CASE SCENARIO

● A 6-year-old boy presented to EMS with pain in left elbow and swelling one hour after
a fall from a swing on his outstretched hand. He was previously healthy, no previous
history of fractures.
● O/E –
- Normal vitals, normal body built, no dysmorphic features.
- Left elbow swelling with ecchymosis, but no wounds seen.
- No features of compartment syndrome were observed.

- Distal pulses palpable

- Sensory and motor examination of median, ulnar and radial nerves were normal.
- X ray – Gartland type III fracture
PEDIATRIC
SUPRACONDYLA
R FRACTURE OF
HUMERUS

Aarushi Kollana
Dhruv Tharun Krishna
Archisha Dutta
Nandana Ullas
 Table of contents
01
Epidemiology
02
Etiology and
and anatomy classification

03 04
Treatment and
Diagnosis complications
01
Epidemiology and
anatomy
EPIDEMIOLOGY
1.Most common fracture around the elbow in children (60%)

2.Peak incidence: 5-8 yrs (median- 6 yrs)

3.95 % are extension type injuries

4.M (63%) > F

5.Non dominant arm 1.5 times more frequently.

6.About 10% to 20% of displaced fractures - alterations in vascular status

7.Neural injuries - 6.5% to 19% of cases involving displaced fractures. Mostly

neurapraxias.
ANATOMY OF DISTAL
HUMERUS
 POSTERIOR ANTERIOR

LATERAL LATERAL
SUPRACONDYLAR SUPRACONDYLAR
MEDIAL
RIDGE RIDGE
SUPRACONDYLAR
RIDGE

SUPRACONDYLAR
FRACTURE LINE

GROOVE FOR ULNAR NERVE

 11

1
9

SUPRACONDYLAR
AREA UNDERGOES
REMODELLING -
BETWEEN 6-7 YRS
 COMMON
COMMON FLEXOR EXTENSOR ORIGIN
ORIGIN
 TROCHLEA AT
6-8 degrees
VALGUS

EXTERNAL ROTATION OF
FOREARM WHEN FLEXED TO 90
LINE PERPENDICULAR AXIS OF DEGREES
TO AXIS HUMERUS
NORMAL X RAY OF ELBOW
SHAFT OF
HUMERUS

64-81 degrees –
BAUMANN’S Normal
ANGLE Difference of > 5
degrees between
UPPER two sides -
BORDER OF Abnormal
EPIPHYSIS OF
CAPITULUM
 ANTERIOR
HUMERAL LINE
SHOULD INTERSECT
CAPITULUM

HUMERO-CAPITELLAR
PASSES THROUGH
ANGLE
MIDDLE THIRD OF
- 45 - 57 degrees
CAPITULUM
02
Etiology and
Classification
 Etiology
Mechanism of injury
● Indirect - Fall on outstretched hand -> forced elbow hyperextension
● Direct (rare) - Fall onto fixed elbow or object striking the elbow

Associated injuries
● Neuropraxia - Anterior interosseous nerve (AIN) - mc nerve palsy
- Radial nerve palsy
- Ulnar nerve palsy
● Vascular compromise
● Ipsilateral distal radius fractures
Salter-Harris Classification
Used to grade fractures in children that involve the growth plate/physis
 Classification
Broad classification - 1. Extension type - 97.7%
2. Flexion type - 2.3%

GARTLAND CLASSIFICATION
● Type I - Ia Non-displaced
- Ib Minimally displaced (<2mm)
● Type II - Displaced in 1 plane, posterior cortex and post. periosteal hinge
intact
- IIa Angulation
- IIb Angulation with rotation
● Type III - Complete displacement in 2 or 3 planes
- IIIa Posteromedial displacement of distal fragment
- IIIb Posterolateral displacement of distal fragment
● Type IV - Complete periosteal disruption with instability in flexion and
extension
- Diagnosed intra-operatively
A - Extension type (97.7%)
B - Flexion type (2.3%)
 Clinical features

● History of fall
● Pain
● Swelling
● S-shaped deformity
● Refusal to move the elbow
● Patient may complain of pseudoparesis
03
Diagnosis
 Clinical Examination

1. Physical exam

a. inspection

i. gross deformity- unusual prominence of tip of olecranon due to backward

tilt of distal fragment

ii. 3 bony point relationship is maintained

iii. ecchymosis in antecubital fossa

iv. Swelling- later, difficult to appreciate deformity

b. motion
i. limited active elbow motion
 Clinical Examination
c. neuro exam
i. Evaluate for
1. Anterior Interosseous Nerve Branch (AION) neurapraxia –branch of the
median nerve most prone to get involved in postero-lateral displacement
of the distal fracture fragment. Inability to flex the interphalangeal joint
of the thumb and the distal interphalangeal joint of the index finger (can't
make A-OK sign)
2. median nerve injury – loss of sensation over volar index finger
3. radial nerve neurapraxia– distal fracture fragment is displaced postero-
medially and the proximal fracture fragment is displaced laterally. Inability
to extend wrist, MCP joints, thumb IP joint
4. ulnar nerve – following flexion type of supracondylar fractures
5. PIP and DIP can still be extended via intrinsic function (ulnar n.)
 Clinical Examination
d. vascular exam (associated brachial artery injury)
i. assess radial and ulnar pulses
■ present or absent by palpation
■ present or absent by biphasic doppler pulse
ii. assess vascular perfusion
■ well perfused
■ warm
■ pink
■ poorly perfused
■ cold
■ pale
■ arterial capillary refill > 2 seconds
iii. Check oxygen saturation with pulse oxymeter
 Imaging
● Radiographs
○ AP and lateral x-ray of the elbow
(really of the distal humerus)
○ Easy diagnosis as displacement is
wide
○ Minimally displaced fractures can
be confused with ossification
centres
○ Compare with other side
○ In an antero-posterior view, one can
see the proximal shift, medial or
lateral shift, medial tilt and rotation
of the distal fragment.In a lateral
view, one can see the proximal
shift, posterior shift, posterior tilt
 Imaging
● posterior fat pad sign

○ lucency on a lateral view along

the posterior distal humerus and
olecranon fossa is highly
suggestive of occult fracture
around the elbow
 Imaging
● 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.
 Imaging
● measurement

○ capitellum moves posteriorly to this

reference line in extension type
fractures and anteriorly in flexion type
fractures
 Imaging
● 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 70-75°, but best judge is
a comparison of the contralateral
side
○ deviation of >5-10° indicates
coronal plane deformity and
should not be accepted
04
Treatment and
complications
 Treatment

1. Nonoperative

○ long arm casting with less than 90° of elbow flexion

2. Operative

○ closed reduction and percutaneous pinning

○ emergent vascular exploration and CRPP

○ open reduction, percutaneous pinning, with/without vascular exploration

 Nonoperative method
● Long arm casting with less than 90° flexion
● Indications
○ warm perfused hand without neuro deficits
○ Type 1 (non displaced) fractures
○ Type 2 fractures in which
■ Anterior humerus line intersects the capitellum
■ Minimal swelling present
■ No medial comminution
● Used for a duration of 3 weeks
● Repeat radiography at 1 week to assess for interval displacement
 Operative methods
1. Closed reduction and percutaneous pinning
● Indications
○ Type ll and lll supracondylar fractures
○ Flexion type
○ Medial column collapse
● Time for the procedure is dictated by neurovascular status
○ Non- urgent(can wait overnight)
○ Urgent(same day- do not wait overnight)
○ Emergent(within hours)
 Non- urgent
● Indications

○ Warm perfused hand without neuro deficits

● Technique

○ Splint in 30°-40° flexion, admit overnight for observation and elevation

for elective surgery

 Urgent
● Indications
○ Pulseless,well-perfused hand
○ Sensory nerve deficits
○ Brachial sign
■ Ecchymosis,dimpling at antecubital Fassa
■ Palpable subcutaneous bone fragment
○ Floating elbow
● Technique
○ Check vascular status after reduction
■ Well perfused- admit and observe for 48 hours
■ Not well perfused- perform vascular exploration
 Emergent
● Indications

○ Pulseless poorly perfused hand

● Technique

○ Check vascular status after reduction

■ Well perfused-admit and observe for 48 hours

■ Not well perfused- perform vascular exploration

 Emergent vascular
exploration and CRPP
● Indications

○ Pulseless white hand(pale cool,no doppler) following CRPP

○ Pulsatileand perfused hand that loses pulse following CRPP

● Technique

○ Remove K-wires and reassess vascular status

○ Ope exploration and reduction if vascular status doesn't improve

Open reduction percutaneous
pinning +/- vascular
exploration
● Indications

○ Open fracture

○ Failed closed reduction

○ Pulseless white or pink hand that is unable to be reduced or there remains

a gap (gap might represent entrapped vascular structure

 Complications
● Pin migration

● Infection

● Cubitus valgus - due to fracture malunion.

● Cubitus varus- due to varus malunion,especially in medial comminution

pattern

● Nerve palsy from injury

● Vascular injury

● Volkmann ischemic contracture

● Postoperative stiffness
Thank you