SUPRACONDYLAR HUMERAL FACTURES IN CHILDREN

• operative treatment in type II and III – to prevent malunion
• medial comminution – subtle finding – if treated non operatively lead to varus mal union
• pulseless limb – angiography not indicated – as delays fracture reduction – which corrects vascular problem
• impending compartment syndrome – high index of suspicion – increased chance if associated forearm # - median nerve injury may mask compartment syndrome
• lateral entry pins – as stable as cross pinning if placed well in fracture lines – no risk of iatrogenic ulnar nerve injury

Introduction

• most common elbow # in children 5-7yrs
• 2/3r d of children with elbow injury have supracondylar #
• boys higher incidence – difference recently equalizing
• left or non dominant side mostly involved

Mechanism of injury and Anatomy

• extension type (97 to 99%) and flexion type
• extension type – fall on to outstretched hand with elbow in full extension
• medial and lateral column of humerus – connected by thin segment of bone between olecranon fossa and coronoid fossa – high risk of#
• elbow extended – olecranon in olecranon fossa – act as a fulcrum
• anterior aspect of the capsule – provides tensile force on the distal humerus proximal to its insertion – results in extension type of injury
• anterior periosteum is torn
• posterior periosteal hinge provides stability to the fracture and facilitates reduction
• direction of the fracture displacement indicates whether the medial or lateral periosteum remains intact
• posteromedial displaced # (MC) - intact medial periosteum – pronation placed medial periosteum in tension and close the hinge – correcting varus malalignment
• posterolateral displaced cases – medial periosteum torn – supination tenses the intact lateral periosteum
• if posterior periosteum torn – unstable in both flexion and extension – multidirectionally unstable – Gartland type IV

Gartland's classification

• Type I
  • non displaced / <2mm
  • intact anterior humeral line
  • may or may not be evidence of osseous injury
  • Posterior fat pad sign may be the only evidence
  • very stable because periosteum intact circumferentially
• Type II
  • >2mm
  • posterior cortex intact, but hinged
  • anterior humeral line does not go through middle third of capitellum – lateral X ray elbow – signifies posterior angulation
  • no rotational deformity due to intact posterior hinge
• Type III
  • displaced with no meaningful cortical contact
  • any rotation in AP X ray
  • usually rotation in sagittal plane and rotation in transverse +/ frontal planes
  • extensively torn periosteum
  • soft tissue and neurovascular injuries
  • comminution and medial column collapse – involvement of medial column signifies the mal rotation in frontal plane
• Type IV
  • circumferentially incompetent periosteum fringe – instability in both flexion and extension

Clinical evaluation

• examine entire extremity
• associated forearm # and compartment syndrome
• soft tissue swelling, ecchymosis
• skin puckering – proximal segment piercing brachialis and engaging dermis – sign of soft tissue damage
• punctuate wound bleeding – open #
• vascular status – compromised in 20%
  • Class I
    • hand warm, red ( well perfused) – radial pulse present
  • Class II
    • hand perfused – radial pulse absent
  • Class III
    • hand cold, blue/ blanched – radial pulse absent
• neurological status
  • ulnar nerve – cross fingers – pinch fingers- palpate I dorsal interosseous contraction
  • hand in wet cloth – area without normal wrinkling response – injury to the nerve supplying that area

X ray

• true AP and true lateral views
• posterior fat pad sign
• true lateral – anterior humeral line cross the capitellum in middle third
  • extension type line passes anterior to capitellum

• Baumann angle or humeral capitellar angle - between long axis of humeral shaft and physeal line of the lateral condyle
  • 9⁰-26⁰
  • decrease indicates the fracture is in varus angulation – seen in subtle comminution of medial column

Treatment

• Initial management
  • Avoid tight bandaging or splinting
  • Elbow in 20 to 40⁰ flexion in splint
  • Traction not justifiable compared to closed reduction and pinning – one night hospital stay, less complications
• Closed reduction and pin fixation
  • GA – first reduced in frontal plane – under C arm – flexed – olecranon pushed anteriorly to correct sagittal deformity and reduce the fracture
  • Acceptable reduction criteria
    • Baumann angle restoration (>10⁰ ) – AP X ray
    • Intact medial and lateral column – Oblique view
    • Anterior humeral line through middle third capitellum – lateral view
    • Rotational malalignment should match with the rotation of shoulder
  • Rotational malalignment unstable – if present reduced with a third fixation pin
  • Reduced # held with 2/3 Kirschner wires
  • Elbow in 40 to 60⁰ flexion
  • Gap in # site, # irreducible, rubbery feeling on attempted reduction, median nerve/ brachial artery trapped in # site – open reduction

Open reduction

• Failed closed reduction, open #, dysvascular limb
• Direct anterior approach – in case of neurovascular compromise
• Direct visualization of brachial artery and median nerve, # components
• Small 5cm transverse incision along cubital fossa – cosmetic approach
• Lateral approach scar tissue contraction – limiting elbow extension
• Posterior approach - not recommended – high rate of loss of motion – risk of osteonecrosis – d/t lose of posterior end arterial supply to trochlea

Type I #

• Long arm cast 60-90⁰ flexion – 3 weeks
• Follow up X ray in one and two weeks – to r/o fracture displacement

Type II#

• Operative intervention than cast immobilization
• Distal humerus give 20% growth of humerus – little remodeling potential
• Growth of upper limb – I yr: 10cm growth – II yr : 6cm – IIIyr : 5cm – IV yr : 3.5cm – V yr: 3cm
• Up to 3 years – growth remaining – non operative treatment may be offered – in cases with capitellum abuts the anterior humeral line but do not cross it
• Child 8-10 yrs – only 10% growth remaining – adequate reduction essential to prevent malunion
• Hyperflexion is needed to maintain the reduction – cast in such position results in raise compartment pressures
• Pronation and flexion positions decrease the flow in brachial artery
• Flexion and supination is good for vascular safety
• In cases of flexion >90⁰ needed – reduction held by pins and elbow flexion less kept ( 45 to 90⁰)

Type III

• If presents in extreme extension or flexion – arm carefully placed in 30⁰ flexion – to minimize vascular insult
• Treated with operative reduction and pin fixation
• Medial column # should be watched for medial comminution – they may not have high displacement of type III # - some advocate closed reduction and pinning for this type to reduce cubitus varus

Type IV

• Extremely unstable cases need open reduction
• Closed reduction also advocated – place 2 Krischner wires in distal fragment – # reduced in AP plane – reduction verified in C arm – rotate C arm to lateral ( instead of moving arm to lateral as commonly done) – reduced in sagittal plane – Kirschner wires driven across the # site

Complications

• Vascular injury
  • Type III supracondylar # - 20-30% absent pulse
  • Absent radial pulse itself not emergency – collateral circulation keeps the perfusion
  • Urgent fixation with pin in ER indicated
  • Absent pulse with no signs of perfusion is an emergency – arm splinted in 20-40⁰ flexion
  • Emergency reduction – not waiting for angiography – if closed reduction not possible – open reduction by anterior approach
  • Artery freed from # site – arterial spasm relieved by lidocaine application, warming, 10-15minutes observation
  • Vascular reconstruction by vascular surgeon if pulse do not return or perfusion lost
  • Pulse present before surgery – absent after pinning and reduction – immediate open re reduction to r/o artery entrapment
• Neurological Injury
  • Older times up to 49% but modern studies 10-20% association
  • Radial nerve previously MC but recently AIN MC in extension type injuries
  • Presents as paralysis of long flexors of thumb and index finger w/o sensory changes
  • Median nerve injury also described – sensory and motor loss present
  • Open reduction of # - exploration of nerve not necessarily indicated in a closed # - neural recovery in 2.5 -6 months
  • Nerve transections rare – exclusively for radial nerve
  • Iatrogenic injury to ulnar nerve with medial placement of pin – removal of pin
• Compartment syndrome
  • Associated in 0.1-0.3% of SC#
  • Forearm compartment syndrome 30-33% association with SC# +BB FA#
  • Increase in compartment pressure at 90 -120⁰ flexion
  • Ecchymosis, swelling even in present pulses with good capillary fill should alert
  • Medial Nerve injury may mask
• Cubitus varus
  • Reason is mal union than growth arrest
  • Baumann angle intact at reduction and remains so at healing
  • Complications of cubitus varus include increased risk of lateral condyle #, pain and tardy posterolateral rotatory instability
• Pin track infections
  • 1-21% cases

Crossed pins compared to lateral entry pins

• ulnar nerve injury in crossed pins are 0 -6%
• two lateral pins to avoid ulnar nerve injury
• elbow flexed 90⁰ – ulnar nerve migrated to even anterior to medial epicondyle in children
• palpation of ulnar nerve or even putting of incision over medial epicondyle – not safe enough for ulnar nerve
• do not use medial pin OR lateral pin inserted first – elbow extended and medial pin inserted (with out elbow hyperflexion)
• for stability
  • maximum pin separation at # site in AP view
  • pins should engage both medial and lateral column just proximal to # site
  • should engage adequate amount of bone proximal and distal to fragments
  • pins slightly in anterior to posterior direction in Lat view
• greater divergence of pins – allow more purchase in medial and lateral column than crossed pins
• three lateral pins have more stability than crossed pins
• pin fixation errors
  • failure to engage both fragments with 2 pins or more
  • failure to achieve bi cortical fixation with 2 pins or more
  • failure to achieve adequate pin separation (>2mm) at # site

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