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supracondylar fracture humerus in children

supracondylar fracture humerus in children

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  • this anatomic location of muscle pull creates a force that tended to displace the distal humeral fragment medially
  • It is a radiographic measurement in AP vies x-ray. It is the angle formed by drawing line along midline of diaphysis of humeral shaft, a line perpedicular to the midline and a line along the physis of lateral condyle. The angle A is original Baumann’s angle and B is used commonly. Normal Baumann’s angle is 64 to 81 degrees. Average is 72 degrees (Williamson).
  • It is a radiographic angle in AP view. A longitudinal line is drawn through long axis of diaphysis and widest part of metaphysis. The angle between the proximal part of diaphyseal line and lateral part of metaphyseal line is meataphyseal-diaphyseal angle. Normal angle is 90 o . Angle greater than 90 degree denotes cubitus varus and lesser than 90 degrees denotes cubitus valgus.
  • N ormally there is angulation of 40 to 45 degrees between the long axis of humerus and long axis of lateral epicondyle
  • F ish tail sign: due to rotation of distal fragement, the anterior border of proximal fragment looks like a sharp spike
  • Crescent sign: normal radioluscent gap of the elbow joint is missing and a crescent shaped shadow due to overlap of capitulum over olecranon is evident and indicates varus or valgus tilt of distal fragement
  • Line drawn proximally through the anterior margin of coronoid passes tangentially through the lateral condyle
  • Closed reduction may not be possible because of interposed soft tissue or neurovascular bundle. A pproach is somewhat controversial.
  • O ne of the reason for stiffness is posterior appraoch coz added injury to uninvolved posterior tissue leads to added scar formation.
  • S keletal traction is usually given for 2 weeks.
  • The lateral pin is generally placed first through the lateral condyle, extending through the proximal fragment and engaging the opposite cortex. The medial pin is then placed through the medial epicondyle. We make a small incision over the medial epicondyle to ensure that the ulnar nerve is not entrapped in the fracture. 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

supracondylar fracture humerus in children supracondylar fracture humerus in children Presentation Transcript

  • SUPRACONDYLARSUPRACONDYLAR FRACTURES OFFRACTURES OF HUMERUSHUMERUS DR. HARDIK PAWARDR. HARDIK PAWAR CARE HOSPITALCARE HOSPITAL
  • Distal Humerus AnatomyDistal Humerus Anatomy  Medial epicondyleMedial epicondyle proximal to trochleaproximal to trochlea ––  Lateral epicondyleLateral epicondyle proximal to capitellumproximal to capitellum ––  Radial fossaRadial fossa –– accommodates margin ofaccommodates margin of radial head during flexionradial head during flexion  Coronoid fossaCoronoid fossa –– accepts coronoid process ofaccepts coronoid process of ulna during flexionulna during flexion
  • DefinitonDefiniton  AAlso called Malgaigne’slso called Malgaigne’s fracturefracture  FFracture line passes justracture line passes just proximal to the bone masses ofproximal to the bone masses of trochlea capitulum and oftentrochlea capitulum and often runs through the apices ofruns through the apices of coronoid and olecranon fossaecoronoid and olecranon fossae or just above the fossae oror just above the fossae or through metaphysis ofthrough metaphysis of humerushumerus  TThe fracture line is generallyhe fracture line is generally transversetransverse in frontal planein frontal plane
  • Supracondylar Fractures of HumerusSupracondylar Fractures of Humerus  It is # whichIt is # which involves the lower end of the humerusinvolves the lower end of the humerus usuallyusually involving the thin portion of the humerus throughinvolving the thin portion of the humerus through Olecranon fossa orOlecranon fossa or Just above the fossa orJust above the fossa or MetaphysisMetaphysis  Most common elbow injuries in children.Most common elbow injuries in children.  Makes up approximately 60% of elbow injuries.Makes up approximately 60% of elbow injuries.  Becomes uncommon as the age increases.Becomes uncommon as the age increases.
  • General considerationsGeneral considerations  Incidence of supracondylar #:Incidence of supracondylar #: a) Agea) Age : peak age : 5-7 yrs: peak age : 5-7 yrs Average age : 6.7 yrsAverage age : 6.7 yrs b) Sexb) Sex : Boys > Girls (Earlier): Boys > Girls (Earlier) Boys = Girls (Latest Trends)Boys = Girls (Latest Trends) c) Sidec) Side : Left > Right: Left > Right ( Non dominant > dominant )( Non dominant > dominant ) d) Nerve injuriesd) Nerve injuries : 7% - Radial > median > Ulnar: 7% - Radial > median > Ulnar e) Vascular injuriese) Vascular injuries : 1%: 1% f) Open injuriesf) Open injuries : < 1%: < 1%
  • g) Cause of #g) Cause of # Fall from height 70% ----- children > 3 yrsFall from height 70% ----- children > 3 yrs Fall from bed children < 3 yrsFall from bed children < 3 yrs Non accidental injury ( Child abuse) children rareNon accidental injury ( Child abuse) children rare h) Associated #sh) Associated #s Distal radius > Scaphoid > Proximal humerus >Distal radius > Scaphoid > Proximal humerus > MonteggiaMonteggia i) Clinical typesi) Clinical types Extension type: 98%Extension type: 98% posteromedial displacement 75%posteromedial displacement 75% posterolateral displacement 25 %posterolateral displacement 25 % Flexion type : 2%Flexion type : 2%
  • Mechanism of injuryMechanism of injury  ForFor Extension typeExtension type ofof SC # humerusSC # humerus Fall on outstretched handFall on outstretched hand ElbowElbow hyper extendedhyper extended Fore arm –Fore arm – pronated orpronated or supinatedsupinated
  • Mechanism of injuryMechanism of injury  ForFor Flexion typeFlexion type of SC # humerusof SC # humerus Fall directly on theFall directly on the elbowelbow rather thanrather than out stretched handout stretched hand
  • Radiographic anatomy of distalRadiographic anatomy of distal HumerusHumerus  What are the radiographic views:What are the radiographic views: Antero posteriorAntero posterior LateralLateral ObliqueOblique Axial ( jones view )Axial ( jones view )
  •  What to look for inWhat to look for in AP View-AP View----- Baumann`s angle---- Baumann`s angle Humero ulnar angleHumero ulnar angle Metaphysio diaphyseal angleMetaphysio diaphyseal angle
  • Radiographic AnatomyRadiographic Anatomy  Baumann’s angleBaumann’s angle is formed by a lineis formed by a line perpendicular to the axis of the humerus, and aperpendicular to the axis of the humerus, and a lateral physeal linelateral physeal line  There is a wide range of normal value, and itThere is a wide range of normal value, and it can vary with rotation of the radiograph.can vary with rotation of the radiograph.  The Baumann angleThe Baumann angle is good measurement ofis good measurement of any deviation of distal humerus`s angulationany deviation of distal humerus`s angulation  In this case, the medial impaction and varusIn this case, the medial impaction and varus position alters the Bauman’s angle.position alters the Bauman’s angle.  Normal avg 72 *Normal avg 72 *  RANGE 64 – 81RANGE 64 – 81  Compare with opposite sideCompare with opposite side
  • Lateral viewLateral view
  • Radiograph Anatomy/LandmarksRadiograph Anatomy/Landmarks  Anterior HumeralAnterior Humeral Line:Line: This is drawn alongThis is drawn along the anterior humeralthe anterior humeral cortex.cortex. It should passIt should pass through the junctionthrough the junction of anterior &of anterior & middle 3middle 3rdrd of theof the capitellum.capitellum.
  • Radiograph Anatomy/LandmarksRadiograph Anatomy/Landmarks  The capitellum isThe capitellum is angulated anteriorlyangulated anteriorly about 30 degrees.about 30 degrees.  The appearance of theThe appearance of the distal humerus is similardistal humerus is similar to a hockey stick.to a hockey stick. 30
  • Radiograph Anatomy/LandmarksRadiograph Anatomy/Landmarks  The physis of theThe physis of the capitellum is usuallycapitellum is usually wider posteriorly,wider posteriorly, compared to thecompared to the anterior portion ofanterior portion of the physisthe physis Wider
  • Anatomical classification of SC #Anatomical classification of SC #
  • Radiographic Classification of SC #sRadiographic Classification of SC #s  Based on X- Ray appreance # displacementBased on X- Ray appreance # displacement GartlandGartland described 3 types:described 3 types:  Type – IType – I : Undisplaced: Undisplaced  Type – IIType – II : Displaced (posterior cortex intact): Displaced (posterior cortex intact)  Type –IIIType –III : Displaced ( no cortical contact): Displaced ( no cortical contact) PosteromedialPosteromedial PosterolateralPosterolateral
  • Type 1: Non-displacedType 1: Non-displaced  Note the non-Note the non- displaced fracturedisplaced fracture (Red Arrow)(Red Arrow)  Note the posterior fatNote the posterior fat pad (Yellow Arrows)pad (Yellow Arrows)
  • Type 2: Angulated/Displaced FractureType 2: Angulated/Displaced Fracture with Intact Posterior Cortexwith Intact Posterior Cortex
  • Type 3: Complete Displacement, withType 3: Complete Displacement, with No Contact between FragmentsNo Contact between Fragments
  • PosteromediaPosteromediall Vs PosterolateralVs Posterolateral  Biceps tendon insertion and axis of muscle pullBiceps tendon insertion and axis of muscle pull lies medial to the shaft of the humeruslies medial to the shaft of the humerus  During fall onto an outstretched supinatedDuring fall onto an outstretched supinated forearm, the forces applied tend to disrupt theforearm, the forces applied tend to disrupt the posteromedial periosteum first and displace theposteromedial periosteum first and displace the fragment posterolaterally.fragment posterolaterally.  Conversely, if a patient falls with the forearmConversely, if a patient falls with the forearm pronated, the distal fragment tends to becomepronated, the distal fragment tends to become displaced posteromediallydisplaced posteromedially..
  •  Medial displacement of theMedial displacement of the distal fragment places thedistal fragment places the radial nerve at riskradial nerve at risk  LLateral displacement of theateral displacement of the distal fragment places thedistal fragment places the median nerve and brachialmedian nerve and brachial artery at riskartery at risk..
  • Clinical signs & SymptomsClinical signs & Symptoms  In most cases, children willIn most cases, children will not move the elbownot move the elbow if a fracture is present,if a fracture is present, although this may not be the case for non-displaced fractures.although this may not be the case for non-displaced fractures.  SwellingSwelling about elbow is aabout elbow is a constantconstant feature, develop within first few hrs.feature, develop within first few hrs.  S shaped deformityS shaped deformity  Distal humeral tendernessDistal humeral tenderness  Anterior plucker sign +veAnterior plucker sign +ve
  • S-shaped configuration of ULS-shaped configuration of UL
  • Physical ExaminationPhysical Examination  Neurologic exam is essential,Neurologic exam is essential, as nerve injuries are common. In mostas nerve injuries are common. In most cases, full recovery can be expectedcases, full recovery can be expected  Neuro-motor exam may be limited by the childs ability toNeuro-motor exam may be limited by the childs ability to cooperate because of pain, or fear.cooperate because of pain, or fear.  Finger , wrist ,Thumb extension– (radial nerve)Finger , wrist ,Thumb extension– (radial nerve)  DIP joint of index and IP joint of thumb flexion – FPL andDIP joint of index and IP joint of thumb flexion – FPL and FDP lat two (median – AIN branch)FDP lat two (median – AIN branch)  Thenar strength – median nerveThenar strength – median nerve  Interosseous - Adductors (ulnar)Interosseous - Adductors (ulnar)
  •  SENSATION :SENSATION :  Radial - dorsal 1Radial - dorsal 1stst web spaceweb space  Median – palmar index fingerMedian – palmar index finger  Ulnar - palmar little fingerUlnar - palmar little finger
  •  Nerve injury incidence is high, between 7 and 16 %Nerve injury incidence is high, between 7 and 16 % (median, radial and ulnar nerve)(median, radial and ulnar nerve)  Anterior interosseous nerve is most commonly injured nerveAnterior interosseous nerve is most commonly injured nerve  In many cases, assessment of nerve integrity is limited , because childrenIn many cases, assessment of nerve integrity is limited , because children can not always cooperate with the examcan not always cooperate with the exam  Carefully document pre manipulation exam, as post manipulationCarefully document pre manipulation exam, as post manipulation neurologic deficits can alter decision makingneurologic deficits can alter decision making Physical ExaminationPhysical Examination
  •  Vascular injuriesVascular injuries are rare, but pulses should always beare rare, but pulses should always be assessed before and after reduction - pulse , warmth ,assessed before and after reduction - pulse , warmth , capillary filling , color , tenderness of volar comparmentcapillary filling , color , tenderness of volar comparment  Painful passive finger extension – indiacates tensePainful passive finger extension – indiacates tense compartmentcompartment  In the absence of a radial and/or ulnar pulse,In the absence of a radial and/or ulnar pulse, the fingers may still be well-perfused, because of thethe fingers may still be well-perfused, because of the excellent collateral circulation around the elbowexcellent collateral circulation around the elbow  Doppler device can be used for assessmentDoppler device can be used for assessment Physical ExaminationPhysical Examination
  • Physical ExaminationPhysical Examination  Thorough documentation of all findings is important. AThorough documentation of all findings is important. A simple record of “neurovascular status is intact” issimple record of “neurovascular status is intact” is unacceptable.unacceptable.  Individual assessment and recording of motor, sensory, andIndividual assessment and recording of motor, sensory, and vascular function is essentialvascular function is essential  Always palpate the arm and forearm forAlways palpate the arm and forearm for signs of compartmentsigns of compartment syndrome.syndrome.
  • RadiogRaphicRadiogRaphic evaluationevaluation
  • AP view X-RaysAP view X-Rays  Baumann’s angleBaumann’s angle  Metaphyseal-Diaphyseal angleMetaphyseal-Diaphyseal angle  Humero-Ulnar angleHumero-Ulnar angle
  • Baumann’s angle:Baumann’s angle: 64o to 81oAv. 72o
  • Metaphyseal-Diaphyseal angleMetaphyseal-Diaphyseal angle
  • Metaphyseal-Diaphyseal angleMetaphyseal-Diaphyseal angle
  • Humero-Ulnar angleHumero-Ulnar angle
  • Lateral view X-RaysLateral view X-Rays Tear dropTear drop signsign
  • AAnterior humeral linenterior humeral line
  • haft-condylar anglehaft-condylar angle 40o -45o
  • FFat padat pad signsign
  • FFish tail signish tail sign
  • Crescent signCrescent sign
  • Coronoid lineCoronoid line
  • ManagementManagement  All suspected cases should be splinted in around 20-30All suspected cases should be splinted in around 20-30 deg at elbow before sending for xraydeg at elbow before sending for xray  Careful physical examination & X-ray evaluationCareful physical examination & X-ray evaluation  Neurologic evaluationNeurologic evaluation  Vascular assessmentVascular assessment Peripheral pulse- radial arteryPeripheral pulse- radial artery Capillary fillingCapillary filling Doppler testDoppler test Evaluate for ipsilat injuries- anywhere from wrist toEvaluate for ipsilat injuries- anywhere from wrist to sternoclavicular jt.sternoclavicular jt.
  •  Tight bandaging/ excessive flexion or excessiveTight bandaging/ excessive flexion or excessive extension should be avoidedextension should be avoided  Associated life threatening complicationsAssociated life threatening complications ( if any) to be attended first.( if any) to be attended first.
  •  Inherent stability due to intact periosteumInherent stability due to intact periosteum  Simple posterior long arm splint for 3-7days.Simple posterior long arm splint for 3-7days.  Elbow 60-90Elbow 60-90oo flexion & Forearm neutral position.flexion & Forearm neutral position.  Check X-ray after 3-7 days to document any displacementCheck X-ray after 3-7 days to document any displacement or lack of it.or lack of it.  Splint converted to long arm cast if no displacement, amdSplint converted to long arm cast if no displacement, amd no swellingno swelling  If displacement noticed # reduction done & cast applied orIf displacement noticed # reduction done & cast applied or pinning done.pinning done. Treatment of type – I #Treatment of type – I #
  •  Duration of immobilisation 3-4wks.Duration of immobilisation 3-4wks.  No need for any physiotheraphy ( Generally )No need for any physiotheraphy ( Generally )  Outcome:Outcome: Predictablly excellent if alignment isPredictablly excellent if alignment is maintained during early healing.maintained during early healing. Hence type – I #s requires carefulHence type – I #s requires careful treatment &treatment & follow up.follow up.
  • Treatment of type – II #Treatment of type – II #  Good stability should be obtained after closed reduction.Good stability should be obtained after closed reduction.  Once satisfactory reduction achieved further management isOnce satisfactory reduction achieved further management is same as type – I.same as type – I.  If medial column collapse present then skeletal stabilisationIf medial column collapse present then skeletal stabilisation with 2 lateral pins is advocated.with 2 lateral pins is advocated.  Recent trends -Recent trends - SELECTIVE PINNINGSELECTIVE PINNING for type – II #sfor type – II #s
  • SELECTIVE PINNINGSELECTIVE PINNING Closed reduction is doneClosed reduction is done Splinting in flexionSplinting in flexion Non movable cuff & collar slingNon movable cuff & collar sling Early careful X-ray follow upEarly careful X-ray follow up If # displacement /angulation noticedIf # displacement /angulation noticed pin stabilisation is done .pin stabilisation is done .
  • Treatment of type – III #Treatment of type – III #  UnstableUnstable  Periosteum tornPeriosteum torn  No cortical contact between fragmentsNo cortical contact between fragments  Associated with significant soft tissueAssociated with significant soft tissue injury/vascular / neuroinjury/vascular / neuro  Treatment options:Treatment options: ReductionReduction either closed or openeither closed or open StabilisationStabilisation either with pins or casteither with pins or cast traction management.traction management.
  • Technique of reduction (closed)Technique of reduction (closed)  Traction – to restore length & alignment.Traction – to restore length & alignment.  Milking maneuver -- if length & alignmentMilking maneuver -- if length & alignment not restored by tractionnot restored by traction  Correction of medial/ lateral displacements.Correction of medial/ lateral displacements.  Correction of rotational deformities.Correction of rotational deformities.  Correction of posterior displacement by --Correction of posterior displacement by -- flexion reduction maneuverflexion reduction maneuver  Elbow held in hyper flexion.Elbow held in hyper flexion.  Fore arm held in pronation – if distal fragment isFore arm held in pronation – if distal fragment is postero medially displaced,postero medially displaced,  Fore arm held in supination -- if distal fragment isFore arm held in supination -- if distal fragment is postero laterally displaced.postero laterally displaced.
  • SKELETALSKELETAL STABILIZATIONSTABILIZATION
  •  ANATOMIC OR NEAR ANATOMICANATOMIC OR NEAR ANATOMIC REDUCTION IS A PREREQUISITE FORREDUCTION IS A PREREQUISITE FOR SKELETAL STABILISATIONSKELETAL STABILISATION
  • Skeletal stabilization after reductionSkeletal stabilization after reduction  Skeletal stabilization after reduction is done eitherSkeletal stabilization after reduction is done either withwith pins or castpins or cast  Now a days skeletal stabilization by casing is not doneNow a days skeletal stabilization by casing is not done as reduction maintenance is not achieved .as reduction maintenance is not achieved .  Generally skeletal stabilization is achieved by means ofGenerally skeletal stabilization is achieved by means of passing pins across the fracture site .passing pins across the fracture site .
  • SetupSetup  The monitorThe monitor should beshould be positioned acrosspositioned across from the OR table,from the OR table, to allow easyto allow easy visualization of thevisualization of the monitor during themonitor during the reduction andreduction and pinningpinning
  •  The C-ArmThe C-Arm fluoroscopy unit can befluoroscopy unit can be inverted, using the baseinverted, using the base as a table for the elbowas a table for the elbow joint.joint.  The child should beThe child should be positioned close to thepositioned close to the edge of the table, toedge of the table, to allow the elbow to beallow the elbow to be visualized by the c-arm.visualized by the c-arm.  Mobilize the imageMobilize the image intensifier but notintensifier but not elbowelbow
  • Pin fixationPin fixation  Options :Options : 2 lateral pins - divergent or parallel2 lateral pins - divergent or parallel 2 crossed pins2 crossed pins 3 lateral pins3 lateral pins 2 lateral and 1 medial pins2 lateral and 1 medial pins
  • Pin FixationPin Fixation  2 lateral pins2 lateral pins - first pin through capitulum- first pin through capitulum  Check in c – armCheck in c – arm  If necessary 3If necessary 3rdrd pin either laterally or medially .pin either laterally or medially .  The medial pin can injury the ulnar nerve.The medial pin can injury the ulnar nerve.  Smooth pins are preferredSmooth pins are preferred  Some advocate usage of aSome advocate usage of a small incission of sizesmall incission of size 1.5 cm1.5 cm over the medial epicondyleover the medial epicondyle and dissection is performed upand dissection is performed up to the level of the medial epicondyle and the ulnar nerveto the level of the medial epicondyle and the ulnar nerve identified and protected and the medial pin appliedidentified and protected and the medial pin applied
  •  Medial pin placement :Medial pin placement : this pin is placed directly throughthis pin is placed directly through the medial epicondyle , using thethe medial epicondyle , using the opposite thumb to pull the softopposite thumb to pull the soft tissues posteriorly, thustissues posteriorly, thus protecting theprotecting the ULNARULNAR NERVE .NERVE .  The pin is directed fromThe pin is directed from posteromedial to anterolateralposteromedial to anterolateral (10(10oo posterior & 40posterior & 40oo with shaft)with shaft) under c arm imaging with theunder c arm imaging with the upper extremity fullyupper extremity fully EXTERNALLLY ROTATEDEXTERNALLLY ROTATED
  •  If 2 lateral pins are used, they should beIf 2 lateral pins are used, they should be 1 ) widely spaced at the fracture site.1 ) widely spaced at the fracture site. 2 ) engaging the medial and lat columns proximal to fracture site2 ) engaging the medial and lat columns proximal to fracture site 3) engaging suffiecient bone in both prox. And distal fragment3) engaging suffiecient bone in both prox. And distal fragment 4) 34) 3rdrd pin if fracture is unstable after 2 pinspin if fracture is unstable after 2 pins STABILITYSTABILITY  3 lateral divergent pins = crossed pins > 2 lateral3 lateral divergent pins = crossed pins > 2 lateral divergent pin > 2 lateral paralleldivergent pin > 2 lateral parallel  If the lateral pins areIf the lateral pins are placed close togetherplaced close together at the fractureat the fracture site,site, Chances of rotationChances of rotation and further displacement.and further displacement. are moreare more
  •  BIOMECHANICAL STUDIESBIOMECHANICAL STUDIES HAVEHAVE PROVED :PROVED : DIVERGENT PINDIVERGENT PIN CONFIGURATIONCONFIGURATION IS FARIS FAR SUPERIOR CONSTRUCT WHENSUPERIOR CONSTRUCT WHEN COMPARED TOCOMPARED TO THETHE PARALLEL PINPARALLEL PIN CONFIGURATIONCONFIGURATION..
  •  If pin fixation is used, the pins areIf pin fixation is used, the pins are usually bent and cut outside the skin.usually bent and cut outside the skin.  The skin is protected from the pinsThe skin is protected from the pins by placing pad around the pins.by placing pad around the pins.  The arm is immobilized.The arm is immobilized.  Pins can easily be removedPins can easily be removed 3 - 4 weeks later.3 - 4 weeks later.  If adequate callus formation isIf adequate callus formation is present, gentle range of motionpresent, gentle range of motion exercises are initiated.exercises are initiated.  In most cases, full recovery ofIn most cases, full recovery of motion can be expected.motion can be expected.
  • Lateral Pin PlacementLateral Pin Placement  AP and Lateral views with 2 pinsAP and Lateral views with 2 pins
  • Contraindication forContraindication for percutaneous pinningpercutaneous pinning  Severe swellingSevere swelling  Open fractureOpen fracture  Irreducible fractureIrreducible fracture  Late diagnosisLate diagnosis
  • Indications for open reductionIndications for open reduction  Open reduction is indicated to obtain alignment ifOpen reduction is indicated to obtain alignment if closed reduction is unsuccessful as with the following,closed reduction is unsuccessful as with the following,  1 or 2 attempts of CR - failed1 or 2 attempts of CR - failed  Button holingButton holing of the proximal fragment throughof the proximal fragment through the anterior soft tissues ,the anterior soft tissues ,  Interposition of the biceps ,Interposition of the biceps ,  Interposition of the neurovascular structures .Interposition of the neurovascular structures . An open reduction is also indicated if there is anAn open reduction is also indicated if there is an openopen fracture ,fracture ,that requires irrigation and debridement .that requires irrigation and debridement .
  • ORIFORIF  AApproachespproaches -- anterior, medial, lateral andanterior, medial, lateral and posterior approach.posterior approach.  MMedial and Lateral approach is usuallyedial and Lateral approach is usually done from the side in which periostealdone from the side in which periosteal hinge is torn.hinge is torn.  In patients with brachial arteryIn patients with brachial artery compromise, an anteromedial approachcompromise, an anteromedial approach isis recommendedrecommended, and in patients with radial, and in patients with radial nerve palsy, lateral and medialnerve palsy, lateral and medial approaches are recommended.approaches are recommended.  AAnterior apporach is preferred to posteriornterior apporach is preferred to posterior approach because posterior approach isapproach because posterior approach is said to lead to stiffness of elbow joint.said to lead to stiffness of elbow joint.
  • ORIF....ORIF....  If open reduction and internal fixationIf open reduction and internal fixation are to be done, they should beare to be done, they should be performed emergently (<8 hours) orperformed emergently (<8 hours) or urgently (≤24 hours) or after theurgently (≤24 hours) or after the swelling has decreased, but not laterswelling has decreased, but not later than 5 days after injury because thethan 5 days after injury because the possibility of myositis ossificanspossibility of myositis ossificans apparently increases after that timeapparently increases after that time..
  • Advantages of ORIFAdvantages of ORIF  DDirect reductionirect reduction  LLarge hematomas can be evacuatedarge hematomas can be evacuated  NNecessity in irreducible fractureecessity in irreducible fracture  The incidence of neurovascularThe incidence of neurovascular ccomplications from the procedure is less.omplications from the procedure is less.
  • Complications of ORComplications of OR  EarlyEarly Neurovacular injuryNeurovacular injury Compartment syndromeCompartment syndrome InfectionInfection  LateLate Stiff elbowStiff elbow Myosistis ossificansMyosistis ossificans Mal unionMal union Non unionNon union
  • Traction ManagementTraction Management  IIt consists of skin and skeletal traction andt consists of skin and skeletal traction and is of historical importanceis of historical importance  due todue to currentcurrent availability of better andavailability of better and effective treatment methods.effective treatment methods.  MMethods of traction:ethods of traction:  SSide arm skin traction (Dunlop traction)ide arm skin traction (Dunlop traction)  OOverheadverhead SSkeletal tractionkeletal traction
  • Traction management...Traction management... IIndications of traction managementndications of traction management  AAn unstable comminuted fracturen unstable comminuted fracture  SSupracondylar comminution or medialupracondylar comminution or medial column comminution that is not suitablecolumn comminution that is not suitable for pinning and would certainly collapsefor pinning and would certainly collapse with simple casting after reductionwith simple casting after reduction..
  • Traction management....Traction management....  Traction can be used to manage type IIITraction can be used to manage type III supracondylar fractures by allowingsupracondylar fractures by allowing swelling to decreaseswelling to decrease..  Skeletal traction is superior to sidearmSkeletal traction is superior to sidearm skskinin traction cause it has less incidencestraction cause it has less incidences of varus deformityof varus deformity..
  • Overhead skeletal tractionOverhead skeletal traction  OverheadOverhead skeletalskeletal tractiontraction is appliedis applied with the help ofwith the help of olecranon wing nutolecranon wing nut Olecranon wing nut
  • Overhead skeletal tractionOverhead skeletal traction  The wing nutThe wing nut offers theoffers the advantage ofadvantage of applying a torqueapplying a torque on the distalon the distal humeral fragmenthumeral fragment by changing theby changing the traction rope'straction rope's position into theposition into the holes in the wingholes in the wing
  • Technique of Overhead skeletalTechnique of Overhead skeletal tractiontraction  AA hole is made through both cortices just distal to thehole is made through both cortices just distal to the coronoid process. A wing nut is then placed through thecoronoid process. A wing nut is then placed through the small incision. The wing nut engages the oppositesmall incision. The wing nut engages the opposite cortex but does not penetrate it.cortex but does not penetrate it.  A sling is used to support the hand and forearm.A sling is used to support the hand and forearm.  TTraction of about 5 pounds is applied, depending onraction of about 5 pounds is applied, depending on the patient's size.the patient's size.  The shoulder should be lifted just off the bed.The shoulder should be lifted just off the bed.  AP and lateraAP and laterall rays should be taken in traction to judgerays should be taken in traction to judge the adequacy of reduction.the adequacy of reduction.  After there is good callus formationAfter there is good callus formation,, the patient isthe patient is removed from traction and placed in a long arm cast,removed from traction and placed in a long arm cast, which is worn for about 2 weeks.which is worn for about 2 weeks.
  • Overhead skeletal tractionOverhead skeletal traction
  • Side arm skeletal tractionSide arm skeletal traction  The arm is abductedThe arm is abducted at shoulder andat shoulder and traction of 1.5 kg istraction of 1.5 kg is applied with theapplied with the elbow at 60elbow at 60oo flexion.flexion. CCounter-traction of 1ounter-traction of 1 kg is applied abovekg is applied above the elbow.the elbow.
  • Supracondylar Humerus Fractures-Supracondylar Humerus Fractures- Flexion typeFlexion type  Rare, only 2%Rare, only 2%  Distal fracture fragmentDistal fracture fragment anterior,flexedanterior,flexed  Ulnar nerve injury -higherUlnar nerve injury -higher incidenceincidence  Reduce with extensionReduce with extension
  • TreaTmenTTreaTmenT
  •  TType I flexion-type supracondylarype I flexion-type supracondylar fractures are stable nondisplacedfractures are stable nondisplaced fractures that can simply be protected infractures that can simply be protected in a long-arm casta long-arm cast
  •  Type IIType II requires some reduction inrequires some reduction in extension, the arm can be immobilizedextension, the arm can be immobilized with the elbow fully extended.with the elbow fully extended.
  • Sultanpur technique of closedSultanpur technique of closed reductionreduction  DDescribed by Sultanpur of Baharainescribed by Sultanpur of Baharain  Two stages of casting:Two stages of casting:  First cast is put until distal end of proximalFirst cast is put until distal end of proximal fragement and is allowed to setfragement and is allowed to set  Forearm in supinationForearm in supination  NNext the distal fragement is pushed backext the distal fragement is pushed back against this castagainst this cast  CCast is then completed with elbow in flexion.ast is then completed with elbow in flexion.
  •  Pinning is generally required for unstablePinning is generally required for unstable type II and III flexion supracondylartype II and III flexion supracondylar fractures.fractures.  Pinning should be performed after closedPinning should be performed after closed reduction with the elbow in mild flexionreduction with the elbow in mild flexion (usually at 30 degrees )(usually at 30 degrees ) or full extensionor full extension,, holding the elbow in reduced positionholding the elbow in reduced position
  •  After pinning a flexion-type supracondylarAfter pinning a flexion-type supracondylar fracture, the arm should be placed in afracture, the arm should be placed in a bivalved cast.bivalved cast.  If the fracture is held in anatomic positionIf the fracture is held in anatomic position with pins, a flexed-arm cast can be usedwith pins, a flexed-arm cast can be used to provide better patient comfort, but ato provide better patient comfort, but a cast with the elbow in almost full extensioncast with the elbow in almost full extension is acceptableis acceptable..
  • Technique of close reduction andTechnique of close reduction and percutaneous pinningpercutaneous pinning
  •  Open reduction -Open reduction - if anatomic closeif anatomic close reduction can not be obtained.reduction can not be obtained.  Anteromedial or Posterior approach,Anteromedial or Posterior approach, rather than an anterior approach.rather than an anterior approach.  To ensure that the ulnar nerve is notTo ensure that the ulnar nerve is not entrapped in the fracture site, exploringentrapped in the fracture site, exploring the ulnar nerve or at least identification isthe ulnar nerve or at least identification is probably advisableprobably advisable..
  •  Traction:Traction:  RRarely usedarely used  SSide arm traction better than overheadide arm traction better than overhead tractiontraction
  • ComplicationsComplications  Immediate :Immediate : a) neurologicala) neurological b) vascularb) vascular  Early :Early : a) compartment syndromea) compartment syndrome b) volkmann`s ischemiab) volkmann`s ischemia  Late :Late : a) mal union : cubitus varus / cubitus valgusa) mal union : cubitus varus / cubitus valgus b) volkmann`s ischemic contractureb) volkmann`s ischemic contracture c) myositis ossificansc) myositis ossificans d) elbow stiffnessd) elbow stiffness
  • ReferencesReferences  Campbell operative orthopaedics, 11thCampbell operative orthopaedics, 11th editionedition  Rockwood and wilkin’s fractures inRockwood and wilkin’s fractures in children, 6th editionchildren, 6th edition  Text book of Orthopaedics,Text book of Orthopaedics, JJohnohn EbnezarEbnezar  Mc Rae’s Practical fractures andMc Rae’s Practical fractures and treatmenttreatment
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