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SUPRACONDYLAR

FRACTURE
 Fracture that occur just above two condyles of the lower humerus.

 Commonly seen in children.

 These injuries are almost always due to accidental trauma, such as


falling from a moderate height

 Fractures around the elbow in adults – especially those of the distal


humerus – are often high-energy injuries which are associated with
vascular and nerve damage.
 Posterior angulation or displacement (extension type) most common
 Anterior angulation or displacement (flexion type)

Extension type Flexion type


Extension type Flexion type
 Fall on an outstretched  Due to direct violence
hand with with the elbow in flexion.
hyperextension injury.
 The clinical presentation is that of a painful swollen elbow
that the patient is hesitant to move.

 The elbow may appear angulated and the upper extremity


shortened.

 Deformity of the elbow is usually obvious and the bony


landmarks are abnormal.

 Open wounds may present.


Gartland’s Classification (applies to extension supracondylar fractures)

 Type 1: undisplaced fracture


 Type 2: angulated fracture with the posterior cortex still in continuity
 Type 3: completely displaced fracture
 AP and Lateral Views of the elbow.

 To diagnose the fracture and adequacy of reduction.

 Lateral view measurement and sign


Fat pad sign (indicates the presence of an elbow joint effusion.)
Anterior humeral line( to assess displacement of distal fragment)
Normal anterior humeral line
Type I
 Type I (undisplaced) fractures are stable and can be treated with cast
immobilisation (posterior slab with elbow flexed almost 90 degrees)
for approximately 3 weeks.
Type II
 Type II usually require reduction (especially when angulation is more
than 20 degrees).
 Although traditionally these fractures were treated non-operatively
with cast immobilisation of the flexed arm to 120 degrees, this
however dramatically increases risk of ischaemic contracture
(Volkmann contracture),
 Percutaneous pinning and cast immobilisation with less than 90
degrees flexion is recommend .
Type III
 Type III fractures can sometimes be treated similarly to type II
(closed reduction and percutaneous pinning) although frequently the
fracture is held open by interposed soft tissues requiring open
reduction.
 Malunion - resulting in cubitus varus

 Ischaemic contracture (Volkmann


contracture) due to damage /
occlusion to the brachial artery

 Damage to the ulnar nerve, median


nerve or radial nerve
 Volkmann’s contracture:
 When the collateral circulation cannot
compensate for occlusion of the
brachial artery
 Lead to ischemia of flexor muscles of
the forearm and cause necrosis.
 Muscle will become thin and
shortened that will eventually lead to
the flexion deformity of the wrist and
fingers (Volkmann’s ischemic
contracture).
EPICONDYLE
FRACTURE
 The most common avulsion injury of the elbow and are typically seen in
children and adolescents.
 Medial epicondyle is avulsed via tension created by structure attached to it which
is flexor muscles.
 The injury is usually extra-articular but can be sometimes associated with an elbow
dislocation (50%).

 These fractures can be classified based on the


 amount of displacement
 whether the medial epicondyle is incarcerated within the joint.
 Fall on an outstretched hand with the elbow in full extension, resulting in sudden
traction on the flexor pronator muscle group of the forearm
 posterior elbow dislocation transmitting force to the medial epicondyle via the
ulnar collateral ligament (accounts for two thirds of cases of medial epicondylar
fractures )
 direct blow (rare)
 chronic injury can also occur both in children (little league elbow) and adults
(golfer's elbow)

Elbow dislocation;
associated with elbow dislocations in up to 50%.
most spontaneously reduce but fragment may be incarcerated in joint.
Traumatic avulsion;
usually occurs in overhead throwing athletes
Elbow dislocation associated with
medial epicondyle fracture. In this
lateral view, fragment is marked
Epicondyle fractures can with circle.
be caused by traction
forces
Symptoms
 medial elbow pain.
• Elbow is placed in 20 degrees of
flexion with the humerus in full lateral
Physical examination rotation and a neutral forearm (while
palpating the medial joint line.
 tenderness over medial epicondyle.
• Applies a valgus force to the elbow.
 valgus instability.
• If the patient experiences pain or
excessive gapping compared to the
contralateral side the test is considered
positive.
 AP and lateral view of elbow.
 Oblique views often helpful as medial epicondyle is located on the posteromedial
aspect of the distal humerus.
 Because the medial epicondyle lies largely outside the
joint capsule, fractures of this structure usually do not
produce distention of the joint capsule.

 Therefore, if a positive fat-pad sign accompanies soft-


tissue swelling, fracture extension distally into the joint
capsule to include the trochlear ossification center and
medial condyle should be considered.

 Radiographic clues to unstable medial condyle fracture in


a young child include;
 soft-tissue swelling
AP view of displaced medial
 a chip or flake of bone from the metaphysis
epicondyle fracture
 the presence of a positive fat-pad sign
• In slightly displaced or nondisplaced fractures of the
medial epiphysis, widening or irregularity of the
apophyseal physis may be the only sign. If the medial
epiphysis is absent, the fragment may be incarcerated
totally into the joint or hidden by the overlying ulnar or
distal humerus.

• A widely displaced fracture-separation of the medial


epicondyle in a patient whose trochlear ossification
center has not yet appeared can indicate that the
cartilaginous trochlea may also be fractured and
attached to the epicondyle. This possibility should be
considered and may warrant surgical exploration. Lateral view - Elbow dislocation
associated with medial epicondyle
• Arthrography may be used to determine the extent of a fracture
fracture and to help distinguish an epicondyle fracture
from a condyle fracture.
 Non-operative
 Brief immobilization (1 to 2 weeks) in a long arm cast or splint.
 Repeat xray after 5 days to ensure no displacement.

 Indications:
 Isolated fractures of the medial epicondyle with between 5 to 15 mm of
displacement heal well.
 Fibrous union of the fragment is not associated with significant symptoms or
diminished function.
 < 5mm displacement usually treated non-operatively, 5-15 mm remains
controversial.
 Operative.
 Open Reduction Internal Fixation.

 Absolute indications:
 Displaced fracture with entrapment of medial epicondyle fragment in joint
 Open fracture
 If medial condyle is involved

 Relative indications:
 Ulnar nerve dysfunction
 > 5-15mm displacement
 Displacement in high level athletes
Arm will be immobilized in a cast and removed after 3 or 4 weeks
 Nerve injury.
 ulnar nerve can become entrapped.
 neuropathy with dislocation which usually resolves.

 Elbow stiffness.
 loss of elbow extension, avoid prolonged immobilization.

 Non-union.
 Missed incarceration of fragment in elbow joint
 They are much rarer than medial epicondyle fractures and represent avulsion of
the lateral epicondyle.
 They are usually seen in the setting of other injuries.
 Incidence typically peaks in the paediatric age group.
 Falls on the hand with elbow extended and forced into varus.
 Fragment will be pulled by extensors.
 In children these injuries are believed to occur due to sudden
traction on the common extensor origin by the extensor musculature.
 In adults lateral epicondylar fractures are usually due to a direct blow.
 Elbow is swollen and deformed.
 Tenderness over the lateral condyle.
 Passive flexion of wrist can be painful.
 Type I: fracture is lateral to trochlea
(elbow joint not affected).

 Type II: fracture through the middle


of trochlea (more common, fragment
becomes more grossly displaced)
 Fracture fragments are primarily cartilaginous. The fracture line through the
cartilage is not visible on radiograph.
 Treatment strategies are therefore based on the amount of displacement.
COMPLICATIONS
 Non union or mal union.
 Recurrent dislocation.
MANAGEMENT
 Undisplaced or minimally displaced injuries can be treated conservatively; Splint
in backslab with elbow flexed 90°, forearm neutral and wrist extended.
 Repeat x-ray after 5 days to ensure there is no displacement
 Splint is removed after 2 weeks.
 In significantly displaced fractures, rigid internal fixation allowing early
mobilisation is an option although conservative management for these patients
also is an option.
 Arm will be immobilized in a cast and removed after 3 or 4 weeks.