Supracondylar humerus fractures in pediatric age group

1. DR.SUBODH PATHAK

3. As the fact Remains….
 Upper-extremity fractures account for 65% to 75% of
all fractures in children
 7% to 9% of upper-extremity fractures involve the
elbow.
 The distal humerus accounts for approximately 86% of
fractures about the elbow region
 Supracondylar fractures are the most frequent elbow
injuries in children, reported to occur in 55% to 75%

4.  Elbow injuries are much more common in children and
adolescents than in adults .
 The peak age for fractures of the distal humerus is
between 5 and 10 years old.
 Houshian et al 1 reported that the average age of 355
children with elbow fractures was 7.9 years (7.2 years in
boys, 8.5 years in girls).
 Cheng et al2 found a median age of 6 years (6.6 years in
boys and 5 years in girls) and a predominance of injuries
(63%) in boys

5. ANATOMY

6. Blood Supply
Extraosseous
 rich arterial
network around
the elbow
 brachial artery

7. Blood Supply
 The major arterial trunk, the brachial artery, lies
anteriorly in the antecubital fossa. Most of the
intraosseous blood supply of the distal humerus comes
from the anastomotic vessels that course posteriorly.

8. OSSIFICATION CENTERS

11. Intra-Articular Structures
 The articular surface lies within the confines of the capsule,
but nonarticulating areas involving the coronoid and radial
fossae anteriorly and the olecranon fossa posteriorly are also
within the confines of the articular cavity.
 The capsule attaches just distal to the coronoid and
olecranon processes. Thus, these processes are intra-
articular The entire radial head is intra-articular, with a
recess or diverticulum of the elbow's articular cavity
extending distally under the margin of the orbicular
ligament. The medial and lateral epicondyles are extra-
articular.

12. TYPES
FLEXION TYPE
EXTENSION TYPE

13. EXTENSION TYPE: Mechanism
 Fall onto the outstretched hand with the elbow in full
extension.
 The olecranon in its fossa in the distal humerus acts as a
fulcrum, whereas the capsule transmits an extension
force to the distal humerus just proximal to the physis as
the elbow hyperextends.

15. Posteromedial versus Posterolateral
Displacement
 Medial displcement is more common- 75%
 Medial displacement of the
distal fragment places the
radial nerve at risk,
 lateral displacement of the distal fragment places the
median nerve and brachial artery at risk

16.  The position of the hand and forearm at the time of
injury plays a role in the direction of the distal humeral
fragment's displacement.
 In a patient who falls onto an outstretched supinated
arm, the forces applied tend to disrupt the
posteromedial periosteum first and displace the
fragment posterolaterally.
 If a patient falls with the arm pronated, the distal
fragment tends to become displaced posteromedially.

17. Role of the Periosteum
 Supracondylar fracture displaces posteriorly, the
anterior periosteum fails and tears away from the
displaced distal fragment.
 The anterior loss of periosteal integrity leads to frequent
failure of anterior callus formation in early fracture
healing

18.  Intact medial or lateral periosteum, the periosteal
hinge, has been said to provide stability after fracture
reduction .
 Forearm pronation after reduction of a
posteromedially displaced supracondylar fracture is
said to stabilize reduction by closing the fracture gap
laterally, tensioning the medial periosteal hinge, and
tightening the lateral ligaments of the elbow.

19.  Forearm pronation
after reduction of a
posteromedially
displaced supracondylar
fracture is said to
stabilize reduction by
closing the fracture gap
laterally, tensioning the
medial periosteal hinge,
and tightening the
lateral ligaments of the
elbow.

20.  Supination of the forearm
creates a downward lateral
tilt of the distal fragment .
 This produces compressive
forces between the
articulating surface of the
ulna and the trochlea's
medial border , which in
turn, generates clockwise
forces about the medial
side of the fracture.

21. Why is it Important to know the
Direction of Displacement????

22.  Because it determines which soft tissue
structures are at risk from the penetrating
injury of the proximal metaphyseal fragment.

24. RADIOLOGY
Standard Views
 Anteroposterior (AP) view with the elbow extended.
 A lateral view with the elbow flexed to 90 degrees and
the forearm
neutral
 Jones View

25. JONES VIEW

26. Anteroposterior Landmarks
 Baumann Angle
 “shaft-physeal” angle
 physeal line and the
long axis of the humerus
 Baumann angle is a good
measurement of any deviation
of the angulation of the
distal humerus
Normal :72 degrees
(range 64 to 81 degrees)

28. Humeral-ulnar angle
 humeral-ulnar angle is the most accurate in
determining the true carrying angle of the elbow
Metaphyseal-Diaphyseal
angle

29. Lateral Landmarks
 Teardrop
 Posterior margin of the
coronoid fossa
 anterior margin of the
olecranon fossa
 Superior border of ossification center of the
capitellum
 Shaft-Condylar Angle
 angulation of 40 degrees between
the long axis of the humerus and
the long axis of the lateral condyle

30.  Anterior Humeral Line
 anterior border of the distal
humeral shaft, it should pass
through the middle third of the
ossification center of the capitellum
 Coronoid Line
 anterior border of the coronoid
process should barely touch the
Anterior portion of the lateral condyle

31. What are we Looking For???

32. Figure of 8 sign

33. Anterior Humeral Line

35. Fat Pad Signs
 Anterior fat pad: coronoid
 Triangular lucency
 The anterior fat pad extends anteriorly out of the margins of the
coronoid fossa
 Coronoid fossa is shallow- sensitive, but not specific

37. Posterior fat pad : olecranon
 Deep
 Moderate to large effusions needed
to displace it
 High specificity for intra articular
disorder( # present in 70%)

43.  Results support the practice of managing children
who have a history of trauma to the elbow, an
elevated posterior fat pad, and no other
radiographic evidence of fracture as if they have a
nondisplaced fracture of the elbow.

44. Radio-Capitellar line

46. The brachial artery is
placed further at risk
by the ulnar-sided
tether of the
supratrochlear artery

47.  Gartland (1959)
 Type 1 non-displaced
 Type 2 Angulated/displaced fracture with intact
posterior cortex
 Type 3 Complete displacement, with no contact
between fragments

49. Type 1

50. Type 2

51. Type 2

52. Type 2: Angulated/displaced
fracture with intact posterior
cortex
 In many cases, the type 2
fractures will be impacted
medially, leading to varus
angulation.
 The varus malposition
must be considered when
reducing these fractures,
applying a valgus force for
realignment.

53. Type 3

54. Type 4
 Described by Leitch et al.
 Type IV fractures are unstable in both flexion and
extension because of complete loss of a periosteal
hinge.
 These fractures occur either as result of trauma or by
excessive flexion force applied during the closed
reduction maneuver.

55. Signs and Symptoms.
 Elbow pain or a child who fails to use the upper
extremity after a fall.
 Point tenderness over the medial and lateral columns
 Type I supracondylar fracture, there is distal humeral
tenderness and restriction of motion, particularly lack
of full extension
 In type III fractures, gross displacement(deformity) of
the elbow is evident

56. Signs and Symptoms.
 An anterior pucker sign may be present if the
proximal fragment has penetrated the brachialis and
the anterior fascia of the elbow

58. Brachialis Sign
Proximal Fragment Buttonholed through Brachialis

59.  A high index of suspicion is needed to recognize
signs of a developing forearm compartment
syndrome, such as considerable swelling or
ecchymosis, anterior skin puckering, and an
absent pulse

60. Ref: Rockwood and Wilkins' Fractures in Children, 7th ed

61. Initial Management
 For fractures with displacement that require
reduction, initial splinting with the elbow in
approximately 20 to 40 degrees of flexion provides
comfort and allows further evaluation.
 Avoid Tight bandaging or splinting ,excessive flexion
or extension, which may compromise the vascularity
of the limb and increase compartment pressure.
 The arm should then be gently elevated

62. Closed Reduction and Pin Fixation
 most common operative treatment
 patient under general anesthesia, the fracture is first
reduced in the frontal plane with fluoroscopic
verification.
 The elbow is then flexed while the
olecranon is pushed anteriorly
to correct the sagittal deformity and
reduce the fracture

63.  Criteria for closed reduction are
 easy reduction,
 stable fracture,
 minimal swelling
 no vascular compromise

64. Criteria for an acceptable reduction1. Restoration of the Baumann angle (which is generally
>10) on the anteroposterior radiograph (with in 4
degrees of normal side) ,
2. intact medial and lateral columns as seen on the
oblique radiographs, and
3. the anterior humeral line passing through the middle
third of the capitellum on the lateral radiograph.

66. Milking maneuver
 This maneuver is carried out by manipulating the soft
tissue over the fracture to pull the soft tissue away from
the proximal fragment rather than simply applying
traction on the bones, which may not allow reduction
of a buttonholed proximal fragment.
Described by Archibeck and Peters

67.  If it the proximal fragment appears to have pierced the
brachialis muscle, the “milking maneuver” is used

68. Milking Maneuver
Milk Soft Tissues over Proximal Spike
Archibeck. Brachialis muscle entrapment in displaced supracondylar humerus fractures: a technique of closed reduction
and report of initial results. J Pediatr Orthop. 1997;17:298.

69.  Next, varus and valgus angular alignment is
corrected by movement of the forearm.
 Medial and lateral fracture translation is
corrected with direct movement of the distal
fragment by the surgeon's thumb(s) with image
confirmation.
 The elbow is then slowly flexed while anterior
pressure is applied to the olecranon with the
surgeon's thumb

70. Reduction
maneuver

71.  After successful reduction, the child's elbow should
sufficiently flex so that the fingers touch the shoulder.
 If not, the fracture likely is still not reduced and is in
extension

72.  Check for intact medial and lateral column under c-arm
(oblique views)

73. Technique of Reduction

74.  If there is a considerable gap in the fracture site or the
fracture is irreducible with a so-called rubbery feeling
on attempted reduction, the median nerve and/or
brachial artery may be trapped
 proceed to an open reduction
 Once reduction is satisfactory,
the elbow is taped in the reduced
position of elbow hyperflexion

75. Type 1 Fractures
 Treated with immobilization for approximately 3 weeks,
at 60- 90 degrees of flexion.
 If there is significant swelling, do not flex to 90 degrees
until the swelling subsides.
 follow-up radiographs be made at one and two weeks to
identify any fracture displacement

77. Type 2 Fractures
 Reduction of these fractures is usually not difficult
 Maintaining reduction usually requires flexion beyond
90°
 Excessive flexion may not be tolerated because of
swelling
 May require percutaneous pinning to maintain reduction
 Percutaneous pinning is the safest form of
treatment for many of these fractures
 Pins maintain the reduction and allow the elbow to be
immobilized in a more extended position
Fitzgibbons. Predictors of failure of nonoperative treatment for type-2 supracondylar humerus fractures. J Pediatr
Orthop. 2011;31:372.

78. Type 3 Fractures
 These fractures have a high risk of neurologic
and/or vascular compromise
 Can be associated with a significant amount of
swelling
 Current treatment protocols use percutaneous
pin fixation in almost all cases
 In rare cases, open reduction may be necessary
 Especially in cases of vascular disruption

79. Indications for Open Reduction
 Inadequate reduction
with closed methods
 Vascular injury
 Open fractures

80. Closed Reduction Percutaneous Pinning
 Treatment of choice for most supracondylar
fractures.
 Open Reduction Usually not Necessary
 Done under strict C Arm Control
 Various configuartions
 Biomechanically Stable

81. Pinning

82. 1. Maximal pin separation at the fracture site.
2. The pins should engage both medial and lateral columns
just proximal to the fracture site.
3. They should engage an adequate amount of bone proximal
and distal to the fragments.
4. On the lateral view, pins should incline slightly in the
anterior to posterior direction in accordance with normal
anatomy.

83.  If placing a medial pin, extend the elbow when placing
the pin to keep the ulnar nerve posterior and out of
harm's way.

85.  If any rotational malalignment present careful in
assessmeny of the stability of the reduction and
probably use a third fixation pin
 The fracture reduction is held with two or three
Kirschner wires
 Elbow is immobilized in 40 to 60 of flexion,
depending on the amount of swelling and the
vascular status.

87. Loss of Fixation…..
In a study of eight supracondylar humeral fractures that
lost reduction, Sankar et al. reported that the loss of fixation
in all cases was due to technical errors that were identifiable
on the intraoperative fluoroscopic images and could have
been prevented with proper technique. They identified
three types of pin-fixation errors:
(1) Failure to engage both fragments with two pins or more
(2) Failure to achieve bicortical fixation with two pins or
more, and
(3) Failure to achieve adequate pin separation (>2 mm) at
the fracture site.

89.  Conclusions:We found no statistical difference in
the radiographic outcomes between lateral-entry and
medial and lateral-pin techniques for the management
of Type 3 supracondylar fractures in children when
evaluated in this prospective and surgeon-randomized
trial, but 2 cases of iatrogenic injury to the ulnar nerve
occurred with medially placed pins.

90.  For operative fixation with medial/lateral entry pins, the probability of
ulnar nerve injury is 5.04 times higher than with lateral entry pins.
When all documented operative nerve injuries are included, the
probability of iatrogenic nerve injury is 1.84 times higher with
medial/lateral entry pins than with isolated lateral pins. Medial/lateral
pin entry provides a more stable configuration, and the probability of
deformity or loss of reduction is 0.58 times lower than with isolated
lateral pin entry. When the prospective studies alone were analyzed,
there were no significant difference in the probability of iatrogenic nerve
injury or deformity and displacement, although the confidence intervals
were wide. This systematic review indicates that medial/lateral entry
pinning, of pediatric supracondylar fractures, remains the most stable
configuration and that care needs to be taken regardless of technique to
avoid iatrogenic nerve injury and loss of reduction.

93.  Earlier Closed reduction and pinning of type
III supracondylar fractures was performed as an
emergent procedure .
BUT……………….
 Is it beneficial??

98. The puzzle of pulse and
perfusion

102. Pink Pulseless Hand
• Injury to the brachial artery can have potentially serious consequences,
such as Volkmann ischemia, loss of limb, and retarded development of the
limb.
• The common practice of watchful waiting for pulseless and perfused
supracondylar fractures may be open to question in favor of a more
aggressive approach.
• Doppler ultrasound may be useful in differentiating patients at risk and
can be part of an effective vascular evaluation.
• Prospective studies are needed to provide more definitive information on
management of supracondylar humerus fractures.

103. Absent pulse on
Arrival
Closed reduction and Lateral pinning
Palpable Pulse
Pink Pulseless Hand
Return of Pulse
in 48 Hours
Pink hand with
Absent Radial Pulse
Periodic Weekly review for 6
weeks

104.  Obliteration of the intact preoperative radial pulse after
closed reduction and pinning is a strong indication for
brachial artery exploration only when accompanied by
evidence of impaired circulation to the hand.
 After 10 to 15 minutes is allowed for resolution of arterial
spasm as a cause for loss of pulse, the brachial artery
should be explored if the hand is not warm and pink.
 Either direct arterial entrapment at the fracture or arterial
compression by a fascial band pulling across the artery may
cause loss of pulse after fracture reduction.
 Other indication for brachial artery exploration is
persistent vascular insufficiency after reduction and
pinning

105.  The management of a persistent pink pulseless hand after a satisfactory closed
reduction in a pediatric supracondylar fracture of the humerus is
controversial.
 Several recent publications have recommended vascular exploration in
contrast to a more conservative approach accepted traditionally. We report the
results of seven patients with a mean follow-up of 36.6 months with a
persistent pulseless, but well-perfused hand postreduction.
 All patients were managed conservatively without vascular exploration. A
palpable return of the radial pulse was seen in six patients at 3 weeks and at 6
weeks follow-up in the other patient with no long-term dysfunction. We
believe that the management of a persistent pink pulseless hand remains a
'watchful expectancy'.
 Surgical exploration should be recommended only if there is either severe
pain in the forearm persisting for more than 12 h after the injury or if there are
signs of a deteriorating neurological function.

106. The pink pulseless hand: a review of the
literature regarding management of
vascular complications of supracondylar
humeral fractures in children.
 Griffin KJ, Walsh SR, Markar S, Tang TY, Boyle JR, Hayes PD.
 Abstract
 Supracondylar fractures of the humerus are the commonest upper limb fractures in
children, accounting for up to 70% of all paediatric elbow fractures.] and are often
complicated by neurovascular injury. Much confusion surrounds the management of the
child with a "pink pulseless hand" post-fracture reduction and several treatment options
have been proposed including observation, immediate exploration and angiography. The
literature contains a number of case series with variable follow-up.
 A child with a pink pulseless hand post-fracture reduction can be
managed expectantly unless additional signs of vascular compromise
develop, in which case exploration should be undertaken.
PMID:
18851922,2009
[PubMed - indexed for MEDLINE]

107. CONCLUSION: The presence of a waveform on a pulse oximeter is a sensitive and
easily available modality in determining vascular perfusion as compared to other
more complex investigations. The high sensitivity of this test will allow surgeons to
objectively determine the requirement for surgical exploration of the brachial artery.
RESULTS:In this series of pulseless perfused hands following operative fixation of
supracondylar fracture, a total of 26 patients were reviewed. All were Gartland grade
III extension type fractures. Postoperative pulse oximeter waveforms were present in
all but 4 patients. These patients subsequently had exploration of the brachial artery
with significant findings. In the remaining 22 patients, waveforms were present and
the child had return of the radial pulse soon after operative fixation without any
further need for surgical exploration. At 24 months follow-up, all children were well
with no neurovascular compromise

111. Pale Hand ,Absent Pulse
NO
CONTROVERSY

112. Pale Hand ,Absent Pulse
IMMEDIATE
EXPLORATION

113. Vascular involvement
(10-15% with type III
Present with absent pulse)

114.  Open reduction through an anterior
approach with medial extension allows
evaluation of the brachial artery and
removal of the neurovascular bundle
entrapped within the fracture site or repair
of the brachial artery.

115. Brachial Artery Exploration
 Orthopaedic surgeon + Vascular surgeon
 Release of a fascial band or an adventitial tether
resolves the problem of obstructed flow.
 The brachial artery should be approached through a
transverse incision across the antecubital fossa, with a
medial extension turning proximally at about the level
of the medial epicondyle .

116.  If Arterial Spasm is the cause ----Release the spasm
 Vascular Graft might be Required.

117. Arterial reconstruction using the basilic vein from
the zone of injury in pediatric supracondylar humeral
fractures: a clinical and radiological series.
Lewis HG, Morrison CM, Kennedy PT, Herbert KJ
 The authors describe the advantages of using the basilic vein as an arterial
conduit in the management of children with supracondylar humeral fractures
requiring vascular repair. This series confirms the safety of
using a donor vein from within the zone of injury for
arterial reconstruction, after a supracondylar humeral
fracture. Benefits include a single surgical wound on the less conspicuous medial
side of the arm, reduced operating time, and preservation of donor veins that may be
subsequently required for the management of atherosclerotic disease.

118. Supracondylar Humerus Fractures:
Complications
 Vascular injury / compromise
 Compartment syndrome
 Neurologic deficit
 Elbow Stiffness
 Pin Track Infections
 Myositis Ossificans- rare
 Nonunion- very very rare
 Osteonecrosis

119. Neurologic Injury
 10% and 20%
 the anterior interosseous nerve actually appears to be the
most commonly injured
 paralysis of the long flexors of the thumb and index finger
without sensory changes
 Nerve transections are rare and almost exclusively
involve the radial nerve
 Closed #- observation
 Neural recovery, regardless of which nerve is injured, generally
occurs after two to 2.5 months of observation, but it may take
up to six months
 Open #- exploration

120. Compartment Syndrome
 0.1% to 0.3%
 Skaggs et al. showed that ecchymosis and severe
swelling even in the presence of an intact radial pulse
with good capillary refill should alert the treating
physician to the possibility of a compartment
syndrome

121. Cubitus Varus
 Some authors have
proposed that unequal
growth in the distal part of
the humerus as the cause.
 This is unlikely as there is
not enough residual growth
left in this area
 The most common reason
for cubitus varus in patients
with a supracondylar
fracture is therefore
malunion rather than
growth arrest

122.  Treatment for cubitus varus has in the past been
considered for cosmetic reasons only.
 Consequences of cubitus varus
 Increased risk of lateral condyle fractures
 Pain
 Tardy posterolateral rotatory instability
 which may be indications for an operative
reconstruction with a supracondylar humeral
osteotomy

123. POST RECOVERY

124. FLEXTION TYPE
 Rare, only 2%
 Distal fracture fragment
anterior and flexed
 Ulnar nerve injury more
common
 Reduce with extension
 Often requires 2 sets of hands
in OF
 Hold elbow at 90 degrees after
reduction to facilitate pinning
Mahan. Operative management of displaced flexion supracondylar humerus fractures in children. J Pediatr Orthop.
2007;27:551.

126. Radiographic findings
 Anterior displacement ,medial or lateral translation
 Associated fractures proximal humerus and radius.
 Fracture classification
 Type I, nondisplaced fracture;
 type II, minimally angulated with cortical contact; and
 type III, totally unstable displaced distal fracture fragment

127. Flexion Type

128. Flexion Type
Pinning

129. Treatment
 Reduce with extension
 hold elbow at 90 degrees after reduction to facilitate
pinning
 Immobilization for type 1
 CR+extension cast
 closed reduction and percutaneous pinning
 Open reduction -anteromedial or posterior approach

130.  1Chen RS, Liu CB, Lin XS et al. Supracondylar Extension
Fracture of the Humerus in Children. J Bone Joint Surg Am.
2001
 Rockwood and Wilkins' Fractures in Children, 7th ed
 Campbell operative orthopaedics 11 ed
 Current Concepts Review Supracondylar Humeral Fractures
in Children, JBJS may 2008.
 Archibeck MJ, Scott SM, Peters CL. Brachialis muscle
entrapment in displaced supracondylar humerus fractures: a
technique of closed reduction and report of initial results. J
Pediatr Orthop. 1997 Apr.;17(3):298–302.
References