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Supracondylar Fracture - Pediatric

Topic updated on 08/22/16 2:14pm
Introduction
  • Epidemiology
    • incidence
      • extension type most common (95-98%)
    • 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
Radius
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  
Type II Displaced, posterior cortex intact   
Type III Completely displaced
Type IV*
Complete periosteal disruption with instability in flexion and extension

  SCH flexed

**

*not apart 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 degrees, but best judge is a comparison of the contralateral side
        • deviation of more than 5 degrees indicates coronal plane deformity and should not be accepted
Treatment
  • 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
    • closed reduction and percutanous pinning  
      • indications
        •  in type II and III supracondylar fractures
    • open reduction with percutaneous pinning
      • indications
        • adequate reduction cannot be obtained closed
        • more frequently required with flexion type fractures
      • technique
        • a variety of approaches are acceptable, including the anterior, medial or lateral
    • immediate closed reduction and percutanous pinning
      • indications
        • vascular compromise is present (e.g, pale, cool hand)
        • "floating elbow"
          • ipsilateral supracondylar humerus and forearm fractures necessitate immediate pinning of both fractures to decrease risk of compartment syndrome 
      • technique
        • check vascular status after reduction 
        • if evidence of poor distal perfusion (cold, pale hand with sluggish capillary refill and distal tip turgor) consider the presence of interposed arterial supply, remove pins and unreduce the fracture
        • 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
Techniques
  • Closed reduction and percutanous pinning post
    • fixation
      • closed reduction (extension-type)
        • posteromedial fragments: forearm pronated with hyperflexion
        • posterolateral fragments: forearm supinated with hyperflexion 
      • two lateral pins   
        • usually sufficient
        • confirm stability under fluoroscopy
      • three lateral pins 
        • biomechanically stronger in bending and torsion than 2-pin constructs
        • when comminution is present, 2 lateral pins may be insufficient, and a 3-pin construct such as this is needed
        • 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
        • pins removed post-operatively around 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 malunion 
    • usually a cosmetic issue with little functional limitations 
  • Recurvatum
    • common with non-operative treatment of Type II and Type III fractures
  • Nerve palsy
    • usually resolve
  • Vascular Injury
    • pulseless hand after closed reduction and pinning (3-4%)    
      • pink, warm, brisk capillary refill = serial vascular examination
      • pale, cool, no doppler signal, sluggish capillary refill = emergent vascular exploration
  • Volkmann ischemic contracture
    • rare, but dreaded complication associated with supracondylar humerus fractures
    • more often 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°
  • Postoperative Stiffness
    • rare after casting or after pinning procedures
      • pins removed and immobilzation discontinued to allow gentle rangoe of motion at 3 weeks following surgery
    • resolves by 6 months 
    • literature does not support the use of physical therapy 
 

 

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Qbank (31 Questions)

TAG
(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? Topic Review Topic
FIGURES: A   B   C   D   E  

1. Figure A
2. Figure B
3. Figure C
4. Figure D
5. Figure E

PREFERRED RESPONSE ▶
TAG
(OBQ12.54) Following successful operative treatment, routine removal of hardware is recommended at 3-4 weeks for which of the following procedures? Topic Review Topic
FIGURES: A   B   C   D   E  

1. Figure A
2. Figure B
3. Figure C
4. Figure D
5. Figure E

PREFERRED RESPONSE ▶
TAG
(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? Topic Review Topic
FIGURES: A          

1. Closed reduction and casting of the supracondylar humerus fracture and distal radius fracture
2. Closed reduction and pinning of both the supracondylar humerus fracture and distal radius fracture
3. Closed reduction and casting of the supracondylar humerus fracture and pinning of distal radius fracture
4. Open reduction and pinning of both the supracondylar humerus and the distal radius fracture
5. Closed reduction and pinning of the supracondylar humerus fracture and closed reduction and casting of distal radius fracture

PREFERRED RESPONSE ▶
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 ▶
TAG
(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? Topic Review Topic
FIGURES: A   B   C      

1. Less biomechanical stability
2. Higher incidence of compartment syndrome
3. Higher chance of osteomyelitis
4. Higher risk of iatrogenic injury to the ulnar nerve
5. Higher risk of iatrogenic injury to the anterior interosseous nerve

PREFERRED RESPONSE ▶
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 ▶
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 nerve most commonly injured in this fracture pattern? Topic Review Topic
FIGURES: A          

1. Weakness of the flexor digitorum profundus 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 ▶
TAG
(OBQ06.227) What is the etiology of cubitus varus following a supracondylar humerus fracture in a child? Topic Review Topic

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

PREFERRED RESPONSE ▶
TAG
(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? Topic Review Topic
FIGURES: A          

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

PREFERRED RESPONSE ▶
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 ▶
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 ▶
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 ▶
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