sc humerus fractures management in chilren

1. Management Of Supracondylar
Humerus Fractures In Childrens
Dr. RAMACHANDRA REDDY
MBBS D.ortho
DNB(Ortho)
Orthopaedic surgeon
Devadoss KHMS hospital
Kodaikanal

2.  It is the most common elbow fracture in children
 It accounts for about 60% of the elbow fractures and
13%-15% of all pediatric fractures
 More common in 5-7 years old children
 Boys are more commonly affected
Introduction

3.  In treatment of the supracondylar fracture, the main
target is to gain anatomic reduction and functional
with no serious complication

4. Mechanism Of Injury
 May be the result of an extension or flexion force on the
distal humerus
 Depending on MOI divided into two types
 Extension type – MC
 Flexion type

5. Extension Type
 MOI- fall on an outstretched hand, which causes
hyperextension of the elbow
 Extension type sc humeral fractures -95% to 98%

6. Flexion Type
 Flexion type Sc fractures are rare
 2% to 5% of cases
 MOI- direct blow on the posterior aspect of a flexed
elbow that results in anterior displacement of the
distal fragment

7. Classifcation
First described by Gartland in 1959

9. Clinical Evaluation
 Child present with a
swollen, tender elbow with
painful range of motion
 S-shaped angulation at
the elbow: due to
displaced fracture
fragments
 Pucker sign: due to
dimpling of skin anteriorly
by penetration of proximal
fragment into brachialis
muscle

11. Examine in Elbow injury
 VASCULAR STATUS – Radial artery Pulsation
[most important ] & Capillary refill time
 NEUROLOGICAL STATUS
M , R ,U
 Check Finger movement
 Check for ‘Stretch sign’ : compartment
syndrome

12. Pucker sign

13. Milking Maneuver

15. Neurological Examination

16. Radiographic Evaluation

17. Treatment

18. Type -1
 the only visible radiographic abnormality is the
presence of a fat pad sign

19. Type 1 fracture with fat pad
sign

20. Type 1
 Immobilization in a long arm cast or splint at 60 to 90
degrees of flexion is indicated for 2 to 3 weeks
 Follow-up x-rays at 1 week are recommended for
assessment of fracture position
 After 1 to 3 weeks, the fracture, as well as the periosteal
reaction associated with its healing, will be obvious

22. Type II
 prefer closed reduction and pinning of most type II
supracondylar fractures
 Two lateral pins are chosen as the initial postreduction
fxation method in nearly all cases

23. Type II

24. Type III
 Closed reduction & percutaneous K wire fixation
 Open reduction & K wire fixation

25. Hyperflexion of elbow Fluoroscopic view of reduction

26. Lateral k wire fixation Medial k wire fixation

27. Supracondylar Humerus Fractures
Associated Injuries
 Vascular injuries are rare, but pulse should always be
assessed before and after reduction
 In absence of a radial and/or ulnar pulse, fingers may
still be well-perfused , because of excellent collateral
circulation around elbow
 These limbs called as
PULSELESS PINK SC
HUMERUS FRACTURE

28. Options
1. Assesment of vascularity
CT ANGIOGRAM
OR
ASSESS CLINICALLY
CAPILLARY REFILLING
PULSE OXIMETRY WAVEFORM AND SATURATION

29. FIXATION OF FRACTURE SHOULD BE DONE
1. closed or open reduction and pinning and observe
OR
2. exploration of brachial artery reduction and pinning
of fracture.

30. Post Operative
Persistant pulseless but well perfused
hand post reduction
what to do ?

31. Review of
literatures

32. Investigations
 Waveform in pulse oximetry
 Colour flow duplex monitoring
 Angiography

33. Clin Orthop Surg. 2013 Mar;5(1):74-81. doi: 10.4055/cios.2013.5.1.74. Epub 2013 Feb 20
Pulse oximetry for the diagnosis and prediction for surgical exploration
in the pulseless perfused hand as a result of supracondylar fractures of
the distal humerus
Soh RC1, Tawng DK, Mahadev A.
 The presence of a waveform on a pulse oximeter is a sensitive
and easily available modality in determining vascular
perfusion as compared to other more complex investigations.
 The high sensitivity of this test will allow surgeons to
objectively determine the requirement for surgical
exploration of the brachial artery.

34. Pulse oximetry waveform

36. Eur J Vasc Endovasc Surg. 2008 Dec;36(6):697-702. doi:
10.1016/j.ejvs.2008.08.013. Epub 2008 Oct 11.
The pink pulseless hand: a review of the literature regarding management of
vascular complications of supracondylar humeral fractures in children.
Griffin KJ1, Walsh SR, Markar S, Tang TY, Boyle JR, Hayes PD.
 Both angiography and colour duplex ultrasound provide little
benefit in the management of these patients.
 A child with a pink pulseless hand post-fracture reduction
can be managed expectantly unless additional signs of
vascular compromise develop, in which case exploration
should be undertaken.

37. WHETHER TO EXPLORE
OR
OBSERVE

38. J Pediatr Orthop B. 2006 Jan;15(1):62-4.
Pink pulseless hand following supra-condylar fractures: an audit
of British practice.
Malviya A1, Simmons D, Vallamshetla R, Bache CE.
If the hand remains pulseless but well perfused after
stabilization the preferred option would be to observe and
rely on collateral circulation rather than treating it more
aggressively.

39. J Pediatr Orthop. 2010 Jun;30(4):328-35. doi: 10.1097/BPO.0b013e3181da0452.
Perfused, pulseless, and puzzling: a systematic review of vascular injuries in
pediatric supracondylar humerus fractures and results of a POSNA questionnaire.
White L1, Mehlman CT, Crawford AH.
 Our study revealed that common dogma regarding watchful
waiting of pulseless and perfused supracondylar fractures
needs to be questioned. In the vast majority of published
cases, an absence of pulse is an indicator of arterial injury,
even if the hand appears pink and warm, suggesting the
need for more aggressive vascular evaluation and vascular
exploration and repair in selected cases. Moreover, patency
rates for revascularization procedures appear sufficiently
high, making this intervention worthwhile.

40. J Pediatr Orthop B. 2011 May;20(3):124-8. doi: 10.1097/BPB.0b013e328342733e.
Management of acute 'pink pulseless' hand in pediatric supracondylar fractures of the
humerus.
Ramesh P1, Avadhani A, Shetty AP, Dheenadhayalan J, Rajasekaran S.
 We believe that the management of a
persistent pink pulseless hand remains a 'watchful
expectancy '
 Surgical exploration should be recommended only
if there is either severe pain in the forearm
persisting for more than 12hrs after the injury or if
there are signs of a deteriorating neurological
function

41. J Bone Joint Surg Am. 2015 Jun 3;97(11):937-43. doi: 10.2106/JBJS.N.00983.
Management of the pulseless pediatric supracondylar humeral fracture.
Badkoobehi H1, Choi PD1, Bae DS2, Skaggs DL1
 Options include immediate vascular exploration or
twenty-four to forty-eight hours of inpatient
observation
 If perfusion is compromised during this period of
observation, an emergency return to the operating
room for vascular exploration and possible
reconstruction is indicated

42. Decision making

43. Pink Pulseless hand – Evaluation and Decision making: Is there a
Consensus?
Vol 1 | Issue 1 | July-Sep 2015 | page:19-22 | Venkatadass K.
Authors : Venkatadass K[1]. International Journal of Paediatric Orthopaedics
July-Sep 2015;1(1):19-22.
 The AAOS guidelines for the management of supracondylar
fractures of humerus in children published in 2010 stated
that We cannot recommend for or against open exploration
of the antecubital fossa in patients with absent wrist pulses
but with a perfused hand after reduction of displaced
pediatric supracondylar humerus fractures” as there was no
strong evidence supporting either observation or
exploration

44. Venkatadass K[1]. International Journal of Paediatric Orthopaedics July-Sep
2015;1(1):19-22.
Hence in the present scenario,
three factors needs to be considered in the decision making
process of pink pulseless hand:
1.Presence of radial artery Doppler signals
2.Presence of good pulseoximeter waveforms and oxygen saturation >95%
3.Intact Median Nerve function

45.  If all the three criteria are met, the recommendation is
to observe the child closely for circulation and
symptoms of compartment syndrome
 If all three are absent, it is an indication of poor
perfusion and it is an indication for arterial
exploration
 The combination of absence of radial artery Doppler
signals and absence of pulse oximeter signals again
indicates poor perfusion and favors exploration

47.  Exuberant Collateral
circulation maintains the
vascularity of the limb
 Radial recurrent artery +
radial collateral branch of
profunda brachi
 superior ulnar collateral
artery + posterior ulnar
recurrent and inferior ulnar
collateral artery

49. Conclusion
 Type 2 and type 3 frctures best treated by closed
reduction and percutaneous pinning
 Both clinical and diagnostic methods have to be taken
into account while making a balanced decision
interms of observation or surgical exploration of a pink
pulseless hand
 Perfect anatomical reduction should be achieved to
avoid future rotational deformity of limb in child

50. References

51. THANK YOU