Supracondylar fractures in_children

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  • Supracondylar fractures in_children

    1. 1. SUPRACONDYLAR FRACTURES IN CHILDREN DEPT. OF ORTHOPEDICS MMMC
    2. 2. RADIOLOGY <ul><li>2 VIEWS – AP & LATERAL </li></ul>
    3. 3. JONE’S VIEW- IN INJURED ELBOW , POST REDN. [ With elbow in full flexion ]
    4. 4. ANTERIOR POST. VIEW <ul><li>BAUMANN’S ANGLE </li></ul><ul><li>ANGLE FORMED BY THE LATERAL EPI PHYSEAL LINE AND THE LONG AXIS OF THE HUMERUS : 80 degree </li></ul>
    5. 5. <ul><li>HUMERO ULNAR ANGLE </li></ul><ul><li>METAPHYSEAL DIAPHYSEAL ANGLE </li></ul>
    6. 6. Lateral view Tear drop sign Ant. dense line – represents the post margin of the coronoid fossa Post. dense line- represents the ant margin of olecranon fossa Inf margin is capitellum
    7. 7. Elbow Fractures in Children: Radiograph Anatomy/Landmarks <ul><li>Anterior humeral line: </li></ul><ul><li>It is drawn along the anterior humeral cortex. </li></ul><ul><li>It passes through the middle of the capitellum. </li></ul>
    8. 9. Elbow fractures in children: radiographic anatomy/landmarks <ul><li>The capitellum is angulated anteriorly about 30 degrees. </li></ul><ul><li>The appearance of the distal humerus is similar to a hockey stick. </li></ul>30
    9. 10. SHAFT CONDYLAR ANGLE- 30 DEG ANT HUMERAL LINE PASS THR. MIDDLE THIRD OF OSSIFICATION CENTER OF CAPITELLUM
    10. 11. Elbow Fractures in Children: Radiograph Anatomy/Landmarks <ul><li>The physis of the capitellum is usually wider posteriorly, compared to the anterior portion of the physis </li></ul>Wider
    11. 12. Elbow Fractures in Children: Radiographic Anatomy/Landmarks <ul><li>Radiocapitellar line – should intersect the capitellum </li></ul><ul><li>Make it a habit to evaluate this line on every pediatric elbow film </li></ul>
    12. 13. What are the problems you see here? Test your Ortho. Sense.
    13. 14. Supracondylar Humerus Fractures <ul><li>Most common fracture around the elbow in children (60 percent of elbow fractures) </li></ul><ul><li>95 percent are extension type injuries, which produces posterior displacement of the distal fragment </li></ul><ul><li>May be associated with a distal radius or forearm fracture </li></ul>
    14. 15. CLASSIFICATION <ul><li>EXTENSION TYPE- 95% </li></ul><ul><li>FLEXION TYPE- 5% </li></ul>
    15. 16. SUPRACONDYLAR # <ul><li>Very commmon in children less than 10 yrs </li></ul><ul><li>Bec. the bony architecture at the sc region is weak </li></ul><ul><li>More common in children with hyper flexibility </li></ul>
    16. 17. Mechanism of injury <ul><li>Fall on out stretched hand [FOOH] </li></ul>
    17. 18. QUICK REVIEW OF FACTS <ul><li>AGE – 84% < 10 YRS </li></ul><ul><li>SEX – BOYS 63.6% </li></ul><ul><li>SIDE – LEFT- 58.6% , RT—42.4% </li></ul><ul><li>NERVE INJURY- 7% </li></ul><ul><li>MEDIAN </li></ul><ul><li>RADIAL </li></ul><ul><li>ULNAR </li></ul>
    18. 19. CLINICAL FEATURES <ul><li>H/O FALL ON OUTSTRETCHED HAND </li></ul><ul><li>Failure to use upper extremity </li></ul><ul><li>GROSS SWELLING & TENDERNESS </li></ul><ul><li>S SHAPED DEFORMITY </li></ul><ul><li>ANT. PUCKER SIGN </li></ul><ul><li>CREPITUS </li></ul><ul><li>3 PT RELATIONSHIP MAINTAINED </li></ul>
    19. 20. Examine in Elbow injury <ul><li>VASCULAR STATUS –Radial artery Pulsation [most important ] & Cap.refill </li></ul><ul><li>NEUROLOGICAL STATUS- </li></ul><ul><li>M , R ,U </li></ul><ul><li>Check Finger movement </li></ul><ul><li>Check for ‘Stretch sign’ : compartment syndrome </li></ul>
    20. 23. Pucker sign/ Brachialis sign
    21. 24. Brachialis Sign- Proximal Fragment Buttonholed through Brachialis
    22. 25. Milking Maneuver- Milk Soft Tissues over Proximal Spike From Archibeck et al. JPO 1997
    23. 26. POST MEDIAL POST LATERAL
    24. 28. Supracondylar Humerus Fractures: Classification <ul><li>Gartland (1959) </li></ul><ul><li>Type 1 non-displaced </li></ul><ul><li>Type 2 Angulated/displaced fracture with posterior cortex in contact </li></ul><ul><li>Type 3 Complete displacement, with no contact between fragments </li></ul>
    25. 29. GARTLAND CLASSFN FOR EXTN TYPE <ul><li>TYPE 1 –UNDISPLACED </li></ul>
    26. 30. Type 1: Non-displaced <ul><li>Note the non- displaced fracture (Red Arrow) </li></ul><ul><li>Note the posterior fat pad (Yellow Arrows) </li></ul>
    27. 31. FAT PAD SIGNS <ul><li>Olecronon post fat pad sign </li></ul><ul><li>Coronoid ant fat pad sign </li></ul><ul><li>Helpful in occult # with effusion </li></ul>
    28. 36. Type 2: Angulated/displaced fracture with posterior cortex in contact
    29. 37. TYPE 2 <ul><li>DISPLACED BUT POST CORTEX IS INTACT </li></ul>
    30. 38. Type 2: Angulated/displaced fracture with intact posterior cortex <ul><li>In many cases, the type 2 fractures will be impacted medially, leading to varus angulation. </li></ul><ul><li>The varus malposition must be considered when reducing these fractures, applying a valgus force for realignment. </li></ul>
    31. 40. TYPE 3 <ul><li>Totally displaced type </li></ul><ul><li>3 a –post medial </li></ul><ul><li>3 b –post lateral </li></ul>
    32. 46. Management <ul><li>All suspected cases should be splinted in around 20-30 deg at elbow before sending for xray </li></ul><ul><li>Neurologic evaluation </li></ul><ul><li>Vascular assessment </li></ul><ul><li>Peripheral pulse- radial artery </li></ul><ul><li>Capillary filling </li></ul><ul><li>Doppler test </li></ul><ul><li>Evaluate for ipsilat injuries- anywhere from wrist to sternoclavicular jt. </li></ul>
    33. 47. TYPE 1 # UNDISPLACED <ul><li>SIMPLE IMMOBILIZATION WITH A POST SLAB IN 90DEG. WITH A CUFF AND COLLAR </li></ul><ul><li>XRAY TO BE RPTED AT 5-7 DAYS TO DOCUMENT FOR ANY DISPLACEMENT </li></ul><ul><li>SLAB KEPT FOR 3 WEEKS </li></ul>
    34. 49. Type ii (displaced with post cortex in contact) Treatment – closed reduction under anaes Traction is applied followed by correction of rotational deformity Extension deformity is corrected with pressure by thumb over the olecranon
    35. 50. Necessity for hyperflexion
    36. 51. TYPE III # TREATMENT METHODS <ul><li>Closed reduction & percut.K wire fixation </li></ul><ul><li>Open redn. & K wire fixation </li></ul>
    37. 52. METHOD OF CLOSED REDN. UNDER GEN. ANAES
    38. 55. Percutaneous K wire fixation
    39. 57. CLOSED REDN WITH K WIRE FIXATION
    40. 58. Lateral Pin Placement <ul><li>AP and Lateral views with 2 pins </li></ul><ul><li>[ fluoroscopic view ] </li></ul>
    41. 59. C-arm / Fluoroscopic Views <ul><li>Jones views with the C-arm can be useful to help verify the reduction </li></ul>
    42. 61. Indications for Surgery <ul><li>Volkmann’s Ischemia </li></ul><ul><li>Irreducible fracture </li></ul><ul><li>Vascular injury </li></ul><ul><li>Open fractures </li></ul>
    43. 62. Medial coloumn collapse Can lead to varus deformity from simple closed redn. If no stabilization is done
    44. 63. Medial Impaction Fracture Type II fracture with medial impaction – not recognized and varus / extension not reduced
    45. 64. Medial Impaction Fracture Cubitus varus 2 years later
    46. 65. Supracondylar Humerus Fractures: Associated Injuries <ul><li>Nerve injury incidence is high, between 7 and 16 % (radial, median, and ulnar nerve) </li></ul><ul><li>Anterior interosseous nerve injury is most commonly injured nerve </li></ul><ul><li>In many cases, assessment of nerve integrity is limited , because children can not always cooperate with the exam </li></ul><ul><li>Carefully document pre-manipulation exam, as post-manipulation neurologic deficits can alter decision making </li></ul>
    47. 66. Supracondylar Humerus Fractures: Associated Injuries <ul><li>5% have associated distal radius fracture </li></ul><ul><li>Physical exam of distal forearm </li></ul><ul><li>Radiographs if needed </li></ul><ul><li>If displaced pin radius also </li></ul>
    48. 67. Supracondylar Humerus Fractures: Associated Injuries <ul><li>Vascular injuries are rare, but pulses should always be assessed before and after reduction </li></ul><ul><li>In the absence of a radial and/or ulnar pulse, the fingers may still be well-perfused, because of the excellent collateral circulation about the elbow </li></ul><ul><li>Doppler device can be used for assessment </li></ul>
    49. 68. Supracondylar Humerus Fractures: Associated Injuries <ul><li>Type 3 supracondylar fracture, with absent ulnar and radial pulses, but fingers had capillary refill less than 2 seconds. </li></ul><ul><li>The pink, pulseless extremity </li></ul>
    50. 69. Supracondylar Humerus Fractures: Complications <ul><li>Malunion –cubitus varus </li></ul><ul><li>Volkmann’s ischemia </li></ul><ul><li>Vascular injury </li></ul><ul><li>Loss of reduction </li></ul><ul><li>Loss of elbow motion </li></ul><ul><li>Pin track infection </li></ul><ul><li>Neurovascular injury with pin placement </li></ul>
    51. 70. Volkmann’s ischemia <ul><li>Diagnose / suspect by </li></ul><ul><li>Severe pain/symptom </li></ul><ul><li>Stretch Pain /sign </li></ul>
    52. 72. Myositis Ossificans
    53. 74. WHY TO PREFER K WIRE IN TYPE3# <ul><li>Type 3 # are intrinsically unstable </li></ul><ul><li>No periosteal hinge </li></ul><ul><li>Rotation of the distal fragment cant be controlled until elbow is hypreflexed </li></ul><ul><li># Tends to rotate in less flexion </li></ul>
    54. 75. <ul><li>4. In fresh cases with swollen elbow not possible to get hyper flexion i.e. More than 90 deg </li></ul><ul><li>5. If app cast after 2-3 days swelling decreases cast becomes loose again rotation is lost </li></ul>
    55. 76. Supracondylar Humerus Fractures- Flexion type <ul><li>Rare, only 2% </li></ul><ul><li>Distal fracture fragment anterior,flexed </li></ul><ul><li>Ulnar nerve injury -higher incidence </li></ul><ul><li>Reduce with extension </li></ul>
    56. 78. Flexion Type
    57. 79. Flexion Type - Pinning
    58. 80. ??????
    59. 81. H/o,FOOSH What is your diagnosis?
    60. 84. THANK YOU

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