Supracondylar Fracture

Grade 3 SC APGrade 3 SC lateral

 

Mechanism

 

FOOSH

 

Epidemiology

 

Age 6 as maximum ligamentous laxity

- < 4 - physeal separation

- > 8 - dislocation

 

Male > F

 

2nd most common upper limb fracture in children (after distal radius)

 

Pathoanatomy

 

Supracondylar region in 6 year old is thin

- thinnest at olecranon fossa (2-3 mm)

- thin lateral & medial columns 

 

Children also tend to hyperextend at the elbows due to increased ligamentous laxity

 

With increasing hyperextension, the anterior periosteum hinge is torn

 

Examination

 

Supracondylar

 

Clinical

 

"S" Shaped arm which is very swollen

 

Pucker sign

- anterior spike impales brachialis to skin

 

Pucker sign 1Pucker sign 2

 

Nerve examination

 

1.  Median nerve

- sensation

 

2.  Anterior interosseous nerve (AIN)

- make circle with index and thumb

- check FPL and FDP index finger

- most common injury in extension type fractures

 

3.  Posterior interosseous nerve (PIN)

- thumb up

 

4.  Ulna nerve

- cross fingers / spread fingers / sensation

- most common injury in flexion type fractures

 

5.  Radial nerve

- decreased sensation first dorsal webspace

 

Classifications

 

Flexion type 2%

 

Supracondylar Flexion Type

 

Extension type 98%

 

Supracondylar Grade 2

 

Gartland Classification Extension Fractures

 

Gartland I - Undisplaced

- < 2 mm

- anterior and posterior cortices intact

 

Gartland 1 supracondylarGartland 2 Supracondylar

 

Gartland II - Displaced with intact posterior cortex

- > 2 mm

- anterior humeral line passess anterior to capitellum

- posterior periosteum is intact

 

Supracondylar Grade 2

 

Gartland III - Displaced, nil cortical contact

- completely displaced

- posteromedial or posterolateral

 

Supracondylar Grade 3Grade 3 SC

 

Gartland IV - Nil cortical contact with complete periosteal disruption

 

Extremely unstable at surgery in both flexion and extension planes

 

Modified by Wilkins

 

Type IIB Rotated

 

Type 2B 1Type 2B 2

 

Type IIIA Posteromedial

 

Commonest

- distal fragment goes posteromedial

- cause cubitus varus

- injures radial nerve which is tethered over lateral spike on proximal fragment

- manage by pronation which tightens medial periosteal hinge

 

Type IIIB Posterolateral

 

Distal fragment goes posterolateral

- causes cubitus valgus

- tend to ER

- injuries median nerve & brachial artery

- these get tethered over medial spike on proximal fragment

- manage by supination which tightens lateral periosteal hinge 

 

The position of stability is achieved with the thumb pointed towards the side of the periosteal disruption

 

Lateral Xray

 

Position for good lateral

- thumb vertical

- hand above elbow

 

Anterior angulation

- shaft - condylar axis

- normally 40o

 

Lines

 

Anterior Humeral LineRadiohumeral Line

 

Anterior humeral line (AHL)

- should pass through middle of capitellum

 

Radio-capitellar line

- pass through capitellum

 

Teardrop 

- shadow above the capitellum

- anterior dense line: posterior margin of the coronoid fossa

- posterior dense line: anterior margin of the olecranon fossa

- inferior portion: ossification center of the capitellum

 

AP X-ray

 

AP elbow paediatricsBaumanns angle paediatric elbow

 

Baumann's Angle

 

Technique

- angle between longitudinal axis humerus and capitellar physis

- should equal uninjured side

- 75o normal

 

Cubitus varus

- varus malposition  > 81° 

 

Cubitus valgus

- < 70o

 

Management

 

Free review articles

 

Vaquero-Picado et al, EFORT OR 2018

 

 

Issue

 

There is limited remodelling potential of the distal elbow after the age of 4

After age 8 - 10, only 10% of growth of humerus remains

 

Algorithm

 

Type 1

 

Cast / collar and cuff

- flex up to splint with triceps

- 3/52

 

Type 2A

 

Closed reduction

- anterior humeral line doesn't contact capitellum

- Baumann's angle > 800 (cubitus varus)

- immobilise in flexion

- careful watching for late displacement

 

Ojeaga et al. J Paediatr Orthop 2020

- 77 type IIa patients

- 77% successfully treated with closed reduction and cast

 

Roberts et al. J Paediatr Orthop 2018

- compared collar and cuff / flexion taping with cast in 39 patients

- no difference

 

Type 2B

 

By definition, have rotation

- MUA + K wire

 

Type III

 

MUA + K wire

 

Flexion type

 

Timing of surgery

 

Takeaway message

- earlier surgery is probably technically easier due to swelling

- surgery can be difficult

- don't do in the middle of the night unless emergency / vascular compromise

 

Loizou et al. Injury 2009

- systematic review of 5 non randomized retrospective studies

- 396 patients

- increased failure of closed reduction with conversion to open reduction with surgery performed > 12 hours

 

Farrow et al. Bone Joint J 2018

- meta-analysis showed no difference between early and delayed surgery

 

Pauci et al. J Orthop Trauma 2018

- increased incidence malunion in surgery performed after midnight

- fractures treated after midnight tended to be more severe

 

Surgical technique

 

Options

- lateral K wires

- crossed K wires

 

Dekker et al. Injury 2016

- systematic review and meta-analysis

- 11 studies (RCTs and prospective cohorts)

- 1158 patients

- loss of reduction in 11.6% of crossed K wires and 12.4% of lateral K wires

- iatrogenic ulna nerve injury in 4% crossed K wires and 0.3% lateral K wires

 

Carrazzone et al. J Should Elbow Surg 2021

- meta-analysis of 12 RCTs

- no difference in functional outcome

- reduced risk of iatrogenic nerve injury with lateral K wires

- greater fixation stability and less loss of reduction with crossed K wires

 

Closed reduction and K wire technique

 

Vumedi video

 

Set up

 

On arm table

Sterile tourniquet available should open reduction be required

 

Manipulation technique (must have adequate reduction, or very unstable and cannot K wire)

 

1.  Consider milking any soft tissues that may be trapped (pucker sign)

 

2.  In-line traction at 30o

- 2 minutes to overcome soft tissues

- check fluoroscopy

 

3.  Reduce translation / rotation / varus and valgus

- adjust carrying angle / Baumann's angle

- avoid medial impaction / cubitus varus

- supination - maximise the traction on the lateral ligments to disimpact lateral side

- pronation - maximise traction on the medial ligaments to disimpact medial side

- check fluoroscopy

 

4.  Flexion pushing olecranon forward with thumb

- shoot through AP to assess reduction

- check Baumann's angle

- check medial and lateral columns with oblique views

 

5.  Hand position (point thumb towards side of impaction)

- posteromedial displacement - hyperpronation in flexion

- posterolateral displacement - hypersupination in flexion

 

6.  Check lateral image

- lock elbow in flexion and rotation

- externally rotate the shoulder

- ensure that the anterior humeral line is correct

- reduction of teardrop on lateral

- may need to increase the flexion

 

Bony landmarks

 

In extension

- medial / lateral epicondyle and olecranon all in a line

 

In flexion

- medial / lateral epicondyle with olecranon from equilateral triangle

 

2 x lateral K wires

 

Advantage

- no risk to ulna nerve

 

Disadvantage

- if not correctly done, can be unstable

 

Technique

- hold elbow in flexion

- place K wire into lateral condyle

- place other index finger on the humerus to guide aim

- 2 x lateral 1.6 mm K wires (consider 2 mm K wires in larger children)

- one K wire on the direct lateral surface, just lateral to the capitellum

- one on the capitellar surface

 

Points

- must engage medial and lateral columns (bicortical)

- make pins divergent for increased stability

- only need 3rd pin if first two not divergent enough

 

Check stability

- place elbow into extension

 

Supracondylar Lateral K wiresSupracondylar Lateral K Wires

 

2.  Crossed K wires 1.6mm

 

Supracondylar fracture cross K wirescross k wires 1crossed k wires 2

 

Advantage

- increased biomechanical strength

- maybe necessary with signification medial comminution

- maybe necessary if unstable after two lateral K wires

 

Disadvantage

- ulnar nerve at risk

 

Small medial open approach

- place arm in external rotation

- place local anaesthetic with adrenaline to decrease bleeding (tourniquet not typically needed)

- mini open approach over medial epicondyle

- dissect down onto the hard medial epicondyle

- identify the common flexor origin to confirm

- K wire directly onto bone

- may need to extend elbow to 90o as in some children the ulna nerve subluxes anteriorly in flexion

- K wire must aim posterior to anterior as medial epicondyle is posterior

 

Points

- wires must cross above the level of the fracture

- engage medial and lateral cortices

 

3. Technical issues

 

1. Significant medial comminution

- cross K wires

 

2. Unstable with excessive flexion

- cross table lateral

- place bump under humerus

- reduce flexion

- may need cross K wires

 

3.  Ipsilateral distal radius fracture

- MUA and K wire the distal radius first

 

Post operative

 

Check pulse (use doppler if needed)

Bend and leave K wires protruding

Cast

Remove K wires at 3 weeks

 

Irreducible supracondylar fracture

 

Vumedi video

 

Problems

- brachialis might be trapped

- brachial artery might be in fracture

 

Management

 

Supracondylar Open

 

Sterile tourniquet

 

Anterior approach

- identify biceps tendon laterally

- identify and tag the median nerve medially

- identify and tag the brachial artery and two venae commitantes between biceps tendon and median nerve

- release soft tissue especially carefully release lacertus

- safest over the median nerve

- open and clean fracture spikes both medially and laterally

- remove any brachialis and periosteum that might block reduction

- perform open fracture reduction with finger

- flex arm and check flouroscopy

 

Pulseless supracondylar

 

Scenarios

 

1.  Pulseless but pink and perfused on presentation

 

Make vascular surgeons aware

 

Urgent closed reduction + K wire

- position at 90o

- ensure pulse returns

- observe closely

 

Louahem et al. Injury 2016

- 42/60 patients had pulse return immediately after closed reduction and pinning

 

3. Pink and well perfused after reduction, no pulse

 

The pulse will return in virtually all patients

- some however on surgical exploration or doppler will be shown to have significant vascular injury

- pulse returns eventually due to collaterals

- patients typically do well regardless

 

Recommend close observation

- consider exploration if no waveform on pulse oximeter

- consider doppler ultrasound

 

Weller et al. JBJS Am 2013

- 1297 supracondylar fractures

- 20 with pink hand, doppler pulse but non palpable pulse after reduction

- all observed closely

- 19/20 pulse returned by discharge or by first post op visit

- 1/20 developed white hand 9 hours post surgery, and needed urgent vascular repair

 

Louahem et al. Injury 2016

- 18 patients with pink pulseless hands had a delayed pulse return up to 11 days later

 

Scannell et al. JBJS Am 2013

- long term follow up on 20 patients with perfused pulseless hand after closed reduced

- all 20 had palpable pulse

- 5/20 had brachial artery occlusion with large collateral vessels on doppler ultrasound

- all patients had normal growth and excellent function

 

Soh et al. Clin Orthop Surg 2013

- 26 patients with pink and perfused

- pulse oximeter used

- 4/26 no waveform on pulse oximeter, all had vascular injury

- 22/26 had wave on pulse oximeter, pulse subsequently returned in all

 

Noaman et al. Microsurgery 2006

- 31 patients with no pulse explored

- all 31 had significant vascular findings including traumatic aneurysm and transection

 

2. Hand white, non perfused, no pulse on doppler after reduction

 

Surgical emergency

- vascular surgeon

- lazy S approach

 

Weller et al. JBJS Am 2013

- 1297 supracondylars

- 5 patients with white hand and no pulse

- all 5 underwent either primary repair or saphenous vein graft

 

4. Pulse present before surgery, no pulse & hand white after closed reduction

 

Brachial artery entrapped in fracture

- anterior lazy S approach

- expose and release brachial artery

- open reduction and K wire

 

Too swollen / skin abraded 

 

1.  Skin traction

- arm straight

- weight over pulley

- body weight counter traction

 

2.  Dunlop traction

- screw in olecranon

- bent arm traction

- difficult to control rotation

 

Complications

 

Nerve Injury 

 

Anterior interosseous nerve (AIN)

 

Most commonly injured

 

Indications for exploration

- post reduction nerve injury with non anatomical reduction

- open injury

 

Barrett et al. JBJS Am 2014

- 35 cases of supracondylar fracture with isolated AIN injury

- all patients had complete return of AIN at mean 49 days (range, 2 - 224 days)

 

Median / ulna nerve / radial nerve

 

Ulna nerve

- associated with flexion type supracondylar fractures

- can be injured during medial K wire (avoid with mini-open approach)

 

Median nerve

- more often injured with severe fractures

- can be injured with lateral K wires

 

Compartment Syndrome

 

Extremely rare, case reports only

However, must monitor overnight as the results of missed acute compartment syndrome are devastating

 

Barrett et al. JBJS Am 2014

- 4400 cases of operatively treated supracondylar fracture

- no patient development compartment syndrome

 

Volkmann's contractures

- permanent flexion of the wrist and hand

- caused by shortening of the flexor muscles of the forearm

 

Malunion 

 

Issues

 

Sagittal plane deformity will remodel

Coronal plane deformity & rotation will not

 

Cubitus Varus 

 

Cubitus VarusCubitus varus

 

Cubitus Varus post supracondylarCubitus varus lateral

 

Most common deformity

- mainly cosmetic problem

- can also be due to medial growth arrest

 

Treatment

 

Corrective osteotomyCorrective osteotomy 2

 

Oblique closing wedge osteotomy via lateral approach

 

JBJS Essential Surgical Techniques

 

Results

 

Solfelt et al. Bone Joint J 2014

- systematic review of 894 children treated for cubitus varus

- mean correction 27o

- 88% good or excellent results

- nerve palsy in 2.5%, although the majority were transient

 

Takagi et al. JBJS Am 2010

- compared coronal plane osteotomy only with multiplane osteotomy

- 86 elbows with cubitus varus

- more loss of correction with multiplane osteotomy

 

Cubitus Valgus  

 

Uncommon

- may cause tardy ulna nerve palsy

- manage by transposing nerve

 

Cubitus valgus

 

Stiffness 

 

Myositis ossificans uncommon 

- may be secondary to remanipulation > 1/52 / later presentation

 

Stiffness usually minimal

- takes up to 1 year to regain full motion

- especially extension

 

AVN Trochlear 

 

Uncommon 

 

Produces fishtail deformity

- deepening of trocheal groove

- DDx: trochlear AVN / central growth arrest / non reduced intercondylar fracture

- can be associated with early degenerative changes

- could consider epiphysiodesis of remaining growth plates, but usually well tolerated

 

Paediatric Elbow Trochlea Avascular Necrosis