Lecture for undergraduate students. Equally useful for postgraduate students.

1. Supracondylar
Fracture of Humerus
Dr. Sundar Karki
MBBS, MS(Ortho), Lecturer
Department of Orthopedic and Trauma
Devdaha Medical College

2. Relevant Anatomy
• The elbow joint is a hinge joint, formed by the articulation
between the lower end of the humerus with the ulna
(humero-ulnar joint), and with the head of the radius
(humero-radial joint).
• The lower end of the humerus is enlarged to form the
trochlea medially and capitulum laterally.
• Medial to the trochlea is a prominent process i.e., medial
epicondyle, and lateral to the capitulum is the lateral
epicondyle.

3. Three bony points relationship
• The three prominent bony points around the elbow i.e., the
medial epicondyle, lateral epicondyle and tip of the
olecranon are important landmarks in the diagnosis of
injuries around the elbow.
• Normally, in an elbow flexed to 90°, these three bony points
form a near-isosceles triangle, but they lie in a straight
horizontal line in an extended elbow.

5. Carrying angle
• When the elbow joint is fully extended and supinated, the
forearm and the arm do not lie in a straight line, but form
an angle . This is called the carrying angle.
• It disappears on flexing the elbow. The normal carrying
angle is 11° in males and 14° in females.
• In injuries around the elbow this angle may decrease or
increase.

7. Ossification around the elbow
• Capitellum is the first ossification center about the elbow to
appear. It appears around 2 years of age.
• The mnemonic “CRITOE” is helpful in remembering the
progression of the radiographic appearance of ossification
centre about the elbow in children:
– C : Capitellum – 2 years
– R : Radius head – 4 years
– I : Internal (medial) epicondyle – 6 years
– T : Trochlea – 8 years
– O : Olecranon – 10 years
– E : External (Lateral) epicondyle – 12 years

9. SUPRACONDYLAR
FRACTURE OF HUMERUS
• These are among the most common fractures in children
and occurs between the age of 5 to 8.
• The fracture is usually caused by a fall on an out-stretched
hand.
• The distal fragment may be displaced either posteriorly or
anteriorly.

10. Mechanism of injury
• Posterior angulation or displacement suggests a
hyperextension injury, usually due to a fall on the
outstretched hand.
• The humerus breaks just above the condyles. The distal
fragment is pushed backwards and (because the forearm is
usually pronated) twists inwards.
• The jagged end of the proximal fragment pokes into the soft
tissues anteriorly, sometimes injuring the brachial artery or
median nerve.

11. Types of Supracondylar fracture
• A supracondylar fracture may be of extension or flexion
type.
• The extension type(80%) is the commoner of the two. In
this,the distal fragment is extended (tilted backwards) in
relation to the proximal fragment.
• In the flexion type(20%), the distal fragment is flexed
(tilted forwards)in relation to the proximal fragment.

13. Displacements
• Commonly, a supracondylar fracture is displaced. The
distal fragment may be displaced in the following
directions:
• (i) posterior or backward shift;
• (ii) anterior or forward tilt;
• (iii) proximal shift;
• (iv) medial or lateral shift;
• (v) medial tilt; and
• (vi) internal rotation.

15. Clinical features
• Gross swelling, and tenderness of elbow joint.
• Crepitus is present but should not be elicited for fear of
increasing the pain and damaging the neighboring
neurovascular structures.
• S-shaped deformity.
• Dimple sign due to one of the spikes of proximal
fragment penetrating the muscle and tethering
the skin.
• Relationship between three bony points is maintained.

16. Clinical features
• “Soft spots” is an effusion beneath anconeus muscle.
• Movements of the elbow both active and passive are
decreased.
• It is essential to feel the pulse distally and check capillary
return; passive extension of the flexor muscles should be
pain-free otherwise there may be concern regarding
ischemia.

17. Radiological examination
• Most often, it is easy to diagnose the fracture because of
wide displacement.
• Sometime the ossifications center around the elbow make
diagnosis of a minimally displaced fracture difficult. A
comparison with an X-ray of the opposite elbow may help.
The following displacements may be seen on an X-ray.
• In an antero-posterior view, one can see the proximal shift,
medial or lateral shift, medial tilt and rotation of the distal
fragment.
• In a lateral view, one can see the proximal shift, posterior
shift, posterior tilt and rotation of the distal fragment

19. Radiological examination
• Classically, supracondylar fracture radiographs will have a
positive posterior fat pad sign, indicative of joint effusion
from a fracture.
• The sensitivity of the posterior fat pad sign is > 70% in the
setting of trauma without visible fractures lines. Anterior
and superior fat pad signs are less sensitive.
• Additional radiographic assessment should include
confirmation that the radial head aligns with the
capitellum in all views.
• Finally, the anterior humeral line should bisect the middle
third of the capitellum; in displaced extension-type injuries,
the capitellum can fall posterior to the anterior humeral
line.

23. Treatment
• Undisplaced fractures require immobilization in an above-
elbow plaster slab, with the elbow in 90° flexion.
• In all displaced fractures, the child should be admitted to a
hospital because serious complications can occur within the
first 48 hours.

24. Treatment (Displaced fracture)
• Most of the displaced supracondylar fracture are treated
with closed reduction and percutaneous K-wire fixation.
• Most displaced fractures are easily reduced by closed
reduction, but they often slip. Hence, it is best to fix them
with one or two K-wires, passed percutaneously under
image intensifier guidance.

25. Technique of closed reduction of a
supracondylar fracture
• Traction with the elbow in 30-40° of flexion.
• Flexion in traction
• Pressure over olecranon
Throughout this maneuver the radial pulse is felt. A posterior
slab is applied in this position for 3 weeks. It is necessary to
make a check X-ray after 48 hours, and after 1 week in order
to detect any redisplacement. In case no redisplacement
occurs, the plaster is removed after 3 weeks.

27. Treatment (Displaced fracture)
• Open reduction and K-wire fixation: In some cases, it is not
possible to achieve a good position by closed methods, or the
fracture gets redisplaced after reduction. In such cases,
open reduction and K-wire fixation is necessary.
• Continuous traction: This is required in cases presenting
late with excessive swelling or bad wounds around the
elbow. The traction may be given with a K-wire passed
through the olecranon ( smith’s traction) or below elbow
skin traction( Dunlop’s traction). These methods are no
longer used.

30. Complications
• The supracondylar fracture is notorious for a number of
serious complications. These can be:
(i) Immediate – occurring at the time of fracture;
(ii) Early – occurring within first 2-3 days;
(iii) Late – occurring weeks to months after the fracture.

31. Immediate Complications
• Injury to the brachial artery: This is a complication
commonly associated with a displaced supracondylar
fracture. The flexor muscles of the forearm may suffer
ischemic damage leading to Volkmann’s ischemia.
• Injury to nerves: The anterior interosseous nerve( branch of
median nerve) is the most commonly injured nerve. Radial
nerve is also sometimes affected. In extension type nerve
injury AIN>median>radial>ulnar (Mnemonics: AMRU)
• Spontaneous recovery occurs in most of the cases.

32. Early Complications(Volkmann’s ischemia)
• This is an ischemic injury to the muscles and nerves of the
flexor compartment of the forearm. It is caused due to
occlusion of the brachial artery by a supracondylar
fracture.
• The muscles supplied by the anterior interosseous artery, a
branch of brachial artery, are most susceptible to ischemic
damage because this artery is an end-artery.
• Most commonly affected muscles are the flexor pollicis
longus and medial half of flexor digitorum profundus. The
muscle ischemia leads to compartment syndrome.

33. Volkmann’s ischemia
• Early diagnosis of Volkmann’s ischemia is of extreme
importance. The following are some of the early signs:
• The child complains of severe pain in the forearm. He is
unable to move the fingers fully.
• Stretch pain: The child complains of pain in the flexor
aspect of the forearm when the fingers are extended
passively.
• Swelling and numbness over the fingers occur rather late.
• There is tenderness on pressing the forearm muscles.

34. Volkmann’s ischemia
• Treatment: Volkmann’s ischemia is an emergency of the
highest order. The following actions need to be taken
urgently in a suspected case:
• Any external splints or bandages that might be causing
constriction are removed.
• The forearm is elevated and the child encouraged to move
fingers.
• If no improvement occurs within 2 hours, an urgent
decompression of the tight compartment is necessary. This
is done by a fasciotomy – an operation where the deep
fascia covering the flexor muscles of the forearm is slit
along its entire length.

36. Late Complications
• Malunion: It is the commonest complication of a
supracondylar fracture and results in a cubitus varus
deformity. The cubitus varus deformity is often termed
the Gunstock deformity.
• Treatment: Cubitus varus deformity is a cosmetic
problem, usually without much functional
impairment. Mild deformity may not require
treatment, but a badly deformed elbow should be
corrected. Treatment is a supracondylar corrective
osteotomy (French osteotomy).

38. Late Complications
• Myositis ossificans: This is an ectopic new bone formation
around the elbow joint, resulting in stiffness. Massage
following the injury, so commonly resorted to in some
places, is a major factor responsible for it.
• Treatment: In the early stages, the elbow is put to rest in
an above-elbow slab for 3 weeks. Following this, gentle
elbow mobilization is started. In some late cases, excision of
the myositic bone or excision arthroplasty of the elbow is
required. Whatever treatment is undertaken, the chances
of the elbow regaining full range of movement are little.

39. Late Complications
• Volkmann’s ischemic contracture (VIC): This is a sequel of
Volkmann’s ischemia. The ischemic muscles are gradually
replaced by fibrous tissue, which contracts and draws the
wrist and fingers into flexion. If the peripheral nerves are
also affected, there will be sensory loss and motor paralysis
in the forearm and hand.

40. Volkmann’s ischaemic contracture (VIC)
• Clinical features: There is marked atrophy of the
forearm, with flexion deformity of the wrist and fingers.
• Volkmann’s sign helps in deciding the cause of flexion
deformity of the fingers. In this sign, it is possible to
extend the fingers fully at the interphalangeal joints
only when the wrist is flexed. On extending the wrist,
the fingers get flexed at the inter-phalangeal joints.
There may be hypoaesthesia or anaesthesia of the hand.

42. Volkmann’s ischemic contracture (VIC)
• Treatment: Mild deformities can be corrected by passive
stretching of the contracted muscles, using a turn-buckle
splint (Volkmann’s splint).
• For moderate deformities, a soft tissue sliding operation,
where the flexor muscles are released from their origin at
the medial epicondyle and ulna, is performed (Maxpage
operation).
• For a severe deformity, bone operations such as shortening
of the forearm bones, carpal bone excision etc. may be
required.