Pediatric Distal Humerus. Supracondylar Humerus Fractures 60% of elbow fractures in children under...

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Pediatric Distal Humerus

Supracondylar Humerus Fractures

• 60% of elbow fractures in children under 7.• 96% extension type, from fall on outstretched

arm with elbow hperextension.• 4% flexion type, from fall on olecranon with

elbow flexed.

Classification-Gartland

• Type I: Nondisplaced, +/- posterior fat pad sign. Where is PFPS? Significance?

Posterior Fat Pad Sign

• PFPS is predictive of occult fracture in 76% of cases.

• The fracture is a supracondylar humerus about 50% of the time.– Skaggs & Mirzayan, JBJS, 2001.

• Type II: Angulated with intact posterior cortex.

• Type II: Anterior humeral line anterior to middle of capitellum.

• Type III: Displaced.– Usually posteromedially.

• Type IV: Multidirectional Unstable.– Leitch, et al., JBJS, 2006.

• Flexion type.

Quick and Dirty Pediatric NV Exam

• Rock-Paper-Scissors-OK– Rock: Median Nv.– Paper: Radial Nv.– Scissors: Ulnar Nv.– OK: AIN.

Neurologic Injury

• Incidence: ~7%.• Anterior interosseous is most common nerve

injured.– Decreased thumb IP and index DIP flexion.

Neurologic Injury: Median Nv.

• May become entrapped in fracture. • May mask compartment syndrome, because

of associated forearm sensory loss.

Neurologic Injury: Ulnar Nv.

•Ulnar nerve injuries more common in flexion supracondylar fractures.•Often iatrogenic.•Quantification of risk: “Number Needed to Harm” = 28– For every 28 pts that have medial/lateral cross

pinning vs lateral pins only, one child will sustain an iatrogenic ulnar nv injury.• Slobogean, et al., JPO, 2010.

Vascular Injury

• Incidence: ~1% (0.5-5%).• Maintain high index of suspicion.• Perform careful physical exam.

Vascular Injury

• Indications for exploration:– Clinically obvious ischemia (white, pulseless hand).– Loss of palpable/dopplerable pulse after fracture

reduction.• Use of arteriography controversial.• Treatment of “pink, pulseless” hand also

controversial.

Compartment Syndrome

• May be difficult to diagnose in kids.• The Three A’s of compartment syndrome in

children:– Anxiety.– Agitation.– Increasing need for Analgesia.

• May occur even in open fractures.

Treatment

• Gartland I: Casting in situ.– Long arm cast or splint in 90-110° flexion for 3-4

weeks.

• Gartland II & III: Closed reduction and percutaneous pinning.

Closed Reduction Technique

Percutaneous Pinning

• Crossed pins vs. Lateral: No biomechanical difference in stability if proper technique and pin placement utilized.– Skaggs, et al., JBJS, 2001.– Davis, et al., CORR, 2000.– Hamdi, et al., JPO, 2010.

• Try to make the 2 lateral pins divergent.• Try not to have pins cross at the fracture site.• Size matters: Pins should be at least the thickness of

the cortex.

Closed Reduction/Percutaneous Pinning: 2 Pins

Closed Reduction/Percutaneous Pinning: 3 Pins

Can you wait to operate? It depends…

• Must have a normal N/V exam.• Must not have severe swelling.• Must still be considered urgent.• NPO status may be a factor in the decision.

Complications

• Ulnar nerve injury.• Cubitus Varus.• Loss of reduction.• Pin site problems (rare!)• Most complications can

be avoided with attention to detail.

Lateral Condyle Fractures

• 17% of elbow fxs. in children.

• Peak incidence: 5-10 years of age.

• Mech: Varus stress to extended elbow, with forearm supinated.

Lateral Condyle Fractures: PE

• Lateral swelling and tenderness.

• Much less prone to NV injury than SCHFs.

Case 2: 7 yo girl fell off monkey bars.Classification?

Lateral Condyle Fractures: Jakob Classification

• Stage I: Nondisplaced.• Stage II: Hinged.• Stage III: Rotated.

Lateral Condyle Fractures: Treatment

• Non-displaced fxs. can be treated with cast immobilization at 90° flexion and supination.

• Frequent follow-up and re-imaging is necessary, to watch for late displacement and subsequent need for operative Rx.

• Open reduction and percutaneous pinning for displaced fractures.– It is necessary to

visualize the anterior joint line/articular surface prior to fixation.

– 2-3 lateral pins:• Across capitellum to

medial epicondyle.• At 45° angle to first pin,

exiting medially and proximally.

• Arthrogram may be helpful in determining extension into the joint and need for open reduction.

Procedure/Positioning

Patient supine on radiolucent table. C-arm comes in perpendicular, from across

the table. Alternatively, hand table with C-arm coming in

from the end may be used.

Procedure/Approach

Kocher Approach:– Slightly curvilinear incision centered over the

lateral condyle.– Internervous plane between the extensor carpi

ulnaris and the anconeous.– Stay anterior: avoid posterior stripping in order to

preserve trochlear/capitellar blood supply.– Open capsule anteriorly and extend distally to

radial head.

Procedure/Reduction & Fixation Clean fragment ends. Reduce using dental pick or

towel clip. 2 pins placed

percutaneously from posterior to incision:– Across capitellum to medial

epicondyle.– At 45° angle to first pin,

exiting medially and proximally.

– At least 0.062” diameter.

Procedure/Tools

You must see all the way to the medial side of the joint, to assess reduction at the most medial extent of the fx. Useful tools to facilitate this:– Mini-Hohmanns or Chandlers.– Dental Mirror.– Head Lamp.

Pearls & Pitfalls The fracture often performs the approach for you. The distal fragment may flip…be certain you have the

articular cartilage oriented properly. There is sometimes lateral metaphyseal

communition that appears as displacement…it is important to assess reduction at the joint line, not the metaphysis.

Try to reapproximate lateral soft tissues to decrease lateral spur formation.

Lateral Condyle Fractures: Complications

• Prone to:– Late displacement.– Mal/Nonunion.– Growth disturbance.– Late deformity.– Loss of ROM.

Medial Epicondyle Fractures

• 10% of elbow fractures.• Peak incidence: 9-15 years of age.• Mech: Fall on extended elbow, with valgus

stress.

• Avulsion of medial epicondyle from the distal humerus by the wrist flexors.

• Usually a SH I or II.• Can be associated with an

elbow dislocation.• The medial epicondyle

can be entrapped in the joint.

• Reduction maneuver to remove epicondyle from joint:– valgus stress on elbow.– supination of forearm.– dorsiflexion of wrist

and fingers.

• Need for reduction/fixation of epicondyle controversial:– Displacement: >1cm.– Angulation: >45°.– Instability: +/- Stress film.– Athletic ability/aspirations.– Associated with elbow dislocation.– ? Risk of tardy ulnar nv. palsy.

• Reduction can be closed or open.

• Fixation can be percutaneous or open.

• Fixation can be k-wires or a screw.

Pediatric Distal Humerus. Supracondylar Humerus Fractures 60% of elbow fractures in children under...

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