SUPRACONDYLAR HUMERAL FACTURES IN CHILDREN - DNB Orthopaedics MS Orthopedics MRCS Exam GUIDE - Orthodnb.com

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Friday, 29 June 2018

SUPRACONDYLAR HUMERAL FACTURES IN CHILDREN

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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