supra condylar humerus anatomy mechanism of injury investigation treasury

Supra condylar fracture in children

1. SUPRA CONDYLAR #S OF HUMERUS IN CHILDREN
IInd M.c # in 1
st
decade.
at 5 –8 years (<) predominant
M : F – 2:1
Deformities & N.V complicns
makes it sereous injury
Injury to R. N, M.N & U.N .
Kinging of Br. A - V.I

2. MECHANISM OF INJURY
Major factors
Lig. Laxity
Relationship of Jt hyper
extn.
Bony architecture of S.C.A
I. Lig. Laxity - for hyper
ext. of major jts.
Children with H.ext of
elbow –more susceptible
for R.ptd s.C. #s.

3. Relationship of Jt. Strs in Hyper extn.
Elbow hyper extends allows linear force through extd
elbow converted to a bending force B.F concentrated
by the Olecranon to weak S.C.A. The ant. Capsule &
ant.portion of col. Ligs taught in hyper exten
reimforce theExt. Force antly Extention of the elbow
increases Two portions of E/Jt. become tightly
interlocked by Lig.force

4. Bony Architecture of S.C.A
Weak at Ist decade
Thinnest portion at O/Fo
Tip of ole.forced during H.Extn.
Elastic epiphysial and art.cart. in the distal portion
act as buffer to transfer the force of hy.extn injuring
to S.C.A

5. Bony Pathology
# is transverse –Just above epicondyles entering thin
area bet. ole & coronoid Fossa – Just prox to widest
ant post diameter # line may transverse or oblique.
Very sharp protruding spikes involve the cortical
portions of S.C. ridges.
These spikes – damage to surrounding tissues.

6. Periosteal changes - in three stages
Stage –1 : Minimally displaced #
periosteum stretches across the ant. #
Site – intact.
Stage – II -More displaced
Distal periosteum torn pulled distally
across the sharp edge of prox.frgf.
leaving a gap antly.
Stage – III – Peri Comply torn antly
Peri remain intact postly medly + Latly.
 The distal portion of prox. frgt. Circumly
stripped of its peri.
A strip interposed between # frgt
prevent complete redn

7. Soft tissue pathology
Brachialis muscle protects the ant. N.V
structures with severe displacement -
med/or lat/spike pemetrates the
Brach.muscle + fascia. Medl spike –
tethering medn n +Bn. A. Ib tall spike
tethe rimg R.N

8. Classification
Classification based on
1.Degree of displacement line
2. type + locn of # line
Depending on distal fragments.
1.Extn type - 97.7%
2.Flexn type - 2.3%
1. # Line upwards backwards
2. # Line down and forwards.

9. Gart land classification
Gart land classification modified by Wilkins (1984) –
most widely accepted system.
Based on radiographic appearance of displit
Type I- Undisplaced.
Type II- Displaced with intact post cortex
Type III - Displaced toally No intact post
cortex distal fragment displaced medly or latly.

10. Post . medl & post latl
Post. Medl displt secondary to
pull of tricepts –
Post latl displacement ury to
either post # manipulation or
rotatory force
Post medl# -varus angln
Post latl # - Valgus
anguln

11. Other Classifications
1.Hendrickson classification based on the appearance
of latl roentgeno gram – 4 types
2.El –Ahwany’s classification – based on the AP, Latl,
taxlal view of Elbow – 5 types.

12. Symptoms
Pain & gross swelling
‘S’ shaped confign – in type III #
Loss of active +passive movements
Symptoms related to N.V injury.
Signs:
1.Anm is short farm in Ni length
 
      
2.Gross swelling + tenderness.
3.Gepitus
4. ‘S’ shaped deformity.
5. Dimple sign
6. Soft spot
7. Movements – active & passive decreased

13. Radiographic Findings
X –Ray
AP
Latl views
Oblique
Bauman’s angle : Angle bet
horizontal line of elbow, line
through latl epiphysics + long
axis of the arm. Nl. Less than 5
o

compared with the other side.

14. Latl view
2. Tear drop signs. Seas in Nl.Disturbed in #
3. Anthumeral line
Along the ant.bord of Shft.
Passes through middle 1/3 of capitulum if passed
through anti.1/3 – inde cates post displacement.
4. Coronoid line :
Along the anti – border of coronoid, just touch
ant.portion of Ltl condyle post. displacement of latl
condyle will project the ossificn Centre post to this
line.

15. 5.
 
Fat pad sign : Not seen N/y
In Effusion- Seem as  Radio luscency ventral
to distal H.Post fat pad can also seen due to effusion.
6. Fish tail sign : due to rotation of distal fragment
ant.border of prox frgt looks like a sharp spike.
7. Gescent sign : Nl radio luscent gap of the
elbow Jt is missing …. A crescent shaped shadow
due to overlap of the capittulum over the olecremen –
indecates either varus or valgus tilt.

16. Management
Adequate History and careful clin : Ex:
Development of pain in Forearm hrs after injury
indicates is chaemia.
Palpate peri pulse for adequacy of bl. Flow. All exten.
Type # Should be splinted in a position Of 20
o
to 30
o

flexion.
Type – 1
Immobilise the lib in a post. Splint or in Oar cast.
Hospitalise – a brief Perd for observation. By 3 weeks
pain +selling subsided. Allow active range of
movement
X ray reveals – active new bone foreman

17. Type II
Rotation +anguln of distal fragment corrected first
followed by flexion of elbow to correct the post.
Anguln. Immorbilise the elbow in flexion with fore
arm in full pronation & maintain the reduction
Type III
Manipuation of the fragment to obtain adequate
reduction. Extend the arm e f. arm in
supine .Displacing the fragments by hyper extention –
applying longiterdinal traction – gradually flexing the
elbow – Counter traction on prox.arm Medl & latl
displacement conrected. Once length and alline ment
corrected elbow is flexed and pronating the fore arm.

18. Traction Techniques
Only method of obtaining a closed redun and reduce
The swelling
I.Skin traction methods
1. Ingenbrightsen’s overhead skintraction
Involved 3 sets of weights - a vertical force was
applied along the arm -elevated over the head
2.Lenear tracation along the fore arm
3.Counter traction to the ant-part of distal arm

19. Dulops side arm skin traction
Elbow in midflexian – predispose to cuitas
varus. So fore arm in supinration
Graham’s extn skin traction
Over come this tendancy in supimation to
varus angulu applying a counter force against
the latl aspect of the distal arm

20. Skeletal tractions
Applied with small wire or pin through the olecranon.
Over head + side arm positions are used. Overhead
supr to side arm traction.
Placement of Ole cranon Pin –
distal to the caronoid proless.
Sketetal traction also with the use of screw using this
screw for
1. The case of application
2. To reduce ulner Nerve injury.

21. Watson & Jonson opposed the use of traction
he believed that lead to
–1. 
  
Capsular contracture and permanent stiffness.
–2. 
  
Infection either pin or screw.
–3. Pin can migrate form side to side
–4. The traction bow direct prssure Local uecrosis
–5. Trans ole cramon pin ulnar N.injury.
Open Reduction
Indicns : 1. A/C Vas. Injury 2. Irruducible #
3. Severely displaced #s 4. Open #s 5. Failure of
satisfactory reduction.

22. Surgery
Curved Incision over lat 1 condyle – 2 cm. Distal to
olecranon carrying it proxly about 6cms above
condyle. Disscet the soft tissue with Anconeus
common extensor origion and retract antly & postly
R.N. postly retract. Evacuae haematoma observe S.C.
figt allignment with prox fragt reduce # e alignment
with prox fragt. Reduce #e 2 steinmann pin. Cuts the
pin out off outside the skin for easy removal close
incision in layers post. Plaster splint applied. Radial
pulse + neurological fn checked. Pins removed after 3-
4 weeks. Active Av. Motion started.

23. Advantages of I ry open reduction
1.Excellent anatomic reduction
2.At surgery, soft tissue obstacles to reduction are
easily removed.
3.Entrapped N.V. structures liberated & Haematorna
evacuated.
4.Marked swelling of elbow subsided easily
Pt will be comfortable soon after surgery.

24. Complications
1.Loss of range of elbow motion
2.Cubitus varus due to inadequate reduction.
3.Post open information.
4.Growth disturbance due to physial injury
5.Neurovasucular injury.
6.Delay in surgery will cause Joint stiffness.