An overview of the approach to diagnosis and treatment of supracondylar humeral fractures in children

1. PAEDIATRIC SUPRACONDLAR
HUMERAL FRACTURES
DR ASI-OQUA E. BASSEY
SUPERVISED BY – DR OMACHOKO OGUCHE

2. Outline
• Introduction
• Aetiology
• Mechanism of injury
• Classification
• Differential diagnosis
• Clinical evaluation
• Investigation
• Treatment
• Complications
• Current trends
• Conclusion

3. Introduction
• Supracondylar humeral (SCH) fractures are fractures that occur just above
the condyles of the humerus
• They are the commonest elbow fractures in children, and also the
commonest fracture operated on in them.
• Peak age of incidence is 5 – 6 years. M = F
• SCH fractures can cause complications resulting in limb loss, surgeons must
be skilled in the diagnosis and treatment of this common problem

4. Aetiology
• FOOSH
• Direct force to elbow

5. Mechanism of injury
• FOOSH with elbow fully extended.
• Force transmitted thru elbow into distal humerus  increased tensile stress
in anterior cortex  Failure of anterior cortex, with fracture line extending
posteriorly and superiorly  may or may not breach posterior cortex
depending on severity of injury.

6. Mechanism of injury
• This is the hyperextension injury – makes up 97-99% of SCH fractures.
• Often occurs with forearm in pronation causing varus and internal rotation of distal
fragment.
• Distal fragment valgus may occur but rare
• Posterior angulation ± translation of distal fragment causes relative anterior
protrusion of jagged end of proximal fragment. This can cause injury to brachialis,
brachial artery and anterior interosseous nerve (branch of median nerve).
• Valgus displacement of distal fragment can cause ulnar palsy due to traction. Ulna
palsy most commonly caused due to faulty pinning though.
• Direct force –
• Fall on tip of olecranon causes reverse mechanism resulting in flexion type injury.
• Quite rare
• Can cause radial

7. Classification
• Wilkins Modification of Gartland Classification
• Type I – undisplaced

8. Classification
• Type II – Displaced. Posterior cortex and periosteal hinge intact

9. Classification
• Type IIa – posterior angulation only
• Type IIb – posterior angulation + varus

10. Classification
• Type III – Completely displaced. Posterior cortex disrupted. Periosteal
hinge intact

11. Classification
• Type IV - Completely displaced. Posterior cortex disrupted. Periosteal
hinge disrupted. Multidirectionally unstable.

12. Differential diagnosis
• Lateral condyle fractures
• Distal humeral osteomyelitis/septic arthritis
• Radial head subluxation
• Inflammatory arthritis

13. Clinical evaluation
• History
• Pain
• Refusal to use limb
• Swollen elbow
• Hx of fall
• Examination
• Tenderness distal humerus
• S-shaped deformity in ≥ Type III
• Puckering on anterior distal humerus

14. Clinical evaluation
• Must do motor, sensory and vascular exam
• Motor
• AIN (Median) – pinch thumb and index (OK sign)
• Radial – extend wrist, thumb and digits (Hi-5)
• Ulnar – Crossed fingers sign
• Sensory
• Median – tip of index
• Radial – 1st web space
• Ulnar tip of little finger
• Vascular – check:
• Colour
• Warmth
• Pulses
• Capillary refill
• Must r/o compartment syndrome

15. • Xrays –
• AP Distal humerus - more accurate than AP elbow in demostrating SCH
fractures, as well as Baumann’s angle.
• Lateral – Type l fractures suggested by posterior fat pad. Easy to identify if
fracture is ≥ Type II. Subtle displacement can be identified by checking
intersection between the anterior humeral line and capitellum.
• Where true AP cannot be obtained, oblique views may be done.
Investigation

17. Treatment
• Type I – immobilize elbow in cast at 90o and neutral rotation for 4
weeks. Check xray at 1 week and 4 weeks. Begin supervised active
ROM after taking off cast.
• Type IIa – Reduce under GA
• Forearm traction with elbow at 10o flexion, and countertraction in arm for 2-
3mins,
• Placing thumb on olecranon, apply an anterior push while gradually flexing
elbow to 120o
• Retain limb in a backslab and sling
• Repeat vascular an neurological exam
• Check xrays
• Follow-up as above

18. Treatment

19. Treatment
• Type IIb & III
• Tend to be unstable with increased risk of neurovascular injury
• Treatment is by reduction under GA and percutaneous pinning under C-arm
• Acceptable reduction – AP: Baumann <80o, restored medial & lateral
columns. Lat: AHL passing thru mid 1/3 of capitellum
• Limb held in backslab at 40-70o
• Serial vascular exam for 1st 24hrs post op
• Check xray at 1 and 4 weeks
• Pins are taken out at 4 weeks, follow-up as for Type IIa
• Type IV management as for Type III

20. Treatment
• CRPP
• Crossed pins vs Lateral pins – Problems: 1. iatrogenic ulnar nerve injury 2.
Stability
• Ulnar nerve injury is predominantly a problem seen in crossed pinning
• While crossed pinning has been hailed for its biomechanical stability, current
trends in lateral pinning have resulted in equivalent stability, making it more
favoured among surgeons today.
• Technical points for success of lateral pinning (Skaggs et al) include
• Maximise pin separation at fracture site
• Engage medial & lateral columns prox to fracture
• Consider third lateral pin where stability after 2 pins is in questions, esp in Types III or IV
fractures
• If surgeon opts for crossed pinning, then lateral pin is placed first, elbow
extended to <70o before placement of medial pin.

21. Treatment
• Open reduction – indications
• Failed closed reduction
• Open fracture
• Vascular injury
• Nerve entrapment post-closed reduction
• Continuous traction – indications
• No skilled surgeon
• No infrastructure
• Severe comminution
• Temporary immobilization to relieve swelling

22. Complications - EARLY
• Nerve injury –
• Commonest is AIN, 2nd is radial, then ulnar (more often iatrogenic)
• Most times are neurapraxias.
• Rx – Most recover in 3-4 months, if they do not then consider NCS and
exploration
• Nerve injury noticed AFTER closed reduction that was not initially present
warrants immediate exploration
• Vascular injury
• Brachial artery may be damaged by jagged end of proximal fragment
• White, pulseless hand at presentation – treatment is CRPP, vascularity in most
would return

23. Complications – EARLY
• Postreduction white and/or pulseless hand – brachial artery
entrapment. Rx - Take out pins and explore artery
• Postreduction pink, pulseless hand – may be due to arterial spasm. Rx
– keep reduced. Observe over 48 hours. Monitor for 3As of paediatric
compartment syndrome – increasing Anxiety, Agitation and Analgesic
requirements. Maintain low threshold for return to theatre to explore
artery
• Compartment syndrome – commoner in severer fractures. Watch for
above signs. Also, undue pain + one positive sign (pulselessness, pain
on passive finger extension, decreased cap refill, diminished
sensation) should trigger urgent action

24. Complications – LATE
• Malunion – unfortunately common. Cubitus varus most often seen.
Emphasis should be on detection of varus at time of fracture
reduction and correct it
• Elbow stiffness/ Heterotopic ossification – Avoid passive elbow
stretch, active elbow exercises instead.

25. Current trends
• ESIN for SCH fractures
• Antegrade ESIN has been found suitable for all types of
supracondylar humeral fractures with good functional results.
• Advantages
• avoidance of iatrogenic ulnar nerve injury
• low rates of cubitus varus
• No need for cast
• Surgeon is able to evaluate clinical motion at all times postoperatively

26. Conclusion
• SCH fractures remain common in our society
• They have potential for significant morbidity and lifelong functional
loss if poorly managed
• Utmost care must be applied in not just treating these fractures but
also in early identification of its complications

27. THANK YOU FOR
LISTENING

28. References
• Blom A, Warwick D, Whitehouse M. Apley and Solomon’s System of
Orthopaedics and Trauma. 10th Ed. Boca Raton: CRC Press, 2018.
Chapter 25: Injuries of the elbow and forearm; p. 781-784.
• Flynn JM, Skaggs DL, Waters PM. Rockwood and Wilkins’ Fractures in
Children. 8th Ed. Philadelphia: Wolters Kluwer Health, 2015. Chapter
16: Principles of Nonunion Treatment; p. 827-860.
• Skaggs DL, Cluck MW, Mostofi A, Flynn JM, Kay RM. Lateral-
entry pin fixation in the management of supracondylar fractures
in children. J Bone Joint Surg Am. 2004 Apr;86(4):702-7.
• https://www.orthobullets.com/pediatrics/4007/supracondylar-
fracture--pediatric