SUPRACONDYLAR FRACTURES OF HUMERUS DR.P.N.PRASAD
Distal Humerus Anatomy Medial epicondyle proximal to trochlea – Lateral epicondyle proximal to capitellum – Radial fossa – accommodates margin of radial head during flexion Coronoid fossa – accepts coronoid process of ulna during flexion
Supracondylar Fractures of Humerus It is # which involves the lower end of the humerus usually involving the thin portion of the humerus through Olecranon fossa or Just above the fossa or Metaphysis Most common elbow injuries in children. Makes up approximately 60% of elbow injuries. Becomes uncommon as the age increases.
General considerations Incidence of supracondylar #: a) Age : peak age : 5-7 yrs Average age : 6.7 yrs b) Sex : Boys > Girls (Earlier) Boys = Girls (Latest Trends) c) Side : Left > Right ( Non dominant > dominant ) d) Nerve injuries : 7% - Median> Radial > Ulnar e) Vascular injuries : 1% f) Open injuries : < 1%
g) Cause of # Fall from height 70% ----- children > 3 yrs Fall from bed children < 3 yrs Non accidental injury ( Child abuse) children < 15 monthsh) Associated #s Distal radius > Scaphoid > Proximal humerus > Monteggiai) Clinical types Extension type: 98% Flexion type : 2%
Mechanism of injury For Extension type of SC # humerusFall on outstretched handElbow hyper extendedFore arm – pronated or supinated
Mechanism of injury For Flexion type of SC # humerusFall directly on the elbow rather than out stretched hand
Radiographic anatomy of distal Humerus What are the radiographic views: Antero posterior Lateral Oblique Axial ( jones view )
What to look for in AP View----- Baumann`s angle Humero ulnar angle Metaphysio diaphyseal angle
Radiographic Anatomy Baumann’s angle is formed by a line perpendicular to the axis of the humerus, and a line that goes through the superior part of physis of the capitellum. There is a wide range of normal for this value, and it can vary with rotation of the radiograph. The Baumann angle is good measurement of any deviation of distal humerus`s angulation In this case, the medial impaction and varus position alters the Bauman’s angle.
Radiograph Anatomy/Landmarks Anterior Humeral Line: This is drawn along the anterior humeral cortex. It should pass through the junction of anterior & middle 3rd of the capitellum.
Radiograph Anatomy/Landmarks The capitellum is angulated anteriorly about 30 degrees. The appearance of the distal humerus is similar to a hockey stick. 30
Radiograph Anatomy/Landmarks The physis of the capitellum is usually wider posteriorly, compared to the anterior portion of the physis Wider
Radiographic Classification of SC #s Based on X- Ray appreance # displacement Gartland described 3 types: Type – I : Undisplaced Type – II : Displaced (posterior cortex intact) Type –III : Displaced ( no cortical contact) Posteromedial Posterolateral
Type 1: Non-displaced Note the non- displaced fracture (Red Arrow) Note the posterior fat pad (Yellow Arrows)
Type 2: Angulated/Displaced Fracture with Intact Posterior Cortex
Type 3: Complete Displacement, with No Contact between Fragments
Clinical signs & Symptoms In most cases, children will not move the elbow if a fracture is present, although this may not be the case for non-displaced fractures. Swelling about elbow is a constant feature, develop within first few hrs. S shaped deformity Distal humeral tenderness Anterior plucker sign +ve
Physical Examination Neurologic exam is essential, as nerve injuries are common. In most cases, full recovery can be expected Neuro-motor exam may be limited by the childs ability to cooperate because of age, pain, or fear. Thumb extension– EPL (radial – PIN branch) Thumb flexion – FPL (median – AIN branch) Cross fingers - Adductors (ulnar)
Physical Examination Nerve injury incidence is high, between 7 and 16 % (median, radial and ulnar nerve) Anterior interosseous nerve is most commonly injured nerve In many cases, assessment of nerve integrity is limited , because children can not always cooperate with the exam Carefully document pre manipulation exam, as post manipulation neurologic deficits can alter decision making
Physical Examination Vascular injuries are rare, but pulses should always be assessed before and after reduction 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 Doppler device can be used for assessment
Physical Examination Thorough documentation of all findings is important. A simple record of “neurovascular status is intact” is unacceptable. Individual assessment and recording of motor, sensory, and vascular function is essential Always palpate the arm and forearm for signs of compartment syndrome.
Treatment General principles: Splinting elbow in comfortable position 20-30degrees of flexion of elbow, pending Careful physical examination & X-ray evaluation. Tight bandaging/ excessive flexion or excessive extension should be avoided Associated life threatening complications ( if any) to be attended first.
Treatment of type – I # Simple posterior long arm splint for 3-7days. Elbow 60-90o flexion & Forearm neutral position. Check X-ray after 3-7 days to document any displacement or lack of it. Splint converted to long arm cast if no displacement. If displacement noticed # reduction done & cast applied or pinning done.
Duration of immobilisation 3-4wks. No need for any physiotheraphy ( Generally ) Outcome: Predictablly excellent if alignment is maintained during early healing. Hence type – I #s requires careful treatment & follow up.
Treatment of type – II # Good stability obtained after closed reduction. Once satisfactory reduction achieved further management is same as type – I. If medial column collapse present then skeletal stabilisation with 2 lateral pins is advocated. Recent trends led to SELECTIVE PINNING for type – II #s
SELECTIVE PINNING Closed reduction is done Splinting in flexion Non movable cuff & collar sling Early careful X-ray follow upIf # displacement /angulation noticed pin stabilisation is done .
Treatment of type – III # Treatment involves management of skeletal injuries & associated soft tissue injuries (if any). Treatment of skeletal injury: Reduction either closed or open Stabilisation either with pins or cast
Technique of reduction (closed) Traction – to restore length & alignment. Milking maneuver -- if length & alignment not restored by traction Correction of medial/ lateral displacements. Correction of rotational deformities. Correction of posterior displacement by -- flexion reduction maneuver Elbow held in hyper flexion. Fore arm held in pronation – if distal fragment is postero medially displaced, Fore arm held in supination -- if distal fragment is postero laterally displaced.
Indications for open reduction Open reduction is indicated to obtain alignment if closed reduction is unsuccessful as with the following, Button holing of the proximal fragment through the anterior soft tissues , Interposition of the biceps , Interposition of the neurovascular structures . An open reduction is also indicated if there is an open fracture ,that requires irrigation and debridement .
ANATOMIC OR NEAR ANATOMIC REDUCTION IS A PREREQUISITE FOR SKELETAL STABILISATION
Skeletal stabilization after reduction Skeletal stabilization after reduction is done either with pins or cast Now a days skeletal stabilization by casing is not done as reduction maintenance is not achieved . Generally skeletal stabilization is achieved by means of passing pins across the fracture site .
Pin Fixation Many children have anterior subluxation of the ulnar nerve with hyperflexion of the elbow . The medial pin can injury the ulnar nerve. Some advocate 2 lateral pins to avoid injuring the median nerve. Some advocate usage of a small incission of size 1.5 cm over the medial epicondyle and dissection is performed up to the level of the medial epicondyle and the ulnar nerve identified and protected and the medial pin applied
Medial pin placement : this pin is placed directly through the medial epicondyle , using the opposite thumb to pull the soft tissues posteriorly, thus protecting the ULNAR NERVE . The pin is directed from posteromedial to anterolateral (10o posterior & 40o with shaft) under c arm imaging with the upper extremity fully EXTERNALLLY ROTATED
If 2 lateral pins are used, they should be widely spaced at the fracture site. If the lateral pins are placed close together at the fracture site, the pins may not provide much resistance to rotation and further displacement. BIOMECHANICAL STUDIES HAVE PROVED : DIVERGENT PIN CONFIGURATION IS FAR SUPERIOR CONSTRUCT WHEN COMPARED TO THE PARALLEL PIN CONFIGURATION.
If pin fixation is used, the pins are usually bent and cut outside the skin. The skin is protected from the pins by placing felt pad around the pins. The arm is immobilized. Pins can easily be removed 3 - 4 weeks later. If adequate callus formation is present, gentle range of motion exercises are initiated. In most cases, full recovery of motion can be expected.
Lateral Pin Placement AP and Lateral views with 2 pins
OR Setup The monitor should be positioned across from the OR table,to allow easy visualization of the monitor during the reduction and pinning
The C-Arm fluoroscopy unit can be inverted, using the base as a table for the elbow joint. The child should be positioned close to the edge of the table, to allow the elbow to be visualized by the c-arm. Mobilize the image intensifier but not elbow
Complications Immediate : a) neurological b) vascular Early : a) compartment syndrome b) volkmann`s ischemia Late : a) mal union : cubitus varus / cubitus valgus b) volkmann`s ischemic contracture c) myositis ossificans d) elbow stiffness