Supracondylar Fractures

An Introduction, Biomechanics, Radiological Diagnosis, Management of Suracondylar Fractures of Children.

1. Supracondylar Fractures Presented by Dr. W. G. P. Kanchana Registrar in Surgery Teaching Hospital Peradeniya

2. Introduction Fracture of distal humerus which is proximal to bone masses of the trochlear and capitulum . Often runs through the apices of coronoid and olecranon fossae, just above the fossae or through the metaphysis of humerus . # goes through the thinnest portion of the bone

3. Epidemiology Most common elbow injury in Children (around 60%) Becomes less common with increasing age Peak age : 5 – 7 yrs Boys > Girls Non Dominant Limb > Dominant Limb Nerve injuries – 7% (Radial > Median > Ulnar) Vascular Injuries – 1% Open # - < 1%

4. Mechanism of Injury Extension Type Commonest Type (95% - 97%)

5. Mechanism of Injury

6. Mechanism of Injury Flexion Type

7. Gartland Classification During the 1950s, these injuries were called the ‘‘misunderstood fracture,’’ as such injuries often resulted in bony deformity and Volkmann’s contracture. In 1959, Gartland described a simple classification scheme to reemphasize principles underlying treatment of patients with a supracondylar humerus fracture. Reliability evaluated by multiple studies. (Barton et al. & De Gheldere et al. – inter-observer reliability 0.74)

8. Gartland Classification

9. Modified Gartland Classification

10. AO Muller Classification of Distal humeral #

11. Radiographic Diagnosis Ossification Centers around the elbow

12. Radiographic Diagnosis X-Ray Views True AP Lateral Oblique Axial (jones view) AP of an elbow in 90 degrees of flexion will give a roughly 45-degree angulated view of the distal humerus and proximal radius and ulna

13. Radiographic Diagnosis

14. Radiographic Diagnosis A rule of thumb is that a Baumann’s angle ≥10 degrees is OK . A decrease in Baumann’s angle compared to the other side is a sign that a fracture is in varus angulation . Further Evaluation May be need, (a) impaction of the medial column (b) supracondylar comminution (c) vertical split of the epiphyseal fragment (T-condylar fractures)

15. Radiographic Diagnosis Gartland type I fracture. Non displaced / Minimally displaced (<2mm) AHL goes across the capitulum . Only sign + ve for a # is the Posterior Fat Pad sign (sail sign)

16. Radiographic Diagnosis Gartland type II fracture. Displaced > 2mm AHL goes anterior to the capitulum . Posterior Cortical Contact is present.

17. Radiographic Diagnosis Gartland type III fracture. No meaningful cortical contact between two fragments.

18. Radiographic Diagnosis Gartland type IV fracture. Has Multidirectional instability. Diagnosed Intraoperatively when in extension capitulum lies posterior to AHL and in flexion capitulum lies anterior to AHL (as in figure)

19. Radiographic Diagnosis Medial collapse signifies malrotation in the frontal plane. (which defines the injury as at least a type II fracture). There is a loss of Baumann’s angle and varus malalignment. The lateral view show reasonable alignment. requires reduction and usually pin fixation to prevent late malunion .

20. Patient Evaluation Approach according to ATLS guidelines. With History of fall - # is high in DDs. Other DDs. Nurse maid elbow - Radial head subluxation Inflammatory arthritis Infection Time and mechanism of injury.

21. Examination Vascular Examination Warm / Cold periphery Red / Blue periphery CRFT Radial pulse present / absent Signs of developing compartment syndrome. Maintain high index of suspicion Pain on passive flexion and extension of fingers Swelling, ecchymosis and anterior skin puckering Tenseness of the volar compartment Anxiety, Agitation and Increased analgesic requirement (3As)

22. Examination Neurological deficits Radial Nerve – Sensation over the dorsal 1 st web space, Wrist and finger extension AIN – OK sign Median Nerve – Sensation over the index finger, Flexion of Fingers Ulnar Nerve – Sensation over the little finger, Interrosei function. Median nerve injury / AIN may mask the pain of compartment syndrome, Thus close monitoring needed. All Documented and informed to relatives / parents

23. Initial Management Initially kept splinted with elbow in a comfortable position. (20 – 40 degree of flexion). Extreme flexion of extension may increase compartment pressure. Avoid tight bandage and splinting. Elbow and hand elevated above heart.

24. Urgency of treatment puckeringtreatment should be urgent In the presence of, poor distal perfusion firm compartments associated forearm # considerable swelling antecubital ecchymosis and skin Several studies have shown that delay of around 8 – 20 hours does not produce significant deleterious effects.

25. Methods of treatment Cast only Closed Reduction and Cast Closed Reduction and Percutaneous Pinning Open Reduction

26. Closed Reduction and Cast Stable, non-displaced #s. (type I) Mildly displaced # (type II) can be reduced closed, using the posterior periosteum as the stabilizing force and maintaining reduction by flexing the elbow >120 degrees. Flexion >120 degrees is the risk of vascular compromise and/or compartment syndrome. Close monitoring needed. Close radiographic follow-up is necessary in the first 3 weeks. (May need to convert to pinning when can not maintain reduction)

27. Closed Reduction and Percutaneous Pinning (CRPP) Most common operative treatment. Initial attempt at closed reduction is indicated in almost all displaced supracondylar fractures that are not open fractures. Technique : Placement of patient and C-arm and the screen is important. Fracture is first reduced in the frontal plane with fluoroscopic verification. The elbow is then flexed while pushing the olecranon anteriorly to correct the sagittal deformity and reduce the fracture.

28. Technique Release of fragment impacted on brachialis muscle Flexing the elbow while pushing olecranon forward to reduce the #

29. Acceptable Reduction Restoration of Baumann’s angle (generally >10 degrees) on the AP view intact medial and lateral columns on oblique views. AHL passing through the middle third of the capitulum on the lateral view. Translation of less than 5mm may be accepted. If # Gap present and Rubbery feeling in reduction, Brachial artery or median nerve may entrapped, thus require open reduction

30. CRPP – Pin configuration

31. Open Reduction Indicated in cases of failed closed reduction, a loss of pulse or poorly perfused hand following reduction, and open fractures. Open reductions led to concerns of elbow stiffness, myositis ossificans , ugly scarring, and iatrogenic neurovascular injury. In setting of severe soft tissue injury and bone injury, better results seen with open reduction.

32. Vascular Injury Radial pulse is absent on initial presentation in 7% to 12% of patients with supracondylar fractures. But an occluded or tethered artery may recover with adequate fracture reduction. Incidence of impaired circulation after an adequate fracture reduction is less than 0.8%.

33. Vascular Injury Pulse may not return immediately after reduction due to arterial spasm. Wait at least 15mins before deciding on brachial artery exploration. Absent radial pulse is not an indication for exploration if good perfusion is maintained. If pulse does not return and hand is poorly perfused, then need brachial artery exploration. If poor perfusion for 6 hours or more, prophylactic forearm compartment release is needed.

34. Vascular Injury Pulseless + median nerve / AIN injury -> Warrants very low threshold for brachial artery exploration and compartment release as, Severe injury is suspected Masking of compartment syndrome

35. Post-op Management Elbow kept at 40 – 70 degrees of flexion. Flexion of 70 degrees or more will increase the risk of vascular compromise and compartment syndrome. Cast is applied with adequate padding. Limb is elevated above the level of the heart atleast 48 hours.

36. Post-op Management Analgesics. Monitor for distal perfusion and compartment syndrome. AP and Lateral Xrays taken at one week . (May need re-reduction if loss of reduction) Cast is removed at 3 weeks . Then Xrays taken out of the cast and pins removed. Gentle ROM exercises are taught. (gentle flexion and extension) R/V at 6 weeks for ROM Check.

37. Complications Pin tract infections 1% to 2.5%. Resolve with removal of pins and antibiotic therapy. One study showed incidence of 0.2% for osteomyelitis. Elbow stiffness Rare. Few studies have shown near normal ROM after 1 year from injury without any formal physiotherapy. Myositis Ossificans (Heterotrophic ossification of muscle) Rare. Can be managed conservatively.

38. Complications Non-union – rare Avascular Necrosis Of trochlear Fragile blood supply to ossification center (more distal # this supply is at risk) Posterior approach to open reduction has increased risk

39. Complications Cubitus Varus malunion rather than growth arrest prevented by making certain Baumann’s angle is intact at the time of reduction and remains so during healing.

40. Thank You