Supracondylar fractures in children (Final)

Supracondylar fractures in children :

Supracondylar fractures in children Presented by: Dr. Ritesh Sinha First year resident, MS-Ortho NAMS

Definiton:

Definiton A lso called Malgaigne’s fracture F racture line passes just proximal to the bone masses of trochlea capitulum and often runs through the apices of coronoid and olecranon fossae T he fracture line is generally transverse

Why common in children?:

Why common in children? Bony architecture at the supracondylar region is weak and vulnerable because: B one is remodelling I t is less cylindrical M etaphysis is just distal to 2 fossae, coronoid and radial fossa H ere the cortex is thin A nterior cortex has a defect in the area of coronoid fossa L axity of ligaments permits hyperextension at the elbow

Epidemiology:

Epidemiology The peak age is between 5 and 8 years. The rate of occurence increases steadily in the first 5 yrs of life, and traditionally boys have higher incidence of this fracture than girls. The average age at fracture is 6.7 years. Left of nondominant side predominates. 2/3rd of children hospitalized with elbow injuries have supracondylar fractures.

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97.7% have extension type and 2.3% have flexion type Nerve injury occurs in atleast 7 % and significant vascular injury in 1 % Radial nerve is most frequently involved (45%), median (32%) and ulnar (23%) is also involved. 0.5% develop volkman’s ischaemic contracuture Almost all supracondylar fractures are caused by accidental trauma rather than abuse 70% s/c fractures are due to fall from height.

Fractures in association with supracondylar fractures::

Fractures in association with supracondylar fractures: Most commonly distal radius fractures . F ractures of scaphoid and proximal humerus. Monteggia fractures dislocation have also been reported .

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Extension type of s/c fracture

Mechanism of injury: :

Mechanism of injury: F all on outstretched hand with elbow in extension. When it is extended beyond neutral position, flexor muscles are at poor mechanical advantage and there is little resistance to injury.

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H yper extension converts linear force into bending force. When the elbow hyperextentds the olecranon in its fossa acts and fulcurm and capsule tramits extension force to distal humerus just proximal to the physis. Linear force

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The elbow becomes tightly interlocked concentrating bending forces to the distal humerus. As bending forces continue the distal humerus fails anteriorly in the supracondylar area, resulting in s/c fracture.

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When the fracuture is complete the distal fragment becomes displaced posteriorly and the strong action of triceps causes distal fragment to migrate proximally.

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Classification of s/c fractures

Gartland classification: :

Gartland classification: Type I : U ndisplace d s/c fracture

Gartland classification: :

Gartland classification: Type II : F racture with posterior cortex intact

Gartland classification: :

Gartland classification: Type III- displaced with no cortical contact, periosteum may be stripped. type IIIa – posteomedial displacement (75%) type IIIb – posterolateral displacement

Wilkin’s Classification: :

Wilkin’s Classification: Type I – undisplaced fractures Type II – displaced fractures with posterior cortex still in continuity IIa – less severely and merely angulated IIb – angulated severely and malrotated Type III – completely displaced fractures

Role of periosteum in s/c fracture: :

Role of periosteum in s/c fracture: As frac tur e displaces posteriorly the anterior periosteum fails and tears away from the distal fragment. Further displacement is accompanied by corresponding increased periosteal disruption and fracuture instability. Intact medial or lateral periosteum (periosteal hinge) is said to produce fracture stability after reduction.

Posteromedial Vs Posterolateral :

Posteromedia l Vs Posterolateral Biceps tendon insertion and axis of muscle pull lies medial to the shaft of the humerus During fall onto an outstretched supinated arm, the forces applied tend to disrupt the posteromedial periosteum first and displace the fragment posterolaterally. Conversely, if a patient falls with the arm pronated, the distal fragment tends to become displaced posteromedially .

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Medial displacement of the distal fragment places the radial nerve at risk L ateral displacement of the distal fragment places the median nerve and brachial artery at risk .

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C linical Features

Clinical Features:

Clinical Features Pain and inability to use limb.

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Swelling of elbow joint

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S- shaped deformity or upper arm.

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Distal humeral tenderness, elbow bruising, limited range of motion.

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There may sometimes be puckering of the skin when the proximal F ragment has penetrated the brachialis and anterior fascia of the elbow Dimple sign

Relationship between 3 bony points is maintained:

R elationship between 3 bony points is maintained

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Arm is short, forearm is normal in length C repitus is present S ymptoms related to vascular and nerve injury may be seen.

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Radiographic evaluation

AP view X-Rays:

AP view X-Rays Baumann’s angle Metaphyseal-Diaphyseal angle Humero-Ulnar angle

Baumann’s angle: :

Baumann’s angle: 64 o to 81 o Av. 72 o

Importance of Baumann’s angle:

Importance of Baumann’s angle It is the most frequently cited method for assessing the fracture reduction and can be co-realted will with the final carrying angle. It is not obscured or invlalidated by elbow flexion or pronation. A change in 5 degrees of Bauman’s angle results in change in 2 degrees of clinical carrying angle.

Limitations of Bauman’s angle:

Limitations of Bauman’s angle Orientation on x-ray beam more than 20 degrees from perpendicular invalidates the measurement (Dodge) Correlation of Baumann’s angle with carrying angle is not accurate in case of young children’s and adolescent, so used only in comparison with normal elbow (Web and Sherman) In treatment of displaced supracondylar fracture Baumann’s angle is inaccurate indicator of carrying angle. (Mohammad)

Metaphyseal-Diaphyseal angle:

Metaphyseal-Diaphyseal angle

Metaphyseal-Diaphyseal angle:

Metaphyseal-Diaphyseal angle

Humero-Ulnar angle:

Humero-Ulnar angle

Lateral view X-Rays:

Lateral view X-Rays Tear drop sign

Anterior humeral line:

A nterior humeral line

Shaft-condylar angle:

Shaft-condylar angle 40 o -45 o

Fat pad sign:

F at pad sign

Fish tail sign:

F ish tail sign

Crescent sign:

Crescent sign

Coronoid line:

Coronoid line

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MANAGEMENT OF S/C #

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Close reduction Traction method Surgery CRPP ( closed reduction and percutaneous pinning) Open reduction and internal fixation

Type I fracture:

Type I fracture The anterior humeral line transects the capitellum. In general, in a type I fracture, the periosteum is intact with significant inherent stability of the fracture. T ype I fracture may only become apparent with repeat x-rays at 1 to 2week follow-up after presentation

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Simple immobilization with a posterior splint applied at 60 to 90 degrees of elbow flexion is done. This arrangement does not put the brachial artery at risk of compression.

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X-rays are obtained 3 to 7 days after fracture to document lack of displacement, and a long arm cast can be applied An acceptable position is determined by the anterior humeral line transecting the capitellum on the lateral x-ray, a Baumann angle of 70 to 78 degrees or equal to the other side, and an intact olecranon fossa.

Type II fractures:

Type II fractures Closed reduction and splinting in flexion Significant swelling, obliteration of pulse with flexion, neurovascular injuries, excessive angulation, and other injuries in the same extremity are indications for pin stabilization of most type II fractures

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Medial column collapse must be identified, as varus deformity may result after close reduction without stabilization. I n such cases skeletal stabilization with pinning will avoid mal-union.

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P inning can be done by two lateral pins through the distal humeral fragment E ngaging the opposite cortex of the proximal fragment, are generally sufficient to maintain fracture alignment .

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Crossed pinning or lateral pinning can be done but crossed pinning is generally not needed Pins are removed 3 to 4 weeks after fixation

Type III fractures:

Type III fractures Neuro-vascular compromise should be assessed carefully Closed reduction and splinting can be done I n case of absent pulse and pale hand or compartment syndrome is suspected immediate reduction and skeletal stabilization is mandatory.

Closed reduction:

Closed reduction Closed reduction under anaesthesia by traction and counter traction methods. E lbow is immobilized in hyper flexion, as in this position triceps acts as internal splint and forearm is pronated as in this position the medial periosteal hinge closes the cortex laterally.

Closed reduction...:

Closed reduction... Criteria for closed reduction are easy reduction, stable fracture, minimal swelling, and no vascular compromise C losed reduction and casting of displaced fractures resulted in a lower percentage of good results and higher percentages of early and late complications compared with skeletal traction, percutaneous pinning, and open reduction

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Close reduction of the fracture is done in extension and maintenance of the reduction through the use of the triceps bridge by holding the elbow in flexion if the pulse and vasculature tolerate this. Doppler ultrasonography , reports have concluded that in displaced extension supracondylar fractures, extending the elbow and supinating the forearm enhance vascular safety. G ood results have also been reported using manipulation, reduction, and immobilization with the elbow in full extension in a plaster slab .

Technique of close reduction:

Technique of close reduction L ongitudinal traction and counter traction is applied

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After the length of limb is maintained lateral and medial tilt is corrected by manipulation R otational deformity is then corrected

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P osterior tilt is then corrected by flexion reduction maneuver which is then performed with pressure of the thumb over the olecranon and to a variable degree, over the distal condyles of the humerus.

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Generally, the fracture reduction can be felt, and the elbow is then held in hyperflexion and pronation to achieve a stable reduction.

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Distal vascular status should be assessed after reduction. I f radial pulse is not palpable, elbow should be extended till the appearance of radial pulse and splintage should be done 10 degrees beyond this.

Percutaneous pinning:

Percutaneous pinning Before the development of the fluoroscopic unit, blind pinning was performed Mo dern imaging techniques and improved power equipment have made percutaneous pinning the standard treatment .

Percutaneous pinning....:

Percutaneous pinning.... 2 types of pinning used commonly C rossed pins is more stable than 2 lateral pins L ateral pinning C rossed pinning

Crossed pins technique:

Crossed pins technique After close reduction, reduction is maintained, and is confirmed with image intensifier before pinning. The lateral pin is always inserted first. P osition for inserting the pin is documented on AP and lateral views .

Crossed pins technique...:

Crossed pins technique... A small incision is made in the skin , and pin is placed using power drill. P in will traverse the lateral portion of the ossified capitellum , cross the physis , proceed up the lateral column, and always engage the opposite medial cortex proximally.

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2nd pin is placed medially C are shoule be taken not to injure ulnar nerve I ncision is made over the skin over medial epicondyle, blunt dissection is made, ulnar nerve is identified and protected and pin is inserted Crossed pins technique...

Crossed pins technique...:

Crossed pins technique... P in is placed through medial epicondyle and should traverse the medial column and engage the opposite lateral cortex and is more horizontal than lateral pin.

Crossed pins:

Crossed pins

Lateral pin technique:

Lateral pin technique N o risk of ulnar nerve injury L ess stable than crossed pin Two pins are placed which are divergent both in AP and lat views S ometimes a third pin may be inserted on lateral side or medial side if the fracture is found to be unstable.

Lateral pin technique....:

Lateral pin technique.... G ood results can be obtained by maximiz ing pin separation at the fracture site engag ing the medial and lateral columns making sure that the pins engage sufficient bone in both the proximal and distal fragments The goal is to have two pins that are divergent on the AP and lateral views. Two pins crossing at the fracture is unsatisfactory because torque will not be satisfactorily resisted, and a rotational deformity may result.

Lateral pin technique....:

Lateral pin technique.... F irst pin ia generally place d through the center of the ossified capit u lum, cross the olecranon fossa, giving it greater stability, and then further penetrate the medial cortex. A second pin is placed through the distal humeral epiphysis lateral to the capi tu lum but clearly within the epiphysis. The pin proceeds up the lateral column and engages the opposite cortex. A fter stabilization of fracture limb should be kept in posterior slab with forearm in neutral postion and elbow flexed to 60-90 degrees.

Lateral pin technique....:

Lateral pin technique.... Maximal pin separation increases the stability with this technique. A fter stabilization of fracture limb should be kept in posterior slab with forearm in neutral postion and elbow flexed to 60-90 degrees.

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Lateral pin

Intramedullary pin fixation:

Intramedullary pin fixation After closed reduction, the pins are inserted proximally at the junction of the middle and proximal third and is passed distally in the shaft, diverging in each of the supracondylar columns. Labo ratory experiments comparing this type of fixation with medial-lateral and lateral pins showed that proximally placed pins diverging in the distal fragment were more stable than other percutaneous pin fixation methods.

ORIF:

ORIF I ndications of ORIF Closed reduction may not be possible because of interposed soft tissue or neurovascular bundle. When there is gross swelling of elbow so that hyperflexion is not possible after reduction. I njury to neurovascular bundle

ORIF:

ORIF A pproaches for surgery are anterior, medial, lateral and posterior approach. M edial and Lateral approach is usually done from the side in which periosteal hinge is torn. In patients with brachial artery compromise, an anteromedial approach is recommended , and in patients with radial nerve palsy, lateral and medial approaches are recommended. A nterior apporach is preferred to posterior approach because posterior approach is said to lead to stiffness of elbow joint.

ORIF....:

ORIF.... After open reduction of the fracture, fixed with pins. Good callus should be observed at the fracture before pin removal, generally 3 to 4 weeks after injury. The most frequent complication of surgical management appears to be a loss of range of motion.

ORIF....:

ORIF.... If open reduction and internal fixation are to be done, they should be performed emergently (<8 hours) or urgently (≤24 hours) or after the swelling has decreased, but not later than 5 days after injury because the possibility of myositis ossificans apparently increases after that time .

Advantages of ORIF:

Advantages of ORIF D irect reduction L arge hematomas can be evacuated N ecessity in irreducible fracture S hort hospital stay I ncidence of complication is less with ORIF The incidence of neurovascular c omplications from the procedure itself is essentially zero.

Traction Management:

Traction Management I t consists of skin and skeletal traction and is of historical importance of late due to availability of better and effective treatment methods. M ethods of traction: S ide arm skin traction (Dunlop traction) O verhead S keletal traction

Traction management...:

Traction management... I ndications of traction management A n unstable comminuted fracture S upracondylar comminution or medial column comminution that is not suitable for pinning and would certainly collapse with simple casting after reduction.

Traction management....:

Traction management.... Traction can be used to manage type III supracondylar fractures by allowing swelling to decrease . Skeletal traction is superior to sidearm skeletal traction cause it has less incidences of varus deformity.

Overhead skeletal traction:

Overhead skeletal traction Overhead skeletal traction is applied with the help of olecranon wing nut Olecranon wing nut

Overhead skeletal traction:

Overhead skeletal traction The wing nut offers the advantage of applying a torque about the distal humeral fragment by changing the traction rope's position into the holes in the wing nuts.

Technique of Overhead skeletal traction:

Technique of Overhead skeletal traction A hole is made through both cortices just distal to the coronoid process. A wing nut is then placed through the small incision. The wing nut engages the opposite cortex but does not penetrate it. A sling is used to support the hand and forearm. T raction of about 5 pounds is applied, depending on the patient's size. The shoulder should be lifted just off the bed. AP and latera l rays should be taken in traction to judge the adequacy of reduction. After there is good callus formation , the patient is removed from traction and placed in a long arm cast, which is worn for about 2 weeks.

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Overhead skeletal traction

Side arm skeletal traction:

Side arm skeletal traction The arm is abducted at shoulder and traction of 1.5 kg is applied with the elbow at 60 o flexion. C ounter-traction of 1 kg is applied above the elbow.

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COMPLICATIONS OF S/C #

Early complications:

Early complications N eurological involvement (10-20%) R ecovery usually occures in 2 to 2 ½ months

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V ascular involvement (10-20% with type III P resent with absent pulse)

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Physeal damage due to repeated manipulation Compartment syndrome (1%)

Delayed complication:

Delayed complication L oss of mobility/Elbow stiffness A verage loss of 4 degree with close reduction and 6.5 degrees with open reduction

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M yositis ossificans

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C ubitus varus

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Avascular necrosis of trochlea

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Flexion type of s/c Fractires

Mechanism of injury:

Mechanism of injury D ue to fall directly on elbow rather than fall on outstretched hand.

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Distal fragment is displaced anteriorly and may migrate proximally in totally displaced fracture. Ulnar nerve is vulnerable to injury in this pattern of injury, and may be entrapped in fracture of healing callus.

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Classification

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Clinical features

Radiographic Evaluation:

Radiographic Evaluation

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Varies form mild angular deformity to complete anterior displacement. Anterior displacement is often accompanied by medial or lateral translation

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Treatment

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T ype I flexion-type supracondylar fractures are stable nondisplaced fractures that can simply be protected in a long-arm cast

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Type II requires some reduction in extension, the arm can be immobilized with the elbow fully extended.

Sultanpur technique of closed reduction:

Sultanpur technique of closed reduction D escribed by Sultanpur of Baharain Two stages of casting: First cast is put until distal end of proximal fragement and is allowed to set N ext the distal fragement is pushed back against this cast C ast is then completed with elbow in flexion.

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Pinning is generally required for unstable type II and III flexion supracondylar fractures. Pinning should be performed after closed reduction with the elbow in mild flexion (usually at 30 degrees ) or full extension , holding the elbow in reduced position

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After pinning a flexion-type supracondylar fracture, the arm should be placed in a bivalved cast. If the fracture is held in anatomic position with pins, a flexed-arm cast can be used to provide better patient comfort, but a cast with the elbow in almost full extension is acceptable .

Technique of close reduction and percutaneous pinning:

Technique of close reduction and percutaneous pinning

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Open reduction may be required for flexion type of supracondylar fractures if anatomic close reduction can not be obtained. B est performed through an anteromedial or posterior approach, rather than an anterior approach. To ensure that the ulnar nerve is not entrapped in the fracture site, exploring the ulnar nerve or at least identification is probably advisable .

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Traction: R arely used S ide arm traction better than overhead traction

References:

References Campbell operative orthopaedics, 11th edition Rockwood and wilkin’s fractures in children, 6th edition Text book of Orthopaedics, J ohn Ebnezar Mc Rae’s Practical fractures and treatment

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Thank you