Conference ext.สิทธิกร ปภาวิน orthokorat

1. Interesting case
Ext. สิทธิกร ปภาวิน 5402161

2. Patient profile
 เด็กชายไทย อายุ 6 ปี

3. Chief Complaint
 ตกต้นไทรแขนซ้ายบวมผิดรูป 1 ชม.ก่อนมาโรงพยาบาล

4. Intial management
 Airway with c spine protection
 Breathing
 Circulation
 Disability
 Exposure and environment control

5. Secondary survey
 ไม่แพ้ยาแพ้อาหาร
 ไม่มีโรคประจาตัว
 ไม่ใช้ยาใดเป็นประจา
 NPO time 8 ชม.ก่อนมาโรงพยาบาล

6. Event
 1ชม.ก่อนมาโรงพยาบาลตกจากต้นไทร จากนั้นปวดแขนข้างซ้ายทันที
และ แขนซ้ายผิดรูป ไม่ยอมขยับข้อศอกแขนและข้อมือ ไม่สลบ ไม่มี
หัวกระแทกพื้น ไม่ปวดหัว ไม่คลื่นไส้

7. Physical Examination (แรกรับ)
 V/S- BT 37.4 C, BP 139/55 mmHg, PR 106/min, RR
20/min O2 sat 97% room air
 GA- alert
 Skin:no rash
 HEENT no wound at face and scalp
 Heart-normal s1 s2
 Lungs-symmetrical chest wall movement, no use
accessory muscle,good air entry,no adventicious sound
 Abdomen-no distension, soft,not tender

8. extremities
S shape deformities,swelling,ecchymosis 3
cm,marked tenderness at distal humerus of left
arm,loss of isosceles triangle,range of motion
limited due to pain,no wound, no fat globue

9. S shape deformities

10. S shape deformities

11. S shape deformities

12. neurovascular
 Radial pulse 2+
 Ulnar pulse 2+
 Capillary refill < 2 sec
 OK sign intact
 Great sign intact
 Bye-bye sign intact

13. Problem list
 Acute left elbow pain and deformities
 History of trauma at left elbow

14. DDx
 Closed Supracondylar fracture of left the
humerus
 Closed Lateral condyla fracture of left the
humerus
 Subluxation of the radial head of left elbow

15. Immobilization
 Temporary splint(woody splint) or Long
posterior arm slap
 Go to x-ray

16. investigation
 Flim elbow true AP,Lat

19. Preoperative Diagnosis
 Closed Totally displace Supracondylar fracture
of left the humerus (GARTLAND 3)

20. Refer
 Definitive treatment
 Close reduction in OR with internal fixation by
K-wire percutaneous crossed pinning
 Apply posterior long arm slab in slightly flexion
and arm sling

21. Postoperative Diagnosis
 Closed Totally displace Supracondylar fracture
of left the humerus (GARTLAND 4 )

24. Post op care
 Elevation/swelling control
 Pain control
 Observe compartment syndrome and
neurovascular complication
 Remove pin and slab at 4 week/clinical union

25. SUPRACONDYLAR
FRACTURES OF
HUMERUS

26. 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

27. 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.

28. 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%

29. g) Cause of #
Fall from height 70% ----- children > 3 yrs
Fall from bed children < 3 yrs
Non accidental injury ( Child abuse) children < 15 months
h) Associated #s
Distal radius > Scaphoid > Proximal humerus >
Monteggia
i) Clinical types
Extension type: 98%
Flexion type : 2%

30. Mechanism of injury
 For Extension type of
SC # humerus
Fall on outstretched hand
Elbow hyper extended
Fore arm – pronated or
supinated

31. Mechanism of injury
 For Flexion type
of SC # humerus
Fall directly on the
elbow rather than
out stretched hand

32. Radiographic anatomy of distal
Humerus
 What are the radiographic views:
Antero posterior
Lateral
Oblique
Axial ( jones view )

33.  What to look for in
AP View----- Baumann`s angle

34. 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.

35. 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.

36. Radiograph Anatomy/Landmarks
 The capitellum is
angulated anteriorly
about 30 degrees.
 The appearance of the
distal humerus is similar
to a hockey stick.
30

37. Radiograph Anatomy/Landmarks
 The physis of the
capitellum is usually
wider posteriorly,
compared to the
anterior portion of
the physis
Wider

38. Anatomical classification of SC #

39. 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

40. Type 1: Non-displaced
 Note the non-
displaced fracture
(Red Arrow)
 Note the posterior fat
pad (Yellow Arrows)

41. Type 2: Angulated/Displaced Fracture
with Intact Posterior Cortex

42. Type 3: Complete Displacement, with
No Contact between Fragments

43. 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

44. S-shaped configuration of UL

45. 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)

46.  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

47.  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

48. 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.

49. 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.

50.  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.
Treatment of type – I #

52.  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.

53. 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

54. SELECTIVE PINNING
Closed reduction is done
Splinting in flexion
Non movable cuff & collar sling
Early careful X-ray follow up
If # displacement /angulation noticed
pin stabilisation is done .

55. 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

56. 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.

58. 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 .

59. 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