Supracondylar fractures in_children

transcript

SUPRACONDYLAR SUPRACONDYLAR FRACTURES IN FRACTURES IN

CHILDRENCHILDREN

DEPT. OF ORTHOPEDICSDEPT. OF ORTHOPEDICS

MMMCMMMC

RADIOLOGYRADIOLOGY

2 VIEWS – AP & LATERAL2 VIEWS – AP & LATERAL

JONE’S VIEW- IN INJURED ELBOW , POST REDN. [ With elbow in full flexion ]

ANTERIOR POST. VIEWANTERIOR POST. VIEW

BAUMANN’S ANGLEBAUMANN’S ANGLE

ANGLE FORMED BY THE LATERAL EPI ANGLE FORMED BY THE LATERAL EPI PHYSEAL LINE AND THE LONG AXIS PHYSEAL LINE AND THE LONG AXIS OF THE HUMERUS : 80 degreeOF THE HUMERUS : 80 degree

HUMERO ULNAR ANGLEHUMERO ULNAR ANGLEMETAPHYSEAL DIAPHYSEAL ANGLEMETAPHYSEAL DIAPHYSEAL ANGLE

Lateral viewLateral viewTear drop sign

Ant. dense line – represents the post margin of the coronoid fossa

Post. dense line- represents the ant margin of olecranon fossa

Inf margin is capitellum

Elbow Fractures in Children:Elbow Fractures in Children:Radiograph Radiograph

Anatomy/LandmarksAnatomy/Landmarks

Anterior humeral Anterior humeral line: line:

• It is drawn along It is drawn along the anterior the anterior humeral cortex. humeral cortex.

• It passes through It passes through the middle of the the middle of the capitellum. capitellum.

Elbow fractures in children:Elbow fractures in children:radiographic anatomy/landmarksradiographic anatomy/landmarks

The capitellum The capitellum is angulated is angulated anteriorly about anteriorly about 30 degrees.30 degrees.The appearance The appearance of the distal of the distal humerus is humerus is similar to a similar to a hockey stick.hockey stick.

SHAFT CONDYLAR ANGLE- SHAFT CONDYLAR ANGLE- 30 DEG30 DEG

ANT HUMERAL LINE

PASS THR. MIDDLE THIRD OF OSSIFICATION CENTER OF CAPITELLUM

Elbow Fractures in Children:Elbow Fractures in Children:Radiograph Radiograph

Anatomy/LandmarksAnatomy/LandmarksThe physis of The physis of the capitellum is the capitellum is usually wider usually wider posteriorly, posteriorly, compared to the compared to the anterior portion anterior portion of the physisof the physis

Elbow Fractures in Children:Elbow Fractures in Children:Radiographic Anatomy/LandmarksRadiographic Anatomy/Landmarks

Radiocapitellar Radiocapitellar line – should line – should intersect the intersect the capitellumcapitellumMake it a habit Make it a habit to evaluate this to evaluate this line on every line on every pediatric elbow pediatric elbow filmfilm

What are the problems you see here?

Test your Ortho. Sense.

Supracondylar Humerus FracturesSupracondylar Humerus Fractures

Most common fracture around the elbow in Most common fracture around the elbow in children (60 percent of elbow fractures)children (60 percent of elbow fractures)95 percent are extension type injuries, which 95 percent are extension type injuries, which produces posterior displacement of the distal produces posterior displacement of the distal fragmentfragmentMay be associated with a distal radius or May be associated with a distal radius or forearm fractureforearm fracture

CLASSIFICATIONCLASSIFICATION

EXTENSION TYPE- EXTENSION TYPE- 95%95%

FLEXION TYPE- FLEXION TYPE- 5%5%

SUPRACONDYLAR #SUPRACONDYLAR #

Very commmon in children less than 10 Very commmon in children less than 10 yrsyrs

Bec. the bony architecture at the sc Bec. the bony architecture at the sc region is weak region is weak

More common in children with hyper More common in children with hyper flexibilityflexibility

Mechanism of injuryMechanism of injury

Fall on out stretched Fall on out stretched hand [FOOH]hand [FOOH]

QUICK REVIEW OF FACTSQUICK REVIEW OF FACTS

AGE – 84% < 10 YRSAGE – 84% < 10 YRS

SEX – BOYS 63.6%SEX – BOYS 63.6%

SIDE – LEFT- 58.6% , RT—42.4%SIDE – LEFT- 58.6% , RT—42.4%

NERVE INJURY- 7%NERVE INJURY- 7%

MEDIANMEDIAN

RADIALRADIAL

ULNARULNAR

CLINICAL FEATURESCLINICAL FEATURES

H/O FALL ON OUTSTRETCHED HANDH/O FALL ON OUTSTRETCHED HAND

Failure to use upper extremityFailure to use upper extremity

GROSS SWELLING & TENDERNESSGROSS SWELLING & TENDERNESS

S SHAPED DEFORMITYS SHAPED DEFORMITY

ANT. PUCKER SIGNANT. PUCKER SIGN

CREPITUSCREPITUS

3 PT RELATIONSHIP MAINTAINED3 PT RELATIONSHIP MAINTAINED

Examine in Elbow injuryExamine in Elbow injury

VASCULAR STATUS –Radial artery VASCULAR STATUS –Radial artery Pulsation [most important ] & Cap.refillPulsation [most important ] & Cap.refill

NEUROLOGICAL STATUS-NEUROLOGICAL STATUS-

M , R ,UM , R ,U

Check Finger movement Check Finger movement

Check for ‘Stretch sign’ : compartment Check for ‘Stretch sign’ : compartment syndromesyndrome

Pucker sign/ Brachialis sign

Brachialis Sign- Proximal Fragment Brachialis Sign- Proximal Fragment Buttonholed through BrachialisButtonholed through Brachialis

Milking Maneuver- Milk Soft Milking Maneuver- Milk Soft Tissues over Proximal SpikeTissues over Proximal Spike

From Archibeck et al. JPO 1997

POST MEDIAL POST LATERAL

Supracondylar Humerus Fractures:Supracondylar Humerus Fractures:ClassificationClassification

Gartland (1959)Gartland (1959)

Type 1Type 1 non-displacednon-displaced

Type 2Type 2 Angulated/displaced fracture Angulated/displaced fracture with posterior cortex in contactwith posterior cortex in contact

Type 3Type 3 Complete displacement, with no Complete displacement, with no contact between fragmentscontact between fragments

GARTLAND CLASSFN FOR GARTLAND CLASSFN FOR EXTN TYPEEXTN TYPE

TYPE 1 –UNDISPLACEDTYPE 1 –UNDISPLACED

Type 1: Non-displacedType 1: Non-displaced

Note the non- Note the non- displaced fracture displaced fracture (Red Arrow)(Red Arrow)

Note the posterior Note the posterior fat pad (Yellow fat pad (Yellow Arrows)Arrows)

FAT PAD SIGNSFAT PAD SIGNS

Olecronon post fat pad signOlecronon post fat pad signCoronoid ant fat pad signCoronoid ant fat pad signHelpful in occult # with effusionHelpful in occult # with effusion

Type 2: Angulated/displaced Type 2: Angulated/displaced fracture with posterior cortex in fracture with posterior cortex in

contactcontact

TYPE 2TYPE 2

DISPLACED BUT POST CORTEX IS DISPLACED BUT POST CORTEX IS INTACTINTACT

Type 2: Angulated/displaced Type 2: Angulated/displaced fracture with intact posterior cortexfracture with intact posterior cortexIn many cases, the type 2 In many cases, the type 2 fractures will be impacted fractures will be impacted medially, leading to varus medially, leading to varus angulation. angulation.

The varus malposition The varus malposition must be considered when must be considered when reducing these fractures, reducing these fractures, applying a valgus force applying a valgus force for realignment.for realignment.

TYPE 3TYPE 3

Totally displaced typeTotally displaced type

3 a –post medial3 a –post medial

3 b –post lateral3 b –post lateral

ManagementManagementAll suspected cases should be splinted in All suspected cases should be splinted in around 20-30 deg at elbow before sending around 20-30 deg at elbow before sending for xrayfor xrayNeurologic evaluationNeurologic evaluationVascular assessmentVascular assessment

Peripheral pulse- radial arteryPeripheral pulse- radial artery Capillary fillingCapillary filling Doppler testDoppler testEvaluate for ipsilat injuries- anywhere from Evaluate for ipsilat injuries- anywhere from

wrist to sternoclavicular jt.wrist to sternoclavicular jt.

TYPE 1 # UNDISPLACEDTYPE 1 # UNDISPLACED

SIMPLE IMMOBILIZATION WITH A SIMPLE IMMOBILIZATION WITH A POST SLAB IN 90DEG. WITH A CUFF POST SLAB IN 90DEG. WITH A CUFF AND COLLAR AND COLLAR

XRAY TO BE RPTED AT 5-7 DAYS TO XRAY TO BE RPTED AT 5-7 DAYS TO DOCUMENT FOR ANY DISPLACEMENTDOCUMENT FOR ANY DISPLACEMENT

SLAB KEPT FOR 3 WEEKSSLAB KEPT FOR 3 WEEKS

Type ii (displaced with post Type ii (displaced with post cortex in contact)cortex in contact)

Treatment – closed reduction under anaes

Traction is applied followed by correction of rotational deformity

Extension deformity is corrected with pressure by thumb over the olecranon

Necessity for hyperflexionNecessity for hyperflexion

TYPE III # TREATMENT TYPE III # TREATMENT METHODSMETHODS

Closed reduction & percut.K wire Closed reduction & percut.K wire fixationfixation

Open redn. & K wire fixationOpen redn. & K wire fixation

METHOD OF CLOSED REDN. METHOD OF CLOSED REDN. UNDER GEN. ANAESUNDER GEN. ANAES

Percutaneous K wire fixationPercutaneous K wire fixation

CLOSED REDN WITH K WIRE CLOSED REDN WITH K WIRE FIXATIONFIXATION

Lateral Pin PlacementLateral Pin Placement

AP and Lateral views with 2 pins AP and Lateral views with 2 pins

[ fluoroscopic view ][ fluoroscopic view ]

C-arm / Fluoroscopic ViewsC-arm / Fluoroscopic Views

Jones views with the C-arm can Jones views with the C-arm can be useful to help verify the be useful to help verify the reductionreduction

Indications for SurgeryIndications for Surgery

Volkmann’s IschemiaVolkmann’s Ischemia

Irreducible fractureIrreducible fracture

Vascular injuryVascular injury

Open fracturesOpen fractures

Medial coloumn collapseMedial coloumn collapse

Can lead to varus deformity from simple closed redn. If no stabilization is done

Medial Impaction FractureMedial Impaction Fracture

Type II fracture with medial impaction – not recognized and varus / extension not reduced

Medial Impaction FractureMedial Impaction Fracture

Cubitus varus 2 years later

Supracondylar Humerus Fractures: Supracondylar Humerus Fractures: Associated InjuriesAssociated Injuries

Nerve injury incidence is high, between 7 and 16 % Nerve injury incidence is high, between 7 and 16 % (radial, median, and ulnar nerve)(radial, median, and ulnar nerve)

Anterior interosseous nerve injury is most commonly Anterior interosseous nerve injury is most commonly injured nerveinjured nerve

In many cases, assessment of nerve integrity is limited , In many cases, assessment of nerve integrity is limited , because children can not always cooperate with the because children can not always cooperate with the examexamCarefully document pre-manipulation exam, as post-Carefully document pre-manipulation exam, as post-manipulation neurologic deficits can alter decision manipulation neurologic deficits can alter decision makingmaking

5% have associated 5% have associated distal radius fracturedistal radius fracture

Physical exam of Physical exam of distal forearmdistal forearm

Radiographs if Radiographs if neededneeded

If displaced pin radius If displaced pin radius alsoalso

Vascular injuries are rare, but pulses should Vascular injuries are rare, but pulses should always be assessed before and after reductionalways be assessed before and after reduction

In the absence of a radial and/or ulnar pulse, In the absence of a radial and/or ulnar pulse, the fingers may still be well-perfused, because the fingers may still be well-perfused, because of the excellent collateral circulation about the of the excellent collateral circulation about the elbowelbow

Doppler device can be used for assessmentDoppler device can be used for assessment

Type 3 Type 3 supracondylar supracondylar fracture, with absent fracture, with absent ulnar and radial ulnar and radial pulses, but fingers pulses, but fingers had capillary refill had capillary refill less than 2 seconds. less than 2 seconds.

The pink, pulseless The pink, pulseless extremityextremity

Supracondylar Humerus Fractures:Supracondylar Humerus Fractures:ComplicationsComplications

Malunion –cubitus Malunion –cubitus varus varus

Volkmann’s ischemiaVolkmann’s ischemia

Vascular injury Vascular injury

Loss of reduction Loss of reduction

Loss of elbow motionLoss of elbow motion

Pin track infectionPin track infection

Neurovascular injury Neurovascular injury with pin placementwith pin placement

Volkmann’s ischemiaVolkmann’s ischemia

Diagnose / suspect byDiagnose / suspect by

Severe pain/symptomSevere pain/symptom

Stretch Pain /signStretch Pain /sign

Myositis Ossificans

WHY TO PREFER K WIRE IN WHY TO PREFER K WIRE IN TYPE3#TYPE3#

Type 3 # are intrinsically Type 3 # are intrinsically unstable unstable

1.1. No periosteal hingeNo periosteal hinge

2.2. Rotation of the distal fragment Rotation of the distal fragment cant be controlled until elbow is cant be controlled until elbow is hypreflexedhypreflexed

3.3. # Tends to rotate in less flexion# Tends to rotate in less flexion

4. In fresh cases with swollen elbow 4. In fresh cases with swollen elbow not possible to get hyper flexion i.e. not possible to get hyper flexion i.e. More than 90 degMore than 90 deg

5. If app cast after 2-3 days swelling 5. If app cast after 2-3 days swelling decreases cast becomes loose again decreases cast becomes loose again rotation is lostrotation is lost

Supracondylar Humerus Fractures- Supracondylar Humerus Fractures- Flexion typeFlexion type

Rare, only 2%Rare, only 2%

Distal fracture fragment Distal fracture fragment anterior,flexedanterior,flexed

Ulnar nerve injury -higher Ulnar nerve injury -higher incidenceincidence

Reduce with extensionReduce with extension

Flexion TypeFlexion Type

Flexion Type - PinningFlexion Type - Pinning

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Supracondylar fractures in_children

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