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Supracondylar fractures of humerus supracondylar fractures of humerus in children zameer ali

Range of motion. Extension 0 degrees Flexion 145 degrees Pronation 80 degree Supination 75 degrees

Functional range of motion. Arc of elbow flexion is about 100 degres. 30-130 degrees. Arc of forearm rotation is 100 degrees. 50 degrees of pronation to 50 degree of supination

Supracondylar fracture of humerus is very common in children It is also called malgaigne;s fracture Supracondylar fracture is one of most common fractures due to fall on outstretched hands and is more common in children because children are more playfull and hence prone to fall Thus upper extremity are vulnerable to fractures

75 % of all fractures in children are seen in upper limbs Incidence of fractures around elbow Supracondylar 65.4% Condylar fractures 25.3% Fracture neck of radius 4.7% Monteggia fracture 2.2% Olecranon fracture 1.65% T condylar fracture 0.8%

Incidence of supracondylar # being almost 65.4 % of fractures around elbow REASONS MECHANISM OF INJURY BONY ARCHITECTURE OF SUPRACONDYLAR AREA LAXITY OF LIGAMENTS AROUND ELBOW

Bony architecture of supracondylar area is weak and vulnerable Cortex is thin Anterior cortex has defect in area of coronoid fossa Metaphysis is just distal to fossa Laxity of ligaments permit hyper extension at elbow

Hyperextension converts linear force into bending force and olecranon concentrates all this force at supracondylar region

MOI- Fall on outstretched hand with elbow in full extension and forearm in supination In patients falling with their forearms supinated, the distal fragment displaces posterolaterally since the periosteum disrupts posteromedially and vice-versa.

Supracondylar fractures of humerus in children Incidence Age- 5-7 yrs.. Avg. 6.7yrs. Sex- M:F= 3:2 boys almost 66% Non dominant side more commonly injured. (left 59% right 41%) Almost all occur following an accidental trauma. Open fracture 2.3 %

Nerve injury 7 % radial nerve 45%,median nerve 32%,ulnar nerve 23%

Supracondylar fracture is broadly classified into Extension type 97.7% Flexion type 2.3% In extension type fracture line runs upwards and backwards And in flexion type it runs downwards and backwards

MOI- Fall on with outstretched hand with elbow in full extension. In patients falling their forearms supinated, the distal fragment displaces posterolaterally since the periosteum disrupts posteromedially and vice-versa.

Medial displacement of the distal fragment places the radial nerve at risk, and lateral displacement places median nerve and the brachial artery at risk.

Account for only 2% of humeral fractures. MOI- fall on the elbow, so that the distal fragment displaces anteriorly and may migrate proximally in a totally displaced fracture.

Gartland’s classification of supracondylar fractures in children Based on the radiographic appearance of fracture displacement. Type1- Undisplaced. Type2- # extended with intact posterior cortex Type3- Circumferential break with loss of posterior continuity. and distal fragment could be either displaced A) posteromedial; B ) poster lateral

Signs and symptoms of supracondylar fracture Pain / tenderness. Inability to use the upper limb / restriction of movements. ( both active and passive) Swelling. +/- Deformity & Abnormal mobility. Crepitations Arm is short forearm is normal in length

S shaped deformity Dimple sign due to one of spikes of proximal fragment penetrating the muscle and tethering skin Relation between three point bony relation maintained

RADIOLOGY AP & lat.of the distal humerus without externally rotating the humerus. Oblique veiws are rarely required.

RADIOLOGICAL PARAMETERS Baumans angle Angle between horizontal line of the elbow and line drawn through lateral epiphysis and long axis of arm Normal; value it is less than 5 degree Tear drop sign it is disturbed in supracondylar fracture but it is seen in normal radiograph

Anterior humeral line A line drawn along anterior border of humerus shaft usually passes through middle 1/3 of capitulum if it passses through 1/3 it indicates posterior displacement of distal fragment Coronoid line ; a line directed proximally along anterior border of coronoid process of ulna should barely touch anterior portion of lateral condyle . Posterior displacement of lateral condyle will project the ossification center posterior to this line

Fat pad sign Olecranon fossa is deep and thus the fat pad here lies totally contained within fossa. not seen on normal lateral radiograph of elbow at 90 degree Distension of capsule with an effusion due to trauma or infection causes olecranon pad to be visualised as radiolucent gap

Fish tail sign Due to rotation of distal fragment ,the anterior border of proximal fragment looks like a sharp spike

Crescent sign Here the normal radiolucent gap of elbow joint is missing and a crescent shaped shadow due to overlap of capitulum over olecranon is evident and indicates varus /valgus tilt of distal fragment

Quick facts Posterior displacement of distal fragment indicated by loss of tear drop sign Coronoid line Anterior humeral line

Coronal tilt of distal fragment usually varus tilt rarely valgus indicated on radiograph by Crescent sign bauman’s angle .

Horizontal rotation of distal fragment indicated by Fish tail sign

Dameron has listed depending on fracture ,four basic types of treatment 1 side arm skin tractioon 2 over head skeltal traction 3 Closed reduction and casting , with or without per cutaneous pinning , and 4 open reduction and internal fixation

Anatomical Closed reduction Longitudinal traction and counter traction. If the length is not restored, “milking maneuver”. Correction of the medial or lateral translation. .

Flexion reduction maneuvre. Hyperflexion and pronation at the elbow. Check x-rays with elbow kept flexed

Cast immobilization technique Type III fracture are intrinsically unstable. They need the elbow to be kept in 120 degrees of flexion whenever possible. If not possible, then the fracture should be stabilized with k-wires.

Type 1 undisplaced type can be satisfactorily treated closed with external fixation such as plaster Type 2 fracture is displaced and is difficult to reduce and to hold by external methods

Type 3 fracture is displaced postero medially or posterolaterally with no cortical contact and periosteum may be striped ;reduction is difficult and maintaining reduction is almost impossible without some form of internal fixation

General Principles: Splinting (immobilisation for 3 weeks). Assesment of the neurovascular status. Other injuries.

Type1 (undisplaced) Long arm splint with forearm in neutral position and elbow flexed to not more than 90 degrees. After 3-7 days, check x-rays to see any displacement. Long arm cast with a ring at the distal portion and a sling around the neck to support the cast for 3 weeks followed by active mobilisation.

If the x-rays show displacement, the fracture is reduced with hyperflexion of the elbow to 120 degrees with pinning. Acceptable x-rays : Anterior humeral line crossing the capitellum, A Baumann’s angle of 70-78 degrees or equal to the opposite side, and An intact olecranon fossa.

Type2 (Displaced with post. Cortex intact) Closed reduction followed by: Plaster cast with elbow at 120 degrees flexion, OR 2. Pinning and plaster cast with elbow at 90 degree flexion. 3. Collar and cuff with elbow at 120degree flexion.

Indications of pinning: Significant swelling. Obliteration of pulse on flexion. Neurovascular injuries Other injuries in the same limb.

Type3 If no vascular compromise, traction and casting. Or Closed reduction, pinning and casting If vascular compromise present, immediate exploration with skeletal stabilisation.

Dameron stated that reduction is not only difficult to achieve but also to maintain in type 2 and type 3 supracondylar fractures because of thinness of bone in supracondylar area of distal humerus For this reason many authors have described percutaneous pinning techiniques

Danielsson and petterson noted loss of reduction when only one pin was used Swenson ,casiano and associates useed two cross pins Arino et al recommended 2 lateral pins Fowles,kassab used one vertical pin and other oblique pin

haddad.,saer and riordian used 2 pins laterally and one pin medially Transient and permanent ulnar nerve damage were rare in all reports even when both medial and lateral pins were used

Per cutaneous fixation after closed reduction has advantage of providing excellent stability of supracondylar fracture in any position of elbow If fracture is not reduced satisfactory and held in unsatisfactory position the outcome will be not good and will be equivalent to as if no pin was used

Cubitus varus deformity is quite high if primary fracture reduction is not good According to wilkins The flexion type of supracondylar fracture is only two to three % of supracondylar fractures Steinmenn pins through condyles and metaphysis are inserted one from medial and one from lateral condyle of humerus

Pins are cut and bent so as they do not migrate proximally and can be retrieved after 3 to 4 weeks

Complications Vascular injury- 10-20% Compartment syndrome- <1%. Elbow stiffness Neurologic deficit- 10-20%. Iatrogenic- ulnar nerve- 1-5%.

Myositis ossificans-rare Non union Avascular necrosis Angular deformity- cubitus varus.

Cubitus varus deformity is most common angular defromity that results from supracondylar fractures in children Cubitus valgus is other deformity which can cause tardy ulnar nerve palsy

Three basic types of osteotomies have been described for cubitus varus/valgus deformity 1 lateral close wedge osteotomy 2 medial open wedge osteotomy and with bone graft and an oblique osteotomy

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Supra condylar fractures

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