2. Also called Malgaigne’s fracture
Fracture line passes just proximal
to the bone masses of trochlea
capitulum and often runs through
the apices of coronoid and
olecranon fossae
The fracture line is generally
transverse
3. X-ray positioning. The
correct method of
taking a lateral view is
with the upper
extremity directed
anteriorly rather than
externally rotated.
4. Bony architecture at the supracondylar region is weak
and vulnerable because:
Bone is remodelling
It is less cylindrical
Metaphysis is just distal to 2 fossae, coronoid and
radial fossa
Here the cortex is thin
Anterior cortex has a defect in the area of coronoid
fossa
Laxity of ligaments permits hyperextension at the
elbow
5. The peak age is between 5 and 8 years.
The rate of occurence increases steadily in the first
5 yrs of life, and traditionally boys have higher
incidence of this fracture than girls.
The average age at fracture is 6.7 years.
Left of nondominant side predominates.
2/3rd of children hospitalized with elbow injuries
have supracondylar fractures.
6. 97.7% have extension type and 2.3% have flexion
type
Nerve injury occurs in atleast 7% and significant
vascular injury in 1 %
Radial nerve is most frequently involved (45%),
median (32%) and ulnar (23%) is also involved.
0.5% develop volkman’s ischaemic contracuture
Almost all supracondylar fractures are caused by
accidental trauma rather than abuse
70% s/c fractures are due to fall from height.
7. MACHANISM OF INJURY
Fall on outstretched hand with
elbow in extension.
When it is extended beyond
neutral position, flexor muscles
are at poor mechanical
advantage and there is little
resistance to injury
8. Hyper extension converts linear
force into bending force.
When the elbow hyperextention,
the olecranon forcefully pushes
into the olecranon fossa and act
as fulcrum while the anterior
capsule simaltaneously provides
a tensile force on the distal
humerus at its insertion.
TENSILE
9. The elbow becomes tightly
interlocked concentrating
bending forces to the distal
humerus.
As bending forces continue
the distal humerus fails
anteriorly in the
supracondylar area, resulting
in s/c fracture.
10. When the fracuture is
complete the distal fragment
becomes displaced
posteriorly and the strong
action of triceps causes distal
fragment to migrate
proximally.
11. Gartland classification:
Type 1 fracture
► It is a non displaced or
minimally displaced
fracture(less than 2 mm), the
posterior fat pad sign may be
only evidence of the fracture,
these fractures are stable type
12. ► Type 2 fracture
It is displaced more than 2
mm with presumably intact,
hinged posterior cortex
► The AHL line is usually
anterior to the capitellum on
a true lateral of elbow,though
in mildly displaced fracture
it may touch the capitellum
13. Type 3 fracture
It is a displaced
supracondylar fracture with a
range of cortical contact
► There is usually extension in
the sagittal plane and rotation in
the frontal and/or transverse
plane
The periosteum is severly torn
and the soft tissue and
neurovascular injuries aften
accompany this fracture
14. ► Type 4 fracture
These fracture are characterized by
incompetent periosteal hinge
circumferncially and defined by
being unstable in both flexion and
extension
► The multidirectional instability is
usually determined under anaesthesia
at a time of operation when on a
lateral view the capitellum is anterior
to the AHL with elbow flexion, and
posterior to the AHL with elbow
flexion
15. Biceps tendon insertion and axis of muscle pull lies
medial to the shaft of the humerus
During fall onto an outstretched supinated arm, the
forces applied tend to disrupt the posteromedial
periosteum first and displace the fragment
posterolaterally.
Conversely, if a patient falls with the arm pronated, the
distal fragment tends to become displaced
posteromedially
16.
17. 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
18. Swelling of elbow joint
Pain and inability to use
limb.
Arm is short, forearm is
normal in length
Crepitus is present
Symptoms related to
vascular and nerve injury
may be seen.
21. There may sometimes be puckering of the skin
when the proximal Fragment has penetrated the
brachialis and anterior fascia of the elbow
DIMPAL SIGN
22. AP VIEW x- ray
• Baumann’s angle
• Metaphyseal-Diaphyseal angle
• Humero-Ulnar angle
23.
24. It is the most frequently cited method for assessing
the fracture reduction and can be co-realted will with
the final carrying angle.
.
A change in 5 degrees of Bauman’s angle results in
change in 2 degrees of clinical carrying angle.
36. CLOSED REDUCTION AND CASTING
Type 1 fracture (undisplaced) are treated with immobilization
and casting
Simple immobilization at 60-90 degree of elbow flexion, with
the forearm in neutral position.
Mildly displaced fracture can be reduced closed, using the
intact posterior periosteum as a stabilizing force and then
holding reduction by flexing the elbow greater than 120
degree.
Less flexion increases the risk of loss of reduction.
Xrays are obtained at 3-7 days after fracture to document lack
of displacement
The duration of immobilization is about 3 weeks
38. After the length of
limb is maintained
lateral and medial
tilt is corrected by
manipulation
Rotational
deformity is then
corrected
39. Posterior tilt is
then corrected by
flexion reduction
maneuver which
is then performed
with pressure of
the thumb over
the olecranon and
to a variable
degree, over the
distal condyles of
the humerus
41. Distal vascular status should be assessed
after reduction.
If radial pulse is not palpable, elbow should
be extended till the appearance of radial
pulse and splintage should be done 10
degrees beyond this.
42. Before the development of the fluoroscopic unit,
blind pinning was performed
Modern imaging techniques and improved
power equipment have made percutaneous
pinning the standard treatment.
43. Crossed pins is more stable than 2 lateral
pins
Crossed
pinning
Lateral pinning
44. After close reduction, reduction is maintained,
and is confirmed with image intensifier before
pinning.
The lateral pin is always inserted first.
Position for inserting the pin is documented
on AP and lateral views
A small incision is made in the skin, and pin is
placed using power drill.
Pin will traverse the lateral portion of the
ossified capitellum, cross the physis, proceed
up the lateral column, and always engage the
opposite medial cortex proximally.
45. 2nd pin is placed medially
Care shoule be taken not to injure ulnar nerve
Incision is made over the skin over medial epicondyle,
blunt dissection is made, ulnar nerve is identified and
protected and pin is inserted
46.
47. No risk of ulnar nerve injury
Less stable than crossed pin
Two pins are placed which are divergent both in AP and
lat views
Sometimes a third pin may be inserted on lateral side or
medial side if the fracture is found to be unstable
48. First pin ia generally placed through the center of the
ossified capitulum, cross the olecranon fossa, giving it
greater stability, and then further penetrate the medial
cortex.
A second pin is placed through the distal humeral epiphysis
lateral to the capitulum but clearly within the epiphysis.
The pin proceeds up the lateral column and engages the
opposite cortex.
After stabilization of fracture limb should be kept in
posterior slab with forearm in neutral postion and elbow
flexed to 60-90 degrees.
49. Maximal pin separation increases the stability
with this technique.
After stabilization of fracture limb should be
kept in posterior slab with forearm in neutral
postion and elbow flexed to 60-90 degrees.
50.
51. Vascular injuries
Compartment syndrome
Neurological deficit
Pin tract infection
Pin migration
Myositis ossificans
Non union
Avascular necrosis
Loss of reduction
Cubitus varus
52. Nerve /vascular entrapment
If there is a gap in the fracture site or the
fracture is irreducible with a rubbery
feeling on attempting reduction, the
median nerve and/or brachial artery may
be trapped in the fracture site
► Proximal fragment has pierced the
bracialis
"Milking maneuver". The biceps are
forcibly 'milked' in a proximal to distal
direction past the proximal fragment,
often culminating in a palpable release of
the humerus posteriorly through the
brachialis
53. The prevalence of compartmemt syndrome is about 0.5 -
0.8%
Classical 5 p's for the diagnosis of compartment syndrome
- pain, pallor, pulselessness, paraesthesia, and paralysis
are poor indicator in children
Pediatric patients often presents with the three A's -
anxiety, agitation, and increasing analgesic requirement
54. Avascular necrosis of trochlea have been reported after
supracondylar humerus fracture
The blood supply of the trochlea's ossification center is
fragile
Symptoms of avascular necrosis of the trochlea do not occur
for months or years
Healing is normal, but mild pain and occasional locking
develop with characteristic radiological changes and range of
motion may be affected depending upon the extent
An important risk factor for AVN is following an open
reduction of fracture through posterior approach
55. Fishtail deformity
presenting at an average 4.7
years after fracture
80% of which had
mechanical symptoms of
locking,catching and painful
limited range of motion
56. A Meta-analysis Of 3,457 Extension-type SCH Fractures
Found An Overall Neuropraxia Rate Of 13%, With The
Median Nerve (5%) Being The Most Common, Followed
By The Radial Nerve 4%. AIN Palsy Presents As Paralysis
Of The Long Flexors Of The Thumb And Index Finger
Without Sensory Changes.
In A Flexion Type Of Supracondylar Fracture, Which Is
Rare, The Ulnar Nerve Is The Most Likely Nerve To Be
Injured.
The Course Of The Ulnar Nerve Through The Cubital
Tunnel, Between The Medial Epicondyle And The
Olecranon, Makes It Vulnerable When A Medial Pin Is
Placed
57. Clinically loss of reduction after extension type
supracondylar humerus fracture is rare in children
Although most children do not require formal physical
therapy.
In most patients, treated with closed reduction with
pinning elbow ROM return to 72% of contralateral elbow
by 6 weeks,86 % by 12 weeks, 98% by 52 weeks
58. Significant loss of flexion can
be caused by lack of anatomical
fracture reduction:
1.posterior distal fragment
angulation
2.Pure horizontal without
angulation
3. Pure posterior translocation
without rotation or angulation
of the distal fragment
4.Horizontal rotation with
coronal tilting,producing a
cubitus varus deformity
59. The reported prevalence is less than 1-2.5%
Pin tract infection generally resolves with pin removal
and antibiotics
However, an untreated patient can result in septic joint
and osteomyelitis, and thus be treated as soon as
diagnosed or suspected
60. It is most common complication in SCH fractures
This complication can be minimized by both bending at
least 1 cm of the pin at a 90 degree angle, at least 1 cm
from the skin, and protecting the skin with thick felt
over the pin ort using pin covers
61. It is remarkably rare
complication, but it can
Occur
This complication have been
described after closed and
open reductions due to
disruption of the brachialis
with injury, but vigorous
post- operative manipulation
or physical therapy
62. The distal humeral metaphysis is a well-vascularized
area with markedly rapid healing, and nonunion of a
supracondylar fracture is very rare
63. Cubitus varus also known as
'Gunstock Deformity‘
The malunion also includes
hyperextension which leads to
increased elbow extension and
decreased elbow flexion
On AP view, the angle of the
physis of the lateral condyle
(baumann's angle) is more
horizontal than is normal
On Lateral view, hyperextension
of the distal fragment posterior to
the AHL goes along with the
clinical findings of increased
extension and decreased flexion of
the elbow
64. The most common reason for cubitus varus in patient
with supracondylar fractures is likely malunion rather
than growth arrest
Cubitus varus can be prevented by making certain
Baumann's angle is intact at the time of reduction and
remains so during healing by achieving stable reduction
and remains so during healing by achieving stable
fixation
Avascular necrosis of the trochlea or medial portion of
the distal humeral fragment can result in progressive
varus deformity
65.
66. For treatment of any posttraumatic malalignments, options
include
1. Observation with expected remodeling
2. Hemi epiphysiodesis
3. Corrective osteotomy
67. Observation is generally not successful in achieving
anatomical alignment as hyperextension may remodel to
some degree in a young child, but in older children,
insufficient remodeling occurs even in joint's plane of
motion
68. Osteotomy is the only way to
correct a cubitus varus deformity
with high probablity of success
It was found that when lateral entry
pins were used to fix the osteotomy,
there were significantly less
complications
1. Medial open wedge osteotomy
2. Lateral closing wedge osteotomy
3. Dome osteotomy
4. Arch osteotomy
69. Machanism of injury
Due to fall directly on elbow rather than fall on
outstretched hand.
70. Distal fragment is displaced anteriorly and may migrate
proximally in totally displaced fracture.
Ulnar nerve is vulnerable to injury in this pattern of injury,
and may be entrapped in fracture of healing callus
A. Supination of the forearm (1) creates a downward lateral tilt of the distal fragment (3). This produces compressive forces between the articulating surface of the ulna and the trochlea's medial border (A1, stippled area), which in turn, generates clockwise forces (2) about the medial side of the fracture. B. Pronation of the forearm (1) creates an upward tilt of the distal fragment (3) due to the compressive forces between the articulating surface of the ulna and the lateral border of the trochlea (B1, stippled area), which in turn, generates counterclockwise forces (2) about the medial side of the fracture.
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).
The md ange
Normally there is angulation of 40 to 45 degrees between the long axis of humerus and long axis of lateral epicondyle
Fish 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
