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Supracondylar humerus fractures

• Supracondylar humerus fractures are most often due to a fall from a height.
• It is usually the nondominant, outstretched arm (and therefore, typically the left arm
since only 8% to 15% of the world’s population is lefthand dominant) that hits the
ground first and hardest.
• Fortunately, most supracondylar fractures are isolated injuries.
• Children with ligamentous laxity and hyperextension at the elbow have a higher
predilection for a supracondylar rather than a forearm fracture with a fall.
• The peak age is 5 to 6 years, which is also a time when children have more
ligamentous laxity and resultant elbow hyperextension.
• The anatomic mechanism of injury is that the olecranon abuts the olecranon fossa,
and the anterior capsule simultaneously provides anterior tension.
• This combination of traumatic forces propagates an extension fracture through the
thin supracondylar bone of the distal humerus.
• Only about 1% of these injuries are open fractures, but near open fractures with
entrapment of the brachialis muscle, periosteum, neurovascular structures, and skin
and subcutaneous tissue in the fracture site are more common.
• On average, there is about an 8% risk of nerve injury.
• However, the more severely displaced the fracture, the higher the risk of
neurovascular compromise.
• Displaced fractures have, on average, a 20% to 40% risk of neurovascular injury.
Supracondylar fractures are the most common and riskiest fractures about the elbow
in a child.
• Floating elbow injuries with simultaneous supracondylar humerus and forearm
fractures are an even higher energy trauma and, therefore, are at more risk for
compartment syndrome.
• Metaphyseal-diaphyseal fractures are more often due to a direct blow and are harder
to align by percutaneous pinning techniques.
• Nonaccidental trauma, including a difficult delivery at birth, can result in a distal
humeral physeal separation.
• A high index of suspicion is necessary for acute diagnosis and treatment of transphyseal
injuries, especially when the secondary centers of ossification have yet to appear.
• T-condylar humerus fractures are usually due to high-velocity sports injuries in the
adolescent and require adult-type treatment for best results
• The displaced fractures are obvious by the deformity at presentation but need a very
careful and critical exam for neurovascular compromise and associated injuries.
• Inspect the anterior cubital fossa for an open fracture, especially when the skin is
tented and ecchymotic.
• Look for skin puckering that indicates the metaphyseal spike of the proximal
fragment has entrapped the subcutaneous tissues.
• A pucker sign means more disruption of the brachialis muscle, soft tissues,
and risk of neurovascular entrapment.
• A precise, step-by-step exam of the three major nerves (median, radial, and
ulnar) in the upper limb and vascularity of the hand (palpable pulses, capillary
refill, and color of the hand) is imperative in all displaced fractures.
• The median nerve motor function is tested by isolating
• extrinsic (FPL and index finger flexor digitorum profundus [FDP II]) and
• intrinsic (thenar opposition) muscles;
• The ulnar nerve
• extrinsics by flexor digitorum profundus small finger (FDP V) and
• Intrinsics by first dorsal interosseous muscle (index finger abduction with metacarpophalangeal [MCP] joint
flexion)
• The radial nerve
• extrinsics by extensor pollicis longus (EPL) (thumb retropulsion and interphalangeal [IP] joint
extension), extensor digitorum communis (EDC) (finger MCP joint extension), and/or wrist extension
assessment.
• Of note, isolated nerve injuries to the anterior interosseous branch of the median nerve (FPL,
FDP II) are the most common motor impairment with pediatric supracondylar
humerus fractures due to this nerve’s location right next to the displaced fracture.
The median nerve
The radial nerve
Posterior Interosseous Nerve
• The direction of fracture displacement usually coincides with the nerve injury and matches
the local anatomy:
• median nerve injury from posterolateral fractures;
• radial nerve injury from posteromedial fractures; and
• ulnar nerve injury from flexion displacement.
• Multiple nerve injuries are common. Sensibility is tested by light touch in all children and two-
point discrimination in children >5 years of age.
• Do not test sensibility by painful pin prick. The median nerve distribution for sensibility is thumb
and index finger pulp; ulnar nerve is small finger pulp; radial nerve is dorsal first web space.
Accurate preoperative documentation is critical to postoperative decision making.
• If you cannot tell the status of a nerve by motor and sensibility testing, be truthful in the chart and
note that. Later, if the nerve is not functioning, an inaccurate exam or record can impair you or
your consultants in making the best decisions about observation versus intervention.
• Radiographic Classification
• For evaluation of an acute elbow injury, anteroposterior (AP) and lateral
radiographs are standard.
• Unfortunately, you usually get at least one if not two oblique views instead.
• Requesting views of the elbow rather than of the distal humerus compounds the
problem since all elbow injuries present with an elbow flexion posture.
• This leads to overlap of the proximal forearm and distal humerus on the AP x-
ray view of the elbow, but AP and lateral views of the distal humerus will reveal
clear images of the fracture.
• Distal humeral varus-valgus alignment is assessed by Baumann angle of the
humeral-capitellar line on the AP view.
• On the lateral view, the anterior humeral line through the anterior half of the capitellum and
the lateral humeral-capitellar angle (usually 40 degrees) defines flexion-extension deformity.
• The anterior humeral line is drawn down the anterior humeral cortex. , A second line is drawn perpendicular
to the AHL from the anterior to the posterior extent of the capitellum and is divided into thirds. In normal
cases, the AHL passes through the middle third of the capitellum
• Since the capitellar secondary center of ossification is the first to appear at 1 to 2 years, the
alignment of the distal humerus in most pediatric traumatic injuries can be evaluated by humeral
capitellar measurements.
• The medial epicondylar epiphyseal angle is used by some to assess fracture malalignment and
adequacy of reduction in the child old enough to have the medial epicondylar secondary center of
ossification.
• An anterior fat pad sign is often normal, but a posterior fat pad sign is frequently indicative of
an occult elbow fracture.
• The use of CT scans is generally reserved for T-condylar humerus fractures, while MRI scans are employed when
there is a diagnostic dilemma or complex fracture dislocation to reveal injuries to the physeal and/or articular
cartilage.
• Ultrasounds are helpful in nonaccidental trauma before the secondary centers of ossification appear.
• Supracondylar and transphyseal fractures are classified by direction and degree of displacement.
• Up to 98% of fractures are displaced in extension.
• The extension fractures are further defined as posteromedial (varus) or posterolateral (valgus).
• Flexion deformity occurs rarely.
• Both extension and flexion fractures have three-dimensional deformity and thus also malrotation.
• The Gartland classification and its modifications define the degree of displacement:
• type I nondisplaced,
• type II displaced but hinged with cortical contact, and
• type III displaced with no cortical contact
• The AO-ASIF Group have defined three types of
distal humeral fracture:

• Type A – an extra-articular supracondylar fracture;

• Type B – an intra-articular unicondylar fracture (one


condyle sheared off);

• Type C – bicondylar fractures with varying degrees of


comminution.
• TYPE A – SUPRACONDYLAR FRACTURES

• These extra-articular fractures are rare in adults.


• When they do occur, they are usually displaced and unstable – probably because
there is no tough periosteum to tether the fragments. In high-energy injuries there
may be comminution of the distal humerus.

• Treatment
Closed reduction is unlikely to be stable and K-wire fixation is not strong enough to
permit early mobilization.
• Open reduction and internal fixation is therefore the treatment of choice.
• TYPES B AND C – INTRA-ARTICULAR FRACTURES
• X-Ray
• The fracture extends from the lower humerus into the elbow joint; it may be difficult
to tell whether one or both condyles are involved, especially with an undisplaced
condylar fracture.
• There is often also comminution of the bone between the condyles, the extent of which
is usually underestimated.
• Sometimes the fracture extends into the metaphysis as a T- or Yshaped break, or else
there may be multiple fragments (comminution).
• The lesson is: ‘Prepare for the worst before operating’. CT scans can be helpful in
planning the surgical approach