Supracondylar fracture Ext.สาโรจน์ 4 ก.ค. 61

1. EXTERN CONFERENCE

2. PATIENT PROFILE
Case เด็กชายไทยอายุ 3 ปี no U/D BW 9.6 kg
CC : ปวดบวมข้อศอกซ้าย 6 ชั7วโมงก่อนมารพ.
PI : 6 ชั7วโมงก่อนมารพ. นั7งซ้อนรถมอเตอร์ไซด์ป้า เกิดอุบัติเหตุล้มเอง เด็กเอาแขน
ซ้ายลงยันพืFน หลังจากนัFนมีอาการข้อศอกปวด บวม ไม่ยอมขยับแขนเอง ป้า
สังเกตเห็นว่าข้อศอกมีอาการผิดรูปจึงรีบพารพ.

3. PRIMARY SURVEY
A: can speak, can flex neck, no tender along c-spine
B: symmetrical chest movement, trachea in midline, no subcutaneous emphysema, clear
and equal both lungs, CCT negative
C: cap refill < 2 sec, BP 137/90 mmHg, PR 115 bpm, BT 37.7 c
D: E4V5M6 pupils 3 mm RTLBE, no lateralization sign
E: Lt. elbow deformity , Abrasion wound along radial side of hand from wrist to
thumb size around 1x1cm. , 2x3 cm. , 2x5 cm. , on woody splint Lt. arm

4. LT. ELBOW DEFORMITY AND AW LT. HAND

5. SECONDARY SURVEY
A: no Hx of drug/food allergy
M: no current medication
P: no underlying disease
L: NPO time 18.00 (5 hr)
E: as present illness

6. PHYSICAL EXAMINATION
Airway and Breathing: spontaneous breathing
Vital signs: BP 137/90 mmHg, PR 115 bpm, RR 20 /min, T 37.7 c
HEENT: not pale conjunctiva, anicteric sclera, no external wound
C-spine: no posterior midline neck pain, no soft tissue contusion or swelling around the
neck
Chest: clear and equal both lungs
CVS: normal S1 S2, no murmur
Abdomen: soft, not tender

7. PHYSICAL EXAMINATION
Extremities: Lt. elbow deformity with limit ROM due to pain , Abrasion wound along
radial side of hand from wrist to thumb size around 1x1cm. , 2x3 cm. , 2x5 cm. ,
Capillary refill Lt. hand <2s.
Neuro: E4V5M6 pupils 3 mm RTLBE, motor Gr V all
­ Special Test :
­ Medial nerve : OK sign – negative , can thumb opposition
­ Radial nerve : can extend wrist or MCP joints can flex finger
­ Ulnar nerve : Froment’s sign - negative
­ Sensory : no loss of any sensory around the hand and arm

8. INVESTIGATION: FILM LT. ELBOW AP LAT

9. DIAGNOSIS
CFX Supracondylar LT. Humerus Gartland III

10. MANAGEMENT
Initial management:
- admit ortho
- NPO
- IV Fluid : 5% DN/3 1000 ml IV rate 50 ml/hr
- Lab Pre-op : CBC , AntiHIV
- Pain Control : Pethidine 15 mg IV q 6 hr.
- ATB : cefazolin 1 g to OR
Definite treatment: Set OR for Close reduction with pinning and Long arm cast

12. SUPRACONDYLAR FRACTURE

13. EPIDEMIOLOGY
- occur most commonly in children age 5-7 years.
- occur in Male = Female

14. MECHANISM OF INJURY
- Fall on out stretching hand.

15. TYPES
- extension type (97.7%)
- flexion type (2.3%)

16. CLINICAL PRESENTATION
- Pain and swelling
- S-Shaped deformity
- Loss of passive and active motions

17. ASSOCIATED INJURY
- Neuropraxia
­ Anterior interosseous nerve (branch of median n.)
­ Radial nerve palsy
­ ulnar nerve palsy
- Vascular compromise (Brachial Artery : Radial and Ulnar artery)
- Ipsilateral distal radius fractures

18. MEDIAN NERVE EXAMINATION
- OK sign (Flexor Pollicis Longus and radial half of Flexor digitorum profundus)
- Thump opposition (opponens pollicis)
- loss of sensation over volar index finger

19. RADIAL NERVE EXAMINAION
- inability to extend wrist or MCP joints

20. ULNAR NERVE EXAMINATION
- Intrinsic muscle “finger crossed” index and middle finger
- Froment’s Sign (Test Adductor pollicis)

21. ELBOW ANATOMY IN PEDIATRICS
- Ossification center “CRITOE”

22. OSSIFICATION CENTER
-

24. GARTLAND CLASSIFICATION
- Type 1 : Nondisplaced Treat by Long arm cast 3-4 wks.
- Type 2 : Displaced with posterior cortex and posterior periosteal hinge intact or
,Deformity is in the sagittal plane only Treat by CR with Long arm cast +/-
pinning
- Type 3 : Complete displaced, often in 2 or 3 planes Treat by CR with long arm cast
with pinning

26. GARTLAND CLASSIFICATION
- Type 4 : Complete periosteal disruption with instability in flexion and extension,
Diagnosed with examination under anesthesia during surgery , Treated most
commonly with CRPP or open reduction if needed
- Medial comminution : Collapse of medial column, loss of Baumann angle, Treated
with CRPP, often requires significant valgus force to reduce
- Flexion type : Mechanism of injury is usually a fall on the olecranon , Treated with
CRPP

27. IMAGING
- Film Elbow AP LAT
- Finding : Posterior Fat pad sign

28. IMAGING (CONT.)
- measurement
­ Displacement of the anterior humeral line
­ anterior humeral line should intersect the middle third of the capitellum in children > 5
years old, and touches the capitellum in children in children <5.
­ capitellum moves posteriorly to this reference line in extension type fractures, and
anteriorly in flexion type fractures
­ Alteration of Baumann angle
­ Baumann's angle is created by drawing a line parallel to the longitudinal axis of the
humeral shaft and a line along the lateral condylar physis as viewed on the AP image
­ normal is 64-81°, but best judge is a comparison of the contralateral side
­ deviation of >5-10° indicates coronal plane deformity and should not be accepted

30. IN THIS CASE

31. IN THIS CASE

32. FINDING FROM RADIOGRAPH

33. MEASUREMENT

34. WHAT ABOUT OPEN REDUCTION WITH PINNING ?
- indication
­ unacceptable closed reduction
­ more frequently required with flexion type fractures (than extension type)
­ when vascular exploration needed
­ open fracture

35. PULSELESS HAND

36. COMPLICATION
- Pin migration
- Infection
- Cubital valgus : cause by fx malunion
- Cubital varus : caused by fracture varus malunion, especially in medial comminution pattern
- Recurvatum : common with non-operative treatment of Type II and Type III fractures
- Nerve Palsy from injury : mechanism = tenting of nerve on fracture, or entrapment in fracture site
M/C anterior interosseous nerve
- Vascular Injury
- Volkmann ischemic contracture (hyperflexion of elbow cause deep volar forearm compartment pressure
and loss of radial pulses
- Postoperative stiffness can be resolve in 6 months

37. THANK YOU