Evolving Concepts in Supracondylar Fractures in Children

1. Evolving Management
Concepts in Supracondylar
Fractures of Humerus in
Children
Prepared By
Dr MADAN MOHAN
Consultant in Orthopaedics
KIMS Trivandrum

2. Timing of Surgery
It is safe to delay surgical treatment
of most type III supracondylar
fractures to within 12 to 18 hours of
injury.

3. Indications for emergent treatment
• Open fracture
• Dysvascular limb
• Skin puckering
• Floating elbow
• Median nerve palsy
• Evolving compartment syndrome
• Young age
• Cognitive disability

4. Type II fractures
• Closed reduction and casting is the primary treatment
only for those patients with minimal swelling and
posterior displacement without rotation or translation
on any radiographic view.
• Follow-up radiographs are obtained 5 to 7 days after
injury.
• Surgical reduction and pinning is performed if the
reduction is not maintained.

5. Pin placement
• In cross pin configuration, the pins are configured to
cross proximal to the fracture site in the midline of the
distal humerus, and they are advanced through the
cortices
• This configuration has been shown in clinical series to
be effective for maintaining reduction and has been
shown in biomechanical testing to be superior to
other pin configurations, including multiple lateral
entry pins

6. Iatrogenic Ulnar Nerve Injury
• Ulnar nerve injury occurs in as many as 10% of
patients.
• Direct nerve penetration or stretching of the nerve
around the pin are possible causes of injury.
• In addition, because in some children the ulnar nerve
subluxates anteriorly out of the ulnar groove when
the elbow is held in maximum flexion, this
complication may occur even when the medial pin is
placed correctly in the medial epicondyle.

7. A, Failure to obtain bicortical fixation across the fracture
secondary to the pin exiting anteriorly through the
fracture site (arrow). B, Failure to obtain bicortical
fixation across the fracture site secondary to
intramedullary pin placement (arrow). C, The pins cross
the fracture site with a spread <2 mm (arrow)

8. A, Preoperative lateral view demonstrating complete
displacement. B, AP view following pin placement
demonstrating the spread of the pins through the
medial and lateral columns. C, Lateral view
demonstrating the spread of the pins in the AP plane

9. Algorithm for pink pulseless limb

10. Cubitus Varus
• Elbow instability 20 to 30 years after sustaining supracondylar
fractures in childhood
• This “tardy posterolateral elbow instability” causes medial
displacement of the elbow mechanical axis, resulting in asymmetric
triceps forces that cause slow attenuation of the lateral collateral
ligament.
• Valgus osteotomy and ligament reconstruction yields satisfactory
results

11. Ideally, the surgery is done ≥1 year
after injury, when elbow range of
motion has stopped improving and
when the child is old enough to
cooperate with postoperative
instructions

12. In children, an increasing
need for narcotic medication
to control pain is the best
indicator of compartment
syndrome