Date post: | 14-Apr-2017 |
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Aetiopathology and Management of Humeral Supracondylar fractures in Children
Dr. Situ Oladele, Orthopedic unit, NHA
Outline• Introduction and definition• Epidemiology• Relevant anatomy (including radiographic anatomy and elbow rules)• Aetiopathology
– Pathological anatomy– Mechanism of injury– Classification
• Management (History, Exam, investigation, treatment)• Complications• Follow-up• Conclusion and references
Introduction and Definition
• Malgaigne’s fracture• Children are prone to falls, often use upper
extremity to break falls (65-75% of all fractures in children are in the upper limb)
• Is a fracture through the thin distal humerus, just proximal to the capitulum usually involving the olecranon fossa or apex of coronoid fossa or metaphysis
Epidemiology
• commonest injury around the elbow (65.4% of elbow injuries)
• Age: < 10years (5-8yr)• Sex: commoner in boys (63.6%)• Usually fall from height (70%)• Commoner on the left humerus (58.6%)• Associated frequent nerve injury (7%)• Open fracture (2.3%)• Frequently a displaced fracture (90%)
Incidence of elbow injuries and Distal humeral fractures
Elbow injuries• Supracondylar
fracture 65.4%• Condylar fracture 25.3%• Fracture neck of
radius 4.70%• Monteggia fracture 2.2%• Olecranon fractures 1.6%• T-condylar fracture 0.8%
Distal humeral fractures• Supracondylar
fracture 69%• Lateral condyle 16.8%• Medial condyle 14.1%• T-condylar 1%
Relevant anatomy
• Carrying angle in children is ≈ 5-25 degree
• Range of motion at full flexion ≈ 150o
• Tips of medial, lateral condyles with olecranon
• Secondary Ossification centres (CRITOE)
Radiographic anatomy
Normal X-Ray: Elbow rules
Aetiopathology
Pathological anatomy
• Supracondylar region is vulnerable to fracture because:– Bone remodelling– Cortex is thin– Laxity of ligaments permits hyper extension of the
elbow against a taut anterior capsule– Anterior cortex has a defect in the area of the
coranoid fossa– Less cylindrical
Mechanism of injury
• Fall on an outstretched hand • Fall on the point of a flexed elbow• Spiked end of displaced proximal end may – penetrate brachialis muscle to damage it– lacerate brachial artery and/or median nerve
• Neurovascular deficit occurring with injury, manipulation, pinning, or compartment syndrome
Classification• EXTENSION TYPE (95-98%)
Gartland’s classification in children:– Type 1: undisplaced– Type 2: mild displacement with intact posterior
cortext• 2A: merely angulated distal fragment• 2B: fragment is both angulated and malrotated
– Type 3: complete displacement without intact posterior cortex
• FLEXION TYPE (2-5%)
• Displacements – Posteromedial (75%)– Posterolateral (25%)
• Open or Closed• Other structural changes– Medial rotation of distal segment– Sideways tilts (angulations)
Disrupted metaphyseal-diaphyseal angle
Management
Clinical presentation
• Acute• Late presentation• Isolated humeral fracture• Complicated by neurovascular compromise
History and Physical Examination
• History: – fall, pain, swelling, inability to use elbow.– Symptoms of neurovascular injury
• Examination: – “S”-shaped deformity of the arm– Local swelling ± bruising– Shortened arm (humerus)– Tender elbow
Physical Exam cont’d
• Dimple sign• Bony crepitus should not be elicited• ↓active and passive range of motion• examination of vascular compromise (elbow
collaterals my keep hand perfused)• Examination of nerve deficit (children may not
co-operate)• Rule out compartment syndrome
Diagnosis
• Essentially Clinical• Supportive investigations– X-ray elbow joint (AP/lateral views):– Posterior displacement of distal fragment • Fat pad sign (sail sign)• Displaced anterior humeral line• Displaced coronoid line• Loss of teardrop sign
DISPLACED TEAR DROP, FAT PAD,CORANOID LINE & CRESCENT SIGNS
–Coronal tilt of distal segment (varus deformity)• Increased Baumann’s angle• Disrupted Metaphyseal-diaphyseal angle• Disrupted humero-ulnar angle• Crescent sign
–Horizontal rotation of distal fragment• Fish-tail sign
FISH TAIL SIGN
BAUMANN’S ANGLE range = 64-81 O
DISPLACED ANTERIOR HUMERAL &CORONOID LINES
Treatment
• Resuscitation using the ATLS protocol in acute setting
• Adequate analgesia; General anaesthesia• Neurovascular compromise is an emergency• Treatment options depends on:– Nature of fracture (Gartland’s class)– General condition of the patient– Presence of neurovascular complication or not
Treatment
• Undisplaced Supracondylar fracture (Gartland type 1):– POP back slab with elbow in flexion for 3 weeks
• Angulated, malrotated or Displaced supracondylar fracture:– Closed reduction – Open reduction– Continuous traction
Treatment: principles of closed reduction
• Done under general anaesthesia• Gentle constant longitudinal traction: elbow at
10o flexion• Correct sideways tilt next• Correct rotational deformity next• Correct antero-posterior tilt/displacement next• Stabilize and immobilize fracture: hyperflex.
Collar and Cuffs, skeletal stabilization• Check X-rays
Treatment
• Gartland type 2A– Closed reduction ± percutaneous pinning with
crossed K- wire • Gartland type 2B and 3– Closed reduction + percutaneous pinning with
crossed K- wire
NB: rotational twist or tilt must be corrected, collar and cuff worn for 3 weeks
Open reduction
• Indications: – Failure of closed reduction– Open supracondylar fracture– Associated neurovascular compromise– Comminuted fracture
• Timing : within 5 days of injury • Complication: ulnar injury
Continuous traction
• Indications:– Failure of manipulation to achieve reduction– Failure to achieve >100O elbow flexion without
vascular compromise– Absence of image intensifier to permit
percutaneous pinning– Severe open injuries, comminuted fractures– Multiple ipsilateral limb injuries
• Skin(Dunlop) or skeletal (Smith’s) traction
Rx of Anteriorly displaced distal segment
• Closed reduction + POP back slab ± pinning with K wires
• Sultanpur (two stage casting) technique
Complications
• Immediaate:– Vascular injury (1%– Nerve injury (7%)
• Early:– Compartment syndrome
• Late:– Volkmann’s ischemic contracture– Joint stiffness– Malunion: Cubital varus or valgus deformity– Myositis ossificans– Non-union
Follow up Care
• Check X-ray in 5-7 days• K-wires are pulled out after 2 weeks• Finger exercises only for first 3 weeks • Supervised forearm and arm exercises for the
second 3 weeks• Osteotomies for correction of gunstock
deformity
Conclusion
• Supracondylar fractures in children is only second to distal forearm fractures in frequency
• Characteristic pathological anatomy and potential for serious functional and esthetic complications
• Early identification and restoration of clinicoradiological abnormalities is vital.
Thank you
References
• Apley’s systems in Orthopedics and fractures by Louis Solomon, David Warwick, Selvadurai Nayagam; Hodder Arnold Publications9th edition
• Textbook of orthopedics by John Ebenezar, Jaypee Brothers, 3rd edition
• Principles and practice of Surgery (Including Surgery in the Tropics) by Badoe, Achampong,
Acknowledgement
• Supracondylar fractures of humerus by Dr. Hardik Pawar, care hospital (slide share)