This document summarizes elbow fractures in children. It describes the mechanism, classification and clinical features of supracondylar fractures. It outlines the treatment for different types of fractures which may include closed or open reduction and percutaneous pinning. Complications discussed are vascular injury, nerve injury, malunion and elbow stiffness.

1. Dr Sanjay k
Junior resident
Department of Orthopaedics
KMCT Medical college
*

2. *Mechanism
*Classification
*Clinical features
*Xrays and diagnosis
*Treatment
*Complications

3. *Most common elbow
fractures in children.
*The distal fragment may be
displaced either
posteriorly or anteriorly.

4. *Posterior angulation or displacement (95% of
cases) 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
(because the forearm is usually pronated) and
twists inwards.
*The proximal fragment pokes into the soft tissues
anteriorly, sometimes injuring the brachial artery
or median nerve.

5. *Anterior displacement is rare - due to
direct violence (e.g. a fall on the point of
the elbow) with the joint in flexion

8. • Type I – an undisplaced fracture
• Type II – an angulated fracture with the
posterior cortex still intact
– IIA: a less severe injury with the
distal fragment merely angulated
– IIB: a severe injury; the fragment is
both angulated and malrotated
• Type III – a completely displaced fracture
• Type IV – an anteriorly displaced fracture

13. 1

18. *pain
*swollen elbow; with a posteriorly displaced fracture
the S-deformity if the elbow is usually obvious and the
bony landmarks are abnormal.
*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
ischaemia.
*The wrist and the hand should be examined for
evidence of nerve injury.

20. X-rays
*The fracture is seen most clearly in the lateral view
* Undisplaced fracture the ‘fat pad’ or ‘sail’ sign; a triangular
lucency in front of and behind the distal humerus like the
sails of a yacht
*due to the fat pad being pushed up by fluid such as a
haematoma.

22. *In the common posteriorly displaced
fracture the fracture line runs
obliquely downwards and forwards
and the distal fragment is tilted
backwards and/or displaced
backwards.

23. *In the anteriorly displaced fracture
the fracture line runs downwards and
backwards and the distal fragment is
angulated forwards.

24. * On a normal lateral X-ray, 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 fracture is suspected.

25. *An anteroposterior view is often difficult to
obtain without causing pain and it may need to
be postponed until the child has been
anaesthetized.
*It may show that the distal fragment is
translated or angulated sideways, and rotated
(usually medially).
* Measurement of Baumann’s angle is useful in
assessing the degree of medial angulation
before and after reduction.

27. *If there is even a suspicion of a fracture, the elbow is gently
splinted in 30 degrees of flexion to prevent movement and
possible neurovascular injury during X-ray examination.
TYPE I : UNDISPLACED FRACTURES
*The elbow is immobilized at 90 degrees and neutral rotation
in a lightweight splint or cast
*Arm is supported by 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 movement
is then allowed.

28. TYPE IIA: POSTERIORLY ANGULATED
FRACTURES – MILD
* Swelling is usually not severe and the risk of vascular
injury is low.
*If the posterior cortices are in continuity, the fracture
can be reduced under general anaesthesia by the
following stepwise manoeuvre :
(1) traction for 2–3 minutes in the length of the arm
with counter traction above the elbow;
(2) correction of any sideways tilt or shift and
rotation (in comparison with the other arm);

29. (3) gradual flexion of the elbow to 120 degrees, and
pronation of the forearm, while maintaining traction
and exerting finger pressure on the olecranon to
correct the posterior tilt.
Then feel the pulse and check the capillary return: if
the distal circulation is suspect, immediately relax the
amount of elbow flexion until it improves.

30. *X-rays are taken to confirm the reduction, checking
carefully to see that there is no varus or valgus
angulation and no rotational deformity.
*The AP view is confusing and unreliable with the elbow
flexed.
* Each column can be assessed by slight internal and
external rotation of the humerus to obtain AP, oblique
views, and Baumann’s angle can be assessed on the
true AP.
*If the acutely flexed position cannot be maintained, or
if the reduction is unstable , the fracture should be
fixed with percutaneous smooth K-wires.

31. *The wires should be advanced slowly with low revolutions
*Care must be taken to protect the ulnar nerve
*Medial mini-open approach is safest for placement of the
medial wire.
*A backslab should be applied.
*Following reduction, the arm is held in a collar and cuff
* the circulation should be checked repeatedly during the
first 24 hours.

32. *An X-ray is obtained after 3–5 days to confirm that
the fracture has not slipped.
*The splint is retained for 3–4 weeks, after which
movements are begun.
* Check X-rays must be obtained on removal of the
splint and wires to ensure that adequate position has
been maintained.

36. TYPES IIB AND III: ANGULATED AND MALROTATED OR
POSTERIORLY DISPLACED FRACTURES
*Usually associated with severe swelling
*difficult to reduce and are often unstable
*considerable risk of neurovascular injury or circulatory
compromise due to swelling.
* The fracture should be reduced under general
anaesthesia as soon as possible and then held with
percutaneous smooth K-wires
* Postoperative management is the same as for type IIA.

37. OPEN REDUCTION
*This is sometimes necessary for
(1) a fracture that simply cannot be reduced closed;
(2) an open fracture;
(3) a fracture associated with vascular damage.
*The fracture is exposed from the lateral side, the
hematoma is evacuated and the fracture is reduced
and held by two K-wires.

38. CONTINUOUS TRACTION
*Traction through a screw in the olecranon, with the
arm held overhead
*Can be used
(1) If the fracture is severely displaced and cannot be
reduced by manipulation;
(2) If, with the elbow flexed 100 degrees, the pulse is
obliterated and image intensification is not available
to allow pinning
(3) for severe open injuries or multiple injuries of the
limb.
Once the swelling subsides, a further attempt can be
made at reduction.

42. ANTERIORLY DISPLACED FRACTURES
*An anteriorly displaced fracture is a rare injury ( less
than 5% of supracondylar fractures ).
*The fracture is reduced by pulling on the forearm with
the elbow semi-flexed, applying thumb pressure over the
front of the distal fragment and then extending the
elbow fully.
* Percutaneous smooth pins are used if unstable.
*A posterior slab is applied and retained for 3–4 weeks.
*Thereafter the child is allowed to regain flexion
gradually.

45. EARLY
1. Vascular injury
*injury to the brachial artery, which before the
introduction of percutaneous pinning, was reported
as occurring in more than 5% of cases.
*Nowadays the incidence is probably less than 1%.
*Peripheral ischaemia may be immediate and severe,
or the pulse may fail to return after reduction.
*More commonly the injury is complicated by forearm
oedema and a mounting compartment syndrome,
* leads to necrosis of the muscles and nerves without
causing peripheral gangrene.

46. URGENT ACTION :
Pain plus one positive sign
* pain on passive extension of the fingers,
* a tense and tender forearm,
*an absent pulse,
*blunting sensation
*Reduced capillary return on pressing the finger pulp

47. *The flexed elbow must be extended and all dressings
removed.
* If the circulation does not improve, then
angiography or Doppler examination is carried out
*the vessel is repaired or grafted
*forearm fasciotomy is performed.
* In extreme cases, operative exploration would be
justified on clinical criteria alone.
*collaboration with vascular or plastic surgical
colleagues is required

48. 2. Nerve injury
*The radial nerve, median nerve (particularly the
anterior interosseous branch) or the ulnar nerve may be
injured.
*Loss of function is usually temporary and recovery can
be expected in 3-4 months.
*If there is no recovery, the nerve should be explored.
*However, if a nerve, documented as intact prior to
manipulation, is then found to be compromised after
manipulation, entrapment in the fracture is suspected
and immediate exploration should be arranged.

49. *The ulnar nerve may be damaged by
careless pin placement.
*It is safest to perform a mini-open approach
on the medial side of the elbow and identify
the nerve before placing the smooth K-wire.
*If the injury is recognized, and the pin
removed, recovery will usually follow.

50. LATE
1. Malunion
*Backward or sideways shifts are gradually smoothed
out by modelling during growth and they seldom give
rise to visible deformity of the elbow.
*Forward or backward angulation may limit flexion or
extension, but consequent disability is slight.
*Uncorrected sideways angulation and rotation are
much more important and may lead to varus (or rarely
valgus) deformity of the elbow
* this is permanent and will not improve with growth

51. *Cubitus varus is disfiguring and cubitus valgus may
cause late ulnar nerve palsy.
* If deformity is marked, it will need correction by
supracondylar osteotomy, usually once the child
approaches skeletal maturity.

54. 2. Elbow stiffness and heterotopic ossification
*Extension in particular may take months to recover,
and the patient and parents should be warned that
some loss of extension is common but unlikely to
affect function.
*Passive elbow stretch should be avoided as it tends
to increase stiffness and may increase the risk of
heterotopic ossification, which otherwise is a rare
complication.

55. *
*Campbell’s operative orthopaedics 13th edition
*Rockwood and Wilkins’s fractures in children 8th
edition
*Apley and Solomon’s system of orthopaedics
and trauma 10th edition
*McRae clinical orthopaedic examination 6th
edition