This document discusses supracondylar humeral fractures in children. It notes that these are the most common pediatric fractures, usually occurring from falls onto an outstretched hand in children ages 5-7. The fractures are classified into 4 types based on displacement and angulation. Type I are undisplaced while types II-IV are increasingly displaced, with type III being completely displaced. Treatment depends on type, with undisplaced or mildly angulated fractures treated with splinting while more severe fractures require closed or open reduction and percutaneous pinning under imaging guidance.

1. Supra-condylar fracture

2. • Supracondylar humeral fracture are the most common pediatric
fractures.
• Accounting for 3% of all children’s fractures.
• The most common age of injury is 5 to 7 years.
• Almost all (98%) are extension type injuries, which is usually caused
by fall on the outstretched hand.
• Flexion type fractures, almost rarer, are most difficult to reduce.
• Flexion type have worse outcomes, and are associated ulnar nerve
injury.

3. • Approximately, 5 – 10% of child have an associated ipsilateral distal
radial fracture.

4. Classification
 Type-I : An undisplaced fracture.
 Type-II : An angulated fracture with the posterior cortex still intact.
 II-A : A less severe injury with the distal fragment merely angulated.
 II-B : A severe injury with the distal fragment is both angulated &
malrotated.
 Type-III : A completely displaced fracture (although the posterior
periosteum is usually preserved, which will assist surgical reduction).
 Type-IV : An anteriorly displaced fracture.

5. Clinical features
• The child is in pain & the elbow is swollen.
• With a posteriorly displaced fracture the S-deformity in the elbow.
• It is essential to feel the pulse distally & check capillary return.
• Passive extension of the flexor muscles should be pain-free otherwise
there may be concern regarding ischemia.
• The wrist & hand should be examined for evidence of nerve injury.

6. X-ray
1. Fad pad sign :
 In undisplaced fracture the ‘fad pad’ or ‘sail’ sign should raise
suspicion.
 This is a triangular lucency in front of & behind the distal humerus
like the sail of a yacht, due to the fad pad being pushed by fluid such
as a hematoma.
2. Anterior humeral line:
 A line drawn along the anterior cortex of the humerus should cross
the middle of the capitellum.
 If the line is anterior to the capitellum, a type-II # is suspected.

8. 3. Baumen’s angle :
 In AP X-ray of the elbow a line drawn along the long axis of the
humeral shaft & a line through the coronal axis of the capitellar
physis.
 Normally the angle is less than 80 degrees.
 If the distal fragment is tilted varus, the increased angle is readily
detected.

10. Treatment
• If there is even suspicion of a fracture, the elbow us gently splinted in
30 degrees of flexion to prevent movement and possible
neurovascular injury during X-ray examination.

11. 1. Type-I : Undisplaced fracture
 The elbow is immobilized in 90° & neutral rotation.
 A light weight splint or a cast is applied & the arm is supported in a
sling.
 It is essential to obtain an X-ray 5-7 days later to check that there
has been no displacement.
 The splint is retained for 3 weeks and supervised movements is
then allowed.

12. 2. Type-IIA : Posteriorly angulated fracture – Mild
 If the posterior cortex are in continuity, the fracture can be reduced
under GA.
 Closed reduction & casting may be used in patients with IIA
injuries.(Camb.)
 Closed reduction & percutaneous pinning with 02 to 03 lateral pins
has become the main form of Rx for type IIB.(Camb.)
 We prefer to pin most of the type-II # because of concerns about the
ability to maintain reduction in a splint or cast.

13. 3. Type-IIB &III:
 These are usually associated with severe swelling, are difficult to
reduce & are often unstable.
 Moreover, there is considerable risk of neurovascular injury or
circulatory compromise due to swelling.
 The fracture should be reduced under GA as soon as possible by the
following manoeuvre :

14. Extension type injury
• Pt. in supine position, traction for 2-3 minutes in length of the arm
with counter traction above the elbow.
• Correction of any sideway tilt or shift and rotation (in comparison
with the arm)
• Gradual flexion of the elbow to 120°, and pronation of the forearm to
lock posterior & medial soft tissue hinge, while maintaining traction &
exerting finger pressure on the olecranon to correct the posterior tilt.
• Then feel pulse & check the capillary return; if the distal circulation is
suspect, immediate relax the amount of elbow flexion until it
improves.

15. • Confirm the Anteroposterior reduction by the image intensification,
aiming the beam through the forearm & rotating the humerus from
medial to lateral column reduction. Confirm lateral reduction to
obtain a lateral view of the elbow.(Camb.)
• Maintain reduction while performing closed percutaneous pinning
with image intensification to verify that the lateral 02 pins engage the
both fracture fragments.(Camb.)
• The pin should be divergent & not cross at fracture site.(Camb.)

16. • If a medial pin used, make a 1cm incision over the medial epicondyle.
• Spread the soft tissues so that the medial epicondyle can be seen &
ensure the ulnar nerve is protected.
• Alternatively, a small soft tissue drill sleeve is used.

17. • A back slab is applied & the arm is held in a collar & cuff sling.
• The circulation should be checked repeatedly during the first 24
hours.
• An X-ray is obtained after 3-5 days to confirm that the # has not
slipped.
• The splint is retained for 3 – 4 weeks, after which movements are
begun.
• Check X-ray must be obtained on removal of the splint & wires to
ensure adequate position has been maintained.

18. Flexion type injury
• For a rarer, flexion type injury, flexing the elbow will further displace
the fragment because of the disruption of the posterior periosteal
hinge.
• The # is reduced by pulling on the forearm with the elbow semi-
flexed, applying thumb pressure over the front of the distal fragment
& then extending the elbow fully.
• Percutaneous smooth pin are used if unstable.
• In this case elbow is need to be pinned in extension.
• A posterior slab is applied if unstable.

19. Complications
Early :
• Vascular injury
• Nerve injury
Late :
• Malunion
• Elbow stiffness
• Heterotopic ossification