This document discusses elbow fractures in children, with a focus on supracondylar humerus fractures. It provides statistics on the prevalence of these fractures, describes examination and classification, and outlines treatment approaches. Specifically, it notes that supracondylar fractures make up 60% of elbow injuries in children. Treatment depends on the Gartland classification, with Types 1 and 2 often immobilized and Type 3 requiring closed or open reduction and pinning. For the "pink, pulseless extremity", the document discusses the changing views between surgical exploration versus watchful expectancy, noting the growing support for initial conservative management. Pulse oximetry waveform and duplex ultrasound are presented as useful tools to monitor vascular status in these complex cases.

1. Supracondylar Humerus
Fractures In Children And Pink
pulseless extremity
Dr. Chandrashekhar Sonawane

2. Elbow Fractures in Children
• Very common injury (approximately 65% of
pediatric trauma)

3. Supracondylar Humerus
Fractures
• Approximately 60 % of Elbow Trauma

4. Hospital Statistics
2012
Paediatrc Fractures12
Fractures around Elbow 7
Supracondylar Humerus 4
Conservative
1
Operative
3
2013
6
4
3
2
1
Total
18
11
7
3
4

5. Elbow Fractures in Children:
Physical Examination
• Swelling
• Pain
• Difficulty in movement at elbow

6. Elbow Fractures in Children:
Physical Examination
• Neuro-motor exam
• Thumb extension– EPL (radial – PIN
branch)
• Thumb flexion – FPL (median – AIN
branch)
• Cross fingers - Adductors (ulnar)

7. Elbow Fractures in Children:
Physical Examination
• signs of compartment syndrome.
• Thorough documentation of all findings is
important. A simple record of “neurovascular
status is intact” is unacceptable.

8. • Rule out associated trauma –
distal forearm fractures seen in 5 %(common )
midshaft humerus fractures(rare)

9. Physical Examination
Nerve injuries – 7 to 16 %
- posterolateral displacement associated with median
and anterior interosseous nerve dysfunction

10. Physical Examination
- posteromedial displacement associated
with radial nerve injury
- ulnar nerve injury more often associated
with flexion type injuries

11. Physical Examination
• Vascular injuries – permanent vascular
compromise of extremity occurs in less that 1%
• Entrapment of brachial artery in fracture site may
compromise circulation of extremity with
reduction
- constant vascular evaluation necessary

12. Elbow Fractures in Children:
Radiographs
• AP and Lateral
• Oblique views may be necessary for evaluation,
especially for the evaluation of suspected lateral
condyle fractures.

13. Elbow Fractures in Children:
Radiograph Anatomy/Landmarks
• Bauman’s angle is formed by a
line perpendicular to the axis of
the humerus, and a line that
goes through the physis of the
capitellum.

14. Elbow Fractures in Children:
Radiograph Anatomy/Landmarks
• Anterior Humeral
Line:

15. Elbow Fractures in Children:
Radiograph Anatomy/Landmarks
• Humerocapitellar
angle
30

16. Elbow Fractures in Children:
Radiograph Anatomy/Landmarks
• Radiocapitellar line
–

17. • Immobilize injured elbow with splint

18. Supracondylar Humerus Fractures:
Classification
• Gartland (1959)
• Type 1 non-displaced
• Type 2 Angulated/displaced fracture with intact
posterior cortex
• Type 3 Complete displacement, with no contact
between fragments

19. Type 1: Non-displaced
• Note the nondisplaced fracture (Red
Arrow)
• Note the posterior fat
pad (Yellow Arrows)

20. Supracondylar Humerus Fractures:
Treatment
• Type 1 Fractures:
• In most cases, these can be treated with
immobilization for approximately 3 weeks, at 90
degrees of flexion. If there is significant swelling,
do not flex to 90 degrees until the swelling
subsides.

21. Type 2: Angulated/displaced fracture
with intact posterior cortex

22. Supracondylar Humerus Fractures:
Treatment
• Type 2 Fractures: Posterior Angulation
• If minimal (anterior humeral line hits part of
capitellum) -immobilization for 3 weeks.
• Anterior humeral line misses capitellum –
reduction necessary.
• If varus/valgus malalignment exists, most
authors recommend reduction.

23. Type 3: Complete displacement,
with no contact between fragments

24. Supracondylar Humerus Fractures:
Treatment
• Type 3 Fractures:
• a high risk of neurologic and/or vascular
compromise,
• Current treatment protocols use percutaneous pin
fixation in almost all cases.
• In rare cases, open reduction may be necessary,
especially in cases of vascular disruption.

25. Treatment
• Type III – closed reduction with percutaneous
pinning
- to close reduce:
1) traction to disengage proximal fragment
2) translation of the distal fragment to proper
medial-lateral orientation,
3) internal rotation deformity corrected,
4) distal fragment is pushed forward with thumb
while flexing the patients elbow to 120 degrees and
pronating the wrist to tighten the periosteal hinge

26. Adequacy of Reduction
• Baumann’s angle
• Relationship of the capitellum to the anterior
humeral line
• Restoration of the anatomy of the olecranon fossa

27. Treatment
• Evaluate with AP and lateral radiograph
• Deviation of >5 degrees relative to Baumann’s
angle in non-injured elbow represents inadequate
reduction

28. Supracondylar Humerus Fractures:
Indications for Open Reduction
• Inadequate reduction
with closed methods
• Vascular injury
• Open fractures

29. Supracondylar Humerus Fractures:
Associated Injuries
• 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

30. Supracondylar Humerus Fractures:
Associated Injuries
• Type 3
supracondylar
fracture, with absent
ulnar and radial
pulses, but fingers
with capillary refill
less than 2 seconds.
• The pink, pulseless
extremity

31. Brachialis Sign- Proximal Fragment
Buttonholed through Brachialis

32. a persistent pulseless, but well-perfused hand
postreduction
What to do?

33. Changing trends
In olden days
Traction
- No reduction in pink pulseless
extremity
- 1) Traction in extension
2) Dunlop traction

35. In Recent Years – Two schools of thought
have evolved
1) surgical exploration
2) watchful expectancy

37. ‘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’.
White L, Mehlman CT, Crawford AH.
J Pediatr Orthop. 2010 Jun;30(4):328-35. doi: 10.1097/BPO.0b013e3181da0452

39. ‘the management of a persistent pink pulseless
hand remains a 'watchful expectancy’.
Ramesh P , Avdhani A , Shetty AP , Dheenadhayalan J , Rajsekaran S
J Pediatr Orthop B. 2011 May;20(3):124-8. doi: 10.1097/BPB.0b013e328342733e

40. ‘Surgical exploration should be recommended
only if there is either severe pain in the forearm
persisting for more than 12 h after the injury or if
there are signs of a deteriorating neurological
function’.
Ramesh P , Avdhani A , Shetty AP , Dheenadhayalan J , Rajsekaran S
J Pediatr Orthop B. 2011 May;20(3):124-8. doi: 10.1097/BPB.0b013e328342733e

41. •Colour-flow duplex monitoring,
• Magnetic resonance angiography and
•Waveform of pulseoximeter

43. • Good waveform on
pulse oximeter
• Poor waveform on
pulse oximeter.

45. ‘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’.
Soh RC, Tawng DK, Mahadev A.
Clin Orthop Surg. 2013 Mar;5(1):74-81. doi: 10.4055/cios.2013.5.1.74. Epub 2013 Feb 20

46. Conclusion
• Supracondylar fractures form large chunk of
total paediatric fractures.
• Fracure classification and Neuro-vascular
assesment is crucial in deciding
management.
• There is growing trend towards watchful
expectancy in pink pulseless extremity.

47. Thank you