SUPRACONDYLAR FRACTURE - PAEDIATRIC.pptx

Supracondylar

1. SUPRACONDYLAR FRACTURE HUMERUS - PAEDIATRIC

2. INTRODUCTION Supracondylar Humerus Fractures are fractures of the distal humerus just above the epicondyles. One of the most common pediatric traumatic fractures resulting from a fall on an outstretched hand.

3. PATHOPHYSIOLOGY 1. Age group: 5-7 years 2. M = F 3.Mechanism: i . Fall on outstretched extremity ii. Thin cross section of bone in that region 4. Associated injuries: a. Neuropraxia: i . Anterior interosseous nerve (AIN) : Most common ii. Radial nerve palsy → second most common

4. iii. Ulnar nerve palsy patterns seen with flexion-type injury iv.Most cases of neurapraxia in supracondylar humerus fractures resolve spontaneously b. Vascular compromise (10%) → Abundant collateral blood supply can maintain circulation despite vascular injury. c. Ipsilateral distal radius fractures.

5. CLINICAL FEATURES A. Symptoms 1. Pain 2. Swelling 3. Refusal to move the elbow B. Examination 1. Gross deformity 2. Swelling 3. Ecchymosis in antecubital fossa

6. 4. Puckering sign : Brachialis sign → indicates proximal fragment buttonholed through brachialis 5. Limited active elbow motion 6. Neurovascular examination must before any reduction maneuver to be certain nerve or vascular injury is not iatrogenic.

7. 7 . Evaluate for: i . AIN neurapraxia ( Kiloh -Nevin sign) a. FPL → Unable to flex the interphalangeal joint of the thumb b. FDP → Distal interphalangeal joint of the index finger

8. ii. Median nerve injury : Loss of sensation over volar index finger iii. Radial nerve neurapraxia → inability to extend wrist, MCP joints, thumb IP joint iv. Assess vascular perfusion: assess pulse present or absent by  P alpation present or absent by biphasic  Doppler pulse a. Well perfused : 1. Warm 2. Pink b . Poorly perfused : 1. Cold 2. Pale 3. Arterial capillary refill >2 seconds

9. CLASSIFICATION Extension type most common (95-98%), Flexion type less common (<5%)

10. RADIOLOGY 1. 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

11. 2.Displacement of the Anterior humeral line : i . Normally, the anterior humeral line intersects the middle third of the capitellum. ii. Capitellum moves posteriorly to this reference line in extension type fractures and anteriorly in flexion type fractures

12. 3. Abnormal Baumann angle: Baumann's angle → a line parallel to the longitudinal axis of the humeral shaft and a line along the lateral condylar physis (AP view). Normal: ~ 75° Deviation of >5-10° indicates coronal plane deformity and should not be accepted

13. MANAGEMENT A. CONSERVATIVE MANAGEMENT: Above elbow slab after closed reduction (elbow flexion less than 90°) → converted to a cast after swelling subsides 1 . Indications: i . Type I (nondisplaced) fractures ii. Type II fractures when: a. Anterior humeral line intersects the capitellum b. Minimal swelling present c. No medial comminution 2. Hand must be warm perfused without neurological deficits

14. Brachialis muscle inter-position is indicated on the left. The ‘’milking maneuver" frees the brachialis muscle from its location in the fracture, allowing a closed reduction.

15. 3. Immobilization in pronation for posteromedial displacement and supination for posterolateral → for 3 weeks 4. Repeat radiographs at 1 week to assess for interval displacement

16. B. OPERATIVE MANAGEMENT : a.Closed Reduction and Percutaneous Pinning (CRPP): 1 . Indications: i . Type II and III supracondylar fractures ii. Flexion type iii. Medial column collapse 2. Timing: i . Non-urgent (can wait overnight) → warm perfused hand without neuro deficits. ii. Urgent (same day - do not wait overnight) a. Pulseless, well-perfused hand

17. b. Sensory nerve deficits c. Excessive swelling d. "Brachialis sign" →↑ chances of arterial injurye . Floating elbow to decrease the risk of compartment syndrome from swelling iii. Emergent (within hours) → pulseless, poorly perfused hand sos vascular exploration

18. 3. Technique: i . 2 Lateral Pins →→ usually sufficient in type II fractures a. Maximize separation of pins at fracture site ( 50% of width of supracondylar region ) b. Engage both medial and lateral columns c. Engage sufficient bone in proximal and distal segments. d. Low threshold for 3rd lateral pin if concern about stability with first 2 pins e. Pins should be inserted with elbow in flexion for extension-type injury and elbow in extension for flexion-type injury

19. ii. 3 Lateral Pins: Biomechanically stronger in bending and torsion than 2-pin construct. a.Comminution b. Type III and type IV (free floating distal fragment)

20. iii. Crossed Pins: a. Biomechanically strongest to torsional stress b.↑ risk of ulnar nerve injury c. ↑↑ risk if placed with elbow in hyperflexion as ulnar nerve subluxates anteriorly over medial epicondyle in some children d. Reduce the risk of ulnar nerve injury by placing medial pin with elbow in extension → use small medial incision (rather than percutaneous pinning)

21. b.Open Reduction and Pinning: if Closed reduction fails Indications: Inadequate reduction with closed methods Vascular injury Open fractures Disadvantage of ORIF: Elbow stiffness Myositis ossificans Ugly scarring latrogenic neurovascular injury

22. COMPLICATIONS EARLY COMPLICATIONs : 1. Pin migration : a relatively common complication, with rates ranging from 1.8% to 5%. This means that even with standard surgical techniques, some children experience the pins moving out of place after surgery. Type of fracture (Type - III) , Pin fixation type (2 pins or 3pins),Increased time of Pin removal,increased BMI,direction of pin insertion influences the Pin migration. Pin migration leads to loss of reduction,injury to neurovascular structures and need of additional surgery.

23. 2. Pin tract Infection : 1% to 2.5%. Resolve with removal of pins and antibiotic therapy. One study showed incidence of 0.2% for osteomyelitis. 3. Neuropraxia : Freq. 10-20 %, and increases with Type lll SFs to 49%. Median Nerve Injury - Posterolateral distal fracture fragment displacement with medial movement of the proximal fracture fragment. Radial Nerve Injury - Lateral proximal fracture fragment displacement. Ulnar nerve Injury - Ulnar nerve can be damaged iatrogenically during medial pin insertion Recovery usually occurs in 3-4 months. If not, it necessitates exploration.

24. 4. Vascular Injury : Brachial artery - most frequently injured in posterolaterally displaced fractures.Brachial artery causes peripheral ischemia leading to contractures. 5.Compartment Syndrome : Compartment syndrome as result of vascular injury,excessive swelling & hyperflexion of elbow to maintain reduction.

25. LATE COMPLICATIONs : 1. Malunion : Cubitus varus (gunstock deformity) or Cubitus valgus deformity due to faulty reduction of the fracture. Cubitus Varus results due to malunion rather than growth arrest. prevented by making certain Baumann's angle is intact at the time of reduction and remains so during healing. Requires Corrective Osteotomies after skeletal maturity.

26. 2. Non-union : Rare 3.Avascular Necrosis of trochlea : Fragile blood supply to ossification center (more distal # this supply is at risk).Posterior approach to open reduction increases risk.

27. 4. Volkmann Ischemic Contracture → Vascular injury and swelling lead to the development of compartment syndrome (with in 12-24 hours).Ischemia and Infarction can progress to Volkmann's Ischemic contructure Fixed flexion of the elbow Pronation of the forearm Flexion of at the wrist Joint - Extension of the MCP Joint.

28. 5.Heterotopic Ossification/Myositis Ossificans : Due to vigorous manipulation or massage after trauma. 6.Elbow stiffness : takes months to recover.Passive stretching should be avoided.

29. PROGNOSIS Long term outcome and function – - very good if the fracture is appropriately diagnosed and treated. Many of the associated complications – Self-limited - Amenable to functional repair with surgical interventions.