Dr Amruth ram reddy
Department of orthopaedics
peak age between 5 and 7 years
boys have a higher incidence of this fracture than
left or nondominant side predominates
A fall from a height accounts for 70% of all fractures
Nerve injury occurs in at least 7% and significant
vascular injury in 1%.
IT IS ALSO CALLED AS MALGAIGNES FRACTURE
FRACTURE LINE PASSES PROXIMAL TO THE BONE
MASSES OF TROCHLEA AND CAPITELLUM.
IT RUNS THROUGH THE APICES OF CORONOID
AND OLECRENON FOSSAE.
A THIN 1 MM WAFER OF BONE FLANKED BY
LARGER MEDIAL AND LATERAL COLOUMNS
FORMS THE DISTAL METAPHYSIS
Supracondylar area is weak and vulnerable because
Bone is less cylindrical
Metaphysis is distal to both coronoid and olecrenon
Anterior cortex has defect in the area of coronoid
Laxity of ligaments permits hyperextension at elbow
Most distal humeral supracondylar fractures are
displaced in extension
flexion-type injuries are seen infrequently.
Mechanism of injury:children try to prevent their fall
by falling on hand with elbow extended
Because of the laxity of the ligaments, the elbow
becomes locked into hyperextension
olecranon in its fossa in the distal humerus acts as a
capsule transmits an extension force to the distal
humerus just proximal to the physis as the elbow
distal humerus fails anteriorly in the supracondylar
the distal fragment becomes posteriorly displaced.
strong action of the triceps produces proximal
displacement of the distal fragment
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
This generates clockwise
forces about the medial side
of the fracture.
Pronation of the forearm
creates an upward tilt of the
distal fragment due to the
compressive forces between
the articulating surface of the
ulna and the lateral border of
about the medial side of the
if patient falls on a outstretched supinated arm, the
posteromedial periosteum is disrupted first .
Fragment is displaced posterolaterally
if patient falls on pronated arm,the distal fragment is
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 risk.
The brachial artery is
placed at risk by the
ulnar-sided tether of
Type2:hinged posteriorly with intact posterior cortex.
Type3:displaced with no cortical contact.
3a:postero medial displacement.
3b:postero lateral displacement
Type4:displaces in to flexion and flexion.
Collapse of medial coloumn where there is loss of
Pain and inability to use the upper extremity after the
Point tenderness over medial and lateral coloumns
suggests this fracture where as tenderness on one side
of elbow suggests other type of injury.
Anterior pucker sign may be present.
It occurs when brachialis has been penetrated by
This is a sign of considerable soft tissue damage
Motor, sensory, and vascular examinations should be
performed in all patients.
discrete sensory areas of the radial nerve (dorsal first web
medial nerve (palmar index finger)
ulnar nerve (palmar little finger).
finger, wrist, and thumb extension (radial nerve),
index ,distal interphalangeal flexion and thumb
interphalangeal flexion (AIN),
thenar strength (median), and interossei (ulnar nerve)
vascular examination :presence of pulse, as well as
warmth, capillary refill, and color of the hand.
High index of suspicion to recognize signs of
developing compartment syndrome.
Passive finger extension and flexion should be tested
and the findings should be accurately recorded.
Entire limb should be evaluated for associated forearm
If present there is increased risk of impending
AP and lateral views of the entire upper extremity.
AP x-ray should always be taken as an AP of the distal
humerus rather than an AP of the elbow.
lateral film should be taken as a true lateral with the
humerus held in the anatomic position and not
Bauman’s angle is formed by a line
perpendicular to the axis of the
humerus, and a line that goes
through the physis of the
There is a wide range of normal for
this value, and it can vary with
rotation of the radiograph.
In this case, the medial impaction
and varus position reduces
Normal range:64 -81degrees
Decreased angle is a sign of varus angulation
It is not obscured by elbow flexion or pronation.
The Baumann angle is not equal to the carrying angle
of the elbow .
Change in 5 deg will result in 2 deg change of clinical
line is drawn through
metaphysis at its widest
point, and longitudinal
line is drawn through
axis of diaphysis; angle
is measured between
lateral portion of
metaphyseal line and
proximal portion of
Normal angle is 90
Angle greater than 90
degrees indicates varus
ANTERIOR HUMERAL LINE
Line: This is drawn
along the anterior
It should pass
middle of the
Radiocapitellar line –
should intersect the
this line should be
evaluated on every
pediatric elbow film
The capitellum is
about 30 degrees.
The appearance of
the distal humerus
is similar to a
FISH TAIL SIGN
The sharp proximal
like a fish tail
proximally along the
anterior border of the
should barely touch
the anterior portion of
the lateral condyle
displacement of the
posterior to this
gap of elbow joint is
A crescent shaped
shadow due to
Indicates varus or
valgus tilt of distal
FAT PAD SIGN
The anterior fat pad is a
anterior to the distal
it is seen clearly, and in
the presence of elbow
effusion, it is displaced
The posterior fat pad is
not normally visible when
the elbow is flexed at right
if an effusion is present, it
will also be visible
crpp(closed reduction and percutaneous pinning)
open reduction and internal fixation.
TYPE 1 FRACTURES
Anterior humeral line transects the capitellum.
The periosteum is intact with inherent stability of
It may become apparent only after one to two weeks
follow up after initial presentation.
Simple immobilization with a posterior splint applied
at 60 to 90 deg flexion.
This angle will not put brachial artery at risk.
patient returns 5 to 10 days after injury for removal of
Radiographs are repeated to ensure that no
displacement has occurred.
the patient is placed in a long-arm cast for an
additional 2 to 3 weeks.
The cast is then removed,mobilisation of elbow
Final check up is done 6 to 8 weeks after cast removal
to check range of movements.
•sling holds the
hand and elbow in
•true elevation of
the extremity, with
the fingers above
the elbow and the
elbow above the
The long arm cast
should be supported
with ring in distal
part of the cast and
sling around the neck
to support the weight
of the cast.
With out this an
occurs at distal
humerus and can
displace the fracture.
TYPE 2 FRACTURES:
Closed reduction and splinting in flexion.
Stabilization with pins is required when there is
Other injuries in same extremity.
Traction is applied with
the elbow in extension
and the forearm in
The assistant stabilizes
the proximal fragment.
fracture is hyperextended
to obtain apposition of
While traction is
maintained, the varus or
valgus angulation along
with the rotation of the
distal fragment is
Once the length and
been corrected, the
elbow is flexed.
Pressure is applied
over the posterior
aspect of the
of the distal
The distal fragment
is finally secured to
If traction does not restore
length and alignment, a
milking maneuver• has
been described to
disengage the proximal
fragment from the soft
It is done by manipulating
the soft tissue over the
fracture to pull the soft
tissue away from the
proximal fragment, which
may not allow reduction of
a buttonholed proximal
It can be done by two lateral pins through the distal
Engaging the opposite cortex of proximal fragment is
sufficient to maintain the alignment.
Crossed pinning can also be done but it is generally not
The arm is immobilized in 30 to 60 degrees of flexion in
either a posterior splint .
The child is observed overnight and discharged with
instructions on cast care and elevation
Pins are removed 3 to 4 weeks after fixation.
TYPE 3 FRACTURES
Neurovascular compramise should be asessed.
Closed reduction can be attempted.
In case of absent pulses,pale hand or compartment
syndrome is suspeected
immediate reduction and skeletal stabilization is
in Closed reduction and cast immobilization results
Percutanious pinning or orif with pins is better option
for type 3 fractures.
First pin is passed through centre of ossified
capitellum,further penetrating medial cortex.
Second pin through distal humeral epiphysis,lateral to
Pin proceeds up the lateral coloumn and engages the
Separate the pins as far as possible at the
Limb immobilised in neutral position in 60 to 90
Crossed pinning is more stable than two lateral pins.
Lateral pin is always inserted first.
unstable posterolaterally displaced fracture, the initial pin
may have to be placed medially.
Pin passes lateral to ossified capitellum,proceeds up the
It engages opposite medial cortex proximally.
2nd pin is placed medially
starting position for a medial pin is the inferiormost aspect
of the medial epicondyle
care should be taken not to injure the ulnar nerve.
The assistant holding the
reduction protects the
ulnar nerve by sweeping
the soft tissues
posteriorly away from
the medial epicondyle.
flexion of the elbow displaces the ulnar nerve
Thus, it is safer to place a medial pin with the elbow in
Similarly, if the arm is immobilized in flexion, the
nerve may be “tented” around the pin,
leading to ulnar nerve symptoms without direct
penetration of the nerve by the pin
INDICATIONS FOR ORIF
ischemic, pale hand that does not revascularize with
reduction of the fracture
an open fracture,
an irreducible fracture
inability to obtain a satisfactory closed reduction.
Anterior, medial, lateral, and posterior approaches
have all been recommended.
operate through the side in which the periosteal hinge
a lateral approach is used for posteromedial
a medial approach is used for posterolateral
direct anterior approach through a transverse anterior
incision in the antecubital fossa, extending proximally,
medially as needed
If open reduction and internal fixation are to be done, they
should be performed emergently (<8 hours) or urgently
(≤24 hours) or after the swelling has decreased,
but not later than 5 days after injury because the
possibility of myositis ossificans apparently increases after
that time .
advantages of ORIF direct reduction
large hematomas can be evacuated
necessity in irreducible fractures
short hospital stay
incidence of complication is less with ORIF
The incidence of neurovascular c omplications from the
procedure itself is essentially zero
side arm skin traction
overhead S keletal traction
indications of traction
An unstable comminuted
or medial column
comminution that is not
suitable for pinning
Fracture that would certainly
collapse with simple casting
Brachial artery injury
incidence in type III fractures has been reported to be
between 2% and 38
complete transection of the brachial artery, an intimal
tear, or compression either between the fracture
fragments or over the anteriorly displaced fragment.
Immediate reduction -limb put in extension.
If no response,closed reduction and percutaneous
limb remains ischemic, exposure of the brachial
vessels can be performed while awaiting the arrival of a
vascular surgeon .
Peripheral nerve injury occurs in approximately 10% to
15% of supracondylar humeral fractures.
anterior interosseous nerve is the most commonly
injured nerve with extension-type supracondylar
nearly all such injuries will spontaneously improve.
within 8 to 12 weeks function is not returning,
consideration should be given to performing nerve
conduction and electromyographic studies
diagnosis based on resistance to passive finger
movement and dramatically increasing pain after
Fasciotomy: if clinical signs are present or if
intracompartmental pressure is greater than 30 mm
a difference of 30 mm Hg between diastolic blood
pressure and compartment pressure should be the
threshold for release.
A classic henry or ulnar approach is used
Cubitus varus and cubitus valgus are the most
common complications of supracondylar humeral
posteromedially displaced fractures tend to develop
posterolaterally displaced fractures tend to develop
varus deformity may be more frequently reported
simply because it is more cosmetically noticeable
Three components that
produce cubitus varus
Lateral closed wedge osteotomy is most frequently
Three basic types of osteotomies have been described:
a medial opening wedge osteotomy with a bone graft,
an oblique osteotomy with derotation,
a lateral closing wedge osteotomy
King and Secor described the medial opening wedge
The disadvantages of this osteotomy are that it gains
it creates a certain amount of inherent instability.
Lengthening the medial aspect of the humerus also
can stretch and damage the ulnar nerve, unless it is
a lateral closing wedge osteotomy is the easiest, the
safest, and inherently the most stable osteotomy.
French and modified french osteotomy
detach the lateral half of the
triceps from its insertion
ulnar nerve can be exposed
distal screw in the anterior
part of the distal fragment
and the proximal screw in the
posterior part of the proximal
excise the wedge of bone from
between the drill points
• it result s from a
blow to the
posterior aspect of
•Distal fragmet is
and may migrate
proximally in a
•type I flexion
fractures with a
splint or cast with
the elbow flexed for
displaced type II
reduce in extension
are treated in an
•Unstable types II