Angiography is typically not indicated Treatment Nonoperative long arm casting with less than 90° of elbow flexion indications login to view 6 more bullets technique login to view 2 more bullets Operative closed reduction and percutanous pinning (CRPP) indications login to view 4 more bullets time to CRPP dictated by neurovascular status login to view 28 more bullets Pain management is often adequate with anti-inflammatory medications alone emergent vascular exploration and CRPP indications login to view 2 more bullets technique login to view 2 more bullets open reduction, percutaneous pinning, +/- vascular exploration indications login to view 6 more bullets Techniques Closed reduction and percutaneous pinning (CRPP) fixation closed reduction (extension-type) login to view 3 more bullets 2 lateral pins login to view 8 more bullets 3 lateral pins login to view 6 more bullets crossed pins login to view 6 more bullets 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% increased risk in age <4.5 years 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 may represent a cosmetic issue with little functional limitations, however has been associated with posterolateral elbow instability can lead to tardy ulnar nerve palsy anterior nerve subluxation is most common cause nerve entrapment by scar tissue and fibrous bands of FCU second most common cause 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%) if perfusion is lost following reduction and pinning, pins should be removed immediately 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